We have shown that most, but not all, Ethiopian babies born at health facilities were kept warm, received good cord care, and put to the breast for early initiation of breastfeeding. Babies born at home were less frequently put to the mother’s breast, and one-third got butter or other products on the umbilicus. The coverage of first six-weeks immunizations were much higher for the facility-born. Appropriate newborn care practices had higher coverage among neonates in Addis Ababa.
This study was based on WHO recommendations for essential newborn care. It was community-based and conducted in five administrative regions and one city administration, covering 90% of the population. The sample is judged to be representative of regions and the whole country. Unlike most previous studies that considered either health facilities or home deliveries, we assessed essential newborn care practices in both settings. The recall period for the care practices was short, since the interviews were performed when the infant was six weeks old. Still, some mothers could have had difficulties in identifying and reporting some of the practices at birth, such as technical details around cord care, especially when deliveries took place at health facilities. This issue could lead to bias in both directions, but an underestimation of favorable procedures is more likely. Most mothers had not attended any formal education, which could reduce their ability to understand some of the more technical questions. However, appropriate training was given to data collectors to communicate with the mothers properly. Some areas had been oversampled in this study, but this was accounted for by weighting factors in all analyses. We adjusted for cluster sampling in all statistical analyses. Fieldwork was performed just before the outbreak of unrest in some regions that may have influenced care practices at facilities and homes.
Appropriate thermal care is the series of measures to keep the baby warm and enhance newborn survival [7]. Most neonates delivered in health facilities were put skin-to-skin on the mother’s breast immediately after birth. This practice was less common in home deliveries. Previous studies in Ethiopia and other low-income countries have reported skin-to-skin contact after birth to be uncommon [4, 17]. This practice may be due to a belief that skin-to-skin contact disrupts the mother’s ability to rest, causing exhaustion or being unfeasible because the mother is in pain [18]. Mothers who received antenatal counseling about essential newborn care could be more likely to practice skin-to-skin care [9–11]. Most babies born in health facilities and half of the home-delivered neonates had delayed bathing until after 24 hours. In a Sub-Saharan African review delayed bathing ranged from 25–75% [17]. The wide range may be due to varying contexts, time at interview, and other factors.
Clean cord care prevents early infections, including neonatal sepsis [19]. The fear of tetanus and other bacterial infections has enhanced the use of a new or boiled instrument to cut the newborn’s cord [20, 21]. New or boiled instruments were used to cut the cord in nine of ten babies born at health facilities and almost the same extent for the home-delivered neonates. Similar findings have been reported from other LMICs, such as Sri Lanka, India, and Bangladesh [22–24]. WHO and the Ethiopian Ministry of Health recommend appropriate cord care by keeping it dry, not applying anything, or applying chlorohexidine gel [25, 26]. According to mothers’ report, three-quarters of the facility-delivered babies had nothing applied, one-tenth received chlorohexidine gel, and a small proportion even got butter on the cord. A quarter of the home-delivered neonates got butter, and a few had petroleum jelly applied. These malpractices, including the use of butter and petroleum jelly in facility and home deliveries, may increase the risk of newborn infections [21].
Around two-thirds of mothers at health facilities and homes initiated breastfeeding within one hour after delivery. In a Sub-Saharan African review early initiation of breastfeeding ranged from 17 to 95% [17]. The current finding from facility delivery was congruent with the 2019 EDHS report [6]. Promoting breastfeeding-friendly health facilities is essential to further improve timely breastfeeding initiation.
Nearly half of the facility-delivered neonates received BCG and the first dose of polio vaccinations within six-weeks postpartum. In contrast, only one-fifth of the home-delivered babies received these vaccines. This coverage was lower than the country’s 2016 and 2019 EDHS reports and other available evidence [6, 27, 28]. The difference may be attributed to impaired health services during the COVID pandemic [29] and the time of interview after delivery (our evaluation as early as six weeks after birth). Delivering at home may delay mothers’ decision to get their babies vaccinated.