Hygiene along the continuum of care in the early post-natal period: an observational study in Nigeria

Abstract

Background Newborns delivered in healthcare facilities in low- and middle-income countries are at an increased risk of healthcare associated infections. Facility–based studies have focused primarily on healthcare worker behaviour during labour & delivery with limited attention to hygiene practices in post-natal care areas and largely ignore the wide variety of actors involved in maternal and neonatal care. Methods This exploratory mixed-methods study took place in six healthcare facilities in Nigeria where 31 structured observations were completed during post-natal care, discharge, and the first 6 hours after return to the home. Frequency of hand hygiene opportunities and hand hygiene actions were assessed for types of patient care (maternal and newborn care) and the role individuals played in caregiving (healthcare workers, cleaners, non-maternal caregivers). Qualitative interviews with mothers were completed approximately 1 week after facility discharge. Results Maternal and newborn care were performed by a range of actors including healthcare workers, mothers, cleaners and non-maternal caregivers. Of 291 hand hygiene opportunities observed at health facilities, and 459 observed in home environments, adequate hand hygiene actions were observed during only 1% of all hand hygiene opportunities. Adequate hand hygiene prior to cord contact was observed in only 6% (1/17) of cord contact related hand hygiene opportunities at healthcare facilities and 7% (2/29) in households. Discharge advice was infrequent and not standardised and could not be remembered by the mother after a week. Mothers reported discomfort around telling non-maternal caregivers to practice adequate hand hygiene for their newborn. Conclusions In this setting, hand hygiene practices during post-natal care and the first 6 hours in the home environment were consistently inadequate. Effective strategies are needed to promote safe hand hygiene practices within the post-natal care ward and home in low resource, high-burden settings. Such strategies need to target not just mothers and healthcare workers but also other caregivers.

Understanding infection prevention behaviour in maternity wards: A mixed-methods analysis of hand hygiene in Zanzibar

“…A similar absence of towels for hand drying was noted in 9 of 10 maternity wards studied in Cambodia ( Bazzano et al, 2015 ) and all six wards in a study of post-natal care in Nigeria ( Nalule et al, 2020 ). The more general issue of hygiene ergonomics has not received much attention, however.…”

“…This conclusion is consistent with other studies showing that neither educational interventions without substantial learner-engagement ( Rowe et al, 2018 ) nor printed educational materials ( Rowe et al, 2005 ) have strong positive effects on health care worker behaviour. Other studies show good knowledge but poor compliance in other settings ( Nalule et al, 2020 ). One exception may be knowledge related to beliefs in the effectiveness of handgel: The interviews suggest that midwives may be somewhat sceptical about its value and if these views are widely held, interventions targeting relevant gel-related knowledge and attitudes may also be beneficial.…”

Hand Hygiene during the Early Neonatal Period: A Mixed-methods Observational Study in Healthcare Facilities and Households in Rural Cambodia

“…Adequate hand hygiene through hygienic births and clean post-natal care is the cornerstone of the WHO recommended strategies to prevent infectionrelated newborn death [5,7]. However, despite the implementation of various hand hygiene promotion strategies in healthcare facilities (HCF) [8,9], hand hygiene compliance by both health care workers, parental and other caregivers during birth and post-natal care [10,11] remains low.…”

“…For facility-based births, the early neonatal period spans multiple environments as the mother-newborn pair transition from the delivery room, to the post-natal care (PNC) room, and discharge to the home environment [5,12,13]. Each of these environments constitutes different contexts, with different primary caregivers, and different environmental, social and psychological drivers of hand hygiene practices important for newborn health [11,[14][15][16][17][18]. For example, healthcare worker compliance with hand hygiene protocols are influenced by institutional factors, such as high workload and limited staff, inadequate infrastructure, and poor gloving practices [11,14,15,19] while maternal handwashing in the home environment is influenced by emotions (nurture, disgust), availability and convenience to handwashing materials, handwashing norms, prohibitive gender norms and roles, and the level of extended family support [20][21][22][23].…”

“…However hand hygiene behaviour in this environment is under investigated as most studies focus on the immediate childbirth period [14,24,25], the neonatal period in the home environment [21,[26][27][28][29] or in the intensive care environment for sick and small newborns [30][31][32]. Studies in resource-limited settings show that newborn care is often conducted by both healthcare workers and family members in the HCF [11,33,34], and by a range of household members in the home environment [11,20,21,35]; however, there is limited attention given to understanding and targeting non-maternal caregivers' behaviours in improvement strategies.…”