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Year : 2022  |  Volume : 11  |  Issue : 3  |  Page : 154-158

Enhancing the quality of neonatal care by improving mothers' knowledge, attitude, and practice through checklist intervention

Special Newborn Care Unit, Department of Pediatrics, K. C. General Hospital, Bengaluru, Karnataka, India

Date of Submission14-Feb-2022
Date of Decision21-Apr-2022
Date of Acceptance21-Apr-2022
Date of Web Publication06-Jul-2022

Correspondence Address:
Sanmithra Patavardhan Koppa Arunakumar
Special Newborn Care Unit, Department of Pediatrics, K. C. General Hospital, Bengaluru, Karnataka - 560 003
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcn.jcn_20_22

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Objectives: The objective of this study is to improve the newborn and self-care practices among postnatal mothers through quality improvement techniques and to create awareness about newborn and perinatal care practices in the Mother and Child Protection (MCP) Card. Materials and Methods: The barriers to low newborn and self-care practices were identified and evaluated using fishbone analysis. An operational team was formed, and a checklist was created. A total of four Plan-Do-Study-Act (PDSA) cycles were carried out. Baseline knowledge was collected using the questionnaire from the checklist. Appropriate education and counseling regarding newborns and self-care practices were taught. A variety of measures were used during counseling. The educated mothers were recalled after 5–7 days to assess their knowledge. Results: A total of 102 postnatal mothers were enrolled in the study, and 78 were available for follow-up after 5–7 days. During all study cycles, median checklist scores increased from 38 to 57 (PDSA 1), 37 to 58 (PDSA 2), 37 to 57 (PDSA 3), and 32.5 to 56 (PDSA 4). The increase in median checklist scores in all the PDSA cycles was statistically significant (P < 0.05). The median difference in checklist score from baseline in the chronological order of PDSA cycles was 19, 21.5, 22, and 23. After educating the mothers about the MCP Card, the percentage of mothers who read the information in the MCP Card increased from <5% to 38%. Conclusion: Quality Improvement principles such as the introduction of a checklist can be successfully implemented to improve the quality of newborns and self-care practices among postnatal mothers.

Keywords: Checklist intervention, mother and child protection card, newborn care, plan-do-study-act cycles, quality improvement

How to cite this article:
Arunakumar SP, Ramabhatta S, Lakshmipathy S R, Raghunandan B G, Rashmi K, Kumaraswamy D, Mol P P, Anushree C. Enhancing the quality of neonatal care by improving mothers' knowledge, attitude, and practice through checklist intervention. J Clin Neonatol 2022;11:154-8

How to cite this URL:
Arunakumar SP, Ramabhatta S, Lakshmipathy S R, Raghunandan B G, Rashmi K, Kumaraswamy D, Mol P P, Anushree C. Enhancing the quality of neonatal care by improving mothers' knowledge, attitude, and practice through checklist intervention. J Clin Neonatol [serial online] 2022 [cited 2023 Jan 30];11:154-8. Available from: https://www.jcnonweb.com/text.asp?2022/11/3/154/350031

  Introduction Top

The researches in knowledge, attitude, and practice (KAP) in neonatal care among mothers in India continue to be limited. The perception and attitude of postnatal mothers toward neonatal care have lots of gaps, especially in those who belong to a lesser socioeconomic status.[1] Increasing KAP has found that newborn care practices such as breastfeeding practices and duration of Kangaroo Mother Care have improved through Quality Improvement methods.[2],[3] The introduction of a simple checklist resulted in a favorable outcome in improving the confidence of mothers in newborn care, and this intervention has the potential for routine application in postnatal care.[4] Despite the fact that the Mother and Child Protection (MCP) Card contains all the information related to pregnancy and perinatal care, only a proportion of mothers are aware of the knowledge provided in the MCP Card as per the National Institute of Public Cooperation and Child Development, New Delhi.[5]

The main objectives of this study were to study the KAP in neonatal care among mothers who are admitted to our hospital, to improve neonatal care through checklist intervention and reassess mothers' KAP, and to create awareness about the newborn and perinatal care practices that are provided in the MCP book.

  Materials and Methods Top

This project is a 4-month hospital-based prospective interventional study carried out in the postnatal wards of K C General Hospital, Department of Health and Family Welfare Services, Bengaluru, from April 5, 2021, to July 21, 2021, in the form of 4 Plan-Do-Study-Act (PDSA) cycles. Admitted mothers who were willing to give written informed consent were included in this study. Noncooperative mothers and those whose neonates were admitted to Special Newborn Care Unit (SNCU), step-down, or for phototherapy were excluded from this study. Seventy-eight out of a total of 102 postnatal mothers were included in the study. The lack of KAP among postnatal mothers led to increased admission to our SNCU and step-down. Less than 5% of the mothers had read the MCP Card. An operational team comprising of specialist pediatricians, medical officers, pediatric postgraduate students, and a child health counsellor was formed. The identified barriers were documented using fishbone analysis [Figure 1]. A checklist comprising of 15 parameters consisting of common and important neonatal practices such as breastfeeding practices, keeping baby warm, urination and bowel habits, bathing habits, umbilical cord care, newborn rashes, jaundice, identification of danger signs, vaccination, and unscientific practices were created. The maternal health-care parameters consisted of dietary habits and self-care. With the help of their inputs and reassessment, each parameter was divided into four topics, and a structured questionnaire consisting of these topics was framed [Table 1]. Simple yes or no close-ended questions, and wherever needed, open-ended questions were framed. The mothers were explained about the procedure of the study. After obtaining verbal consent from the mothers, basic socioeconomic details and significant antenatal and perinatal history were taken. These questions were asked on the next day after delivery during clinical rounds. A score of one was assigned for each topic in the parameter (total score = 4). Zero score was recorded for the questions that were answered wrong and a score of one was recorded for the right answer. Proper practices in each of these fields were educated among mothers on the same day. The MCP Card was used to educate the mothers. Pictorial representations, for example, the flip charts, posters, and takeaways, for Kangaroo Mother Care, rashes, umbilical cord care, and vaccination were used during education.
Figure 1: Fishbone analysis – Reasons for poor newborn and self-care practices

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Table 1: Pro forma template

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We conducted a total of four PDSA cycles. Each intervention was conducted at an interval of approximately 10–20 days. Intervention was carried out in the form of mass education. Any queries regarding newborn care or self-care were clarified during education and counseling. The eligible mothers were recalled to the hospital on the 7th day. The same questionnaire was used to reassess in the SNCU outpatient department block. During reassessment, the mothers were asked to demonstrate breastfeeding practices along with answering other questions. Score was awarded for correct methods. Feedbacks from the mothers were also noted down on reassessment. Due to the second wave of COVID-19 and lockdown restrictions throughout India, from the second PDSA cycle, it was decided to include only mothers who have undergone lower segment cesarean section mode of delivery. The mothers were counseled as mentioned above, and the follow-up date was changed after the 5th day.

Data collection was repeated after each intervention before beginning the next cycle. The improvement in KAP in mothers was analyzed using Wilcoxon signed-rank test to determine the statistical significance in our interventions. P ≤ 0.05 was considered statistically significant. We used linear regression to determine whether parity and level of education were significant predictors of the baseline and follow-up checklist scores. All statistical significances were calculated to a 95% confidence interval.

  Results Top

We attend to around 3000 deliveries/year at our hospital. The study included 102 postnatal mothers. Out of this, 78 mothers were eligible for follow-up. The remaining 24 mothers were excluded as nine newborns were admitted to SNCU and the 15 were dropouts. Out of 78 mothers, 39 were primigravida, five were uneducated, 38 had studied up to 10th standard, 17 mothers had studied up to 12th standard, and 18 were graduates. Thirty-seven newborns were males and 41 were females.

The results for the four PDSA cycles are shown in [Table 2]. The pre- and post-counseling results of all the parameters are shown in [Table 3].
Table 2: Results of four Plan-Do-Study-Act intervention cycles

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Table 3: Mother's knowledge before and after intervention

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  Discussion Top

Although the neonatal mortality rate in India has decreased from 85.1/1000 live births in 1969 to 21.7/1000 live births in 2019,[6] the self-care and newborn care after delivery among mothers are a major concern for both the health-care professionals and the mothers. There is a need to reduce morbidity among these populations. Majority of the Quality Improvement studies have been directed at the antenatal care, and a handful of studies are present regarding newborn care practices.

Padiyath et al. highlight the mothers' KAP toward newborn care. This article reveals that the knowledge of mothers was insufficient in areas of umbilical cord care, thermal care, and vaccine-preventable diseases. Administration of gripe water and oil instillation into the nostrils of newborns was widely practiced by mothers.[1] In a study performed in rural Karnataka regarding newborn care, Kesterton and Cleland have recorded harmful newborn care practices in the form of unhygienic cord-cutting, delayed breastfeeding, and early bathing.[7] Similar interference from relatives who did not have adequate knowledge about newborn care comprised the maximum in faulty newborn care in our study.

A couple of quality improvement studies have stressed on improving components of newborn care in India. Sharma et al. wanted to improve breastfeeding practices among mothers during the hospital stay. Using Quality Improvement methods, they successfully increased the proportion of neonates receiving early breastfeeding within 1 h of birth from 55% to 95%. Furthermore, the percentage of neonates on exclusive breast feed during hospital stay increased from 72% to 98% after four PDSA cycles.[2] Similarly, at the All India Institute of Medical Sciences, Joshi et al. increased the duration of Kangaroo Mother Care from a baseline of 3 h to 6 h in eligible preterm infants, and the results were sustained at 6–12-month period using a quality improvement approach.[3]

In the first PDSA cycle, linear regression model displayed that the educational status of the mothers was significantly associated with the follow-up score only (P = 0.003). Interestingly, it was noted that the mean follow-up checklist score in multigravida (55.93 ± 4.36) was less than that of the primigravida (56.41 ± 3.08). In the third PDSA cycle, linear regression model showed that parity was significantly associated with the follow-up checklist score (P = 0.033) but not with the baseline score. There was no difference in the median between follow-up scores of the first and third PDSA cycles. Although the follow-up median decreased in the fourth PDSA cycle when compared to the first, there was a significant increase in the Hodges‒Lehmann median difference with a confidence interval of 95%. In all the cycles, the primigravida mothers had less baseline knowledge about newborn care when compared to the multigravida mothers.

Our project is unique and this type of checklist intervention in newborn and self-care practices is the first of its kind in this region. Radenkovic et al. have also used this type of checklist intervention for achieving improvement in newborn care practices.[4] We used a 15-parametered in contrast to their 8-parametered checklist, and we followed up the mother and neonate after 5–7 days in the outpatient instead of a telephonic interview. We asked the mothers to demonstrate the proper breastfeeding practices.

The MCP Card was introduced by the Government of India in 2010. It is a recording-monitoring cum-counseling card and an excellent learning tool for informing and educating the mother and family on different topics of maternal and child care. The main components are safe motherhood, newborn care, growth and development of the child, and immunization schedule.[8] Mani et al. state that only 13.3% of mothers had read the MCP Card, and maternal awareness remains poor among mothers who possessed the MCP Card.[9] Prabhakar et al. used the MCP Card to educate the pregnant and lactating mothers about the nutrition and infant feeding practices and therefore no warning was noted in the mean z-scores for weight-for-age in the infant's 1st year of life.[10] After educating the mothers about the MCP Card, we observed that the percentage of mothers who read the information in MCP card increased from <5% to 38%.

At the end of each cycle, both the groups had a very positive impact of the checklist intervention. While we strengthened our communication skills and understood our patients better, the mothers felt very confident about looking after their newborns. Feedbacks from the mothers were positive and most of them thanked us for providing so much information using flip charts, pictures, and takeaways. Some of the mothers wrote the answers on their pro forma sheet when they came for follow-up. Even the uneducated mothers were confident after the intervention.

Limitations of this study

The small sample size as compared to the total number of deliveries per year is due to the second wave of COVID-19 and lockdown restrictions. This checklist did not interpret the mothers' knowledge about neonatal dry skin but was educated regarding the same.

  Conclusion Top

To summarize, the checklist brought in a statistically significant improvement in maternal knowledge and confidence in all four cycles as compared to the baseline. The MCP Card is a great tool to educate mothers regarding optimal newborn and self-care practices. This checklist can be added to the MCP Card and incorporate more mothers to expand this project on a statewide or a nationwide platform. Any modifications to the checklist can be implemented to provide a standardized quality of neonatal care.


We would like to thank Mrs. Padmavathi C, Child Health Counselor of our department who has counseled all the postnatal mothers regarding proper newborn care and self-care practices.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Padiyath MA, Bhat BV, Ekambaram M. Knowledge attitiude and practice of neonatal care among postnatal mothers. Curr Pediatr Res 2010;14:147-57.  Back to cited text no. 1
Sharma S, Sharma C, Kumar D. Improving the breastfeeding practices in healthy neonates during hospital stay using quality improvement methodology. Indian Pediatr 2018;55:757-60.  Back to cited text no. 2
Joshi M, Sahoo T, Thukral A, Joshi P, Sethi A, Agarwal R. Improving duration of Kangaroo mother care in a tertiary-care neonatal unit: A Quality Improvement Initiative. Indian Pediatr 2018;55:744-7.  Back to cited text no. 3
Radenkovic D, Kotecha S, Patel S, Lakhani A, Reimann-Dubbers K, Shah S, et al. Improving maternal confidence in neonatal care through a checklist intervention. BMJ Qual Improv Rep 2016;5:u210655.w4292.  Back to cited text no. 4
Paul DK, Bhatia N, Gopalakrishnan S, Singh P, Nautiyal H, Kaul AJ. Evaluation of usage of MCP Card. New Delhi, India: National Institute of Public Cooperation and Child Development; 2019.  Back to cited text no. 5
The World Bank. Mortality Rate, Neonatal (per 1,000 live births)-India Washington DC, USA: The World Bank; 2019. Available from: https://data.worldbank.org/indicator/SH.DYN.NMRT?end=2019&locations=IN&start=1969. [Last accessed on 2022 Jan 26].  Back to cited text no. 6
Kesterton AJ, Cleland J. Neonatal care in rural Karnataka: Healthy and harmful practices, the potential for change. BMC Pregnancy Childbirth 2009;9:20.  Back to cited text no. 7
Kumar V, Mohanty PN. Evidence and Best Practice Haryana, India: SWACH: Survival for Women and Children Foundation. Available from: http://www.swach.org/ebp-mhfw-mcp-card/. [Last accessed on 2022 Jan 26].  Back to cited text no. 8
Mani MR, Johnson AR, Joseph J, Jyothis S, Joseph L, Cleetus RP, et al. Knowledge regarding pregnancy and child care among mothers in possession of mother and child protection card in a rural maternity hospital in Karnataka. J Med Sci Health 2020;6:36-42.  Back to cited text no. 9
Prabhakar K, Kalaivani K, Kowsalya S, Ramachandran P. Use of mother child protection card for improving infant feeding practices. Indian J Nutr Diet 2019;56:351-64.  Back to cited text no. 10


  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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