Cultural, Institutional and Policy Impact on Neonatal Safety Practice in Ethiopia: A Concept from Policy Dialogue

Abstract

The first 28 days is the most critical time for the survival of newborns and is the most essential time to intervene to reduce under-five mortality rapidly. This paper summarized the gaps found related to neonatal mortality in Ethiopia. A stakeholder discussion was held, and a dialogue report was written. From the report, three themes emerged. Institutional level readiness and safety was the first theme where the absence of enough room for neonatal care was stressed. A neonatal intensive care unit is absent in most hospitals. The attention given to neonatal death is minimal compared to labouring mothers. The cultural issue was the second theme in which mourning for the death of a newborn is forbidden. The death of the newborn is handled as a secret, and the burial place is in the backyard. Lastly, the theme of policy-level attention to neonates showed no policy direction guides the audit of neonatal death.

1. Introduction

Neonatal mortality is the probability of dying within the first month of life [1, 2]. The first 28 days is the most critical time for the survival of newborns, and it is the most essential time to intervene to reduce under-five mortality too [3] rapidly. Out of the 5.2 million global under-five deaths, about half (2.4 million, 47%) occur among neonates [4, 5].

Almost all neonatal deaths (98%) occur in low- and middle-income countries, with 78% in Southern Asia and sub-Saharan Africa. Eight of the ten countries with the highest neonatal mortality are in Africa including Ethiopia [4, 5, 6, 7].

Preterm birth, intrapartum-related complications (birth asphyxia or inability to breathe at birth), infections and congenital disabilities are the main causes of most neonatal mortality [5].

The Sustainable Development Goals (SDG) aimed to reduce neonatal mortality in all countries to at least as low as 12 per 1,000 live births. The 2021 report of SDG shows a global decline of neonatal mortality from 30 to 17 deaths per 1,000 live births [8].

The situation in Ethiopia shows that there was a slow reduction in progress between the years 2000 and 2016, which is a 41% decline when compared to the 60% reduction in under-five mortality and a 50% reduction in infant mortality in the same period [1, 9, 10].

On the other hand, the Ministry of Health of Ethiopia (MoH) planned to reduce neonatal mortality to 21 per 1000 live births at the end of 2024/25 [11]. However, the progress seems to be out of track as the rate of neonatal mortality has shown a rising trend in recent years (from 29 deaths per 1000 live births in 2016 to 33 deaths per 1000 live births in 2019) [1, 10].

Neonatal mortality declined from 46 to 35 deaths per 1000 live births among facility delivery, but the rate remains higher than that of home delivery, which declined from 38 to 30 deaths per 1000 live births. Such higher reports of facility death than that of home delivery were assumed to be associated with the limited service availability and readiness to provide basic essential newborn care services [12].

Thus, these gaps were recognized, and an evidence-based policy brief summarizing the best available evidence to describe the problem of neonatal mortality in Ethiopia and potential solutions for addressing the problem was developed. This evidence-based policy brief was then used to facilitate a stakeholders’ dialogue, highlighting and providing insight into the problem itself, its causes, and the solutions indicated in the document. The dialogue participants being from different backgrounds and organizations, the focus of the discussion was multidimensional which touched different aspects of neonatal safety and care. The cultural influence and aspect of neonatal mortality are stressed during the dialogue. The emphasis given to neonatal health issues at policy level, institutional/health facility level and societal/community level was also raised. These entail practice, safety, perception and national direction surrounding neonatal health. Hence, the authors of the evidence-based policy brief tried to summarize the idea of the dialogue participants in a structured manner so that it will be an input for policymakers, programme managers, healthcare professionals, partners working on reducing neonatal mortality and any interested stakeholders. This concept paper tried to bring comprehensive factors that are critical in improving the health of neonates.

So, the concept paper is significant for policymakers, programme managers, clinicians and other health professionals in identifying the gaps found in the health and safety of neonates. The paper also shows a fertile area where researchers can embark in the future by bringing new findings and recommendations. Moreover, this paper tried to look at the most widely overrun issue of neonatal care and safety and cultural issues that influence neonatal health. In general, this paper is expected to provide critical insight into the future of neonatal care and policy in Ethiopia.

2. Methods

A structured discussion focused on an evidence-based policy brief was held in Ethiopia for 2 days by participating key stakeholders working on neonatal health. This discussion, namely “stakeholders’ dialogue on Reducing Neonatal Mortality in Ethiopia: A Call for Urgent Action!” served as a scientific discussion platform to get and incorporate constructive evidence into a document that was produced by researchers and helped enrich the evidence-based policy brief document with more insights to inform policymakers.

The dialogue was prepared by the knowledge translation directorate at the Ethiopian Public Health Institute. This brief was prepared by a team composed of experts on evidence synthesis from the knowledge translation directorate of the Ethiopian Public Health Institute and experts on neonatal health from the Federal Ministry of Health of Ethiopia.

The dialogue was held in May 2021 for 2 days. Brief sensitization presentations on knowledge translation and health technology assessment and presentation on the prepared evidence-based policy brief were made and discussions were held. The discussions reflected on neonatal mortality with the community/societal perception of neonatal death, the facility level attention and the policy level attention given to neonatal death.

The dialogue report was translated into English and written verbatim from the note of note-takers (six note-takers). Then, based on the content of the dialogue report, thematization was carried out. Accordingly, cultural issues, institutional issues and policy-level issues were identified as three themes that emerged from the dialogue report. So, we prepared this paper based on the discussion output from different professionals, representatives, and governmental and non-governmental organizations.

2.1 Method of discussion

The policy brief document prepared by the knowledge translation team of the Ethiopian Public Health Institute (EPHI) on “Reducing Neonatal Mortality” was provided to each participant to go through the document. Then, the discussion was moderated by an experienced professor. The following rules were applied during the discussion:

• Every participant has an equal right to participate and contribute in the dialogue regardless of his/her position or the organization he/she is delegated from.

• The dialogue does not NECESSARILY aim for consensus rather, it aims to generate insight and perspectives on the issues.

• The participants should choose language for discussion; feel free to express your opinion in a language you prefer to do so.

• Chatham House Rule, which states that: “Participants are free to use the information received during the meeting, but neither the identity nor the affiliation of the speaker(s), nor that of any other participant, may be revealed,” should respected.

2.2 Participant of the dialogue

About 50 invited professionals and non-professionals from different organization participated in the meeting. Participants were invited from governmental organizations (federal, regional, zonal and district representatives), specialized hospitals which mainly focus on neonatal care, non-governmental organizations working on neonatal programmes, community representatives, the House of People’s Representatives and the Office of the Prime Minister. Professionally, participants were neonatologists, public health professionals, health extension workers (community health workers from rural and urban), clinicians, researchers, consultants, programme managers, policymakers, etc.

3. Discussion outputs

3.1 Facility-level attention to neonatal death and safety of care

The safety of care provided for neonates at the health facility level is questionable in Ethiopia. The dialogue participants stressed that there were not enough rooms for neonatal care at health facilities as all attention is given exclusively to the labouring mother during delivery. This is because maternal death is given much attention at the national level and brings accountability for incidents. A neonatal intensive care unit (NICU) is absent in most hospitals, and the available units are just for name-holding with minimum functionality. Most NICU rooms lack the necessary materials, professionals and other supplies. The location of the NICU room is usually at some corner of the corridor of hospitals with minimal space.

When a pregnant mother comes to the hospital for delivery, there will be a gynecologist, obstetrician, midwifery and other professionals for the mother. The room is equipped in a way that will support the mother during labour and birth. But in most cases, no professional is just committed to caring for the newborn. There is no pediatrician or neonatologist in the room.

The location of the neonatal room is another problem. As discussed earlier, the room committed for neonatal care is at some corner of a hospital building and is usually too far away from the delivery room. It puts newborns at risk of exposure to uncontrolled temperature when transporting them to the other room. This is worsened by a structural problem. Delivery room and neonatal room should be designed in a way that it could keep both the mother and newborn safe, which is not common here since most hospitals are initially designed without a neonatal room, and the rooms are added later to accompany the need for neonatal care now.

Whenever there is a maternal death, there will be a shock wave across the health institute where the death happened, there will be an investigation for the cause of the death, and higher officials will be part of the team to identify the cause of death and try to bring accountability. But when there is death of neonates, in most cases, nobody in the hospital and higher officials are concerned. It is common to hear such cases, and nobody is in a position to investigate the cause of death. Sometimes, the death of a newborn is reported as a stillbirth at hospitals, not to take responsibility for the death by health professionals. Such practice has the probability of under-reporting the rate of neonatal mortality in the country, suppressing the search for a solution to the problem.

A clear indication of less emphasis on the death of neonates is seen by the fact that every hospital has a team assigned to investigate the cause of every maternal death, which does not hold for neonatal death. The team is there to exhaustively analyze the cause of maternal mortality and provide a full investigation report to the next higher level. This allows the higher level to analyze the cause, categorize the issue, give feedback to the lower level, and take corrective actions.

3.2 Policy level attention to neonates and adapting best practice

As mentioned in the introductory part, reducing neonatal and maternal deaths is the top priority area of low- and middle-income countries. It is also among the global agendas. But the attention given to these two areas of priority is not uniform. Although there is a strategy for child survival, it is indicated by the dialogue participants that there is no guideline to investigate neonatal death as “There is guideline that guide the activity of practitioners to investigate and report the case of maternal death. There is a system called Maternal Death Surveillance and Report (MDSR). But, unlike the death of mothers there are no developed guidelines that help investigate the death of neonates. There is no policy direction that guide the audit and investigation of neonatal death.”

In Ethiopia, there was a movement called “No mother should die while giving birthlife,” to raise community awareness and funds for activities to reduce maternal mortality. After the initiative was started, the community and government purchased different resources like ambulances, which were committed to serving pregnant mothers. Community awareness was also focused on reducing maternal death through media, community education and other means. This initiative successfully created awareness and sensitized the community on maternal death. Unfortunately, similar or comparable initiatives are not in place to address neonatal deaths like maternal deaths. Thus, it is recommended that a direction for the future could be adapting and piloting similar initiatives and movements that have been seen to be effective in reducing maternal death burden and bringing awareness around neonatal mortality.

3.3 Community/societal perception of neonatal death

There is a perception by the community that newborns are not considered as human beings. Even their death is not recognized as human death but simply as material loss referred as ‘it disappeared’ or ‘Tefa/

’ in Amharic language and only a mother mourns the death of her neonate baby to whom the loss is real.

Culturally, it is forbidden to mourn for the death of a newborn because newborns are not considered human. There will be no tent erected for the death of a newborn like how it is done for any other person. The death of newborn is handled as a secret, and the burial place is in the backyard. But the burial place for any older individual is in a proper graveyard in a church or a selected place. There will be few or no gatherings of families, community and relatives for the death of the newborn. In most cases, the death of newborn is not announced to relatives and neighbors. But older people’s death is usually given much attention and is accompanied by many ceremonies. For the death of the old, families and relatives will be informed of the death, people will have waited to join the burial ceremony for days, and there will be a big gathering during the burial day. But for the newborn who has not started life and is not a full being yet, as the common saying goes in society, there is nothing to be done for his/her death.

Different signs are non-verbal representations of someone who has lost a close person in Ethiopia. These include making a tent in front of the home of the family of deceased, wearing black cloth, not shaving hair and beard (for males), not wearing beautifying ornaments, not using different make-ups for beautifying, etc. This norm, however, is neglected and sometimes seen as inappropriate when it comes to the death of a neonate.

4. Discussion

This concept paper was prepared to capture the pertinent points from the dialogue conducted on the evidence brief prepared on the reduction of neonatal mortality in Ethiopia. Hence, the outputs of the discussion were summarized and presented in three themes. These are institutional issues, policy-level issues and cultural issues.

Looking at institutional issues related with neonatal care, it is indicated that hospitals and other health facilities are not well equipped and safe to provide effective service to neonates. The attention given to neonates at health facilities is sub-optimal compared to the magnitude of the problem. The dialogue participants emphasized the negligence of neonatal services at health facilities compared to other services. This claim was supported by a survey that assessed the readiness of more than 100 primary hospitals in Ethiopia. The survey reported that the minimum national neonatal intensive care unit (NICU) standard requirement for infrastructure was met by only 63% of hospitals. The average number of neonatal intensive care unit-trained nurses per primary hospital was below the recommended national standard. The survey also found that the minimum national requirement for medical equipment and renewables for neonate care was met only by 24% hospitals, 65% for essential laboratory tests, and 87% for clinical services and procedures [13].

On the other hand, neonatal care during birth is given less attention at health facilities in Ethiopia, especially during birth. While everybody rushes to save the lives of the mother, neonates get neglected. Different professionals are assigned to attend delivery, but no specialized professional is assigned for neonatal care during birth. Report finding also shows that about 61% of neonatal death is accounted to poor quality of care, and only about half of maternal death is associated with poor quality of care [14].

Neonatal death is also not well counted and reported as it happens. Most of the time, neonatal death is counted and recorded as still birth. Different documents also discuss the problem of undercounting and under-reporting neonatal deaths, which in turn is a critical problem in identifying the cause of deaths and devising effective interventions [2, 5].

In Ethiopia, there was an impactful policy attention/movement on the reduction of maternal mortality. There was a visible commitment from policymakers and programme managers to the movement. This can be evidenced by the conferences being held here and there with the motto of “No woman should die while giving life,” which mainly focused on the mother, not the newborn [15, 16]. There were regular women/pregnant mother conferences and gatherings aimed to improve mother awareness of institutional delivery led by health professionals. At such conferences, the major topic discussed was institutional delivery, where neonatal mortality or safety was bypassed. Such important initiatives and attention should have also been given to neonatal care. Nevertheless, there is no such initiative that focuses on neonatal mortality.

There is a system of auditing, investigating and reporting maternal deaths in Ethiopia. Guidelines were developed, and training was also provided to health professionals working on maternal health. The guideline is a way of finding the number of mother who died during delivery, where they died and the reason for their death [17, 18]. But, no such system exists to record and study the reason for newborn death. This clearly manifests the political commitment to maternal health and sub-optimal attention to neonatal mortality. Therefore, given that the attention provided to maternal health is encouraging, similar initiatives should be expanded to care for newborns.

At the community level, the death of a newborn is not considered the death of a human being. It is kept a secret and is not known to neighbors, relatives or others. The burial process is commonly managed by the birth attendant (usually grandmothers, older women or traditional birth attendants). These practices and perceptions were confirmed by a study conducted in Ethiopia. According to the study, neonates are considered “strangers to families and neighbours” because newborns are unknown to neighbors or relatives. The study states that if a newborn is dead after birth, it is not treated as human by the culture of the society. The participants replied that mourning for the death of a newborn is not culturally acceptable. Even mourning for a newborn is considered as if it brings more bad incidents like additional death to the family [9, 19]. The burial process of a deceased newborn is in the home of the family or in the backyard, which is done with an intent to keep the death hidden. The burial process is only known to family members, few relatives and close neighbors [19].

5. Implications and recommendations

The community-level perception of the death of newborns can impact reducing the death of neonatal mortality. Such type of practice in society makes the death of newborns get less attention from decision makers, policymakers and programme managers. It also masks the investigation of the cause of neonatal death and leaves neonatal death uncounted because neonatal death remains hidden in society. So, neonatal mortality should be made public and discussed so that possible solutions can be sought at community, facility or policy level.

At the health facility, again, minimal attention was given to the death of neonates. All attention is on saving the mother, especially during labour and birth. Even though this is a positive practice, it should not be done at the expense of neonatal care, as this is a critical time to save the lives of many neonates. There is structural or institutional marginalization of neonates at the health facility level. Such marginalization of neonatal care at health facilities should be intervened by programme managers, policymakers and health professionals. As gynecologists, obstetricians and midwives are assigned to attend delivery and care for the mother, neonatologist, pediatrician or neonatal nurses should accompany the newborn to the labour ward.

There should be a system of auditing and reporting neonatal deaths so that possible interventions can be made. A team or committee that works on neonatal mortality should be established at every health facility, such as the Maternal Death Surveillance and Report (MDSR). It should be noted that improving the system of reporting neonatal mortality is a matter of human right and a means of reducing neonatal mortality.

At a policy level, even though there are guidelines and initiatives, neonatal mortality is not given due attention despite the scale of the problem. Guidelines and directives should be developed for safer neonatal care and properly reporting and counting neonatal mortality. Like that of maternal death, similar initiatives and movements should be in place to advocate for and create community awareness on the issue of neonatal safety and mortality.

To sum up, all actors including community members, policymakers and health professionals, should look at the existing gaps and work collaboratively to reverse the current trend of neonatal mortality. There should be initiatives and a supportive policy environment to support advocacy of neonatal care. The impactful initiatives implemented to reduce maternal mortality in Ethiopia should be expanded for neonatal health and safety. There should be platforms to transfer knowledge from effective interventions in other areas, like maternal care, to neonatal care. Health facilities’ wards and departments should be redesigned in a way that can enhance the health and safety of neonates.

Authors’ contributions

All authors equally participated in organizing the dialogue meeting. Throughout the entire event, all authors took notes. All authors wrote the final document after discussing the paper’s subject, structure and concept. The final text was revised and approved by all authors. The final document was read and approved by the author(s).

Funding

The dialogue meeting was organized with the support of the Partnership for Evidence and Equity in Responsive Social Systems (PEERSS). There is no funding obtained for the preparation and publication of this specific manuscript.

Competing interests

The authors declare that they have no competing interests.