Yeshiwork Eshetu, Demeke Assefa, Kebebush Zepre and Asegedech Wondimu
Correspondence Address :
Department of Public Health
College of Medicine and Health Science
Wolkite University, Wolkite
Received on: May 26, 2023, Accepted on: July 03, 2023, Published on: July 07, 2023
Citation: Eshetu Y, Assefa D, Zepre K, Wondimu A (2023). Level of Knowledge towards Essential Newborn Care and its Determinants among recently Delivered Women, North Shewa Zone, Oromia Region, Ethiopia. A Community Based Cross-sectional study.
Copyright: 2023, Kebebush Zepre, et al. Ricke. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Objective: This study’s objective is to evaluate the level of mothers’ knowledge on Essential newborn care and related aspects in North Shewa zone, Oromia Region, Ethiopia.
Method: Between February and March 2019, a cross-sectional community based study was carried out. While opinion leaders, medical professionals, programmers, and elderly women in the community participated in in-depth interviews, data were gathered from 386 randomly chosen women through interviews. Data entry and analysis were done using EPI-info version 3.5.3 and SPSS version 21. For the purpose of evaluating potential associations, logistic regression analysis was used.
Result: The study participants knew a lot about the essential newborn care in 46.4% of cases. Women with poor literacy rates (adjusted odd ratio [AOR=0.153, 95% confidence interval (CI)=(0.052-0.445)], women, had lower knowledge of essential newborn care. Women with household incomes of less than or equal to 2350 ETB [AOR=0.311, 95% (CI)=(0.113-0.858)] and women whose first antenatal care(ANC) appointment is at sixteen weeks or more gestation [AOR=0.535, 95% (CI)=0.311-0.921]. Additionally supporting the survey’s findings in many ways is the qualitative data.
Conclusion and recommendation
In Fiche Town, it was discovered that illiterate women, those who had their first ANC appointment at sixteen weeks or later, and those whose household income was less than or equal to 2350 ETB had relatively low knowledge of essential newborn care (ENBC). Stakeholders should place a priority on enhancing women’s educational opportunities and income generation, which will in turn aid to enhance their health-seeking behavior and level of familiarity with essential newborn care.
Keywords: Mothers, Knowledge, Essential Newborn Care, Community, Oromia region
Despite a decreased percentage of deaths among children under the age of five, neonatal mortality is still significant [1,2]. In 2017, there were reportedly 2.5 million newborn deaths worldwide . Neonatal mortality accounts for almost two-thirds of all baby deaths and 45% of under-five deaths worldwide, despite the neonatal period being excessively brief . Worldwide, low- and middle income (LMIC) nations like Ethiopia, where half of deliveries take place at home, account for nearly all newborn mortality (98%) [5-7]. According to the evidence, up to 50% of newborn deaths can be averted by using cost-effective interventions that can be used before, during, and after delivery. By seven days following birth, that number rises to 75% . More than 85% of infant deaths are due to three major, preventable causes: complications associated with preterm, neonatal deaths related to childbirth (including birth asphyxia), and neonatal infections, particularly in developing nations . Efforts to improve the health of infants are made possible through the essential newborn care (ENBC) package of intervention. To reduce newborn mortality and morbidity in both affluent and developing nations, it is the only most cost-effective measure . In response to the severity of the issue, the World Health Organization (WHO) has developed a set of recommendations for Essential Newborn Care Practices (ENBCP), which are cost-effective and evidence-based methods for enhancing neonatal outcomes. All parties involved in the care of the neonate, including as the mother, the community, and the government, are expected to follow this recommendation . The sustainable development goal (SDG) set by the international community aims to reduce neonatal and underfive mortality rates to 12 and 25 deaths per 1000 live births, respectively, by 2030 . ENBC includes immediate care at birth (delayed cord clamping, thorough drying, assessment of breathing, skin to skin contact, early initiation of breast feeding), thermal care, Resuscitation if needed, Support for breast feeding, recognition and response to danger signs  In its efforts to carry out its commitment to implement the health strategy, the Ethiopian government has prioritized mother and child health. As a result, the Federal Minister of Health (FMOH) implemented prenatal and postnatal home visits by health extension workers (HEWS) in all regions of the nation, and the Community-Based Newborn Care (CBNC) has been integrated a platform of HEP across continuum of care to improve the survival of newborns [13-15]. Despite all current efforts to lower the NMR, it has only slightly decreased from 39 fatalities per 1000 live births in 2000 to 33 deaths per 1000 live births in 2019.The NMR in the regional state of Oromia was 40 fatalities per 1000 live births, which is much higher than the national average .
The practice of ENBC depends on mothers having awareness about it. Studies designed to evaluate mothers’ awareness of ENBC have been carried out in various regions of Ethiopia [17-22]. The results show a considerable difference between the knowledge of ENBC among women in the various research locations, ranging from 36.1% (20) to 80.4% (19). Additionally, local differences in deciding factors exist. Furthermore, the Oromia region lacks such studies. As a result, it’s critical to evaluate the extent of ENBC knowledge and determining factors in order to identify any gaps. The findings might offer methods for raising mother’s degree of ENBC understanding, which would aid to increase newborn survival.
Methods and Materials
Study area and period
The study was conducted in Fiche Town, North Shewa Zone of Oromia region from February to March 2019. Fiche is located 112 Km Northwest of Addis Ababa and the capital town of North Shewa. It has four Kebeles (the lower administrative unit). The population of fiche town is estimated at 45,135, of which the female population is 51%. There are 9988 women of reproductive age, of whom 1,566 were reported to have delivered within 12 months preceding the survey. Fiche town has 11 health extension workers those serve the population and has a health infrastructure with health services delivering through a network of one hospital, two health center, one family Guidance association and 17 private clinics. ANC, institutional delivery and postnatal service coverage were found to 63%, 33% and 74% respectively  (Fiche town Administrative Health Office, report 2018, unpublished data).
Study design and study population
A community- based, cross-sectional survey, supplemented by qualitative study was carried out. The source population was women in the reproductive age group (15-49 years) who gave birth within 12 months prior to the study and those women who have infant (irrespective of the place of delivery), who were permanent resident in the town, and who volunteered to participate in the study were considered as study participants. Yet, those women who were severely sick and women who delivered died fetus were excluded from the study. For qualitative study an in depth interview were undertaken with healthcare provider (urban HEW, Nurses and midwifery working at MCH), elderly women, community leaders, religious leaders and health programmers.
Sample size determination
The sample size was calculated using a single population proportion formula, following such assumptions as 95% confidence level, 4% margin of error between the sample and the population, 29.3% proportion of women who were knowledgeable on ENBC in reference to previous study , population correction was made to get correct sample size, 10% non-response rate. Accordingly, 389 women were included as study participants. A total of thirty four in-depth interviews were planned, but based on information saturation, only twenty six were undertaken.
All kebeles in the town were grouped into four strata, in order to obtain the required number of sample from all kebeles, all women who delivered in the previous 12 months prior to the date of the study were registered to get sample frame. The calculated sample size was allocated using proportional to population size, and simple random sampling procedure was used to select eligible participant. Participants in the qualitative study included health programmer, health care providers which included urban HEW, Nurses and midwifery working at MCH, elderly women, religious leaders and community leaders who were identified on the basis of their knowledge regarding newborn’s & child health and/ or had a specific role in effort to improve child health in the community.
Data collection tools and procedure
A pretested structured and semi structured questionnaire was used to collect the data. The questionnaire was adopted from previous studies [16,17,23]. The questionnaire was prepared in English language and translated into local language (Afaan Oromo) then translated back into English to ensure consistency. The tool was designed to measure socio-demographic characteristics, obstetric history, maternal services utilization, source of information, counseling about ENBC and knowledge about ENBC. Four diploma nurses who were recruited from facilities out of the study area and those who know and speak the local language were trained to collect the data. Data collection was closely supervised by two public health professionals who were recruited from health facilities out of the study area. At the end of every day the data collection, completeness and consistency of data was checked, and any incomplete questionnaire was returned to data collectors, based on ID numbers for completion. Prior to the start of data collections, a two days training was provided to the data collectors and supervisors to discuss the aim of the study, data collection methods, ethical issues and procedures. This was complemented with practical role-plays and field exercises. An open ended checklist with probes was used to collect evidence on local understanding on essential newborn care knowledge and cultural beliefs. Twenty- six in-depth interviews were completed by the principal investigator who was supported by an assistant who recorded the information. Operational definition/Measurement/ The Knowledge of essential newborn care was assessed under six components:-breast feeding, thermal care, immunization, eye care, cord care, and danger sign identification. For each component, the correct response to the questions (consistence with WHO Essential newborn guidelines) was given a score of Ì” ’1 Ì• and incorrect and unknown response was given Ì”Ì• 0 Ì• score. Finally, it was dichotomized as good or poor knowledge based on the sum of correct response by taking the mean score as cutoff point. Which was 11.2 the mean score of the distribution. Those scoring below mean were considered to have poor knowledge and above and equal to the mean considered to have good knowledge .
Data processing and analysis
Data was entered into Epi-Info 3.5.3 statistical software and exported to the Statistical Package for Social Science (SPSS) version 21 for cleaning and analysis. Descriptive statistics were performed, and the findings were presented with text, tables, and figures. Binary logistic regression was used to assess the association between each independent variable and the dependent variable. Model fitness was tested using Hosmer and Lemeshow statistics and (p-value > 0.05 showed a good fit model). All variables with a P-value<0.05 in the bivariate analysis were included in the final model of multivariable analysis to control all possible confounders. Normality was tested using numerical and graphical methods. The data points were close to the diagonal line, indicating a normal distribution. An approximate bell-curve shape was observed in the histogram, indicating that the data may have come from a normal population. Multicollinearity was checked and variables with a VIF above 10 and significant correlation were excluded from the model. Multicollinearity and interaction effects were analyzed, in the final model; there was no significant effect modification among the factors. The adjusted odds ratio, along with 95% CI, was undertaken to identify independent factors of ENBC. A P-value <0.05 was considered to declare a result as a statistically significant association. The qualitative data were transcribed and sorted into themes following the research questions. Accordingly, raw data were categorized under what is known about essential newborn care which includes cord care, thermal care, breast feeding, immunization and identification of newborn danger signs and cultural beliefs and what needs to improve in the future.
Data quality management
To guarantee data quality, all individuals who are responsible for data collection and supervision were trained. The tool was pretested in one of the town in roomies region on 5% of the total sample households to check for consistency, clarity, and sequence of questions, and also to familiarize the data collectors with the tool. Data was checked on a daily basis to ensure that it was complete, accurate, and consistent, and any necessary corrections were made. Epi-info 3.5.3 was used to enter and clean data before exporting it to SPSS for analysis.
Patient and Public Involvement
The research question for this study was developed based on the identified gap in relation to the subject matter, the background information was constructed using information from local leaders, the study participants were invited to be involved in the study voluntarily to respond on the questionnaire and they have been informed as the finding of this study will be disseminated to all stakeholders through publication, seminars, and local meetings.
Written ethical clearance was obtained from the research and ethical committee of the school of public Health, Addis Ababa University /Ref No/065/11. A formal letter was written to the Fiche town administration council and Town’s Health office from the School of Public Health. On the basis of this, permission was obtained from the town health office and each kebele administration to conduct the study. Written informed consent was obtained from every participant who agreed to take part in the study. They were assured about the confidentiality of their response.
Socio demographic characteristics of study population
A total of 386 women out of 389, who gave birth within 12 months prior to this study have responded, making response rate 99.2%. Age of participants ranged from 16 to 42 years with a mean age of 26.8 ± 4.7. Two hundred sixty one (67.6%) of the respondents were found to be 20-29 years of age. Majority (94%) of the respondents were orthodox. Three hundred forty three (88.9 %) were married and more than half (57.8%) respondents were Oromo. About one-third (30.3%) of the respondents were illiterate while the remaining could at least read and write. One hundred forty two (36.8%) were housewives and more than one third (37.3%)) respondents earn 151-650 birr/month. Concerning to infants’ sex and age participated, the proportion of male to female infant were almost equal and two hundred (53.4%) of the participants were greater than six months (Table1).
Obstetric and maternal health service utilization
One hundred and thirty-six (35.2%) of the respondents were primigravida while, 44 (11.4%) of them had had four or more pregnancies. Ninety- Five percent of study participants reported as they attended at least one ANC visit during their recent pregnancy, half (50.7%) have attended four or more visits and six (1.6%) had made only one visit. Near to half (48.2%) of them initiated their first ANC before 16 weeks of pregnancy, as recommended. Three hundred and forty (92.6%) of respondents have received some antenatal care from a nurse or midwife. (Multiple responses allowed: but data not showed). Three hundred and forty-two (88.6%) respondents gave birth athealth institutions supported by skilled health care providers, Three hundred and sixty- two (93.8%) of respondents had normal vaginal delivery whereas twenty four (6.2%) of them had caesarian section. Few women (17.4%) reported receiving a post check by health worker or health extension workers in the first weeks after delivery either at home or at a health facility (Table 2). The qualitative findings ascertained that the expansion of ANC, delivery and PNC services facilitation is made available to the community and this encourages mothers to get the services when they need them. An in-depth interview participants point out; “ The motto of ministry of Health that says ‘Every mother must deliver in health facilities’ has increased the number of mothers that deliver in the health facilities and this on the other hand increased the number of newborn getting the Essential newborn care” ( IDI, health programmers, community leaders)
Counseling on Essential Newborn care
Among the study participants, two hundred and eighty-two (73.1%) received counseling messages about newborn care during pregnancy, the most frequent counseling message about newborn care was breast feeding which account 208(74%). As to the areas of counseling on ENBC; 166 (43%) of them confirmed that they received on two areas while ten (2.6%) of them received three and more areas during pregnancy. Fifty- nine (15.3%) received counseling messages about ENBC during postnatal period. From those received counseling message the most frequently received counseling message was on immunization 50 (82.2%). Thirty- nine (10.1%) of respondents agreed that they received on two areas, while7 (1.8%) of them on three and more areas during postnatal (Multiple responses allowed) (Table 3).
Source of Information about Essential Newborn care
All the study participants reported to have been informed about Essential Newborn care. Multiple responses reveled that information shared through mass media 300 (37.6%), from health workers at the health facility levels 253(31.7%), from health extension workers at the community level 140 (17.6%) and from relative and friends 104 (13.0%) were major sources of information about essential newborn care.
The qualitative findings revealed that health workers, HEW, mass media and community-levels discussions are important sources of information about ENBC:-An in-depth interview participant pointed out that:- “Electronic media like Radio and TV provide health education on newborn care. This media education has created good opportunities to improve the knowledge of mothers on newborn care for those who have access to these medias” (IDI, An elderly woman)
Knowledge on care of umbilical cord
Three hundred and sixty one (93.5%) of mothers were aware that the umbilical cord should be cut with new blade and/ or boiled blade/scissors. Three hundred forty (88%) of survey participants were aware that the umbilical cord should be tied with new string/ thread (Table 4). The qualitative findings revealed that almost all study participants were aware of cutting and tying the umbilical cord with unclean or unsterile materials can exposed the newborn to infection like HIV. Especially, the health professional explained that using unclean/unsterile cutting/tying materials can exposed the newborn to neonatal tetanus. “Now a day our community has developed awareness on the need of clean tying and cutting the cord with new and boiled razor blade/scissors due to the fear of HIV transmission and other infection to the newborn.”(IDI, one of the community leaders) Regarding to cord stump, three hundred and three (78.5%) of mothers recognized that the umbilical stump should be left uncovered without any dressing while, 163 (42.2%) participants were aware that the cord stump should be clean and dry or nothing should be applied except order medication). The qualitative findings ascertained that community members were aware that umbilical cord should be left uncovered and nothing should be applied on the cord stump except order medication. One of religious leader respondent said that: “Before urban health extension program had started: we had the understanding of applying different leaves like ‘as tenagar in Amharic’ on the umbilical cord believing that it helps to dry the wound. Now a day, we have quitted applying different leaves because we have understood that umbilical cord must be kept dry and clean.”(IDI, religious leader). But an elderly woman holds a different view describe her idea like this: “Butter or Vaseline is applied on the cord stump to moist, and reduced bleeding so that the cord can get off in few days’’(IDI, an elderly woman).
Knowledge of thermal care
Two hundred and ninety-four (76.2%) of mothers knew that newborn should be wiped and/or dried before delivery of placenta. Three hundred (77.7%) of mothers recognized that the newborn should be wrapped before the delivery of placenta. Concerning to the immediate placement of the newborn, only forty (10.4%) of survey participants were aware that the newborn should be placed on mother’s chest/belly. one hundred and ninety-eight (51.3%) of the study participants were aware that bathing of the newborn should be at least 24 hours after delivery of baby (Table 4). The qualitative findings revealed that almost half of the respondents were aware of bathing immediate after delivery up to few hours with cold water can expose the new born to hypothermia, pneumonia and other health problems.
Knowledge on breast feeding
Regarding to breast feeding, 271 (70.2%) of the study participants were aware that initiation of breast feeding should be within one hour of birth (as recommended), Majority (94.3%) of respondents knew that colostrums /first milk/ should give first for the newborn, ninety percent of the respondents were aware that newborn should fed on demand and ninety two percent of mothers knew duration of exclusive breast feeding (Table 4). The qualitative findings revealed that the community members were aware that giving plain/sugar water, water with common rue (tenaadam) and fenugreek (abesh)immediate after birth up to six months would expose the newborn infant to infections, malnutrition and other health problems like diarrhea. Another in-depth interview participant having different view point out: “Butter is given to an infant immediately after birth up to a few days once or twice a day so that the newborn’s abdomen becomes soft and excretes his/her feces easily or to avoid constipation.” (IDI,)
Knowledge on eye care
Regarding to eye care, among the respondents, 66 (9.7%) of them were aware the newborn eye’s should be cleaned separately with sterile swab immediate after birth, while 37(9.6%) recognized that applying eye ointment within one hour of birth prevent conjunctivitis (Table 4)
Knowledge on newborn danger signs
Among the total respondents, 317 (82.1%) of them stated that they had the information about newborn danger signs. Multiple response revealed that the only newborn danger sign for which there was high awareness among mothers was fever 198 (62.5%).To lesser extent, mothers were also aware of poor feeding 80 (25.2%), and few mother listed newborn danger sign, yellow palms, eyes, or soles 14 (4.4%) In general, mothers’ knowledge of newborn danger signs was low, with only 9.1% of respondents were knowledgeable (able to name 3 or more danger signs out of a list of 11)
Over all knowledge of Essential Newborn Care
Regarding to overall knowledge of essential newborn care, out of three hundred Eighty-six samples, one hundred seventynine (46.4%) of them correctly respond and scored mean and above of the knowledge assessment criteria and considered as having good knowledge about essential newborn care (Figure 2).
Factors affecting knowledge of essential newborn care
Bivariate analysis shows that, the mother’s educational status, occupation, income, parity, ANC follow up, Time of first ANC booking, TT vaccination status, place of delivery, person assisted at delivery, and services provider at PNC were found to have a strong association with ENC. The findings reveal that mothers with lower educational level, unemployed mothers, having less number of parity, ANC booking date after 16 weeks, no TT vaccination history, mothers who delivered at home and those mothers delivered without SBA have significant association with the knowledge of essential newborn care. Despite such evidence of predictors of ENBC in bivariate, multivariate logistic regression showed that women whose educational level were lower, women whose monthly household income were lower and mothers her first ANC booking date were above and equal to 16 weeks have a significant association with essential newborn care. Accordingly, illiterate women were 0.153 times less likely to be knowledgeable about ENC than those women who were above grade 10 educational level (AOR= 0.153, 95% CI: 0.052, 0.445), also read and write women were 0.162 times less likely knowledgeable about ENBC as compared to women who were above grade 10 educational level [AOR=0.162, 95 % CI: 0.027, 0.989) Women whose household income less than or equal to two thousand three hundred fifty ETB were 0.311 times less likely knowledgeable about ENBC as compared to women whose household income greater than two thousand three hundred fifty (AOR=0.311, 95% CI: 0.113, 0.86). Women who book first ANC after 16 week of gestation were 0.535 times less likely knowledgeable about ENBC than women who book first ANC earlier (AOR=0.535, 95% CI: 0.31, 0.92) (Table5).
In this study, the level of respondents overall good knowledge on essential newborn care is 46.4%. This knowledge level is lower compared to previous finding from Ethiopia (80.4%) , India, tertiary care hospital, Udupi district (76.7%) , JJR maternity center Bangalore, Karnataka (52%) , maternity centers of Madurai corporation (65%)  and Bangladesh, Dhaka Shish hospital (55.3%) , Pakistan (57%) , India (60.0%) , Himalayas (51%) , Ghana (62.2%)  and Bangladesh (88.7%) . The possible justification might be due to the difference in socio-economic status, diference in infrastructure, accessibility of the health care system, promotion of ENBC, commitment given to CBNC. This study suggests that the awareness creating approaches of ENBC during antenatal and postnatal follow up in this study area were ineffective. Hence, involving all the responsible stakeholders, and evidence based strategies during pregnancy, delivery and postnatal period to boost mother’s awareness regarding ENBC is our recommendation. Besides, in the qualitative finding one of Interviewees forwarded suggestions that support the low level of knowledge about ENBC as follows: “Butter or Vaseline is applied on the cord stump to moist and reduced bleeding so that the cord can get off in few days” (IDI, an elderly woman) This knowledge level report is higher when compared to previous study in Ethiopia (36.1%) , Bangladesh (19%) , India (15%) . The suggested reason of this difference could be, due to the especial attention has been given to newborn and maternal health care by the government of Ethiopia, FMOH, NGO and other stakeholder. Furthermore the qualitative finding supported it as an Interviewees point out this higher level of knowledge as follow:- “Before urban health extension program had started; we had the understanding of applying different leaves like ‘as tenagar in Amharic’on the umbilical cord believing that it helps to dry the wound. Now a day, we quitted applying different leaves because we have understood that the umbilical cord must be kept dry and clean” (IDI, a religious man) In this study, educational status of the women was found to have statistically significant association with knowledge of ENBC. Women who were illiterate were 0.153 times, able to read and write were 0.162 times less likely knowledgeable as compared to women who above grade ten educational levels. This findings was consistent with the studies from India  and Bangladesh . The possible explanation could be, educated women are expected to have awareness & knowledge on the advantage of ENBC, they are more likely seek modern health care than those who are not. Education is likely to improve the general status of women and help them to build confidence to make decisions about them and their child health and have better access to information through reading and media about maternal and child health. Similarly, household income was found to have statistically significant association with knowledge of ENBC. Women whose household income less than or equal to two thousand three hundred fifty ETB were 0.311 times less likely knowledgeable about ENBC as compared to women whose house hold income greater than two thousand three hundred fifty. This finding was consistent with the studies from other settings from India [26,36]. The possible reason could be, Those women who have better household income are expected to have health information health care access and more likely to seek modern health care than those who had no better health care. This helps to have better knowledge on ENBC than who are not. Similarly, time of ANC registration was also found to have statistically significant association with knowledge about ENBC. Women who registered for ANC sixteen weeks and above of gestation were 0.535 times less likely knowledgeable about ENBC than women who registered less than sixteen weeks of gestation. This finding was consistent with the studies from Sir-land  Ghana . The possible suggestions late registered women are expected to have less frequency of exposure or contact to health provider during pregnancy. They are less likely to get education or counseling message about newborn care than those who registered early.
To the best of the authors’ knowledge, this is the most comprehensive study of its kind in Fiche town, Also, the fact that the study has used a mixed-method approach and community based make the findings stronger.
As of any cross-sectional study, the findings of the current study may not provide strong evidence of the direct cause and effect relationship between ENBC knowledge and explanatory variable. As the study was focused on one of the town, the result may not be conclusive to the region at large. Also, some of the participants in the survey were interviewed 1 year after delivery, and therefore, some recall bias may have affected the findings.
Conclusion and recommendation
Essential newborn care knowledge was found to be relatively low in Fiche town. Among women who were illiterate, first booking at sixteen weeks and above and whose house hold monthly income less than or equal to 2350 ETB. Stakeholders should give emphasis to improve women education and their income generation and promote mothers for early booking and contact for ANC at first trimester, in the fact that in turn helps to improve their health seeking behavior and knowledge about essential newborn care.
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