Study setting.

This study was set in Karnataka, which had an infant mortality rate of 27 per 1000 live births in 2015–2016 (slightly below the national average of 32.3), down from 43 since 2005–6 [26]. Mothers and family members were recruited to participate in this study if they attended CCP sessions in one of the four district hospitals (large tertiary hospitals) in Chikkaballapur, Ramanagara, Dharwad and Bagalkot, Karnataka and who had completed a short survey 28-day post-discharge survey as part of a separate on-going study covered under a separate IRB [18]. The 15-minute post-discharge survey covered questions on knowledge and behavior of key behaviors; and self-report of complications or readmissions, which will be reported separately. This qualitative research provides insight into participants’ perception of the CCP sessions, how and why families performed behaviors, and explores facilitators and barriers to change. At the time of planning for this qualitative study (July 2019), the implementation and research team looked at the eight study sites from the larger neonatal study and selected facilities based on delivery load in the last month, CCP attendance in the last month, geographic location in Karnataka, number of sessions run each month, and quality of sessions. Recently delivered mothers participated in the survey if they were 18 years or older, delivered within the hospital, and neither the mother nor newborn died before discharge. These participants would have attended sessions within selected district hospitals within January-February 2020.

Sampling strategy and inclusion criteria.

Based on the post-discharge survey responses, study team members purposively recruited interview participants based on whether newborn complications were reported, given this is a main health outcome CCP aims to impact. The goal was to recruit equal numbers of mothers and families with and without reported newborn complications. Only individuals who spoke Kannada and/or Hindi were recruited. Mothers and family members who did not complete the 28-day post discharge survey were not included. The sampling targets were set at 40 participants total (20 family caregivers and 20 recently delivered mothers with half the participants reporting baby complications) due to expected saturation in responses.

Data collection instruments.

The research team developed separate semi-structured interview guides for mothers and family members with questions aimed at understanding how the CCP influenced behaviors, knowledge, and confidence among women and family members. Interview questions covered the following themes: attitudes, beliefs, and norms around newborn and maternal care practices (including perceptions, benefits, risks, challenges, facilitators), and acceptability and feasibility of the CCP. Particular focus was on specific health behaviors (i.e. exclusive breastfeeding, dry umbilical cord care until it falls off, handwashing before feeding and touching the baby, skin-to-skin care on a routine basis and if the baby is cold, unrestricted maternal diet for women, and danger sign recognition during the neonatal period), and experience for women and families who experienced baby complications (see Table 1). Among participants who reported a complication with their newborn, follow up questions around health seeking behavior and follow up actions were explored.

Researcher team composition.

A third-party external agency conducted the semi-structured interviews; four of the interviewers were female and one male. This external agency was trained on the CCP program, interview guide, and interview techniques. Staff had Kannada, Hindi, and English language capacities and came from social science and public health training. After an initial recruitment call to confirm participant interest, the interviewers would call to schedule the interview. Interviewers conducted the interviews within the household where other household members would often observe the interview. Logistically, it was challenging to enforce privacy with the new mother or family caregiver given the newborn needs and the local cultural context. An interviewer and note-taker pair conducted the interview at the participants’ home from February-March 2020 (before the COVID-19 pandemic), audio-recorded, and transcribed and translated into English. The research team read transcripts for quality and de-identified transcripts.

The research tools and protocol were first piloted by members of the research team (who were not involved in eventual data collection), and the interview guide was refined and simplified. After the third-party agency was trained, they piloted the interview guides as well and received interviewing feedback. The research team and external agency iterated on the interview guide during this period, refining language, probing questions, and question flow, based off of initial interview responses (S2, S3 Texts). Results of this qualitative research are reported against Standards Reporting for Qualitative Research guidelines [27]. Additional information regarding the ethical, cultural, and scientific considerations specific to inclusivity in global research is included in the S1 Checklist.

Ethical review.

This study received IRB clearances from Harvard University in Boston, USA and ACE Ethics Committee in Karnataka, India. All participants underwent a written consent process for the interview and audio recording and signed (or provided thumbprints if they couldn’t read) in their local language.

Analysis process.

Research team members, who did not conduct interviews, created a codebook after reviewing five de-identified interviews through a mix of inductive and deductive coding. A doer/non-doer analysis framework informed codebook development to understand why people performed or did not perform a specific behavior [28]. The finalized codebook included themes around barriers and facilitators for key behaviors, health seeking behavior in the event of neonatal complications, and impact from CCP sessions (S4 Text). The same researchers then coded the interviews using Dedoose online software and reviewed each other’s codes [29]. They kept in touch with the interview team as questions arose. The analysis is based on the key behaviors according to the doer/non-doer framework, to understand barriers, facilitators, and context for the key behaviors and associated impact of the CCP program.

Influence on knowledge, preventive behaviors, and confidence of newborns’ family caregivers.

We analyzed five main, preventive behaviors taught in the CCP: exclusive breastfeeding, handwashing, skin to skin care, dry cord care, and non-restrictive mother postpartum diet. The data indicates that respondents come into the CCP with prior knowledge on newborn care behaviors and receive knowledge from multiple different sources including healthcare providers, family, friends, and media channels. Cultural norms and social beliefs also have an influence on individual newborn care behavior.

Exclusive breastfeeding.

Breastfeeding is not a new behavior to most respondents. They have prior knowledge through their own personal experience (previous children, observing other women in family breastfeed), advice from health care workers (doctors and nurses at the hospital, Anganwadi workers) and advice from family and community members. Several (n = 7) respondents said that the CCP offered them new knowledge on breastfeeding including positioning, breastfeeding technique, using a pillow to help support the baby and the mother’s back, and burping.

Normally, everyone would breastfeed however they liked…By doing it the way that they taught us it has been more convenient for the baby to drink breastmilk… and also it is “easier” for us…like this we can hold the baby(showing with hands how to cradle the baby in her arms before breastfeeding) put one hand on the baby’s back and this way (showing with hands making a ‘V’ with her finger on her chest indicating a scissor position to support the nipple). Doing this has made it easy for me to hold the baby and also it is more convenient for the baby this way to drink milk. (Mother, complication group)

Respondents felt most confident in their ability to breastfeed when they are producing enough milk for their baby and when their baby is consuming enough breastmilk. In general, the most commonly mentioned barrier to breastfeeding is a lack of milk production.

All respondents said their babies were fed breastmilk (n = 42) but several respondents said that they also fed their newborn other foods, indicating suboptimal or nonexclusive breastfeeding. In general, respondents that experienced problems with milk production supplemented breast milk with other items (prior to six months of age) including cow’s milk and glucose water. One respondent that experienced difficulty producing breast milk was prescribed powder milk and provided it to her newborn. Respondents said that they breastfed with complementary feeding of animal milk (cow, sheep) (n = 5) or glucose water (n = 1) because the mother was not producing enough breast milk. Other items fed to newborns included almond paste (n = 1), ground dates and almonds mixed in with breast milk “for strength” (n = 1), Ghutti (herbal medicine for infants) and honey paste (n = 1), and honey (n = 2). Several respondents also fed their baby gripe water (not prescribed) (n = 7) and prescribed medicine (n = 2) to help with digestion and gas, and growth.

Handwashing.

Most respondents have prior existing knowledge about good hand washing practice. Based on the data, handwashing seems to be a generally understood and accepted behavior (even prior to CCP attendance); it is a common behavior that is not unique to newborn care. The majority of respondents (n = 35) practiced regular hand washing before attending the CCP. Overall, mothers and family caregivers are aware of the importance of washing hands with soap. Respondents recognized the importance of handwashing (n = 39) and understood the benefits including being able to make the link between good handwashing practice and preventing infection.

Respondents attributed to CCP that they now regularly wash their hands with soap before touching their baby (n = 14), five respondents said that their family members also wash their hands now with soap before touching their baby and they are now more careful to wash hands more frequently with soap (n = 7). The CCP helped this group of respondents understand the benefits of using soap in addition to water when hand washing and helped respondents understand the importance of washing their hands prior to touching their newborn in order to help minimize spread of infection to their baby. One respondent stated that they do not follow the exact method of handwashing taught in the CCP but still wash their hands. Overall, respondents reported having regular access to water (in-house pipes, borewell, stored water) and soap which facilitates handwashing behavior. A few respondents also have access to hand sanitizer (n = 3). In general, the CCP influenced when respondents wash hands, including after using the bathroom, before eating and/or serving meals to family members, after doing housework, after coming home from doing outside work, and before touching their baby (including before breastfeeding and after handling a dirty diaper):

Respondent: We brought a dettol (soap) to our home and we are using it to wash our hands. We wash our hands using it before touching the baby….

Interviewer: Is there any difference in the way of hand washing before and after listening to the group class?

Respondent: Yes, there is a difference.

Interviewer: How?

Respondent: I was not used to hand washing before listening to the class and started to wash after listening to them in the group class.

Interviewer: Can you tell me what you mean by you were not used to hand washing?

Respondent: I used to wash my hands only before and after having my meal earlier but now I keep washing my hands often because I have to carry my baby now. Everyone in our home washes their hands now.

Interviewer: So, everyone in your home washes their hands using dettol now?

Respondent: Yeah, everyone in our home uses the dettol in our home to wash their hands. (Mother, no complication group)

They said that we have to use dettol or soap to wash our hands. We have to wash our hands after coming home from outside or after touching anything. We have to wash our hands properly before touching the baby. We are following the same in our home. (Family Caregiver, no complication group)

Skin-to-skin care.

Overall, responses indicate that there is limited existing knowledge about skin-to-skin care for newborns. The data show that there aren’t any strong existing cultural and social beliefs around the practice, and family and community members are not offering advice around this behavior. Respondents’ knowledge of skin-to-skin care seems to be coming from the CCP and other healthcare workers.

More than half of respondents said that they do not practice skin to skin care (n = 25) although 29 respondents believe that there are benefits to skin-to-skin care including newborn weight gain, increased bonding between mother and newborn, and transfer of warmth. Many respondents (n = 33) said they learned about skin to skin from the CCP and some respondents (n = 6) could recall the use of a doll to demonstrate skin-to-skin care (“hugging”, “wrapping of doll”). However, there is variation among respondents in their understanding of how and when to perform skin-to-skin care. Responses regarding how skin-to-skin care should be performed varied and were sometimes contradictory to what was taught in the CCP. The following are examples of responses when respondents were asked how and when to perform skin-to-skin care:

• Baby should be bare
• Baby should be wrapped
• “Tie like a frog”
• Only mother and father can do skin-to-skin
• Any family member can do skin-to-skin
• Place baby on chest
• Place baby on stomach
• Family caregiver must bathe before practicing skin-to-skin
• Must bathe newborn before practicing skin-to-skin
• No direct skin contact with baby, must have cloth in between
• Only if baby is weak or cold
• Not if baby is weak/premature

A few respondents (n = 5) said that skin-to-skin care should only be done after the mother or family member bathes. Nineteen respondents said that skin-to-skin care should be practiced when the baby is cold or has a problem (when the newborn is “underweight” or “weak”, when the newborn has a “fever”).

When the weight of the baby is low, they said to wrap the baby warm while putting him to sleep….They said to put the baby on chest and lay down while watching TV. They said to put the baby on the stomach with a bare body. (Mother, no complication group)

A few respondents (n = 7) said they did not feel the need to practice skin-to-skin because their baby is healthy and others (n = 4) did not want to practice skin-to-skin because they felt their newborn was “too weak” (premature) and they were scared to carry their newborn because it could cause harm to the baby in some way.

He is very small. I am afraid that I may drop him, so I have not given him ‘chest warmth.’ (Mother, no complication group)

Cord care.

Over half of respondents (n = 27) had prior knowledge around dry cord care practice. Sources of knowledge included advice around cord care from family members, influence of “elders”, prior personal experience, and information from healthcare workers (physicians, nurses, ASHA workers). Over half of respondents (n = 22) said they learned new information from the CCP or the CCP reinforced dry cord care knowledge.

We didn’t do anything to the baby’s umbilical cord madam. It fell on the 6th day when we were still in hospital. We did not apply any oil or powder to it. They informed us in that class not to apply any powder as babies may get infections due to that which will lead to problems. Our baby did not face any such problems and it was all fine. (Mother, no complication group)

The majority of respondents (n = 37) did not put anything on the cord or cord area and allowed the cord to naturally dry and fall off. Several of these respondents recalled that putting something on the cord could lead to infection (n = 7) and a few respondents recalled that dry cord care prevents infection and pus formation (n = 2). A few respondents (n = 5) put something onto the cord before it fell off (hot coconut oil, powder, castor oil, “boric powder”). Respondents that put something onto the cord before it fell off explained this was due to direct advice from a family member (“elders”, mother-in-law, sister). Thirteen respondents applied something (oil, powder) to the cord area after the cord fell off. Common reasons given for applying items to newborn cord or cord area include: to reduce pain, keep cord area dry, reduce redness, heal a cut, stop bleeding, or stop pus.

Mother postpartum diet restriction.

Almost all respondents (n = 38) said that the mother restricted specific foods and/or liquids post-pregnancy, either for a specified (e.g. days or months) or unspecified amount of time. Thirty-three of these respondents could recall that the CCP recommended that the mother not restrict any food or liquid. However, six respondents recalled being told during the CCP to avoid certain foods (cold food, spicy food, salty food, oily food). In general, respondents offered contradictory answers to interview questions about maternal postpartum diet. When initially asked if they restrict any foods, respondents typically answer “No” and say that they follow what was taught in the CCP, but when probed about specific food items (fruits, spicy foods etc.) then the respondent said that the mother does restrict certain foods and liquids.

The majority of respondents restrict despite what they recall being instructed to do in the CCP. The data shows that a complex set of factors influence maternal postpartum diet restriction including individual beliefs, advice from family, advice from extended community, and cultural practices. Mothers seem to receive mixed messages and contradictory advice around diet from various sources. Key sources of advice include elders within their family such as their mother, grandmother, and mother-in-law. The elder women of the household often prepare food for the mother and therefore have control over what and when she eats; she is dependent on what her family provides her and has little choice.

If the mother eats spicy food the baby gets dysentery and a burning sensation in his stomach. That is the reason I do not give her spicy food. I do not use green chilies. I use only red chili powder. I prepare food with very little quantity of chili powder. (Family Caregiver, complication group)

There are strong held social beliefs about risks to the newborn and mother from consuming certain foods or drinking too much liquids. Consequently, respondents avoid eating certain foods and consuming too much liquid. The most common restricted foods and liquids include:

1. ○ Foods and liquids that are believed to cause cold in mother and baby such as certain fruits, specific vegetables, and cold water
2. ○ “Hard foods” such as certain grains and lentils, which are believed to make the baby’s stomach “hard” (not able to digest) and cause pain
3. ○ Foods that are believed to cause “heat” such as spicy food
4. ○ Foods that are believed to cause infection or “pus formation” after a c-section (rice)
5. ○ Water: several participants restrict maternal consumption of water because they believe it will cause issues in the newborn’s small stomach, “twisting” in the stomach, and pain (n = 8). Out of these respondents a few said they restricted water or thinned milk because they had given birth to a male child (n = 3).

In general, participants seem to have regular access to meals with grain, fruits, vegetables, and water. A few respondents (n = 4) said that they do not restrict any foods or liquids post pregnancy. Three of these respondents directly attributed this to what they learned in the CCP.

They told me to have more water all the time madam. We were not knowing the benefits of having more water. They told me that I can produce more milk for the baby if I eat good nutrition food. It’s the same with water as well. They explained to me that If I drink more water in the morning then I can produce more milk for the baby at the same time. If I don’t drink the water in the evening then I cannot produce the milk for the baby in the evening and in such situations, we may think that there is a problem in producing the milk and we rush to hospital. So, to avoid such things I have to eat good nutritious food and should drink more water all the time. I told the same thing to my mother as well. My mother is an old lady and they think that I will produce thin milk if I drink more water and that milk will not give any protein to the baby. That is the reason they don’t allow me to drink more water. They explained all the right things in the group session which helped me a lot. (Mother, complication group)

Out of the three respondents, two said that food/liquid restriction was present for their first child but for the second baby there was no restriction due to what they learned in the CCP. Several respondents (n = 11) made the connection between a good maternal postpartum diet and breast milk production.

Interviewer: Is your confidence about breastfeeding affected by the group class?

Respondent: My confidence is increased by the class.

Interviewer: How?

Respondent: They told us what to eat if we can’t produce more milk. They informed me to eat all the foods except cold foods, which can lead to not enough breastmilk. They even mentioned eating non-vegetarian food. That is what we are following at home. That is the reason I am confident that my baby is getting enough milk for him. (Mother, no complication group)

Identifying danger or warning signs.

We interviewed 23 respondents (13 mothers and 10 family members) that self-reported a post-discharge newborn complication in a follow-up survey conducted by Noora Health. Out of the 23 respondents identified using the survey, the most commonly reported complications were fever (n = 6) and cold/cough (n = 5), followed by cord infection (n = 4), jaundice (n = 2), rash (n = 2), infection from drinking “womb water” (n = 1), problems with urine production (n = 1), vomiting (n = 1), and gas (n = 1). From the analysis, we identified nine additional respondents from the non-complication stratum who mentioned that their newborn experienced some sort of problem (not originally mentioned in the 28-day post discharge survey). These respondents reported cord infection (n = 3), cold (n = 2), breathing problems (n = 1), rash (n = 1), stomach pain (n = 1), and discomfort when passing urine (n = 1). Two respondents (both family members) believed that the reason for their baby’s problem (fever, constipation, stomach pain) was due to maternal diet.

A few respondents (n = 4) said that the CCP influenced their knowledge and understanding of danger signs related to their newborn’s complications (3 fever, 1 cord infection). Four respondents said that the CCP influenced their symptom management and three respondents said that the CCP influenced their health seeking behavior. Several respondents (n = 4) said that the CCP had no influence on their ability to identify danger signs, symptom management, or health seeking behavior. In general, respondents either tried to manage symptoms at home with medicine from the pharmacy and/or they went to a clinic or hospital for treatment. There was no mention among respondents of utilizing a traditional healer.

In the group class they told us not to apply any sort of oil to the umbilical cord as it will lead to infections and wounds may turn to worse. We have to take the baby to the doctor if there are any wounds near the umbilical cord. They asked us to always check the umbilical cord for any wounds but my baby had nothing as such. After one month our baby got a wound near the umbilical cord area. So, we took the baby to hospital and they prescribed ointment and powder to apply and we were applying that to the baby. (Mother, no complication group)

Overall, respondents reported that they were able to recognize when their baby had a problem and understood the importance of seeking medical advice and treatment. The data indicate that health seeking behavior (taking baby to the clinic or hospital) is common among parents of newborns and that respondents believe they are able to recognize when something is wrong with their baby. In general, responses indicate that prior knowledge contributed to health seeking behavior. It is possible that the CCP reinforced certain knowledge around danger signs and behaviors (symptom management, health seeking behavior) but we cannot determine that with our current data.

At the start of the interview, all respondents (n = 42) were asked “In the group meeting, the Nurses talked about a lot of things that could go wrong for a baby. How did hearing about these things make you feel? Why?” Most respondents described danger signs taught. Fifteen respondents recalled being told about jaundice during the CCP and eight of these respondents recalled the symptoms of jaundice including yellowish discoloration of the eyes or body. Two respondents recalled that in the CCP the nurses said to take the baby to the hospital if they noticed breathing problems including if the baby started to “breathe heavy” and two respondents recalled that that in the CCP the nurses said to take the baby to the hospital if the “feet turn blue” and if the body turns blue. It is possible that respondents are able to recall the various danger signs discussed in the CCP but in this study the interview guide did not specifically explore each danger sign discussed in the CCP with each respondent.