Newborn in a Jakarta hospital about to be placed in an incubator. Photo: Jhpiego
Of the 3 million deaths among newborns each year, about 28% are caused by infections. Many of these infections may be preventable by improving the handwashing behavior of mothers and others close to the infant during the vulnerable neonatal period (< 28 days of life). A 2008 study from Nepal found that the newborns of mothers who reported washing their hands with soap were 44% less likely to die during the neonatal period than the newborns of mothers who did not report washing their hands with soap. Unfortunately, far too often, mothers of newborns do not wash their hands with soap. Why is this the case? MCHIP has supported in-depth qualitative research to understand better the factors that prevent mothers from not washing their hands during the vulnerable neonatal period. This post describes some of the lessons being learned from these three rich data countries (Bangladesh, Indonesia, and Kenya).
Despite their dramatically different cultural contexts, mothers across the countries were unsurprisingly similar in many respects. As mothers in even the highest-income countries can attest to, the birth of a new baby brings great joy and no small amount of change to the mother’s life. Even while mothers described a desire to nurture their babies, and improve their own habits in order to ensure the health and well-being of their newborns, they found that numerous barriers stood in the way of even the simple behavior of washing hands with soap when necessary.
There is no rest for the weary. Mothers of newborns are busy people! Activities such as caring for older children, cooking for the family, and cleaning the home do not stop when a new baby is born. In the midst of the added responsibilities of frequent breastfeeding, nappy changing, and essential cooing and cuddling, mothers find it difficult to step away to wash their hands with soap even if their hands are soiled.
Handwashing materials are not conveniently located. As busy as they are, mothers have a hard time washing their hands because, often, the materials they need to wash hands (soap and water) are not present in the places where mothers spend time with their newborns. In Bangladesh, mothers are advised to remain relatively secluded with their newborns for about 40 days after birth in order to protect the baby. If a mother does not have the necessary tools to dispense water and soap, she cannot wash her hands when she needs to, and does not feel like she can walk away from the newborn during that fragile time to seek out the necessary materials in another part of the house or compound.
Handwashing is not in the mother’s hands alone. Unfortunately, many mothers (pregnant or otherwise) lack the minimal power needed in their familial structures to prioritize purchasing and maintaining soap in the home for handwashing, and for enforcing handwashing by those higher in the hierarchy than themselves. While mothers can often ask their other children, and sometimes even their husbands, to wash their hands, they typically cannot ask their in-laws to do so. Poignantly, a woman in Bangladesh indicated that, even if she were given materials to aid her handwashing, she feared ridicule from her in-laws.
Research on how to promote handwashing to new mothers, and the effects of such promotion, are underway. But, programs can begin to address this important health behavior by developing interventions that make use of the cross-cultural drivers and barriers to maternal handwashing. Here are some suggestions to aid in the development of such interventions:
Highlight the vulnerability of the newborn period. Mothers and all secondary caregivers (e.g. grandmothers, aunts, and so on) should be made aware, if they are not already, of the high risk of infections and their consequences to the newborn with the immature immune system.
Make handwashing more convenient. Provide materials to pregnant women to support handwashing in the places where they will spend time with their newborn. Such basic materials as a water dispenser, a soap dish, and bars of soap, may overcome very basic barriers to handwashing.
- Encourage a social norm identifying handwashing with soap as a loving, nurturing behavior. Re-fashioning the social norm around handwashing will not necessarily be easy but it may be hugely rewarding. Mothers’ groups, peer-to-peer promotion, intentional gossip, social marketing approaches, and other strategies to change the social norm regarding handwashing may be helpful to promote the concept that handwashing is a critical way for a new mother to demonstrate her desire to nurture her newborn.
Enlist the support of fathers, grandmothers, and other persons of influence. In many places, mothers cannot improve their own hand hygiene, or that of others, without the support of others more powerful in the family structure. Interventions should motivate fathers, grandmothers, and grandfathers to play an active role in ensuring the health and well-being of the newborn, and providing access to the necessary tools to wash hands.