Rationale for the Framework

3.2.1 Socio-demographic factors as predictors of good newborn care practices

Previous research has established the association of socio-demographic factors with newborn care practices. For instance, household newborn care practices during delivery have been found to be associated with maternal socio-demographic factors such as education and ethnicity (Thapa et al, 2000: Sharan, 2004); breastfeeding of newborns is influenced by the mother’s age (Holman, 2001; Sharan, 2004). Therefore, this study conceptualizes socio-demographic factors as one of the important determinants of good newborn care practices.

3.2.2 Socio-economic factors as predictors of good newborn care practices

A study by Sharan (2004) found an association between economic status and cord care practices. It is apparent that the mothers belonging to higher economic status are better exposed to health care information and services, thus are more likely to demonstrate safer newborn care practices. Therefore, the present study considers household socio-economic status as one of the predictors of good newborn care practices.

3.2.3 Use of maternal health services as a predictor of good newborn care practices

Home-based delivery practices are related to use of antenatal care services. Sharan (2004) found a positive association between antenatal care and cord care and early breastfeeding, which indicates that if a woman receives ANC services, she is likely to get information on safe cord cutting and early breastfeeding. Receiving such information enables her to adopt good practices. Similarly, receiving the assistance of a skilled birth attendant during delivery and the use of postnatal care services are also likely to provide women with information that might help them to demonstrate safe newborn care practices. Hence, in the conceptual framework of the current study, use of maternal health services has been examined as a possible determinant of good newborn care practices.

3.2.4 Mothers’ knowledge of specific newborn care practices as a predictor of good newborn care practices

The literature related to knowledge and health service utilisation shows that the mothers’ knowledge can influence health care practices in several ways (Senerath et al, 2007; Sharan, 2004). It is also evident from the literature that the knowledge factor is an important intermediate factor that mediates other factors to demonstrate good practices. On one hand knowledgeable mothers are more inclined to use health services and thus practice safe newborn care behaviours. On the other hand, the use of health services increases a woman’s knowledge and the ability to practise safe newborn care behaviours. In this framework it is assumed that knowledgeable mothers are more likely to use maternal health services and practice good newborn care practices, but that using health services makes women more knowledgeable.

3.2.5 Birth preparedness as a predictor of good newborn care practices

Birth preparedness has been recognised as an important factor for a healthy pregnancy outcome but preparing for birth is not commonly practised in Nepal. Making preparations for birth during pregnancy might influence newborn care practices. Therefore, the current study conceptualizes that there might be an association between making birth preparations and demonstrating good newborn care practices.

3.2.6 Health workers’ counselling as a predictor of good newborn care practices

A study by Baqui et al (2006) found a positive impact of antenatal counselling on clean cord care, thermal care and early breastfeeding. In Nepal, FCHVs play an important role in educating mothers on various health matters including safe motherhood and newborn care. FCHVs as health human resources are different from health workers because they do not have specific qualifiactions. They are just female volunteers who are selected locally at ward levels and are given short term trainings to educate pregnant women and mothers on various health matters. They also distribute few health commodities such as condom, iron tablets, cotrimoxazole and oral redhydration salts at community level. Hence, this study conceptualizes that receiving counselling from health workers as well as receiving advice from FCHVs on specific newborn care issues during pregnancy might influence good newborn care practices.

3.2.7 Exposure to media as a predictor of good newborn care practices

Radio emerged as the most important source of information on early breastfeeding in two out of three districts in the baseline survey of the CB-MNC program conducted in Nepal (VaRG, NFHP & USAID, 2007). Television was also frequently reported as a source of information on early breastfeeding by the new mothers (VaRG & NFHP, 2005a). The study also reported that the knowledge of maternal and newborn danger signs are better among women who were the members of radio listener groups. Although, studies have not examined the association of newborn care practices with radio listening and television viewing, it could be expected that women having access to radio and television receive health information and thus will be more inclined towards demonstrating safe newborn care practices. Therefore, exposure to mass media such as radio and television has been considered as a possible predictor of good newborn care practices.

3.2.8 Health system factors as a predictor of good newborn care practices

Evidence provided by Kumar et al (1997) shows that women living in a catchment area of health institutions with higher level facilities such as primary health care centres are more likely to use services than women living in one with limited service facilities such as sub health posts. The qualitative study by Thapa et al (2000) examining the birth related practices and their determinants in Nepal reports that supply side factors such as lack of heating arrangements in hospital and a distant health facility are also the reasons for the high prevalence of deliveries at home. Therefore, it is expected in this framework that the supply system factors, including the type of health institution and its distance, could have influenced service utilisation and thus, newborn care practices. Based on this evidence, this study conceptualizes health system factors as one of the important predictors of good newborn care practices.

3.2.9 Cultural factors as a predictor of good newborn care practices

Beliefs in supernatural powers such as God, spirits and evil are still widely prevalent in the rural areas of Nepal, India and Bangladesh. Cutting the cord is considered unholy; bathing immediately after birth is considered important to purify and protect the baby from skin infections. Breastfeeding is withheld up to several days after birth as colostrum is considered

dirty and poisonous for the baby (Thapa et al 2000; Darmstadt, 2006; Gurung, 2008). These findings suggest that such cultural traditions have a deep impact on newborn care practices. Therefore, cultural factors have been considered as one of the determinants of good newborn care practices in this study.

3.3 Conclusions

The conceptual framework of this study is based on Mosley and Chen’s child survival framework for developing countries and Andersen’s behavioural model of health service utilization. In the conceptual framework of the study, there are nine sets of independent variables- 1) Socio-demographic factors, 2) Socio-economic status, 3) Use of maternal health services, 4) Birth preparedness, 5) Knowledge of the mother, 6) Counselling/advice by health workers/FCHVs, 7) Health system factors, 8) Exposure to media, and 9) Cultural factors, which are expected to have some association with the three outcome variables of interest. However, out of those nine sets of independent variables, this study was limited to the examination of the independent and the combined effect of the seven sets of independent variables (socio- demographic factors, socio-economic status, use of maternal health services, birth preparedness, mother’s knowledge, counselling by health workers/FCHVs, and exposure to the media) on the outcome variables of interest. Two variable sets (cultural factors and health system factors) have not been studied as data were not available. The outcome variables of interest to this study are the three newborn care practices: 1) safe cord cutting, 2) early breastfeeding, and 3) delayed bathing.

CHAPTER FOUR