title: Is essential newborn care provided by institutions and after home births? Analysis of prospective data from community trials in rural South Asia.
abstract: BACKGROUND
  Provision of essential newborn care (ENC) can save many newborn lives in poor resource settings but coverage is far from universal and varies by country and place of delivery. Understanding gaps in current coverage and where coverage is good, in different contexts and places of delivery, could make a valuable contribution to the future design of interventions to reduce neonatal mortality. We sought to describe the coverage of essential newborn care practices for births in institutions, at home with a skilled birth attendant, and at home without a skilled birth attendant (SBA) in rural areas of Bangladesh, Nepal, and India.
  
  
  METHODS
  We used data from the control arms of four cluster randomised controlled trials in Bangladesh, Eastern India and from Makwanpur and Dhanusha districts in Nepal, covering periods from 2001 to 2011. We used these data to identify essential newborn care practices as defined by the World Health Organization. Each birth was allocated to one of three delivery types: home birth without an SBA, home birth with an SBA, or institutional delivery. For each study, we calculated the observed proportion of births that received each care practice by delivery type with 95% confidence intervals, adjusted for clustering and, where appropriate, stratification.
  
  
  RESULTS
  After exclusions, we analysed data for 8939 births from Eastern India, 27 553 births from Bangladesh, 6765 births from Makwanpur and 15 344 births from Dhanusha. Across all study areas, coverage of essential newborn care practices was highest in institutional deliveries, and lowest in home non-SBA deliveries. However, institutional deliveries did not provide universal coverage of the recommended practices, with relatively low coverage (20%-70%) across all study areas for immediate breastfeeding and thermal care. Institutions in Bangladesh had the highest coverage for almost all care practices except thermal care. Across all areas, fewer than 20% of home non-SBA deliveries used a clean delivery kit, the use of plastic gloves was very low and coverage of recommended thermal care was relatively poor. There were large differences between study areas in handwashing, immediate breastfeeding and delayed bathing.
  
  
  CONCLUSIONS
  There remains substantial scope for health facilities to improve thermal care for the newborn and to encourage immediate and exclusive breastfeeding. For unattended home deliveries, increased handwashing, use of clean delivery kits and basic thermal care offer great scope for improvement.
authors.affiliation: Clinical Operational Research Unit, University College London, 4 Taviton Street, London WC1H 0BT, UK. c.pagel@ucl.ac.uk.
authors.forename: Christina
authors.initials: C
authors.lastname: Pagel
authors.forename: Audrey
authors.initials: A
authors.lastname: Prost
authors.forename: Munir
authors.initials: M
authors.lastname: Hossen
authors.forename: Kishwar
authors.initials: K
authors.lastname: Azad
authors.forename: Abdul
authors.initials: A
authors.lastname: Kuddus
authors.forename: Swati Sarbani
authors.initials: SS
authors.lastname: Roy
authors.forename: Nirmala
authors.initials: N
authors.lastname: Nair
authors.forename: Prasanta
authors.initials: P
authors.lastname: Tripathy
authors.forename: Naomi
authors.initials: N
authors.lastname: Saville
authors.forename: Aman
authors.initials: A
authors.lastname: Sen
authors.forename: Catherine
authors.initials: C
authors.lastname: Sikorski
authors.forename: Dharma S
authors.initials: DS
authors.lastname: Manandhar
authors.forename: Anthony
authors.initials: A
authors.lastname: Costello
authors.forename: Sonya
authors.initials: S
authors.lastname: Crowe
mesh_terms: D001459:Bangladesh / Q000453:epidemiology; D016000:Cluster Analysis; D036861:Delivery, Obstetric / Q000379:methods*; D003906:Developing Countries; D005260:Female; D006700:Home Childbirth; D006801:Humans; D007194:India / Q000453:epidemiology; D007226:Infant Mortality / Q000639:trends; D007231:Infant, Newborn; D008880:Midwifery / Q000458:organization & administration; D009390:Nepal / Q000453:epidemiology; D011247:Pregnancy; D011295:Prenatal Care / Q000458:organization & administration*; D011446:Prospective Studies; D012424:Rural Population