Newborn Care Practice and Associated Factors among Mothers of One-Month-Old Infants in Southwest Ethiopia

Newborn care refers to the care that is provided to the baby from birth to one-month-old by a caregiver or by the mothers including thermal care, hygienic care, cord care, eye care, breastfeeding, immunization, and identification of newborn danger signs. According to Ethiopian Demographic and Health Survey (EDHS) 2016, the neonatal mortality rate was 29 deaths per 1000 live births, and the postneonatal mortality rate was 19 deaths per 1000 live births with neonates contributing 48 deaths per 1000 of the infant mortality. Neonatal mortality accounts for approximately two-thirds of all infant mortality worldwide. Objective. The objective of this study was to assess newborn care practice and associated factors among mothers with babies of one-month-old in Hossana town, Southern Nations, Nationalities, and Peoples' Region, Ethiopia, 2018. Methods. A community-based cross-sectional study was conducted among randomly selected 422 mothers with babies of one-month-old in Hossana town, southwest Ethiopia. The data were entered to EpiData 3.1 and exported to Statistical Package for the Social Sciences (SPSS) version 22. Bivariate and multivariate analyses were applied, and frequencies and odds ratios were calculated to determine the prevalence and associated factors, respectively. Results. In this study, 31% of participants had good newborn care practice based on three composite variables such as 84% who have done early breastfeeding initiation, 32.9% who have done safe cord care, and 30.6% who have done thermal care. Educational status of the mother's, primary (AOR = 2.80, 95% CI: 1.027-7.637), secondary (AOR = 2.596, 95% CI: 0.921-7.316), and college and above (AOR = 3.63, 95% CI: 1.056-12.492); mothers who practiced handwashing (hygiene) before touching a newborn (AOR = 2.552, 95% CI: 1.092-5.963); and mothers who had good knowledge on newborn care practice (AOR = 15.638, 95% CI: 3.599-67.943) were significantly associated with newborn care practice. Conclusion and Recommendation. The present study indicated that the level of comprehensive newborn care practice was unsatisfactory; all responsible bodies were giving attention and intervene on the predictors to improve newborn care practice and provide health education regarding newborn care practice. Education level, health education (counseling) on hygiene, and knowledge of mother on newborn care practice were independent predictors of newborn care practice.


Introduction
Essential newborn care is the basic care required for every baby and comprises thermal care (delayed bathing, drying, and keeping the baby warm through skin-to-skin contact), infection prevention (promoting and supporting handwashing for all caregivers and providing hygienic umbilical cord and skin care), feeding support (early and exclusive breastfeeding), and postnatal care, including monitoring of newborns for danger signs of serious infections and identifying babies requiring additional care [1]. Deaths in the newborn period (first 28 days) are a growing proportion of all child deaths [2], and essential newborn care practice is used to decrease neonatal morbidity and mortalities if given appropriately [3].
There is a global underfive mortality rate of 42.5 per 1000 live births; of those deaths, 45% were newborns, with a neonatal mortality rate of 19 per 1000 live births [4,5], and although underfive and infant mortalities have been reduced, neonatal mortality remains largely unchanged in Nepal [6].
In Ethiopia, neonatal morbidity and mortality rates were among the highest in the world [7] and neonatal mortality was found to be 214 out of 4888 live births with the rate of 43.8 per 1000 live births in north Gonder [8], and also, according to the EDHS report, neonatal mortality was 29 per 1000, 41per 1000, and 38 per 1000 in urban and rural, respectively, in Ethiopia [9].
Even only 26% of births occur in a health facility, there is an increase in neonatal death [9]. To reduce newborn death, newborn care becomes the health priority [5]. Families, are focus on immediate newborn care at home and changes in household level practices to prevent newborn death, illness and to promote health of newborn care in Ethiopia [1]. Merely 13% of newborns receive a postnatal check within two days of birth [9]. The level of newborn care practice is scanty, inconclusive, and there are limited studies conducted in this area that focus on practices of newborn care and associated factors among mothers in this region (SNNPR).

General Objective
The objective of this study was to assess newborn care practice and associated factors among mothers of one-monthold infants in Hossana town, Hadiya zone, southern Ethiopia, 2018.

Specific Objectives
where n is the minimum sample, p is the 52.1% prevalence level for early breastfeeding on four regions of Ethiopia [10], D is the margin error (0.05), and Zða/2Þ is the standard normal.

Sampling Procedure.
A survey was conducted among 422 women having a one-month infant in Hossana town. A multistage sampling technique was used to select study participants, and the study was conducted in all kebeles found in the town. A proportional allocation to the size of the population was done to decide the number of women required from each kebeles.
Finally, a simple random sampling technique was applied to identify women to be included in the survey. When more than one eligible respondent is present in a selected household, one respondent is selected on the spot by a lottery method.

Data Collection Process. Seven diploma midwives and
five diploma nurses were recruited from other kebeles. Training was given for both data collectors and supervisors for two days before the actual data collection about data collection techniques go through the questionnaire questions with questions, ways of data collection, supervision and final clarification was given to those who have doubts.

Operational Definitions and Definition of Terms.
Newborn care: it refers to the care provided to the baby from birth to 28 days of age by a caregiver or by the mothers including thermal care, hygienic care, cord care, eye care, breastfeeding, immunization, and identification of newborn danger signs. Practice of newborn care: a mother was asked questions that cover the practice of newborn care which includes early initiation of breastfeeding and providing colostrums, cord care, and thermal care. The investigator developed composite index questions in the above issues that assigned a score of one [1] = correct response (consistent with the WHO essential newborn care guidelines) and 0 = incorrect response (inconsistent with the WHO/Unicef essential newborn care guidelines); any mother who did not know the answer is considered to have an incorrect response.
Good knowledge of mothers on newborn care: those mothers who respond correctly above 50% of knowledgerelated questions.
Poor knowledge of mothers on newborn care: those mothers who respond correctly less than or equal to 50% of knowledge-related questions.
Newborn care practice: good newborn care practice: those mothers who mentioned three newborn care practices; poor newborn care practice: those who reported two or less newborn care practices.
Kebele: it is the smallest administrative unit, similar to a ward, a neighborhood, or a localized and delimited group of people and a part of woreda (district).

Data Quality
Management. Data quality was assured by using a pretested data collection tool, and training was given for data collectors and supervisors before actual data collection. Supervisors were engaged in continuous supervision and monitoring during data collection. Completeness and consistency of data were checked by supervisors, data clerks, and investigators before and during data entry. 5.6. Data Analysis. Collected data was checked for its completeness and then coded and entered into EpiData version 3.1, and entered data was exported to SPSS version 20 for analysis. Binary and multivariate logistic regressions were employed. Frequencies and proportions were computed. A significant association was determined by odds ratios with p value < 0.05, at 95% confidence interval. Finally, the results were presented in the form of tables, figures, and charts as appropriate.

Results
A total of 422 mothers who had one-month infants were involved in the study, yielding a 100% response rate. More than half of the respondents, 215 (50.9%), had given the first bath for newborn baby within the first 24 hours of delivery, and 293 (69.4%) placed the newborn baby to skinto-skin contact always until the baby becomes stable ( International Journal of Pediatrics to the cord immediately after cutting up to 7 days except ordered medication, 294 (69.7%) handled umbilical cord after cutting without dressing, 327 (77.5%) bathed her newborn baby after 24 hours after delivery, 372 (88.2%) breastfed their baby within 1 hour after delivery, 368 (87.2%) believed feeding breast milk as the first food for a newborn baby after delivery, and 367 (87.0%) had knowledge about newborn danger sign (Table 4).
From the total of 422 participants, the mentioned danger signs of a newborn baby are as follows: 84.8% were poor sucking, 77% were fast breathing, 64% had hypothermia, 64.7% had fever, 46% had drowsiness (unconscious), and 66.1% had cord bleeding and infection (Figure 1).
In this study, the proportion of newborn care practices was 130 (30.8%) of the respondents in terms of the three composite practices, namely, 354 (83.9%) were early breastfeeding initiation, 139 (32.9%) were safe cord care, and 129 (30.6%) were thermal care (delay bathing) (Figure 2).

Factors
That Associated with Newborn Care Practice. In this study, education of the mothers, mothers who had practice handwashing, and knowledge of mothers on newborn care practice were significantly associated with newborn care practice.
Hence, those who had primary, secondary, and college and above educational status had three times (AOR = 2:80, 95% CI: 1.027-7.637), three times (AOR = 2:596, 95% CI: 0.921-7.316), and four times (AOR = 3:63, 95% CI: 1.056-12.492) more likely to practice newborn care than mothers who had no formal education, respectively, mothers who had practice handwashing were three times more likely to practice newborn care than mothers who had not practice

Discussion
In this study, one-third of the participants had good newborn care practice based on three composite variables such as early breastfeeding initiation 83.9%, safe cord care 32.9%, and thermal care 30.6%. Good newborn care practice was almost nearly similar to study done in Aksum Town, North Ethiopia (26.7%) [11], but this study was lower than the study done in Mandura District, Northwest Ethiopia (40.6%), Gulomekada District, Eastern Tigray (92.9%), Mekelle City, North Ethiopia (81.1%) [7,12,13], and Damot pulasa Woreda, southern Ethiopia (24%) [14], and the difference may be due to socioeconomic, access of awareness among the study participants, geographical variation, and health-seeking behavior across the different cultures or cultural beliefs.
Thermal care was 30.6% in this study and nearly similar to the study done in Aksum Town, North Ethiopia (32.6%) [11], but lower than the study done in Hoima District, western Uganda (67.2%) [15], Mandura District, Northwest Ethiopia (37.8%) [7], Mekelle City, North Ethiopia (66.9%) [13], and Tharu, Chitwan district (96.6%) [6], and this difference may be due to relatively an increased awareness about the harmful effect of traditional foreign substance application to the umbilical cord.
Knowledge of the mother on newborn care practice had a significant association with newborn care practice and similar to the study in Hoima District, western Uganda, Gulomekada District, Eastern Tigray, and Mekelle City, North Ethiopia [12,13,15].
Education of the mothers (primary, secondary, and college and above) also has a significant association with newborn care practice and was similar to the study done in Mandura District, Northwest Ethiopia, and Mekelle City, North Ethiopia [7,13].
Mothers who had health education on hygiene (hand) had a significant association with newborn care practice in this study, but no study was similar to this result.

Conclusions
In this study, almost one-third of the mothers had good newborn care practice and it was very low when compared with other studies done in the country. Mothers' educational status, mothers who had health education on hygiene, and knowledge of mothers on newborn care practice were independent predictors of newborn care practice.

Recommendations
Based on the findings of this study, we recommend the following: (i) Hadiya Zone Health Bureau: to work hard on the promotion of health facility delivery system and to increase the level of newborn care practice and involve health extension workers to apply hometo-home visit program to convince all childbearing women on the positive outcome of health facility delivery service to have good newborn care practice (ii) Health care providers: to provide ongoing education and counseling to mothers to give birth at a health facility to have good newborn care practice during ANC follow-up (iii) Health care planners: to provide health education during ANC and PNC regarding these predictors (iv) Future researcher: we suggest researchers to undertake repeatable studies in this area, and as this study lacks qualitative information that can underpin the quantitative study results, we recommend that the researcher have to do qualitative study design and other methods

Limitation of the Study
The cross-sectional nature of the study is impossible to establish a temporal relationship between newborn care practice and identified risk factors.

Abbreviations
ANC: Antenatal care CSA: Central Statistical Agency EDHS: Ethiopian Demographic and Health Survey ENBC: Essential newborn care HEW: Health extension worker ICF: Infant and children feeding