Newborn care practices at home and health facilities in Tigray, Ethiopia: a qualitative assessment

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In 2019, about half of all under-five mortality was contributed by the newborn deaths, which was estimated to be about 2.4 million deaths worldwide.1 In Ethiopia, the estimated neonatal mortality rate stands at 33 deaths per 1,000 live births.3 The study will outline newborn care practices both in homes and in the public health care system in Tigray. Methods: The qualitative study employed two data collection methods, namely, focus group discussions and in-depth interviews. The study was conducted in five zones of the Tigray region. In all, 16 focus group discussions and 46 in-depth interviews were held with community representatives and health workers. Data were transcribed and then analyzed using the ATLAS.ti software for thematic coding using an inductive approach. Themes identified were discussed in detail prior to coding. Result: The community perspective shows that there is enough knowledge regarding basic newborn care and harmful traditional practices; however, practices have not been resolved. Active engagement of parents, especially mothers, in facility-based care is socially and economically limited. Health Professionals' Perspective: Weight measurements for home births, as opposed to those in facilities, are not regularly carried out, with many newborn babies not having their weight measured. There are missed home births despite having a home birth notification framework in place. HEWs conduct postnatal care via routine home visits; however, there is weak continuum of care and referral feedback from hospitals. Besides these, widespread shortages of electricity and phototherapy machines and community awareness for care of preterm and LBW babies were noted. Parents' experiences are shaped by the forces of economic insecurity and social issues. Conclusion: The improvement of newborn care practices at home and health facilities is an important milestone that the Ethiopian Federal Ministry of Health is seeking to achieve as it works toward the reduction of the neonatal mortality rate. This feat will be realized at the facility level when actionable strategies, resource commitments, strengthening of the HEP, and health education are implemented. Newborn care Home Health Facility Practices referral continuum of care harmful traditional practices Background The neonatal period remains the most vulnerable period for child survival. Deaths among newborns accounted for almost half of all deaths among under-five children, with an estimated 2.4 million newborn deaths worldwide in 2019. 1 The major causes include intrapartum-related events, complications from preterm birth, sepsis and meningitis, and congenital problems. 2 Four-fifths of the newborn deaths occur in sub-Saharan Africa and Southern Asia, 4 while the estimated neonatal mortality rate is 33 deaths per 1,000 live births in Ethiopia. 3 Indeed, most preterm babies have the possibility of survival if evidence-based care is provided in a cost-effective way without necessarily having to require ICU support. 5 Quality postnatal interventions at healthcare facilities and appropriate basic home care can improve outcomes dramatically in such newborns. Facility-based newborn care has been ensured through the provision of NICUs in hospitals by the Ministry of Health in Ethiopia. In Ethiopia, there is the Health Extension Program through which, a cadre of trained Health Extension Workers and Women Development Armies/Groups, there is an intention to make contact with the community through home visits. The HEP is thus among the most innovative community-based health initiatives that have been in operation since 2004/2005. 6 HEWs also contribute to maternal and newborn care through antenatal follow-ups, postnatal visits, making connections with WDAs who facilitate the contacts between mothers and HEWs. A meta-analysis of the community-based intervention studies up to 2010 showed reductions in stillbirths, neonatal, and perinatal mortality rates. It also documented increased referrals to health facilities due to pregnancy complications and early initiation of breastfeeding, thus proving this model of care significantly affected early neonatal mortality. 7,8 It was expressed in another review that the visits during the early postpartum period within 48 hours led to improved results. 9 Proof-of-concept studies reported similarly and estimated a 45% reduction in neonatal mortality associated with these interventions. 10 These studies, therefore, affirm that the community-based HEP coupled with strengthened collaboration between HEWs and WDAs must be promoted to improve newborn survival. Methodology and Study Design A qualitative assessment was carried out in five zones of Tigray, one of Ethiopia's nine regional states, between the months of March and April 2017. The selected zones included Southern, Southeastern, Eastern, Central, and Mekelle. The total number of zones in Tigray is seven. The qualitative approach was employed in data collection to capture in detail how and why newborn care practices influence neonatal survival. Data Collection The following methods were used in the collection of data: 1. Fifteen in-depth interviews with mothers of infants born in the last one month, 11 community health workers including health extension workers and members of women development groups, and 11 health facility workers including nurses and midwives. 2. Three in-depth interviews and one focus group discussion with grandmothers. 3. Six in-depth interviews and two focus group discussions with grandfathers of under-two children. Participants were randomly selected based on being a parent or grandparent to children under the age of two years to avoid recall bias. Study Setting The present qualitative study was conducted in five zones of the Tigray region, northwest part of Ethiopia. The region has a projected population of 5,055,999 and a neonatal mortality rate of 28 per 1,000 live births. 3 The socio-demographic characteristics of the study area are defined in Table 1. Table: 1 Socio-demographic characteristics of Tigray, 2019 Characteristics of the study Region The Region (Tigray) Demographic indicators Population, No. 5,055,999 Male 49.2% Female 50.8% Neonatal mortality, No. per 1,000 live births) 28 Facility Birth 72.4% Percentage of women with a postnatal check during the first 2 days after birth 62.9% primary health care coverage 96% Mini EDHS 2019 and National 2015/16 census projection Study Design The present qualitative study embraced a participatory approach whereby two major methods of data collection were employed: focus group discussions and in-depth interviews. Sampling and Sample Size The Tigray region is sub-divided into seven zones, including South, Southeastern, Eastern, Central, Mekelle, Western, and Northwestern. Of these, supported by the Tigray Regional Health Bureau, five were randomly selected for focus group discussions and in-depth interviews, as illustrated in Table 2. Table 2 : The Five zones, districts and health facilities of the region included in this study. Zones Wereda (District) Health facility South Maichew, Endamehoni, Nikaah Maichew lemlem Karl hospital, Neksege Health Center South eastern Degua temben, Alasa, Arebay Hagereselam primary hospital, Alasa Health Center Eastern Adigrat, Gantaafeshum, Kitagedeba Adigrat hospital, Bizet Health Center Centeral Abi-adi, Guya Abi-adi hospital, Guya Health Center Mekelle Mekelle, Serawat Ayder Referral Hospital, Serawat Health Center The 1991, Zonal and District assignments of Tigray region The staff for the interviews was selected in advance of data collection from a subsample of health facilities across each tier of the public health care system in the zones of interest, including HPs and HCs. In total, the study carried out 16 focus group discussions and 46 in-depth interviews. Selection of the locations considered various local characteristics including urban, semi-urban, and rural, while considering they were within 150 km from Mekelle, the capital city of Tigray. Study Participants To this regard, in-depth interviews were conducted with 11 community health workers including health extension workers and members of women's development groups, 11 health workers including nurses and midwives, and 15 mothers whose infants were born within the last month. FGDs were conducted with mothers and fathers of children aged less than two years with 6 to 12 participants in each group. A total of three IDIs and one FGD were conducted with grandmothers, and six IDIs and two FGDs involved grandfathers of children aged less than two years old. Prior to the study, the health directors had provided detailed information on the potential participants. Parents and grandparents participating were selected in order to make sure of recent recall and reduce bias. Data Collection Method The research team developed a comprehensive data collection instrument with the aim of eliciting in-depth information from the community and health facilities regarding practices, beliefs, and norms related to newborn care. Nine data collectors, all holding an MPH degree, were trained on qualitative research methods, as well as harmonizing their views with those of the research team, composed of professionals from pediatrics and public health, and experts from the Tigray Regional Health Bureau. FGDs were conducted using participatory methods with open-ended questions that allowed free interaction among participants in airing their thoughts. The IDIs were conducted in locations convenient for the respondents and took approximately an hour on average. A total of 16 FGDs were carried out in the five study areas, with each discussion taking approximately an hour or two. All the sessions were recorded using digital recorders, and the research team, together with the key informants, held daily debriefing sessions. A debriefing guide was developed to record important concepts and observations. The guide was continuously updated for further interviews. Data Analysis Important findings were collectively analyzed during analysis workshops attended by the research team and data collectors. Data recorded were first transcribed to an analyzable format with the assistance of the ATLAS.ti software to create thematic coding. An inductive approach to theme identification was utilized whereby in-depth discussions of the identified themes preceded coding. Ethical Oversight Ethical approval for this qualitative study was given by the Institutional Review Board of Mekelle University. The Tigray Regional Health Bureau gave written support to each district health office. Written and verbal consent was obtained from all participants. Credibility The research team had all key informant researchers who were holders of MPH degrees conduct the coding and data collection. Ongoing supervision by the research team was maintained throughout data collection, and during the debriefing processes. A total of two analysis workshops were conducted-one midway through data collection for learning purposes and one at the conclusion to review findings. The validation and dissemination workshops were conducted with higher officials, facility directors, and health workers from the study area. Participants shared their observations and information that enriched the findings and skillfully disseminated the results to stakeholders. Results Description of Sample A total of sixteen FGDs were conducted with community representatives: grandfathers, grandmothers, mothers, and fathers of children under two years of age. The composition comprised two groups of grandfathers, one group of grandmothers, ten groups of mothers, and three groups of fathers. Each FGD comprised between six and twelve participants. Participants' age ranged from seventeen to seventy-three years. The highest education attainment among discussants was diploma; however, a significant proportion was illiterate. These were the reported number of children by participants and ranged from a high of eight children to a low of one. Further, forty-six IDIs were conducted with community representatives and health workers. Health workers in this study were nurses, midwives, and health extension workers (HEWs), while community representatives were WDAs, grandfathers, and mothers of LBW or preterm babies who initiated or did not initiate KMC. Precisely, the participants in this study were four nurses, ten midwives, five WDAs, and seven HEWs. These included six grandfathers, three grandmothers, six mothers with preterm babies who did not initiate KMC, and nine mothers who did. The limit for the age of IDI participants was also from seventeen to sixty years. The participants who were health workers had varying lengths of service with a maximum of fourteen years and minimum of seven months. A greater proportion of the health worker participants had degree qualifications. On the contrary, the highest class grade attained by community representative was the tenth class, and almost half of them were unlettered. Regarding the number of offspring, maximum number borne by community representatives is six and half of the mothers reported having one child only. Community Viewpoint about the Care of the Newborn Health Status of a Baby Across these studies, participants defined a healthy baby as one that gains weight, is able to breastfeed properly, remains physically active, sleeps well, and exhibits normal breathing and crying—excessive crying has been taken as indicative of the baby's illness. As one mother from the Semen Health Center in Mekelle City illustrated, "A baby is healthy if he/she can sleep well for more than 12 hours per day." Another mother from Bizet Health Center in the Eastern Zone added that if a baby cries day and night, this might indicate a health problem or that the baby is sick. Type of Care Needed for a Healthy Baby The following are the important practices to ensure newborn health, according to the listed responses: hygienic care-baby bathing, exclusive breastfeeding for six months and supplementary feeding thereafter, thermal care-keeping the newborn warm to avoid cold exposure, initiation of breastfeeding with colostrum immediately after birth, vaccination, follow-up on antenatal care, proper nutrition for the mother, and institutional delivery. A focus group discussant, a mother with children under two years of age from Semen Health Center in Mekelle City, cited that butter should not be an early feeding initiation; it stated, "A newborn baby's gastrointestinal system cannot digest it, and it may create health problems." In an in-depth interview, the grandfather of a newborn from Neksege Health Center explained newborn care by reflecting on how to cultivate plants: "Like a plant, a newborn baby needs proper cultivation; both plants and babies deserve strict care until they grow up properly." Danger Signs Participants listed several danger signs, which create concern by family members. Symptoms of vomiting, diarrhea, respiratory illness, refusal/inability to breastfeed, high fever, tonsillitis, uvulitis, measles/polio, convulsions, abdominal pain/cramps, and excessive bleeding. Excessive bleeding of the circumcision site of the male infants was a concern for one mother participating in the focus groups held at Semen Health Center. Thermal Care and Baby Bath The interviewees kept reiterating that a cold infection may cause respiratory diseases marked by cough, rapid breathing, chest pain, and general body weakness. They reiterated how being wrapped up early enough with more clothes would keep the baby warm, hence preventing such conditions. A father at Guya Health Center in the central zone added that exposure to cold might even cause eye discharge that could eventually cause trachoma. Another mother from the Mekelle Hospital warned of the risk of catching cold, which may develop into pneumonia and result in tuberculosis. All the participants stated that a newborn baby should not be taken out for at least the first week of life and should stay indoors, with all doors and windows closed. A change in practice concerning bathing was mentioned by an interviewed grandmother from Serawat Health Center in Mekelle City: "We now delay bathing until 24 hours after birth in order not to make them cold before attaching the baby to his/her mother for breastfeeding." On the other hand, a grandmother from Alassa in the central zone believed that newborn babies must be given a bath right after birth to clean off the blood. Breastfeeding Most of the respondents realized the importance of early initiation of BF and the benefits of colostrum. They reported that mothers who deliver in health facilities are counseled to start their babies on breast milk as soon as they deliver and should not waste the colostrum. A mother from Bizet in the eastern zone focus group reported, "For my baby, I initiate with the breast milk (colostrum); it should not be anything else like butter or sugar water." Respondents emphasized early initiation ensures newborns receive important nutrients. Mothers whose newborns were unable to suck received breast milk via syringe after it was extracted from the mother. Feeding Practices for Preterm and Low Birth Weight Babies A mother interviewed from Meremeyti in the southern zone gave a traditional belief, saying, "At home, I may give butter as an initiation of feeding." This has been typical for some mothers, more so those who delivered at home, who did not have information on the benefits of colostrum. Many discarded it as undigested by the newborn's stomach. Babies born in the hospital, on the other hand, were more likely to be initiated with formula or cow's milk due to factors such as NICU admissions and documented insufficient milk supply from mothers. They were then introduced to breastfeeding a day later. Other mothers used the fear of transmitting HIV to their baby as another reason for formula-feeding them. A discussant in the focus group, a grandmother from Neksege in the southern zone, exemplified this when she said, "The major concern in our society is that HIV could be transmitted from mother to newborn through breastfeeding." A mother from Guya in the central zone who has children under two years old shared the following past practices: "In the past, if a mother could not produce enough breast milk, the baby was breastfed by another woman's milk—sister, grandmother, relative, or neighbor." Cord Care Practices Accelerating healing through substances applied to the umbilical cord was reportedly important according to mothers. The most used substance applied is butter, though many declared it a harmful traditional practice. One mother in the focus group discussion from Guya in the central zone shared, "I do not apply anything except prescribed medication to the cord; it will dry by itself." Social Factors Influence Family Experiences During Hospitalization The participants reported that social matters, including economic status and domestic responsibilities, play a significant role in parents' participation in the care of the newborns during their hospitalization. Parents, especially mothers, bear the biggest responsibility in child-caring and are stressed by the need to attend to family matters, which can limit the visiting of their children while in hospital. These mothers, due to being at home with other children, worry that the other siblings may fail to go to school and that family provisions, including food and other requirements, will not be provided, thereby presenting psychosocial consequences on members. However, the support from neighbours, grandmothers, and husbands also assists other mothers in caring for the baby during extended hospitalisation. Provision of Care and Health Education All the respondents pointed out that health education on newborn care for mothers comes from health professionals like HEWs, midwives, nurses, and physicians, as well as the WDA and grandmothers. Such practices include colostrum feeding, exclusive breastfeeding, supplementary feeding, keeping the baby warm, methods of bathing, and cord care. In health facilities, decisions pertaining to care of the newborns are usually taken by the health professionals. However, at home, decisions regarding the type of care are often taken by the grandmothers and sometimes husbands. Many respondents acknowledged that mothers are the primary caregivers for newborns, but most often the grandmother or mother-in-law is also highly invested and may take on a prominent role if the mother is a primigravida. Some fathers in urban areas also assume newborn care responsibilities. A participant from the Southern Zone of Adigudom with children under two years stated, "Newborn care decisions are made at home predominantly by the mother because she is taking care of the baby." Another participant reiterated that maternal caregiving practices are also socially accepted within the community. Most of the respondents have the view that modern society confirms yes to the fact that the tendency and nature of this society, itself make parents hurry their children to hospitals for ailments like tonsillitis or uvulitis. All the same, uvulectomy and herbal treatment for tonsillitis are still being performed in villages. Harmful Traditional Practices The informants identified that there are instances, such as babies delivered at home, where feeding starts with sweetened water or honey before breast milk, especially when the mother has a problem secreting milk. Sweetened water or honey stimulates the appetite of such babies. Other mothers asserted that uvulectomy, if traditionally performed and not using medicine, can cure uvulitis. Further, the informants emphasized that generally, circumcision is more successful in males through medical means compared to traditional methods. Health Professionals' Views on Newborn Care Practices 1 . Newborn Care Practices in Health Facilities and at Home by HEWs 1.1 Measurement of Weight Most of the participants, HEWs included, mentioned that weight for all newborns delivered in health facilities is measured routinely as part of the care package. However, a number of nurses and midwives agreed that there are critical situations where newborns may not be weighed immediately-for example, a hypothermic or seriously ill baby may be stabilized before weighing. As one NICU nurse in Adigrat Hospital mentioned, "In such cases, it may be better not to disrupt the care of oxygen and hypothermia to take them out for weight; let the immediate health of the baby come first." Participants reported that HEWs and WDA are an integral part of identifying home births and bringing mothers to the health facility for weight measurement. A midwife in Degua Tembien said, "I do not think babies are weighed at home. They usually come to the health facility even during the fourth stage of labor. Most home births do not remain unweighed." Almost all participants reported that newborns delivered at home are usually not weighed because of the lack of weighing scales. Some participants reported a lack of awareness about the importance of weight measurement both in the community and among health professionals, including HEWs. Although some of the HEWs recognized the importance of home weight measurements, they reported having weighing scales and providing postnatal visits for weighing babies at 24 hours, 3 days, 7 days, and 42 days after delivery. They also stated a monthly growth monitoring schedule in health posts but indicated periods of falling behind. A HEW from Guya Health Center remembered, "There is no baby who is not weighed. All babies are usually weighed. In the past, we mainly checked the umbilical cord and provided Vitamin A, but since we received ICCM training in Mekelle in 2016, we have emphasized weighing more in our home visits." The HEWs also commented that even after home visits, most mothers do not know the weight of their newborns. Approximately 80% of the respondents identified the cut-off point for LBW as less than 2.5 kg and the remaining less than 2.2 kg. Methods used by participants in calibrating weighing scales were determined: almost all midwives and nurses used pre-calibrated weights such as bags of normal saline or one-kilogram stones. Conversely, some midwives and nurses and almost all the HEWs used a zero indicator for the calibration of the scale. 1.2 Other Essential Newborn Care Practices 1.2 Other Essential Newborn cares According to the participants, certain essential newborn care practices are well applied in the health facilities. These included the use of tetracycline eye ointment, vitamin K, skin-to-skin contact, thermal care through swaddling with dry clothes, and provision of hats and socks. Health workers also emphasize the need to teach mothers the concept of thermal care. Advice given is on avoiding bathing the newborn for the first 24 hrs, dressing him/her with thick clothes, frequent breastfeeding and visiting the health facility as soon as danger signs appear. Discharge from health facilities is according to presence or absence of complications. Across the participants, all indicated that healthy newborns are usually discharged after six hours of delivery, provided there are no complications. On the contrary, discharge time can be extended for as long as 24 hours in case a health center is situated in rural areas or where congestion is minimal. For preterm or low birth weight infants or additional maternal and neonatal complications, their discharge guidelines vary. Newborns with KMC may be allowed to stay in the health facility until the baby becomes stable and is able to breastfeed well, or until other medical conditions are well addressed. 2. Current Strategies to Identify Home Births and Care Practices Given at Home after Delivery 2.1 Methods of identifying Home Births: About 70% of deliveries in this region occur in health facilities, which leaves a big gap since 30% of deliveries occur at home. These discrepancies make it difficult to reduce these high neonatal mortality rates of 33 per thousand nationally and 28 per thousand regionally. 3 Description of Networks All participants reported that there is a usual network of WDA members, HEWs, and midwives. In the WDA, each woman is linked with a network of others in her catchment area, amounting to 1-5 other women. WDAs report to HEWs the number of pregnant women identified and may also directly inform midwives about the figures. Mobilizing all pregnant women to deliver in health facilities is the key concern of this network. It is principally during labour that the family of the woman and the WDAs are responsible for contacting either HEWs or arranging transport via ambulance or midwives. As one midwife from Abi-Adi Hospital pointed out, "When a woman delivers at home or when labor has started, the information flows through the established network to the HEWs. For example, a woman who gave birth at home in Kola Tembien may come to our health center with the help of HEWs. They have a strong network." Participants acknowledged that home births occurred because of delays in ambulance services, lack of support from family members, or perceived safety. However, the existing network is promoting post-delivery checkups as well as other care. But, home visits by many mothers are not being carried out for one or another reason such as meetings, training sessions, distance, or failure of reporting either by mother or WDAs. Some participants also noted communication gaps between HEWs, midwives, and WDAs; there are cases when the HEWs learn about home deliveries 2-7 days later. HEWs also mentioned that they may not learn about home births if the mother is from outside their catchment area. A common scenario was illuminated by a HEW from Alassa Kebele: "Pregnant women who live far from their parents continue ANC follow-ups at nearby health posts or facilities but want to deliver at their parents' kebele when they reach term, which is more common among nulliparas, due to better social support. Recently, we have started informing HEWs in that kebele by phone if it is within the same district. However, tracking women outside our kebele remains challenging." Participants argued that the involvement of the strategy in making the findings should continue as before through the established network, but increased the numbers of HEWs and strengthened the relationships from WDAs and HEWs. Some participants suggested creating awareness in the community about the dangers of home deliveries and training HEWs on thermal care and KMC during implementation at the community level. One midwife at Alassa Health Centre identified a critical problem: "The big problem is the lack of bedrooms in maternity waiting rooms. If this were improved, many mothers would prefer to stay with us after the fourth ANC visit. There is also a lack of food provision at the health centre, and for this reason, many mothers return home. As long as these issues are not improved, home deliveries will continue, making it difficult to identify newborns who are born at home. 2.2 Home-Based Postnatal Care by HEWs Health Extension Workers are also expected to provide postnatal care at home following birth in rural areas. Health Extension Workers ideally conduct home visits in a systematic sequential timing: at 24 hours, 3 days, 7 days, and 42 days postpartum. However, participants indicated that this is inconsistently adhered to due to other commitments like meetings and training sessions. Some HEWs did report that there were times when they did not visit for as long as two weeks. In absence of the HEWs, it is expected that midwives are supposed to cover these responsibilities. However, midwives and nurses working in the hospitals explained that they are not responsible for providing PNC at home but give advice to mothers during discharge to go back to health facilities for scheduled PNC. The practices most reported to have been conducted by the HEWs in the course of the home visit include monitoring for cord bleeding, weight of the infant, assessment of breastfeeding practices and identification of danger signs in both mother and baby. These activities are crucial in ensuring postpartum women and their newborns remain healthy. 3. Referral System for Newborns 3.1 Reasons for Referral The reasons leading to a referral of newborns from lower to higher health facilities were prematurity and low birth weight, stated in order, problem-feeding, respiratory condition, and birth defects. Other participants from health centers included lack of improvement following KMC care, complications of the umbilical cord, jaundice, sepsis, and persistent vomiting as additional causes for referral. One midwife from Bizet Health Center identified their referral criteria: "If the service is not available here and we think they would be better taken care of elsewhere, we refer them. For example, if a preterm/LBW baby has not improved with KMC and is unable to take expressed milk, we refer the baby to a higher-level hospital for feeding through a nasogastric tube." 3.2 Referral Chains and Bottlenecks in the Newborns Referral System The referral system works both ways: from lower to higher facility level and vice versa. From higher to the lower facility level, referrals mainly serve a follow-up purpose, especially from health centres to health posts HEWs. More than half of the participants mentioned that when a health professional refers a sick newborn, they usually go together with the baby and mother in an ambulance. However, two hospitals reported limitations in routine availability because of a lack of their own vehicles. The nurse from the NICU, Adigrat Hospital, commented, "We use an ambulance from the town administration for referrals when we have a case. This needs improvement; the hospital should have its own ambulance. Sometimes this service is interrupted, and we have to send patients via public transport. This situation is very distressing for mothers and neonates, especially with blood-soaked clothes and family members. Almost all HEWs and some midwives reported using referral slips when referring a newborn. Only two participants reported practicing thermal care and support for breastfeeding during transport to the referral site. Generally, the referral chain would move from HEWs at health posts to health centers (HC) and on to hospitals, or directly from persons to HCs and hospitals. One NICU nurse shared frustrations about the referral system: "Some institutions refer babies with no obvious problems. I doubt whether the workers at the delivery service are trained well. Most health officers and midwives lack skills in offering appropriate breastfeeding counseling; thus, many babies are referred unnecessarily due to inability to suck or early neonatal sepsis. Others come from institutions that refer babies with real problems that need management at a hospital level. Generally, there are serious problems in the referral process." A downward referral system from health centres to HEWs seems to work better compared to the referral system from hospitals to health centres. The midwives and HEWs also reported on the use of green and yellow cards that were provided to the mothers when they are being discharged, linking them to HEWs and the Women Development Army for follow-up and postnatal check-ups. The HEWs also said that sometimes midwives will call them regarding mothers and babies who need follow-up after discharge. Some participants acknowledged that even then, with these cards, some women would remain silent. Participants from both hospitals and health centres also felt a lack of feedback from the hospitals back to the health centres. 4. Health Problems and Recommended Care for Preterm and LBW Babies 4.1 Health Problems Associated with Preterm and LBW Babies This was the most commonly mentioned health problem associated with PTB and LBW babies by many participants. Other common health problems reported included respiratory distress syndrome, hypothermia, and sepsis. A few participants identified complications such as hypoglycemia, pneumonia, malnutrition, jaundice, and general body weakness. 4.2 Knowledge of Health Care Providers on the Care of Preterm and LBW Babies Some key care practices for preterm/LBW infants which the participants mentioned included: breastfeeding for those who can suck, NG tube feeding with expressed milk, KMC, and heaters or incubator care for thermal care. Other participants also mentioned the hygiene to be maintained, including the use of socks, thick towels, and hats to prevent hypothermia, along with frequent checking of the baby's temperature. If mothers are unable to produce milk, formula feeding can also be recommended. A NICU nurse working in Mekelle Hospital explained, "Though the scientific recommendation is breast milk, when the mothers are short of breast milk, they are always obliged to use formula". 4.3 Actual Practice Around the Care of Preterm and LBW Babies Almost all midwives and nurses reported that they were counselling mothers on frequent and exclusive breastfeeding and the importance of KMC. They also talked about the expression of breast milk and its administration to infants through syringes or NG tubes in cases when direct breastfeeding is not possible. Simultaneously, some participants reported the use of formula milk for newborns in cases when mothers have problems with lactation, although they were aware that from a scientific point of view, such practices are not recommended. For thermal care, hats, socks and cotton clothes provided by mothers or the facility were used; though facilities in most instances did not have enough linen for this purpose. Participants reported that preterm and LBW infants also received routine newborn care such as vitamin K and tetracycline eye ointment just like term infants. A midwife from Kasech Health Centre said, "We apply KMC to premature new-borns immediately after delivery and advise the mothers to continue at home." A nurse in the NICU at Adigrat Hospital said, "Here in this department, all the procedures are followed up strictly, and we are well trained and accountable for our practice." A health extension worker at Neksege Health Centre said the following about discharge practices: "Though I might not be aware of all that goes on in the health center, I believe most mothers have knowledge on the importance of skin-to-skin contact and frequent breastfeeding. In cases where mothers frequently breastfeed their babies, babies grow fat and stronger." 5. Challenges Faced by Health Workers in Providing Newborn Care Services Participants were most consistent in their complaint about how very difficult the care of preterm and LBW babies was. This includes the perpetual shortage of basic supplies such as socks, hats, and towels important for the care and thermal stability of these vulnerable newborn babies. These items are recommended to be brought into the health facility by pregnant mothers during ANC visits as part of birth preparedness and complication readiness; however, most mothers usually never heed the advice. Moreover, participants pointed out that many mothers of preterm or LBW babies are often seen to take the advantage by leaving the facility before they meet the KMC discharge criteria, thus posing risks to the health of both mother and child. Added to that, there were infrastructural limitations regarding access to electric power and a shortage of machines for phototherapy treatment of jaundice in newborns. These were further compounded by a lack of community awareness of the kind of care preterm and LBW infants require. A health officer from Bizet Health Center said, "In the past, items like socks, hats, and towels were donated by NGOs to our health center. We teach mothers during ANC that when they come to deliver, it is better to bring these materials, but most of them never listen." Discussion The current review adopts a qualitative approach to examine newborn care practices from the community perspective and that of health care providers. Community Perspective on Newborn Care The findings from the current study reveal an overall optimism in newborn care in this community, especially in the identification of the sick newborn. It was striking to note that congenital anomalies were never mentioned in any of the group discussions. Quantitative studies previously conducted in Ethiopia had documented alarmingly low levels of awareness on newborn danger signs among mothers: only 29.3% listed three or more from a list of eleven signs . 11 Studies done in Mekelle, Tigray, and Arbaminch demonstrated higher awareness, with 50.6% and 40.9% of mothers able to report at least three danger signs. 12,13 Positive approaches to newborn care practices have been reflected in our study's respondents, but not without the continuation of some practices which are harmful, such as the use of butter for early initiation of feeding. However, there has been considerable awareness of the timely initiation of BF and the advantages of colostrum, as well as the concept of exclusive breastfeeding up to six months. However, some mothers, especially the ones who delivered at home, remained ignorant of the benefits of colostrum and used other options like sugar water, honey, or butter for initial feeds. These findings are supported by other studies, which have documented similar misconceptions surrounding early feeding practices. 14 An example is the study from rural Karnataka, India, that reported that castor oil is given traditionally before initiation of breastfeeding, as this is believed to clean the system of the infant and the use of sugar solutions as prelacteal feeds. 15 Lack of close contact also puts the newborn at serious risk of hypothermia, as feeding is made more difficult and heat loss is hastened. 16 While there was limited understanding among respondents of the relationship between cold exposure and its effects, encouraging beliefs about early wrapping and skin-to-skin contact were in evidence. Community experiences reported regarding health facilities reinforce this suggestion. One study in governmental health centers of Addis Ababa found that 68.6% of the mothers believed that warm clothing prevents heat loss in neonates and 50.8% identified skin-to-skin contact as a protective behavior against cold. 14 Generally, although there are positive aspects in community knowledge and practices regarding newborn care, there are significant gaps that surely require selective educational interventions in order to improve maternal awareness and thereby impact newborn health outcomes. Some apply chlorhexidine to the umbilical stump in line with national recommendations for cord care to prevent infection and expedite healing. Mothers in our study knew that application of substances to the cord enhances quicker healing; many mothers mentioned the use of butter. This is further supported by the findings of Callaghan-Koru et al., who stated that 21% of the respondents answered that the cord was treated with butter.12 Another study conducted in Governmental Health Centers in Addis Ababa, Ethiopia, revealed that 10.4% of mothers had the belief that butter should be applied on the stump. 14 However, in a different Indian study, 5.3% of the traditional providers used castor oil to burn the tip of the cord as a method to prevent bleeding and infection, which just goes to prove the regional differences in cord care practices. 15 Indeed, our study further elaborated on the psychosocial factors that contribute to significant parental experiences of facility newborn care: financial constraints and domestic responsibilities, especially when child-rearing responsibilities are borne by mothers. It is in such circumstances that parents may be compelled to leave the facility against medical advice before the newborn's treatment is complete. A study carried out in Pediatric Wards at Al Jahra Hospital in Kuwait noted that 17.5% of neonates were discharged against medical advice, with 31% giving domestic obligations and the inconvenience of hospitalization as their reasons for leaving the hospital early. 17 Results indicate that newborns rely primarily on their mothers for care, although grandmothers and mothers-in-law, particularly for first-time mothers, also provide significant support. Fathers in some urban settings may provide infant care, though the roles of fathers are limited. This agrees with findings in a Ugandan study which mentioned that patriarchal community norms and values hinder male involvement in maternal and child health because males have limited sensitization. 18 Many times, the respondents reported that health education was always received from health professionals like health extension workers, midwives, nurses, and physicians but also the Women Development Army and grandmothers, about issues like colostrum feeding, exclusive breastfeeding, supplementary feeding, keeping the baby warm, bathing, and cord care. Evidence from community-based newborn care projects in India indicates that mobilizing at least a third of pregnant women into participatory learning and action groups is one of the cost-effective ways to address maternal and neonatal survival challenges in resource-poor countries. 7 Healthcare Professionals’ Perspectives to Newborn Care Practices This study emphasizes that weight measurement at birth, though a routine practice in health facilities, experiences delays in most instances where newborns require critical care and active resuscitation. In the case of home births, there is also variability in weighing practices. Some health extension workers use the portable weighing scales meant for postnatal home visits to weigh the infants, while others do not own these weighing scales and hence do not measure weight during the home visits. Others carry the mothers to health facilities for weighing and clinical assessment. Findings from the African Neonatal Sepsis Trial conducted in Democratic Republic of the Congo, Kenya, and Nigeria show that CHWs can identify newborns with illness with reasonable accuracy and weight and refer appropriately. 19,20,21 ENC encompasses a wide approach that involves many important interventions along the continuum of care: from preconception to conception, immediately after birth, and through the postnatal period. Core practices such as early initiation of breastfeeding, skin-to-skin contact, delayed bathing to prevent hypothermia, and appropriate care of the umbilical cord have been enhanced through the promotion of preventive behaviors by home visits. 14 To this end, ENC practices such as wrapping newborns in dry cloth, the use of socks and hats at health facilities, and advice to mothers on how to maintain thermal care, are well practiced according to the participants' reports. Participants also indicated that discharge occurs about six hours after delivery, although this would extend to 24 hours in those cases assessed at rural health centers or non-congested facilities with no complications. Discharge times for mothers of preterm or LBW infants, those on KMC, and mothers and neonates with other complications differ from that mentioned above. A population-based survey conducted in Mekelle City, North Ethiopia, indicated that 81.1% of postnatal mothers reported good ENC practices. 22 Facility births accounted for 72.4% of deliveries in the region3. The remaining 27.6% of births outside health facilities may immensely thwart efforts at reducing the high national and regional neonatal mortality rates standing at 33 and 28 per thousand live births, respectively. 3 Network System Effectiveness in Home Birth Identification and Postnatal Care: The network already established among WDA, HEWs, and midwives has been mentioned as an asset to be utilized in the identification of home births and follow-up visits from referrals to health facilities. However, the present study identifies delays in ambulance services, lack of familial support during delivery, and perceived safety at home as some of the facilitating factors for mothers to choose home delivery. Despite such challenges, the network tries to ensure follow-up care with necessary check-ups among mothers who delivered at home. On the other hand, however, the study points to serious gaps concerning home visits by the HEWs. Factors include meetings, training commitments, geographical distance, and a lack of communication from either the mothers or WDAs themselves that hinder timely postnatal visits. In addition, HEWs often receive late notifications regarding home deliveries, especially in cases where mothers come from outside their designated catchment areas. A community-based, collaborative quality improvement initiative to improve postnatal care coverage in rural Ethiopia estimated that 34% of the women notified HEWs during labor or within 48 hours after delivery. Of the women who did so in a timely manner, as many as 94% received PNC. Timely notification to HEWs reportedly occurred more often among mothers whose care provider's mobile number was known to them. 23 In one review, focusing on postnatal care with a specific emphasis on home visitation, only Sri Lanka succeeded in showing high coverage of postnatal home visits sustained over time. Many countries have pursued ambitious schedules for postnatal home visits, but few have achieved anything remotely resembling meaningful coverage that significantly impacts newborn mortality. 24 In our study, HEWs were tasked with providing postnatal care in rural areas. Though they have a schedule for visits to the houses, meetings, trainings, and other logistics interfere with the schedule. The major activities they performed during the home visit they did were cord inspection for bleeding, weight checkup of babies, assessment of breast feeding, and checking danger signs In contrast, in a study in rural Hebei, China, it was also reported that a mere 8% of mothers received a timely postnatal home visit within one week of delivery. Of those who received visits, only 37% were counseled about infant feeding and only 32% about cord care. The study found that personnel shortages and transportation problems were major obstacles to visiting mothers at home. 25 Additionally, studies related to newborn care in Cambodia reported that the midwife often did not provide full breastfeeding advice at the time of delivery and usually discharged women from health centers in less than 24 hours to their homes. 26 These findings point to the imperatives of an improved communication and logistic support in the health network, as prerequisites for better postnatal care coverage and adequate and timely support for mothers and newborns. Newborn Referral System The present investigation examined the reasons for referrals from lower to higher health facilities for newborns and listed preterm and low birth weight infants, breastfeeding difficulties, respiratory distress, and congenital malformations among other common reasons. Other contributory factors from participants attending health centers included no improvement after KMC, complications of the umbilical cord, jaundice, sepsis, and vomiting, reflecting a wider scope of neonatal health problems within our healthcare system. A formative study in newborn care in Cambodia suggested that midwives at the health centres also often reported limited experience and familiarity with the newborn treatment. Many patients, therefore, like to go directly for care at higher-level hospitals when they perceive the condition of their infant to be severe. Alternatively, some families use nearby health centres because of cost-effectiveness and proximity; hence, the complexity of the patient decision on referral patterns. 26 The referral system was supposed to facilitate both upward and downward referrals between lower and higher-level facilities. Notably, the providers typically accompany mothers and infants in the case of referrals using an ambulance; even the routine availability of ambulances had its limitations, though. 27 Currently, the use of a referral slip for newborns has been found to work in most cases; however, there are serious breaks in the continuum of care during transportation related to thermal care and support for breastfeeding. There were also concerns raised on unnecessary upward referrals due to lack of skills at the care providers. A similar study in India on the status of newborn transport showed that most neonatal referrals were either self-organized or poorly managed by referring facilities, with many lacking appropriate pre-referral stabilization and advice on care en route. An alarming finding was that a small percentage of newborns referred were accompanied by skilled attendants or received advice on their care en route. 28 Regarding downward referrals, our study showed that the linkage from health centers to HEWs is more effective than those from hospitals to health centers. Effective telephone communication among HEWs and midwives has contributed much to the successful follow-up care for mothers after discharge. Critical gap exists in referral feedback from hospitals to referring facilities. Pedrana et al. found referral feedback with the SijariEMA system was only 66.2% effective; this again reflects deficiencies in the mechanisms of communication and the provision of feedback at the referral. 29 The results in general show the challenges and opportunities regarding the referral system of newborn care and point out the need for more health provider training, improvement in transport protocols, and most effective communication channels to ensure full newborn care at all levels in the process of referral. Health Problems and Recommended Care for Preterm and Low Birth Weight Babies Our study identified that health workers have a fair level of knowledge regarding the care of preterm/low birth weight infants. However, gaps between knowledge and practice were identified among some providers of services. A study related to ours conducted in the public health facilities of the eastern zone of Tigray identified that 74.65% of health care providers had adequate knowledge on newborn care, and overall, 72.77% demonstrated good newborn care practices. 30 Challenges Faced by Health Workers in the Care of Preterm/LBW Newborns The study found out that health workers faced several challenges while managing the preterm or LBW baby. There was a marked deficiency of socks, hats, and towels while caring for babies. Most mothers of preterm or LBW babies preferred to go home before fulfilling the discharge criteria for KMC. Other reported challenges included no electricity, a lack of adequate phototherapy machines, and limited community awareness on the care of preterm and LBW infants. In this regard, two very important predictors of the newborn care practices among health care providers were: availability of essential materials and type of health facility. 24 More importantly, a KAP assessment on immediate newborn care among health care providers in public health centers in Addis Ababa showed that only 40.4% practice at least half of the recommended standard actions for preterm and LBW infants. 31 Conclusion Improved service delivery at the facility level will require resources and actionable strategies aimed at ensuring high-quality, timely care at health facilities and appropriate home newborn care practices in order to reduce neonatal mortality rates nationally and regionally. Strengthening HEP and integrated health education initiatives would address issues related to home births, postnatal care visits, and harmful traditional practices that affect newborns within the community. Creation of awareness programs both at facilities and community levels regarding birth preparedness, weighing at birth, completion of care at facilities prior to discharge, and correction of misconceptions related to preterm and LBW infants are some of the necessary steps which would go a long way in improving newborn care practices in general. An appropriate referral system with proper referral care, maintenance of the warm chain, and suitable transportation also requires to be instituted. Finally, enhancing the capacity of the providers of care in the recognition of indications for referral will go a long way in the improvement of neonatal outcomes. Declarations Acknowledgements: The Authors thank the Tigray Regional health bureau, the Administration and health workers of the health centers, the health posts, mothers, families and community representatives without whose cooperation this study would not have been possible. Authors contributions THA1 conceived the study. THA1 was the principal investigator, designed the study and drafted the manuscript. THA1, MYH1, AHB1, DSG1, SAB3, AAM3 developed the study instrument, conducted the study, analysed data and assisted with write-up of the manuscript. YBZ2, TAB4 and FAG4 were involved in data collection and interpretation and manuscript preparation. All authors read and approved the final manuscript. The corresponding author certifies that all listed authors meet the authorship criteria and that no others meeting the criteria have been omitted. Availability of Data and Materials: No additional data are available. The qualitative data, individual stories and narratives have been taken in personal settings. Informants were assured of confidentiality for their contribution to the research project and that it would not be shared. Funding: No funder Ethical approval and consent to participate Ethical approval to conduct the assessment was obtained from the Institutional review board of Mekelle University. In addition, support letter from Tigray regional health bureau and permission from medical directors of the respective facilities was obtained. On the other hand, informed consent in writing was obtained from each key informant before actual data collection. The processes were performed as per guidelines of a relevant authority. Data privacy was assured by keeping all data in a secure and safe place throughout the study period. Data access was available to only the researchers for any cross validation or any validation. Consent for publication: Not applicable. Competing interests: This manuscript declares no competing financial interest's declaration from any person or organization, or non-financial competing interests such as political, personal, religious, ideological, academic, intellectual, commercial or any other. Author details: 1 Department of Pediatrics and Child Health, School of Medicine, College of Health Sciences, Mekelle University, Mekelle, Ethiopia. 2 Department of Gynecology and obstetrics, School of Medicine, College of health sciences, Mekelle University, Mekelle, Ethiopia. 3School of public health, College of Health sciences, Mekelle University, Mekelle, Ethiopia. 4Tigray regional health bureau, Mekelle, Ethiopia. THA 1* : [email protected] , MYH: [email protected] ,AHB: [email protected] ,DSG: [email protected] , YBZ: [email protected] , SAB: [email protected] , AAM: [email protected] ,TAB: [email protected] FAG: [email protected] References World Health Organization. Newborns: Improving Survival and Well-Being. Geneva: World Health Organization; 2020. Available from: https://www.who.int/news-room/fact-sheets/detail/newborns-reducing-mortality. Accessed September 10, 2020. World Health Organization. Global Health Observatory (GHO) Data 2017. Geneva: World Health Organization; 2017. Available from: https://www.who.int/data/gho/data/themes/topics/indicator-groups/indicator-groupdetails/GHO/causes-of-child-death. Accessed January 22, 2020. Ethiopian Public Health Institute (EPHI) [Ethiopia] and ICF. 2021. Ethiopia Mini Demographic and Health Survey 2019: Final Report. Rockville, Maryland, USA: EPHI and ICF. Every Preemie—SCALE (Scaling, Catalyzing, Advocating, Learning, and Evidence Driven). Status of Preterm and Low Birth Weight Demographics, Risk Factors and Health System Responsiveness in USAID’s 24 MCH Priority Countries. Washington, DC: Every Preemie—SCALE; 2019. Available from: https://www.everypreemie.org/wp-content/uploads/2019/07/SummaryProfile_7.10.19.pdf. Accessed March 25, 2020. Health Services Insights. Qualitative Assessment of the Quality of Care for Preterm, Low Birth Weight, and Sick Newborns in Ethiopia. 2014;14:1-13. MEDICC Review. July 2011;13(1). Neogi SB, Prost A, Colbourn T, Seward N, Azad K, Coomarasamy A, Copas A, et al. Women’s groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis. Lancet. 2013;381(9879):1736-46. Lassi ZS, Haider BA, Bhutta ZA. Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes. Cochrane Database Syst Rev. 2010;10(11) Gogia S, Ramji S, Gupta P, Gera T, Shah D, Mathew JL, et al. Community based newborn care: a systematic review and meta-analysis of evidence: UNICEF-PHFI series on newborn and child health, India. Indian Pediatr. 2011;48(7):537-46. Kirkwood BR, Manu A, ten Asbroek AH, Soremekun S, Weobong B, Gyan T, et al. Effect of the Newhints home-visits intervention on neonatal mortality rate and care practices in Ghana: a cluster randomised controlled trial. Lancet. 2013;381(9884):2184-92. Callaghan-Koru JA, Tadesse G, Deyessa N, et al. Discharge against medical advice among children admitted into pediatric wards at Al Jahra Hospital, Kuwait. BMC Pediatr. 2013;13:198. Awareness and associated factors towards neonatal danger signs among mothers attending public health institutions of Mekelle city, Tigray, Ethiopia. J Child Adolesc Behav. 2015;3:144. BioMed Research International. Community health workers: A crucial role in newborn health care and survival. Hindawi; 2019. Article ID 9180314. Available from: https://doi.org/10.1155/2019/9180314. Advances in Public Health. Health care quality improvement in low-resource settings. Hindawi; 2018. Article ID 8921818. Available from: https://doi.org/10.1155/2018/8921818. BMC Pregnancy Childbirth. Postnatal care with a focus on home visitation. 2009;9:20. World Health Organization. WHO/FHE/MSM/93.2. Abd El Malek V, Alexander S, Al Anezi F. Discharge against medical advice among children admitted into pediatric wards at Al Jahra Hospital, Kuwait. Available from: https://www.examplelink.com. Muheirwe N, Nuhu N. Community health interventions for neonatal care in Ethiopia. BMC Public Health. 2019;19:1048. Available from: https://doi.org/10.1186/s12889-019-7371-3. AFRINEST Group. Simplified regimens for management of neonates and young infants with severe infection when hospital admission is not possible. Pediatr Infect Dis J. 2013;32. PMID: 23945572. AFRINEST Group. Treatment of fast breathing in neonates and young infants with oral amoxicillin compared with penicillin–gentamicin combination. Pediatr Infect Dis J. 2013;32. PMID: 23945574. Community health workers: A crucial role in newborn health care and survival. J Glob Health. 2014;4(2):020302. Available from: https://doi.org/10.7189/jogh.04.020302. Berhea TA, Belachew AB, Abreha GF. Knowledge and practice of Essential Newborn Care among postnatal mothers in Mekelle City, North Ethiopia: A population-based survey. PLoS ONE. 2018;13(8). Available from: https://doi.org/10.1371/journal.pone.0202542. Journal of Midwifery & Women's Health. Volume 59, Supplement 1. January/February 2014. Hodgins S, McPherson R, Kerber K. Postnatal care, with a focus on home visitation: a design decision-aid for policymakers and program managers. Chen et al. Postnatal care and home visitation: A review. BioMed Central; 2014. Available from: http://creativecommons.org/licenses/by/2.0. Healthcare. 2016;4:94. Available from: https://doi.org/10.3390/healthcare4040094. Buch P, Mankad M, et al. Status of newborn transport. J Pharm Biomed Sci. 2016;16(16):4. Buch PM, Singh S, Patel R, et al. Status of newborn transport in periphery and risk factors of neonatal mortality among referred newborns. J Pharm Biomed Sci. 2012;16(9):1-6. Pedrana E, et al. Assessing the effect of the Expanding Maternal and Neonatal Survival program on improving stabilization and referral for maternal and newborn complications in Indonesia. Int J Gynecol Obstet. 2019;144(Suppl. 1):30–4. DOI: 10.1002/ijgo.12733. Berhe T, et al. Effectiveness of newborn care interventions in Ethiopia. BMC Pediatr. 2017; 17:157. Available from: https://doi.org/10.1186/s12887-017-0915-8. Ethiopia Journal of Pediatrics and Child Health. 2011;7(7) Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 3 posted You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3132020","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":350647644,"identity":"1d26ab4e-0358-4b77-b7d1-cb6c3cdcf272","order_by":0,"name":"Tedros Hailu Abay","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAy0lEQVRIiWNgGAWjYHACAyA+wMDG3sDATJR6HrgWngOkamGQSCBSiz1787YPHxjuyPNJvjH8XFBhw8Df3p2A3xaeY8UzZzA8M2yTzjGWnnEmjUHizNkN+LVI5Bgz8zAcZgRqMZDmbTvMYCCRS0CL/BuwFvs2yTPGv4nTIsED1pLYJsFjRqQtZ9KKGWcwHE5u40krswbyeAj6hb398GaGDwyHbecDGbd5Kmzk+Nt78WsBA8Z/IJLDAGwtYeVIFj4gRfUoGAWjYBSMIAAATHc+zIC1w5cAAAAASUVORK5CYII=","orcid":"","institution":"Mekelle University","correspondingAuthor":true,"prefix":"","firstName":"Tedros","middleName":"Hailu","lastName":"Abay","suffix":""},{"id":350647645,"identity":"4e8d4158-6fcd-4d5e-ab62-4c6fd95cc8b4","order_by":1,"name":"Marta Yemane Hadush","email":"","orcid":"","institution":"Mekelle University","correspondingAuthor":false,"prefix":"","firstName":"Marta","middleName":"Yemane","lastName":"Hadush","suffix":""},{"id":350647646,"identity":"4a6ef603-7715-45b6-acd3-5e4586b55777","order_by":2,"name":"Amanuel Hadgu Berhe","email":"","orcid":"","institution":"Mekelle University","correspondingAuthor":false,"prefix":"","firstName":"Amanuel","middleName":"Hadgu","lastName":"Berhe","suffix":""},{"id":350647647,"identity":"b4418f73-d5c0-482d-b110-273b4d043b4e","order_by":3,"name":"Dawit Seyoum Gebremariam","email":"","orcid":"","institution":"Mekelle University","correspondingAuthor":false,"prefix":"","firstName":"Dawit","middleName":"Seyoum","lastName":"Gebremariam","suffix":""},{"id":350647648,"identity":"d441a2a7-aff8-488f-8688-919f47062a4c","order_by":4,"name":"Yibrah Berhe Zelelew","email":"","orcid":"","institution":"Mekelle University","correspondingAuthor":false,"prefix":"","firstName":"Yibrah","middleName":"Berhe","lastName":"Zelelew","suffix":""},{"id":350647649,"identity":"75326bba-55ee-4c80-9090-b6187cc5df4b","order_by":5,"name":"Selemawit Asfaw Beyene","email":"","orcid":"","institution":"Mekelle University","correspondingAuthor":false,"prefix":"","firstName":"Selemawit","middleName":"Asfaw","lastName":"Beyene","suffix":""},{"id":350647650,"identity":"2b065c2b-6a7f-4a67-b851-00db5eca9ca9","order_by":6,"name":"Araya Abraha Medhanyie","email":"","orcid":"","institution":"Mekelle University","correspondingAuthor":false,"prefix":"","firstName":"Araya","middleName":"Abraha","lastName":"Medhanyie","suffix":""},{"id":350647651,"identity":"389be2d5-aadd-4216-8361-c49768e681cd","order_by":7,"name":"Fisseha Ashebir Gebregziabher","email":"","orcid":"","institution":"Tigray regional health bureau","correspondingAuthor":false,"prefix":"","firstName":"Fisseha","middleName":"Ashebir","lastName":"Gebregziabher","suffix":""},{"id":350647652,"identity":"83947947-2a14-49ba-9844-df0c76819a4d","order_by":8,"name":"Tirhas Asmelash Berhe","email":"","orcid":"","institution":"Tigray regional health bureau","correspondingAuthor":false,"prefix":"","firstName":"Tirhas","middleName":"Asmelash","lastName":"Berhe","suffix":""}],"badges":[],"createdAt":"2023-07-02 04:44:11","currentVersionCode":3,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-3132020/v3","doiUrl":"https://doi.org/10.21203/rs.3.rs-3132020/v3","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":64407555,"identity":"bc9aad00-21bd-41a0-b2e3-6a81589fb08e","added_by":"auto","created_at":"2024-09-12 18:09:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":738901,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3132020/v3/e0aeda61-df76-4c72-843d-bb1b70b7ad6e.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eNewborn care practices at home and health facilities in Tigray, Ethiopia: a qualitative assessment\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eThe neonatal period remains the most vulnerable period for child survival. Deaths among newborns accounted for almost half of all deaths among under-five children, with an estimated 2.4 million newborn deaths worldwide in 2019.\u003csup\u003e1\u003c/sup\u003e The major causes include intrapartum-related events, complications from preterm birth, sepsis and meningitis, and congenital problems.\u003csup\u003e2\u003c/sup\u003e Four-fifths of the newborn deaths occur in sub-Saharan Africa and Southern Asia,\u003csup\u003e4\u003c/sup\u003e while the estimated neonatal mortality rate is 33 deaths per 1,000 live births in Ethiopia.\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eIndeed, most preterm babies have the possibility of survival if evidence-based care is provided in a cost-effective way without necessarily having to require ICU support.\u003csup\u003e5\u003c/sup\u003e Quality postnatal interventions at healthcare facilities and appropriate basic home care can improve outcomes dramatically in such newborns.\u003c/p\u003e\n\u003cp\u003eFacility-based newborn care has been ensured through the provision of NICUs in hospitals by the Ministry of Health in Ethiopia. In Ethiopia, there is the Health Extension Program through which, a cadre of trained Health Extension Workers and Women Development Armies/Groups, there is an intention to make contact with the community through home visits. The HEP is thus among the most innovative community-based health initiatives that have been in operation since 2004/2005.\u003csup\u003e6\u003c/sup\u003e HEWs also contribute to maternal and newborn care through antenatal follow-ups, postnatal visits, making connections with WDAs who facilitate the contacts between mothers and HEWs.\u003c/p\u003e\n\u003cp\u003eA meta-analysis of the community-based intervention studies up to 2010 showed reductions in stillbirths, neonatal, and perinatal mortality rates. It also documented increased referrals to health facilities due to pregnancy complications and early initiation of breastfeeding, thus proving this model of care significantly affected early neonatal mortality.\u003csup\u003e7,8\u003c/sup\u003e It was expressed in another review that the visits during the early postpartum period within 48 hours led to improved results.\u003csup\u003e9\u003c/sup\u003e Proof-of-concept studies reported similarly and estimated a 45% reduction in neonatal mortality associated with these interventions.\u003csup\u003e10\u003c/sup\u003e These studies, therefore, affirm that the community-based HEP coupled with strengthened collaboration between HEWs and WDAs must be promoted to improve newborn survival.\u003c/p\u003e"},{"header":"Methodology and Study Design","content":"\u003cp\u003eA qualitative assessment was carried out in five zones of Tigray, one of Ethiopia\u0026apos;s nine regional states, between the months of March and April 2017. The selected zones included Southern, Southeastern, Eastern, Central, and Mekelle. The total number of zones in Tigray is seven. The qualitative approach was employed in data collection to capture in detail how and why newborn care practices influence neonatal survival.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe following methods were used in the collection of data:\u003c/p\u003e\n\u003cp\u003e1. Fifteen in-depth interviews with mothers of infants born in the last one month, 11 community health workers including health extension workers and members of women development groups, and 11 health facility workers including nurses and midwives.\u003c/p\u003e\n\u003cp\u003e2. Three in-depth interviews and one focus group discussion with grandmothers.\u003c/p\u003e\n\u003cp\u003e3. Six in-depth interviews and two focus group discussions with grandfathers of under-two children.\u003c/p\u003e\n\u003cp\u003eParticipants were randomly selected based on being a parent or grandparent to children under the age of two years to avoid recall bias.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe present qualitative study was conducted in five zones of the Tigray region, northwest part of Ethiopia. The region has a projected population of 5,055,999 and a neonatal mortality rate of 28 per 1,000 live births.\u003csup\u003e3\u003c/sup\u003e The socio-demographic characteristics of the study area are defined in Table 1.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003cstrong\u003eTable: 1\u0026nbsp;\u003c/strong\u003eSocio-demographic characteristics of Tigray, 2019\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"95%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.974704890387855%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics of the study Region\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.025295109612145%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eThe Region (Tigray)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.974704890387855%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDemographic indicators\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.025295109612145%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.974704890387855%\" valign=\"top\"\u003e\n \u003cp\u003ePopulation, No.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.025295109612145%\" valign=\"top\"\u003e\n \u003cp\u003e5,055,999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.974704890387855%\" valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.025295109612145%\" valign=\"top\"\u003e\n \u003cp\u003e49.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.974704890387855%\" valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.025295109612145%\" valign=\"top\"\u003e\n \u003cp\u003e50.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.974704890387855%\" valign=\"top\"\u003e\n \u003cp\u003eNeonatal mortality, No. per 1,000\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;live births)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.025295109612145%\" valign=\"top\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.974704890387855%\" valign=\"top\"\u003e\n \u003cp\u003eFacility Birth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.025295109612145%\" valign=\"top\"\u003e\n \u003cp\u003e72.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.974704890387855%\" valign=\"top\"\u003e\n \u003cp\u003ePercentage of women with a postnatal\u0026nbsp;\u003c/p\u003e\n \u003cp\u003echeck during the first 2 days after birth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.025295109612145%\" valign=\"top\"\u003e\n \u003cp\u003e62.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.974704890387855%\" valign=\"top\"\u003e\n \u003cp\u003eprimary health care coverage\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.025295109612145%\" valign=\"top\"\u003e\n \u003cp\u003e96%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Mini EDHS 2019 and National 2015/16 census projection\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe present qualitative study embraced a participatory approach whereby two major methods of data collection were employed: focus group discussions and in-depth interviews.\u003c/p\u003e\n\u003cp\u003eSampling and Sample Size\u003c/p\u003e\n\u003cp\u003eThe Tigray region is sub-divided into seven zones, including South, Southeastern, Eastern, Central, Mekelle, Western, and Northwestern. Of these, supported by the Tigray Regional Health Bureau, five were randomly selected for focus group discussions and in-depth interviews, as illustrated in Table 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e: The Five zones, districts and health facilities of the region included in this study.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"618\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.184466019417474%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eZones\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.980582524271846%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eWereda (District)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.83495145631068%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth facility\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.184466019417474%\" valign=\"top\"\u003e\n \u003cp\u003eSouth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.980582524271846%\" valign=\"top\"\u003e\n \u003cp\u003eMaichew, \u0026nbsp;\u003c/p\u003e\n \u003cp\u003eEndamehoni, Nikaah\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.83495145631068%\" valign=\"top\"\u003e\n \u003cp\u003eMaichew lemlem Karl hospital,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNeksege Health Center\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.184466019417474%\" valign=\"top\"\u003e\n \u003cp\u003eSouth\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eeastern\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.980582524271846%\" valign=\"top\"\u003e\n \u003cp\u003eDegua temben,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAlasa, Arebay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.83495145631068%\" valign=\"top\"\u003e\n \u003cp\u003eHagereselam primary hospital,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAlasa Health Center\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.184466019417474%\" valign=\"top\"\u003e\n \u003cp\u003eEastern\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.980582524271846%\" valign=\"top\"\u003e\n \u003cp\u003eAdigrat,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eGantaafeshum, Kitagedeba\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.83495145631068%\" valign=\"top\"\u003e\n \u003cp\u003eAdigrat hospital,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBizet Health Center\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.184466019417474%\" valign=\"top\"\u003e\n \u003cp\u003eCenteral\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.980582524271846%\" valign=\"top\"\u003e\n \u003cp\u003eAbi-adi, Guya\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.83495145631068%\" valign=\"top\"\u003e\n \u003cp\u003eAbi-adi hospital,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eGuya Health Center\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.184466019417474%\" valign=\"top\"\u003e\n \u003cp\u003eMekelle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.980582524271846%\" valign=\"top\"\u003e\n \u003cp\u003eMekelle, Serawat\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.83495145631068%\" valign=\"top\"\u003e\n \u003cp\u003eAyder Referral Hospital,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSerawat Health Center\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; The 1991, Zonal and District assignments of Tigray region \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe staff for the interviews was selected in advance of data collection from a subsample of health facilities across each tier of the public health care system in the zones of interest, including HPs and HCs. In total, the study carried out 16 focus group discussions and 46 in-depth interviews. Selection of the locations considered various local characteristics including urban, semi-urban, and rural, while considering they were within 150 km from Mekelle, the capital city of Tigray.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo this regard, in-depth interviews were conducted with 11 community health workers including health extension workers and members of women\u0026apos;s development groups, 11 health workers including nurses and midwives, and 15 mothers whose infants were born within the last month. FGDs were conducted with mothers and fathers of children aged less than two years with 6 to 12 participants in each group. A total of three IDIs and one FGD were conducted with grandmothers, and six IDIs and two FGDs involved grandfathers of children aged less than two years old. Prior to the study, the health directors had provided detailed information on the potential participants. Parents and grandparents participating were selected in order to make sure of recent recall and reduce bias.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection Method\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research team developed a comprehensive data collection instrument with the aim of eliciting in-depth information from the community and health facilities regarding practices, beliefs, and norms related to newborn care. Nine data collectors, all holding an MPH degree, were trained on qualitative research methods, as well as harmonizing their views with those of the research team, composed of professionals from pediatrics and public health, and experts from the Tigray Regional Health Bureau.\u003c/p\u003e\n\u003cp\u003eFGDs were conducted using participatory methods with open-ended questions that allowed free interaction among participants in airing their thoughts. The IDIs were conducted in locations convenient for the respondents and took approximately an hour on average. A total of 16 FGDs were carried out in the five study areas, with each discussion taking approximately an hour or two. All the sessions were recorded using digital recorders, and the research team, together with the key informants, held daily debriefing sessions. A debriefing guide was developed to record important concepts and observations. The guide was continuously updated for further interviews.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eImportant findings were collectively analyzed during analysis workshops attended by the research team and data collectors. Data recorded were first transcribed to an analyzable format with the assistance of the ATLAS.ti software to create thematic coding. An inductive approach to theme identification was utilized whereby in-depth discussions of the identified themes preceded coding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Oversight\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this qualitative study was given by the Institutional Review Board of Mekelle University. The Tigray Regional Health Bureau gave written support to each district health office. Written and verbal consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCredibility\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research team had all key informant researchers who were holders of MPH degrees conduct the coding and data collection. Ongoing supervision by the research team was maintained throughout data collection, and during the debriefing processes. A total of two analysis workshops were conducted-one midway through data collection for learning purposes and one at the conclusion to review findings.\u003c/p\u003e\n\u003cp\u003eThe validation and dissemination workshops were conducted with higher officials, facility directors, and health workers from the study area. Participants shared their observations and information that enriched the findings and skillfully disseminated the results to stakeholders.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eDescription of Sample\u003c/p\u003e\n\u003cp\u003eA total of sixteen FGDs were conducted with community representatives: grandfathers, grandmothers, mothers, and fathers of children under two years of age. The composition comprised two groups of grandfathers, one group of grandmothers, ten groups of mothers, and three groups of fathers. Each FGD comprised between six and twelve participants. Participants\u0026apos; age ranged from seventeen to seventy-three years. The highest education attainment among discussants was diploma; however, a significant proportion was illiterate. These were the reported number of children by participants and ranged from a high of eight children to a low of one.\u003c/p\u003e\n\u003cp\u003eFurther, forty-six IDIs were conducted with community representatives and health workers. Health workers in this study were nurses, midwives, and health extension workers (HEWs), while community representatives were WDAs, grandfathers, and mothers of LBW or preterm babies who initiated or did not initiate KMC. Precisely, the participants in this study were four nurses, ten midwives, five WDAs, and seven HEWs. These included six grandfathers, three grandmothers, six mothers with preterm babies who did not initiate KMC, and nine mothers who did.\u003c/p\u003e\n\u003cp\u003eThe limit for the age of IDI participants was also from seventeen to sixty years. The participants who were health workers had varying lengths of service with a maximum of fourteen years and minimum of seven months. A greater proportion of the health worker participants had degree qualifications. On the contrary, the highest class grade attained by community representative was the tenth class, and almost half of them were unlettered. Regarding the number of offspring, maximum number borne by community representatives is six and half of the mothers reported having one child only.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCommunity Viewpoint about the Care of the Newborn\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHealth Status of a Baby\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAcross these studies, participants defined a healthy baby as one that gains weight, is able to breastfeed properly, remains physically active, sleeps well, and exhibits normal breathing and crying—excessive crying has been taken as indicative of the baby\u0026apos;s illness.\u003c/p\u003e\n\u003cp\u003eAs one mother from the Semen Health Center in Mekelle City illustrated, \u0026quot;A baby is healthy if he/she can sleep well for more than 12 hours per day.\u0026quot; Another mother from Bizet Health Center in the Eastern Zone added that if a baby cries day and night, this might indicate a health problem or that the baby is sick.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eType of Care Needed for a Healthy Baby\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe following are the important practices to ensure newborn health, according to the listed responses: hygienic care-baby bathing, exclusive breastfeeding for six months and supplementary feeding thereafter, thermal care-keeping the newborn warm to avoid cold exposure, initiation of breastfeeding with colostrum immediately after birth, vaccination, follow-up on antenatal care, proper nutrition for the mother, and institutional delivery. A focus group discussant, a mother with children under two years of age from Semen Health Center in Mekelle City, cited that butter should not be an early feeding initiation; it stated, \u0026quot;A newborn baby\u0026apos;s gastrointestinal system cannot digest it, and it may create health problems.\u0026quot;\u003c/p\u003e\n\u003cp\u003eIn an in-depth interview, the grandfather of a newborn from Neksege Health Center explained newborn care by reflecting on how to cultivate plants: \u0026quot;Like a plant, a newborn baby needs proper cultivation; both plants and babies deserve strict care until they grow up properly.\u0026quot;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDanger Signs\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants listed several danger signs, which create concern by family members. Symptoms of vomiting, diarrhea, respiratory illness, refusal/inability to breastfeed, high fever, tonsillitis, uvulitis, measles/polio, convulsions, abdominal pain/cramps, and excessive bleeding. Excessive bleeding of the circumcision site of the male infants was a concern for one mother participating in the focus groups held at Semen Health Center.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eThermal Care and Baby Bath\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe interviewees kept reiterating that a cold infection may cause respiratory diseases marked by cough, rapid breathing, chest pain, and general body weakness. They reiterated how being wrapped up early enough with more clothes would keep the baby warm, hence preventing such conditions. A father at Guya Health Center in the central zone added that exposure to cold might even cause eye discharge that could eventually cause trachoma. Another mother from the Mekelle Hospital warned of the risk of catching cold, which may develop into pneumonia and result in tuberculosis.\u003c/p\u003e\n\u003cp\u003eAll the participants stated that a newborn baby should not be taken out for at least the first week of life and should stay indoors, with all doors and windows closed. A change in practice concerning bathing was mentioned by an interviewed grandmother from Serawat Health Center in Mekelle City: \u0026quot;We now delay bathing until 24 hours after birth in order not to make them cold before attaching the baby to his/her mother for breastfeeding.\u0026quot; On the other hand, a grandmother from Alassa in the central zone believed that newborn babies must be given a bath right after birth to clean off the blood.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eBreastfeeding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost of the respondents realized the importance of early initiation of BF and the benefits of colostrum. They reported that mothers who deliver in health facilities are counseled to start their babies on breast milk as soon as they deliver and should not waste the colostrum. A mother from Bizet in the eastern zone focus group reported, \u0026quot;For my baby, I initiate with the breast milk (colostrum); it should not be anything else like butter or sugar water.\u0026quot; Respondents emphasized early initiation ensures newborns receive important nutrients. Mothers whose newborns were unable to suck received breast milk via syringe after it was extracted from the mother.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFeeding Practices for Preterm and Low Birth Weight Babies\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA mother interviewed from Meremeyti in the southern zone gave a traditional belief, saying, \u0026quot;At home, I may give butter as an initiation of feeding.\u0026quot; This has been typical for some mothers, more so those who delivered at home, who did not have information on the benefits of colostrum. Many discarded it as undigested by the newborn\u0026apos;s stomach. Babies born in the hospital, on the other hand, were more likely to be initiated with formula or cow\u0026apos;s milk due to factors such as NICU admissions and documented insufficient milk supply from mothers. They were then introduced to breastfeeding a day later. Other mothers used the fear of transmitting HIV to their baby as another reason for formula-feeding them. A discussant in the focus group, a grandmother from Neksege in the southern zone, exemplified this when she said, \u0026quot;The major concern in our society is that HIV could be transmitted from mother to newborn through breastfeeding.\u0026quot;\u003c/p\u003e\n\u003cp\u003eA mother from Guya in the central zone who has children under two years old shared the following past practices: \u0026quot;In the past, if a mother could not produce enough breast milk, the baby was breastfed by another woman\u0026apos;s milk—sister, grandmother, relative, or neighbor.\u0026quot;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCord Care Practices\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccelerating healing through substances applied to the umbilical cord was reportedly important according to mothers. The most used substance applied is butter, though many declared it a harmful traditional practice. One mother in the focus group discussion from Guya in the central zone shared, \u0026quot;I do not apply anything except prescribed medication to the cord; it will dry by itself.\u0026quot;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSocial Factors Influence Family Experiences During Hospitalization\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe participants reported that social matters, including economic status and domestic responsibilities, play a significant role in parents\u0026apos; participation in the care of the newborns during their hospitalization. Parents, especially mothers, bear the biggest responsibility in child-caring and are stressed by the need to attend to family matters, which can limit the visiting of their children while in hospital. These mothers, due to being at home with other children, worry that the other siblings may fail to go to school and that family provisions, including food and other requirements, will not be provided, thereby presenting psychosocial consequences on members. However, the support from neighbours, grandmothers, and husbands also assists other mothers in caring for the baby during extended hospitalisation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eProvision of Care and Health Education\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the respondents pointed out that health education on newborn care for mothers comes from health professionals like HEWs, midwives, nurses, and physicians, as well as the WDA and grandmothers. Such practices include colostrum feeding, exclusive breastfeeding, supplementary feeding, keeping the baby warm, methods of bathing, and cord care.\u003c/p\u003e\n\u003cp\u003eIn health facilities, decisions pertaining to care of the newborns are usually taken by the health professionals. However, at home, decisions regarding the type of care are often taken by the grandmothers and sometimes husbands. Many respondents acknowledged that mothers are the primary caregivers for newborns, but most often the grandmother or mother-in-law is also highly invested and may take on a prominent role if the mother is a primigravida. Some fathers in urban areas also assume newborn care responsibilities.\u003c/p\u003e\n\u003cp\u003eA participant from the Southern Zone of Adigudom with children under two years stated, \u0026quot;Newborn care decisions are made at home predominantly by the mother because she is taking care of the baby.\u0026quot; Another participant reiterated that maternal caregiving practices are also socially accepted within the community.\u003c/p\u003e\n\u003cp\u003eMost of the respondents have the view that modern society confirms yes to the fact that the tendency and nature of this society, itself make parents hurry their children to hospitals for ailments like tonsillitis or uvulitis. All the same, uvulectomy and herbal treatment for tonsillitis are still being performed in villages.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHarmful Traditional Practices\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe informants identified that there are instances, such as babies delivered at home, where feeding starts with sweetened water or honey before breast milk, especially when the mother has a problem secreting milk. Sweetened water or honey stimulates the appetite of such babies. Other mothers asserted that uvulectomy, if traditionally performed and not using medicine, can cure uvulitis. Further, the informants emphasized that generally, circumcision is more successful in males through medical means compared to traditional methods.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHealth Professionals\u0026apos; Views on Newborn Care Practices\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1\u003cem\u003e. Newborn Care Practices in Health Facilities and at Home by HEWs\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1.1 Measurement of Weight\u003c/p\u003e\n\u003cp\u003eMost of the participants, HEWs included, mentioned that weight for all newborns delivered in health facilities is measured routinely as part of the care package. However, a number of nurses and midwives agreed that there are critical situations where newborns may not be weighed immediately-for example, a hypothermic or seriously ill baby may be stabilized before weighing. As one NICU nurse in Adigrat Hospital mentioned, \u0026quot;In such cases, it may be better not to disrupt the care of oxygen and hypothermia to take them out for weight; let the immediate health of the baby come first.\u0026quot;\u003c/p\u003e\n\u003cp\u003eParticipants reported that HEWs and WDA are an integral part of identifying home births and bringing mothers to the health facility for weight measurement. A midwife in Degua Tembien said, \u0026quot;I do not think babies are weighed at home. They usually come to the health facility even during the fourth stage of labor. Most home births do not remain unweighed.\u0026quot;\u003c/p\u003e\n\u003cp\u003eAlmost all participants reported that newborns delivered at home are usually not weighed because of the lack of weighing scales. Some participants reported a lack of awareness about the importance of weight measurement both in the community and among health professionals, including HEWs. Although some of the HEWs recognized the importance of home weight measurements, they reported having weighing scales and providing postnatal visits for weighing babies at 24 hours, 3 days, 7 days, and 42 days after delivery. They also stated a monthly growth monitoring schedule in health posts but indicated periods of falling behind.\u003c/p\u003e\n\u003cp\u003eA HEW from Guya Health Center remembered, \u0026quot;There is no baby who is not weighed. All babies are usually weighed. In the past, we mainly checked the umbilical cord and provided Vitamin A, but since we received ICCM training in Mekelle in 2016, we have emphasized weighing more in our home visits.\u0026quot;\u003c/p\u003e\n\u003cp\u003eThe HEWs also commented that even after home visits, most mothers do not know the weight of their newborns. Approximately 80% of the respondents identified the cut-off point for LBW as less than 2.5 kg and the remaining less than 2.2 kg. Methods used by participants in calibrating weighing scales were determined: almost all midwives and nurses used pre-calibrated weights such as bags of normal saline or one-kilogram stones. Conversely, some midwives and nurses and almost all the HEWs used a zero indicator for the calibration of the scale. 1.2 Other Essential Newborn Care Practices\u003c/p\u003e\n\u003cp\u003e1.2 Other Essential Newborn cares\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAccording to the participants, certain essential newborn care practices are well applied in the health facilities.\u003c/p\u003e\n\u003cp\u003eThese included the use of tetracycline eye ointment, vitamin K, skin-to-skin contact, thermal care through swaddling with dry clothes, and provision of hats and socks. Health workers also emphasize the need to teach mothers the concept of thermal care. Advice given is on avoiding bathing the newborn for the first 24 hrs, dressing him/her with thick clothes, frequent breastfeeding and visiting the health facility as soon as danger signs appear. Discharge from health facilities is according to presence or absence of complications.\u003c/p\u003e\n\u003cp\u003eAcross the participants, all indicated that healthy newborns are usually discharged after six hours of delivery, provided there are no complications. On the contrary, discharge time can be extended for as long as 24 hours in case a health center is situated in rural areas or where congestion is minimal. For preterm or low birth weight infants or additional maternal and neonatal complications, their discharge guidelines vary. Newborns with KMC may be allowed to stay in the health facility until the baby becomes stable and is able to breastfeed well, or until other medical conditions are well addressed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2. Current Strategies to Identify Home Births and Care Practices Given at Home after Delivery\u003c/em\u003e\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.1 Methods of identifying Home Births: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAbout 70% of deliveries in this region occur in health facilities, which leaves a big gap since 30% of deliveries occur at home. These discrepancies make it difficult to reduce these high neonatal mortality rates of 33 per thousand nationally and 28 per thousand regionally.\u003csup\u003e3\u003c/sup\u003e Description of Networks All participants reported that there is a usual network of WDA members, HEWs, and midwives. In the WDA, each woman is linked with a network of others in her catchment area, amounting to 1-5 other women. WDAs report to HEWs the number of pregnant women identified and may also directly inform midwives about the figures. Mobilizing all pregnant women to deliver in health facilities is the key concern of this network.\u003c/p\u003e\n\u003cp\u003eIt is principally during labour that the family of the woman and the WDAs are responsible for contacting either HEWs or arranging transport via ambulance or midwives. As one midwife from Abi-Adi Hospital pointed out, \u0026quot;When a woman delivers at home or when labor has started, the information flows through the established network to the HEWs. For example, a woman who gave birth at home in Kola Tembien may come to our health center with the help of HEWs. They have a strong network.\u0026quot; Participants acknowledged that home births occurred because of delays in ambulance services, lack of support from family members, or perceived safety.\u003c/p\u003e\n\u003cp\u003eHowever, the existing network is promoting post-delivery checkups as well as other care. But, home visits by many mothers are not being carried out for one or another reason such as meetings, training sessions, distance, or failure of reporting either by mother or WDAs. Some participants also noted communication gaps between HEWs, midwives, and WDAs; there are cases when the HEWs learn about home deliveries 2-7 days later. HEWs also mentioned that they may not learn about home births if the mother is from outside their catchment area. A common scenario was illuminated by a HEW from Alassa Kebele: \u0026quot;Pregnant women who live far from their parents continue ANC follow-ups at nearby health posts or facilities but want to deliver at their parents\u0026apos; kebele when they reach term, which is more common among nulliparas, due to better social support. Recently, we have started informing HEWs in that kebele by phone if it is within the same district. However, tracking women outside our kebele remains challenging.\u0026quot;\u003c/p\u003e\n\u003cp\u003eParticipants argued that the involvement of the strategy in making the findings should continue as before through the established network, but increased the numbers of HEWs and strengthened the relationships from WDAs and HEWs. Some participants suggested creating awareness in the community about the dangers of home deliveries and training HEWs on thermal care and KMC during implementation at the community level.\u003c/p\u003e\n\u003cp\u003eOne midwife at Alassa Health Centre identified a critical problem: \u0026quot;The big problem is the lack of bedrooms in maternity waiting rooms. If this were improved, many mothers would prefer to stay with us after the fourth ANC visit. There is also a lack of food provision at the health centre, and for this reason, many mothers return home. As long as these issues are not improved, home deliveries will continue, making it difficult to identify newborns who are born at home.\u003c/p\u003e\n\u003cp\u003e2.2 Home-Based Postnatal Care by HEWs\u003c/p\u003e\n\u003cp\u003eHealth Extension Workers are also expected to provide postnatal care at home following birth in rural areas. Health Extension Workers ideally conduct home visits in a systematic sequential timing: at 24 hours, 3 days, 7 days, and 42 days postpartum. However, participants indicated that this is inconsistently adhered to due to other commitments like meetings and training sessions. Some HEWs did report that there were times when they did not visit for as long as two weeks.\u003c/p\u003e\n\u003cp\u003eIn absence of the HEWs, it is expected that midwives are supposed to cover these responsibilities. However, midwives and nurses working in the hospitals explained that they are not responsible for providing PNC at home but give advice to mothers during discharge to go back to health facilities for scheduled PNC.\u003c/p\u003e\n\u003cp\u003eThe practices most reported to have been conducted by the HEWs in the course of the home visit include monitoring for cord bleeding, weight of the infant, assessment of breastfeeding practices and identification of danger signs in both mother and baby. These activities are crucial in ensuring postpartum women and their newborns remain healthy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3. Referral System for Newborns\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e3.1 Reasons for Referral\u003c/p\u003e\n\u003cp\u003eThe reasons leading to a referral of newborns from lower to higher health facilities were prematurity and low birth weight, stated in order, problem-feeding, respiratory condition, and birth defects. Other participants from health centers included lack of improvement following KMC care, complications of the umbilical cord, jaundice, sepsis, and persistent vomiting as additional causes for referral.\u003c/p\u003e\n\u003cp\u003eOne midwife from Bizet Health Center identified their referral criteria: \u0026quot;If the service is not available here and we think they would be better taken care of elsewhere, we refer them. For example, if a preterm/LBW baby has not improved with KMC and is unable to take expressed milk, we refer the baby to a higher-level hospital for feeding through a nasogastric tube.\u0026quot;\u003c/p\u003e\n\u003cp\u003e3.2 Referral Chains and Bottlenecks in the Newborns Referral System\u003c/p\u003e\n\u003cp\u003eThe referral system works both ways: from lower to higher facility level and vice versa. From higher to the lower facility level, referrals mainly serve a follow-up purpose, especially from health centres to health posts HEWs. More than half of the participants mentioned that when a health professional refers a sick newborn, they usually go together with the baby and mother in an ambulance. However, two hospitals reported limitations in routine availability because of a lack of their own vehicles. The nurse from the NICU, Adigrat Hospital, commented, \u0026quot;We use an ambulance from the town administration for referrals when we have a case. This needs improvement; the hospital should have its own ambulance. Sometimes this service is interrupted, and we have to send patients via public transport. This situation is very distressing for mothers and neonates, especially with blood-soaked clothes and family members.\u003c/p\u003e\n\u003cp\u003eAlmost all HEWs and some midwives reported using referral slips when referring a newborn. Only two participants reported practicing thermal care and support for breastfeeding during transport to the referral site. Generally, the referral chain would move from HEWs at health posts to health centers (HC) and on to hospitals, or directly from persons to HCs and hospitals. One NICU nurse shared frustrations about the referral system: \u0026quot;Some institutions refer babies with no obvious problems. I doubt whether the workers at the delivery service are trained well. Most health officers and midwives lack skills in offering appropriate breastfeeding counseling; thus, many babies are referred unnecessarily due to inability to suck or early neonatal sepsis. Others come from institutions that refer babies with real problems that need management at a hospital level. Generally, there are serious problems in the referral process.\u0026quot;\u003c/p\u003e\n\u003cp\u003eA downward referral system from health centres to HEWs seems to work better compared to the referral system from hospitals to health centres. The midwives and HEWs also reported on the use of green and yellow cards that were provided to the mothers when they are being discharged, linking them to HEWs and the Women Development Army for follow-up and postnatal check-ups. The HEWs also said that sometimes midwives will call them regarding mothers and babies who need follow-up after discharge. Some participants acknowledged that even then, with these cards, some women would remain silent. Participants from both hospitals and health centres also felt a lack of feedback from the hospitals back to the health centres.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e4. Health Problems and Recommended Care for Preterm and LBW Babies\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e4.1 Health Problems Associated with Preterm and LBW Babies\u003c/p\u003e\n\u003cp\u003eThis was the most commonly mentioned health problem associated with PTB and LBW babies by many participants. Other common health problems reported included respiratory distress syndrome, hypothermia, and sepsis. A few participants identified complications such as hypoglycemia, pneumonia, malnutrition, jaundice, and general body weakness.\u003c/p\u003e\n\u003cp\u003e4.2 Knowledge of Health Care Providers on the Care of Preterm and LBW Babies Some key care practices for preterm/LBW infants which the participants mentioned included: breastfeeding for those who can suck, NG tube feeding with expressed milk, KMC, and heaters or incubator care for thermal care. Other participants also mentioned the hygiene to be maintained, including the use of socks, thick towels, and hats to prevent hypothermia, along with frequent checking of the baby\u0026apos;s temperature. If mothers are unable to produce milk, formula feeding can also be recommended. A NICU nurse working in Mekelle Hospital explained, \u0026quot;Though the scientific recommendation is breast milk, when the mothers are short of breast milk, they are always obliged to use formula\u0026quot;.\u003c/p\u003e\n\u003cp\u003e4.3 Actual Practice Around the Care of Preterm and LBW Babies\u003c/p\u003e\n\u003cp\u003eAlmost all midwives and nurses reported that they were counselling mothers on frequent and exclusive breastfeeding and the importance of KMC. They also talked about the expression of breast milk and its administration to infants through syringes or NG tubes in cases when direct breastfeeding is not possible. Simultaneously, some participants reported the use of formula milk for newborns in cases when mothers have problems with lactation, although they were aware that from a scientific point of view, such practices are not recommended. For thermal care, hats, socks and cotton clothes provided by mothers or the facility were used; though facilities in most instances did not have enough linen for this purpose. Participants reported that preterm and LBW infants also received routine newborn care such as vitamin K and tetracycline eye ointment just like term infants.\u003c/p\u003e\n\u003cp\u003eA midwife from Kasech Health Centre said, \u0026quot;We apply KMC to premature new-borns immediately after delivery and advise the mothers to continue at home.\u0026quot; A nurse in the NICU at Adigrat Hospital said, \u0026quot;Here in this department, all the procedures are followed up strictly, and we are well trained and accountable for our practice.\u0026quot;\u003c/p\u003e\n\u003cp\u003eA health extension worker at Neksege Health Centre said the following about discharge practices: \u0026quot;Though I might not be aware of all that goes on in the health center, I believe most mothers have knowledge on the importance of skin-to-skin contact and frequent breastfeeding. In cases where mothers frequently breastfeed their babies, babies grow fat and stronger.\u0026quot;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e5. Challenges Faced by Health Workers in Providing Newborn Care Services\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants were most consistent in their complaint about how very difficult the care of preterm and LBW babies was. This includes the perpetual shortage of basic supplies such as socks, hats, and towels important for the care and thermal stability of these vulnerable newborn babies. These items are recommended to be brought into the health facility by pregnant mothers during ANC visits as part of birth preparedness and complication readiness; however, most mothers usually never heed the advice.\u003c/p\u003e\n\u003cp\u003eMoreover, participants pointed out that many mothers of preterm or LBW babies are often seen to take the advantage by leaving the facility before they meet the KMC discharge criteria, thus posing risks to the health of both mother and child.\u003c/p\u003e\n\u003cp\u003eAdded to that, there were infrastructural limitations regarding access to electric power and a shortage of machines for phototherapy treatment of jaundice in newborns. These were further compounded by a lack of community awareness of the kind of care preterm and LBW infants require.\u003c/p\u003e\n\u003cp\u003eA health officer from Bizet Health Center said, \u0026quot;In the past, items like socks, hats, and towels were donated by NGOs to our health center. We teach mothers during ANC that when they come to deliver, it is better to bring these materials, but most of them never listen.\u0026quot;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe current review adopts a qualitative approach to examine newborn care practices from the community perspective and that of health care providers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCommunity Perspective on Newborn Care\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe findings from the current study reveal an overall optimism in newborn care in this community, especially in the identification of the sick newborn. It was striking to note that congenital anomalies were never mentioned in any of the group discussions. Quantitative studies previously conducted in Ethiopia had documented alarmingly low levels of awareness on newborn danger signs among mothers: only 29.3% listed three or more from a list of eleven signs .\u003csup\u003e11\u003c/sup\u003e Studies done in Mekelle, Tigray, and Arbaminch demonstrated higher awareness, with 50.6% and 40.9% of mothers able to report at least three danger signs.\u003csup\u003e12,13\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003ePositive approaches to newborn care practices have been reflected in our study\u0026apos;s respondents, but not without the continuation of some practices which are harmful, such as the use of butter for early initiation of feeding. However, there has been considerable awareness of the timely initiation of BF and the advantages of colostrum, as well as the concept of exclusive breastfeeding up to six months. However, some mothers, especially the ones who delivered at home, remained ignorant of the benefits of colostrum and used other options like sugar water, honey, or butter for initial feeds. These findings are supported by other studies, which have documented similar misconceptions surrounding early feeding practices.\u003csup\u003e14\u003c/sup\u003e An example is the study from rural Karnataka, India, that reported that castor oil is given traditionally before initiation of breastfeeding, as this is believed to clean the system of the infant and the use of sugar solutions as prelacteal feeds. \u003csup\u003e15\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLack of close contact also puts the newborn at serious risk of hypothermia, as feeding is made more difficult and heat loss is hastened.\u003csup\u003e16\u0026nbsp;\u003c/sup\u003eWhile there was limited understanding among respondents of the relationship between cold exposure and its effects, encouraging beliefs about early wrapping and skin-to-skin contact were in evidence. Community experiences reported regarding health facilities reinforce this suggestion. One study in governmental health centers of Addis Ababa found that 68.6% of the mothers believed that warm clothing prevents heat loss in neonates and 50.8% identified skin-to-skin contact as a protective behavior against cold.\u003csup\u003e14\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eGenerally, although there are positive aspects in community knowledge and practices regarding newborn care, there are significant gaps that surely require selective educational interventions in order to improve maternal awareness and thereby impact newborn health outcomes.\u003c/p\u003e\n\u003cp\u003eSome apply chlorhexidine to the umbilical stump in line with national recommendations for cord care to prevent infection and expedite healing. Mothers in our study knew that application of substances to the cord enhances quicker healing; many mothers mentioned the use of butter. This is further supported by the findings of Callaghan-Koru et al., who stated that 21% of the respondents answered that the cord was treated with butter.12 Another study conducted in Governmental Health Centers in Addis Ababa, Ethiopia, revealed that 10.4% of mothers had the belief that butter should be applied on the stump.\u003csup\u003e14\u003c/sup\u003eHowever, in a different Indian study, 5.3% of the traditional providers used castor oil to burn the tip of the cord as a method to prevent bleeding and infection, which just goes to prove the regional differences in cord care practices.\u003csup\u003e15\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eIndeed, our study further elaborated on the psychosocial factors that contribute to significant parental experiences of facility newborn care: financial constraints and domestic responsibilities, especially when child-rearing responsibilities are borne by mothers. It is in such circumstances that parents may be compelled to leave the facility against medical advice before the newborn\u0026apos;s treatment is complete. A study carried out in Pediatric Wards at Al Jahra Hospital in Kuwait noted that 17.5% of neonates were discharged against medical advice, with 31% giving domestic obligations and the inconvenience of hospitalization as their reasons for leaving the hospital early.\u003csup\u003e17\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eResults indicate that newborns rely primarily on their mothers for care, although grandmothers and mothers-in-law, particularly for first-time mothers, also provide significant support. Fathers in some urban settings may provide infant care, though the roles of fathers are limited. This agrees with findings in a Ugandan study which mentioned that patriarchal community norms and values hinder male involvement in maternal and child health because males have limited sensitization.\u003csup\u003e18\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eMany times, the respondents reported that health education was always received from health professionals like health extension workers, midwives, nurses, and physicians but also the Women Development Army and grandmothers, about issues like colostrum feeding, exclusive breastfeeding, supplementary feeding, keeping the baby warm, bathing, and cord care. Evidence from community-based newborn care projects in India indicates that mobilizing at least a third of pregnant women into participatory learning and action groups is one of the cost-effective ways to address maternal and neonatal survival challenges in resource-poor countries.\u003csup\u003e7\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHealthcare Professionals\u0026rsquo; Perspectives to Newborn Care Practices\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study emphasizes that weight measurement at birth, though a routine practice in health facilities, experiences delays in most instances where newborns require critical care and active resuscitation. In the case of home births, there is also variability in weighing practices. Some health extension workers use the portable weighing scales meant for postnatal home visits to weigh the infants, while others do not own these weighing scales and hence do not measure weight during the home visits. Others carry the mothers to health facilities for weighing and clinical assessment. Findings from the African Neonatal Sepsis Trial conducted in Democratic Republic of the Congo, Kenya, and Nigeria show that CHWs can identify newborns with illness with reasonable accuracy and weight and refer appropriately. \u003csup\u003e19,20,21\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eENC encompasses a wide approach that involves many important interventions along the continuum of care: from preconception to conception, immediately after birth, and through the postnatal period. Core practices such as early initiation of breastfeeding, skin-to-skin contact, delayed bathing to prevent hypothermia, and appropriate care of the umbilical cord have been enhanced through the promotion of preventive behaviors by home visits.\u003csup\u003e14\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eTo this end, ENC practices such as wrapping newborns in dry cloth, the use of socks and hats at health facilities, and advice to mothers on how to maintain thermal care, are well practiced according to the participants\u0026apos; reports. Participants also indicated that discharge occurs about six hours after delivery, although this would extend to 24 hours in those cases assessed at rural health centers or non-congested facilities with no complications. Discharge times for mothers of preterm or LBW infants, those on KMC, and mothers and neonates with other complications differ from that mentioned above. A population-based survey conducted in Mekelle City, North Ethiopia, indicated that 81.1% of postnatal mothers reported good ENC practices.\u003csup\u003e22\u003c/sup\u003e Facility births accounted for 72.4% of deliveries in the region3. The remaining 27.6% of births outside health facilities may immensely thwart efforts at reducing the high national and regional neonatal mortality rates standing at 33 and 28 per thousand live births, respectively.\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eNetwork System Effectiveness in Home Birth Identification and Postnatal Care:\u003c/p\u003e\n\u003cp\u003eThe network already established among WDA, HEWs, and midwives has been mentioned as an asset to be utilized in the identification of home births and follow-up visits from referrals to health facilities. However, the present study identifies delays in ambulance services, lack of familial support during delivery, and perceived safety at home as some of the facilitating factors for mothers to choose home delivery. Despite such challenges, the network tries to ensure follow-up care with necessary check-ups among mothers who delivered at home.\u003c/p\u003e\n\u003cp\u003eOn the other hand, however, the study points to serious gaps concerning home visits by the HEWs. Factors include meetings, training commitments, geographical distance, and a lack of communication from either the mothers or WDAs themselves that hinder timely postnatal visits. In addition, HEWs often receive late notifications regarding home deliveries, especially in cases where mothers come from outside their designated catchment areas. A community-based, collaborative quality improvement initiative to improve postnatal care coverage in rural Ethiopia estimated that 34% of the women notified HEWs during labor or within 48 hours after delivery. Of the women who did so in a timely manner, as many as 94% received PNC. Timely notification to HEWs reportedly occurred more often among mothers whose care provider\u0026apos;s mobile number was known to them.\u003csup\u003e23\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eIn one review, focusing on postnatal care with a specific emphasis on home visitation, only Sri Lanka succeeded in showing high coverage of postnatal home visits sustained over time. Many countries have pursued ambitious schedules for postnatal home visits, but few have achieved anything remotely resembling meaningful coverage that significantly impacts newborn mortality.\u003csup\u003e24\u003c/sup\u003e In our study, HEWs were tasked with providing postnatal care in rural areas. Though they have a schedule for visits to the houses, meetings, trainings, and other logistics interfere with the schedule. The major activities they performed during the home visit they did were cord inspection for bleeding, weight checkup of babies, assessment of breast feeding, and checking danger signs\u003c/p\u003e\n\u003cp\u003eIn contrast, in a study in rural Hebei, China, it was also reported that a mere 8% of mothers received a timely postnatal home visit within one week of delivery. Of those who received visits, only 37% were counseled about infant feeding and only 32% about cord care. The study found that personnel shortages and transportation problems were major obstacles to visiting mothers at home.\u003csup\u003e25\u003c/sup\u003e Additionally, studies related to newborn care in Cambodia reported that the midwife often did not provide full breastfeeding advice at the time of delivery and usually discharged women from health centers in less than 24 hours to their homes.\u003csup\u003e26\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThese findings point to the imperatives of an improved communication and logistic support in the health network, as prerequisites for better postnatal care coverage and adequate and timely support for mothers and newborns.\u003c/p\u003e\n\u003cp\u003eNewborn Referral System\u003c/p\u003e\n\u003cp\u003eThe present investigation examined the reasons for referrals from lower to higher health facilities for newborns and listed preterm and low birth weight infants, breastfeeding difficulties, respiratory distress, and congenital malformations among other common reasons. Other contributory factors from participants attending health centers included no improvement after KMC, complications of the umbilical cord, jaundice, sepsis, and vomiting, reflecting a wider scope of neonatal health problems within our healthcare system.\u003c/p\u003e\n\u003cp\u003eA formative study in newborn care in Cambodia suggested that midwives at the health centres also often reported limited experience and familiarity with the newborn treatment. Many patients, therefore, like to go directly for care at higher-level hospitals when they perceive the condition of their infant to be severe. Alternatively, some families use nearby health centres because of cost-effectiveness and proximity; hence, the complexity of the patient decision on referral patterns.\u003csup\u003e26\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThe referral system was supposed to facilitate both upward and downward referrals between lower and higher-level facilities. Notably, the providers typically accompany mothers and infants in the case of referrals using an ambulance; even the routine availability of ambulances had its limitations, though.\u003csup\u003e27\u003c/sup\u003e Currently, the use of a referral slip for newborns has been found to work in most cases; however, there are serious breaks in the continuum of care during transportation related to thermal care and support for breastfeeding.\u003c/p\u003e\n\u003cp\u003eThere were also concerns raised on unnecessary upward referrals due to lack of skills at the care providers. A similar study in India on the status of newborn transport showed that most neonatal referrals were either self-organized or poorly managed by referring facilities, with many lacking appropriate pre-referral stabilization and advice on care en route. An alarming finding was that a small percentage of newborns referred were accompanied by skilled attendants or received advice on their care en route.\u003csup\u003e28\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eRegarding downward referrals, our study showed that the linkage from health centers to HEWs is more effective than those from hospitals to health centers. Effective telephone communication among HEWs and midwives has contributed much to the successful follow-up care for mothers after discharge. Critical gap exists in referral feedback from hospitals to referring facilities. Pedrana et al. found referral feedback with the SijariEMA system was only 66.2% effective; this again reflects deficiencies in the mechanisms of communication and the provision of feedback at the referral.\u003csup\u003e29\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThe results in general show the challenges and opportunities regarding the referral system of newborn care and point out the need for more health provider training, improvement in transport protocols, and most effective communication channels to ensure full newborn care at all levels in the process of referral.\u003c/p\u003e\n\u003cp\u003eHealth Problems and Recommended Care for Preterm and Low Birth Weight Babies\u003c/p\u003e\n\u003cp\u003eOur study identified that health workers have a fair level of knowledge regarding the care of preterm/low birth weight infants. However, gaps between knowledge and practice were identified among some providers of services. A study related to ours conducted in the public health facilities of the eastern zone of Tigray identified that 74.65% of health care providers had adequate knowledge on newborn care, and overall, 72.77% demonstrated good newborn care practices.\u003csup\u003e30\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eChallenges Faced by Health Workers in the Care of Preterm/LBW Newborns\u003c/p\u003e\n\u003cp\u003eThe study found out that health workers faced several challenges while managing the preterm or LBW baby. There was a marked deficiency of socks, hats, and towels while caring for babies. Most mothers of preterm or LBW babies preferred to go home before fulfilling the discharge criteria for KMC. Other reported challenges included no electricity, a lack of adequate phototherapy machines, and limited community awareness on the care of preterm and LBW infants. In this regard, two very important predictors of the newborn care practices among health care providers were: availability of essential materials and type of health facility.\u003csup\u003e24\u003c/sup\u003e More importantly, a KAP assessment on immediate newborn care among health care providers in public health centers in Addis Ababa showed that only 40.4% practice at least half of the recommended standard actions for preterm and LBW infants.\u003csup\u003e31\u003c/sup\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eImproved service delivery at the facility level will require resources and actionable strategies aimed at ensuring high-quality, timely care at health facilities and appropriate home newborn care practices in order to reduce neonatal mortality rates nationally and regionally. Strengthening HEP and integrated health education initiatives would address issues related to home births, postnatal care visits, and harmful traditional practices that affect newborns within the community. Creation of awareness programs both at facilities and community levels regarding birth preparedness, weighing at birth, completion of care at facilities prior to discharge, and correction of misconceptions related to preterm and LBW infants are some of the necessary steps which would go a long way in improving newborn care practices in general.\u003c/p\u003e\n\u003cp\u003eAn appropriate referral system with proper referral care, maintenance of the warm chain, and suitable transportation also requires to be instituted. Finally, enhancing the capacity of the providers of care in the recognition of indications for referral will go a long way in the improvement of neonatal outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Authors thank the Tigray Regional health bureau, the Administration and health workers of the health centers, the health posts, mothers, families and community representatives without whose cooperation this study would not have been possible.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTHA1 conceived the study. THA1 was the principal investigator, designed the study and drafted the manuscript. THA1, MYH1, AHB1, DSG1, SAB3, AAM3 developed the study instrument, conducted the study, analysed data and assisted with write-up of the manuscript. YBZ2, TAB4 and FAG4 were involved in data collection and interpretation and manuscript preparation. All authors read and approved the final manuscript. The corresponding author certifies that all listed authors meet the authorship criteria and that no others meeting the criteria have been omitted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials:\u003c/strong\u003e No additional data are available. The qualitative data, individual stories and narratives have been taken in personal settings. Informants were assured of confidentiality for their contribution to the research project and that it would not be shared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e No funder\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval to conduct the assessment was obtained from the Institutional review board of Mekelle University. In addition, support letter from Tigray regional health bureau and permission from medical directors of the respective facilities was obtained. On the other hand, informed consent in writing was obtained from each key informant before actual data collection. The processes were performed as per guidelines of a relevant authority. Data privacy was assured by keeping all data in a secure and safe place throughout the study period. Data access was available to only the researchers for any cross validation or any validation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e This manuscript declares no competing financial interest\u0026apos;s declaration from any person or organization, or non-financial competing interests such as political, personal, religious, ideological, academic, intellectual, commercial or any other.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1 Department of Pediatrics and Child Health, School of Medicine, College of Health Sciences, Mekelle University, Mekelle, Ethiopia.\u003c/p\u003e\n\u003cp\u003e2 Department of Gynecology and obstetrics, School of Medicine, College of health sciences, Mekelle University, Mekelle, Ethiopia.\u003c/p\u003e\n\u003cp\u003e3School of public health, College of Health sciences, Mekelle University, Mekelle, Ethiopia.\u003c/p\u003e\n\u003cp\u003e4Tigray regional health bureau, Mekelle, Ethiopia.\u003c/p\u003e\n\u003cp\u003eTHA\u003csup\u003e1*\u003c/sup\u003e: \u003ca href=\"mailto:[email protected]\"\[email protected]\u003c/a\u003e\u0026nbsp; , MYH:\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003ca href=\"mailto:[email protected]\"\[email protected]\u003c/a\u003e\u0026nbsp; \u0026nbsp;,AHB: \u003ca href=\"mailto:[email protected]\"\[email protected]\u003c/a\u003e ,DSG: \u003ca href=\"mailto:[email protected]\"\[email protected]\u003c/a\u003e, \u0026nbsp;YBZ: [email protected] \u0026nbsp;, SAB: \u003ca href=\"mailto:[email protected]\"\[email protected]\u003c/a\u003e , AAM: \u003ca href=\"mailto:[email protected]\"\[email protected]\u003c/a\u003e ,TAB:\u003ca href=\"mailto:[email protected]\"\[email protected]\u003c/a\u003e\u0026nbsp; FAG: \u003ca href=\"mailto:[email protected]\"\[email protected]\u003c/a\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eWorld Health Organization. Newborns: Improving Survival and Well-Being. Geneva: World Health Organization; 2020. Available from: https://www.who.int/news-room/fact-sheets/detail/newborns-reducing-mortality. Accessed September 10, 2020.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. Global Health Observatory (GHO) Data 2017. Geneva: World Health Organization; 2017. Available from: https://www.who.int/data/gho/data/themes/topics/indicator-groups/indicator-groupdetails/GHO/causes-of-child-death. Accessed January 22, 2020.\u003c/li\u003e\n \u003cli\u003eEthiopian Public Health Institute (EPHI) [Ethiopia] and ICF. 2021. Ethiopia Mini Demographic and Health Survey 2019: Final Report. Rockville, Maryland, USA: EPHI and ICF.\u003c/li\u003e\n \u003cli\u003eEvery Preemie—SCALE (Scaling, Catalyzing, Advocating, Learning, and Evidence Driven). Status of Preterm and Low Birth Weight Demographics, Risk Factors and Health System Responsiveness in USAID’s 24 MCH Priority Countries. Washington, DC: Every Preemie—SCALE; 2019. Available from: https://www.everypreemie.org/wp-content/uploads/2019/07/SummaryProfile_7.10.19.pdf. Accessed March 25, 2020.\u003c/li\u003e\n \u003cli\u003eHealth Services Insights. Qualitative Assessment of the Quality of Care for Preterm, Low Birth Weight, and Sick Newborns in Ethiopia. 2014;14:1-13.\u003c/li\u003e\n \u003cli\u003eMEDICC Review. July 2011;13(1).\u003c/li\u003e\n \u003cli\u003eNeogi SB, Prost A, Colbourn T, Seward N, Azad K, Coomarasamy A, Copas A, et al. Women’s groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis. Lancet. 2013;381(9879):1736-46.\u003c/li\u003e\n \u003cli\u003eLassi ZS, Haider BA, Bhutta ZA. Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes. Cochrane Database Syst Rev. 2010;10(11)\u003c/li\u003e\n \u003cli\u003eGogia S, Ramji S, Gupta P, Gera T, Shah D, Mathew JL, et al. Community based newborn care: a systematic review and meta-analysis of evidence: UNICEF-PHFI series on newborn and child health, India. Indian Pediatr. 2011;48(7):537-46.\u003c/li\u003e\n \u003cli\u003eKirkwood BR, Manu A, ten Asbroek AH, Soremekun S, Weobong B, Gyan T, et al. Effect of the Newhints home-visits intervention on neonatal mortality rate and care practices in Ghana: a cluster randomised controlled trial. Lancet. 2013;381(9884):2184-92.\u003c/li\u003e\n \u003cli\u003eCallaghan-Koru JA, Tadesse G, Deyessa N, et al. Discharge against medical advice among children admitted into pediatric wards at Al Jahra Hospital, Kuwait. BMC Pediatr. 2013;13:198.\u003c/li\u003e\n \u003cli\u003eAwareness and associated factors towards neonatal danger signs among mothers attending public health institutions of Mekelle city, Tigray, Ethiopia. J Child Adolesc Behav. 2015;3:144.\u003c/li\u003e\n \u003cli\u003eBioMed Research International. Community health workers: A crucial role in newborn health care and survival. Hindawi; 2019. Article ID 9180314. Available from: https://doi.org/10.1155/2019/9180314.\u003c/li\u003e\n \u003cli\u003eAdvances in Public Health. Health care quality improvement in low-resource settings. Hindawi; 2018. Article ID 8921818. Available from: https://doi.org/10.1155/2018/8921818.\u003c/li\u003e\n \u003cli\u003eBMC Pregnancy Childbirth. Postnatal care with a focus on home visitation. 2009;9:20.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. WHO/FHE/MSM/93.2.\u003c/li\u003e\n \u003cli\u003eAbd El Malek V, Alexander S, Al Anezi F. Discharge against medical advice among children admitted into pediatric wards at Al Jahra Hospital, Kuwait. Available from: https://www.examplelink.com.\u003c/li\u003e\n \u003cli\u003eMuheirwe N, Nuhu N. Community health interventions for neonatal care in Ethiopia. BMC Public Health. 2019;19:1048. Available from: https://doi.org/10.1186/s12889-019-7371-3.\u003c/li\u003e\n \u003cli\u003eAFRINEST Group. Simplified regimens for management of neonates and young infants with severe infection when hospital admission is not possible. Pediatr Infect Dis J. 2013;32. PMID: 23945572.\u003c/li\u003e\n \u003cli\u003eAFRINEST Group. Treatment of fast breathing in neonates and young infants with oral amoxicillin compared with penicillin–gentamicin combination. Pediatr Infect Dis J. 2013;32. PMID: 23945574.\u003c/li\u003e\n \u003cli\u003eCommunity health workers: A crucial role in newborn health care and survival. J Glob Health. 2014;4(2):020302. Available from: https://doi.org/10.7189/jogh.04.020302.\u003c/li\u003e\n \u003cli\u003eBerhea TA, Belachew AB, Abreha GF. Knowledge and practice of Essential Newborn Care among postnatal mothers in Mekelle City, North Ethiopia: A population-based survey. PLoS ONE. 2018;13(8). Available from: https://doi.org/10.1371/journal.pone.0202542.\u003c/li\u003e\n \u003cli\u003eJournal of Midwifery \u0026amp; Women\u0026apos;s Health. Volume 59, Supplement 1. January/February 2014.\u003c/li\u003e\n \u003cli\u003eHodgins S, McPherson R, Kerber K. Postnatal care, with a focus on home visitation: a design decision-aid for policymakers and program managers.\u003c/li\u003e\n \u003cli\u003eChen et al. Postnatal care and home visitation: A review. BioMed Central; 2014. Available from: http://creativecommons.org/licenses/by/2.0.\u003c/li\u003e\n \u003cli\u003eHealthcare. 2016;4:94. Available from: https://doi.org/10.3390/healthcare4040094.\u003c/li\u003e\n \u003cli\u003eBuch P, Mankad M, et al. Status of newborn transport. J Pharm Biomed Sci. 2016;16(16):4.\u003c/li\u003e\n \u003cli\u003eBuch PM, Singh S, Patel R, et al. Status of newborn transport in periphery and risk factors of neonatal mortality among referred newborns. J Pharm Biomed Sci. 2012;16(9):1-6.\u003c/li\u003e\n \u003cli\u003ePedrana E, et al. Assessing the effect of the Expanding Maternal and Neonatal Survival program on improving stabilization and referral for maternal and newborn complications in Indonesia. Int J Gynecol Obstet. 2019;144(Suppl. 1):30–4. DOI: 10.1002/ijgo.12733.\u003c/li\u003e\n \u003cli\u003eBerhe T, et al. Effectiveness of newborn care interventions in Ethiopia. BMC Pediatr. 2017; 17:157. Available from: https://doi.org/10.1186/s12887-017-0915-8.\u003c/li\u003e\n \u003cli\u003eEthiopia Journal of Pediatrics and Child Health. 2011;7(7)\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Newborn care, Home, Health Facility, Practices, referral, continuum of care, harmful traditional practices","lastPublishedDoi":"10.21203/rs.3.rs-3132020/v3","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3132020/v3","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eABSTRACT\u003c/p\u003e\n\u003cp\u003eBackground: The neonatal period is the most vulnerable age for child survival. In 2019, about half of all under-five mortality was contributed by the newborn deaths, which was estimated to be about 2.4 million deaths worldwide.1 In Ethiopia, the estimated neonatal mortality rate stands at 33 deaths per 1,000 live births.3 The study will outline newborn care practices both in homes and in the public health care system in Tigray.\u003c/p\u003e\n\u003cp\u003eMethods: The qualitative study employed two data collection methods, namely, focus group discussions and in-depth interviews. The study was conducted in five zones of the Tigray region. In all, 16 focus group discussions and 46 in-depth interviews were held with community representatives and health workers. Data were transcribed and then analyzed using the ATLAS.ti software for thematic coding using an inductive approach. Themes identified were discussed in detail prior to coding.\u003c/p\u003e\n\u003cp\u003eResult: The community perspective shows that there is enough knowledge regarding basic newborn care and harmful traditional practices; however, practices have not been resolved. Active engagement of parents, especially mothers, in facility-based care is socially and economically limited. Health Professionals' Perspective: Weight measurements for home births, as opposed to those in facilities, are not regularly carried out, with many newborn babies not having their weight measured. There are missed home births despite having a home birth notification framework in place. HEWs conduct postnatal care via routine home visits; however, there is weak continuum of care and referral feedback from hospitals. Besides these, widespread shortages of electricity and phototherapy machines and community awareness for care of preterm and LBW babies were noted. Parents' experiences are shaped by the forces of economic insecurity and social issues.\u003c/p\u003e\n\u003cp\u003eConclusion: The improvement of newborn care practices at home and health facilities is an important milestone that the Ethiopian Federal Ministry of Health is seeking to achieve as it works toward the reduction of the neonatal mortality rate. This feat will be realized at the facility level when actionable strategies, resource commitments, strengthening of the HEP, and health education are implemented.\u003c/p\u003e","manuscriptTitle":"Newborn care practices at home and health facilities in Tigray, Ethiopia: a qualitative assessment","msid":"","msnumber":"","nonDraftVersions":[{"code":3,"date":"2024-09-12 18:01:28","doi":"10.21203/rs.3.rs-3132020/v3","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}},{"code":2,"date":"2024-09-06 19:16:36","doi":"10.21203/rs.3.rs-3132020/v2","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2023-07-19 13:17:53","doi":"10.21203/rs.3.rs-3132020/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"dc4ed2bd-2675-4418-a325-7dbe3b434014","owner":[],"postedDate":"September 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-05T10:29:55+00:00","versionOfRecord":[],"versionCreatedAt":"2024-09-12 18:01:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v3","identity":"rs-3132020","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3132020","identity":"rs-3132020","version":["v3"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}