How neonates are treated in west Africa: adding to the evidence
Authors: Adama Baguiya
Journal: The Lancet Global Health (2020)

Good, respectful intrapartum care is a fundamental aspect of the rights of mothers and neonates to be treated with dignity, particularly during childbirth and the postnatal period. The Article by Emma Sacks and colleagues,1Sacks E Mehrtash H Bohren M et al.The first 2 h after birth: prevalence and factors associated with neonatal care practices from a multicountry, facility-based, observational study.Lancet Glob Health. 2021; 9: e72-e80Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar published in The Lancet Global Health, studied neonatal care practices in three west African countries and comes after the primary analysis of the same project, which focused on how women in three west African countries and Myanmar are treated during childbirth.2Bohren MA Mehrtash H Fawole B et al.How women are treated during facility-based childbirth in four countries: a cross-sectional study with labour observations and community-based surveys.Lancet. 2019; 394: 1750-1763Summary Full Text Full Text PDF PubMed Scopus (96) Google Scholar It is very encouraging to see that neonates were not left out of such a valuable project. The Article findings provide a useful contribution to the body of evidence on how neonates are treated, particularly in a low-income country setting. As suggested by previous research,3Tuncalp Ö Were WM MacLennan C et al.Quality of care for pregnant women and newborns—the WHO vision.BJOG. 2015; 122: 1045-1049Crossref PubMed Scopus (375) Google Scholar in efforts to ensure a good quality of health care during pregnancy and childbirth, we should care not only for the mothers, but also for the neonates, and take a mother–neonate dyad perspective. In their analysis, Sacks and colleagues not only added their voices to the call to consider neonotes, but also quantified the prevalence of mistreatment of neonates immediately after birth in resource-constrained countries.1Sacks E Mehrtash H Bohren M et al.The first 2 h after birth: prevalence and factors associated with neonatal care practices from a multicountry, facility-based, observational study.Lancet Glob Health. 2021; 9: e72-e80Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar The authors found a high prevalence of practices that can be classified as mistreatment. We believe the amount of mistreatment could be even higher, and might have been underestimated by the study because of the Hawthorne effect (ie, the modification of actor behaviour in response to the presence of an observer). Nevertheless, this view does not affect the validity of the results, or the relevance of the interpretation, provided in the Article. Data on neonatal mortality and morbidity indicate that the first 2 h after birth are crucial. Yet, because this period is also crucial to maternal survival, health workers might inadvertently put more effort into caring for the mother than for the neonate, unless there are enough adequately skilled staff and the environment enables good-quality care of neonates. Sacks and colleagues raised serious concerns about a failure to provide recommended care and about the potential physical mistreatment of neonates. The concept of mistreatment is neither unambiguous nor standardised. A review by Larson and colleagues4Larson E Sharma J Nasiri K et al.Measuring experiences of facility-based care for pregnant women and newborns: a scoping review.BMJ Global Health. 2020; 5e003368Crossref PubMed Scopus (3) Google Scholar highlighted alarming gaps in the measurement of user experience for maternal and neonatal care, including an absence of validated tools to measure the effects of interventions and policies on user experience. Therefore, a lot of work is required to reach agreement on what does and does not constitute neonatal mistreatment. This process should consider differences in cultural background, social norms, and medical practices, and the contributions of local researchers and care providers are also required. As suggested by Sacks and colleagues,1Sacks E Mehrtash H Bohren M et al.The first 2 h after birth: prevalence and factors associated with neonatal care practices from a multicountry, facility-based, observational study.Lancet Glob Health. 2021; 9: e72-e80Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar some of what is considered to be mistreatment might not be considered as such by the care providers themselves, depending on the context, their background and knowledge of neonatal care, and what they think the neonate might, or might not, need. This difference might also explain why, although some babies did not receive recommended care, in the meantime care providers did tasks such as routine suctioning that are not recommended. Some of these bad practices could be full of good intentions. Also, in the settings in which the study was done, often there is a shortage of skilled staff for emergency obstetric and neonatal care, and inadequate amounts of equipment available. At times, health workers have to make difficult choices, balancing how to handle the mother with how to handle her baby throughout this crucial period, and it is no surprise if, unfortunately, they tend to care more for the mother than for the neonate. Little is known about why some neonates are left unattended, slapped, or held upside down. As part of future research, a qualitative study could help to better understand the context, perception, and perspective of care providers and mothers, concerning how neonates should be treated. For now, these findings should be used to advocate for a substantial change that will require efforts at different levels and beyond care providers, to thoroughly assess health facilities and the needs of their staff to improve or provide respectful maternity care for both mothers and neonates. Although there is no consensus on what constitutes mistreatment, or not, some practices highlighted in the Article should clearly not be sustained. Neonates should be treated with equity and dignity, regardless of the origin and characteristics of their mothers and families. Regardless of its frequency and statistical significance, denying care to a newborn baby because the family did not pay is mistreatment of the baby, and psychologically punishing to the mother and family. It is definitely not a good way of welcoming a baby into the world. We should be thankful to the authors for raising this issue and for calling for such practices to end. I declare no competing interests. The first 2 h after birth: prevalence and factors associated with neonatal care practices from a multicountry, facility-based, observational studyA high proportion of neonates did not receive recommended care practices, and some received practices that might constitute mistreatment. Further research is needed on understanding and measuring mistreatment to improve care, including respectful care, for mothers and neonates. Full-Text PDF Open Access