Current Pediatric Research

Abstract

Introduction: Neonatal mortality in Ethiopia remains high accounting for 29 per 1,000 live births. Objective: This study compares the knowledge of neonatal danger signs and associated factors of mothers who gave birth at home and health facilities in Northwest Ethiopia. Methods: A comparative community-based cross-sectional study was conducted. A simple random sampling method was used to select the participants. A binary logistic regression analysis was used to identify correlations. Result: A total of 650 mothers were interviewed. Of these, 50.7% (95%, CI=45.7, 55.9) of the mother is aware of the signs of neonatal danger in the district. Knowledge of neonatal danger sign is higher among those who give birth in health care 60.1% than home births 41.1% mothers. Maternal age (AOR:3.99, 95% CI:(1.45-11.03)), age new born (AOR:0.53, 95% CI:(0.36-0.78)), Para (AOR:1.27, 95% CI:(1.37-5.31)), postnatal care attendance (AOR=2.42,95% CI:(1.47, 3.96)) were significantly associated with overall mother’s knowledge. Whereas, residence (AOR:3.09, 95% CI : (1.44, 6.64)) and occupational of husband (AOR:0.23, 95% CI:(0.201,0.67)) were significantly associated with mothers who give birth in health care. Age of new born (AOR: 0.50, 95% CI : (0.28,0.896)), parity(AOR: 0.29, 95% CI:(0.113,0.74)), antenatal care (AOR:12.04, 95% CI:(5.9,24.65)) was closely associated with home birth mother. Conclusion: The overall mother's knowledge of neonatal danger signs was low but was high among mothers who delivered at health institutions than those who delivered at home. This implies that we need to strengthen the awareness of neonatal danger signs among home-delivered mothers.

Introduction

Neonatal mortality is one of the world's most neglected and still a significant public health problem. It is estimated that globally, four million deaths during the first 4 weeks of life occur every year, and 75% of neonatal deaths happen in the first week of life [1,2]. Out of the whole neonatal deaths, 99% occur in Low and Middle Income Countries (LMICs), mostly in sub-Saharan Africa [1,3-5]. A majority of these newborn deaths occur at home, indicating that few families recognize signs of newborn illness, and/or a majority of the neonates are not taken to health facilities when they are sick [4]. Demographic and health survey data from 40 countries collected between 1995 and 2003 reported that more than 50 percent of neonatal deaths occur after home birth [6-8].

Different tools to facilitate the identification of these health problems and reduce neonatal mortality have been introduced into health programs in several countries [9]. Integrated Management of Newborn and Childhood Illness (IMNCI) developed by the WHO focuses on the assessment of general danger signs in the examination of neonates presenting with illness at health care centers [9]. The danger signs of severe illness included are the history of difficult feeding, convulsion, respiratory rate of over 60 breaths per minute, severe chest indrawing, body temperature above 37.5°C, body temperature below 35.5°C, movements when only stimulated, yellow soles (a sign of jaundice), umbilical redness or draining pus, skin boils, eyes draining pus, and vomiting [10]. Over the past several decades, the global incidence of under-five mortality has steadily decreased. Death during the neonatal period accounts for almost two-thirds of all deaths in the first year of life and 40% of deaths before the age of five [1,11,12]. Evidence shows that decreasing the proportion of deliveries conducted at home could reduce prenatal death by nearly half [1,13,14].

Africa, accounting for a prevalence rate of 39%, has scored the slowest decrement in NMR with a decline of only 19% from 1990 to 2010, compared to a 43% decline in high-income countries [10]. Ethiopia is one of the top ten countries of global neonatal mortality, with an estimated 122,000 newborn deaths per year [4]. The Ethiopian Demographic Health Survey (EDHS) surveys have shown close to 73% of delivery in Ethiopia takes place at home, indicating the potential to miss to recognize the danger signs early [15]. Recent studies identified that predictors for knowledge about neonatal danger signs were educational status, obstetric status, health institutions related factors, the consumption of Maternal and Child Health (MCH) services, and place of births [16-22]. There are inadequate studies in Ethiopia which assessed the mother's knowledge about neonatal danger signs and associated factors which affect the knowledge status, and none in the current study setting. This study estimated the maternal level of knowledge towards neonatal danger signs by comparing mothers who delivered at home and health facilities.

Methodology

A community based comparative cross-sectional study was conducted in Meicha District, North Ethiopia from March to April 2018. Meicha is located 543 Km away from the Northwest of Addis Ababa, the capital city of Ethiopia. The total population of the Meicha district was 614,022 in 2018. The local communities in the district largely depend on agriculture [23]. Mothers who lived at least 6 months in Meicha districts and gave live birth two months before the data collection were included for the interview. Mothers who were not mentally competent for an interview or had any psychiatric disorders and/or had a serious illness were excluded from the study.

The sample size was calculated using a two population proportion formula; considering mother's knowledge of neonatal dangers sign 41% [17], 95% confidence level (1.96), Power 80% design effect 1.5% and 5% possible non-response rate.The sample size was estimated to be 650 (325 homedelivered and 325 Health institutions delivered). A simple random sampling technique was employed to recruit study participants. We have recruited 25 of 53 kebeles in the district through simple random sampling (lottery method) and numerated 917 mothers who gave birth the last two months (381 at Home and 536 at Health institution), which served as a sampling frame. Then, the sample size was allocated proportionally for each selected kebeles.

The interview was conducted at the study participants’ homes. The dependent variable of the study was knowledge status towards neonatal danger signs, dichotomized as good and poor knowledge. Good knowledge was assumed if a mother who mentioned three of the ten danger signs for neonate without probing and more than three danger signs with probing [21,24]. Recently delivered mothers were assumed as a mother who delivered before 2 months of the survey irrespective of how many births gave before. Data were collected via an interview with a pre-tested and structured questionnaire. Three nurse diploma collectors and one BSc nurse supervisor were used to collecting and controlling the data. We delivered training for data collectors and supervisors on the study’s objective, ethical procedures, and data collection techniques. The questionnaire consisted of information on socio-demographic characteristics, obstetric characteristics, and place of delivery, maternal health service exposure, health Institutions related factors, and other questions.

Data were coded, entered into Epi-Data version 3.1, and exported into SPSS version 21 software for analysis. A binary logistic regression model was used to determine factors affecting knowledge of neonatal danger signs. We have fitted three separate logistic regression models: (i) Model to determine the association between exposure variables and knowledge to neonatal danger signs among all mothers irrespective of place of delivery; (ii) Model to determine the association between exposure variables and knowledge of neonatal danger signs among mothers delivered at home; and (iii) Model to determine the association between exposure variables and knowledge to neonatal danger signs among mothers who delivered at the health facility. Multicollinearity was checked to test correlation among predictor variables and Hosmer and Lemeshow test P-value (>0.2) was conducted to check the fitness of the model. Odds ratio and P-value was determined to check the association between variables and pvalue< 0.05 was considered as a cut-off for statistical significance.

Ethical clearance was obtained from the Institute of Public Health, College of Medicine and Health Sciences, University of Gondar. A letter of permission was obtained from administrative bodies of the West Gojam zone Heath Department, Meicha district, and selected kebeles. A letter of cooperation from kebeles administrators was also secured. Finally, written and verbal consent was obtained from every study participant included in the study during data collection time after explaining the objectives of the study and the right to withdraw from the study at any time. Written informed consent was obtained from a parent or guardian for participants under 16 years old.

Results

Socio-demographic characteristics of the participant's

A total of 637 mothers' (with a response rate of 98%) were interviewed. Out of the total participated women, 316(49.6%) of them delivered at health institutions, and 321(50.4%) at home. The mean age of the study participants was 29.59(SD +6.52) years. Among the study participants, 158(45.4%) health institutions and 190(5.5%) home-delivered mothers were able to read and write (Table1).

Effect of place of birth on knowledge of neonatal danger signs and associated factors among mothers in Meicha district, northwest Ethiopia: A community-based comparative cross-sectional study.

Table 1. Socio-demographic characteristics and knowledge of neonatal danger sign among health institution and home- delivered mothers in Meicha District, Northwest Ethiopia, 2018. ETB: Ethiopia Birr, HID: Health institution delivered, HD: Home Delivered, NDS: Neonatal Danger Sign.

Mother’s knowledge of neonatal danger signs at health institution and home delivery

Health workers were the most common source of information for neonatal danger signs, which was recorded in 392(73.7%) mothers (Figure1). The majority of participants (83.4%) had information heard about neonatal danger signs for their recent birth. Out of the total participants, 80.5% of mothers knew at least one danger sign (Table 2).

Table 2. Knowledge of neonatal danger signs at health institution and home delivery mothers in Meicha district, northwest Ethiopia 2018.

Figure 1: Diagramatic presentation of source information with mother the last two month giving birth at home and health institution in Meicha Woreda, Northwest Ethiopia 2018.

The overall Knowledge of neonatal danger sign was 50.7% (95%, CI=45.7, 55.9). The proportion of mothers having good knowledge of neonatal danger sign was 60.1%(95%, CI=55.1, 65.8) among health Institutions delivered and 41.1% (95%, CI= 35.8, 46.1) among home-delivered mother (Figure 2).

Figure 2: Diagrammatic presentation of mother’s knowledge of neonatal danger sign between Health Institution and Home delivered mothers in Meicha Woreda, north west Ethiopia 2018.

Obstetric, health institution, and maternal and child health services related factors

One hundred eleven (66.1%) of health institutions and 57 (31.7%) home delivery mothers had four and more ANC visits. Out of the total participants, 175 (60.4%) of health institutions, and 56 (71.8%) home-delivered mothers had a history of PNC attendance. Among the interviewees, 188 (61%) of health institution delivered mothers, and 126(41.0%) home-delivered mothers had access to modern health facilities in their localities. One hundred eighty-five (62.1%) of health institutions and 124 (40.3%) home-delivered mothers Effect of place of birth on knowledge of neonatal danger signs and associated factors among mothers in Meicha district,
northwest Ethiopia: A community-based comparative cross-sectional study.

hadreported that health workers had a good approach for patients (Table 3).

Table 3. Obstetric, health institution, and maternal and child health services related factors and knowledge of NDS among mothers in Meicha district, Northwest Ethiopia 2018.HID: Health Institution Delivered, HD: Home Delivered, HP: Health Professional, HEW: Health Extension Worker, TBA:Traditional Birth Attendance, NDS:Neonatal Danger Sign, SVD: Spontaneous Vaginal Delivery.

Factors associated with the mother's knowledge of NDS

As described in the methodology section, we have fitted three different models to assess the mother’s knowledge of neonatal danger signs. The first model was fitted to assess the overall factors of the mother's knowledge of neonatal danger signs.

Variable such as place of birth,age, postnatal follow-up, parity, age of the newborn, and far from health center was significantly associated with mothers' knowledge of neonatal danger sign among all mothers irrespective of their place of birth.

This model shows that place of delivery, age of mothers, mothers who attended postnatal care, and distance from a health facility were significantly associated factors with knowledge of neonatal danger signs.

The odds of being knowledgeable about neonatal danger signs among mothers who delivered at the health facility were 11 times higher than mothers who delivered at home (AOR: 11.21, 95% (5.407, 24.483). Mothers age 15-19 years (AOR: 3.99, 95% CI (1.45, 11.03)), and mothers' who participate in postnatal care (AOR: 2.42, 95% CI (1.47, 3.96)) were more likely knowledgeable than their counterparts. Mothers with a baby less than 30 days old were 47% times (AOR: 0.53, 95% CI (0.36, 0.78)) less like to know about the danger of signs of neonates than mothers a baby older than 30 days. Besides, mothers who lived more than 10 km away from the health facility were 54% (AOR: 0.46, 95% CI (0.27, 0.78) less likely toknow the danger of signs of neonates than mothers who live in a radius of 10 km of the health facility. The odds of being knowledgeable about neonatal danger signs among mothers who delivered four or more times were 27% higher than mothers who delivered two to four times (AOR: 1.27, 95% CI (1.37, 5.31)) (Table 4).

Table 4. Factors associated with knowledge of neonatal danger sign among mothers in Meicha District, Northwest Ethiopia, 2018. *: Significant results, 1: Reference category, **: p-value<0.001, *: p-value = 0.05.

The second model was fitted to determine factors affecting knowledge of neonatal danger signs among mothers who delivered at the health facility. Accordingly, the residence and occupational status of the husband showed a significant statistical association.The odds of being knowledgeable about neonatal danger signs among mothers who live in urban three times were higher than mothers who live in rural(AOR=3.09, 95% CI (1.44, 6.64). Health institutions delivered mothers with farmer occupations were 77% (AOR=0.23 95% CI (0.207, 0.67) more likely to be knowledgeable than their counter parts (Table 5).

Table 5. Factors associated with knowledge of neonatal danger sign among health institutional delivered mothers in Meicha district, Northwest Ethiopia, 2018.*: Significant results, 1: Reference category, **: p-value<0.001, *: p-value = 0.05.

The third model was fitted for home-delivered mothers only. As a result, home delivers mothers who had a baby older than 30 days were 50% (AOR=0.50, 95% CI=(0.28, 0.896) higher to be knowledgeable about neonatal danger signs than their counterparts. The odds of being knowledgeable about neonatal danger sign among mothers who attend ANC was 12 times more than mothers who did not attend ANC (AOR=12.04, 95%

CI (5.9, 24.65). Mothers who gave four or more births were three times more likely to know about neonatal danger signs than those who gave birth once (AOR=0.29, 95% CI=0.113, 0.74). Mothers who received postnatal care services were four times more likely to know (AOR=0.27, 95% CI=0.138, 0.51) than those who did not receive (Table 6).

Table 6. Factors associated with knowledge of neonatal danger signs among home delivery mothers in Meicha district, Northwest Ethiopia, 2018.*: Significant results, 1: Reference category, **: p-value<0.001, *: p-value = 0.05.

Discussion

This study determined the knowledge of neonatal danger signs and assessed associated factors in Ethiopia. Mothers who identified neonatal danger signs early had a great potential to reduce neonatal mortality. In this study, the overall knowledge of neonatal danger signs was about 51%.There was a significant difference in mothers' knowledge of neonatal danger signs with the place of birth where 60% of them delivered at health institutions and 41% of them at home. The odds of being knowledgeable about neonatal danger signs among mothers who delivered at the health facility were 11 times higher than mothers who delivered at home. This is not surprising as mothers who delivered at health facilities may acquire information about neonatal danger signs either through mass health information sessions provided every morning in health facilities or direct counseling from health workers during deliver [21,25,26].

The overall mother knowledge of neonatal danger sign this study was 50.7%. This finding was in line with the other study conducted in Ethiopia and Bangladesh reporting 50.3%-51% but lower than the study conduct in Egypt (68%-70%) and Ghana (72%) [16,19,27,24,28]. The possible reasons for the observed differences might be due to: (i) The effectiveness of involvement of community Health Extension Workers (HEWs), (ii) The level of attention given by health institutions, and (iii) Variations in residence (urban/rural) and cultural variations which may negatively or positively affect the level of knowledge neonatal danger sign [16,21]. The main factor influencing the level of knowledge neonatal danger sign of the district identified in this study was the age of mothers, postnatal follow-up, parity, age of the newborn, and long distance from the health center.

In the current study, the odds of being knowledgeable about neonatal danger signs among mothers who delivered four or more were 27% higher than mothers who delivered two to four times. This finding is consistent with other studies in Egypt and Bangladesh [8,17]. Our study also revealed that mothers with a baby less than 30 days old were 47% more likely to know about neonatal danger signs than their counterparts. This might be due to that mother who received the immunization package might get information on neonatal danger signs.

Mothers who participate in postnatal care were two times more likely to know about neonatal danger signs than their comparator, a finding consistent with other studies [18,19]. This could be due to that mothers who had received postnatal care services are counseled about neonatal danger signs, which in turn increases knowledge about neonatal danger signs [18]. The findings of the present study also indicate that mothers age 15-19 years were four times more likely to know about neonatal danger signs than their counterparts and this was in agreement with the studies conducted in Bangladesh and Ethiopia [8,16]. This present study also documented that mothers more than 10 km away from the health facility were 54% times less likely to know about neonatal danger signs than their counterparts. This is due to the physical proximity of health facility which affects the utilization of services [18].

This study has the following limitations. First, recognition of danger signs may be higher with different data collection techniques, such as using a list of danger signs or images. Second, the cross-sectional design of the study measures the exposures and outcomes simultaneously, which could not allow us to conclude the causative effect between exposures and outcomes.Third, the quantitative nature of the study did not allow us to explore the reasons for poor knowledge of neonatal danger signs.

Conclusion

This study confirmed that mothers who delivered at a health facility knew more about danger signs of neonates than those who delivered at home. Age, antenatal care, and postnatal care attendance showed a significant association for knowledge of neonatal danger signs among home-delivered mothers, whereas, residence and occupational status of the husband for knowledge of neonatal danger signs among health institutiondelivered mothers. This implies that it is important to give emphasis, especially for home-delivered mothers to increase awareness about the advantage of ANC and PNC follow-ups, which will improve the knowledge of neonatal danger signs.

List of Abbreviations:

ANC: Antenatal Care; CSA: Central Statically Agency; EDHS: Ethiopia Demographic Health Survey; ENC: Essential Newborn Care; HC: Health Center; HEWs: Health Extension Workers; IMNI: Integrated Management of Newborn and Childhood Illness; IMR: Infant Mortality Rate; MCH: Maternal and Child Health; NMR: Neonatal Mortality Rate; PNC: Postnatal Care; TBA: Traditional Birth Attendant; UNESCO: United Nations Educational Scientific and Cultural Organization; UNICEF: United Nation Children's Emergency Fund; WHO: World Health Organizations

Acknowledgments

We are highly indebted to all participants of the study, supervisors of data collection, and data collectors for their worthy efforts and participation in this study. We are also thankful for administrative bodies at all levels who endorsed us to undertake this study.

Availability of Data and Materials

All relevant data are within the paper. The SPSS data of individual patients are not permitted to be provided to other bodies, as outlined by the Ethics Committee who approved the study. However, Teferi can provide an anonym zed data set for researchers who need further clarification.

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