Introduction
Methods
Study design
Study settings
EENC implementation
EENC practices
Intervention group
Control group
Sample size estimation
Postpartum mother-newborn pairs
Interested stakeholders
Data collection
Mail survey for health facilities
Questionnaire survey for mother-newborn pairs
Qualitative survey with interested stakeholders
Neonatal health indicators of interest
Data analysis
Results
Demographic characteristics of mother-newborn pairs
Total (N = 1298) | Guizhou Province (n = 421) | Qinghai Province (n = 280) | ||||||||
---|---|---|---|---|---|---|---|---|---|---|
Intervention (n = 599) | Control (n = 699) | t/χ2 | P | Intervention (n = 150) | Control (n = 271) | t/χ2 | P | Intervention (n = 137) | Control (n = 143) | |
Maternal | ||||||||||
Age (\(\overline{x }\)±SD) | 26.11 ± 5.44 | 26.33 ± 5.18 | 0.766# | 0.444 | 24.16 ± 6.10 | 25.73 ± 5.84 | 2.596 | 0.010 | 26.37 ± 5.12 | 26.14 ± 5.20 |
Education level | 14.096# | 0.003 | 13.028 | 0.005 | ||||||
Primary school or below | 169 (28.21) | 149 (21.32) | 37 (24.67) | 33 (12.18) | 77 (56.20) | 85 (59.44) | ||||
Junior high school | 214 (35.73) | 274 (39.20) | 85 (56.67) | 164 (60.52) | 22 (16.06) | 21 (14.69) | ||||
Senior high school | 110 (18.36) | 154 (22.03) | 18 (12.00) | 40 (14.76) | 10 (7.30) | 20 (13.99) | ||||
College or higher | 106 (17.70) | 122 (17.45) | 10 (6.67) | 34 (12.55) | 28 (20.44) | 17 (11.89) | ||||
Nationality | 22.276# | < 0.001 | 42.334 | < 0.001 | ||||||
Minorities | 298 (49.75) | 284 (40.63) | 90 (60.00) | 75 (27.68) | 136 (99.27) | 128 (89.51) | ||||
Han nationality | 301 (50.25) | 415 (59.37) | 60 (40.00) | 196 (72.32) | 1 (0.73) | 15 (10.49) | ||||
Parity | 7.490# | 0.024 | 0.537 | 0.765 | ||||||
First birth | 216 (36.06) | 228 (32.62) | 39 (26.00) | 73 (26.94) | 61 (44.53) | 48 (33.57) | ||||
Second birth | 194 (32.39) | 265 (37.91) | 42 (28.00) | 83 (30.63) | 42 (30.66) | 60 (41.96) | ||||
Third birth or above | 189 (31.55) | 206 (29.47) | 69 (46.00) | 115 (42.44) | 34 (24.82) | 35 (24.48) | ||||
Infants | ||||||||||
Birthweight (g) | 2.673# | 0.263 | — | 0.350* | ||||||
< 2500 | 13 (2.17) | 26 (3.72) | 3 (2.00) | 10 (3.69) | 5 (3.65) | 6 (4.20) | ||||
2500 ~ 4000 | 570 (95.16) | 653 (93.42) | 145 (96.67) | 252 (92.99) | 127 (92.70) | 133 (93.01) | ||||
> 4000 | 16 (2.67) | 20 (2.86) | 2 (1.33) | 9 (3.32) | 5 (3.65) | 4 (2.80) | ||||
Birth length (cm) (\(\overline{x }\)±SD) | 49.59 ± 1.76 | 50.33 ± 1.71 | 7.699 | < 0.001 | 50.41 ± 1.90 | 50.01 ± 0.69 | 3.086 | 0.002** | 49.62 ± 2.10 | 51.00 ± 2.00 |
Gestational age | 6.443# | 0.011 | 5.689 | 0.017 | ||||||
Full-term birth | 589 (98.33) | 670 (95.85) | 149 (99.33) | 257 (94.83) | 133 (97.08) | 140 (97.90) | ||||
Premature/ Low birthweight | 10 (1.67) | 29 (4.15) | 1 (0.67) | 14 (5.17) | 4 (2.92) | 3 (2.10) |
Qinghai Province (n = 280) | Sichuan Province (n = 282) | Ningxia Hui Autonomous Region (n = 315) | ||||||||
---|---|---|---|---|---|---|---|---|---|---|
t/χ2 | P | Intervention (n = 152) | Control (n = 130) | t/χ2 | P | Intervention (n = 160) | Control (n = 155) | t/χ2 | P | |
Maternal | ||||||||||
Age (\(\overline{x }\)±SD) | -0.377 | 0.707 | 26.57 ± 4.40 | 26.57 ± 4.04 | 0.202 | 0.840 | 27.37 ± 5.51 | 27.38 ± 4.63 | 0.021 | 0.984** |
Education level | 6.315 | 0.097 | — | 0.002* | 7.939 | 0.047 | ||||
Primary school or below | 5(3.29) | 2 (1.54) | 50 (31.25) | 29 (18.71) | ||||||
Junior high school | 58 (38.16) | 25 (19.23) | 49 (30.63) | 64 (41.29) | ||||||
Senior high school | 59(38.82) | 67(51.54) | 23 (14.38) | 27 (17.42) | ||||||
College or higher | 30 (19.74) | 36 (27.69) | 38 (23.75) | 35 (22.58) | ||||||
Nationality | 12.370 | < 0.001 | — | 0.461* | 1.379 | 0.240 | ||||
Minorities | 0 (0.00) | 1 (0.77) | 72 (45.00) | 80 (51.61) | ||||||
Han nationality | 152(100.00) | 129 (99.23) | 88 (55.00) | 75 (48.39) | ||||||
Parity | 4.615 | 0.100 | 19.408 | < 0.001 | 0.861 | 0.650 | ||||
First birth | 61 (40.13) | 61 (46.92) | 55 (34.38) | 46 (29.68) | ||||||
Second birth | 54 (35.53) | 62 (47.69) | 56 (35.00) | 60 (38.71) | ||||||
Third birth or above | 37 (24.34) | 7 (5.38) | 49 (30.63) | 49 (31.61) | ||||||
Infants | ||||||||||
Birthweight (g) | — | 0.940* | — | 0.351* | — | 0.402* | ||||
< 2500 | 3 (1.97) | 5 (3.85) | 2 (1.25) | 5 (3.23) | ||||||
2500 ~ 4000 | 143 (94.08) | 123 (94.62) | 155 (96.88) | 145 (93.55) | ||||||
> 4000 | 6 (3.95) | 2 (1.54) | 3 (1.88) | 5 (3.23) | ||||||
Birth length (cm) (\(\overline{x }\)±SD) | 5.635 | < 0.001* | 50.14 ± 1.48 | 49.85 ± 0.91 | -1.907 | 0.058 | 48.65 ± 1.98 | 49.97 ± 1.32 | 6.986 | < 0.001** |
Gestational age | 0.003§ | 0.954 | 2.553§ | 0.110 | 0.586§ | 0.444 | ||||
Full-term birth | 150 (98.68) | 123(94.62) | 157 (98.13) | 150 (96.77) |
Coverage of EENC core interventions
Total (N = 1298) | Guizhou Province (n = 421) | Qinghai Province (n = 280) | ||||||||
---|---|---|---|---|---|---|---|---|---|---|
Intervention (n = 599) | Control (n = 699) | t/χ2 | P | Intervention (n = 150) | Control (n = 271) | t/χ2 | P | Intervention (n = 137) | Control (n = 143) | |
SSC | 463.344# | < 0.001 | 368.234 | < 0.001 | ||||||
Any SSC | 596 (99.50) | 343 (49.07) | 149 (99.33) | 12 (4.43) | 137 (100.00) | 61 (42.66) | ||||
Time of SSC initiation post birth (min) | 331.742# | < 0.001 | — | < 0.001* | ||||||
< 1 | 507 (85.07) | 75 (21.87) | 138 (92.62) | 0 (0.00) | 88 (64.23) | 60 (98.36) | ||||
1 ~ 10 | 89 (14.93) | 211 (61.52) | 11 (7.38) | 5 (41.67) | 49 (35.77) | 0 (0.00) | ||||
11 ~ 59 | 0 (0.00) | 36 (10.50) | 0 (0.00) | 5 (41.67) | 0 (0.00) | 1 (1.64) | ||||
≥ 60 | 0 (0.00) | 21 (6.12) | 0 (0.00) | 2 (16.67) | 0 (0.00) | 0 (0.00) | ||||
SSC duration (min) | 535.143# | < .0001 | — | < 0.001* | ||||||
< 10 | 15 (2.52) | 136 (39.65) | 2 (1.34) | 7 (58.33) | 3 (2.19) | 24 (39.34) | ||||
10 ~ | 51 (8.56) | 132 (38.48) | 0 (0.00) | 2 (16.67) | 23 (16.79) | 29 (47.54) | ||||
30 ~ | 40 (6.71) | 70 (20.41) | 9 (6.04) | 3 (25.00) | 2 (1.46) | 7 (11.48) | ||||
60 ~ | 25 (4.19) | 3 (0.87) | 3 (2.01) | 0 (0.00) | 1 (0.73) | 0 (0.00) | ||||
≥ 90 | 465 (78.02) | 2 (0.58) | 135 (90.60) | 0 (0.00) | 108 (78.83) | 1 (1.64) | ||||
Breastfeeding | ||||||||||
Successful first-time breastfeeding with provision of SSC | 523 (87.75) | 270 (78.72) | 2.381# | 0.123 | 147 (98.66) | 5 (41.67) | — | < 0.001* | 133 (97.08) | 61 (100.00) |
Any breastfeeding | 579 (96.66) | 641 (91.70) | 12.823# | < 0.001 | 149 (99.33) | 238 (87.82) | 17.232 | < 0.001 | 135 (98.54) | 140 (97.90) |
Initiation (min) | 25.898# | < 0.001 | 34.615 | < 0.001 | ||||||
≤ 60 | 526 (90.84) | 515 (80.35) | 146 (97.99) | 180 (75.63) | 134 (99.26) | 105 (75.00) | ||||
61 ~ 90 | 32 (5.53) | 67 (10.45) | 0 (0.00) | 10 (4.20) | 1 (0.74) | 30 (21.43) | ||||
> 90 | 21 (3.63) | 59 (9.20) | 3 (2.01) | 48 (20.17) | 0 (0.00) | 5 (3.57) | ||||
Duration (min) | 47.046# | < 0.001 | 47.243 | < 0.001 | ||||||
< 10 | 80 (13.82) | 62 (9.67) | 6 (4.03) | 27 (11.34) | 62 (45.93) | 17 (12.14) | ||||
10 ~ | 178 (30.74) | 221 (34.48) | 47 (31.54) | 79 (33.19) | 71 (52.59) | 32 (22.86) | ||||
20 ~ | 73 (12.61) | 172 (26.83) | 19 (12.75) | 81 (34.03) | 0 (0.00) | 55 (39.29) | ||||
30 ~ | 248 (42.83) | 186 (29.02) | 77 (51.68) | 51 (21.43) | 2 (1.48) | 36 (25.71) | ||||
Exclusive breastfeeding | 536(92.57) | 409(63.80) | 131.476# | < 0.001 | 142 (95.30) | 96 (40.34) | 116.922 | < 0.001 | 133 (98.52) | 112 (80.00) |
No applied medicine to the umbilical cord | 590 (98.50) | 68 (9.73) | 1042.438# | < 0.001 | 147 (98.00) | 1 (0.37) | 403.733 | < 0.001 | 134 (97.81) | 65 (45.45) |
Routine eye care | 558(93.16) | 61(8.73) | 965.278# | < 0.001 | 150 (100.00) | 0 (0.00) | 421.000 | < 0.001 | 135(98.54) | 59(41.26) |
Intramuscular injection of vitamin K1 | 589(98.33) | 622(88.98) | 71.015# | < 0.001 | 149(99.33) | 270 (99.63) | 0.000§ | 1.000 | 137 (100.00) | 142 (99.30) |
Qinghai Province (n = 280) | Sichuan Province (n = 282) | Ningxia Hui Autonomous Region (n = 315) | ||||||||
---|---|---|---|---|---|---|---|---|---|---|
t/χ2 | P | Intervention (n = 152) | Control (n = 130) | t/χ2 | P | Intervention (n = 160) | Control (n = 155) | t/χ2 | P | |
SSC | 111.094 | < 0.001 | 8.959§ | 0.003 | 4.208§ | 0.040 | ||||
Any SSC | 151 (99.34) | 121 (93.08) | 159 (99.38) | 149 (96.13) | ||||||
Time of SSC initiation post birth (min) | — | — | — | < 0.001* | 244.389§ | < 0.001 | ||||
< 1 | 132 (87.42) | 8 (6.61) | 149 (93.71) | 7 (4.70) | ||||||
1 ~ 10 | 19 (12.58) | 91 (75.21) | 10 (6.29) | 115 (77.18) | ||||||
11 ~ 59 | 0 (0.00) | 17 (14.05) | 0 (0.00) | 13 (8.72) | ||||||
≥ 60 | 0 (0.00) | 5 (4.13) | 0 (0.00) | 14 (9.40) | ||||||
SSC duration (min) | 113.372 | < 0.001 | 233.929 | < 0.001 | 167.786 | < 0.001 | ||||
< 10 | 2 (1.32) | 44 (36.36) | 8 (5.03) | 61 (40.94) | ||||||
10 ~ | 2 (1.32) | 25 (20.66) | 26 (16.35) | 76 (51.01) | ||||||
30 ~ | 4 (2.65) | 50 (41.32) | 25 (15.72) | 10 (6.71) | ||||||
60 ~ | 16 (10.60) | 1 (0.83) | 5 (3.14) | 2 (1.34) | ||||||
≥ 90 | 127 (84.11) | 1 (0.83) | 95 (59.75) | 0 (0.00) | ||||||
s | ||||||||||
Successful first-time breastfeeding with provision of SSC | 0.642§ | 0.423 | 148 (98.01) | 103 (85.12) | 15.664 | < 0.001 | 95 (59.75) | 101 (67.79) | 2.147 | 0.143 |
Any breastfeeding | 0.000§ | 1.000 | 143 (94.08) | 119 (91.54) | 0.686 | 0.407 | 152 (95.00) | 144 (92.90) | 0.611 | 0.435 |
Initiation (min) | 35.569 | < 0.001* | 2.691 | 0.260 | 13.737 | < 0.001 | ||||
≤ 60 | 134 (93.71) | 106 (89.08) | 112 (73.68) | 124 (86.11) | ||||||
61 ~ 90 | 3 (2.10) | 7 (5.88) | 28 (18.42) | 20 (13.89) | ||||||
> 90 | 6 (4.20) | 6 (5.04) | 12 (7.89) | 0 (0.00) | ||||||
Duration (min) | 125.772 | < 0.001 | — | < 0.001 | 6.432 | 0.092 | ||||
< 10 | 0 (0.00) | 9 (7.56) | 12 (7.89) | 9 (6.25) | ||||||
10 ~ | 10 (6.99) | 42 (35.29) | 50 (32.89) | 68 (47.22) | ||||||
20 ~ | 16 (11.19) | 6 (5.04) | 38 (25.00) | 30 (20.83) | ||||||
30 ~ | 117 (81.82) | 62 (52.10) | 52 (34.21) | 37 (25.69) | ||||||
Exclusive breastfeeding | 24.250 | < 0.001 | 127 (88.81) | 96 (80.67) | 3.396 | 0.065 | 134 (88.16) | 105 (72.92) | 11.048 | 0.001 |
No applied medicine to the umbilical cord | 93.283 | < 0.001 | 150 (98.68) | 2 (1.54) | 266.132 | < 0.001 | 159 (99.38) | 0 (0.00) | 311.025 | < 0.001 |
Routine eye care | 107.880 | < 0.001 | 152 (100.00) | 0 (0.00) | 282.000 | < 0.001 | 121 (75.63) | 2 (1.29) | 182.784 | < 0.001 |
Intramuscular injection of vitamin K1 | 0.000§ | 1.000 | 152 (100.00) | 130 (100.00) | — | — | 151 (94.38) | 80 (51.61) | 73.619 | < 0.001 |
Neonatal health indicators
Model 1 | Model 2a | |||||||
---|---|---|---|---|---|---|---|---|
OR | 95% CI | \(S_{{\overline{X} }}\) | P | OR | 95% CI | \(S_{{\overline{X} }}\) | P | |
Neonatal diarrhea | 0.327 | 0.123, 0.867 | 0.498 | 0.025 | 0.326 | 0.123, 0.865 | 0.498 | 0.024 |
Umbilical infection | 2.292 | 0.547, 9.592 | 0.731 | 0.256 | 2.278 | 0.544, 9.539 | 0.731 | 0.260 |
Eye infection | 0.147 | 0.045, 0.483 | 0.608 | 0.002 | 0.147 | 0.045, 0.483 | 0.608 | 0.002 |
Neonatal mortality | 0.393 | 0.082, 1.890 | 0.802 | 0.244 | 0.391 | 0.081, 1.884 | 0.802 | 0.242 |
EENC satisfaction of stakeholders
Theme category | Main findings | Quotations |
---|---|---|
Satisfaction | ||
Recognition | EENC-recommended practices gained wide acceptance of policymakers and health staff | "Positive feedback from the newborn’s family members means that EENC is acceptable and applicable." (a policymaker in the intervention group of Sichuan Province) |
"We are highly willing to implement EENC practices. After the EENC implementation, we are delighted to observe the health benefits, and our traditional conceptions have changed. Particularly, SSC, umbilical cord care, as well as eye care, bring benefits not merely to us, but also to mothers and newborns." (a health staff in the intervention group of Sichuan Province) | ||
Policy | The positive effects of EENC implementation promoted the establishment of principles on neonatal health at both county and hospital levels | "We issued some health policies to promote EENC. For example, the 'Safe Neonatal Project' has been listed to our 13th Five-Year Plan. In the next five years, we will continuously incorporate this project into the 14th Five-Year Plan, as the focus of newborn health improvement." (a policymaker in the intervention group of Guizhou Province) |
Emotion | EENC practices, particularly SSC, improved mothers' happiness | "One mother said: it is really such a great feeling! I am so happy!" (a health staff in the intervention group of Sichuan Province) |
SSC strengthened parent–child bonding | "My baby was put on my breast immediately after birth, and there was a good sense of intimate attachment between by little baby and me. I felt so excited and happy. (Interviewer: Is this feeling different from your previous two babies? Mother: I feel more intimate with this one)." (a postpartum mother receiving SSC in the control group of Qinghai Province) | |
Health outcomes | EENC implementation was perceived to be associated with reduced incidence risk of neonatal hypothermia and umbilical cord infection, and neonatal mortality | "Before EENC introduction, newborns were separated from their mothers after delivery, and the incidence risk of hypothermia was quite high. However, hypothermia incidents have decreased considerably since EENC practices were implemented among pregnant women who delivered vaginally in 2018." (a health staff in the intervention group of Ningxia Hui Autonomous Region) |
"I notice that after EENC implementation, the incidence risk of umbilical infection has been reduced distinctly, and the occurrence is scarcely observed." (a health staff in the intervention group of Qinghai Province) | ||
Sustainability | Most interviewees expressed their determination to continue to implement EENC-recommended practices | "EENC-recommended practices should be further scaled up in our poverty-stricken areas." (a health staff in the intervention group of Ningxia Hui Autonomous Region) |
Work support | The implementation of EENC provides support for health workers, including improvement of professional skills, standardization of vital clinical practices, and conservation of medical consumables | "Some practices, including eye care, and vitamin K1 administration, are simple and easy to operate, which may partly explain the reason for the successful scale-up in our pilot hospital."(a health staff in the intervention group of Ningxia Hui Autonomous Region) |
"EENC promotes exclusive breastfeeding, which reduces neonatal diarrhea and allergies induced by breastfeeding substitutes. The health effects in turn alleviate our routine workload." (a health staff in the intervention group of Guizhou Province) |