https://orcid.org/0009-0002-2748-9910
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Abstract
Background
Newborn hypothermia is a condition that affects newborn survival if measures are not taken to prevent heat loss, especially in the first 28 days of life. Various studies have been conducted in this area, but there is a lack of information about how post-natal mothers specifically keep their newborns warm in a hospital setting. This study explored the preventive practices for newborn hypothermia among post-natal mothers in selected health facilities in the Kilimanjaro region.
Method
A qualitative descriptive study with a constructivist approach was conducted from April to June 2024 in the Kilimanjaro region involving 12 post-natal mothers. Participants were selected purposively at the post-natal ward. In-depth interview, guided by a semi-structured interview guide developed by researchers together with an audio recorder, was used to collect information from the participants. Data was analyzed using conventional thematic analysis.
Results
Twelve (12) semi-structured interviews were conducted with post-natal mothers. Four (4) themes and eight sub-themes emerged; Body covering measures (Covering baby with multiple coats of cottoned materials, Preparing baby clothing before delivery), diversity of room temperature controlling measures(Maintaining indoor heating to warm the room and maintaining indoor lighting to increase room temperature), skin-to-skin and feeding practices(Keep a baby in physical contact with the mother for warmth and Breastfeeding practices and body care measures(Massaging the neonates with oil to maintain skin warmth and bathing practices).
Conclusion
Keeping the baby appropriately covered, ensuring the room is warm, maintaining continuous skin-to-skin contact with timely breastfeeding, and delaying bathing were commonly practiced reports by participants and may inform educational interventions or future quantitative studies evaluating their effectiveness.
Citation: Daniel E, Seif SA, Millanzi WC (2026) Exploring preventive practices of newborn hypothermia among post-natal mothers in selected public health facilities in Kilimanjaro region: Qualitative descriptive study. PLoS One 21(9): e0357756. https://doi.org/10.1371/journal.pone.0357756
Editor: Syeda Humaida Hasan, Chittagong Medical College, BANGLADESH
Received: November 23, 2025; Accepted: August 23, 2026; Published: September 10, 2026
Copyright: © 2026 Daniel et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: Concerning the data set of the underlying results of the manuscript. All relevant data are within the manuscript and its supporting files. Raw data, such as transcripts and translations, cannot be shared publicly because of the confidentiality assurance given to participants at the time of consent. Hence, the data can be accessed through the institutional research review committee (IRRC) of the University of Dodoma through drpc@udom.ac.tz after being processed and accepted by the committee.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Every family prepares for a newborn with great anticipation and pleasure, but losing a newborn due to hypothermia, which can be prevented with low-cost resources, can dismantle their family bond and provide psychological trauma. Newborn hypothermia is said to occur when the core body temperature of a newborn drops to 36.5°C and is classified into mild hypothermia (360C-36.40C), moderate hypothermia (320C-35.90C), and severe hypothermia <320C [1].
Newborns are vulnerable to temperature fluctuation, especially in the first 28 days of life, which predisposes them to different complications like hypothermia, hypoglycemia, sepsis, and asphyxia, which are core contributors to newborn mortality [2]. According to the World Health Organization (WHO), it was estimated that 2.3 million newborns died within the first 28 days of life in 2022, with sub-Saharan Africa having the highest neonatal mortality rate in the world at 27 deaths per 1,000 live births (6). Moreover, in Tanzania, it is estimated that newborn mortality is about 24 deaths per 1,000 live births, while the target is 12 per 1,000 live births by 2030 [3]which indicates a double increase instead of a decline. This also shows there was a need to intervene appropriately by providing appropriate thermal care and other related interventions.
Hypothermia is an important aspect in the avoidance of preventable newborn deaths, so great care is highly required, especially in this period, to achieve Sustainable Development Goal 3.2 [4], and post-natal mothers are important in maintaining newborn thermal protection, particularly after being discharged from the hospital when clinical oversight is minimal. Previous studies have shown that most of the post-natal mothers lacked sufficient knowledge on preventing hypothermia [5], some knew exactly how to keep the newborn warm [6], and others had poor practices, like early bathing [7]. This also highlights the need to explore the preventive practices of newborn hypothermia.
In lower and middle-income countries(LMIC), the preventive practices employed by post-natal mothers, including skin-to-skin contact, early initiation of breastfeeding, and avoidance of cold exposure, directly impact newborn outcomes [8]. Moreover, post-natal mothers play a great role in newborn’ lives, and their practices will have an impact on the existence of the problem, as previous studies have reported post-natal mothers did not practice skin-to-skin contact, newborns were soaked in water in the first 24 hours after delivery, and late initiation of breastfeeding was reported, all of which influence newborn hypothermia [9,10]. These findings highlight the critical need to explore the preventive practices among postnatal mothers. Moreover, women from different cultures, especially in lower and middle-income countries, have their own way of caring for children to prevent hypothermia; some practices may be detrimental, as they are not scientifically based, such as bathing a newborn within 24 hours after delivery [11,12]. Furthermore, there is limited data in the setting on the adopted preventive practices of neonatal hypothermia by postnatal mothers, as previous studies focused on medical treatment and use guidelines rather than exploring the real practices implemented by the postnatal mothers.
Therefore, the study intended to explore the preventive practices of newborn hypothermia among postnatal mothers in the Kilimanjaro region.
Materials and methods
Study approach and design
This study was grounded in the interpretivist paradigm, adopting a relativist ontology that acknowledges the existence of multiple, subjective realities shaped by individual contexts. To operationalize this perspective, a qualitative descriptive design was employed. The researcher opted for this design because it provides a direct description of participants’ experiences without a deep theoretical context of a particular topic under investigation, and also because the design is flexible and has sufficient procedures to provide a thorough understanding of the phenomenon [13]
Researcher characteristics and reflexivity
The principal researcher is a midwifery specialist with eight years of clinical and academic experience spanning labor and delivery, postnatal care, and neonatal units. This background provided high levels of theoretical sensitivity, allowing for deep immersion in the clinical stance of newborn care. However, the research recognized that this professional expertise could introduce pre-understandings or subjective biases. To mitigate this, the study adopted a stance of reflexive objectivity. The research employed Husserlian bracketing, deliberately setting aside personal clinical assumptions to approach the data from a tabula rasa perspective. This was operationalized through rigorous reflexive practices, including reflexive journaling, whereas a dedicated log was maintained to document personal feelings, expectations, and emerging insights, ensuring a clear distinction between participant narratives and researcher interpretations.
Moreover, the study used field notes from the observations of non-verbal cues and environmental context, which were recorded to provide a thick description of the interview setting. Peer debriefing was also employed through ongoing dialogue with the research team, which served as a reflexive check, challenging potential subjectivity and ensuring the findings were anchored strictly in the participants’ voices. By utilizing the self as a reflexive instrument rather than a mere data collection tool, the researcher ensured that the findings present an authentic co-construction of meaning, balanced by clinical insight and methodological detachment.
Study setting
The study was conducted in selected health facilities, including Hai district hospital, Pasua, Longoi, and Majengo health centres, involving post-natal mothers. These facilities were chosen due to the high number of deliveries and the diversity of care provided to reflect the variation of newborn prevention practices across the Kilimanjaro region. Hai district hospital and Pasua health centre, located in urban areas, handle approximately 236 and 218 deliveries per month, respectively, and offer comprehensive emergency obstetric and newborn care (EmONC), neonatal intensive care units (NICU), as well as basic emergency obstetric and newborn care (BEmonc). Moreover, Majengo and Longoi health centres, situated in urban and rural areas respectively, have around 196 and 60 deliveries each month and provide basic emergency obstetric and newborn care, including kangaroo mother care. Interviews were conducted in private, conducive, and friendly environments within the hospital or health centre.
Sampling strategy
The study employed a criterion-based purposive sampling, a strategic approach designed to identify and recruit information-rich cases that align with the research objectives. The primary goal was to engage participants who possessed a broad experiential understanding of the phenomenon, specifically regarding newborn hypothermia preventive practices. To ensure a holistic and comprehensive dataset, the research utilized a maximum variation sampling technique. This involved the deliberate inclusion of participants with diverse socio-demographic backgrounds, including variations in parity, educational attainment, occupational status, and the level of health facility utilized for delivery. This diversity was essential to capture a wide spectrum of perspectives and to mitigate the risk of homogenous bias. In alignment with qualitative methodology, the final sample size was not predetermined. Instead, recruitment was guided by the dual principles of data saturation; Consequently, participants were enlisted until thematic saturation was reached, characterized by the moment when additional interviews produced no new conceptual revelations or developing themes [14]. Furthermore, participants were recruited purposively through an oral announcement in the study setting, in which the postnatal mothers were approached individually.
Study population
The study population comprised 12 postnatal mothers with newborns who received delivery services at the selected healthcare facilities. To ensure data accuracy, participants were selected purposively based on specific inclusion criteria, including being in the postnatal period and having the cognitive and linguistic capacity to provide detailed verbal accounts of their experiences. Nevertheless, the study applied strict exclusion criteria to uphold ethical standards, including the exclusion of mothers with acute post-delivery complications or those categorised as critically ill, to prioritise maternal well-being and ensure that participants were in a stable condition to participate in the interview process.
Data collection method
A face-to-face in-depth interview was used to collect qualitative data on preventive practices for newborn hypothermia among postnatal mothers.
Procedure: The in-depth interview was conducted in a private, comfortable room with adequate lighting where participants felt at ease expressing themselves. To ensure confidentiality and privacy, the door was closed during the interview. The researcher positioned himself directly in front of the participant and introduced himself, along with a research assistant, to establish a therapeutic relationship before beginning. The interviews started after the researcher explained the purpose, benefits, risks, voluntary nature of participation, privacy, and confidentiality. Subsequently, the researcher obtained informed consent from participants and provided codes to protect their identities. Initially, a researcher gathered demographic data and asked participants to consent to an audio recording. The interview was conducted by two researchers: the principal researcher, who led the interview, and a research assistant, a nurse working in the labour and post-natal wards, responsible for noting non-verbal cues and preparing the environment, including setting up and testing the audio recorder. The interview was conducted in Swahili to facilitate active participation.
The researcher began each interview with a general question to gain a broad understanding of the participants’ experiences, followed by several probing questions to delve deeper into the preventive practices related to newborn hypothermia. The researcher used an audio recorder to record the interviews and field notes to capture verbal cues and memos. The interview duration depended on the participant’s tolerance and patience in describing their experiences related to the topic being interviewed. However, the duration of the interview varied from 30 to 90 minutes, and the researcher, together with the research assistant, summarised the key issues immediately after each conducted interview.
Data collection tool
The qualitative interview guide was used to collect data (S1 File: Interview guide). The researcher designed the tool in accordance with the research question. Before the main data collection, the tool was piloted to 6 participants from a non-study facility to ensure questions were clear, relevant, and culturally acceptable. Their feedback was used to refine the tool accordingly. The tool focused on questions regarding preventive practices for newborn hypothermia, with three main interview topics to delve into the details of this phenomenon, enabling participants to share their experiences that closed-ended questions might miss. Additionally, the audio recorder was used to capture and preserve the interview audio. Furthermore, the audio recorder was pre-tested before the actual data collection to ensure its functionality, data transferability, and audible sound capture, thereby ensuring the tool’s credibility for this study.
Data analysis plan
The study employed Conventional Thematic analysis, following the rigorous six-phase recursive framework established by Braun and Clarke [15]. The initial phase of data preparation involved the exact transcription of audio recordings, followed by their translation into English. The translation procedure was executed in partnership by both authors, who are native speakers of the Swahili language. A verification of the translated transcripts against the original was conducted to guarantee linguistic fidelity and conceptual richness. The English transcripts were subsequently examined and re-examined by two authors to acquire understanding of the contents. To enhance the inductive nature of the study, analysis was conducted at the manifest level, prioritizing the explicit meanings shared by participants. The process was operationalized as follows:
Familiarisation was the first stage at the manifest level of thematic analysis that involved transcribing the data from audio to text, reading and re-reading the data, and identifying the initial ideas about the interviewed topics to familiarise with the collected data.
Secondly, generating initial codes was the second stage after familiarisation, where the researcher systematically coded the interesting and peculiar characteristics of the entire data set, assembling data relevant to each code. The researcher identified meaningful units of text in the form of phrases that were highlighted with colours. Moreover, the two coders discussed differences in their codes until they came to a consensus.
Thirdly, searching for themes which involved organizing codes from various interview participants into potential themes, combining multiple codes to create a single theme. The researcher identified patterns among the concepts and began to develop themes according to the coding patterns.
Reviewing themes was another stage in which the researcher reviewed and refined the themes to ensure they were accurate and relevant to the data. The themes were compared with the data to ensure a true presentation of the participant’s voice.
After identifying the final themes, the researcher defined and named them in a way that presented the real meaning of the phenomenon. Also, the researcher examined the names of the themes to ensure they were sufficiently descriptive and brief for inclusion in the report. Also, the identified themes were reviewed and discussed by the research team.
Lastly, producing a report and writing up was the final stage of thematic analysis that involved writing the report using the analysed data. The report comprised a narrative description and quotations from participants.
Trustworthiness
To ensure the trustworthiness and authenticity of the findings, the study adhered to the criteria proposed by Lincoln and Guba [16], including:
Credibility: Credibility was ensured through persistent observation of the participants to identify participants’ cues, behaviors, and unique features presented by the participants. In addition, data were audio recorded and then transcribed verbatim to ensure that each information provided by the participants was captured and analysed. Dependability was ensured by recruiting participants purposefully, using an interview guide, and triangulating two methods of data collection using field notes and audio recording, to capture the data during data analysis. Also, audit trails were ensured through a clear explanation of the research process, data collection and analysis to enable external auditors to value the study. Confirmability was ensured by participant validation of transcripts (member checking) through reviewing the original interview data alongside the analysed data, use of participants’ verbatim quotes to present the results, repeated reading of transcripts to grasp the content, and careful generation of themes to reflect participants’ voices.
Ethical consideration
Ethical clearance was sought from the institutional research review committee (IRRC) of the University of Dodoma on 30 January 2024, with Ref. No. MA.84/261/69/2. The study abided by the ethical principles of the Declaration of Helsinki by the World Medical Association (2001). The participants, before the data collection process, were given detailed information about the purpose of the study, benefits and risks of participation, research procedures, participants’ roles in the study, and freedom to participate freely and withdraw from the study at any time they wish. Each participant was asked to sign an informed consent form before participation. Furthermore, participant anonymity was maintained to ensure the confidentiality and privacy of the participants, and all information from the field was secured for authorised persons only. Furthermore, during qualitative data collection, the confidentiality and integrity of the data that were collected through audio recording were guaranteed by the implementation of security measures, such as encoding and password protection. Also, anonymisation and privacy maintenance were adhered to.
Results
Participants’ social demographic characteristics
Twelve [12] participants were interviewed, and all participants completed the interview. Thematic data saturation was achieved with the 12th interviews. The characteristics of the participants involved in the study are presented in Table 1.
The analysis of the data collected resulted in four themes: body covering measures, diversity of room temperature controlling measures, skin-to-skin and feeding practices, and body care measures. These themes were supported by eight sub-themes which are Covering the baby with multiple coats of cottoned materials, preparing baby clothing before delivery, maintaining indoor heating to warm the room, maintaining indoor lighting to increase room temperature, keeping a baby in physical contact with the mothers for warmth, breastfeeding practices, Massaging the newborn with oil to maintain skin warmth and Bathing practices as shown in Table 2.
Theme one: Body covering measures
Body covering measures refer to all actions that are taken by post-natal mothers to dress their newborn to protect them against cold, these measures include the use of heavy clothes made up of cotton materials, baby shawls, hats, and socks. Participants demonstrated that keeping the baby warm and preventing catching a cold is enhanced by body covering, which will help to maintain the baby’s body temperature. Within this theme, two sub-themes were identified.
- i. Covering the baby with multiple coats of cotton materials
The participants viewed the use of multiple coats of cottoned materials to dress the baby as one of the preventive practices that protects newborns from catching a cold and finally developing hypothermia. These multiple coats of cottoned materials, such as heavy clothes like kitenge and Khanga (a brightly coloured, thick and thin, rectangular cloth), are mostly used by the mothers to dress their newborn, especially those that are made up of cotton since they can retain warmth as compared to non-cotton materials. Some participants described that these materials were prepared before delivery and are used to swaddle the baby from head to lower extremities to protect most of the areas that are sensitive to cold. The quote below from one of the participants attests this;
“First of all, you will cover the baby well with heavy clothes that do not permit the cold and which are not wet to free him from the cold” (P7-L)
Another participant reported that, after the baby is born, it is very important to dress the baby in clothes that are made up of cotton as they do not permit cold, and the following quotes from the participants can justify this.
“Some clothes are made of materials that aren’t able to maintain warmth, which can cause the baby to catch a cold once you cover him. But other clothes are made of cotton materials that can support warmth” (P5-H)
Furthermore, participants also demonstrated that they cover newborns with many clothes to protect against diseases like pneumonia; however, this justifies their awareness of the complications related to hypothermia if left unattended. A P8-P delivered to her second baby attested.
“When the baby is born, I put him in socks, a hat, and a lot of wraps so that he doesn’t get cold and become warm and prevent him from getting pneumonia” (P8-M)
- ii. Preparing baby clothing before delivery
Baby clothing refers to all baby materials that are used to protect the baby against hypothermia. These are widely used by many women who were interviewed, and most of the women demonstrated that before delivery, they make preparation, which involves buying, washing, ironing, and packing them in a prepared bag ready to wait for the expected day for delivery. One of the participants from the interview explains this.
“Before I came to give birth, I made preparations for baby clothes like caps and socks; I bought, washed, and ironed them. This is because we were also taught during the clinic by nurses to prepare them to protect babies from colds after birth” (P1-P)
However, it was noted that during the interview, some of the postnatal mothers described that they made preparations for their babies’ clothing before delivery, and some didn’t prepare them until they delivered, with the reason that they didn’t prepare because they were not sure if they would deliver a live baby. One of the participants reported this
“These baby clothes were prepared by others; I did not prepare them. What happens if you make plans but end up not delivering the baby alive? Who is going to dress them?” (P4-M)
Theme two: Diversity of room temperature controlling measures
During an interview, the participants highlighted that to keep the baby warm, there is a need to control the external environment and keep the room warm including closing the window and doors, switching off the fan if available, using of charcoal stove to heat the room and switching on the electric bulb in the room throughout the night with the hopes, these measures can keep the room warm and finally will prevent the baby from catching cold hence preventing hypothermia. From this theme, three sub-themes were developed.
- i. Maintaining indoor heating to warm the room
Unwanted air current from entering the room is a key challenge that predisposes newborns to hypothermia. To prevent this, the majority of the postnatal mother explained that when they are at home, they close windows, and curtains and switch off the fan to maintain the warmth of the room. Furthermore, other participants use the charcoal stove to warm the room. This practice they do, especially during the winter period, by placing a charcoal stove far away from the bed, either near the door or in the living room, and the heat that will be generated will spread to all rooms and finally to the place where the baby is sleeping. Despite being aware of the consequences of using the charcoal stove in the room, the participants who were interviewed still use it as a preventive practice for newborn hypothermia. As one mother reported:
“As for the house, it depends on the environment where you live. Maybe the house has big windows that let in the cold. You need to make a lot of effort to keep the curtains closed to make sure that any part does not let in the cold” (P4-M)
Another participant said that:
“When I return home, I have to close the windows and doors, and I have to switch off the fan while at home” (P3-P)
Another mother said
“Right now, I am a parent, and the room I am going to use should be warm all the time that heat helps the baby, and me too……… I used to light the charcoal stove to boil the soup (a liquid food especially with meat, fish or vegetable) and water, so the heat would spread in the room. In many cases, the charcoal stove is also harmful; for that reason, I always put it in the living room, and its heat will spread throughout the house, so the child gets air and heat too, because let’s not just say heat, even air has its benefits” (P10-P)
- ii. Maintaining indoor lighting to increase room temperature
Indoor lighting plays a great role in maintaining the room temperature through heat generation as adequate lighting contributes to an indoor temperature which helps to warm the room and prevent the occurrence of hypothermia among newborns. One of the participants reported that they use electric bulbs or solar bulbs that they switch on throughout the night to maintain the room temperature. This practice prevents newborn hypothermia.
The participant stated that:
“Also, switching on an electric light bulb throughout the night, even if you use solar light, helps to increase the temperature in the room” (P7-L)
Another participant reported that
“In the room, I will make sure to close the windows, the room should not have a fan, and the electric light should be left on so that it can help generate heat, when the baby sleeps, the lights should be left on, like electric bulbs at night” (P12-L)
Theme three: Skin-to-skin and feeding practices
The interview revealed that postnatal mothers use skin-to-skin and feeding practices as a preventive measure against newborn hypothermia. Other participants mentioned that after the baby was delivered, the baby was placed on their chests by the health care providers, and also asked to start breastfeeding immediately as a way of creating a bond with their babies as well as protecting them from getting hypoglycemia, which will lead to hypothermia. Skin to skin is not commonly practised among mothers since few participants mentioned it as a way of preventing newborn hypothermia some of the participants further mentioned that after delivery, they don’t practice skin-to-skin contact at their practices because the cord stump is still wet and intact; maybe if the cord drops off also, they said skin-to-skin is for low-birth-weight babies and not for the full term, and also the initiation of breastfeeding was determined by the condition of the baby, such as crying, sleep, mothers’ activities after delivery, and early handling of the baby to them from health care providers. Hence, skin-to-skin contact and feeding practices enable the baby to get heat through either flow of the mother’s heat to the baby through skin-to-skin contact and also through the milk that breastfeeding contains a lot of calories, which also is the source of heat. The three sub-themes were identified under this theme.
- i. Keep a baby in physical contact with the mother for warmth
The narratives show that physical contact, like putting the baby on the mother’s chest, is non-existent to almost all of the participants, with a few mothers who were able to mention and practice, especially after delivery. Most of this physical closeness is done after the second stage of labour, when the baby is delivered, the baby is placed on the mother’s chest by the health care professional to gain warmth from the mother, but not a regular practice for these post-natal mothers. Furthermore, other mothers demonstrate that putting the baby under the mother’s chest is for low-birth-weight babies and not for babies with normal birth weight.
The above statement was explained by the following participant
“I also know that when a baby is underweight, he is placed in a kangaroo to get the warmth of his/her mother, but I do not know how it increases the temperature, but I only know that it is for babies with low weight” (P1-P)
Another participant explained that
“Putting the baby on the chest, skin to skin was done after giving birth, the baby was placed after I did not put him again and I have never done that again even with other children” (P7-L)
Furthermore, other mothers are afraid to have physical closeness with their babies because the stump is still fresh, and physical contact with the baby’s abdomen will hurt the stump. This can be justified by the following statement from one of the participants
At the moment, I can’t because I see that the umbilical cord has not been dropped off. On my side, maybe what I can do is, when the cord is dropped off, it will be fine. Maybe I can hurt the umbilical cord of the baby. I think that is the main reason why you cannot put the baby on the chest because the umbilical cord has not dropped off (P12-L).
- ii. Breastfeeding practices
Also, breastfeeding practice was mentioned by the mother as a way of preventing newborn hypothermia among newborns. One mother said during feeding, the baby is kept near the mother’s abdomen, hence there is a transfer of heat from the mother to the baby, which also helps to keep the baby warm.
“Also, the breastfeeding method helps because I am warm here and my milk is also warm, so when I breastfeed the baby, the breast milk is going to reduce the cold” (P11-H)
Another mother said
The early breastfeeding method can help the child to warm up because when you breastfeed, you hug him, and hence, he gets his mother’s warmth (P6-H)
Moreover, mothers do not perceive breastfeeding as a measure that should be carried out in a rigid schedule and are therefore oriented on feeding on demand, such as crying of the babies, handling of the baby by health care providers and completion of activities such as bathing carried out by the mothers after delivery
“…….. What helps me know that he wants to suckle is that you can find him crying because of hunger. When you see him calm, you will know that it was hunger” (P11-H)
Theme four: Body care measures
Body care measures involve bathing activities and topical oil application on the newborn’s skin to enhance warmth and promote comfort and sleep. Participants during the interview explained that babies need to receive care after delivery, and one of the cares is the use of oil to keep the skin smooth and warm after wiping or bathing using warm water to remove dirt, to promote a good feeling for the baby, and to enable the baby to sleep well. These measures were described by post-natal mothers aimed at softening the skin and promoting skin warmth, and are done a few hours after delivery. Within this theme, two sub-themes emerge: massaging the newborn with oil to maintain skin warmth and bathing practices.
- i. Massaging the newborn with oil to maintain skin warmth
Applying oil to baby skin may be beneficial, possibly through physical stimulation while applying the oil, which also improves thermoregulation. Newborn’s massage, used for preventive as well as therapeutic processes, participants reported using coconut or parachute oil to improve baby’s skin and warmth. As one mother described that
“I apply coconut oil on the baby to soften her skin and the coconut oil also helps to keep the baby warm” (P9-P)
Coconut or parachute oil massage is common and all post-natal mothers are reported to engage in this behaviour. Applying oil to the baby’s skin after delivery is a common practice that was demonstrated by the mothers. Participants also highlighted the use of coconut oil as a means of warming the baby. Coconut or parachute oil was used to improve skin condition and to reduce the incidence of hypothermia by reducing trans-epidermal water loss, hence improving thermoregulation.
Another participant reported;
“There is also applying coconut oil to the baby; you massage the baby with oil, making the baby feel warm. It’s coconut oil. I used to massage the neck, legs, and just the whole body, and when you bathe the baby, you have to massage with oil because when you put the baby in the water, he becomes cold……., so he warms quickly” (P8-M)
- ii. Bathing practices
The practice of wiping or bathing newborns within health facilities after birth is prevalent due to cultural and knowledge differences, contradicting the standard care of newborn care. Wiping or bathing of the newborn even before 24 hours is common in our setting, since after delivery, the presence of vernix caseosa and blood on the newborn’s skin is perceived as dirty. Therefore, the mothers described using lukewarm water obtained from home and soft clothes obtained from local shops to bathe their babies to promote comfort, smooth sleep, and warmth for the baby.
This statement can be justified by the following participants as reported:
“I wiped the baby because I noticed that the blood hadn’t been wiped off thoroughly. Maybe he wasn’t wiped too much due to his skin being soft, but because he continues to be here, I wiped him again. To wipe the baby, I need a soft cloth and lukewarm water. We usually start to wipe him after a few hours post-delivery—not soon after delivery, but before the cold comes in” (P4-M).
Another participant explained:
“In my experience, I bathe the baby with warm water twice a day at noon and before sundown to make it comfortable and so that he can sleep well” (P6-H)
Discussion
The study explored individualised preventive practices for newborn hypothermia, in which 12 post-natal mothers participated, and revealed that different preventive practices and other practices were minimally practised. Interviewed post-natal mothers agree on the importance of thermal care to the newborn from birth to 28 days. The research findings indicate that post-natal mothers take different measures to protect their newborn from getting hypothermia, some of the initiatives are body covering measuring, skin-to-skin and feeding practices, prebonding, diversity of room temperature controlling measures, preparing baby clothes before delivery and body care measures such as the use of swaddling materials like heavy cotton clothes, baby costumes like baby shawl, blankets capes and hat.
But is not apparent all mothers take these measures as required to protect their newborn against catching a cold, some of the preventive practices such as skin-to-skin contact are not well practised and are avoided due to fear of hurting the stump as well as breastfeeding practices are not initiated timely and their initiation is determined by the state of their babies either crying, sleeping and awake. According to the West Guji Zone South Ethiopia study, a cross-sectional study by Wako [9] indicated that drying and wrapping, head covering and early initiation of breastfeeding were common practices while delayed bathing and skin-to-skin contact were infrequently practised [17]. This is also similar to our findings which have indicated some of the preventive practices that are taken into consideration were head covering and wrapping in heavy clothes.
Another study done in South India indicated that rooming in and covering with old cotton clothes was among the preventive practices that were performed by the mothers to protect their newborn against hypothermia, while skin-to-skin care was not common practice, these findings were in alignment with our findings which also revealed room in practices, use of heavy cotton material to cover the babies were among of the findings that were taken into consideration by the postnatal mothers in the study area. Similarly, the findings were also consistent with the study done in Kenyata National Hospital, Kenya, a mixed study on thermoregulation practices among mothers with newborn babies, which indicated that rooming in and the use of warm clothes were among thermoregulation practices to protect their babies against hypothermia [18]. Also, these findings are similar to the study conducted in Northern India and Malawi, which also found that community members were not familiar with skin-to-skin care and did not practice it [19,20].
Also, the study findings are similar to the study conducted in Ghana to assess the knowledge and quality of essential newborn care practices in La Dade Kotopon Municipality, which indicated that some practices used in keeping babies warm were keeping close to the mother’s skin, wrapping with warm clothes, and bathing of the baby with warm water [21]. Our findings were contrasted with the study findings done in Islamabad capital territory in Pakistan that assessed essential newborn care practices in squatters’ settlements and that of Kenya and revealed that skin-to-skin contact was practised to more than half of the mothers (57%) within ten minutes of birth [22,23], this indicates that skin to skin contact is an evidence-based intervention for regulation and maintenance of newborn body temperature and is also the catalyst for breastfeeding.
Therefore, this study provides a critical evidence gap in newborn hypothermia prevention practices specific to the Kilimanjaro region, which can be generalised to lower- and middle-income countries, revealing an implementation gap despite thermal care practices and policies established by the World Health Organisation.
Strengths and limitations of the study
The study provides first-hand preventive practices of newborn hypothermia among postnatal mothers. Moreover, Triangulation was done at the data source level. The study also has limitations, like the study didn’t explore the recommended practices versus those not recommended. Also, further interviews were not conducted to ensure data adequacy after saturation was reached. The study relied on mothers’ opinions and failed to account for the experiences of health professionals, such as midwives and paediatricians, and the study did not triangulate data from multiple sources, such as from nurses and midwives, which lead to selection bias.
Conclusion
In conclusion, body covering measures, diversity of room temperature controlling measures, skin-to-skin contact and feeding practice, and body care measures were among the preventive practices elucidated by post-natal mothers in the study area. However, some preventive practices, like indoor heating using charcoal stoves to warm the room, could be avoided in order to improve newborn and maternal health. Furthermore, skin-to-skin contact, the commencement of breastfeeding within one hour, and covering newborns with caps and socks are priority practices for newborn hypothermia prevention, requiring suitably tailored behaviour modification interventions among post-natal mothers.
Recommendations
For further studies.
- 1. The cause of the lack of skin-to-skin care and delayed initiation of breastfeeding should be further explored for a potential solution
- 2. Further studies, an observation study should be carried out to observe the real practices of post-natal mothers, like skin-to-skin contact, which will help to quantify these practices
For action
- 1. The Ministry of Health should develop multifaceted prevention strategies for newborn hypothermia, which should include community-based intervention, empowering postnatal mothers to adhere to recommended practices, and improving the availability of thermal care equipment in the healthcare system.
- 2. Post-natal mothers should be trained in thermal care during antenatal care contacts to enhance the development of positive behaviours from conception to post-delivery on thermal care practices.
Acknowledgments
The research team appreciate the administration of the health facilities where this study was conducted.
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