Figure 1 and Figure 2 present the distribution of newborn drying in the two countries. An overwhelming majority of women (87%) said that their newborns were dried immediately or within 1 hour in Malawi. In Bangladesh, 68% of women said that their newborns were dried within 5 minutes of birth, 16% within 5-9 minutes following birth and 7%, 10 minutes or later. The percentage of newborns not dried was 5% and 6% in Malawi and Bangladesh respectively.

Figure 1.  Newborn drying in Malawi.

Figure 2.  Newborn drying in Bangladesh.

Table 1 and Table 2 show distributions of drying of the newborn in each country and how they vary by facility and key variables. About 90% of newborns were dried in both countries. With such high coverage, differentials across socio-demographic subgroups were generally weak. However, several variables showed notable differences. While newborns who were born in a facility in Malawi were significantly more likely to be dried compared to those born outside a facility (93% vs 84%), in Bangladesh, there is no discernible difference. Likewise, in Malawi, births with a skilled provider were more likely to be dried (95%) compared to those with an unskilled provider (78%) though this pattern was not found in Bangladesh. Women who had had no antenatal visits were least likely to have a newborn that was dried (53%) compared to others with such care (1 or more visits, >90%) in Malawi. This differential was significant in Bangladesh as well but differences in levels were not substantial. In both countries, women who had a C-section reported less drying than women with vaginal births (eg, in Bangladesh, 87% vs 92%). In addition, in Malawi, place of residence was also a marker for differences in drying with a larger proportion of mothers in rural areas reporting that the baby was dried immediately after birth. In Bangladesh, mother’s education and household wealth also show significant differences in the results regarding newborn drying with mothers with no education and in the poorest households reporting lower levels of newborn drying. Despite significance, differences are not substantial.

We examined the distribution of timing of bathing of newborns for the first 100 hours of life, shown in Figure 3 and Figure 4 (excluding cases where newborns were not bathed, about 10% in Malawi and 5% in Bangladesh, or were missing). In both countries, there is a small but important percentage of newborns who are bathed immediately after birth (about 10% in Malawi and 8% in Bangladesh). The graphs also show clear evidence of heaping of the data. In Malawi, this is evident on hours 24, 48 and 72 which correspond to 1, 2 and 3 days. Similarly, in Bangladesh, some heaping occurs at 24 and 72 hours.

Figure 3.  Bathing of newborns in Malawi in hours.

Figure 4.  Bathing of newborns in Bangladesh in hours.

Table 3 and Table 4 show bathing after 24 hours in Malawi and Bangladesh. In these tables, cases of never bathed, don’t know and missing were removed from analysis. In Malawi, only 26% of newborns were bathed after 24 hours, while in Bangladesh, 74% were bathed after 24 hours. In both countries, there were few missing cases (not included in the Tables 3 and 4 Table 4). Comparing by place of birth, newborns in facilities were more likely to have a delayed bathed compared to those born outside of facilities in both countries (see Table 3 and 4 Table 4). Newborns in Malawi and Bangladesh who were born using a skilled provider or those who were born with a C-section were more likely to have a delayed bath than those who were born to an unskilled provider or those born by a vaginal birth. For example, in Bangladesh, among all newborns, 92% born using a skilled attendant was bathed after 24 hours while only 60% born without a skilled attendant was bathed after 24 hours.

Monitoring ENC is needed to identify programmatic coverage gaps and to provide an empirical basis for policy, accountability and investment to improve newborn survival and care. The renewed emphasis on newborn survival on the global agenda has led to the inclusion of new questions and modules on ENC in survey programs for the collection of data on key indicators in a systematic manner. For instance, in the latest round of MICS surveys, launched in late 2016, questions on ENC including thermal practices, cord care and skin-to-skin contact are included for countries to use. Changes have also occurred for the DHS surveys, which has an optional newborn care module with similar topics.

Levels of drying are remarkable similar in the two countries with nearly all newborns being dried. However, bathing practices differ in the two countries, with newborns in Malawi being bathed much earlier than those of Bangladesh. These levels seen in Malawi are much lower than those seen in Uganda in other literature [12]. The analysis also shows that skilled providers are important for the delivery of timely drying in both countries and drying in Malawi. However, given that a sizeable proportion of births occur outside of facility settings, it would be useful to ensure that unskilled providers are able to provider these two elements of thermal care. This recommendation is supported by the 2009 WHO/UNICEF joint statement on home visits for newborns, wherein both skilled and unskilled providers are endorsed for certain elements of care, including thermal care, following the time of birth [17].

Our results show that the measurement approaches used in these two surveys are not standardized. This is to be expected as these are initial efforts to measure these variables in the survey programmes. Drying data for the two surveys are largely incomparable. While the Malawi survey data allow a category of ‘immediate drying’, this category also includes cases of drying within 1 hour. The Bangladesh survey provides response categories using ranges of minutes and no ‘immediate’ drying category. As such, both cases do not allow an easy calculation of the ‘immediate drying’ indicator, which in part reflects the lack of clarity of what constitutes ‘immediate’. These concerns are largely addressed in the latest round of MICS and the DHS optional module on newborn care. In MICS6, the relevant question asks if the newborn was wiped or dried soon after birth, while the DHS asks if the newborn was wiped dry within a few minutes. It is of course necessary to note that both question approaches allow a certain level of subjectivity to measure the immediacy of drying, an approach that is necessary until there is an agreed definition of what ‘immediate drying’ refers to.

With reference to newborn bathing, the major methodological issue is that the cut-off for the indicator is for values greater than 24 hours. Both surveys show heaping of data at the 24-hour mark, which is used as a cut-off for indicator calculation. Similar heaping of data exists across different health and nutrition indicators such as low birth weight (at 2500 g). Due to this issue, in the latest round of MICS, after the question on bathing is asked, an addition probe is activated if the respondent says that the newborn was bathed on the 1 day/24-hour mark to ascertain if the bath took place before, after or on that exact moment. A similar approach can be useful for surveys using the DHS approach. We also detect that in Malawi an important proportion of cases was not bathed, but in Bangladesh, there were much fewer cases. It would be important to monitor this proportion in future surveys and to understand the circumstances that produce this outcome.

There are important limitations in this paper that should be considered when interpreting the results. Data on ENC practices used in the analysis are based on mother’s recall of care provided to the newborn soon after birth. Apart from recall, women not know if certain events have occurred or the exact timing, especially in the case of C-sections, where the mother and newborn may be quickly separated. This may explain why women who had a C-section reported lower levels of drying. As with other measures based on mother’s recall, this could have led to differential recall bias and may not entirely reflect the level of quality of care in facilities [18]. This is particularly the case for interventions that occur during the postpartum period as it is an intense moment for mothers. The Malawi MICS 2014, newborns who were not dried were skipped out of the question on bathing which can potentially under-estimate the indicator level, given that some newborns who are not dried could have a bath later than the 24-hour period. Due to the questions asked, a comparable measure of immediate drying could not be calculated. As such, the analysis in this paper focusses on newborns who were ever dried or not.

Our findings shed light into gaps on two essential yet simple newborn care interventions, which at low cost, can help maintain the newborn in a stable condition. The results also indicate potential areas of intervention for training up of staff for implementing drying and bathing in these countries. Further research is required to study the results of the new MICS and DHS approaches to measuring drying and bathing in different countries to ensure that the intention of these questions are properly reflected.