Effective coverage of newborn postnatal care: assessing the service contact-content gap in 32 low- and middle-income countries using household survey data.

Background: High-quality postnatal care (PNC) is essential for newborn survival. However, newborn PNC coverage indicators do not reflect the quality of care received. We estimated effective coverage of newborn PNC by incorporating content of care and calculated the contact-content gap in 32 low-and middle-income countries (LMICs). Methods: Using household survey data from 32 LMICs, we defined effective coverage of newborn PNC as the proportion of mothers or babies who received five essential signal functions as part of their newborn's PNC check by a medically trained provider within the first two days of birth. We calculated the contact-content gap as the absolute difference between service coverage of newborn PNC and effective coverage of newborn PNC, in percentage points (pp). We described inequalities in effective coverage of newborn PNC by mother's age, parity, wealth, education, residence, antenatal care seeking, delivery facility type, and managing authority. Results: The median effective coverage of newborn PNC was 27.5% across countries, ranging from 2.1% (95% confidence interval (CI) = 1.6, 2.7) in Burundi to 78.3% (95% CI = 74.3, 81.8) in Armenia. We identified large PNC contact-content gaps, up to 52.6 pp in The Gambia. Content of care was generally poor, with only 37.1% of mothers across countries receiving counselling on newborn danger signs. We found important demographic, socioeconomic, and health systems inequalities in newborn PNC effective coverage, disproportionately favouring newborns whose mother was older (35-49 years), primiparous, lived in urban areas, belonged to the wealthiest households, had at least secondary education, and delivered in a hospital or the private sector in most countries. Conclusions: In most countries, a substantial number of newborns who are checked during PNC do not receive all basic services. Effective coverage measures offer a more comprehensive estimate for assessing service gaps, driving action, and ensuring health gains. Addressing the missed opportunities of inadequate care content and focussing on equity will be critical to improve survival of all mothers and newborns.