Assessment of Essential Newborn Care Practices in the Squatter Settlements of Islamabad Capital Territory in Pakistan

Reseasrch Article

J Pediatr & Child Health Care. 2021; 6(2): 1043.

Assessment of Essential Newborn Care Practices in the Squatter Settlements of Islamabad Capital Territory in Pakistan

Hassan RH¹*, Hamid SH¹, Reza TR², Hanif KH², Blanchard JB³ and Emmanuel FE³

¹Health Services Academy, Islamabad, Pakistan

²Centre for Global Public Health, Islamabad, Pakistan

³Institute of Global Public Health, University of Manitoba, Canada

*Corresponding author: Rameeza Hassan, Health Services Academy, Islamabad, Pakistan

Received: May 28, 2021; Accepted: June 18, 2021; Published: June 25, 2021


Background: While Pakistan has shown progress in reducing child mortality, significant challenges exist in reducing neonatal mortality rate. WHO recommends a package of “essential newborn care” practices based on effective coverage to improve newborn survival.

Aim: To assess the coverage of Essential Newborn Care (ENC) as defined by WHO guidelines, in the squatter settlements of Islamabad Capital Territory (ICT).

Methods: This cross-sectional survey gathered community-based data on newborn care practices from 416 eligible mothers within randomly selected squatter settlements of ICT. Three composite outcomes (safe cord care, optimal thermal care and good neonatal feeding) were generated by combining individual practices from a list of WHO recommended ENC practices. ENC was considered when all practices within each domain of safe cord care, ideal thermal care and good neonatal feeding were fulfilled.

Results: Only 2.9% of newborns received all components of WHO recommended ENC. Seventeen percent newborns received safe cord care, 40.4% received optimal thermal care and 28.8% followed WHO recommended neonatal feeding practice. Various cultural and societal misconceptions were reported which translate into harmful practices for newborn care.

Conclusion: The study highlighted an extremely low coverage level of effective essential newborn care. Pakistan needs to address issues of quality care for newborns through policy and programs which focus on Maternal, Newborn, and Child Health (MNCH) continuum of care. It needs a concerted effort at the grass root level, especially training front line workers to educate mothers on various cultural and societal misconceptions that translate into harmful practices for newborns.

Keywords: Effective coverage; Essential newborn care; Safe cord care; Optimal thermal care; Good neonatal feeding


NMR: Neonatal Mortality Rate; NNS: National Nutrition Survey; WHO: World Health Organization; PDHS: Pakistan Demographic and Health Survey; MICS: Multiple Indicator Cluster Survey; SPSS: Statistical Package for Social Sciences; LHS: Lady Health Supervisor; LHW: Lady Health Workers; ICT: Islamabad Capital Territory; RMNCH: Reproductive, Maternal, Newborn and Child Health


While the world has seen significant progress in improving child survival in recent decades, nearly 2.5 million neonates died in 2017 alone, showing a 51% reduction in the Neonatal Mortality Rates (NMR) compared with a 58% decline in under-five mortality rate [1,2]. The neonatal period defined as “the initial 28 days in the life of a newborn infant or neonate” is considered as the most critical phase owing to the high vulnerability of infections during this period [3]. It is also regarded as a sensitive marker of the quality of health care for women and newborns within the continuum of care that spans pre-conception, pregnancy, childhood and adolescence [4]. Huge disparities in the rates of neonatal mortality exist across various regions, with South Asia alone accounting for 38% of neonatal deaths worldwide [2]. While Pakistan has shown progress in reducing child mortality, significant challenges exist in reducing the neonatal mortality rate, which shows insignificant improvement compared to infant mortality and under-five mortality [5]. Serial data from demographic health surveys conducted in Pakistan shows an NMR of 55 deaths per 1,000 live births between 1992 to 2012 which improved to 42 deaths per 1,000 live births in the most current 5-year period [6,7]. The mortality patterns also vary across various districts and between urban, semi-urban and rural populations where the neonatal mortality rates are twice more than the national average [8].

For years, the performance of health systems has been evaluated by the fraction of people who are provided a service among those who need it [9]. More recently, the concept of effective coverage was introduced, which not only focuses on health services utilization but also emphasizes on quality, thus moving beyond the concept of mere provision of health services to a more comprehensive approach towards newborn care [10]. WHO recommends a comprehensive package of “Essential Newborn Care” (ENC) practices for improving newborn survival and reducing illnesses associated in the early days of life [11]. In Pakistan, the highest level of early newborn care is reported from Islamabad Capital Territory (ICT) at 55%. However, this data only reported “contact coverage” and did not assess what “package of services” were included. It also focused on urban populations and did not include the squatter settlements within ICT, which has mostly remains neglected in larger national surveys in Pakistan [12]. We therefore, conducted this study in the squatter settlements of ICT to understand the level of effective coverage of essential newborn care. It is also important to determine if the care received is within the parameters of essential newborn care as defined by WHO guidelines for effective decision making and formulating healthy policies centered on essential newborn care in Pakistan.


Using a cross-sectional design, this study gathered data on newborn care practices from mothers residing in the squatter settlement of ICT, who delivered a live baby in the past twelve months. A squatter settlement is defined as “a residential area whose inherent non-legal status deprives the households belonging to lower-income group from adequate or minimum level of services and infrastructure”. Eligible mothers who gave birth to newborns with congenital abnormalities, who failed to provide informed consent or were not mentally stable to take the interview were excluded from participation in the study.

Sampling procedure and sample size

Of the 37 squatter settlements in ICT, nine most populated squatter settlements were randomly selected in the first stage. A list of households with children up to 1 year of age was developed and eligible households were randomly selected in the next stage of sampling. In households with more than one eligible study participants, one of the child was randomly selected. Assuming the prevalence of postnatal newborn care at 55%, the sample size was calculated to capture the population parameter with a 95% confidence level, and a 5% bound on the error of estimation. It was inflated by 10% to adjust for nonresponses and data errors to a final sample size of 416 for this study.

Data collection and field procedures

Information provided by selected mothers in a face to face interview was recorded on a pre-designed, pre-tested structured questionnaire. The questionnaire was developed in English, translated into Urdu and back-translated into English to eliminate translation errors. Urdu version of the questionnaire was administered in the field. Data were collected between April 2019 to July 2019 by a team comprising of 4 public health graduates a field supervisor and lady health workers from the LHW program, who facilitated field work. The entire team was trained in field and data collection procedures in a three days training. A field office was established at the Health Service Academy in Islamabad, where field teams met daily to discuss field schedules and proceeded to the field. Prior to field data collection, pilot testing was carried out to examine the reliability of the data collection tool, the content and procedures. All necessary modifications in the questionnaire were made accordingly. Field work was facilitated by Lady Health Workers (LHWs) from the federal government run LHW program, who provided assistance to the research team.

Data management and analysis

A data management team supervised by a data manager and two data entry operators worked alongside the field team. All questionnaires received from the field were coded, and entered into a CS pro database specially designed for the study. The final data set was analyzed using Statistical Package for Social Sciences (SPSS v.22). Descriptive analysis was conducted by calculating mean with standard deviation for continuous variables and proportions for categorical variables. To estimate effective essential newborn care three composite variables; safe cord care, optimal thermal care and good neonatal feeding were developed. Each composite variable comprised of three components; i) Safe cord care encompassed use of a hygienic instrument to cut the cord, hygienic tying of the cord and application of nothing or chlorhexidine to the cord; ii) Optimal thermal care included immediate drying the newborn with in ten minutes, immediate skin to skin contact of newborn and mother and delayed bath with warm water for at least 6 hours of birth; iii) Good neonatal feeding comprised of breastfeeding initiation within an hour of birth, giving colostrum and no pre-lacteal feed. Each of these variables were dichotomized into a ‘yes’ or ‘no’ response. Coverage of composite variable was calculated based on positive response to all the three variables within each domain. Effective essential newborn care was considered when all practices within each domain of safe cord care, ideal thermal care and good neonatal feeding were fulfilled.

The study followed international ethical guidelines including obtaining informed consent from respondents, privacy and confidentiality of information obtained. The research protocol was approved by the Ethics review committee of Health Service Academy, Islamabad.


Sociodemographic and economic characteristics

Of the 416 mothers interviewed 93.8% (n=390) were currently married and were living with their husbands. The average age of the respondents was 26.7±4.8 years with 31.9% being less than 25 years. A large majority of participants were married at a young age with approximately 46% less than 20 years old at the time of their marriage. One-quarter (24.5%) of the mothers were illiterate with no formal education, while less than 10% had more than 10 years of education. Nearly one third were working women, and 69% lived in a joint/extended family system, with their husbands being the key family income providers (Table 1).