Infection contributes to a significant proportion of neonatal death and disability worldwide, with the major burden occurring in the first week of life. Environmental conditions and gaps in water, sanitation and hygiene (WASH) practices may contribute to the risk of infection, particularly in settings where health centers are expanding to meet the growing demand for skilled care at birth and homes do not have adequate access to water and sanitation. A qualitative approach was used to understand the environmental context for infection prevention and control (IPC) and WASH associated behaviors in health centers where women give birth, and in homes of newborns, in a rural Cambodian province. Structured observations and focus group discussions revealed important gaps in optimal practices, and both structural and social barriers to maintaining IPC during delivery and post-partum. Solutions are available to address the issues identified, and tackling these could result in marked environmental improvement for quality of care and neonatal outcomes. Water, sanitation and hygiene in home and health center environments are likely to be important contributors to health and should be addressed in strategies to improve neonatal survival.

Background: Newborn mortality in Cambodia remains high, with sepsis and complications of delayed care-seeking important contributing factors. Intervention study objectives were to improve infection control behavior by staff in health centers; improve referral of sick newborns; increase recognition of danger signs, and prompt care-seeking at an appropriate health facility; and appropriate referral for sick newborns by mothers and families of newborn infants. Methods: The stepped-wedge cluster-randomized controlled trial took place in rural Cambodia from February 2015 to November 2016. Sixteen clusters consisted of public health center catchment areas serving the community. The intervention included health center staff training and home visits to mothers by community health volunteers within 24 h of birth and on days 3 and 7 after delivery, including assessment of newborns for danger signs and counselling mothers. The trial participants included women who had recently delivered a newborn who were visited in their homes in the first week, as well as health center staff and community volunteers who were trained in newborn care. Women in their last trimester of pregnancy greater than 18 years of age were recruited and were blinded to their group assignment. Mothers and caregivers (2494) received counseling on handwashing practices, breastfeeding, newborn danger signs, and prompt, appropriate referral to facilities. Results: Health center staff in the intervention group had increased likelihood of hand washing at recommended key moments when compared with the control group, increased knowledge of danger signs, and higher recall of at least three hygiene messages. Of mother/caregiver participants at 14 days after delivery, women in the intervention group were much more likely to know at least three danger signs and to have received messages on care-seeking compared with controls. Conclusions: The intervention improved factors understood to be associated with newborn survival and health. Well-designed training, followed by regular supervision, enhanced the knowledge and self-reported behavior of health staff and health volunteers, as well as mothers' own knowledge of newborn danger signs. However, further improvement in newborn care, including care-seeking for illness and handwashing among mothers and families, will require additional involvement from broader stakeholders in the community.

Global coverage and scale up of interventions to reduce newborn mortality remains low, though progress has been achieved in improving newborn survival in many low-income settings. An important factor in the success of newborn health interventions, and moving to scale, is appropriate design of community-based programs and strategies for local implementation. We report the results of formative research undertaken to inform the design of a newborn health intervention in Cambodia. Information was gathered on newborn care practices over a period of three months using multiple qualitative methods of data collection in the primary health facility and home setting. Analysis of the data indicated important gaps, both at home and facility level, between recommended newborn care practices and those typical in the study area. The results of this formative research have informed strategies for behavior change and improving referral of sick infants in the subsequent implementation study. Collection and dissemination of data on newborn care practices from settings such as these can contribute to efforts to advance survival, growth and development of newborns for intervention research, and for future newborn health programming.

BackgroundAppropriate and timely breastfeeding practices markedly improve lifelong health outcomes for newborns, children, and mothers. Exclusive breastfeeding is reported to be widely practiced in Cambodia, and important progress has been made toward achieving improved child health outcomes, but newborn mortality has been slow to reduce and breastfeeding practices remain suboptimal.MethodsFormative research was conducted in Takeo province, Cambodia to describe the practical, cultural, and social factors underlying current breastfeeding behaviors to inform the design of a newborn survival intervention that may improve breastfeeding. In-depth interviews, observations, a collection of visual media, and focus groups were employed to gather qualitative data.ResultsThe results revealed knowledge and practice gaps in behavior that likely contribute to breastfeeding barriers, particularly in the areas of infant latch, milk production, feeding frequency, and the use of breast milk substitutes. The predominant theme identified in the research was a dearth of detailed information, advice, and counseling for mothers beyond the message to exclusively breastfeed for 6 months.ConclusionFuture newborn survival interventions and postnatal care counseling in this area must go beyond the exclusive breastfeeding message. To achieve further impact, it will be necessary to disseminate comprehensive and locally appropriate information on breastfeeding and to improve counseling in order to support successful breastfeeding and to contribute to population-level health gains.