Identification of model newborn care practices through a positive deviance inquiry to guide behavior-change interventions in Haripur, Pakistan.

A positive deviance (PD) inquiry identifies uncommon, model practices that a follow-on program can spread. PD has been used to rehabilitate malnourished children, but not for improving newborn health. Save the Children Federation/US (SC) conducted newborn PD cycles in communities (total population about 5,000 each) in two project areas in Haripur District, Pakistan among Afghan refugees and among local Pakistanis. Each PD cycle included planning, community orientation, situation analysis, PD inquiries, and community feedback with action planning. PD inquiries were in-depth interviews to identify uncommon behaviors among surviving asphyxiated newborns, thriving low birthweight babies, surviving newborns who had danger signs, and normal newborns. The Afghan caregivers showed better use of services and some household practices than their Pakistani counterparts, consistent with duration of SC presence (15 years vs. 18 months, respectively). The practices of both groups for clean delivery, thermal control, immediate and exclusive breastfeeding, and fathers' involvement were weak. But PD individuals, families, and/or birth attendants modeled good maternal care and immediate, routine and special newborn care. Communities enthusiastically committed to change behavior and form neighborhood support groups for better newborn care, including a demand for hygienic delivery. The PD approach for the newborn is more complex than for child nutrition. Yet this pilot-test proposed a conceptual framework for household newborn care, suggested tools and methods for information gathering, identified PDs in two settings of different risk, galvanized SC staff to the potential of the approach, mobilized communities for better newborn health, and drafted a newborn PD training curricula.