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Ronald P. Parlato, Gary L. Darmstadt,
and Anne Tinker

Saving Newborn Lives Initiative

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© Save the Children 2004

All rights reserved. Publications of Saving Newborn Lives initiative SAVING NEWBORN LIVES INITIATIVE, supported by the
of Save the Children can be obtained from Saving Newborn Lives, Bill & Melinda Gates Foundation, is a global initiative to improve
Save the Children US, 2000 M Street NW, Suite 500,Washington, the health and survival of newborns in the developing world. Sav-
DC 20036 (tel: 202-293-4170; fax: 202-637-9362). Requests for ing Newborn Lives works with governments, local communities
permission to reproduce or translate SNL publications for non- and partner agencies in developing countries to make progress
commercial distribution should be addressed to SNL Public toward real and lasting change in newborn health.
Affairs Department at the above address.
SAVE THE CHILDREN is a leading international nonprofit
Save the Children does not warrant that the information con-
child-assistance organization working in over 40 countries world-
tained in this publication is complete and correct and shall not be
wide, including the United States. Our mission is to make lasting
liable for any damages incurred as a result of its use.
positive change in the lives of children in need. Save the Children
is a member of the international Save the Children Alliance, a
Printed in the United States of America.
worldwide network of 30 independent Save the Children organi-
Editor: Robin Bell zations working in more than 100 countries to ensure the well-
Editorial and design assistance: Julia Ruben being and protect the rights of children everywhere.
Cover design: Kinetik Communications
Front cover photo: Brian Moody
Back cover photo:Thomas Kelly
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Ronald P. Parlato, Gary L. Darmstadt,

and Anne Tinker

Saving Newborn Lives Initiative

Washington, DC
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Many people put their thoughts, time, and effort into the shape and content of this publication. The
authors wish to thank Nancy Nachbar and Annette Bongiovanni of the Academy for Educational
Development, who made valuable contributions to early drafts of the document. La Rue Seims of
Saving Newborn Lives, Save the Children, prepared parts of Chapter 4. Our thanks also go to
Claudia Fishman of CDC, Peter Winch of Johns Hopkins University, Jose Martines of WHO, Nita
Bhandari of AIIMS, Alessandra Bazzano of the London School of Hygiene, and Steven Wall, David
Marsh, Frances Ganges, Malia Boggs, and Nabeela Ali of Save the Children, all of whom helped with
their technical review. The authors are also grateful to David Oot, Director of the Office of Health,
Save the Children, for his continued support and advice. Sarah Holland, Julia Ruben, Michael Foley,
and Megan Renner deserve acknowledgment for for their assistance in the preparation of the docu-
ment. Finally, the authors wish to thank all SNL staff who field-tested this guide and offered timely
and useful comments throughout the development process.

Without the generousity of the Bill & Melinda Gates Foundation, Saving Newborn Lives would not
be able to adapt qualitative research tools to the urgent goal of reducing newborn deaths. Our thanks
to the Gates Foundation for its support and guidance.

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Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ii
Table of Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iii
How to Use this Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Chapter 1: Antenatal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
Chapter 2: Intrapartum Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
Chapter 3: Postnatal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
Chapter 4: Research Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
Chapter 5: Applying Data Analysis to BCC Planning and Programming . . . . . . . . . . . . . . . . . . . .33
Appendix: Qualitative Research Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40
Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41


Figure 1. Essential Newborn Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Table 1. All ENC Periods: Constraints and Lines of Inquiry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
Table 2. Antenatal Period: Lines of Inquiry about Current Practices . . . . . . . . . . . . . . . . . . . . . . .13
Table 3. Antenatal Period: Constraints and Lines of Inquiry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
Table 4. Intrapartum Care: Lines of Inquiry about Current Practices . . . . . . . . . . . . . . . . . . . . . .18
Table 5. Intrapartum Care: Lines of Inquiry about Constraints . . . . . . . . . . . . . . . . . . . . . . . . . . .20
Table 6. Immediate Newborn Care: Lines of Inquiry about Current Practices . . . . . . . . . . . . . . .22
Table 7. Immediate Newborn Care: Lines of Inquiry about Constraints . . . . . . . . . . . . . . . . . . . .24
Table 8. Neonatal Care: Lines of Inquiry about Current Practices . . . . . . . . . . . . . . . . . . . . . . . . .26
Table 9. Neonatal Care: Lines of Inquiry about Constraints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28
Table 10. Qualitative Research: Methods and Examples of Newborn Care Applications . . . . . . . .30
Table 11. Analyzing Qualitative Data and Developing a BCC Strategy . . . . . . . . . . . . . . . . . . . . . . .35

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The purpose of this guide is to provide a ready supply factors shown in prior qualitative
reference tool for conducting qualitative research research studies to limit or discourage the
and planning a behavior change communications adoption of evidence-based ENC practices.
strategy to improve newborn care practices. In This guide also provides sample lines of
this guide, we label this research ‘qualitative,’ but inquiry that correspond to each current
it is important to note that the term ‘formative’ practice and constraint. These lines of
can be used to describe it as well. The guide has inquiry are designed to suggest where and
been designed with the understanding that the how to look for answers; however, they will
qualitative research and analysis could be carried need to be adapted for direct use in qualita-
out by subcontracted technical agencies or indi- tive research questionnaires.
viduals who would supply the information to
program managers. The program manager will • Guidelines for identifying target audiences
not design, develop, or execute field studies, but and assessing the decision-making
rather will provide terms of reference and processes of their members. This can
informed technical supervision and manage- include assessing family decision-making.
ment. This can also include eliciting information
about those members of the community,
No matter how well-qualified, the researcher may other than the extended family, who are
be new to the subjects of Essential Newborn influential in ENC decision-making—such as
Care (ENC) and Behavior Change Communication traditional practitioners and facility-based
(BCC). In this regard, this guide will help orient health workers. Not only is it important to
the program manager and the researcher to these identify who is exerting influence over
technical areas and help to ensure that the important ENC decisions, but it is also
research remains focused to generate information imperative to understand the beliefs of those
that will inform the design of BCC programs. influential individuals themselves.

This guide provides: • Procedures involved in qualitative research

methods, such as in-depth interviews and
• Evidence-based practices that have been focus group discussions.
shown to have the most significant and direct
implications for newborn health, mortality • Practical guidance on how to move to the next
and morbidity.1 These are the target practices steps after qualitative research—the all-impor-
from which to choose while designing the tant phases of data analysis and BCC plan-
qualitative research. It is strongly recom- ning and programming.
mended that only practices from this list be
selected to ensure consistency and maintain a Introduction to Chapter Structure
focus on evidence-based practices.
Each of the ENC chapters (Chapters 1 – 3) of
• Methods to identify the current practices of the guide includes matrices (Tables 1-9) present-
local communities and lists of constraints— ing comprehensive lines of inquiry for both cur-
informational, social, cultural, economic, or rent practices and constraints.

How to Use this Guide 1

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Each of these chapters is divided into the follow- Various factors might allow the researcher to
ing sections: focus and simplify inquiries:

1. Presentation of evidence-based ENC practices • In some cases, a particular evidence-based

and sub-practices and a discussion of their practice is already common in the country. In
importance, answering the question: “What Malawi, for example, antenatal care is already
proven, evidence-based interventions lead to understood and practiced. Similarly, in many
lower neonatal mortality and morbidity?” areas of Bangladesh, exclusive breastfeeding
is the norm rather than the exception. Under
2. Presentation of lines of inquiry to determine these circumstances there is no need for
current ENC practices, answering the ques- additional research, for these practices will
tions: “What are the current practices, and to probably not require further attention.
what degree or under what circumstances
might they be changed?” • Another consideration is whether other
agencies are already addressing certain ENC
3. Presentation of lines of inquiry to determine practices. Another international organization,
those constraints pertaining to each evidence- for example, may be implementing or have
based practice, answering the question: recently implemented a program to promote
“What factors inhibit or discourage people’s better maternal nutrition, exclusive breast-
ability and willingness to practice evidence- feeding, or tetanus toxoid immunization,
based ENC?” thus obviating the need for additional
research or programming.
These chapters address the three temporal peri-
ods of care: antenatal, intrapartum, and postna- • In other cases, although no current or prior
tal. Within each period there are major evidence- programs exist, there may be a sufficient
based practices and sub-practices, and for each of body of existing knowledge on the subject.
these there may be a variety of informational, Others may have done exploratory research
social, cultural, economic, and supply constraints that is sufficient to form the basis for BCC
that limit or discourage behavior change. planning in particular subject areas. In SNL
focus countries, for instance, the baseline
Nevertheless, it is unlikely that program man- survey may supply enough relevant informa-
agers will have to deal with all practices or all tion to reduce the need for further invest-
questions. ment in certain qualitative research topics.

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Newborn mortality is one of the world’s most and delivery), and postnatal—and promotes a vari-
neglected health problems. It is estimated that ety of interventions that have proven effective.
globally, four million newborns die before they
reach one month of age and another four mil- The success of any program designed to pro-
lion are stillborn each year. Deaths during the mote and improve ENC practices depends on
neonatal period (the first 28 days of life) account three key factors:
for almost two-thirds of all deaths in the first year
of life and 40 percent of deaths before the age 1. Increasing the demand for ENC practices
of five.
2. Providing relevant, appropriate, and useful
Most of these deaths could be prevented information to enable individuals to act on
through proven, cost-effective interventions, this demand
such as tetanus toxoid immunization or exclusive
breastfeeding. The Saving Newborn Lives (SNL) 3. Assuring the supply of those goods and serv-
initiative is designed to reduce neonatal mortality ices necessary to meet this demand
and morbidity by strengthening and expanding
these and other interventions in Africa, Asia, and For example, while clean delivery requires the
Latin America. supply of a clean blade and tie to cut the umbili-
cal cord, it first requires that families desire to use
Behavior Change Communications (BCC) is these products. Thus, they need to appreciate the
a process that provides timely, relevant, and benefits of a clean blade and tie and also know
useful information to local communities how to use them.
that can be used to encourage families to Figure 1: Essential Newborn Care
improve newborn care practices. Successful
behavior change requires a thorough under- • Drying and warming
standing of the target audience. Qualitative • Routine ANC visits • Ensuring breathing/newborn
research provides essential information • Birth preparedness resuscitation
• Danger signs/complications • Immediate breastfeeding
about what could motivate this audience to • Clean cord care
improve its newborn care practices.

This guide is intended to discuss behavior

Antenatal Intrapartum Postnatal
change within the context of Essential Care Care Care
Newborn Care (ENC) and to provide guide-
lines on how to plan, manage, and use qual-
itative research and design a BCC strategy. INTRAPARTUM CARE • Routine postnatal care visits
• Skilled attendance at delivery • Exclusive breastfeeding
• Clean delivery • Maintenance of
Essential Newborn Care Practices
• Danger signs/complications warmth/cleanliness
• Newborn danger
As represented in Figure 1, the SNL initiative signs/complications
focuses on the three important periods of Adapted from: Marsh DR, Darmstadt GL, Moore J, Daly P, Oot D,Tinker A.
ENC—antenatal, intrapartum (during labor "Advancing Newborn Health and Survival in Developing Countries: A
Conceptual Framework." J. Perinatology 22 (2002): 572-576

Introduction 3
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Similarly, while birth preparedness requires iden- Social, cultural, and economic constraints are not
tifying available transportation and upgraded insurmountable barriers to change. Under-
referral facilities, it also requires a demand for standing them can assist communications plan-
these services as well as the ability to pay for ners to customize the crafting of messages and
them. On the informational side, families must media. In reality, improvements in newborn care
first be able to recognize danger signs and com- practices have been seen throughout the world.
plications, be confident that referral care will help Immediate and exclusive breastfeeding rates have
ensure the survival of mother and newborn, and increased dramatically in many countries due to
be motivated to act on this knowledge. successful BCC programs. Social mobilization
campaigns have increased demand for tetanus
Some practices, such as immediate and exclusive toxoid coverage and thus reduced the incidence
breastfeeding or drying and warming the new- of death from a disease for which prevention is
born, require little in the way of supplies or absolutely paramount. BCC initiatives have been
products, but a great deal in the way of convic- equally successful in increasing rates of antenatal
tion. A new mother and her family must under- care and skilled care at birth.
stand the value of immediate and exclusive
breastfeeding, must value it enough to give up Qualitative Research
the traditional feeding habits for newborns and
infants, and must be convinced that regardless of Qualitative research offers specialized techniques
the practices of other women and their families, for obtaining and understanding in-depth infor-
this practice will be beneficial for their child. mation about what people know, think, and do.
Qualitative research analyzes social patterns and
Promoting evidence-based practices for new- traditions that influence decision-making. It con-
born caregivers and modifying practices that are siders cultural beliefs and convictions that give a
harmful will improve newborn health and reduce religious and philosophical significance to new-
mortality and morbidity. However, for numerous born care. It looks at economic constraints that
reasons, demand for evidence-based newborn limit the ability of families and communities to
care practices is often quite low. First, many fam- practice positive behaviors even when they may
ilies do not receive the information required to have the knowledge and conviction to do so.
understand the relationship between improved
practices and better health outcomes. Second, Qualitative research, however, is not merely
the presentation of this information may not descriptive; it is practical, useful, and dynamic. It
take into account existing social, cultural, and investigates not only why people do what they
economic constraints to behavior change. Third, do, but more importantly, what can help them to
well-established and traditional newborn care change. It provides the BCC planner with ade-
practices may be strongly reinforced by family quate information to identify the most effective
and community structures that tend to favor entry point for behavior change negotiation, and
them over innovation. the most acceptable and feasible degree of
change within existing constraints.
Economic constraints are perhaps the most sig-
nificant of these barriers to demand for health An example of how qualitative research data can
services. Cost—whether a simple lack of funds be used to design appropriate and persuasive
or opportunity cost—is a formidable deterrent messages comes from the Hausa population in
to behavior change.2 rural Nigeria. Qualitative research showed that
immediately after birth, families commonly give

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newborns water that has been poured over paper practice as a major breach in tradition. Prelacteal
on which verses from the Koran have been feeds often fulfill important sociocultural func-
inscribed—a practice rooted in a centuries-old tions—uniting families, reaffirming family roles,
tradition. According to Hausa beliefs, this prac- sanctifying the life of the newborn, and demon-
tice provides the vulnerable newborn the protec- strating religious respect and homage. It may
tion of Allah. At the same time, the Hausa only be possible to modify the practice gradually,
believe that breast milk is good for the newborn over the longer term. In general, the potential
and that through drinking breast milk, the new- health impact of a behavior change should be
born eats and drinks what the mother does. A assessed in relation to its feasibility and social
BCC campaign promoting exclusive breastfeed- acceptability—a judgment best made with the
ing among the Hausa combined these two beliefs participation of the target community.
into a communication strategy. If the mother
drinks Koranic verses, it was argued, the benefits Qualitative research, then, can provide answers
would pass on to the newborn through her breast to the following questions:
milk. Respecting both medical judgment (avoid-
ing giving water to the newborn) and the local tra- • Which practices are likely to remain unchanged
ditions and beliefs of the Hausa population, the despite even the best BCC programs?
campaign was a success.
• Which practices have the fewest social, eco-
In this case and many others, qualitative research nomic, or cultural constraints and thus are
has provided BCC planners with the client-based most amenable to change and most likely to
data on which to ground the development of lead to improved health outcomes?
communication strategies—suggesting creative
approaches to balancing demands of a tradition- • Which practices are amenable to change, but
al society with the value of modern health con- may not significantly impact health status and
cepts. In short, qualitative research leads to an thus may not be valuable, cost-effective tar-
understanding of what people are currently gets for BCC programs?
doing, why they are doing it, what changes might
be feasible within the context of existing con- • For practices that appear amenable to change
straints, and how communicators might effec- and are known to have a significant impact
tively address these changes. on health, what might convince families to
improve them?
At the same time, qualitative research can help
the BCC planner rule out those ENC practices Constraints4
that might not be the most practical or viable pri-
orities. Changing certain practices may simply A constraint is defined as any factor that limits
represent too great a social, cultural, or econom- behavior change. Several types of constraints are
ic risk to justify an investment of limited BCC detailed below:
resources. The practice of ritual prelacteal feeds, for
example, is common in many parts of the • Informational constraints refer to the
world—often tied to long-standing cultural tradi- client’s lack of information regarding cur-
tion, social practice, or religious belief.3 Although rent or recommended ENC practices and
the Hausa were generally open to modifying their their health outcomes. That is, aside from
practice in favor of exclusive breastfeeding, other social, cultural, and economic constraints, a
communities might consider discontinuing their major reason for not adopting a new prac-

Introduction 5
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tice can simply be lack of knowledge and a • Cultural constraints refer to cultural pat-
sound understanding of its availability, use, terns and beliefs in a community that dis-
or benefits. courage the adoption of new ENC practices.
Numerous traditions regarding pregnancy
• Social constraints refer to social patterns in a and childbirth are related to religious practice
community that discourage the adoption of and reaffirm the important roles and convic-
new ENC practices. For example, in many tra- tions of family members. While such prac-
ditional areas, older relatives such as mothers- tices can certainly be modified, BCC planners
in-law still have considerable say over decisions must appreciate their multifaceted sociocul-
concerning pregnancy, birth, and child care. In tural nature and realize how slow they may be
more modern urban communities, their influ- to change.
ence may be weaker, while the influence of the
mass media may be stronger. Similarly, hus- • For example, beliefs in the spiritual
bands in more traditional areas may dictate endowment of the placenta can divert
their wives’ activities, but this influence may attention from and influence immediate
diminish in some urban areas where women care for the newborn. These beliefs can
have greater independence or education. become a life or death matter, particularly

Table 1. All ENC Periods: Constraints and Lines of Inquiry

Constraints Lines of Inquiry

Determine the degree to which pregnant women and their famlies:

1. Can recognize danger signs and complications
2. Realize the importance of seeking care and know where to seek it
3. Understand hygiene and the need for a clean delivery
Determine the degree to which:
Social Constraints 1. Existing patterns of family authority and responsibility affect the adoption of ENC practices
2.The adoption of ENC practices is contingent upon social approval and/or results in any nega-
tive social consequences
1. How concepts of privacy and modesty affect decisions to seek antenatal, intrapartum, or post-
natal care
Cultural Constraints 2. How fatalism, acceptance of God's will, or a sense of political or social powerlessness affects
ENC and care-seeking
3. How beliefs concerning the spiritual nature of the placenta affect the immediate care of the
Determine the degree to which:
1. Cost is a factor in the choice of delivery attendant or place of delivery; or in decisions to seek
antenatal, intrapartum, or postnatal care or referral care for complications
2. Cost is a factor in practicing clean delivery (i.e., purchase of products such as a clean delivery
3. Opportunity costs affect antenatal, postnatal, or referral care-seeking or other ENC decisions
(e.g., exclusive breastfeeding)
1.The extent to which ENC health services and products are available at public health facilities,
Supply Constraints on the private market, or in local communities
2. If the quality of these products and services is adequate to attract clients, or at least to not
discourage them

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in the first critical moments after birth Progressive Behavior Change

when the newborn’s risk of asphyxia and
hypothermia are greatest. Perhaps the most important aspect of qualitative
research is the concept of progressive change.
• Concepts of ‘hot’ and ‘cold’ are often That is, given the constraints that make behavior
related less to temperature than philo- change difficult, to what degree and under what
sophical systems. Similarly, attitudes circumstances might individuals change?
toward hygiene and cleanliness are often
more a function of environmental reality For example, a family may be severely limited
than lack of understanding. The concept financially and living on the margin in terms of
of hygiene in a community without run- economic productivity. If, as a result, the family
ning water, sanitation, fly screens, dust is unable to spare the time or resources for a
covers, etc., is quite different from that in pregnant woman to make the four prescribed
communities with the resources to exer- antenatal care visits, encouraging her to attend
cise such protective measures. at least one or two visits may be a viable short-
term alternative.
• Economic constraints refer to either unavail-
ability of cash or credit to pay for ENC Qualitative researchers need to evaluate whether
goods and services, or opportunity cost situ- the existing constraints are so severe that change
ations wherein the adoption of a new ENC is not possible, or more commonly, whether
practice reduces productivity in other areas. incremental, progressive change may be more
feasible. The question repeated many times
Lines of Inquiry throughout this guide—“To what degree and
under what circumstances might current prac-
Lines of inquiry are simply guidelines for the tices be changed?”—goes to the heart of this
researcher—not questions to be inserted into a issue, and should be explored for each line of
qualitative research questionnaire. They are inquiry presented in the various matrices.
intended to suggest areas of investigation that
previous research efforts have found productive. For example, if a pregnant woman states that
For example, although there may be only one line after her last delivery she had not breastfed exclu-
of inquiry in the matrix that concerns hygiene sively, the researcher would pose the question,
and cleanliness (see Table 1), a field investigator “What would make it easier for you to adopt this
would be expected to ask a number of questions practice?” before asking more probing questions,
about the issue and would need to probe further: such as, “Do you think you could at least not give
What is the current concept of cleanliness? How water to your newborn?” or “Would you consid-
is it affected by environmental conditions? Is the er increasing the number of times you breastfeed
concept of antisepsis understood? in a day?” In short, lines of inquiry should lead
to deeper, core questions regarding ability and
All lines of inquiry indicated in this guide are evi- willingness to change.
dence-based. That is, research has shown they
can elicit information about behavior, knowl- Behavioral trials, conducted with members of a
edge, attitudes, and beliefs that are relevant to target audience in their own community, are par-
ENC behavior change. Table 1 includes an amal- ticularly effective for assessing the feasibility of
gam of many constraints and lines of inquiry for adopting new practices. As extensions of the
all ENC periods. qualitative research process, behavioral trials

Introduction 7
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negotiate possible changes with families (previ- required by social custom to accompany his wife
ously identified through in-depth interviews, on trips outside the family compound or com-
group discussions, focus groups, etc.) in a real life munity (e.g., to the health center for ANC), may
setting. This process can help validate the be unwilling to give up what he considers to be
assumptions made from qualitative research and more productive labor time.
in the strategic planning process.
Traditional healers are another common influ-
In one study in Bangladesh, qualitative research ence. Though losing authority and respect in
determined that bathing the newborn on the first some communities as modern media and ideas
day of life was almost universal. This practice make inroads, they remain powerful and influen-
was based on the conviction that an infant is tial in more isolated communities.
born unclean and therefore must be cleansed
before being handled. This perceived “uncleanli- Overall, an accurate identification of key influen-
ness” has more to do with ritual, tradition, and tials in a community is best made on the basis of
ceremony than with practical, common desires to qualitative research.
cleanse the newborn of blood and afterbirth.
BCC planners wondered whether families might Research Methods
compromise between current practice and no
bathing at all. In a series of behavioral trials using Qualitative research is usually conducted using
a doll to simulate possible practices, the planners standard methodological tools. The two most
identified a set of new practices that were closer common are in-depth interviews and focus
to the ideal and acceptable to trial families. One groups.
of the most successful compromise practices was
giving a brief sponge bath with warm water, in a These and other useful methodological tools for
warmed room, followed by immediate drying qualitative research are discussed in some detail
and wrapping with clean, dry cloths. in Chapter 4.

Target Audiences Strategic Planning

In addition to addressing factors that determine An understanding of the informational, social,

behavior, qualitative research is also essential for cultural, and economic constraints that deter-
identifying those individuals who exert the great- mine family and community behavior opens
est influence on newborn care decisions because the door to communicating with target popu-
mothers rarely make these decisions on their lations. Research data are valued most when
own. Although mothers-in-law and husbands are they are used to guide the BCC planner in the
often cited as the key influentials in ENC family development of BCC campaigns using elec-
decision-making, their influence varies according tronic, print, and other mass media, and/or
to local practice, and they are not the sole source interpersonal communication.
of authority.
As mentioned above, qualitative research can
For example, husbands often have the strongest enable the BCC planner to select priority prac-
influence on economic decisions regarding both tices—those leading to the greatest improve-
financial outlay (e.g., funds for emergency trans- ments in newborn health and survival and which
port, purchase of clean delivery equipment) and are amenable to change. As evident in Figure 1
opportunity cost. A husband, who may be (page 3), several ENC practices are recommend-

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ed, and each one of these practices can be broken birth. That is, they understand the importance
down into sub-practices. For example, interven- of receiving a newborn in a warm environment.
tions to promote breastfeeding include: a) A possible communication strategy to promote
encouraging a mother to put her newborn to the drying, wrapping, or skin-to-skin contact might
breast immediately, b) encouraging her to avoid begin with ambient temperature and the con-
prelacteal or interlacteal feeds, c) encouraging her cept of warmth as they experience it as adults,
to feed colostrum, d) helping her to appropriate- and then advance to more thorough practices
ly position the infant at the breast, and e) encour- for their newborns.
aging her to continue feeding exclusively through-
out the first six months of her infant’s life. Qualitative research data can be used to identify
specific target audiences: influential members of
Based on the data generated from clients, a BCC the family and community, newborn caregivers
planner can make critical decisions concerning and health providers, and pregnant women
which of the major ENC practices and sub-prac- themselves. Importantly, qualitative research
tices should be considered the highest priorities. can help program managers design information
and media specifically tailored to these audi-
Qualitative research can also enable the BCC ences, given their particular roles and responsi-
planner to determine the appropriate communi- bilities within the family and community. The
cation strategy for each selected priority practice. strategies noted above are provided as examples
If drying and warming are selected as priority to illustrate how qualitative research data can be
practices, how should one work with the commu- transformed into a BCC strategy. These and
nity to promote these practices? To what beliefs, other issues relating to the application of quali-
expectations, and hopes should one appeal? tative research data are explored in some depth
Some communities, such as those in the alti- in Chapter 5.
plano of Bolivia, already warm a room before

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1.1 What proven, evidence-based issues such as nutrition, hygiene, family plan-
interventions lead to lower neona- ning, preparation for breastfeeding, child devel-
opment, minor discomfort during pregnancy,
tal mortality and morbidity?
and danger signs and complications, can also be
an effective method for encouraging healthy
EVIDENCE-BASED PRACTICES household practices.

1. Pregnant women should make at least The World Health Organization (WHO) recom-
four ANC visits to a health provider mends at least four ANC visits. However, it is not
trained in midwifery skills. only the number of ANC visits that is important;
the quality of service and counseling received is
2. Pregnant women and their families, as
well as health providers, should be able
even more important. As mentioned previously
to recognize danger signs and compli- in the introduction, both demand and supply
cations of pregnancy, and know must be assured.
when/how to seek appropriate referral
care if needed. Recognition of danger signs and complica-
tions of pregnancy: Regardless of whether a
3. Pregnant women, families, and commu- woman seeks ANC, it is important that she, her
nities should prepare for birth, includ- family, and her health providers know when,
ing their responses to potential mater- how, and where to seek care from an appropri-
nal and newborn emergencies. ately skilled professional. Below is a list of pri-
ority danger signs and complications during
pregnancy of which everyone should be aware:
Routine ANC visits: Antenatal care is impor-
tant, not only for the clinical appraisal of preg-
nancy and remedial clinical interventions per- • Vaginal bleeding
formed by trained professionals, but also for the • Convulsions (fits)
counseling and educational services provided for • Loss of consciousness
the benefit of both mother and newborn. • Severe headaches with or without dizziness
Ensuring proper tetanus toxoid immunization, • Fever
educating women on the danger signs and com- • Difficulty breathing (especially with dizziness
plications of pregnancy, and preparing them for and/or very pale skin)
immediate, exclusive breastfeeding are particular- • Contractions/labor pains or water breaking
ly important. Although their significance varies before 37 weeks gestation
geographically, maternal malnutrition, malaria,
and reproductive tract infections may adversely If the mother experiences any of the above,
affect newborn health outcomes;5 thus they she should know to seek professional care
should also be addressed in the context of ANC. immediately, day or night, as these signs could
Professional counseling by trained staff (and in indicate a life-threatening condition for her
some cases, trained peer counselors) regarding and/or the fetus.

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The mother should also be aware of less seri- Qualitative research should first investigate prac-
ous danger signs that require consultation as tices currently performed during pregnancy rela-
soon as possible: tive to the evidence-based practices listed above:
Do women go for ANC? When and how fre-
• Pale skin quently? What is the content of these visits? Can
• Cloudy urine they and their families recognize danger signs
• Foul smelling vaginal discharge and complications during pregnancy? Do fami-
• Swelling of the face, hands, feet, or legs lies adequately prepare for birth and anticipate
the possibility of an emergency?
Birth preparedness: The third important ante-
natal practice for a pregnant woman, her family, Recognizing danger signs and complications can
and her community is preparation for the birth be a problematic line of inquiry for the qualita-
and any potential referral care needs. Birth pre- tive researcher, due to the subjective nature of
paredness may affect newborn survival by ensur- many symptoms. For example, in communities
ing that in the event of serious danger signs and where diarrhea, malaria, or upper respiratory
complications, not only will they be recognized, infections are common and frequent, a fever may
but the mother and newborn will be able to reach be overlooked or disregarded and its significance
an appropriate medical facility in a timely fash- inaccurately gauged. Difficulty breathing is also
ion, and the family will be able to access and subject to local interpretation, particularly in the
afford quality emergency care. Thus, “preparing” preterm infant or in the presence of frequent
for birth consists of several practices: respiratory infections or environmental pollution
and dust. Therefore, it is important not only to
• Selecting a skilled birth attendant6 find out what people claim to know and recog-
• Selecting a health facility to go to if the moth- nize, but also to ascertain the depth and accuracy
er or newborn experience complications of their knowledge. Identifying and using the
• Identifying and assuring emergency trans- local terms for commonly recognized danger
portation to a health facility signs can also be essential for eliciting and
• Setting aside sufficient money to pay for
recording accurate responses.
emergency transportation and medical care
The second step for qualitative research should
1.2 What are the current prac-
be to determine what it would take for families to
tices, and to what degree or under adopt more positive behaviors—how and to
what circumstances might they be what degree could the current practices be mod-
changed? ified? Based on an understanding of the informa-
tional, social, cultural, economic, and supply con-
Identifying current newborn care practices is the straints, good researchers may be able to infer
first step in preparing a foundation for the design what changes are feasible. However, it is only by
and development of a BCC program. Under- probing prospective behavior that one can deter-
standing the degree to which women and their mine the real degree of change that might be
families would be willing to accept new practices acceptable and achievable.
and change their current behavior—that is, what
changes they would make and under what condi- For example, if a woman states that she does not
tions they would make them—is essential to craft- seek ANC because of economic constraints, she
ing realistic, relevant behavior change messages. might reconsider attending just one antenatal

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visit instead of four. Similarly, another woman 1.3 What factors limit or discour-
might be unwilling to seek ANC more than once age people’s ability and willingness
because of cost, but she might agree if the visit
to practice evidence-based ENC?
could be made at home. She might also agree to
pay for ANC visits if she perceived the quality of
service to be better. Overall, although families There are four major categories of demand
may not be willing or able to take all recommend- constraints that affect ability and willingness to
ed birth preparedness measures, they might be move from existing newborn care practices to
willing to take some of them. An understanding of the evidence-based ENC practices recom-
the positive potential for progressive behavior mended by SNL:
change, in addition to an understanding of the
negative constraints on behavior change, is • Informational constraints: a simple lack of
essential to the crafting of effective BCC strate- information, knowledge, or experience need-
gies and messages. ed to make informed ENC choices

Table 2 lists priority practices of the antenatal • Social constraints: patterns of family and
period and several corresponding lines of inquiry community authority, roles, and responsibilities
that researchers may want to address to deter-
mine the current level of compliance with evi- • Cultural constraints: religious beliefs or tra-
dence-based practices. ditional rituals and other practices

Table 2. Antenatal Period: Lines of Inquiry about Current Practices

Current Practices Lines of Inquiry

1.Whether pregnant women currently receive any ANC
2. If they do, where and from whom they receive it
Routine ANC Visits
3.The timing and frequency of these visits
4.The procedures performed and counseling provided during these visits
5.What would facilitate an increased number of visits
1.When respondents feel that mother or newborn are in danger during pregnancy, and the
Recognition of Danger local terms for these symptoms of illness
Signs and Complications of 2.What their responses would be to these symptoms
Pregnancy 3.The health provider or facility to which they would go to seek care for these symptoms
4.Which danger signs/complications are generally perceived or recognized as such; and
which ones are not recognized, misperceived, or misinterpreted
Determine if pregnant women and their families:
1. Select a skilled birth attendant to assist at delivery
2. Prepare for emergencies that might occur during pregnancy, labor, or delivery
3. Identify a particular health facility to go to in case of an emergency
4. Identify emergency transportation
Birth Preparedness 5. Set aside funds for emergency care and transportation
6.What would facilitate 2-5, above
1. If there is a community fund for use in maternal or newborn emergences
2. If so, how families gain access to this fund

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• Economic constraints: deficiency of indi- that local terms are identified, the local context is
vidual, family, or community resources, understood, and the respondents answer as clear-
translating into lack of access to health ly as possible. Interviewers should determine only
goods and services whether people’s knowledge conforms to the clin-
ical definitions used by the researcher. Finally, it is
Some of the issues meriting particular attention important to explore prospective responses to
in the antenatal period include: symptoms; specifically, from whom and under
what circumstances help is sought.
ANC visits and economic constraints:
Although the concept of financial cost will be Birth preparedness: While health professionals
easily understandable to families and field inter- understand implicitly the need for emergency
viewers, the concept of opportunity cost may not preparation, many local residents may not appre-
be. In fact, it is likely to be far greater than any ciate its importance. This is due not only to infor-
cash outlay. Field investigators must be aware of mational constraints, but also to cultural percep-
this factor and probe for relevance. Male family tions of risk, destiny, or fate, and economic per-
members, for example, may not wish to accom- ceptions of power. That is, the cost of preparing
pany their wives to the clinic simply because they for an emergency for middle class urban families
do not feel they can lose a valuable morning or may be considered relatively small compared with
day of work. the benefits. This is not likely to be true for poor
rural families living on the economic margins.
Knowledge and understanding of danger Similarly, middle class urban audiences may have
signs and complications: Assessing family gained a certain confidence in public and private
members’ knowledge on this topic is not a health facilities, believing that they can in fact
straightforward task. It is complicated by the sub- improve health outcomes, while poorer families
jectivity of many of the symptoms—including may believe that they are better off caring for the
their context—and the various local terms used mother and newborn at home. In short, while the
to describe them. Bleeding, for example, may be concept of birth preparedness seems simple and
considered natural and normal during pregnancy, straightforward, current practices may be inti-
as some spotting is quite common. Similarly, the mately linked to subtle informational, social, cul-
expression “difficulty breathing” may simply be tural, and economic factors.
applied to a bad cold or congestion during a very
dusty, windy time of year. Therefore, interview- Table 3 provides lines of inquiry that have proven
ers must be trained to probe carefully to ensure fruitful in research on antenatal care practices.

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Table 3. Antenatal Period: Lines of Inquiry about Constraints

Consraints Lines of Inquiry

Determine whether pregnant women and their families:

1. Know the benefits of seeking ANC
2. Understand the importance of attending ANC more than once
3. Understand the importance of proper home care during pregnancy
Informational Constraints 4. Understand the importance of preparing for a maternal or newborn emergency
5. Understand the relationship between danger signs and complications during
pregnancy and maternal and neonatal mortality and morbidity
6. Understand the relationship between proper care during pregnancy and positive
birth outcomes
1.The necessity of having an accompanying male relative
Social and Cultural 2. Privacy or modesty concerns about disrobing in the presence of a health
Constraints provider
3. Other religious or cultural rituals or beliefs
4. Perceptions of service quality
Determine if cost is a factor in:
1. Selection of health providers
Economic Constraints 2. ANC attendance
3. Setting aside of emergency funds for transportation and care

Determine if the availability of transportation affects ANC attendance or emer-

Transportation Constraints gency care planning

Time Constraints Determine how other obligations (e.g., work, childcare) affect ANC attendance.
1.The most influential family or community members for each major antenatal
Influence of Decision-Makers 2.Whether their influence is positive or negative (i.e., how or to what extent the
influential party encourages or discourages evidence-based practices)
3.What influence pregnant women have, if any, over decisions concerning care dur-
ing pregnancy

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2.1 What proven, evidence-based Recognition of danger signs and complica-

interventions lead to lower neona- tions of labor and delivery: As with antena-
tal care, the second aspect of intrapartum care
tal mortality and morbidity?
critical to the survival and well-being of moth-
er and newborn is the ability to recognize when
to seek referral or emergency care from an
1. A skilled birth attendant should appropriately trained professional. Below is a
assist at the delivery. list of priority danger signs and complications
of the intrapartum period of which everyone
2. Pregnant women and their families, as should be aware:
well as birth attendants, should be able
to recognize danger signs and compli-
• Bleeding
cations of labor and delivery, and
know when/how to manage or seek • Convulsions (fits)
appropriate referral care if needed. • Loss of consciousness
• Prolonged labor >12 hours
3. All deliveries should be “clean” to pre- • Preterm labor
vent infection. • Prolapsed cord or noncephalic presenting part
• Meconium discharge during labor
Skilled attendance at delivery: The impor- • Fever
tance of this aspect of intrapartum care has been
well documented historically. However, at pres- Because a woman in labor may not be able to
ent only about half of all women in developing assess her own risk, it is important that the birth
countries deliver with a skilled attendant. When attendant immediately recognize and appropri-
a skilled attendant is not yet available, trained ately manage or arrange referral care for danger
community-based birth attendants can help signs and complications. Therefore, qualitative
improve newborn health and survival. research should be designed to assess the knowl-
Incorporating community-based health providers edge and understanding of mothers, their fami-
in maternal and neonatal health programs should lies, and birth attendants.
be accompanied by strengthening the links along
the household to the hospital continuum of care, The birth preparations recommended in the
including a long-term plan for training and pro- antenatal period (identifying a referral facility,
viding sufficient skilled attendants. All SNL pro- securing emergency transport, and setting aside
grams focus on strengthening the midwifery emergency funds) play their most critical role in
skills of birth attendants, whether at health facil- the intrapartum period. These measures can
ities or in the community, to provide counseling, expedite transfer of the mother and newborn in
conduct clean and safe deliveries, recognize dan- an emergency, thereby saving lives.
ger signs, take appropriate action to help both
mother and newborn survive, and refer compli- Clean delivery: Newborns are also more likely
cated cases to a higher level of care as needed. to survive if the delivery is clean—that is, if

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actions are taken to help prevent infection. Just as 2.2 What are the current prac-
“preparing for birth” consists of several practices, tices, and to what degree or under
ensuring a clean delivery also is comprised of a
what circumstances might they be
set of sub-practices. A “clean delivery” means:
• All those attending to the mother or new-
born wash their hands with soap and water Again, the first step for qualitative research is to
before, during, and after delivery investigate the practices currently followed during
the intrapartum period in relation to the evidence-
• Perineal area is washed before each examina- based practices listed above. Second, the research
tion and before delivery, and nothing foreign must determine the degree to which and under
is put into the vagina (i.e., nothing but the what conditions behavior change would be accept-
examiner’s hand, and only when necessary) able and feasible. This helps to ensure the design of
a BCC program that is both realistic and relevant.
• Delivery surface is clean or, at a minimum,
the birth does not occur on the bare floor Thus, qualitative research should first obtain
or ground information about the practices and procedures
currently followed during labor and delivery:
Who is present at what times during labor and
delivery? What do they do to assist the birth?
Can they recognize danger signs and complica-

Table 4. Intrapartum Care: Lines of Inquiry about Current Practices

Current Practices Lines of Inquiry

1.Whether pregnant women use a skilled attendant for delivery
Skilled Attendance at 2.Where pregnant women deliver, whether at home or at a health facility
Delivery 3.Who attends to the needs of mother and newborn during labor and delivery
4. If a family would consider using a skilled birth attendant for delivery, and what would
make this decision easier and/or the practice more acceptable or feasible
1.When respondents feel that mother or newborn are in danger during labor and deliv-
ery, and the local terms for these symptoms of illness
Recognition of Danger Signs 2.What their responses would be to these symptoms
and Complications of Labor 3.The health provider or facility to which they would go to seek care for these symp-
and Delivery toms
4.Which danger signs/complications are generally perceived or recognized as such; and
which ones are not recognized, misperceived, or misinterpreted
1.Whether those attending to mother or newborn wash their hands with soap and
water before, during, and after delivery
2. On what surface women deliver, whether it is cleansed with soap and water or other
traditional materials, and whether it is cleansed more than once during labor and
Clean Delivery delivery
3.Whether the perineal area is cleansed before vaginal examinations and delivery
4.What would make these decisions about cleansing easier and the practices more
acceptable or feasible
5.Whether anything foreign is put into the vagina, and under what conditions this prac-
tice might be discontinued

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tions during delivery, and what are their dition people’s ability and willingness to change
responses to these? Are clean delivery proce- intrapartum care practices. When investigating
dures followed? these constraints, there are a number of impor-
tant issues that must be addressed for the intra-
With regard to recognizing danger signs and partum period. Some which merit particular
complications, it is again important to find out attention include:
not only which symptoms are known and recog-
nized, but also the depth and accuracy of this Birth attendants: While the advantages of
knowledge and what actions they would prompt skilled birth attendants may be obvious to pro-
in response. It is also important to understand fessionals, families, influenced by norms of tradi-
how birth attendants respond to danger signs or tion, trust, friendship, and privacy, often have a
complications during delivery. different perspective. They may also be suspi-
cious of letting “outsiders” into personal mat-
After identifying current practices, qualitative ters, and may rightly conclude that a skilled birth
research should then determine what it would attendant will cost more. Qualitative research,
take for the adoption of evidence-based prac- therefore, must probe the depths of these con-
tices. If a pregnant woman does not practice victions, and determine whether and under what
clean delivery, what might make such changes conditions the use of birth attendants might
more acceptable or feasible? Under the current become more acceptable or realistic.
circumstances, what would be the most appropri-
ate degree of change to promote? For example, Concepts of privacy and modesty: In soci-
although families might consider it awkward or eties where these concepts are highly valued for
cumbersome to have the birth attendant wash women, families may not choose birth attendants
her hands during delivery, they might accept the who require that they undress (as may be
more important practice of washing immediately required by many doctors and nurses) or may
before. If they feel that physical cleaning of the avoid facilities where they would be in the pres-
delivery surface is all that is required (i.e., no spe- ence of strangers.
cial birthing cloth or plastic) and are unwilling to
change, they might consider the more important Knowledge and understanding of danger
use of a clean blade and tie for cord care. signs and complications: Determining knowl-
edge of danger signs and complications is com-
Table 4 (page 20) lists priority practices of the plicated by the local terms and context, as well as
intrapartum period and several corresponding by the subjectivity of many of the symptoms.
lines of inquiry that researchers may want to Interviewers must probe carefully to ensure that
address to determine the current level of compli- responses are clear and accurately interpreted;
ance with evidence-based practices. they must be trained to assess only whether
knowledge conforms to the clinical definitions of
2.3 What factors limit or discour- the symptoms.
age people’s ability and willingness
Clean delivery: This is a complex subject
to practice evidence-based ENC? because it is comprised of several sub-practices;
researchers will have to explore each one careful-
As with antenatal care, a variety of informational, ly. For example, hand washing before delivery may
social, cultural, economic, and other factors con- seem logical and immediately understandable to

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skilled health providers, but may not be so to Perhaps most importantly, many families may not
trained birth attendants and families who are be aware or understand that using soap and copi-
often used to hand washing after delivery. ous amounts of water can help prevent infec-
Similarly, while there may be many families who tions. They also may not possess the financial
would consider hand washing before delivery, they resources to buy soap or may not have easy
may find it awkward or inconvenient to wash fre- access to clean water, particularly if it must be
quently during delivery. carried from afar or has a high economic value.

Traditional concepts of cleanliness and Table 5 provides lines of inquiry that have
hygiene: In many cases, local or traditional atti- proven fruitful in previous research on intra-
tudes underlie decisions concerning clean deliv- partum care practices.
ery; thus researchers should address these.

Table 5. Intrapartum Care: Lines of Inquiry about Constraints

Constraints Lines of Inquiry

Determine if pregnant women and their families:

1. Understand the importance/benefits of using trained/skilled birth attendants
2. Understand the relationship between danger signs and complications during labor and delivery and
maternal and newborn mortality and morbidity
Informational 3. Understand the importance of washing hands with soap and water before, during, and after delivery
Constraints 4. Know the benefits of delivering on a clean surface
1.What benefits or harm are perceived to result from putting foreign objects into the vagina
2. Families' perceptions about the availability of emergency care, and the quality and cost of that care
3.Why women say they do not give birth on a clean surface
1.The common perceptions of "clean" and "dirty" (e.g., of hands, of instruments used during delivery, or
of the surface on which the woman gives birth)
2.The common definitions of a clean/dirty environment
Social and 3.The perceptions of a link between cleanliness and infections, if any
Cultural 4.The degree to which poor facility attendance is influenced by perceived low quality of service and
Constraints attention
Determine to what degree the following inhibit choosing a birth attendant/institutional birth:
1.The necessity of having an accompanying male relative
2. Privacy/modesty - concerns about disrobing before a health provider
3. Other religious or social rituals or beliefs
4. Unacceptable/unfamiliar practices
1.The extent to which cost influences the choice of delivery attendant or place of delivery (home or
2.Whether families feel that they have access to and can afford the supplies they need to ensure clean
delivery (e.g., soap and water, cloths or towels)
Transportation Determine how, if at all, transportation issues affect the choice of delivery attendant or place, or care-
Constraints seeking for danger signs and complications.
1.The most influential family or community members for each major practice listed above
Influence of
2.Whether their influence is positive or negative (i.e., how and to what extent the influential party
encourages or discourages evidence-based practices)
3.The extent to which pregnant women have influence, if any, over decisions concerning care during
labor and delivery

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3.1 IMMEDIATE NEWBORN CARE There are two possible practices in this regard:

• Lay the newborn on the mother’s abdomen,

3.1.1 What proven, evidence-based
with the mother’s skin touching the new-
interventions lead to lower neona- born’s skin (skin-to-skin contact, also
tal mortality and morbidity? referred to as Kangaroo Mother Care). Cover
both newborn and mother with a clean and
dry cloth, towel, or blanket.
• If skin-to-skin contact is not possible, lay the
1. Newborns should be thoroughly dried
wrapped newborn on the mother’s abdomen
immediately after delivery and kept warm.
or next to the mother on a clean and dry
2. Newborns should be observed for crying cloth, towel, or blanket. Cover the newborn
and breathing immediately after delivery; and keep him or her covered with another
asphyxiated newborns should be recognized clean and dry cloth, towel, or blanket.
and resuscitated.
Bathing the newborn is generally not necessary
3. Newborns should be immediately breastfed. on the first day, and should be postponed until
the infant is stable—at least six hours, but
4. Cord care procedures should be clean. preferably no earlier than 24 hours after birth.
The bathwater and the room should be heated
when bathing.

Drying and warming: A newborn regulates his Ensuring breathing: The newborn that, despite
or her body temperature much less efficiently the stimulation provided by vigorous drying, has
than an adult, and loses heat more easily, espe- not cried, is not breathing regularly, or is gasping
cially from the head. To prevent hypothermia, one minute after birth, needs immediate inter-
the newborn should be thoroughly dried with a vention. The skilled birth attendant should be
clean cloth or towel as soon as the head and body equipped and prepared to perform resuscitation,
are fully delivered and before the placenta is deliv- preferably by bag-and-mask.
ered. Besides limiting loss of body heat, the stim-
ulation this provides can promote breathing and Immediate breastfeeding: The newborn should
aid an asphyxiated newborn. be breastfed within one hour after birth, and
should be fed only breast milk (see section 3.2).
The newborn should then be wrapped, including
the head, with a clean and dry cloth or towel. In Clean cord care: Clean cord care practices are
addition to immediate wrapping, the newborn’s crucial to prevent infection. The umbilical cord
warmth should be ensured after delivery through should be cut with a clean (boiled) blade and tied
contact with the mother, especially for infants with clean (boiled) materials. No substances
with a low birth weight. should be put on the stump.

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3.1.2 What are the current prac- cared for? When is the newborn first breastfed?
tices, and to what degree or under Second, the researcher must determine what it
would take for the adoption of evidence-based
what circumstances might they be
ENC practices. For instance, although keeping
changed? warm is a natural human instinct, the newborn’s
high risk of hypothermia and the consequent
As in the first two chapters, the first task for qual- need for special attention to his or her warmth
itative research is to elicit information about what may not be well understood. Probing questions
people currently do to care for the newborn should be asked to determine what steps families
immediately after delivery. Specifically, the might take to give their newborns added thermal
sequence of immediate newborn care should be protection. Might they consider drying the new-
explored: What is done to dry and warm the new- born before delivery of the placenta, providing at
born, and when is this done in relation to delivery least a light covering, and keeping the infant in
of the placenta? When and how is breathing contact with the mother or another caregiver?
assessed and ensured? How is the cord cut and

Table 6. Immediate Newborn Care: Lines of Inquiry about Current Practices

Current Practices Lines of Inquiry

1.Whether newborns are dried and wrapped immediately after birth, and before delivery of the
2. If so, how and with what materials
3. If not, whether families would consider drying/wrapping the baby immediately after delivery, and
what might facilitate this
4.Where the newborn is placed immediately after delivery; before and after delivery of the
placenta and after drying, and for how long
Drying and 5.Whether the newborn has skin-to-skin contact with the mother
Warming 6. If not, whether families would consider it possible to put the newborn immediately against
mother's skin/body
7.What would make this practice (or modifications of it) more acceptable or feasible
8.Whether the newborn remains with the mother immediately after delivery, and if separated, how
soon after birth and for how long
9. How soon after delivery the newborn is first bathed and by whom (e.g., family member, birth
attendant, etc.)
10. If it would be acceptable to delay bathing until the second day of life, if not longer
11.The temperature of the bath water and the room during bathing
1.Whether and when attention is given to assessing the newborn's cry and breathing, and who
makes this assessment
Ensuring Breathing 2.What signs of breathing are assessed
3.What is done for the non-breathing newborn, by whom, and for how long
4. If breathing is not assessed (and assisted, if necessary) immediately after birth, what might
facilitate this
1.What instruments/materials are used to cut and tie the cord
2.What measures, if any, are taken to clean these instruments (e.g., if they are boiled)
Clean Cord Care 3.What might facilitate the use of clean instruments for cord care
4.What substances, if any, are applied to the cord stump and by whom
5.The frequency and duration of this treatment
6.Whether it would be acceptable to simply keep cord stump clean and dry, and apply nothing

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Table 6 lists priority practices of the immediate

and of even greater urgency. Consequently, more
postnatal period and several corresponding lines
attention is often paid to the delivery of the pla-
of inquiry that researchers may want to pursue to
centa than to the newborn. At the same time,
determine the current level of compliance with
because spiritual identity also means that the
evidence-based practices. newborn and the placenta are equal beings at
birth, mothers and caregivers should be able to
3.1.3 Which factors limit or dis- address the immediate needs of the newborn. In
courage people’s ability and will- any case, this subtle and often profound belief
ingness to practice evidence- has important ramifications for ENC behavior
change and must be carefully explored.
based ENC?
Concepts of hygiene and cleanliness:
When investigating constraints on immediate Hygiene and aseptic conditions may be unknown
newborn care, there are a number of important or very difficult to achieve in many poor commu-
issues that must be addressed. Those warranting nities. People may be unaware of the environ-
particular attention include: mental dangers of infection, and may be unable
to do much to combat them. This pervasive
Concept of warmth: While warmth appears to acceptance of unhygienic conditions may extend
be a basic human concept, in reality there can be to cord care, newborn drying and wrapping,
many subjective versions of warmth. Members materials, etc.
of the same household often disagree on the
most comfortable temperature. The elderly A related issue may arise in those cultures where
often feel cold more intensely than the young. birth is considered polluting; in this situation,
On the subject of ENC, many women who laying the newborn against the mother’s skin or
experience a “shiver reflex” immediately after delaying bathing may be considered dangerous.
birth draw the conclusion that their bodies and Moreover, these practices may be a violation of
skin are colder than those of the newborn, and religious beliefs, perceived as compromising the
thus refuse skin-to-skin contact. It is critical for religious standing of those who have contact
investigators to gauge indigenous perceptions of with the “polluted” infant. There may also be
warm and cold to create accurate and effective sociocultural reasons why families do not prac-
BCC messages of drying and warming. tice clean cord care; they may believe that apply-
ing certain substances on the cord helps it to
Concept of the spiritual endowment of the heal, when in fact, this practice increases the
placenta: While most Western cultures view the risk of infection. Often there is a religious or
placenta as essential to the growth and survival cultural significance to the application of cer-
of the fetus while in the womb, but of no value tain substances.
after birth, many other societies believe it is
endowed with a spirit. Because of this separate Table 7 lists priority practices of the immediate
spiritual identity, and also because of fears in postnatal period and several corresponding lines
some societies that the undelivered placenta may of inquiry that researchers may follow to deter-
move upwards in the chest and choke the mine the current level of compliance with evi-
woman, the “delivery” of the placenta is often dence-based practices.
considered as important as that of the newborn,

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Table 7. Immediate Newborn Care: Lines of Inquiry about Constraints

Constraints Lines of Inquiry

Determine to what degree pregnant women, their families, and birth attendants:
1. Understand the importance of immediately drying and warming the newborn
2. Understand the importance of ensuring that the newborn is breathing, and if so, if they know
how to stimulate breathing
3. Know the benefits of clean cord care, and understand the consequences of putting
nothing/putting certain substances on the cord
4. Understand the effects of bathing the newborn immediately, and the benefits of delaying
5. Understand the importance of warming the room and water for bathing
1.Whether the placenta is believed to be endowed with any spiritual nature and how this con-
cept affects the relative way the newborn is regarded and the attention given him/her imme-
diately after birth
2.Whether people think that what they do (e.g., to dry and warm the newborn, establish
breathing, care for the cord in a clean manner, delay bathing) can have any impact on a new-
Social and Cultural born’s survival, and how
Constraints 3.To what extent people feel that they can control whether their newborn lives or dies
4.Whether some people may consider it better for a newborn to die than to live, and if so
5.Whether the belief that certain negative practices (e.g., not drying or attending to the new-
born immediately after birth) are important to determine whether the infant is fit to survive
6.What effect religious beliefs, such as ritual pollution, have on immediate newborn care, par-
ticularly with regard to bathing

Determine whether families can afford clean materials to dry and warm the newborn, to cut the
Economic Constraints cord, and to provide a warm bath (e.g., warm water, clean towels or cloths that have been
washed in soap and water, a heating source for bath water, a heating source for the room).

Influence of Decision Determine the most influential members of the family and the community concerning the ENC
Makers practices discussed above.

1. People's definitions of "dirty and clean" (e.g., materials used for labor and delivery,
hands/body parts, the instruments used during the delivery)
2.Whether people believe they can and should improve the hygiene and/or cleanliness of their
household environment, and to what extent economic or environmental factors are con-
Other Constraints straints
3. If there are certain conditions that cannot be changed
4.When a cloth/instrument is considered "clean" and when a cloth/instrument is considered
5. How, if at all, the occurrence of a maternal complication affects newborn drying and warm-
ing, establishment of breathing, cord cutting and care, and bathing practices

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In addition, it is very important that the infant is
3.2.1 Which proven, evidence- exclusively breastfed; that is, not given water or
any other substances. Immediate and exclusive
based interventions lead to lower breastfeeding are of particular importance for
neonatal mortality and morbidity? preterm and low birth weight newborns.

Maintenance of warmth and clean environ-

EVIDENCE-BASED PRACTICES ment: The principles of keeping the newborn
1. Mother and newborn should have routine warm and maintaining cleanliness (particularly
postnatal care visits with a health provider, hand-washing when handling the newborn),
particularly during the first week after birth. remain priorities for preventing hypothermia and
infection in the postnatal period. Special atten-
2. Newborns should be exclusively breastfed. tion should be given to warming and hygiene for
preterm and low birth weight newborns.
3. Warmth and clean environment should be
maintained. Recognition of newborn danger signs and
complications: As in the antenatal and intra-
4. Mothers and their families should be able
to recognize newborn danger signs and
partum periods, the practice of complication
complications, and know when/how to preparedness is critical. The mother and her fam-
manage or seek appropriate referral care if ily, as well as health providers, should be aware of
needed. the following common danger signs and compli-
cations during the neonatal period:

Routine postnatal care visits: While the opti- • Inability to feed adequately or cessation
mal timings of postnatal visits for healthy new- of sucking
borns have not yet been adequately tested in • Weak or abnormal cry or cessation of crying
developing countries to allow an evidence-based • Lethargy or loss of consciousness
recommendation, research suggests that key • Redness of the umbilicus extending to the
intervention times to prevent neonatal deaths
skin of the abdomen
are: immediately after delivery, on day 2 – 3, and
• Discharge (pus) from the umbilicus
on day 6 – 7, at a minimum.
• Localized skin infection (pustules)
• Discharge from or redness of the eyes
Exclusive breastfeeding: In the postnatal peri-
od, the most important practice is to establish • Persistent vomiting and/or abdominal distention
immediate and exclusive breastfeeding. This ben- • Difficulty breathing (including chest in-draw-
efits both the mother and the newborn. For the ing on inspiration or grunting on exhalation)
mother, immediate breastfeeding stimulates uter- • Fast breathing (> 60 breaths per minute)
ine contractions and delivery of the placenta, and • Fever or unusually cold body temperature
thus may reduce the risk of postpartum hemor- • Convulsions, seizures, or fits
rhage. For the newborn, early breastfeeding pro- • Yellow discoloration (jaundice) of the skin—
vides nutrition and warmth, and colostrum the further “down” the body (i.e., hands and
(mother’s “first milk”) contains substances that feet) the worse the jaundice
help prevent infection.

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3.2.2 What are the current prac- mothers and their families recognize newborn dan-
tices, and to what degree or under ger signs and complications? Do mothers and
what circumstances might they be newborns attend postnatal care visits?
Just as it is important to identify current prac-
Qualitative researchers should first obtain informa- tices, it is also important to determine what it
tion about current ENC behaviors for the neona- would take for evidence-based practices to be
tal period: When is the newborn put to the breast adopted. To what degree might progressive
for the first time? Does the newborn receive any- behavior change be possible? For example, exclu-
thing other than breast milk in the first month (and sive breastfeeding is the exception rather than the
throughout the first six months) of life? Are norm in many countries. One reason, particular-
warmth and clean care practices maintained? Can ly in hot climates, lies in the perception that

Table 8. Neonatal Care: Lines of Inquiry about Current Practices

Current Practices Lines of Inquiry

1. How soon after delivery the newborn is put to the breast for the first time
2.What might facilitate breastfeeding immediately after birth, or make this decision easier or
more acceptable
3.Whether mothers give colostrum to the newborn
4. If not, under what circumstances would mothers give colostrum
Immediate and 5.What substances (other than breast milk) are given to the newborn, who administers these,
Exclusive Breastfeeding and when and how frequently they are administered
6.Whether mothers would consider feeding nothing but breast milk/colostrum to their new-
7. If not, whether mothers would at least be willing to reduce the amount/frequency of these
prelacteal or interlacteal feeds
8.What would make the decision to exclusively breastfeed easier or the practice more accept-
1. How the newborn's warmth is maintained during the neonatal period (e.g., contact with
mother, wrapping, covering, etc.)
Maintenance of 2.The frequency of bathing, and water/room temperature during baths
Warmth and Clean 3.Whether those caring for the newborn wash their hands, with what, and how often
Environment 4. If other materials with which the newborn comes into contact are cleansed, and how/with
what they are cleansed
5. If warmth and clean environment are not maintained, what would facilitate these practices or
make them more acceptable
1.When respondents feel that a newborn is in danger during the neonatal period, and the local
Recognition of terms for these symptoms
Newborn Danger Signs 2.What their responses would be to these symptoms
and Complications 3.The health provider or facility to which they would go to seek care for these symptoms
4.Which danger signs/complications are generally perceived or recognized as such; which ones
are not recognized or are misinterpreted
1.Whether newborns currently receive any postnatal care
2. If they do, where and from whom they receive it
Postnatal Care Visits
3.The timing and frequency of these visits
4.The procedures performed and counseling provided during these visits
5.What would facilitate an increased number of visits

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breastfeeding does not provide adequate fluid. tional and immunological properties that it pos-
However, a number of breastfeeding promotion sesses. In many cultures, colostrum is considered
projects have been successful in encouraging an unclean substance that must be extruded (dis-
mothers to discontinue the practice of giving carded) before the milk can be fed. Others con-
water to newborns, at least during cooler times of sider it a purgative, and still others believe it to be
the year. a neutral, but non-nutritive cleansing substance.
It is important for the researcher to determine
Qualitative research should also explore possibil- the convictions that families have regarding
ities for behavior change negotiation on the issue colostrum’s negative properties, as well as the
of prelacteal feeding. Prelacteal feeds, such as depth of these beliefs. In other words, in societies
honey, tea, ghutti, or sugar water, can be harmful, that believe colostrum to be simply a neutral, non-
as they may cause infections and diarrhea. The nutritive substance, changing practices may be
risks of this ritual are even more serious if sub- much easier than in those societies that think it is
stances (like honey) are routinely given a number a purgative. In areas where immunization pro-
of times as an interlacteal feed. The goal of qualita- grams are already well accepted,
tive research in these situations is to determine if likening colostrum to the infant’s first immuniza-
there are conditions under which a family might tion may be an effective behavior change message.
agree to reduce the amount and frequency of
prelacteal feeds. Limiting the practice to the Prelacteal feeds: Prelacteal feeds are considered
anointing of the newborn’s lips, rather than actu- an important social and cultural custom that, like
ally introducing the food itself, might also be a marriage, confirmation, and circumcision, confer
feasible compromise in some cultures. special importance on certain family members
and confirm their role and responsibilities within
Table 8 lists priority practices of the neonatal the family. In some cultures, prelacteal feeds are
period and several corresponding lines of inquiry religiously significant, the practice seen as
that researchers may want to address to deter- bestowing God’s protection upon the newborn.
mine the current level of compliance with evi- While it is is, consequently, particularly difficult
dence-based practices. to eliminate, it may be possible to modify the
practice, retaining its traditional ritual values
3.2.3 What factors limit or discour- while reducing the adverse health risks (see for
age people’s ability and willingness instance, the Hausa ritual, described on p. 4-5).
to practice evidence-based ENC?
Breastfeeding and economic factors/oppor-
tunity costs: One of the greatest obstacles to
For neonatal care, as with the previous ENC
exclusive breastfeeding can be the opportunity
periods, a variety of informational, social, cultur-
cost of the practice. While some BCC programs
al, economic, and other factors can affect peo-
have portrayed breastfeeding as a no-cost option,
ple’s ability and willingness to change to evi-
in reality that is far from the case. Breastfeeding
dence-based practices. When investigating these
a newborn 8 to 10 times a day, which is usual in
constraints on neonatal care, there are a number
on-demand feeding cycles, represents a distinct
of important issues that must be addressed.
economic cost whether a woman works within or
Those meriting particular attention include:
outside the home. In modernizing urban soci-
eties where women work in the organized sector,
Colostrum: Many societies reject feeding the
exclusive breastfeeding may represent an oppor-
newborn a mother’s colostrum, despite the nutri-
tunity cost that is simply too great to bear.

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Similarly, in more traditional societies where born danger signs and complications listed previ-
women’s domestic labor is arduous and continu- ously may appear obvious to the experienced
ous, time taken for breastfeeding reduces other health professional, they are, in fact, somewhat
productive work. Therefore, the decision not to subjective and open to local interpretation. It is
breastfeed is a logical one when the perceived critical that when performing qualitative
economic benefits of labor exceed the perceived research, interviewers define local terms and
advantages of breastfeeding. Qualitative researchers context for various illnesses and signs of illness,
should investigate the economic ramifications of and agree upon minimum criteria to accept as
breastfeeding and determine whether economi- recognition of each danger sign.
cally productive women could increase the fre-
quency of breastfeeds. Table 9 suggests areas of investigation that have
been productive in former research on neonatal
Knowledge and understanding of danger care practices.
signs and complications: Although the new-

Table 9. Neonatal Care: Lines of Inquiry about Constraints

Constraints Lines of Inquiry

Determine the perceived positive or negative effects of:

1. Giving colostrum to the newborn
2. Giving only breast milk
3. Putting the newborn to breast within an hour of delivery
Determine whether mothers believes:
4.Their breast milk provides sufficient food and liquid
5.Their breast milk supply is adequate in the first month
1. Common perceptions of colostrum: whether it is considered dirty, a purgative, a non-nutri-
tive precursor to breast milk, etc.
2.Whether there are any rituals in which substances are given to the newborn, and for what
Social and Cultural reasons
Constraints 3.Whether keeping the newborn with the mother is perceived as important, and if not, why
4. How belief in the spiritual endowment of the placenta affects the timing of first breastfeed-
ing (i.e., do women wait for the placenta to be delivered)
5.Whether families realize that breastfeeding helps stimulate delivery of the placenta and
limit the risk of postpartum hemorrhage
6.Whether the mother’s age or the newborn’s birth order or sex is a factor in breastfeeding
1.Whether women's economic opportunities, at home or outside the home, interfere with
Economic Constraints exclusive breastfeeding
2.Whether women believe that their diet or inadequate food availability influence the quanti-
ty/quality of breast milk
Determine whether mothers perceive exclusive breastfeeding in the first month to be more
Time Constraints or less time consuming than other feeding alternatives, and what effect, if any, this may have on
feeding behavior

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4.1 Overview In a group interview, all respondents are inter-

viewed and urged to respond. No attempt is
The previous chapters of this guide provide lines made to record the answers for each respondent
of inquiry to investigate current ENC practices separately. A group interview can be done using
and the various constraints limiting ENC behavior a structured or semi-structured questionnaire
change. Actual field research may be designed and with closed or open-ended questions.
implemented on the basis of these lines of inquiry.
Individual interviews may be more effective for
There are many different qualitative research exploring sensitive topics that the interviewee
methods available, ranging from those that are would not feel comfortable discussing in a group
widely applicable, such as focus groups, to more setting, such as the relative value of a female child.
specific, but equally useful techniques, such as
mapping. The choice of methods depends on Table 10 presents these and other common qual-
many factors. The two most commonly used itative research methods and gives the salient
qualitative research methods follow: features of each, with examples of newborn
care applications.
Focus groups are best used to probe a com-
plex, narrowly focused issue. A topic that For those program managers who desire more
involves cultural and religious beliefs and prac- detailed and technical information about these
tices, for example, may require the patient, delib- and other qualitative research methods, a list of
erate, participatory techniques that characterize resources has been provided in Appendix 1.
focus groups. A topic such as exclusive breast- Included are in-depth guides to both focus
feeding, which is conditioned by a number of groups and group interviews and a general guide
social, cultural, and economic factors, also lends to qualitative methods, with detailed instructions
itself to focus group discussions. on their use.

Focus groups are usually comprised of 8 to 12 4.2 Selection of Respondents, Data

persons of similar background. A skilled facilita- Analysis, and Reporting
tor guides the discussion—probing beliefs and
attitudes underlying the topic of interest—while Selection of Respondents
members of a study team may record answers.
Techniques for the selection of respondents for
Individual or group interviews are often used qualitative studies are not random, but rather
when factual information needs to be collected, based upon the researchers’ judgment of which
such as the current practices of health personnel. respondents would generate the best-quality data.
It may be more efficient to collect this informa- In some cases, respondents may be selected who
tion from a number of workers gathered in one are especially vocal, for example. Respondents are
place than to interview them individually. A usually selected based on similarities in terms of
group of health workers may be asked, for exam- criteria such as age, sex, and socioeconomic status.
ple, “Why did you want to become a community
health worker?”

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Table 10. Qualitative Research: Methods and Examples of Newborn Care Applications
Examples of Newborn Care
Method Description Features
• Uses a structured • Generates detailed • Home care practices during preg-
questionnaire with information regarding nancy
Individual open-ended ques- practices and con- • Steps taken to prepare for delivery
In-depth Interview tions to probe prac- straints
tices and beliefs in • Elicits information on
detail sensitive topics
• Uses a structured or • Allows for efficiently • The degree to which pregnant
semi-structured collecting information women and their families recognize
instrument to probe from several respon- danger signs and complications of
Group Interview practices and beliefs, dents at the same the antenatal, intrapartum, and post-
but anyone in the time natal periods
group can respond • The degree to which cost is a factor
in the choice of delivery attendant or
place of delivery
• Explores central • Allows for in-depth • Practices surrounding initiation of
Focus Group themes or issues; exploration of focused breastfeeding
Discussion (FGD) allows for free and topics
open discussion with
• A trained observer is • The most accurate • Sanitation in the home, including
present to observe way of recording prac- availability and use of soap and
Direct practices firsthand tices, but requires water
Observation highly skilled • Where the newborn is placed
observers and is time directly after birth
consuming • How the newborn is dried and
• Uses actual or recre- • Enables participants to • Quality of care received during
ated stories about a focus on a real-life antenatal, intrapartum, and postnatal
Narratives or particular topic to ENC situation periods
Scenarios explore practices • Often situates partici- • Process of birth and emergency
and beliefs or pants within a familiar preparation
prompt discussion sociocultural context

• The first two types • Encourages partici- • Community mapping of a village

of mapping ask par- pants to identify and with health post, health providers,
Mapping ticipants to visualize describe systems or and TBAs to explore sources of
Techniques community or social patterns with which help for newborn problems
• Community systems; body map- they are so familiar • Social mapping of organizations,
• Social ping asks partici- that they rarely define such as occupational, social, or reli-
• Body pants, for example, them gious groups
to visualize their • Body mapping of reproductive
reproductive systems organs, fetal growth, or bodily
changes of pregnancy
• Asks participants to • Indicates how respon- • Newborn or maternal danger signs
Grouping organize and rank dents prioritize items and complications grouped by type,
Techniques various elements of according to particular severity, cause, frequency of occur-
the ENC system characteristic(s) rence, and/or treatment

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Data Analysis Chapter 5 explains how to set up an analytical

framework for qualitative research.
Qualitative data are most often analyzed by hand.
The basic data analysis steps include reviewing, Reporting
coding, summarizing, and interpreting the data
collected. Community members may actively par- Qualitative research methods answer questions
ticipate in the analysis either individually, in small such as “who,” “what,” “when,” “where,” “why,”
groups, or in a workshop setting. Examples of and “how.” Questions such as “how often” and
how analyses for focus groups or interviews can “how many” are more appropriately answered by
be conducted include: quantitative research methods. Reports of quali-
tative research, therefore, should state trends but
• Individually or in small groups: Researchers should not attempt to quantify results using num-
go through their interview notes and for each bers or percentages. Examples of the types of
respondent (e.g., mother), put the answer to statements that could be made on the basis of
each question on a separate index card. Then qualitative methods follow:
the index cards are reviewed, common
themes are identified, and the cards are sort- • There was a general perception in the com-
ed according to each theme. Each theme can munities where group interviews were con-
then be summarized in a few words and the ducted that health care staff had improved
results interpreted. their treatment of newborns and their moth-
ers since ENC training was introduced.
• In a workshop: All researchers go through
their interview notes together in a workshop. • Of those young mothers (< 20) who partici-
One question at a time is written on a flipchart, pated in focus groups in peri-urban commu-
and interviewers read out all the responses they nities, most mentioned the importance of
obtained for each question, while someone antenatal care in improving safe delivery after
records them. The group next identifies the community health workers began making
most common responses. Then, group discus- house-to-house visits. Very few mentioned
sion can focus on interpreting these common the importance of antenatal care in focus
responses and deciding upon the appropriate groups held before this intervention.
actions to improve health interventions.
Including direct quotations from participants
There are several computer programs that per- within the report can sometimes capture the rich-
form analyses of qualitative data, and reader- ness of the data collected.
friendly guides are available to aid in their usage.7

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Once qualitative research has been completed, Certain practices are conditioned by eco-
the program manager will 1) analyze the infor- nomic necessity. For example, additional
mation and 2) based upon this data analysis, ANC visits represent opportunity costs,
make appropriate decisions concerning program and the purchase of clean delivery kits or
design. BCC strategic planning will address both products may be inhibited by limited finan-
media programming—selection of outlets, cial resources.
design of messages, format, and presentation—
and interpersonal communication (IPC) training Other practices are limited by access to or
and implementation programs. supply of goods and services. If emergency
referral services are not available in a partic-
5.1 Using Qualitative Research Data ular area, then it is programmatically
unsound and ethically dubious to promote
The design of BCC programs will use the the immediate evacuation of mothers and
results of qualitative research in the following newborns in distress to a health facility.
principle ways: Similarly, if emergency funds for birth pre-
paredness are promoted but no community
1. Identification of priority practices: If loan or transport systems have been created,
qualitative research has been conducted the message may be quickly discredited.
properly, considerable effort will have been
invested in determining which current prac- Therefore, program managers and researchers
tices are amenable to change given informa- must recognize these limitations and identify
tional, social, cultural, economic, and supply con- sound priority practices. As has been shown
straints. Qualitative research can also be used in the tables throughout this document, lines
to offer insights into how and why current of inquiry have been designed to answer the
positive ENC behaviors are practiced or questions “Would you consider adopting X
have come about. behavior?” and “To what degree or under
what circumstances would you change your
If certain practices, such as prelacteal feeds, current practice?” Other lines of inquiry
are strongly embedded within traditional assess the nature and quality of existing prac-
social patterns and cultural and religious tices; how deeply rooted, integral to social
beliefs, changing them may not be feasible— and cultural patterns, and strictly governed by
at least within the lifetime of most BCC pro- existing networks of authority they are. An
grams. On the other hand, practices for analysis of these lines of inquiry will answer:
which there are few prevailing sociocultural
constraints may be relatively easy to change. • When given sound ENC information
For example, mothers who already under- from a trustworthy source, are people at
stand the importance of ANC visits may all willing to change?
quite readily agree to increase attendance
from two visits to three. • What are the easiest or first things they
would change about their current practice?

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• Even if people indicate a willingness to cerning possible strategies for progressive

change, is the change feasible within change—that is, the most acceptable and fea-
existing social, cultural, economic, and sible degree of behavior change to promote
supply realities? for a particular audience at a particular time.

It should be noted that the final selection of pri- Women in a recent BCC breastfeeding pro-
ority practices will be a function of two other gram in India were encouraged, as a first step
important factors: to exclusive breastfeeding, to eliminate “top
milk” (a water-based liquid thought to sup-
• Epidemiology and tipping points: A plement or “top off ” breast milk). In many
particular practice may be considered fea- other countries, a similar focus in exclusive
sible, given an analysis of constraints, but breastfeeding campaigns was placed on elim-
may not be cost-effective as a priority. For inating water from the newborn’s breastfeed-
example, many countries have already ing regimen. Because giving the newborn
achieved considerable success in increas- water has no particular religious or tradition-
ing the rates of ANC attendance. Given al significance, and because it is has such a
the evolution of social norms, practices pernicious effect on newborn health, this was
that have achieved 50% coverage tend to an ideal place to begin the progressive behav-
accelerate geometrically in acceptance past ior change process.
this “tipping point.” Thus, it will be far
easier to achieve change from 50% to 60% Qualitative research inquiries will also point
than from 10% to 20%. Usually, as a prac- the researcher towards possible areas for
tice becomes increasingly common and negotiated behavior change. For example,
close to evolving into a social norm, social some potentially harmful practices, such as
dynamics are such that little additional bathing the newborn immediately after birth,
investment is required to move the popu- may be modified or replaced by more positive
lation to near-complete compliance. practices, such as delaying bathing or cleaning
the newborn instead with a warm, damp cloth.
• Parallel programs and investments:
Most Safe Motherhood projects focus on 3. Identification of behavioral entry points:
ANC, recognition of danger signs and Qualitative research data will provide valu-
complications during pregnancy, skilled able insights regarding entry points for
attendance at birth, and responsible and behavior change—that is, common practices
prompt referral. Therefore, although the or beliefs on which one can build a case for
qualitative research may show that these improved ENC. For example, in many cul-
areas are particularly promising as priori- tures there is a common practice of heating a
ties, other programs may already be ade- room before the delivery of a child.
quately addressing them. BCC invest- Certainly, if there is already this belief about
ments within the context of an ENC pro- warmth, it could be built upon to encourage
gram, therefore, may focus on other pri- families to increase that warmth and also
orities, such as postnatal care. apply it in new circumstances. Similarly, if
there is a strong cultural belief about the
2. Selection of a progressive change strate- equivalent souls of newborn and placenta, this
gy: The research results will provide the BCC belief could be developed to stress the impor-
programmer with valuable information con- tance of caring for both simultaneously.

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All people are aware to some degree of the actually do—prelacteal feeds, early administra-
signs and symptoms of disease. A sore throat, tion of water, supplemental feeding, etc.
runny nose, and sneezing may presage the
onset of a cold. A queasy stomach often pre- • Informational, social, cultural, and eco-
cedes diarrhea. BCC strategies should also be nomic constraints: List those constraints
able to build on these common perceptions that have emerged from the research and are
to increase the recognition and appreciation most likely to interfere with behavior change.
of danger signs and complications during the That is, what factors limit or discourage the
antenatal, intrapartum, and postnatal periods. practice of evidence-based ENC?

5.2 Setting Up an Analytical • Supply constraints: The strategic planning

Framework process must also consider elements of
ENC—such as service delivery, essential
drugs, clean delivery supplies, etc.—from the
It is extremely important for program managers
perspective of supply. That is, although qual-
and researchers to develop an analytical frame-
itative research will have identified families’
work for the qualitative research before the
perceptions of the supply of these elements,
research begins. That is, the purpose and applica-
the actual situation in terms of the availability
tions of the data generated and the manner in
of supplies and services must also be
which it will be organized should be determined
assessed. No responsible BCC program can
ahead of time.
promote the increased use of health facilities,
their services, and supplies unless they are in
Table 11 is a suggested matrix for organizing the
fact already available and accessible or the
data gathered in qualitative research, which should
ENC program has assured their availability.
be completed following the data collection:
• Feasibility of change: Based on the infor-
• Evidence-based practices: Before begin-
mation on constraints and underlying ENC
ning qualitative research, select those prac-
practices, determine which of the current
tices that have the greatest potential impact
practices are the most likely to be modified.
on newborn health. Consider the relative
That is, for which of the high-impact prac-
anticipated health impact of the practices
tices are there a minimum of social, cultural,
based on available evidence and rank the
economic, and supply constraints? Rank the
impact of each as high, medium, or low.
feasibility of change for each as high, medi-
um, or low.
• Current practices: After qualitative research
has been completed, list the current practices
• Behavioral trials of improved practices:
of women, family members, or caregivers
Once high feasibility, high impact practices
that correspond to each of the potential
have been identified, additional exploration
high-impact practices. For exclusive breast-
may be necessary to determine what women,
feeding, for example, indicate what women
Table 11. Proposed Matrix for Analyzing Qualitative Data and Developing a BCC Strategy
Informational, Social, Behavioral
Evidence- Final
Current Cultural, Economic, Feasibility Trials of Communication
Based Priority
Practices and Supply of Change Improved Strategies
Practices Practices
Constraints Practices

After the Research 35

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families, birth attendants, and communities BCC Strategic Planning

would be willing to do to change them. Trials
of improved practices can be a useful way to The BCC Strategic Plan is the formal document
do this. They provide feedback on the prob- to be used by executing agencies, be they NGOs,
ability of getting people to adopt a particular research institutions, or governments, when
new behavior. These trials are a technique to selecting, designing, and developing media and
elicit and negotiate those solutions that are materials, and when designing and implementing
the most appropriate, acceptable, and realis- IPC training. It summarizes the results of the
tic from the client’s perspective. qualitative research and defines: a) the priority
practices considered the most amenable to
• Final priority practices: Given the effort change and most likely to have the greatest
required to change behavior, particularly impact on neonatal health and survival, and b)
practices rooted in ritual or tradition, it is the communication strategies most appropriate
important to select no more than 4 to 5 priority for each priority practice. In other words, the
practices on which to focus in any BCC cam- plan identifies the most acceptable and effective
paign or program. These priority practices ways to encourage people to progress toward
should be taken from among those identified adoption of evidence-based ENC priority prac-
as both high impact and high feasibility. tices. A communication strategy is derived both
from responses to the question “What change
• Communication strategies: Finally, based might you consider in your current behavior?”
on the behavioral information derived from and from an analysis of those factors that con-
qualitative research, determine the best com- tribute to existing positive behavior.
munication methods for encouraging clients
to change from current practices to priority The BCC Strategic Plan is based on qualitative
practices. Qualitative research should answer research data that have been subjected to a rigor-
the questions: “What information do clients ous analytical process. Therefore, the plan offers
need to help them move along the path to pri- conclusions and recommendations that have
ority practices?” and “What might be the been derived directly from real-life experience.
most persuasive and effective ways to present The priority practices presented in the plan are
this information?” Communication strategies those meeting the criteria of high impact and
may also be derived from learning why and high feasibility. The communication strategies
how families that have adopted positive ENC presented should have been selected from many
practices came to make these decisions.8 options, and should be those most likely to
appeal to client communities.
5.3 BCC Planning and
Programming The BCC Strategic Plan, therefore, can be
used as a guide for:
The planning and programming steps to be taken
after completion of data analysis are explained 1. Developing media
below. In addition to the planning of the BCC
program, a monitoring and evaluation strategy 2. Developing IPC training materials
should be developed for performance assess-
ment and impact evaluation. The plan will assist the program manager to
develop media and IPC training materials in the
following ways:

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• It will indicate which priority practices should be certainly of interest to individual communi-
addressed. Given constraints of time and budg- ties, are expensive and difficult to manage on
et, the chances of behavior change increase a large scale. The point is not to exclude
when investments of time, effort and either posters or community-based media,
resources are focused on a few, key practices. but to ensure that if used they are cost-effec-
tive; that is, relative to the investments in cash
• It will suggest the behavioral approach most likely to and management costs, they will have a sig-
succeed for each priority practice within the particu- nificant impact on behavior change.
lar social, cultural, and economic context. For
example, in some countries an initial focus • The design of all media should reflect the
on immediate breastfeeding may be more strategic principles articulated in the BCC
likely to yield significant results than a focus Strategic Plan. There should be a focus only
on exclusive breastfeeding. Similarly, a pro- on priority messages, and each medium
gram emphasizing that immediate breast- should respect only one unique selling prin-
feeding eases placental delivery may be more ciple—the communication strategy recom-
effective in bringing about behavior change mended in the plan. Of course, every medi-
than the more common nutritional or um is different in terms of nature and utility:
immunological arguments. A poster is simple and declaratory with strik-
ing graphics and text, a brochure provides
Media Selection, Design and Production more textual materials and some illustrations,
and a community drama incorporates local
The following are suggested guidelines for creat- folklore and traditions. Nevertheless, all
ing effective media: media should promote the same priority
practices and use the same communication
• The selection of media should be based on strategies as presented in the plan.
coverage, audience, and cost. Unlike their
commercial cousins, most BCC campaigns If a program manager, based on qualitative
have limited finances; therefore the selection research and strategic planning, decides to
of media becomes all the more important. If promote immediate breastfeeding by focus-
a particular medium has limited coverage, if ing on its role in easing/hastening delivery of
its per-beneficiary cost is high relative to the the placenta, this focus should be retained
expected impact on behavior change, or if it throughout the campaign. Although other
is of limited interest to clients, then it should advantages of breastfeeding may supplement
not be programmed. For example, there has this unique selling principle, the emphasis on
been a tendency on the part of BCC planners this initial message must be maintained.
over the last three decades to use program Similarly, if another program chooses to
posters, despite the fact that they are often focus on the nutritive qualities of breast
expensive to produce, work best only in milk, that message should be the focus
sophisticated multimedia campaigns, and throughout the BCC campaign.
provide only reminder information. A com-
mitment to community-based, participatory • The design of individual media should be
programming has at times led other BCC based on creative thinking. Once the BCC
planners to overprogram community dramas, Strategic Plan has established the priority
puppetry, and folk media. These media, while practices to be stressed, the communication

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strategies to be applied, and the types of qualitative research and included in the BCC
media to be programmed, program managers Strategic Plan.
must then design each medium. While the
qualitative research will in some cases pro- IPC agents are those community-based and facil-
vide useful data to guide this process (i.e., ity-based personnel responsible for the dissemi-
information on hopes, aspirations, expecta- nation of information about ENC. They may be
tions, concerns, fears, etc.—the staples of doctors and nurses at a health care facility. They
commercial advertising), in most cases it will may be midwives or TBAs. They may be village
not. Therefore, the program manager should volunteers with no health training, but with expe-
recruit those communication agencies with rience in health promotion.
the most creative and innovative personnel.
A creative professional is one who: a) under- These IPC agents should be trained in the following:
stands the audience from previous sales
experience, b) can easily review, understand, • Priority practices: IPC agents should fully
and assimilate qualitative research data to understand which practices are to be pro-
glean insights about product/service appeal, moted, why they are important, and how they
and c) can follow instincts and suggest cre- contribute to newborn health.
ative designs that still remain within prevail-
ing sociocultural norms. • Current practices: It is important for IPC
agents to fully understand the current prac-
While not every country has a highly devel- tices they are dealing with—the point of
oped advertising or marketing industry, most departure for behavior change.
have professionals with at least some relevant
commercial or social experience. During the • Constraints: IPC agents must know why
competitive bidding process that characterizes clients have not yet changed their behavior,
most subcontracting, the program managers and why it may be difficult to change.
should be particularly attentive to the creative
experience of proposed staff; this experience • Communication strategy: Community IPC
should be documented and available. agents should be trained in the communica-
tion strategies enunciated in the Strategic
• Media production should be as professional Plan, for it is on the basis of these strategies
as possible, within cost constraints. The most that they will develop individualized family
creative media designs can be wasted by infe- behavior change programs.9
rior production. Although production is
often expensive, once cost-effective media • Case histories and negotiated behavior
have been selected, sufficient investment change planning: In order to be effective in
should be made to assure quality, attractive- the field, every IPC worker should be trained
ness, and appeal. in the essentials of taking reliable case histo-
ries—eliciting and recording information
IPC Training about how mothers and families have prac-
ticed ENC in the past—and in developing
The development of IPC training materials is negotiated behavior change plans. These plans
similar to the design and development of identify the degree to which a family is willing
media, for every training course should incor- to change over a given time period; they are
porate the strategic principles generated from essential for establishing the IPC workplan.

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• Work planning and management: Although not successfully implemented or utilized until
an IPC worker may be well trained, an essen- the focus was taken off the campaign's logis-
tial key to ultimate behavior change is man- tics and put on demand creation.10 SNL's qual-
agement—how to develop a reasonable and itative research found that the demand prob-
realistic workplan, and how to work effec- lem was due not only to restrictions on
tively and efficiently within this supervisory women's mobility, but also to lack of support
and management plan. by fathers, husbands, mothers-in-law, and com-
munity leaders, whose involvement turned out
Conclusion to be absolutely essential for the campaign.

Qualitative research assists program managers After conducting qualitative research through
and researchers in developing effective, feasible, focus groups in two randomly selected dis-
and acceptable BCC strategies to improve new- tricts, SNL took the lessons learned to design a
born care practices. It allows for the common demand-generating program where, instead of
or "normal" practice to be identified and the being administered by male service providers,
gap between that practice and the evidence- the three doses were administered by lady
based or "best" practice to be recognized. Once health workers, door-to-door. The campaign
the causes of this gap have been identified, the began by raising awareness among the numer-
relevant constraints can be probed, understood, ous decision-makers, and also respected the
and finally modified. cultural norms of privacy. As a result, national
coverage increased dramatically in just two
In Nepal, SNL used in-depth qualitative years- exceeding the 80 percent target.
research findings to create a BCC strategy
focusing on priority behaviors - such as Not every practice will, even after thorough
delayed bathing for prevention of hypother- qualitative research, be amenable to change to
mia- and disseminated these messages through match the evidence-based practice, but the
radio vignettes, community dramas, and indi- more aspects of essential newborn care that
vidual and group counseling. The midterm can be successfully integrated into the
results of Nepal's program in the Kailali woman's and her family's decisions and
District, showing an increase in delayed actions - through the antenatal, intrapartum,
bathing (for at least 24 hrs) from 7% to 68% or postnatal periods - the more likely that the
in less than 2 years, provides an example of health of the newborn and mother will
the insight that qualitative research can give to improve. Moreover, change is likely to occur
changing behavior, even with those practices incrementally from current to best practices.
most resistant to change. Similar success in Admittedly, qualitative research and a success-
delaying bathing has been reported in the ful BCC strategy are only a small part of
Sylhet District of Bangladesh, after researchers improving newborn health. Families overcom-
undertook a well-designed formative research ing economic, social, and informational barri-
effort, as outlined in this guide. ers to embrace new ENC practices, though
necessary, must also be complemented by
Pakistan's maternal and neonatal tetanus elimi- knowledgeable health workers, accessible serv-
nation program - involving the extremely ices, and adequate supplies.
effective tetanus toxoid immunization - was

After the Research 39

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Directory of Qualitative Research Manuals

Winch, Peter, Jennifer Wagman, Rebecca Malouin, and Garrett Mehl. January 2000. Qualitative
Research for Improved Health Programs: A Guide to Manuals for Qualitative and Participatory Research on
Child Health, Nutrition, and Reproductive Health. Support for Analysis and Research in Africa (SARA)
project, USAID, Bureau for Africa, Office of Sustainable Development. Available from Website:

Qualitative Research Manuals

Aubel, Judi. 1993. Qualitative Research for Improved Health Program Design: Guidelines for Studies for Using
the Group Interview Technique. Development Policy Department, International Labor Office, Geneva,
Switzerland. Available in English, Spanish, and French. Email: or Fax: (41) 22

Debus, Mary. 1988. The Handbook for Excellence in Focus Group Research. Academy for Educational
Development/HEALTHCOM. Available in English, Spanish, and French. BASICS Information
Center, 1600 Wilson Boulevard, Suite 300, Arlington, VA 22209. Phone: (703) 312 6800, Fax: (703)
312 6900, or Email:; or Academy for Educational Development, 1825
Connecticut Avenue NW, Washington, DC 20009, Phone: (202) 884 8118, Fax: (202) 884 8491, or
Email: or

Nachbar, Nancy, et al. Assessing Safe Motherhood in the Community: A Guide for Formative Research. 1998.
MotherCare/John Snow, Inc. 1616 N. Fort Myer Drive, 11th Floor, Arlington, VA 22209, Phone:
(703) 528 7474, Fax: (703) 528 7480, Email:, or Website:

Weiss, William, and Paul Bolton. Training in Qualitative Research Methods for PVOs and NGOs (and
Counterparts). 2000. Center for Refugee and Disaster Studies, The Johns Hopkins University School
of Public Health. 615 N. Wolfe Street, Baltimore, MD 21205. Phone: (443) 287-7277.
Available from Website: <>.

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1. Bhutta ZA, Darmstadt GL, and Hassan B. Community-Based Interventions for Improving Perinatal and
Neonatal Outcomes in Developing Countries: A Review of the Evidence. Submitted to Pediatrics (suppl.); in press.
2. Opportunity cost is the value of productive labor lost due to behavior change.
3. A prelacteal feed is a substance that is given before breastfeeding is initiated.
4. The focus of this guide is on demand. It does not address in detail the various supply factors
that influence behavior change, such as the availability and accessibility of quality services, drugs,
or other health products.
5. Marsh DR, Darmstadt GL, Moore J, Daly P, Oot D, and Tinker A. “Advancing Newborn
Health and Survival in Developing Countries: A Conceptual Framework.” J. Perinatology 22 (2002):
6. A skilled birth attendant is a person with midwifery skills (for example, a doctor, midwife, or
nurse) who has been trained in the skills necessary to provide competent care during pregnancy
and childbirth. If a woman does not have access to a skilled attendant, at a minimum she should
seek an attendant trained in the evidence-based practices recommended in this guide. Based on
Reduction of maternal mortality, A Joint WHO/UNFPA/UNICEF/World Bank Statement (Geneva:
WHO, 1999).
7. See the Directory of Qualitative Research Manuals, in the Appendix.
8. Communication approach developed by Save the Children – is based on the assumption that
negative behavior can be changed through a better understanding of the determinants of positive
behavior and the translation of that understanding into BCC messages.
9. Community IPC agents should also be trained in a number of practical aspects of BCC pro-
grams such as workplanning, monitoring and evaluation, etc.
10. Ramussen, B and Ali, N. “Moblizing Demand for Maternal and Neonatal Tetanus
Immunization: Reaching Women in Pakistan.” Shaping Policy for Maternal and Newborn Health: A
Compendium of Case Studies (Baltimore: JHPIEGO: 2003) 23-28.

Notes 41
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Ronald P. Parlato
Ron Parlato has over 30 years of experience in international
development, specializing in behavior change communica-
tions. At CARE India, he designed and implemented one of
the first behavior change campaigns to address health and
social issues through social marketing. He has been a film
producer for youth media, designed and implemented forma-
tive research, and done both training and impact evaluation.
He was a staff member for the World Bank in the United
Nations Water and Sanitation Decade program; a Senior
Development Advisor for PATH in Ukraine; and from 2001
to 2003 was the Behavior Change Advisor for Saving New-
born Lives.

Gary L. Darmstadt
Dr. Gary L. Darmstadt is the Senior Research Advisor for
the Saving Newborn Lives initiative of Save the Children and
Assistant Professor in the Department of International
Health at Johns Hopkins University in Baltimore. He trained
in Pediatrics at Johns Hopkins and in dermatology at Stan-
ford University. He also completed training in pediatric infec-
tious diseases at the University of Washington, where he
was formally Assistant Professor in the Departments of
Pediatrics and Medicine. His research expertise includes
developing improved strategies for prevention, detection,
and management of bacterial neonatal infections, and pro-
moting healthy newborn care practices and management of
illness at the community level in developing countries.

Anne Tinker
Anne Tinker is the Director of the Saving Newborn Lives
initiative at Save the Children. She has over 25 years of
experience in health and population in over 35 countries,
with an emphasis on reproductive and child health. She is
on leave from the World Bank, where she has been a Lead
Health Specialist in the South Asia Region and the global
Human Development Network, and was previously a Global
Advisor on women's health and safe motherhood. She was
also Division Chief in the Office of Health, USAID. She holds
graduate degrees in international studies (Georgetown U.)
and public health (Johns Hopkins U.). She has authored many
articles and publications on women’s and children’s health.
310496.Cover.qxd 7/9/2004 8:26 PM Page 4


Save the Children/US
2000 M Street NW
Suite 500
Washington, DC 20036

About Saving Newborn Lives

Tools for Newborn Health Series

Newborn health care poses unique problems for health profes-

sionals and program managers in developing countries, where
most women deliver at home, and where health care for new-
borns is virtually non-existent. Improving household practices,
introducing newborn health into pre- and in-service training for
health workers at every level, and integrating newborn health
care in the home and community with care in the facility require
“fine-tuning” of established methodologies. In shaping solutions
for the context of newborn health, Saving Newborn Lives has
come up with innovative approaches to qualitative research, eval-
uation methods, behavior change communication, and training
techniques that are precisely tailored to meet the challenges of
institutionalizing newborn health care.

The SNL Tools for Newborn Health Series is designed to share

the innovative techniques used by SNL with policymakers, health
professionals, and others who are working to improve newborn
health care in developing countries.

Volumes in the SNL Tools for Newborn Health series include:

• Care for the Newborn: A Reference Manual
• Qualitative Research to Improve Newborn Care Practices
• Social Mobilization for MNT: Guidelines for
Immunization Campaigns