Effect of maternal education and encouragement on newborn care utilization: a health system intervention

This health system intervention was performed in the urban health centers of the two catchment areas of Tehran Defined Population, which covered 10 of the 22 municipality districts of Tehran. The two catchment areas included 10,000 families in the intervention and 20,000 families in the control areas. The census method was used for the selection of both intervention and control groups. The intervention group included all 1544 newborns in intervention areas of TDP who were born from November 2017 until August 2018 and were referred to UHCs for mandatory newborn screening tests. The study’s control group included all 3293 newborns born in the same period in control areas of TDP and were referred to UHCs for newborn screening tests. Newborns were followed until the end of the second month of life. The intervention included newborn-care-oriented education and encouraging parents to utilize NBC services. The control group received conventional care at UHCs. The utilization of newborn care was compared among the intervention and control groups.

This study was performed in the two catchment areas of Tehran Defined Population (TDP). TDP includes two areas, intervention and control, which form a defined population representative of Tehran [10, 11].

The intervention areas include 10,000 families, 40,000 individuals under the coverage of health services provided by 10 UHCs in 10 municipality districts of the total 22 districts in Tehran. These ten districts consist of two districts from each of the five socioeconomic regions of the city, including north, east, center, west, and south, according to the Tehran Urban Health Equity Assessment and Response Tool study (Urban HEART) [12]. To care for potential selection bias, the control areas are were selected to be the neighboring areas of the intervention areas, as presented in Fig. 1. The control areas include almost 20,000 families, 80,000 individuals. Thus, the intervention group and the control group would be matched in terms of socioeconomic status and access to healthcare.

Both public and private sector provide newborn care services in Iran:

Like all other Iran cities, NBC and screening tests in Tehran are available in the public sector for all newborns in UHCs free of charge. All newborns need to complete at least 17 NBCVs, which start from the third day after birth to 72 months. This study focuses on the first three NBCVs, which have recently been added to NBC’s schedule, which are to be performed in the first 2 months after birth. According to the national guideline, the first visit should be performed in the first 3–5 days of life, the second in 14–15 days, and the third in 30–45 days. The guideline of Iran is consistent with the World Health Organization recommendations on postnatal care of mother and newborn [13, 14]. The main components of NBC include assessment of the general appearance of the newborn, neonatal jaundice, weight, height, head circumference, vision, and developmental milestones; immunization; iron and folic acid supplementation; and counseling about breastfeeding, nutrition, maternal and neonatal hygiene, and family planning [14]. Screening tests are mandatory and should be carried out three to 5 days after birth. The tests include screening for phenylketonuria, congenital hypothyroidism, and glucose-6-phosphate-dehydrogenase deficiency. Screening tests of newborns who require hospitalization are carried out in the hospitals [8]. Midwifery graduates provide NBC in the UHCs. Newborns are referred to the attending general practitioners in the UHCs in cases of warning signs such as low birth weight, jaundice, infection, poor milk sucking, cyanosis, craniosynostosis, and not reaching the developmental milestones. The general practitioners then refer newborns to pediatricians if needed [14]. It is noticeable that the first dose of oral poliomyelitis, hepatitis B virus; and BCG vaccines were administered for neonates at hospital at the time of discharge.

Newborns could receive NBC services from the private sector at the pediatricians’ office and the hospitals’ pediatric clinics, for which they will be charged. Laboratories of hospitals or private laboratories also provide screening tests. The out-of-pocket costs vary based on the type of medical insurance.

Unlike the public sector, the focus of the pediatricians in the private sector is more on treatment rather than prevention. Although they usually follow the national guidelines of NBC in terms of the schedule and the treatment measures, they do not emphasize prevention aspects, supporting breastfeeding, and maternal education as much as healthcare providers in the public sector. The reason could be the lack of enough training on prevention in the medical curriculum [15].

The intervention included newborn-care-oriented education and encouraging parents to utilize NBC services. This process encompassed providing in-person health education, reinforcing the vital role of prompt NBC in the wellbeing of newborns, explaining the components of a standard NBCV, and distributing healthcare-oriented pamphlets and booklets. Healthcare providers in UHCs were assigned verbal education of parents in the intervention group about the role of NBC in improving their newborns’ health, based on a pre-prepared passage, which was the same in all the UHCs. They would also encourage and remind parents to bring their children for newborn care. Mothers in the control group would receive the conventional NBC services with the same quality from midwives in a shared room in the UHC. Less time would be allocated for their education or encouragement.

The inclusion criteria were living in the catchment area for the intervention group and the surrounding neighborhoods for the control group and parents’ consent to participate. Newborns who had severe health conditions and therefore were admitted to hospital or needed follow-up by specialists, died in the first 2 months of life or were lost track of due to reasons like moving out of the covered districts of TDP were excluded.

The census method was used for the selection of both intervention and control groups. The intervention group included all newborns in intervention areas of TDP who were born from November 2017 until August 2018 and were referred to UHCs for mandatory newborn screening tests. The study’s control group included all newborns born in the same period in control areas of TDP and were referred to UHCs for newborn screening tests.

Among 4870 (intervention = 1551, control = 3319) newborns included in the study, 33 were excluded from, and finally data of 4837 (intervention = 1544, control = 3293) were analyzed. A more detailed flowchart for sampling is shown in Fig. 2.

Variables included parents’ sociodemographic characteristics, mothers’ age at the time of marriage, number of alive children, type of birth, place of screening tests, time and place of NBCVs, healthcare providers, and whether families were encouraged to perform NBC while going for the screening tests. Data were recorded at the time of visits or collected from written medical records.

The mean (SD) age of mothers was 29.3 (4.9) in the intervention group and 29.9 (5.0) in the control group. The mean (SD) age of mothers at the time of marriage was 22.5 (4.3) in the intervention group and 22.8 (4.6) in the control group. The mean (SD) age of fathers was 33.7 (5.4) in the intervention group and 34.3 (5.8) in the control group. Other sociodemographic characteristics of parents are presented in Table 1.

Some 57% of newborns in the intervention group and 37% in the control group received all their three NBCVs. The number of newborns who did not complete all their three NBCVs and had one or two NBCVs was higher in the control group. In addition, 9% of newborns in the intervention group and 14% in the control group did not receive any NBCVs. Newborn care utilization among the intervention and control group is presented in Table 2.

The number of newborns who received NBCVs increased from the first to the third visit, as 1007 (65.2) newborns in the intervention group, and 1583 (48.1) in the control group received their first NBCV; 1176 (76.2) newborns in the intervention group and 1880 (57.1) in the control group received their second NBCV, and 1304 (84.5) newborns in the intervention group and 2609 (79.2) in the control group received their third NBCV. The number of NBCVs was higher among newborns in the intervention group, those brought to UHCs for screening tests, and those whose parents were encouraged to perform NBCVs. In addition, attendance in the first NBCV was higher among newborns born via normal vaginal delivery (Table 3). No significant correlations were found between the mean number of NBCVs and number of alive children, mothers’ age, their level of education, the age of mothers at the time of marriage, type of birth, and fathers’ age, level of education, their job, and whether their family has medical insurance.

Among all newborns, 721 (51.5) in the intervention group and 953 (33.7) in the control group received all their three NBCVs in UHCs; 28 (1.8) in the intervention group, and 108 (3.3) newborns in the control group at pediatricians’ office; and 23 (1.5) in the intervention group, and 18 (0.5) newborns in the control group at pediatric clinics of hospitals. Other newborns received NBC services from more than one healthcare provider. Therefore, the proportion of each healthcare provider was calculated according to the number of total NBCVs. Of the total 4632 NBCVs for the intervention group, three per newborn, 3487 (75.3) were received. Of the total 9879 NBCVs for the control group, three per newborn, 6072 (61.5) were received. UHCs were the main healthcare facilities for NBC, as 3046 (87.4) visits in the intervention group and 5064 (83.4) in the control group were performed in UHCs.

The main place for screening tests was UHCs. Other healthcare facilities for screening tests are presented in Table 4. Only six newborns in the intervention group and 18 newborns in the control group did not have their screening tests. As many as 1188 (76.9) parents in the intervention group and 1286 (39.1) parents in the control group had been encouraged to perform NBCVs while going for screening tests. In addition, newborns who did their screening tests in UHCs were more likely to complete all the three NBCVs compared to those who did their screening tests in pediatricians’ office or pediatric clinic in hospital: 1826 (45.6%); 95% CI [44.0, 47.1] versus 265 (32.0%); 95% CI [28.8, 35.1], p < 0.001.

As many as 2590 newborns received the first NBCV: 546 (21.0) newborns were born through normal birth, among whom 492 (90.1) newborns were brought to healthcare facilities by their mothers for the first NBC; and 2046 (79.0) newborns were born through caesarian section, among whom 1553 (75.9) were brought to healthcare facilities by their mothers.

This is the first population-based interventional study to focus on the effect of encouragement and active follow-up on bringing newborns for NBCVs and utilizing newborn care services in Tehran. The study was conducted in the Tehran Defined Population catchment area, which forms a defined population representative of Tehran. The study included an intervention group and a control group, who were selected via census sampling from the same catchment area to eliminate the confounding variables. Both groups were matched in terms of socioeconomic status. In addition, the study included a large sample and multiple UHCs.

Newborns who, due to any reason, needed to be hospitalized or receive further care by specialists could not be followed, which was the limitation of the study.