Introduction
Reducing neonatal morbidity and mortality remains a key goal of health systems in low and middle-income countries (LMICs) where 2.5 million neonatal deaths occur annually.1 India bears 27% of the global burden of neonatal deaths; 750 000 newborns die in India within the first month of life annually.2
Although institutional deliveries have nearly doubled in India over the past decade,3 inadequate follow-up has created several gaps in care. Families often miss coming back for scheduled follow-ups, with about 40% dropping out by the first follow-up visit in LMICs.4 Additionally, many patients fall through the safety net as health workers are not able to reach and provide care for the newborns at home.5 For many families, facility-based childbirth is the only window of opportunity to equip families with the knowledge and skills needed to care for their newborns.
Postnatal education, particularly predischarge education, has been identified as a ‘low-hanging fruit’ to improve newborn outcomes and reduce mortality by improving the adoption of newborn care practices.6 7 But key limitations have been identified in the implementation of such programmes. The majority of programmes focus on singular health topics, primarily breastfeeding or impart education to only one family member, most often the mother. These limitations need to be overcome to address unmet educational needs.7
Hospitals in LMICs can play a key role in imparting postnatal education,4 but without established procedures, the delivery of critical health education in-hospital is limited or missed altogether. A survey in district hospitals in India found less than half the mothers reported the receipt of any amount of education postdelivery and before discharge.7 Moreover, low health literacy, sociocultural diversity, power dynamics and language barriers affect patient provider relationships, thereby adding to the difficulty in understanding the advice given by doctors and nurses. Often, families are not prepared for their roles as primary caregivers and essential newborn care practices that could save lives and avert suffering are not followed at home.8
Program description
In July 2017, 12 district hospitals, 6 in each state, were selected by the governments of Punjab and Karnataka to launch the Care Companion Programme (CCP) as a pilot programme. These hospitals have monthly delivery volumes of 100–800 deliveries and are the primary government hospitals in their respective districts. The hospitals were selected based on need for the programme and willingness to implement the programme. Noora Health inspired CCP was implemented as a public-private partnership undertaking. The role of the private partner was to design the model including creating and deploying the teaching tools, training the hospital staff, working with administrators and other hospital staff to ensure integration of the training into their daily workflow. The formulation and approval of the curriculum, early testing of material and localisation and approvals from various stakeholders took place in the first half of 2017. The hospitals were to provide the infrastructure support, staff time and administrative support to help run the programme.
The programme uses an evidence-based curriculum for postnatal counselling, covering multiple behaviours for improving neonatal and maternal health.9 Skills taught include key healthy behaviours like exclusive breastfeeding, dry cord care, skin to skin care, mother’s diet, early recognition of danger signs and complications for mother and baby and appropriate healthcare seeking by the families. Behaviour change specialists created tools and methods to teach this curriculum using a human-centred design process, including needs finding interviews with families and discussions with local and regional health experts. Visuals and materials were tailored to the cultural practices of local populations using field testing, key informant interviews and iterative design. The Department of Health in the respective states, as well as District Surgeons and Medical Officers of each hospital, provided final approvals for materials included in the training curriculum. These materials included videos played on a television monitor installed in the postnatal wards, flipcharts, dolls for role play and hand-outs. Examples of the training materials can be accessed at https://drive.google.com/drive/folders/1e6Kl75IGLIxdxXqkDDet2h2Lsb9hcHiP
The initial training of trainers was conducted by a master trainer who trained nurses and counsellors from the 11 district hospitals in a workshop over two 8-hour days. Learning was assessed by a pre–post test. Nurses and counsellors were introduced to the tools, adult learning principles, health communication skills to engage their audiences and the specific health topics and skills that they needed to teach families. A hospital-specific rotational roster was created in order to maximise the number of deliveries covered, acknowledging that some families may discharge before being offered the class due to length of stay and resource constraints. Typically, 30–45 min sessions were held 1–2 sessions per week in the postnatal wards, including intensive care and caesarean delivery wards. In the hospitals, mothers and families were taught these skills by the nurses or counsellors in group sessions which facilitates behaviour adoption.10 On an average 1–2 members of a family attended these sessions.
Classes were held at times outside of physician rounds and food services to ensure that nurses were available for teaching. Security guards often helped gather patients and families in the wards and made attempts to include maximum family members. The nurse or counsellor covered a predefined list of topics, using flip charts and demonstrations followed by a video. Interaction was encouraged throughout the class and a question and answer session took place at the end of the session. The nurses were also encouraged to bring in their expertise to adapt to the needs of the group and local context. Families were encouraged to practise some of the skills while still in the hospitals. Programme managers visited each hospital once a week to monitor the fidelity of the programme, gather learnings for future refinement and provide feedback to improve the sessions.
Training of the trainers occurred after the preintervention data collection phase in June 2017. The programme launched in July 2017 and by August 2017, all hospitals were running the CCP.
The primary SMART (Specific, Measurable, Applicable, Realistic, and Timely), aim of the CCP is to improve patients’ postdischarge outcomes, reduce complications and increase families’ adherence to recommended newborn and maternal care practices. Our objective in the study was to assess the effect of CCP on family’s reported adoption of newborn care practices and newborn outcomes in the neonatal period.