3.3 Newborn Care at Household/Community Level

Photo credits: IRC/Kelli Ryan

• Identify pregnant women early through outreach and community informants, or through an antenatal care register at the local health facility.
• Conduct an initial visit with pregnant women in their homes. Identify women in preterm labor and refer to nearest health facility for care.
• At that visit, promote the use of formal health facilities for antenatal care, birth and postnatal care.

Provide information to families and community leaders about the closest facility, including mobile clinics, location, hours of operation and options for transport to the facility, including emergency transport. In crisis settings where access to facilities is not safe or is not possible with additional resources, ENCabbreviation services can be provided through ongoing home visits (Section 5.3). While WHOabbreviation recommends eight antenatal visits commencing early in pregnancy (first trimester),^[1] a minimum of four is recommended in humanitarian settings.

Key activities in this period center around birth preparedness and complication readiness, including developing a birth plan with the woman and family that includes emergency transport, security and monetary considerations.

• To ensure a clean delivery, families should be provided with a clean delivery kit (Box 3.5) with instructions on how to use it in the event that healthcare facilities are inaccessible or unavailable.
• Counsel women on nutrition during pregnancy, reduced workload, risk of the particular infectious disease outbreaks that might increase burden of disease (if known).
• Provide health education on prematurity, preterm labor and care for small babies.

To prevent/manage infections:

• In malaria endemic areas, distribute ITNabbreviation to pregnant women for use during pregnancy and after birth, and educate women and families how to use the ITNs (e.g., after birth, the newborn sleeps with the mother under the ITNabbreviation).
• Provide TTabbreviation vaccination as required and screening and treatment for STIsabbreviation. Where this is not possible, counsel women to visit the local health center as soon as possible in order to access HIVabbreviation, STIabbreviation and malaria interventions, as well as vaccinations.

The importance of safe and respectful birth practices should also be introduced during pregnancy visits. One of the most critical interventions to prevent maternal and newborn death is the provision of respectful and quality care by skilled birth attendants in a health facility that is equipped with drugs and medical supplies needed to manage complications.

• Encourage birth in a health facility, but counsel families that if a birth happens to/is being planned to take place at home, they should arrange for a SBAabbreviation to assist with the home birth and/or should go to the health facility as soon after birth as possible for an examination of both mother and baby.
• Emphasize that mother and baby should not be separated, particularly immediately after birth.
• Discuss early and exclusive breastfeeding, cleanliness and safe newborn care.

Photo credits: Jhpiego

No birth is without risk and therefore all should be supported by a skilled birth attendant with access to referral care if complications arise.

• If labor (including premature) begins at home, support transfer to a health facility.
• During the birth, implement clean and respectful birth practices (Box 3.6 and Figure 3.2)
• Provide thermal care by immediately, thoroughly drying the baby and placing the baby on mother’s chest until the first breastfeeding, including colostrum (initiated usually within the first hour of birth where possible).
• For all newborns who are breathing at birth and do not require resuscitation, do not bulb suction the mouth and nose, and do not clamp the cord for at least one minute after birth.^[2] For further details on cord clamping, see Box 3.7
• For babies who don’t start spontaneous breathing within 60 seconds clear the airway and immediately start tactile stimulation by rubbing the back and thorough drying.info See Box 3.8 and Figure 3.3 for further guidance.

Photo credits: UNICEF/NYHQ2010-0266/Noorani

During the immediate postnatal period (within the first hour of birth)

• Ensure that the mother and newborn are not separated; continue thermal care by placing the baby, skin-to-skin, on the mother’s chest, and covering with a blanket and hat, for at least 60 minutes and until initiation of exclusive breastfeeding (usually within one hour) (Box 3.2).
• Assess breastfeeding and provide support where needed.
• Delay bathing the newborn for at least 24 hours to prevent heat loss and hypothermia.
• Monitor for danger signs (Box 3.3 and Box 3.4) and if danger signs are present, refer mother and baby to the nearest hospital for advanced care. Timely referral is critical to reduce mortality and morbidity. Where referral is not possible, please see Table 3.1 for further guidance.
• Continue clean practices such as handwashing for those handling the newborn to prevent infections (Figure 3.2).
• Provide clean dry cord care. In settings where the application of harmful substances on cords is prevalent, apply 4% CHXabbreviation (7.1% digluconate gel or liquid) to the cord (Box 3.9), in line with national guidelines.
• Educate women and families to look for danger signs (Box 3.3), and to seek care promptly when they are detected.
• Identify, support and if necessary refer newborns who need additional care

In case of Intrapartum Complications

• Transfer newborns with any evidence of complications, including breathing difficulties, for more advanced care as soon as logistically feasible.
• If CHWs or other cadres are trained to assist in home deliveries, they should have knowledge of the referral system and where advanced care is available nearest to the household before the birth, in case complications arise (see Section 5.2. Developing a Referral System).

For pre-term and/or LBWabbreviation babies

• Refer all babies born before 37 weeks gestation and/or all LBWabbreviation newborns (< 2500g/5.5 lb) to more advanced care (ideally, in a formal hospital setting; see below).
• Place all babies weighing less than 2500g/5.5 lb in STSabbreviation position with their mother or a surrogate and take them immediately to a health facility for follow up.

During the first week after birth (second hour following birth up to seven days)

For home births, ensure that a skilled health personnel or a trained community health workers is contacted to:

• Conduct postnatal care checks (i) as soon as possible within the first 24 hours, (ii) between 48–72 hours, (iii) between day 7-14 (iv) during week 6 after birth. Most maternal and neonatal deaths occur in the first three days after birth, in particular on the day of birth, with another increase in mortality during the second week after birth. It is therefore important that visits take place during these key windows to provide continuity of quality and respectful care. Home visits from trained health workers during the first week after birth are recommended for babies and women that are healthy and do not require additional care. Where home visits are not feasible or not preferred, outpatient postnatal care contacts are recommended.
• Weigh the newborn baby using a newborn weighing scale or a foot length card that has been calibrated to the local setting and record birth weight appropriately.
• Provide eye care by giving the baby a single dose of tetracycline hydrochloride 1% eye ointment in each eye for prevention of conjunctivitis.
• Provide the newborn with 1 mg of vitamin K intramuscularly (IM) and provide immediate vaccination according to national vaccination protocol. Commonly used vaccines for newborns immediately after birth are hepatitis B, Polio and BCGabbreviation for tuberculosis. Encourage hepatitis B vaccine in areas of high Hepatitis B endemicity.^[3]
• Continue health promotion activities including promotion of exclusive breastfeeding, thermal care for the baby, hand washing for people touching the baby and hygienic cord and skin care.
• Continue to examine the baby for danger signs of serious illnesses, and continue to encourage the family to look for these danger signs (Box 3.3 and Box 3.4) and promote appropriate care seeking behaviour
• If danger signs are detected, facilitate access for the mother and baby to the closest health facility or hospital.
• Encourage HIVabbreviation-positive mothers to access HIVabbreviation testing and other care for their newborns.
• Inform women and families of the importance of an immunization visit for the newborn at 6 weeks.

For pre-term and/or LBWabbreviation babies

• Follow-up on all preterm and LBWabbreviation (<2500gs) babies after birth at home or discharge from the health facility through extra postnatal visits, preferably at home. These should occur on within the firs 24 hours, (ii) between 48-72 hours, (iii) between day 7-14..
• Ensure immediate referral to facility-based care for newborns showing any danger signs (Box 3.3) as well as signs of jaundice (Box 3.10).

For babies exhibiting danger signs

Where referral or hospitalization is not possible, recent guidelines from WHOabbreviation^[4] provide recommendations for antibiotic regimens provided by trained health care providers. Note that critical illness should always be treated in hospital and not outpatient facilities. If families refuse hospitalization or referral is not possible, the following recommendations (Table 3.1) should be considered by a trained health provider to provide an outpatient treatment of infection. Treatment regimens should be informed by disease surveillance systems when feasible and appropriate, to ensure treatment approaches consider local antimicrobial resistance trends.

Source: WHO. Managing Possible Serious Bacterial Infection in Young Infants when Referral is Not Feasible. WHO, 2015.