Essential Newborn Care Services in Nonpublic Health-Care Facilities in Southeast Nigeria

Introduction

Essential Newborn Care (ENC) is care required for every newborn baby regardless of delivery location or birth weight and this care should be continued for at least the first 7 days after birth. ¹ Following delivery, the transition from the fetus to neonate represents a series of dramatic physiologic changes. Those changes need skilled personnel interventions to ensure that they occur with the least possible problem. ²

To minimize problems newborns encounter after birth, the World Health Organization (WHO) recommended a standard of care that encompasses a series of 10 steps, which in turn has a set of activities. These recommended ENC includes dry and stimulate, evaluate breathing, cord care, keep the newborn warm, initiate breastfeeding in the first 1 hour of life, administer prophylactic antibiotics into eyes, administer vitamin K intramuscularly, place the newborn’s identification bands on the wrist and ankle, weigh the newborn when stable and warm, and record all observations of the baby. ³

The implementation of these care activities minimize the incidence of neonatal morbidity and mortality. ⁴ Even though there was a substantial decline in the global neonatal mortality rate (NMR) since 1990, high NMR is concentrated in Sub-Saharan Africa (40/1000) and South Asia (26.9/1000). ⁵ Nigeria is among the top 3e contributors to the global burden of infant mortality with a NMR that has stagnated between 37 and 41 per 1000 live births over the past 3 decades. ⁶ More than a million of these neonatal deaths occur on their first day of life, which would have been minimized with appropriate implementation of ENC.^{2, 4, 7–9}

Even though each step of ENC is designed to be implemented based on prioritization of newborn problems and/or its impact on neonatal life, most studies from different parts of the world have indicated incomplete or inappropriate practice of ENC.^{10, 11}

This study set out to assess the practice and the determinants of adequate ENC services provided to babies immediately after delivery in privately owned health facilities in southeast Nigeria.

Methodology

Results

Characteristics of the Health Facilities Studied

In all, a total of 77 health facilities were surveyed. About 4-in-10 of the health facilities surveyed were located in Enugu and the remainder located in Abakaliki (26%), Awka (18.2%), and Nnewi (13%). Most of the health facilities surveyed (96.1%) were privately owned while 3.9% were owned by faith-based organizations. The majority, 49 (63.6%), of the facilities surveyed were owned by specialists, while the rest were owned by nonspecialists. The mean birth rate of the health-care facilities enrolled in this study was 342.2 per year (Table 1).

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Table 1.

Showing Characteristics of the Health Facilities.

Variable		Frequency (N = 77)	Percentage
Highest educational qualification (HEQ)	Specialist	49	63.6
	Nonspecialist	28	36.4
Level of care	Secondary health facility	77	100.0
Ownership	Private	74	96.1
	Faith-based	3	3.9
City of hospital location	Enugu	33	42.9
	Nnewi	10	13.0
	Abakaliki	20	26.0
	Awka	14	18.2
Annual birth rate	Mean	342.2	SD = 549.2
	Median	120	1QR = (60 – 360)

Abbreviation: SD, standard deviation; IQR, interquartile range.

Essential Newborn Care Practices in the Health Facilities

About a fifth of surveyed facilities (23.4%) practiced cord clamping between 1 and 3 minutes of childbirth, 15.6% used chlorhexidine for cord care, 28.6% administered vitamin K1, 2.6% practiced routine eye care with erythromycin while practice of skin-to-skin care within first 1 hour after delivery was done in 19.5% of surveyed facilities. Most of the surveyed facility (92.0%) practiced putting newborn to mother’s breast within 1 hour following delivery, 57.1% practiced bathing after 24 h of delivery and over half of surveyed facilities (68.8%) engaged in “no routine prescription of drugs” after delivery. In summary, it was observed that over two-thirds of surveyed health care facilities, (64.9%) had poor ENC practice score (0–3) while the remaining 27 (35.1%) facilities had good ENC practice score of (4–8) (Table 2 and Figure 1).

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Table 2.

Showing Practices on the Immediate Care of the Baby in the Health Facilities

Parameter	Variables	Frequency	Percentage
Time of cord clamping	Immediate	59	76.6
	1–3 min	18	23.4
Cord care	Both	48	62.3
	Chlorhexidine gel	12	15.6
	Both	17	22.1
Vitamin K1 administration	Yes	22	28.6
	No	55	71.4
Routine eye care	Yes	2	2.6
	No	75	97.4
Time of bathing of babies	After 24 h	44	57.1
	Within 24 h	33	42.9
Skin-to-skin after birth	Yes	15	19.5
	No	62	80.5
Routine drug prescription after birth	Yes	24	31.2
	No	53	68.8
Breastfeeding within an hour of delivery	Yes	71	92.2
	No	6	7.8
Formula feeding after caesarean sections	Yes	65	84.4
	No	12	15.6

OPEN IN VIEWER Figure 1.

Bar Chart Showing Practice Score on the Immediate Care of Babies in Health Facilities.

Predictors of Good Practices of Essential Newborn Care Among Surveyed Facilities

The relationship between good ENC practice score and characteristics of each health facility surveyed was assessed and it was noted that only the city where the health-care facility was located showed a significant association with good practice of ENC. More health facilities located in Abakaliki and Awka had good practice score of ENC compared to facilities in Enugu and Nnewi (P = .001) (Table 3).

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Table 3.

Showing Relationship Between Practice Score on Immediate Care of Babies and Characteristics of the Facilities

Variable		Practice Score
		Poor	Good	X2/U	P Value
HEQ hospital owner	Specialists	32	17	0.008	.928
	Nonspecialists	18	10
Ownership	Private	48	26	0.004	.949
	Faith-based	2	1
City of hospital location	Enugu	28	5	19.004	.001*
	Nnewi	9	1
	Abakaliki	7	13
	Awka	6	8

Notes: X², chi-square test; U, Mann-Whitney U test; P, test statistic is significant at .05 level. Bold values of P is statistical significant.

Discussion

This study set out to explore the practice of ENC and its determinants among health-care facilities in southeast Nigeria.

Our study noted that approximately two-thirds of facilities surveyed did not implement adequate ENC necessary for optimal survival of newborns in its facilities. This finding was corroborated by a similar cross-sectional study conducted to assess quality of newborn care immediately after birth in 643 health facilities across six sub-Saharan African countries. In all countries assessed, it was observed that inadequacies existed in ENC services with causes ranging from poor health worker knowledge, poor performance in key routine newborn care practices to lack of equipment needed to provide these essential newborn services. ¹² These observations in Africa are unfortunate especially when compared to another study conducted in 226 public health facilities in Afghanistan which showed a higher proportion of babies received ENC. ¹³ In the study, it was noted that close to 90% of babies delivered at health-care facilities were dried immediately and 89.7% had sterile cutting of umbilical cords. Other ENC practices noted in the study included skin-to-skin contact (49.2%), airway clearing and/or stimulation (72.5%), and prompt resuscitation with a bag and mask (72.5%). ¹³ Even though the Afghanistan study was conducted exclusively in public health-care facilities compared to only private/faith-based ones in our study, it does demonstrate that practice of ENC services can be achieved in resource-limited setting with proper planning and motivation on the part of health-care leaders. The WHO in its 2017 press release noted that to prevent or significantly reduce the 5.1 million babies that die within the first month of their life, political and health-care leaders must be committed to universal health coverage and essential newborn health services which are critical to life saving newborn interventions. ³

It was also noted in this study that more than two-thirds of the surveyed health facilities correctly implemented only 3 of the 8 ENC practices. Toma et al ¹⁴ and Amsalu et al ¹⁵ also documented poor practice scores in Jos Nigeria and conflicted affected areas of Somalia. Yosef et al ¹⁶ and Ayenew et al^17–19 on the contrary reported high practice scores in Ethiopia which was attributed to the availability of frequent on-the-job trainings as observed in a study in Southwest Ethiopia. The practice of intramuscular Vitamin K1 and routine eye care at birth were poor in our study, a finding corroborated by Toma et al ¹⁴ in Jos Nigeria. The reason for this is unknown but reinforces the need for training and retraining to emphasize the importance of the implementation of all aspects of ENC services.

Finally, our study noted that only the city where health facilities were located significantly predicted good practice score for ENC with Abakiliki showing the strongest association. The reason for this finding is not immediately clear but we believe that the difference in good practice score of newborn care in the surveyed communities may be influenced by the sociodemographic characteristics of its residents. Awka and Abakiliki are well known to have higher proportion of civil servants who are relatively more educated and may have better understanding of the concept of ENC compared to residents in Nnewi who are predominantly traders. This understanding could significantly influence the quality of newborn services provided by health-care facilities in these localities.

Similarly, the good practice of ENC in Abakiliki may also be related to the Maternal and Child Survival program (MCSP) which was conducted in Ebonyi and Kogi by the USAID in 2018. ²⁰ The program focused on strengthening newborn care, training, and enlightenment of health-care providers on adaptation and development of newborn training materials, operational guidelines and provided support to the states for health planning to ensure sustainability of MCSP activities. ²⁰ This lends credence to the WHO call for continuous public enlightenment campaign and robust funding together with frequent retraining of health-care workers in ENC practices. This is where government support and regulations in individual countries play a decisive role.