Mothers' hygiene experiences in confinement centres: A cohort study.

INTRODUCTION: Ethnic Malaysian Chinese used to observe the 1-month postpartum confinement period at home and many families would engage a traditional postpartum carer to help care for the mother and newborn. A recent trend has been the development of confinement centres (CCs) which are private non-healthcare establishments run by staff not trained in health care. Concerns about hygiene in CCs arose after infections were reported. We describe the practice of hand hygiene observed in CCs, the availability of resources for hygiene, and the prevalence of health-related problems in CCs.
METHODS: This is a cohort study of ethnic Chinese mothers intending to breastfeed their healthy infants. They were recruited post-delivery along with a comparison group who planned to spend their confinement period at home. After their 1-month confinement period, they were contacted for a structured telephone interview about their experience. To avoid any alteration in behaviour, mothers were not told at recruitment that they had to observe hygiene practices. Multiple logistic regression was used to assess the effect of place of confinement on rates of infant health problems.
RESULTS: Of 187 mothers, 88(47%) went to 27 different CCs while 99(53%) stayed at home. Response rates for the 1-month interviews were 88%(CC) versus 97%(home). Mothers in CC group stayed in one to four-bedded rooms and 92% of them had their baby sleeping separately in a common nursery described to have up to 17 babies at a time; 74% of them spent less than six hours a day with their babies; 43% noticed that CC staff had inadequate hand hygiene practices; 66% reported no hand basins in their rooms; 30% reported no soap at hand basins; 28% reported inexperienced or inadequate staff and 4% reported baby item sharing. Among the mothers staying at home, 35% employed a traditional postpartum carer for her baby; 32% did not room-in with their babies, but only 11% spent less than 6 hours a day with their babies. Of mothers who employed traditional postpartum carers, 32% did not know if their carer washed hands after changing diapers and 18% reported that their carer did not. Health problems that were probably related to infection (HPRI) like fever and cough were similar between the groups: 14%(CC) versus 14%(home) (p = 0.86). Multiple logistic regression did not show that CCs were a factor for HPRI: aOR 1.28 (95% CI 0.36 to 4.49). Three mothers reported events that could indicate transmission of infection in CCs.
CONCLUSION: We found unsatisfactory hygiene practices in CCs as reported by mothers who spent their confinement period there. Although we were not able to establish any direct evidence of infection transmission but based on reports given by the mothers in this study, it is likely to be happening. Therefore, future studies, including intervention studies, are urgently needed to establish an appropriate hygiene standard in CCs as well as the best method to implement this standard. Training CC staff with hygiene knowledge so that they can be empowered to contribute to the development of these standards would be important.

Background

The postpartum period is an important time for women of Chinese ethnicity in Malaysia and elsewhere [1, 2]. Despite modernisation, most families still adhere strictly to a 30-day ‘confinement period’ known among the Chinese as ‘zuo yue zi’, with many do’s and don’ts passed down from generations to generations [2, 3]. During the confinement period, women follow traditional practices to maintain the balance between the ‘Yin’ and the ‘Yang’. It is believed that childbirth causes an imbalance between the ‘Yin’ and the ‘Yang’ and failure to restore this balance could potentially be detrimental to the mother’s health [4]. According to the ancient Chinese philosophy, the ‘Yin’ and ‘Yang’ are attributes of all things or phenomena in the universe. They are of opposing characters. For example, ‘Yin’ refers to ‘cold’ while ‘Yang’ refers to ‘warmth’ [5]. Therefore, practices that assist the ‘Yang’ which is reduced during childbirth are emphasized. This includes ensuring that the mother ‘keeps warm’ by avoiding draughts and consuming a specially prepared confinement diet [4].

Many families engaged a traditional postpartum carer, known locally as a ‘confinement lady’ or ‘yue sao’ to stay in the new mother’s home during the confinement period and assist the mother. The traditional postpartum carer is traditionally someone who is considered an expert in the necessary postpartum diet and practices. Their skills were probably obtained through experience rather than formal training [1, 6]. The traditional postpartum carer would move into the home for the entire duration of the confinement. She would usually be given her own room. Depending on the mother’s preference and feeding choice, the baby might room-in with the traditional postpartum carer during the night or be with the mother. The traditional postpartum carer would have full access to the baby as her primary role would be to care for the baby in order for the new mother to ‘rest’.

Over the last decade, confinement centres (CCs) where post-partum Chinese mothers could stay and observe traditional post-partum practices during their confinement period, have emerged as an alternative option. There are no published reports on why some mothers choose to go to CCs instead of opting for the traditional postpartum carer, but the reduced availability of the traditional confinement lady, and the increased availability of CCs could be a reason. CCs are private establishments, usually converted from residential or commercial properties, with rooms for mothers’ accommodation. CC staff are generally women who are familiar with the Chinese cultural confinement requirements and diet, similar to a traditional postpartum carer. Although some CCs do employ qualified nurses and midwives [6], others may employ untrained staff to help [7].

Concerns about hygiene in these centres arose when anecdotal reports suggested that babies in CCs were frequently hospitalised with serious infections. In 2007, Rai et al published a report about an Echovirus infection outbreak in a CC and poor hygiene practices in that CC were highlighted [8]. Therefore, to learn more about how hygiene is practiced in CCs, we asked mothers who had chosen to stay in a confinement centre about hygiene practices they had observed during the stay. Mothers who had employed a traditional postpartum carer to help them at home were also asked about the traditional postpartum carer’s hygiene practice. This is part of a larger study where we looked at mothers’ breastfeeding experiences in CCs and compared these with a cohort of women who had their traditional confinement period at home [7].

The aim of this paper is to describe the practice of hand hygiene observed in CCs, the availability of resources for hygiene and to determine the prevalence of health-related problems in CCs.

Methods

Details of the study methods are published in the our primary paper on the breastfeeding experience of mothers staying in CCs [7] and we describe these in brief here. Malaysian mothers of Chinese ethnicity who intended to spend their confinement period in a CC, who had delivered term healthy infants and had the intention to breastfeed, were recruited prior to discharge from August to October 2017. For every mother that went to a CC, we also recruited a comparison mother, who was as far as possible the next woman from the same hospital who went home for her confinement period. Some of the mothers who went home engaged a traditional postpartum carer. For this paper, we used this comparison group to gauge hand hygiene practices in the CC with the traditional postpartum carer, and to compare health-related problems in CCs with those in the community. Recruitment and collection of demographic characteristics was done by the baby’s attending doctor, who apart from this was not otherwise involved in the study. Written consent was obtained from the mothers prior to recruitment. Demographic characteristics which included mother’s age, education level, gravida as well as her infant’s sex, gestational age and birth weight, were collected using a self-administered questionnaire. To avoid any alteration in behaviour, mothers were not told at recruitment that they would be asked about hygiene practices.

After discharge, there was no contact between the research team and the mother until immediately after her 30-day confinement period. At this point we conducted a telephone interview with all mothers. Two recent graduates from our medical school were trained to conduct the interviews. In order to reduce variability, we designed a set of structured questions and the two interviewers followed these during the interview. The training involved an understanding of the data that is to be collected, familiarisation with the structured questions and mock interviews. During analysis we could not find any systematic differences in responses across interviewers.

We firstly asked mothers questions related to their baby’s general health. We then categorised the reported health related problems to those that we judged were possibly related to infection and those that were probably not related to infections. Health problems possibly related to infection (HPRI) included fever, diarrhoea. Those that we judged to be health problems that were unlikely related to infection (HPUI) included neonatal jaundice and regurgitation of feeds. If any health problem was reported, we asked if they had sought advice from a healthcare professional.

Where applicable, we asked whether or not they had observed their CC staff or traditional postpartum carer (in the case of those at home), washing their hands before handling their babies; and their response if hand-washing practices were not observed. We did not ask mothers staying at home who did not employ traditional postpartum carer whether or not their family members washed hands because the information was deemed to be possibly unreliable. Specifically for mothers who went to CCs, we asked the number of rooms in their CC, the number of mothers staying together in a room, if they had a hand basin in their room, if soap was available in all hand basins, what was provided for mothers to dry their hands, whether alcohol hand sanitizers were available, the number of babies in each nursery, availability of quarantine rooms for sick mothers or babies and their perception of cleanliness in their CC (either very dirty, somewhat dirty, clean or very clean). At the end of the interview, we asked mothers to share with us anything else they would like to about their experience in CCs. A sample of the interview questions (S1 File) can be found in the Supporting Information File.

All questions used had been tested in a separate group of mothers not involved in the study. The telephone interview was conducted by two trained research staff and the responses were directly entered into a specially designed interview form. A sample size of 188 was calculated based on the primary objectives of the primary study [7].

This study was registered with the National Medical Research Registry (NMRR-17-1174-36384 S1) and received ethical approval from the Joint Penang Independent Ethics Committee (JPEC 02-18-0026). All mothers gave written informed consent.

Data analyses

We tabulated the demographics of the mothers according to place of confinement. Continuous data was presented as means with standard deviations (SD) and categorical data presented as frequency with percentage (%). Chi-square analysis was used to compare the baseline characteristics between mothers staying in confinement centres (CCs) and those staying at home. Responses from mothers when asked, “Is there anything else about your CC that you would like to share?” were tabulated and categorized into groups. Some of these free field responses were quoted as illustrations. We used simple logistic regression and multiple logistic regression after adjusting for clinically important confounders to determine the likelihood of HPRI and HPUI as a function of CCs. The results were presented as crude and adjusted odd ratios (cOR and aOR) with 95% confidence intervals (CI). Statistical analysis was done using Stata 13 [9]. We considered a p-value of less than 0.05 as significant.

Results

A total of 187 mothers consented to participate, of which 88 (47%) stayed in a CC and 99 (53%) went home. At one-month post-partum, we were able to interview 77 (88%) mothers from the CC group and 96 (97%) from the home group. Based on the reported names of the CCs given by the mother, the 77 mothers in the CC group had gone to one of probably 27 CCs during their confinement period. Unfortunately, we were not able to verify reported names of CC because at the time of the study there was no record of all CCs in Penang available, and we are therefore uncertain about the exact number of CCs in the study. Of the 96 mothers from the home group, 34 hired a traditional postpartum carer while the remainder received care from family members (Fig 1).

Fig 1

Study flow diagram.

Flowchart of the cohort study showing the number of mothers who were recruited before discharge from the hospital after delivery of their baby, the number of mothers who went to a confinement centre or their own homes, and the number of mothers that completed the telephone interview a month after delivery. Some of the mothers who went back home hired a traditional postpartum carer to help during the confinement period.

Demographic characteristics

The maternal and infant demographic characteristics are presented in Table 1. The overall mean maternal age was 32 (SD 4) years. Most mothers had tertiary education, and all had at least secondary school education, which reflects what is expected in Penang. The overall mean infant gestational age was 39 (SD 1) weeks and mean birth weight 3149 (SD 322) g. We found that significantly more primiparas went to CCs (53% CC vs 34% H, p = 0.01) but there were no differences in the age, education background, mode of delivery; infant gestation and birth weight between the two groups (Table 1).

Table 1

Demographic characteristics of the mothers and infants (n = 187).

Characteristics	Place of confinement, n (%)
	Confinement centre (n = 88)	Home (n = 99)
Age of mothers (years), mean (SD)	32 (4)	32 (3)
Received tertiary education	70 (80)	80 (81)
Primigravida*	47 (53)	34 (34)
Male infant	45 (51)	56 (57)
Gestational age at birth (weeks), mean (SD)	39 (1)	39 (1)
Infant’s birth weight (g), mean (SD)	3141 (304)	3156 (339)

* p < 0.05

Description of confinement centres

The description of the CCs came from mother’s reports during the interview. More than one mother may have stayed in the same CCs. The CCs had between four to 10 rooms for mother’s accommodation.

The number of mothers staying together in a room ranged from one to four. Forty-five mothers occupied a single bedded room, 20 mothers occupied a two-bedded room, 11 occupied three-bedded room and one stayed in a four-bedded room. Most of the mothers did not room-in with their babies (n = 71, 92%). Instead, their babies slept in the common nursery; and majority of mothers (n = 57, 74%) spent less than six hours a day with their babies. Regardless of CC size, all had a single common nursery for babies. The number of babies in the nursery at a time was reported to range from one to 17.

Of the mothers staying at home, 31 (32%) did not room-in with their babies, but only 11 (11%) spent less than six hours a day with their babies.

Hygiene and infection control measures at confinement centres

When asked to rate the overall cleanliness of the CCs using a Likert scale of 0 to 3, with ‘0’ being very dirty and ‘3’ being very clean, all mothers reported that their centre was either ‘clean’ (n = 41, 53%) or ‘very clean’ (n = 36, 47%). However, only 17 (22%) mothers noticed that their CC staff washed hands in between handling babies and 33 (43%) mothers noticed that CC staff did not. When asked what they did if the CC staff failed to wash hands before handling a baby, two mothers reported that they went on to ask the staff to do so; two mothers said that they had not thought that this was something to be concerned about, and one just said that she felt sorry for the staff who was short-handed at that time. The remaining 27 (35%) mothers did not know if CC staff washed hands (Table 2).

Table 2

Mothers’ perception that hand hygiene was practised before handling babies.

	Hand hygiene practised	Hand hygiene not practised	Don’t know if hand hygiene is practised
CC staff (n, %)	17 (22)	33 (43)	27 (35)
Traditional postpartum carer (n, %)	34 (35)	6 (18)	11 (32)

Only 55 (63%) of mothers reported that their CCs supplied hand soap. Among the 32 (36%) mothers who reported that their CCs provided alcohol-based hand sanitizers, three reported that alcohol-based hand sanitizers were restricted to staff use only. Twenty-six (34%) mothers reported the availability of a sink for hand washing in their room. Only 23 (30%) mothers reported availability of hand towels for drying hands and some of these items were reported to be either a single cloth-towel that was shared by everyone in the centre or toilet rolls (Table 3).

Table 3

Mothers’ perception of the availability of hand hygiene resources at CCs (a total of 77 responses from 59 mothers at 26 CCs).

Hand hygiene resource	Available (n, (%))
Hand basin in own room	26 (34%)
Readily available hand soap at each sink	55 (71%)
Hand towels to dry hands	23 (30%)
Alcohol hand sanitizers	32 (42%)

The availability of a quarantine room for sick mothers was reported by 17% of mothers while the availability of quarantine rooms for sick babies were reported by 24% of mothers. We do not have details on whether the quarantine rooms were meant for single or multiple users. One mother reported that her CC required all visitors to don gowns prior to entering the nursery. When the mothers were asked if there was anything else they would like to share with us, they revealed one or more of the comments related to poor hygiene listed in Table 4. These comments came from 31 mothers. It is likely that some of these mothers could have been in the same CC but we do not have information to determine what proportions of CCs had these issues.

Table 4

Comments related to hygiene in confinement centres.

Comments	Number of mothers who made this comment
Staff shortage and inexperienced staff who were unaware of hygiene practices	9
Only one toilet to be shared by all mothers hence quite dirty	4
A common towel used to burp all babies in the nursery	2
A common hand towel used by all mothers to wipe their hands	2
The same pail that was used for holding bath water was used for washing the floor	1
The same basin used to wash babies’ bottoms was also used to wash milk bottles	1
Milk bottles that fell to the floor (staff fell asleep) were simply picked up and used to continue feeding the baby without being washed	1
Breast-pump parts were just soaked in hot water and not properly sterilized	1
Use of a common milk bottle that was sticky and dirty looking	4
Infrequent changing of diapers, cot sheets and bed sheets	10
Nursery cramped and not spaced	4
3 babies sharing a single cot	4
Flies and mosquitos in their room	2
Poor quality paper hand towels—toilet rolls that easily disintegrate	8
Alcohol hand sanitizers were only for staff usage	3

With regards to hygiene practices by traditional postpartum carers at home, 6 (18%) of mother reported that their traditional postpartum carer did not wash hands before handling their baby and after changing diapers while 11 (32%) mothers did not know whether their traditional postpartum carer practiced hand hygiene. When we asked what they did when they saw poor hand hygiene, two reported that they asked their traditional postpartum carer to do so, while four did not do anything.

Babies’ general health at CCs and at home

Baby’s general health at CCs and home were generally similar. HPRI were reported by 11 mothers (14%) from CCs compared to 13 mothers (14%) from home; p = 0.86. Of these, 10 mothers from CC compared to 13 mothers from home consulted a healthcare professional. Reported HPRI included one or more of these: ‘fever’, ‘viral infection’, ‘cough’, ‘stuffy nose’ ‘runny nose’ and ‘oral thrush’. None of the infants from the CC group had any form of serious illness. One infant from the Home group was hospitalised for an unspecified viral infection which the mother thought was caught from the baby’s older brother.

The main HPUI was ‘jaundice’. Others included one or more of the following: ‘colic’, ‘constipation’, ‘regurgitation’ and ‘umbilical hernia’. HPUI were reported by 70 mothers (92%) from CCs compared to 88 mothers (92%) from home; p = 0.92. Of these, 43 mothers from CC and 63 mothers from home consulted a healthcare professional.

Simple logistic regression showed no association between HPRI and place of confinement, OR 1.08 (95% CI 0.45 to 2.57), p = 0.86. There was also no association between HPUI and place of confinement, OR 1.06 (95% CI 0.35 to 3.20), p = 0.92. Multiple logistic regression adjusted for known clinically important confounders (maternal education level, spent less than six hours a day with baby, not sleeping with baby at night and no exclusive breastfeeding) also did not show that the CC or home was a factor affecting HPRI, aOR 1.28 (95% CI 0.36 to 4.49), p = 0.71; or HPUI, aOR 2.01(95% CI 0.52 to 7.82), p = 0.32 (Table 5).

Table 5

Crude and adjusted ORs for HPRI and HPUI defined by place of confinement.

		Number of mothers who reported (n)	Odds Ratio, OR (95% CI)	Adjusted Odds Ratio, aOR (95% CI) a
HPRI	Confinement Centres (n = 77)	11	1.08 (0.45, 2.57)	1.28 (0.36, 4.49)
	Home (n = 96)	13
HPUI	Confinement Centres (n = 77)	70	1.06 (0.35, 3.20)	2.01 (0.52, 7.82)
	Home (n = 96)	88

HPRI: Health problems probably related to infections

HPUI: Health problems probably unrelated to infections

a Adjusted for maternal education level, spent less than six hours a day with baby, not sleeping with baby at night and no exclusive breastfeeding

When we asked mothers if they had anything else to share with us, we found three events that could indicate a possibility of infection transmission in CCs. One mother reported that there were visits from the health authorities to her CC because a number of babies (but not her baby) in her CC had fever and were hospitalized. One mother reported that all babies in her CC had either blocked or runny noses within a one-week period. Another thought the oral thrush and rashes on her baby were due to sharing of a baby wash cloth at the CC. The mothers who reported these events came from three different CCs.

Discussion

The main finding from our study was inadequate hand hygiene and infection control facilities in CCs. Despite this, mothers reported that they were satisfied with their CC’s cleanliness. Meanwhile, hand hygiene was also inadequate among the traditional postpartum carers for mothers staying at home. Due to small numbers, we were unable to show whether there was a difference for the type and prevalence of reported health problems between the two groups. Nevertheless, the report that a CC had visits from the health authorities could indicate that infection related events were occurring and this would be of concern. Unlike home postpartum care where the baby is cared for within his own family, CCs use a single nursery for many babies and infections can easily spread from one to another. As stated in the introduction, we were aware of reported outbreaks and this was part of the motivation for this study.

Practices at CCs that may potentially have caused infection were noted. These practices most likely result from lack of resources, inconsistent hand hygiene practices and over-crowding. There was probably a lack of awareness both among the CC staff and mothers about the importance of hand hygiene. We were surprised to find 35% of mothers not cognisant of whether or not their CC staff washed hands before handling their babies.

We are unable to find other studies looking at confinement centres, but our study draws parallels with studies conducted with nursing homes and child-care centres. One similarity between CCs and nursing homes is that they have populations who are relatively susceptible to infection. These studies found that over-crowding and lack of hand hygiene led to infection transmission [10, 11]. A number of studies described how infection could be prevented through improving hand hygiene practices, the availability of resources and improved role modelling [12-16]. In addition, these studies also found that education and training could effectively increase hygiene practices in nursing homes [11, 16, 17]. Drawing from the findings of these studies, it is very likely that all of these could apply to CCs. Therefore, we could expect that if education and training were put in place, hygiene practices in CCs could improve. In addition, prior exploration of mothers’ and CCs’ staff understanding and knowledge about hygiene would be useful when designing training. However, good hand hygiene practices are known to be one of those practices that are difficult to sustain and therefore regular audit and feedback to improve sustainability might also be needed [18].

Current guidelines for hygiene practice in healthcare settings differ little in their recommendations but not much is known about the appropriate standard of care in community settings such as CCs. Infection control as it is practiced in healthcare settings may be difficult to implement in CCs and is costly. There is currently little research to guide practice. It is noted that CCs are not healthcare institutions, and their staff are not healthcare staff. In addition, the traditional confinement care offered by CCs is not a medical treatment but at the same time CCs need to be cognisant of the increased infection risk to neonates and have adequate infection prevention strategies in place.

Studies have shown that nursing homes struggle to strike a balance in attempting to preserve a homelike environment and hospital-level measures to control of infection [11, 19, 20]. This is likely to apply to the CC environment as well. CCs would need to consider what measures if implemented would be accepted by both staff and mothers and could be complied with. However, at the same time there is no doubt that infection control measures are needed and hand hygiene is obviously the place to start. Research in this area is much needed as well as research on effective training and methods of consolidating hand hygiene practice in CCs. In addition, since there were reports of shared equipment and feeding items, these should also be further pursued.

Many of the home-based traditional postpartum carers in our control group were also reported to not practice good hand hygiene. There is currently no literature about their hygiene knowledge and practices. However, to improve safe practices, home-based traditional postpartum carers should also be drawn into training interventions.

We found many mothers who stayed at CCs were discouraged from rooming-in with their babies, and their babies spent most of the time in the nursery [7]. This could partly be due to traditional belief of the need for mothers to rest but it could also be due to convenience of caring for all the babies in one place. Since there is a body of evidence showing that both mother-infant rooming-in and breastfeeding prevent infections [21-24], ways to improve these practices could also be looked at. Although exclusive breastfeeding rates in this study cohort were as good if not better that other local populations, most of the mothers were just feeding their babies with expressed breastmilk and not breastfeeding directly from the breast [7]. Feeding expressed breastmilk carries an increased risk of infection since it involves use of breast pumps and bottles which need a high level of disinfection [25]. One way to improve direct breastfeeding would be to provide training to CC staff so that they can be empowered to provide support for direct breastfeeding and to provide rooming-in facilities for mother and baby. This might mean that maternal accommodation needs further studies to establish appropriate recommendations, for example, spacing between mothers. There is also a possibility of considering kangaroo care as a means of infection prevention, but studies are needed both in terms of feasibility and safety of practicing kangaroo care in a CC setting.

A limitation of our study would be that we did not have accurate data on which CC the mothers went to. We feel that our sample of mothers reasonably represents the mothers using CCs in Penang, however it is probable not all CCs in Penang were represented in the data. Since our sampling was of women and not CCs and these 77 women went to around 27 CCs, our data represents the number of women and their babies who were exposed to poor hygiene practices and not the number of CCs having poor hygiene practices. Another limitation of the study was the sample size which was not calculated to show a difference in HPRI rates. It is also important to note that our findings are those perceived by mothers.

The data was collected after they had left the CC and we did not verify their reports.

In addition, if for instance a hand basin was not perceived to be present, we were unable to determine which one of these 3 possibilities could be taking place. Once possibility was that hand basin was actually not present and the participant had actually looked for it and could not find it. Another possibility was that they were not even aware that a hand basin should be present and had not noticed it even if the hand basin was actually present (observer bias). The third possibility was that the hand basin was actually present, but they could not recall (recall bias).

To overcome these biases, further studies, perhaps using direct observation could be performed and should involve CC operators and managers. Therefore, there is a need to establish rapport with them early.

Conclusion

We found unsatisfactory hygiene practices in CCs as reported by mothers who spent their confinement period there. We were not able to establish any direct evidence of infection transmission. However, based on a previous report [8] and the anecdotal reports given by mothers in this study along with the hygiene practices reported in this paper, it is likely to be happening. Therefore, future studies, including intervention studies, are urgently needed to establish an appropriate hygiene standard in community postpartum care facilities such as these, as well as the best method to implement this standard. Training CC staff to empower them with hygiene knowledge so that they can be involved and contribute to the development of these standards would be important.

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19 Jul 2021

PONE-D-21-03743

Mothers’ hygiene experiences in confinement centres: a cohort study

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This paper explores hygiene conditions for women undergoing post partum confinement in homes and in confinement centres in Malaysia, with a focus on hand hygiene in the confinement centres. The researchers interviewed mothers over the telephone after the confinement.

Interesting paper and topic.

Major Comments:

Line 219: Can the authors include the exact questionnaire for the interviews as a supplementary file? Seeing the specific questions is very useful for interpreting the results.

Table 4 is perhaps the most interesting part of the manuscript and so I'd like to see a bit more detail provided on this part of the study. What was the question used to glean this information? Did the interviewer suggest any of these responses are did they all come from an open ended question with no prompting? Can you say something about the relative frequency of the different issues? I'd be particularly interested in knowing what proportion of the facilities had these issues.

My impression of some of the issues raised in table 4 is that they are both more likely to cause infection than failure to wash hands between babies and that many of them are much easier to fix than low hand hygiene compliance. E.g., contaminated bottles and towels, no bath tub to bathe the babies etc. After hearing these reports, do the authors remain confident that "However, at the same time there is no doubt that infection control measures are needed and hand hygiene is obviously the place to start" (line 308)? To me, these seem like low hanging fruit rather than the hand-washing. I'd appreciate reading the authors view on this in the discussion.

Regarding the differences between the confinement centres and home: I agree that the results presented may be due to a false positive, but I think that the authors also should be less confident that this is certainly the case (line 278). It may be the case that infection rates in the home are also quite bad. I think a sensitivity analysis might be warranted. What this would to is tell you what effect size you are capable of detecting with 80% power with the given sample size. Conducting a sensitivity analysis in G*power (free software) will tell you what odds ratio you can detect with 80% power in your study. If this suggests odds ratios far in excess of what you might reasonably expect based on other studies of hygiene and infant care, you know that your study was underpowered and that your conclusion of a false negative is at least a plausible interpretation.

Minor Comments:

A few additional lines explaining what the confinement period is and how widespread it is would be useful at line 60.

At line 68, might be worth noting the reasons women choose the confinement centres over the TPCs. Is there a cost difference, for example?

At line 92, provide more information about how the women were sampled. What was the sampling frame? Was the selection random?

At line 127, provide more information on the research staff who conducted the interviews. Interviewer effects are common in this kind of work (i.e., one interviewer tends to elicit different responses). Can the authors confirm that there were no systematic differences in the responses to the different interviewers?

Line 109: Can the authors explain why "baby being inactive" suggests infection: to a non-medically trained reader like myself, this is not obvious.

Table 3: include percentages so it matches the other tables.

I'm not sure it is reasonable to include the anecdotal evidence on lines 266: in statistical terms, observations like this have little ability to pick up on true differences are may be due to chance. Perhaps the editor has a view on this?

Thank you authors for this interesting read!

Reviewer #2: The manuscript included an interesting and important topic. The paper has potential to improve further if include some more results/information, if available and thereby discuss accordingly. The specific comments are as below:

Abstract:

1. Under methods section, need to mention clearly the type of interview conducted.

2. Line 38-39: Does it mean rest 88% reported satisfactory hand hygiene practice of their TPCs during caring their babies

3. Page 3, line 39: Under result section, need to specify what does refer to ‘unsatisfactory hand hygiene’

4. Page 3, line 51: Rather say ‘customized training’ in place of empowering CC staff

Background:

1. Page 4, line 61: For the international readers, please describe what is ‘Yin and Yang’

2. Page 4, line 63: Since TPC is not a standard term, consider to spell out throughout the paper instead of using abbreviation

Methods:

1. Page 5, line 97-98: What data collection tools was used to collect baseline data?

2. Page 5, line 107 and 109: Instead of using the word ‘judged’, consider to replace with ‘assessed’ since this is a judgmental word

3. Page 6, line 125: What type of interview guideline was used for the interview-structured questionnaire, semi-structured or in-depth interview guideline? Please mention clearly

Data analyses:

1. Page 7, line 138: ‘baseline characteristics’- need to describe under the method section what was the information/data collected for baseline

Results

1. Page 8, line 159: The sub-heading is ‘Baseline characteristics’. Is this baseline or demographic characteristics?

2. Page 9, line 175: Table title shall be demographic characteristics

3. Page 10, line 187: “Regardless of CC size, all had a single common nursery for babies”. Please include the range of CC accommodation. This will help to understand readers how many babies stayed in a nursery. In a CC some mothers could occupy single to three or multi-bedded rooms but it doesn’t give the scenario the size of a CC or # of babies stayed in the common nurseries in the CCs.

4. Page 10, line 190: ‘……only 11 spent less than six hours a day with their babies’. Consider present the characteristics of CCs and accommodation arrangements in a table format.

5. Page 10, line 194: ‘….their centre was either clean or very clean’….Was the question asked in Likert scale?

6. Page 10, line 195-196: Since mother were not aware about the hand hygiene behavior, there is a possibility of recall bias. Also need to say if any mother could not recall the HH practice properly.

7. Page 10, line 200-201: This is a big %. This also reflect somewhat the mothers’ perception to importance of the hand hygiene. While this recall bias is a limitation, it is also an important point of discussion

8. Page 10, line 202: In the title of the table 2, it mentioned ‘Mothers’ perception’…but the table doesn’t reflect any perception, rather it only reported CC staff’s HH practices observed/noticed by the mothers. Please correct the spelling in the 2nd and 4th column heading ‘practiced’

9. Page 11, line 210: What is the % of singles cloth towel for common use and the toilet rolls supplied by the CCs?

10. Page 11, line 212: The table doesn’t present any perception. Rather this is only the availability of hand hygiene resources reported by the mothers

In the 3rd row of the table 3, need to mention the hand sanitizer is only for staff use.

11. Page 11, line 215-216: Was the quarantine rooms for single mother or baby or for multiple but limited persons?

12. In the table 4, 3rd row, did it mean same bottle use to feed multiple babies?

13. Page 12, line 232: ‘….11 mothers did not know whether their TPC practices hand hygiene’... didn’t know or couldn’t remembers? Since this was the home setting, not clear what was the arrangement of mothers and babies staying, in the same room or different room?

Also check the typo ‘did not washed’ in line 231.

14. Page 13, line 242: ‘…. Hospitalized for viral infection…..’ Did the mother mention what was the infection?

15. Page 14, line 268: ‘…… because a number of babies in her CC had fever….’ Was her baby also included here?

Discussion

1. Page 15, line 280-282: In this sentence it discussed the lack of hand hygiene and other practices likely result from lack of resource, inconsistent hand hygiene practices…..’

I wonder you’ve explored mothers’ general perception of hygiene, cleanliness and any link between lack of hand hygiene practices/cleanliness and potential illness/infection.

Although some results presented mother’s perception of sharing items as cause of babies’ illness, the above-mentioned variables either not explored or presented. Therefore, would like to suggest to present those data, if available and then discussed in the discussion section.

2. Page 15, line 284-285: ‘One similarity with these is that they are populations…..’ Did you mean mothers at nursing homes and conferment centres? Consider to rephrase the sentence

3. Page 15, line 289-290: To design a compelling and effective educational training, understanding of mothers’ and caregivers’ perceptions and practices related to hygiene is crucial, which are still under explored in this study.

4. Page 16, line 300-303: Same as comment as earlier. To improve the risk perception and IC practices, caregivers’ perceptions and knowledge in CCs need to be assessed/identified to design an acceptable intervention.

5. Page 17, line 316-317: The authors pointed out that many mothers who stayed at CCs were discouraged from rooming-in with their babies, which also suggest for further research to understand the existing norms and ritual among this group at the neonatal period.

6. Page 17, line 321: In this sentence, not sure what does mean by the ‘direct breastfeeding rates’.

The following sentence indicate that the exclusive BF included the expressed breastmilk. It needs to be mentioned explicitly and also present in the results section.

7. Page 17, line 324-325: In this sentence, it discussed about empowering the CC staff. But earlier it mentioned that the CCs were discouraged from rooming-in mothers with babies… so at this point rather make the point to encourage/train CC’s for direct BF by mothers, so that they could also encourage mothers for direct BF.

8. Page 17, line 336: The authors mentioned that “It is also important to note that our findings are those perceived by mothers”… One major limitation of this data is mothers informed about the hand hygiene practice after one month from their memory. Moreover, during recruitment, mothers were not informed that they would be asked about their observation for HH practices of the caregivers to avoid any alteration. However, on the other hand it could be mothers’ recall bias to report about hand hygiene practices. Moreover, measuring hand hygiene events is always tricky which includes not only the overall hand hygiene practices but also critical times that would potential for pathogen transmission. The data also does not reflect the mothers’ general perceptions to hand hygiene and other infection control practices. Without knowing these it is difficult to conclude whether mothers feel the need for hand hygiene during feeding and handing neonates. Because there is a link between mother’s risk perceptions and reported hand hygiene behavior. If the data support the above-mentioned information, would recommend to include those. Otherwise need to mention as limitation.

9. Page 18, line 338: Include reference where discussed ‘observer bias’.

10. Page 18, line 339-340: Also direct observation may require

Conclusion

1. Page 19, line 348: Better to replace the word ‘Empowering’ with ‘Training’

2. Page 19, line 348-350: Revise the sentence

• In the figure/ diagram that described enrollment, need some correction. Insert the required spaces between words in the diagram. In some places 2nd bracket ‘{‘ was used, which is not an usual practice for a diagram/figure

• Overall English grammar and some spelling (specific style (American/British) allowed in this journal) need to be checked

**********

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Reviewer #1: No

Reviewer #2: No

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13 Sep 2021

Editor's comment

Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

Authors' reply

Thank you. We have edited the manuscript to meet PLOS ONE’s style requirements. Please let us know if we have missed anything.

Editor's comment

Please including more information on the number of interviewers, their training and characteristics; and please provide the interview guide used.

Authors' reply

The interview guide has been added as a supplementary file. Information about the interviewers has been added in Line 125 to Line 130.

“Two recent graduates from our medical school were trained to conduct the interviews. In order to reduce variability, we designed a set of structured questions and the two interviewers followed these during the interview. The training involved an understanding of the data that is to be collected, familiarisation with the structured questions and mock interviews. During analysis we could not find any systematic differences in responses across interviewers.”

Editor's comment

We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

Authors' reply

We have uploaded the anonymized data set necessary to replicate our study findings as a Supporting Information file. We have indicated this addition in Line 398 to Line 399.

Editor’s comment

Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section.

Authors' reply

We have removed it from the other section. Our ethics statement now only appears in the Method section in Line 157.

Editorial Office’s comment

Please include a legend for figure 1.

Authors' reply

We have included a legend as follows:

“Flowchart of the cohort study showing the number of mothers who were recruited before discharge from the hospital after delivery of their baby, the number of mothers who went to a confinement centre or their own homes, and the number of mothers that completed the telephone interview a month after delivery. Some of the mothers who went back home hired a traditional postpartum carer to help her during the confinement period.”

Editorial Office’s comment

Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

Authors' reply

We have included captions as follows:

“A sample of the interview questions (S1. Interview) can be found in the Supporting Information File.” (Lines 150-151).

“A sample of the interview questions (S1. Interview) and the minimal anonymized data set (S2. Dataset) have been uploaded as Supporting Information files.” (Lines 398-399)

Reviewer #1

This paper explores hygiene conditions for women undergoing post partum confinement in homes and in confinement centres in Malaysia, with a focus on hand hygiene in the confinement centres. The researchers interviewed mothers over the telephone after the confinement. Interesting paper and topic.

Authors' reply

Thank you for your comments and suggestions to improve our manuscript. We have edited many sections of our manuscript. The line numbers indicating where the changes are made refer to the line numbers in the cleaned up revised manuscript (the copy without the "track changes")

Reviewer #1

Line 219: Can the authors include the exact questionnaire for the interviews as a supplementary file? Seeing the specific questions is very useful for interpreting the results.

Authors' reply

We have included this as a Supplementary file.

Reviewer #1

Table 4 is perhaps the most interesting part of the manuscript and so I'd like to see a bit more detail provided on this part of the study. What was the question used to glean this information? Did the interviewer suggest any of these responses are did they all come from an open ended question with no prompting?

Authors' reply

We have made this line clearer by including text to inform readers that these answers were obtained without any prompting.

“When the mothers were asked if there was anything else they would like to share with us, they also revealed one or more of the comments related to poor hygiene listed in Table 4.” (Line 239 to Line 241)

Reviewer #1

Can you say something about the relative frequency of the different issues?

Authors' reply

Yes, we have added this into Table 4.

Reviewer #1

I'd be particularly interested in knowing what proportion of the facilities had these issues.

Authors' reply

We do not know what proportion of the facilities had these issues. Several of these mothers could have gone to the same facility. We have added information in the text to clarify this.

"These comments came from 31 mothers. It is likely that some of these mothers could have been in the same CC but we do not have information to determine what proportions of CCs had these issues." (Line 241 to Line 243)

Reviewer #1

My impression of some of the issues raised in table 4 is that they are both more likely to cause infection than failure to wash hands between babies and that many of them are much easier to fix than low hand hygiene compliance. E.g., contaminated bottles and towels, no bath tub to bathe the babies etc. After hearing these reports, do the authors remain confident that "However, at the same time there is no doubt that infection control measures are needed and hand hygiene is obviously the place to start" (line 308)? To me, these seem like low hanging fruit rather than the hand-washing. I'd appreciate reading the authors view on this in the discussion.

Authors' reply

We think that these are likely isolated observations, and it is not low hanging fruit because we don’t know where this was happening and how frequently it was occurring. Our data suggests that hand hygiene is a common problem and therefore it is a good place to start. However, we agree that the reports of shared equipment and feeding need to be addressed and hence have added this sentence at the end of the paragraph.

“In addition, since there were reports of shared equipment and feeding items, these should also be further pursued.” (Line 337 to Line 338)

Reviewer #1

Regarding the differences between the confinement centres and home: I agree that the results presented may be due to a false positive, but I think that the authors also should be less confident that this is certainly the case (line 278). It may be the case that infection rates in the home are also quite bad. I think a sensitivity analysis might be warranted. What this would to is tell you what effect size you are capable of detecting with 80% power with the given sample size. Conducting a sensitivity analysis in G*power (free software) will tell you what odds ratio you can detect with 80% power in your study. If this suggests odds ratios far in excess of what you might reasonably expect based on other studies of hygiene and infant care, you know that your study was underpowered and that your conclusion of a false negative is at least a plausible interpretation.

Authors' reply

We are not sure what false positive the reviewer is referring to because Lines 277 - 278 in the original document stated that there is no difference between CCs and home.

For the current version, we have added this explanation to make it clearer. “Due to small numbers, we were unable to show whether there was a difference for the type and prevalence of reported health problems between the two groups.” (Line 294 to Line 296 of the current version).

In addition, the aim of the paper was to describe hygiene practices in CCs so we don’t think we would pursue this issue.

Reviewer #1

Minor Comments:

A few additional lines explaining what the confinement period is and how widespread it is would be useful at line 60.

Authors' reply

The background has been edited to include this information.

"…to a 30-day ‘confinement period’ known among the Chinese as ‘zuo yue zi’, with many do’s and don’ts passed down from generations to generations. During the confinement period, women follow traditional practices to maintain the balance between the ‘Yin’ and the ‘Yang’. It is believed that childbirth causes an imbalance between the ‘Yin’ and the ‘Yang’ and failure to restore this balance could potentially be detrimental to the mother’s health. According to the ancient Chinese philosophy, the ‘Yin’ and ‘Yang’ are attributes of all things or phenomena in the universe. They are of opposing characters. For example, ‘Yin’ refers to ‘cold’ while ‘Yang’ refers to ‘warmth’. Therefore, practices that assist the ‘Yang’ which is reduced during childbirth are emphasized. This includes ensuring that the mother ‘keeps warm’ by avoiding draughts and consuming a specially prepared confinement diet." (Line 59 to Line 70)

Reviewer #1

At line 68, might be worth noting the reasons women choose the confinement centres over the TPCs. Is there a cost difference, for example?

Authors' reply

We have also added this information in Line 83 to Line 86: “There are no published reports on why some mothers choose to go to CCs instead of opting for the traditional postpartum carer, but the reduced availability of the traditional confinement lady, and the increased availability of CCs could be a reason."

Reviewer #1

At line 92, provide more information about how the women were sampled. What was the sampling frame? Was the selection random?

Authors' reply

As mentioned in Lines 91 - 98 of the original manuscript, details about how the women were sampled published in Foong 2020.

To address the reviewer’s concerns, we have added more information to our current text as follows:

“Malaysian mothers of Chinese ethnicity who intended to spend their confinement period in a CC, who had delivered term healthy infants and had the intention to breastfeed, were recruited consecutively prior to discharge from August to October 2017. For every mother that went to a CC, we also recruited a comparison mother, who was as far as possible the next woman from the same hospital who went home for her confinement period. Some of mothers who went home engaged a traditional postpartum carer” (Line 107 to Line 113 of the current manuscript)

Reviewer #1

At line 127, provide more information on the research staff who conducted the interviews. Interviewer effects are common in this kind of work (i.e., one interviewer tends to elicit different responses). Can the authors confirm that there were no systematic differences in the responses to the different interviewers?

Authors' reply

We have added a line in the text to indicate this at Line 126 to Line 130.

"In order to reduce variability, we designed a set of structured questions and the two interviewers followed these during the interview. The training involved an understanding of the data that is to be collected, familiarisation with the structured questions and mock interviews. During analysis we could not find any systematic differences in responses across interviewers."

Reviewer #1

Line 109: Can the authors explain why "baby being inactive" suggests infection: to a non-medically trained reader like myself, this is not obvious.

Authors' reply

Since there were actually no babies being reported as ‘inactive’ by mothers, we have decided to take this word out to avoid confusion to non-medically trained readers.

Reviewer #1

Table 3: include percentages so it matches the other tables.

Authors' reply

Percentages are now included in Table 3.

Reviewer #1

I'm not sure it is reasonable to include the anecdotal evidence on lines 266: in statistical terms, observations like this have little ability to pick up on true differences are may be due to chance. Perhaps the editor has a view on this?

Thank you authors for this interesting read!

Authors' reply

We have reworded the sentence in the text as below:

“We were not able to establish any direct evidence of infection transmission. However, based on a previous report and the anecdotal reports given by mothers in this study along with the hygiene practices reported in this paper, it is likely to be happening.” (Line 383 to Line 386.)

Reviewer #2

The manuscript included an interesting and important topic. The paper has potential to improve further if include some more results/information, if available and thereby discuss accordingly.

Authors' reply

Thank you for your comments and suggestions to improve our manuscript. We have edited many sections of our manuscript. The line numbers indicating where the changes are made refer to the line numbers in the cleaned up revised manuscript (the copy without the "track changes")

Reviewer #2

The specific comments are as below:

Abstract:

1. Under methods section, need to mention clearly the type of interview conducted.

Authors' reply

We have added the information as below:

“After their 1-month confinement period, they were contacted for a structured telephone interview about their experience." (Line 22 to Line 23)

Reviewer #2

Line 38-39: Does it mean rest 88% reported satisfactory hand hygiene practice of their TPCs during caring their babies.

Authors' reply

No. Lines 38-39 of the original document mentioned that “18% of mothers who employed TPCs reported that their TPC had unsatisfactory hand hygiene practices.”

Of the remaining 82%, 32% didn’t know whether or not their TPC had satisfactory hand hygiene practices. To make this clear, we have edited the sentence to include the percentage of those that said that they did not know whether or not their TPC practised hand hygiene.

"Of mothers who employed traditional postpartum carers, 32% did not know if their carer washed hands after changing diapers and 18% reported that their carer did not." (Line 38 to Line 40)

Reviewer #2

Page 3, line 39: Under result section, need to specify what does refer to ‘unsatisfactory hand hygiene’

Authors' reply

We have re-written this in Line 38 to Line 40:

"Of mothers who employed traditional postpartum carers, 32% did not know if their carer washed hands after changing diapers and 18% reported that their carer did not."

Reviewer #2

Page 3, line 51: Rather say ‘customized training’ in place of empowering CC staff

Authors' reply

Empowering is more than customized training, although it might start with this. Empowering suggests that the CC staff would take ownership of the infection control.

We have edited the sentence as below:

“Training CC staff with hygiene knowledge so that they can be empowered to contribute to the development of these standards would be important.” (Line 51 to Line 52)

Reviewer #2

Background:

Page 4, line 61: For the international readers, please describe what is ‘Yin and Yang’

Authors' reply

We have now described this in Lines 61 to Line 70.

Reviewer #2

Page 4, line 63: Since TPC is not a standard term, consider to spell out throughout the paper instead of using abbreviation

Authors' reply

Thank you for the suggestion. We have now spelt this out in full.

Reviewer #2

Methods:

Page 5, line 97-98: What data collection tools was used to collect baseline data?

Authors' reply

Baseline data was collected using a self-administered questionnaire. We have added this information in Line 118 to Line 121.

"Demographic characteristics which included mother’s age, education level, gravida as well as her infant’s sex, gestational age and birth weight, were collected using a self-administered questionnaire."

Reviewer #2

Page 5, line 107 and 109: Instead of using the word ‘judged’, consider to replace with ‘assessed’ since this is a judgmental word

Authors' reply

We believe that the word “judged'' is more appropriate in this situation. Assessments would be based on criteria. Eg. we “assess” students in an exam.

Reviewer #2

Page 6, line 125: What type of interview guideline was used for the interview-structured questionnaire, semi-structured or in-depth interview guideline? Please mention clearly

Authors' reply

We have added this information in Line 126 to Line 130.

"In order to reduce variability, we designed a set of structured questions and the two interviewers followed these during the interview. The training involved an understanding of the data that is to be collected, familiarisation with the structured questions and mock interviews. During analysis we could not find any systematic differences in responses across interviewers."

Reviewer #2

Data analyses:

Page 7, line 138: ‘baseline characteristics’- need to describe under the method section what was the information/data collected for baseline

Authors' reply

We have added this information in Line 118 to Line 121.

“Demographic characteristics which included mother’s age, education level, gravida as well as her infant’s sex, gestational age, birth weight, were collected using a self-administered questionnaire.”

Reviewer #2

Results

Page 8, line 159: The sub-heading is ‘Baseline characteristics’. Is this baseline or demographic characteristics?

Authors' reply

We have edited the sub-heading to demographic characteristics in Line 185.

Reviewer #2

Page 9, line 175: Table title shall be demographic characteristics

Authors' reply

Thank you. Edited as suggested in Line 194.

Reviewer #2

Page 10, line 187: “Regardless of CC size, all had a single common nursery for babies”. Regardless of CC size, all had a single common nursery for babies”. Please include the range of CC accommodation. This will help to understand readers how many babies stayed in a nursery. In a CC some mothers could occupy single to three or multi-bedded rooms but it doesn’t give the scenario the size of a CC or # of babies stayed in the common nurseries in the CCs.

Authors' reply

The range of accommodation had been mentioned in Lines 186 -187 of the original document and we have kept this sentence in Line 199 to Line 200 of the current version

“The CCs had between four to 10 rooms for mother’s accommodation.”.

In Line 206 to Line 207 of the current version, we have also mentioned that “The number of babies in the nursery at a time was reported to range from one to 17.”

We do not have information on how many mothers there were at any one time, but we have information that there could be as many as 17 babies in a nursery. Since almost all were singletons, we assume there would the same corresponding number of mothers.

Reviewer #2

Since mother were not aware about the hand hygiene behavior, there is a possibility of recall bias. Also need to say if any mother could not recall the HH practice properly.s stayed in the common nurseries in the CCs

Authors' reply

We had already mentioned recall bias in Line 336 of the original document. To make this even clearer, we have made further elaboration in the current version. Meanwhile, ‘recall bias’ is part of it, but it is not just about recall bias. It also relates to whether the participants were aware of what to look for.

" In addition, if for instance a hand basin was not perceived to be present, we were unable to determine which one of these 3 possibilities could be taking place. Once possibility was that hand basin was actually not present and the participant had actually looked for it and couldn’t find it. Another possibility was that they were not even aware that a hand basin should be present and had not noticed it even if the hand basin was actually present (observer bias). The third possibility was that the hand basin was actually present, but they could not recall (recall bias)." (Line 370-376)

Reviewer #2

Page 10, line 190: ‘……only 11 spent less than six hours a day with their babies’. Consider present the characteristics of CCs and accommodation arrangements in a table format

Authors' reply

Since the accommodation arrangements are described by participants are actually only their perception, we feel that further detail could be misleading. Therefore, we have decided not to take up this suggestion.

Reviewer #2

Page 10, line 194: ‘….their centre was either clean or very clean’….Was the question asked in Likert scale?

Authors' reply

Yes, this was asked as a Likert scale.

We have added this information in Line 212 to Line 214.

“When asked to rate the overall cleanliness of the CCs using a Likert scale of 0 to 3, with ‘0’ being very dirty and ‘3’ being very clean, all mothers reported that their centre was either ‘clean’ (n = 41, 53%) or ‘very clean’ (n = 36, 47%).”

Reviewer #2

Page 10, line 195-196: Since mother were not aware about the hand hygiene behavior, there is a possibility of recall bias.

Authors' reply

We agree that there is a possibility of recall bias and had addressed this in the discussion of the original document in Lines 336 – 339. “The data was collected after they had left the CC and we did not verify their reports. Therefore, they could be subject to recall bias as well as observer bias.”

We have now also added more text into the discussion to further elaborate on this. "In addition, if for instance a hand basin was not perceived to be present, we were unable to determine which one of these 3 possibilities could be taking place. Once possibility was that hand basin was actually not present and the participant had actually looked for it and couldn’t find it. Another possibility was that they were not even aware that a hand basin should be present and had not noticed it even if the hand basin was actually present (observer bias). The third possibility was that the hand basin was actually present, but they could not recall (recall bias)." (Line 370 to Line 376)

Reviewer #2

Also need to say if any mother could not recall the HH practice properly.

Authors' reply

This had been presented in Lines 199 - 200 as well as in Table 2 of the original manuscript but we have further revised this sentence in the current manuscript.

“The remaining 27 (35%) mothers did not know if CC staff washed hands. (Table 2).“ (Line 219 to Line 220 of current manuscript)

Reviewer #2

Page 10, line 200-201: This is a big %. This also reflect somewhat the mothers’ perception to importance of the hand hygiene. While this recall bias is a limitation, it is also an important point of discussion.

Authors' reply

We agree and have added text in the discussion to address this.

"There was probably a lack of awareness both among the CC staff and mothers about the importance of hand hygiene. We were surprised to find 35% of mothers not cognisant of whether or not their CC staff washed hands before handling their babies." (Line 304 to Line 306.)

Reviewer #2

Page 10, line 202: In the title of the table 2, it mentioned ‘Mothers’ perception’…but the table doesn’t reflect any perception, rather it only reported CC staff’s HH practices observed/noticed by the mothers.

Authors' reply

We left it as perception to make the point that different participants would have a different level of awareness of the presence of these items in their CC. We can’t actually tell whether the items listed were present from their retrospective report. It is not just about recall either. If a hand basin is not perceived to be present:

1. was it because the it wasn’t actually present and the participant is quite sure of that (because they had looked for it)

OR

2. was it because they weren’t even aware that a hand basin should be present and if it was there they just didn’t notice it

OR

3. was it because they cannot recall?

We have also included this into the text in Line 370 to Line 376.

Reviewer #2

Please correct the spelling in the 2nd and 4th column heading ‘practiced’.

Authors' reply

The word here is used as a verb and not a noun, hence we think it should remain as ‘practised’ and not ‘practiced’. We are using British English.

Reviewer #2

Page 11, line 210: What is the % of singles cloth towel for common use and the toilet rolls supplied by the CCs?

Authors' reply

This has been added to the Table 3 and Table 4.

We have considered hand towels to be either cloth or paper towels including toilet rolls.

Reviewer #2

Page 11, line 212:

In the 3rd row of the table 3, need to mention the hand sanitizer is only for staff use.

Authors' reply

We have clarified this in the text in Line 224 to Line 226, and also in Table 4.

“Among the 32 (36%) mothers who reported that their CCs provided alcohol-based hand sanitizers, three reported that alcohol-based hand sanitizers were restricted to staff use only.”

Reviewer #2

Page 11, line 215-216: Was the quarantine rooms for single mother or baby or for multiple but limited persons?

Authors' reply

We do not have details about this.

We have added a sentence stating, “We do not have details on whether the quarantine rooms were meant for single or multiple users.” In Line 237 to Line 238.

Reviewer #2

In the table 4, 3rd row, did it mean same bottle use to feed multiple babies?

Authors' reply

Table 4, 3rd row was a statement recorded verbatim by a participant. It meant that the CC used one common towel when burping different babies. The interviewer did not clarify with the participant if this meant a same bottle was used to feed multiple babies.

Reviewer #2

Page 12, line 232: ‘….11 mothers did not know whether their TPC practices hand hygiene’... didn’t know or couldn’t remembers? Since this was the home setting, not clear what was the arrangement of mothers and babies staying, in the same room or different room?

Authors' reply

Added to the background (Line 75 to Line 80)

“The traditional postpartum carer would move into the home for the entire duration of the confinement. She would usually be given her own room. Depending on the mother’s preference and feeding choice, the baby might room-in with the traditional postpartum carer during the night or be with the mother. The traditional postpartum carer would have full access to the baby as her primary role would be to care for the baby in order for the new mother to ‘rest’."

Reviewer #2

Also check the typo ‘did not washed’ in line 231.

Authors' reply

Thank you for spotting the typo. ‘washed’ changed to ‘wash’.

Reviewer #2

Page 13, line 242: ‘…. Hospitalized for viral infection…..’ Did the mother mention what was the infection?

Authors' reply

The mother just mentioned that the doctor said it was a viral infection.

We have added the word ‘unspecified’ into the sentence to make this clearer. (Line 262).

Reviewer #2

Page 14, line 268: ‘…… because a number of babies in her CC had fever….’ Was her baby also included here?

Authors' reply

No, her baby was not included.

Reviewer #2

Discussion

Page 15, line 280-282: In this sentence it discussed the lack of hand hygiene and other practices likely result from lack of resource, inconsistent hand hygiene practices…..’

I wonder you’ve explored mothers’ general perception of hygiene, cleanliness and any link between lack of hand hygiene practices/cleanliness and potential illness/infection.

Although some results presented mother’s perception of sharing items as cause of babies’ illness, the above-mentioned variables either not explored or presented. Therefore, would like to suggest to present those data, if available and then discussed in the discussion section.

Authors' reply

This is a great idea but unfortunately, we cannot draw any conclusions from our data. The participants that reported the illness might have been on the alert for the hygiene issues whereas participants in CCs where all was well might not have noticed the lack of hygiene.

Reviewer #2

Page 15, line 284-285: ‘One similarity with these is that they are populations…..’ Did you mean mothers at nursing homes and conferment centres? Consider to rephrase the sentence

Authors' reply

Rephrased sentence to “One similarity between CCs and nursing homes is that they have populations who are relatively susceptible to infection.” Line 308 to Line 310.

Reviewer #2

Page 15, line 289-290: To design a compelling and effective educational training, understanding of mothers’ and caregivers’ perceptions and practices related to hygiene is crucial, which are still under explored in this study.

Page 16, line 300-303: Same as comment as earlier. To improve the risk perception and IC practices, caregivers’ perceptions and knowledge in CCs need to be assessed/identified to design an acceptable intervention.

Authors' reply

Thank you for this good suggestion. We have added this into the text in Line 317 to Line 318. “In addition, prior exploration of mothers’ and CCs’ staff understanding and knowledge about hygiene would be useful when designing training.”

Reviewer #2

Page 17, line 316-317: The authors pointed out that many mothers who stayed at CCs were discouraged from rooming-in with their babies, which also suggest for further research to understand the existing norms and ritual among this group at the neonatal period.

Authors' reply

For some strata in Chinese society, not rooming-in is the norm. We added a sentence to explain this.

“This could partly be due to traditional belief of the need for mothers to rest but it could also be due to convenience of caring for all the babies in one place.” (Line 344 to Line 346).

Reviewer #2

Page 17, line 321: In this sentence, not sure what does mean by the ‘direct breastfeeding rates’.

The following sentence indicate that the exclusive BF included the expressed breastmilk. It needs to be mentioned explicitly and also present in the results section.

Authors' reply

Clarified the sentence with some additional text.

“Although exclusive breastfeeding rates in this study cohort were as good, if not better that other local populations, most of the mothers were just feeding their babies with expressed breastmilk and not breastfeeding directly from the breast.” (Line 348 to Line 351)

Reviewer #2

Page 17, line 324-325: In this sentence, it discussed about empowering the CC staff. But earlier it mentioned that the CCs were discouraged from rooming-in mothers with babies… so at this point rather make the point to encourage/train CC’s for direct BF by mothers, so that they could also encourage mothers for direct BF.

Authors' reply

We have added into the sentence that providing training to CC staff will help empower them to provide support for direct breastfeeding.

“One way to improve direct breastfeeding would be to provide training to CC staff so that they can be empowered to provide support for direct breastfeeding and to provide rooming-in facilities for mother and baby.” (Line 352 to Line 355).

Reviewer #2

Page 17, line 336: The authors mentioned that “It is also important to note that our findings are those perceived by mothers”… One major limitation of this data is mothers informed about the hand hygiene practice after one month from their memory. Moreover, during recruitment, mothers were not informed that they would be asked about their observation for HH practices of the caregivers to avoid any alteration. However, on the other hand it could be mothers’ recall bias to report about hand hygiene practices. Moreover, measuring hand hygiene events is always tricky which includes not only the overall hand hygiene practices but also critical times that would potential for pathogen transmission. The data also does not reflect the mothers’ general perceptions to hand hygiene and other infection control practices. Without knowing these it is difficult to conclude whether mothers feel the need for hand hygiene during feeding and handing neonates. Because there is a link between mother’s risk perceptions and reported hand hygiene behavior. If the data support the above-mentioned information, would recommend to include those. Otherwise need to mention as limitation.

Authors' reply

Thank you. We have added text into the discussion to address this in Line 370 to 379.

“In addition, if for instance a hand basin was not perceived to be present, we were unable to determine which one of these 3 possibilities could be taking place. One possibility was that hand basin was actually not present and the participant had actually looked for it and couldn’t find it. Another possibility was that they were not even aware that a hand basin should be present and had not noticed it even if the hand basin was actually present (observer bias). The third possibility was that the hand basin was actually present, but they could not recall (recall bias).

To overcome these biases, further studies, perhaps using direct observation could be performed and should involve CC operators and managers. Therefore, there is a need to establish rapport with them early.”.

Reviewer #2

Page 18, line 338: Include reference where discussed ‘observer bias’.

Authors' reply

We are not sure why a reference is needed for observer bias but have added a short definition of it in brackets in the text in Line 373 to Line 376.

“Another possibility was that they were not even aware that a hand basin should be present and had not noticed it even if the hand basin was actually present (observer bias). The third possibility was that the hand basin was actually present but they could not recall (recall bias).”

We have also added some information about overcoming observer bias.

“To overcome this bias, further studies, perhaps using direct observation could be performed and should involve CC operators and managers.” (Line 377 to Line 379)

Reviewer #2

Page 18, line 339-340: Also direct observation may require.

Authors' reply

We are unsure what the reviewer means here.

Reviewer #2

Conclusion

Page 19, line 348: Better to replace the word ‘Empowering’ with ‘Training’

Authors' reply

We have revised the sentence to incorporate this in Line 388 to Line 390.

“Training CC staff to empower them with hygiene knowledge so that they can be involved and contribute to the development of these standards would be important.”.

Reviewer #2

Page 19, line 348-350: Revise the sentence

Authors' reply

We have revised the sentence as below:

“Training CC staff to empower them with hygiene knowledge so that they can be involved and contribute to the development of these standards would be important.” (Line 388 to Line 390)

Reviewer #2

• In the figure/ diagram that described enrollment, need some correction. Insert the required spaces between words in the diagram. In some places 2nd bracket ‘{‘ was used, which is not an usual practice for a diagram/figure

• Overall English grammar and some spelling (specific style (American/British) allowed in this journal) need to be checked

Authors' reply

We did not use any of such brackets and are unable to locate any such brackets being used, nor anything that needs spaces between the words in the figure. Grammar and spelling have been checked.

Submitted filename: Reply to Editors and Reviewers2.docx

Click here for additional data file.

6 May 2022

Mothers’ hygiene experiences in confinement centres: a cohort study

PONE-D-21-03743R1

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Reviewer #1: All comments have been addressed

Reviewer #3: All comments have been addressed

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Reviewer #3: Yes

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Reviewer #3: Yes

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Reviewer #1: No

Reviewer #3: Yes

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Reviewer #1: All my points have been addressed. Thank you authors for this interesting work. Look forward to seeing more research on this area in future.

Reviewer #3: This article is substantially improved from its original version. Cultural considerations regarding Confinement Centers is a fascinating topic which is under researched. I think it is good to have this somewhat straightforward and simple topic about hand hygiene published. But there is clearly so much for future research, including not only links to breastfeeding (which the authors have already published on and which they reference), but also to larger questions about cultural considerations regarding postpartum care in general. The current paper also references their other paper on breastfeeding for the methods, and I think the authors could talk more about their methods in this article as well. I appreciate they did not want to repeat what is already published, but the reader would benefit from additional methods details which are published in their breastfeeding paper. Although I do think the reader does benefit from reading the author's other paper as well. This article is a well written and on a fascinating topic, albeit framed in a very specific way, and I believe should lead to future research on cultural considerations regarding postpartum care.

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Reviewer #1: No

Reviewer #3: Yes: Dr Tanya M Cassidy

13 May 2022

PONE-D-21-03743R1

Mothers’ hygiene experiences in confinement centres: a cohort study

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