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Introduction: Driven by international programs specifically targeting neonatal survival, a set of recommended care practices is being promoted in West Africa. Using data from a multi-centered anthropological study, we enquire as to how local practices integrate the recommendations disseminated by these programs. Method: The surveys were conducted in rural localities in five countries: Benin, Burkina Faso, Mali, Mauritania, and Togo. In every site, the investigations combined ethnography of newborn care and in-depth interviews in maternity homes and homes. Results: The care of newborns is based on a set of local social representations and logics, where medical recommendations are integrated heterogeneously. In maternity wards, health professionals face difficulties in implementing recommended practices, and make various conciliations when faced with local material and social constraints. In private homes, the “messages” promoting life-saving care for newborns punctuate conversations, but lead to various interpretations and variations in care. Discussion: The irregular integration of medical recommendations in neonatal care is analyzed around three areas: the divergence of intentions around the birth, the dissonances between the recommended care and the local conceptions of the newborn, the influence of intra-family power relations. Considering the complexity of the changes in neonatal care, we argue for the implementation of programs that respect local cultures, and for health professionals to skillfully accommodate conflicting constraints.