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Nursing and Health Sciences (2015), 17, 347–353
Research Article
Nepalese primiparous mothers’ knowledge of newborn care Sharmila Shrestha, RN (Doctoral Student)1 Kumiko Adachi, RN, PhD, CNM, PHN,2 Marcia A. Petrini, RN, PhD, FAAN,3 Akihiro Shuda, RN, PhD, PHN2 and Sarita Shrestha4 Departments of 1Human Health Science and 2Midwifery, Tokyo Metropolitan University, Tokyo, Japan, 3HOPE School of Nursing, Wuhan University, Wuhan, China and 4Iwamura College of Health Science, Bhaktapur, Nepal
Abstract
A cross-sectional study was carried out to explore the knowledge level of newborn care and to investigate the relationship between newborn-care knowledge and selected demographic variables among primiparous mothers. It was carried in outpatient department of a maternity and women’s hospital in Kathmandu, Nepal with 276 primiparous mothers between 38 and 42 weeks of gestation. Data were collected during the antenatal period with using two instruments: the Newborn-care Knowledge Questionnaire and State-Trait Anxiety Inventory for Adults. Participants had a moderate level of knowledge on newborn care (56%), and among its four components, participants had lowest knowledge in breastfeeding (44%) and adequate knowledge (78%) of immunization. Maternal education and socioeconomic status had a significant, positive association with newborn-care knowledge. Newborn-care knowledge was strongly predicted by anxiety. This is the first study to examine the maternal levels of knowledge of newborn care in Nepal. This study identified specific knowledge gaps in newborn care among primiparous mothers. Moreover, the results suggest the need of maternaleducation programs in improving the health and well-being of mothers and newborns.
Key words
maternal knowledge, newborn care, Newborn-care Knowledge Questionnaire, Nepal perinatal.
INTRODUCTION Newborns are a vulnerable group, and therefore need a high level of attention and care, as their health and survival depend on it. Newborn mortality is one of the world’s most neglected health problems. Of the approximately four million global neonatal deaths that occur annually, 98% occur in developing countries, where most newborns die at home while they are cared by mothers, relatives, and traditional birth attendants (World Health Organization (WHO) and Save the Children, 2011). During the neonatal period, exclusive breastfeeding and hypothermia management (Hill et al., 2010) could prevent more than 70% of current deaths through essential newborn care. According to Nepal’s National Neonatal Health Strategy (2009), hypothermia (less than 36.5°C) is the fourth leading cause of neonatal death, and 16% of hypothermic neonates die during the first week after birth. Knowledge of newborns is essential for primiparous mothers, who must be well-informed of the needs and proper care of their babies. Mothers have to have correct knowledge, and act proper to raise healthy children (Salam, 1995). It is Correspondence address: Shrestha Sharmila, Division of Nursing Sciences, Faculty of Human Health Sciences, Tokyo Metropolitan University, 7-2-10 Higashiogu,Arakawa-ku, Tokyo 116-8551, Japan. Email: [email protected] Received 18 July 2014; revision received 3 November 2014; accepted 7 November 2014
© 2015 Wiley Publishing Asia Pty Ltd.
known that some infants are unhealthy because of mothers’ lack of knowledge or wrong and traditional applications (Kabakus et al., 2000; Atiyeh & El-Mohandes, 2005). Gupta et al. (2010) stipulated that correct knowledge and practices regarding newborn care were lacking among mothers. In Nepal, the common reasons behind harmful practices were lack of awareness and traditional cultural practices (Devkota & Bhatta, 2011). Primiparous mothers had poor level of knowledge about newborn-care issues (Senarath et al., 2007). In Nepal, newborn-care practices are not satisfactory and there are some unacceptable practices, such as taboos and superstitions associated with caring for the newborns, which adversely affect their health. This study, therefore, sought to identify the actual and exact need of primiparous mothers regarding newborn care. Moreover, it helps to determine primiparous mothers’ lack or level of knowledge for planning the process of educating mothers to improve infant health. Tinker and Ransom (2003) argued that millions of newborn deaths could be avoided if more resources were invested in proven low-cost interventions designed to address newborn needs. There are multiple demographic variables that affect maternal knowledge on newborn care. A mother’s educational level is an important factor affecting her infant’s health. Lande et al. (2004) showed that while an increase in the mother’s education level improves the quality of infant care, a decrease in her education level increases the doi: 10.1111/nhs.12193
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possibility of growth deficiencies, feeding problems, and even mortality in infants. Knowledge of newborns can decrease anxiety (Sercekus & Mete, 2010). Women attending antenatal classes experienced less anxiety during the postnatal period (Ip et al., 2009; Ferguson et al., 2013). Childcare responsibilities and lack of knowledge and preparation are sources of frustration and fatigue for new mothers (Kanotra et al., 2007). Conversely, if mothers are unable to respond to their infant’s cues and to appropriately give care, they will eventually develop negative feelings about the maternal role (Tessier et al., 1992). In Nepal, joint family (i.e. with in-laws and their families) is common, and women have less power and autonomy than men even in making decisions about their own health care and, women often have unequal access to food, education, and health care.
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primiparous mothers. The expectation was that women with low educational level and poor socioeconomic status, living with joint family, with no previous experience regarding newborn care would have a poor level of knowledge about care of the newborn. In addition, they would expect an inverse relationship between newborn-care knowledge and anxiety among primiparous mothers.
METHODS Design This investigation was a cross-sectional, correlation study of the level of knowledge about newborn care and its relationship with selected demographic variables among primiparous mothers.
Traditional newborn-care practices in Nepal Traditional practices cannot be neglected in considering the achievement of better neonatal care in developing countries, such as Nepal. Cultural beliefs and practices are important in the care of Nepalese women and their babies during the postpartum period. They are transmitted intergenerationally from mothers to daughters in order to ensure the health of new mothers and their babies. Nepal is predominantly rural, where household newborn-care practices are poor, and some are harmful (Yadav, 2007). Traditional beliefs and practices, such as separating newborns from their mothers immediately after birth and the application of harmful substances to the cord could also adversely affect neonatal survival (MoHP (Ministry of Health and Population), USAID, ICF Macro, New ERA., 2011). In Nepal, bathing a baby soon after birth is widely prevalent to purify the baby, because the baby’s body is coated with vernix, which is considered dirty. (Gurung, 2008). It is quite common to give prelacteal feeds, such as honey, sugar, and ghee, to newborn babies instead of colostrum. In traditional culture, colostrum is regarded as unholy, and sucking colostrum is believed to make babies sick (McKenna & Shankar, 2009). In rural areas of Nepal, the majority (73%) of births take place at home, and of these, 55% of women are assisted by relatives and traditional birth attendants (Nepal Family Health Program (NFHP) & New ERA, 2010). Approximately half of pregnant women have received the World Health Organization’s (WHO) recommended four antenatal care (ANC) visit ,and 85% have only one ANC visit (Joshi et al., 2014). Nepal is a small, landlocked country, with a population of 30 million (Index Mund, 2013) and more than 60 ethnic groups. The people of Nepal are poor, and communication systems and infrastructure are lacking resulting in a lack of access to healthcare for many people (MoPH et al., 2011). The gross national product per head was only approximately $US1300 per annum in 2012 (Index Mundi, 2013). The literacy rate of women was 48.3%, and 73% for men in 2010 (Index Mundi, 2013). The total fertility rate is 2.36 births per woman (Index Mundi, 2013). In this study, we explored the knowledge level of newborn care and investigated the relationship between newborn-care knowledge and selected demographic variables among © 2015 Wiley Publishing Asia Pty Ltd.
Participants The participants were recruited from a central-level referral hospital of a maternity and women’s hospital, located in Kathmandu, Nepal. The inclusion criteria for participation were pregnant women who were married, primiparous with a single and uneventful pregnancy, between 38 and 42 weeks of gestation, and able to speak and read the Nepali language. Those who fulfilled the eligibility criteria were approached for participation while they were in the outpatient department for ANC checkup. A total of 276 women participated in this study.
Outcome measures Newborn-care Knowledge Questionnaire Maternal knowledge of newborn-care was measured by the Newborn-care Knowledge Questionnaire (NKQ), which was developed by the researcher. The researcher adopted newborn questions from the Nepal Demographic and Health Survey (MoPH, 2011) and reviewed these based on the relevant literature (Beck et al., 2004; Kinzie & Gomez, 2006; Malata et al., 2007; Weiner et al., 2011). The questionnaire was examined by experts in midwifery, and modifications were made based on their advice.The draft questionnaire was again reviewed by educational midwives, and then the tool was pretested. The test–retest technique was used for reliability of the tool. The NKQ had acceptable test–retest reliability (r = 0.78) and internal consistency (Cronbach’s α = 0.76). The NKQ consists of four sections and a total of 23 items, requiring a single answer for each question, with an assigned “1” score for correct answers and “0” for incorrect answers. The questionnaire consists of the following knowledge areas: maintenance of body temperature (items 1–7), breastfeeding (items 8–15), infection prevention (items 16–20), and immunization (items 21–23). The sum of the scores comprises the newborn-care knowledge score of the participants. The highest possible score is 23 (100%), and knowledge levels are categorized as low (< 50%), moderate (50–75%), and adequate (> 75%).
Newborn-care knowledge in Nepal
State-Trait Anxiety Inventory for Adults (STAI-AD) The Nepali versions of the State-Trait Anxiety Inventory for Adults (STAI-AD) were used to measure maternal anxiety during the antenatal period, which was developed by Spielberger et al. (1983). The STAI-AD has been adapted to more than 30 languages for cross-cultural research and clinical practice. Anxiety is measured on a four-point Likert-type scale, with scores ranging from 1 (no) to 4 (totally). The total score for state anxiety varies from 20 to 80, and is categorized as mild (20–39), moderate (40–59), and severe (60–80); (Norouzia et al., 2013). Cronbach’s alpha was 0.86 in this study. The Educational variable was classified based on three levels: primary (1–5 class), secondary (5–10 class), and college (above 10 class), and the score was classified as low (primary) = 1, middle (secondary) = 2, and high (college) = 3. Total income per month was categorized as low (≥ $US56) middle ($US157–261), and high ($US < 261), and the score was classified as low = 1, middle = 2, and high = 3.
Ethical considerations The study was approved from the Ethical Committee of Tokyo Metropolitan University and the study venue. All participants were assured that their data would be kept confidential, their participation was voluntary, and that they could withdraw at any time.
Data-collection procedures The researcher approached eligible women at the antenatal clinic to identify potential candidates. The women were informed the nature of the study and were invited to participate. This resulted in a total of 276 respondents. They were requested to complete the NKQ, STAI-AD, and demographic questionnaires in the waiting room of the ANC clinic. The data were collected with the help of two research assistants who were registered nurses in Nepal. They were trained in study procedures by the first author before the commencement of the study.
Data analysis Descriptive statistics were used to analyze the demographic information. Participants’ knowledge level on newborn care was analyzed with descriptive statistics.The χ2-test, Spearman rank correlation, and logistic regression analysis were used to analyze the relationship between newborn-care knowledge and selected demographic variables. An alpha level of 0.05 was used.
RESULTS The 276 participants ranged in age from 18 to 37 years, with approximately two-thirds aged 21–30 years. More than half (61%) lived in joint families. Mean household income per month was $US201.24 (standard deviation = $US50.44, 100 rupees [Nepalese rupee] = $US1.05). A total of 135 (49%)
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Table 1.
Participant knowledge of care of the newborn (n = 276)
Variables Maintain body temperature Breastfeeding Infection prevention Immunization
Total score
Minimum score obtained
Maximum score obtained
Mean
Standard deviation
7
1
7
3.88
1.23
8 5
0 0
7 5
3.53 3.13
1.26 1.42
3
0
3
2.33
0.84
participants were educated up to secondary level, 87 (32%) up to college level education, and 54 (20%) up to primary level. In our study, 133 (48%) participants had previous experience of newborn care and 143 (52%) did not.
Level of Nepalese primiparous mothers’ knowledge of newborn care Of the 276 participants, 107 (39%) had low, 130 (47%) had moderate, and 39 (14%) had an adequate level of newborncare knowledge. Participants’ mean and percentage of their total score on the NKQ was 12.88 (56%). Mean knowledge score for maintenance body temperature was 3.88 ± 1.23, for breastfeeding it was 3.53 ± 1.26, for infection prevention it was 3.13 ± 1.42, and for immunization it was 2.33 ± 0.82 (Table 1). This finding indicated that participants had a good knowledge of immunization compared with the other components. Participants’ correct response on NKQ components are shown in Table 2. In this study, a small proportion of respondents (n = 36, 13%) had knowledge about the maintenance of body temperature to prevent hypothermia whilst 96 (34.8%) had knowledge of skin-to-skin contact between baby and mother as one of the most effective methods to maintain newborn body temperature. Only 110 (39.9%) participants had knowledge of delaying bathing. However, 270 (97.8%) knew how to cover the baby. The majority of participants (n = 225, 81.5%) had knowledge of early breastfeeding, even though 132 (47.8%) planned to give prelacteal feeds to their newborns. Only 12 (4.3%) knew that the first breast milk, colostrum, contains antibodies, and only 53 (19.2%) knew about the purpose of burping after breastfeeding. The results showed that 204 (73.9%) participants had knowledge of the best technique of umbilical cord care, even though 224 (88.8%) planned to apply some substance to it. The majority of the participants (n = 206, 74.6%) had knowledge of signs and symptoms indicating that the newborn was in danger, but only 116 (42%) had knowledge of signs of infection. The analysis revealed that low-income women were nine (95% confidence interval [CI] = 8.30–97.98) times more likely to have a low level of newborn-care knowledge, and middle-income women were 7.65 (95% CI = 1.93–30.28) times more likely. Women who had a primary level of education were 9.18 (95% CI = 2.39–35.22) times more likely to © 2015 Wiley Publishing Asia Pty Ltd.
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Table 2. Participants’ correct knowledge components (n = 276)
responses
on
Knowledge components Maintain body temperature
Breastfeeding
Infection prevention
Immunization
Average weight Skin-to-skin contact to maintain body temperature Maintain body temperature to prevent hypothermia Best timing for first baby bath Wrap baby immediately after bath Clothes used for summer season Best technique to cover body First breastfeeding starting time Colostrum containing antibiotics Frequency of breastfeeding Will give prelacteal feeding Method of burping after feeding Purpose of burping Reasons for baby crying Age to start solid foods Danger signs for normal baby Signs of infections Best technique for umbilical cord care Plan to apply something for healing the umbilical cord Sign of umbilical cord infection Aim of immunization Bacillus Calmette–Guerin vaccine vaccine prevents tuberculosis Oral polio vaccine can be given immediately after birth
newborn-care
n
%
121 96
43.8 34.8
36
13.0
110 262
39.9 94.9
176 270 225 12 37 132 137 53 109 269 206 116 204
63.8 97.8 81.5 4.3 13.4 47.8 49.6 19.2 39.5 97.5 74.6 42.0 73.9
244
88.4
95 245 177
34.4 88.8 64.1
222
80.4
have a low level of newborn-care knowledge, and those with a secondary level of education were 3.24 (95% CI = 1.41– 7.42) more likely. Women with moderate anxiety were 2.53 (95% CI = 1.17–6.83) and 1.69 (95% CI = 0.83–4.17) times more likely to have a low- and middle-level knowledge of newborn care indicating that women with higher income and education had adequate knowledge of newborn care, and those with a low income and education had poor knowledge of newborn care.
Relationship between newborn-care knowledge and selected demographic variables There were significant associations between newborn-care knowledge and anxiety (χ2 = 64.91, P < 0.00), household income (χ2 = 22.19, P < 0.00), and education (χ2 = 17.87, P < 0.001), but no significant association between previous experience about newborn care and newborn-care knowledge (χ2 = 0.24, P = 0.88) and types of family (χ2 = 0.64, P = 0.73) (Table 3). There was a positive correlation between newborn-care knowledge, household income (r = 0.26, P < 0.00), and education (r = 0.25, P < 0.00), but no correlation between previous experience with newborn © 2015 Wiley Publishing Asia Pty Ltd.
care(r = 0.29, P = 0.64) and types of family (r = 0.02, P = 0.67) (Table 4). There was a negative correlation between newborn-care knowledge and anxiety (r = −0.46, P < 0.00). As indicated by the results, maternal anxiety, education, and socioeconomic status had an inverse and significant correlation with maternal knowledge on newborn care.
DISCUSSION There are a lack of studies in Nepal that have rigorously assessed maternal knowledge of newborn care. The acquisition of knowledge of newborn care by primiparous mothers is commonly viewed as a key strategy to improve maternal and infant health. Overall, mothers’ knowledge of newborn-care issues was not adequate in the study sample. Among the four components of newborn-care knowledge, participants had higher knowledge of immunization and lower knowledge of breastfeeding compared to other components of the questionnaire. The majority of the participants knew about early breastfeeding, but few knew of the frequency for breastfeeding and that colostrum contains antibodies. Colostrum is discarded because of a belief that its thickness and viscosity make it difficult for newborn to swallow. This finding supported previous studies (Gupta et al., 2010 & Sreeramareddy et al., 2006) Some mothers discarded colostrum, as they perceived that it caused disease (Dessalegn & Shikur, 2013). Prelacteal feeding is common in developing countries. In Nepal, it is common practice to give prelacteal feeds instead of colostrum. Our study also revealed that prelacteal feeding is widespread. In the southern part of Nepal, 80.4% of newborns receive prelacteal feeds within the first two weeks of life (Karas et al., 2012). In Tanzania, prelacteal food is also given to newborns before initiating breastfeeding (Mrisho et al., 2008). A study conducted by Chaudhary et al. (2011) showed that all participant mothers knew that they had to breastfeed their babies, but did not know the appropriate timing for breastfeeding and colostrum feeding. Mothers’ knowledge of early breastfeeding was an important predictor of healthy breastfeeding practices (Tuladhar, 2010). Similarly, Gupta et al. (2010), in a study in India, found that more than one-third (36.6%) of mothers initiated breastfeeding within one hour of birth, and 30.2% initiated breastfeeding after one day. Our study revealed that few respondents had knowledge of delayed bathing and the maintenance of body temperature to prevent hypothermia.This finding supported previous studies (Sreeramareddy et al., 2006; Gupta et al., 2010). Nepal is a predominantly rural country, where household practices of newborn care reflect impoverishment, with some being harmful (Yadav, 2007). Mrisho et al. (2008) reported that newborns were dipped into cold water to make them cry. Bathing newborns soon after birth makes them more vulnerable to hypothermia and interferes with their suckling ability. In this study, primiparous mothers had inadequate knowledge of skin-to-skin contact (kangaroo mother care). A study conducted by Samuel et al. (2011) also indicated that
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Table 3. Relationship between knowledge about newborn care and study variables
Variables Antenatal anxiety Total income
Education
Previous experience with newborn care Type of family
Categories
Low n
Mild Moderate Low Middle High Primary (1–5) Secondary(6–10) College (> 10) Yes No Joint Nuclear
62 45 30 74 3 29 58 20 50 57 64 43
Newborn-care knowledge Moderate Adequate n n 124 6 25 90 15 22 60 48 63 67 82 48
Table 4. Spearman correlation coefficient among demographic variables and newborn-care knowledge (n = 276)
Measures Anxiety Household income Education Previous experience about newborn care Type of family
Newborn-care knowledge r P-value −0.46** 0.26** 0.25** 0.29 0.02
< 0.00 < 0.00 < 0.00 0.64 0.67
**Correlation is significant at the 0.01 the level (two tailed).
primiparous mothers had a lack of knowledge about kangaroo mother care. Respondents knew about the best techniques of umbilical cord care, even though a large proportion (80.1%) planned to apply some types of substance to the umbilical cord to promote healing in line with existing traditional beliefs and practices in the community. A study conducted by Padiyath (2010) found that participants had comparatively poorer knowledge in the areas of umbilical cord hygiene. Approximately 41% of newborns received an application of substances, such as oil, herbal paste, and ash, on their cord stump (MoPH et al., 2011). This kind of practice has also been noted in other South Asian countries, such as Bangladesh, India, and Pakistan (Khadduri et al., 2008; Moran et al., 2009; Gupta et al., 2010). Maternal education has the potential to serve as a strong influence on mothers’ choices to break away from harmful traditional beliefs and practices. Community awareness must be intensified to make people aware of newborn care. In our study, participants had satisfactory knowledge on immunizations. A study conducted by Devkota and Bhatta (2011) in Nepal also showed that 65% of participants vaccinated their babies. In Nepal, 87% of children between the
39 0 1 29 9 3 17 19 20 19 22 17
Total n 225 51 56 193 27 54 135 87 133 143 168 108
χ2-value
P-value
64.91
< 0.00
22.19
< 0.00
17.87
0.001
0.24
0.88
0.64
0.73
ages of 12 and 23 months were fully immunized by the time the survey was conducted (MoPH, 2011). Education helped to prepare mothers to cope with new situations during pregnancy and the postpartum period. Socioeconomic status is an important factor influencing newborn health and illness. Poor education and low socioeconomic status are linked with poorer child health (Department for Children, Schools and Families, 2007). Women who have a higher level of educational and good economic status have adequate newborn-care knowledge, and those who do not have low newborn-care knowledge. This study also supported Lande et al, (2004) that an increase in a mother’s educational level improves the quality of infant care. A similar study showed that knowledge of breast milk was highly associated with a mother’s education (Banu et al., 2012). Previous studies have suggested that parents’ socioeconomic status is associated with child survival (Kabir et al., 2001; & Hossain & Islam, 2008). Mothers with more education were found to have adequate knowledge of breast milk, as compared to mothers with lower levels of education and those who were illiterate (Banu et al., 2012). Women with lower levels of education and income are vulnerable, and this finding strongly indicates that these women should be followed more closely by health professionals. In this study, no significant relationship existed between previous experience with newborn care, types of families, and newborn-care knowledge. Maternal education and awareness have a strong influence on mothers’ capacity to break away from traditional beliefs and practices that could be harmful to newborns. The significant findings in this study suggest that women who have low anxiety have adequate knowledge of newborn care, and those who have moderate-to-severe anxiety have poor knowledge of newborn care. Lower levels of newborn-care knowledge predicted higher levels of anxiety. A study conducted by Sercekus and Mete (2010) showed that knowledge of newborns decreased anxiety. Research suggests that an increase in a mother’s educational level improves the quality of infant care; therefore, © 2015 Wiley Publishing Asia Pty Ltd.
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continuing education and guidance are necessary requirements for maternal and newborn health (Lande et al., 2004).
Limitations and future research There were several limitations in this study. First, the study was conducted in a hospital with a sample of only primiparous mothers due to time and personnel constraints. Therefore, a replication of the study should be conducted in other hospitals and community settings with primiparous and multiparous mothers. Only one central hospital was chosen for data collection, so there is a need to collect data from different hospitals and communities and different geographic areas. The small sample size in our study limits our ability to draw conclusions about the level of maternal knowledge on newborn care in primiparous mother in Nepal. The NKQ was a newly-developed questionnaire and needs to be used in various studies in different counties, especially in developing countries. Future studies should be conducted with a larger sample size, include different health centers, and that long-term follow-up care should be arranged. Future research could include a replication of the study with a larger and more diverse sample of primiparous and multiparous mothers from several different hospitals and communities.
Conclusions This study represents a small step towards being able to detect knowledge level among primiparous mothers about newborn care. This research helps to address the actual and specific learning needs of primiparous mother regarding newborn care and it identifies areas which should be targeted in primiparous mothers’ education in order to improve infant health. Of particular significance, is that there was a positive relationship between newborn-care knowledge and maternal education and socioeconomic status among primiparous mothers. There was an inverse relationship between newborn care knowledge and anxiety. As a whole, participants had a moderate level of knowledge related to newborns, and good knowledge of immunization. Participants had low knowledge about colostrum containing antibodies, the frequency of breastfeeding, and the maintenance of body temperature for newborns to prevent hypothermia. Maternal education and socioeconomic status had a significant, positive association with knowledge about newborn-care. Maternal education and economic status was positively associated with newborn-care knowledge. A lower level of education of the mother is a risk factor for newborn health, so these women should be followed more closely by nurses.
Implications Maternal education and awareness can serve as a strong influence in helping mothers to break away from traditional beliefs and practices that could be harmful to newborns. Therefore, education and awareness about newborn care are essential for developing countries, such as Nepal. These © 2015 Wiley Publishing Asia Pty Ltd.
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health-promotion activities could decrease maternal and neonatal mortality and morbidity. The findings of our study strongly suggest that continuing maternal-education programs in Nepal requires close attention and ongoing monitoring to ensure that the mothers’ knowledge gaps who care for the next generation are addressed. This study is likely to contribute to improving the health and well-being of mothers and newborns. It could also help in the development of intervention for policy makers and nurses during the antenatal and postnatal periods. Future research on maternal newborn care is needed to test nursing interventions and measure healthcare outcomes. Finally, neonatal issues in Nepal deserve more attention from researchers in order to identify local problems and plan effective strategies to correct them.
CONTRIBUTIONS Study Design: SS (Sharmila Shrestha), KA. Data Collection and Analysis: SS, SS. Manuscript Writing: SS (Sharmila Shrestha), KA, MAP, AS.
REFERENCES Atiyeh GN, El-Mohandes A. Preventive healthcare of infants in a region of Lebanon: Parental beliefs, attitudes and behaviors. Matern. Child Health J. 2005; 9: 83–90. Health Reports, 10, 57–67. Banu B, Hasnin S, Khanom K. All effects of education level of father and mother on perceptions on breastfeeding. J. Enam Med. Coll. 2012; 2: 67–73. Beck D, Ganges F, Goldman S, Long P. 2004. Care of newborn reference manual. Washington, DC: save the Children Federation. [Cited 17 Sep 2013.] Available from URL: http://fmp.ueh.edu.ht/ PDF/Care_of_Newborn_SNL.pdf. Chaudhary RN, Shah T, Raja S. Knowledge and practice of mothers regarding breast feeding: a hospital based study. J. Health Renaiss. 2011; 9: 194–200. Department for Children, Schools and Families. 2007. Children and young people today: evidence to support the development of the children’s plan. [Cited 29 Aug 2013.] Available from URL: https://www.education.gov.uk/publications/eOrderingDownload/ Childrenandyoung_people_today.pdf. Dessalegn T, Shikur M. Maternal knowledge of optimal breastfeeding practices and associated factors in rural communities of Arba Minch Zuria. Int. J. Nutr. Food Sci. 2013; 2: 122–129. Devkota MD, Bhatta MR. Newborn-care practices of mothers in a rural community in Baitadi, Nepal. Health Prospect 2011; 10: 5–9. Family Health Division. Nepal National Neonatal Health Strategy. Kathmandu: Department of Health Services, Ministry of Health, 2009. Ferguson S, Davis D, Browne J. Does antenatal education affect labour and birth? A structured review of the literature. J. Women Birth 2013; 26: 5–8. Gupta P, Srivastava VK, Kumar V et al. Newborn-care practices in urban slums of Lucknow city, UP. Indian J. Community Med. 2010; 35: 82–85. doi: 10.4103/0970-0218.62570. [Cited 29 Aug 2013.] Available from URL: http://www.ijcm.org.in/text.asp?2010/35/1/ 82/62570. Gurung G. Practices on immediate care of newborn in the communities of Kailali district. J. Nepal Med. Coll. 2008; 10: 41–44. Hill Z, Tawiah-Agyemang C, Manu A et al. Keeping newborns warm: beliefs, practices and potential for behaviors change in rural Ghana. Trop. Med. Int. Health 2010; 12: 42–49.
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Hossain M, Islam M. Socio-economic variables affecting infants and children mortality in Bangladesh. Internet J. Health 2008; 9: 118– 125. Index Mundi. 2013. World data atlas. [Cited 17 Nov 2013.] Available from URL: http://www.indexmundi.com/Nepal/population.html Ip WY, Tang CSK, Goggins WB. An intervention to improve women’s ability to cope with childbirth. J. Clin. Nurs. 2009; 18: 2125–2135. Joshi C, Torvaldsen S, Hodgson R, Hayen A. Factors associated with the use and quality of antenatal care in Nepal: a population-based study using the demographic and health survey data. BMC Pregnancy Childbirth 2014; 14: 94. Kabakus N, Acik, Y, Aygun, AD. Opinions and attitudes of Turkish mothers about febrile illness of their children. Turk. J. Pediatr. 2000; 43, 56–62. Kabir A, Islam MS, Ahmed MS, Khalique BMA. Factors influencing infant and child mortality in Bangladesh. Int. J. Serving Int. Community Med. Sci. 2001; 1: 292–295. Kanotra SD, Angelo D, Phares TM, Morrow B, Barfield W, Lansky A. Challenges faced by new mothers in the early postpartum period: an analysis of comment data from the 2000 pregnancy risk assessment monitoring system (PRAMS) survey. J. Matern. Child Health 2007; 11: 549–558. Karas DJ, Mullany LC, Katz J, Khatry SK, Darmatadt GL, Tielsch JM. Home care practices for newborns in rural southern Nepal during the first 2 weeks of life. J. Trop. Pediatr. 2012; 58: 200– 207. Khadduri R, Marsh DR, Rasmussen B, Bari A, Nazir R, Darmstadt GL. Household knowledge and practices of newborn and maternal health in Haripur district, Pakistan. J. Perinatol. 2008; 28: 182–187. Kinzie B, Gomez P. 2006. Basic maternal and newborn-care: a guide for skilled providers. Maternal and Neonatal health. [Cited 30 Aug 2013.] Available from URL: http://www.accesstohealth.org. Lande B, Andersen LF, Veierod MB et al. Breast-feeding at 12 months of age and dietary habits among breast-fed and nonbreast-fed infants. J. Public Health Nutr. 2004; 7: 495–503. Lucen A, Bilkis B, Kazi AR, Khurshida K. Factors associated with knowledge about breastfeeding among female garment workers in Dhaka City. J. Public Health 2012; 1: 249–255. Malata A, Hauck Y, Monterosso L, McCaul K. Development and evaluation of a childbirth education programme for Malawian women. J. Adv. Nurs. 2007; 60: 67–78. McKenna KM, Shankar RT. Practice of pre-lacteal feeding to newborns among Hindu and Muslim families. J Midwifery Women’s Health 2009; 54: 78–81. Ministry of Health and Population (MoPH), United States Agency for International Development (USAID), ICF Macro, & New ERA. 2011. Nepal Demographic and Health Survey 2011–2012. Moran AC, Choudhury NU, Zaman Khan N et al. Newborn-care practices among slum dwellers in Dhaka, Bangladesh: a quantitative and qualitative exploratory study. Kathmandu, Nepal: Ministry of Health and Population, USAID, ICF Macro, and New ERA, Calverton, Maryland. BMC Pregnancy Childbirth 2009; 9: 54.
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Mrisho M, Schellenberg JA, Mushi AK, Obrist B, Mshinda H et al. Understanding home-based neonatal care practice in rural southern Tanzania. Trans. R. Soc. Trop. Med. Hyg. 2008; 102: 669– 678. Nepal Family Health Program (NFHP) & New ERA. 2010. A midterm survey for NFHP II: Family Planning, Maternal, Newborn and Child Health situation in rural Nepal. Kathmandu, Npal: NFHP & New ERA: Nepal. Norouzia F, Keshavarza M, SeyedFatemib N, Montazeric A. The impact of kangaroo care and music on maternal state anxiety. J. Complement. Ther. Med. 2013; 21 (5): 468–472. Padiyath MA. Knowledge attitude and practices of neonatal care among postnatal mothers. J. Curr. Pediatr. Res. 2010; 14: 147–152. Salam CM. Mothers’ perception of infant care and self-care competence after early postpartum discharge. Int. J. Childbirth Educ. 1995; 10: 30–40. Samuel BN, Priscilla NLW, Regina O et al. Perception and practice of Kangaroo Mother Care after discharge from hospital in Kumasi, Ghana: a longitudinal study. BMC Pregnancy Childbirth 2011; 11: 99. Senarath, U., Fernando, D., Vimpani, G., & Rodrigo, I. Factors associated with maternal knowledge of newborn care among hospitaldelivered mothers in Sri Lanka. Trans. Roy. Soc. Trop. Med. Hyg. 2007; 101 (8): 823–830. Sercekus P, Mete S. Turkish women’s perceptions of antenatal education. Int. Nurs. Rev. 2010; 57: 395–401. Spielberger CD, Gorsuch RL, Lushene R, Vagg PR, Jacobs GA. 1983. State-trait anxiety inventory for adults: manual, instrument and scoring guide consulting. Palo Alto, California: Psychologists Press Mind Garden. Sreeramareddy CT, Joshi HS, Sreekumaran BV, Chuni N. Home delivery and newborn-care practices among urban women in western Nepal: a questionnaire survey. BMC Pregnancy Childbirth 2006; 6: 27. Tessier R, Piche C, Tarabulsy GM, Muckle G. Mothers’ experiences of stress following the birth of a first child: identification of stressors and coping resources. J. Appl. Soc. Psychol. 1992; 22: 1319–1339. Tinker A, Ransom E. Healthy mothers and healthy newborns: “The Vital Link”. Washington, DC: Population Reference Bureau, 2003. Tuladhar S. 2010. The determinants of good newborn-care practices in the rural areas of Nepal. University of Canterbury, Health Sciences Centre, master thesis. [Cited 21 Aug 2013.] Available from URL: http://ir.canterbury.ac.nz/handle/10092/5061. Weiner EA, Billamay S, Partridge JC, Martinez MA. Antenatal education for expectant mothers results in sustained improvement in knowledge of newborn-care. J. Perinatol. 2011; 31: 92–97. World Health Organization and Save the Children. 2011. Newborn Deaths Decrease but Account for Higher Share of Global Child Deaths. Joint Press Release 30 August 2011. [Cited 30 Aug 2013.] Available from URL: http://www.who.int/mediacentre/. Yadav S. Newborn-care: traditional practices in Nepal. Stud. BMJ 2007; 15: 293–336.
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Nursing and Health Sciences (2015), 17, 347–353
Research Article
Nepalese primiparous mothers’ knowledge of newborn care Sharmila Shrestha, RN (Doctoral Student)1 Kumiko Adachi, RN, PhD, CNM, PHN,2 Marcia A. Petrini, RN, PhD, FAAN,3 Akihiro Shuda, RN, PhD, PHN2 and Sarita Shrestha4 Departments of 1Human Health Science and 2Midwifery, Tokyo Metropolitan University, Tokyo, Japan, 3HOPE School of Nursing, Wuhan University, Wuhan, China and 4Iwamura College of Health Science, Bhaktapur, Nepal
Abstract
A cross-sectional study was carried out to explore the knowledge level of newborn care and to investigate the relationship between newborn-care knowledge and selected demographic variables among primiparous mothers. It was carried in outpatient department of a maternity and women’s hospital in Kathmandu, Nepal with 276 primiparous mothers between 38 and 42 weeks of gestation. Data were collected during the antenatal period with using two instruments: the Newborn-care Knowledge Questionnaire and State-Trait Anxiety Inventory for Adults. Participants had a moderate level of knowledge on newborn care (56%), and among its four components, participants had lowest knowledge in breastfeeding (44%) and adequate knowledge (78%) of immunization. Maternal education and socioeconomic status had a significant, positive association with newborn-care knowledge. Newborn-care knowledge was strongly predicted by anxiety. This is the first study to examine the maternal levels of knowledge of newborn care in Nepal. This study identified specific knowledge gaps in newborn care among primiparous mothers. Moreover, the results suggest the need of maternaleducation programs in improving the health and well-being of mothers and newborns.
Key words
maternal knowledge, newborn care, Newborn-care Knowledge Questionnaire, Nepal perinatal.
INTRODUCTION Newborns are a vulnerable group, and therefore need a high level of attention and care, as their health and survival depend on it. Newborn mortality is one of the world’s most neglected health problems. Of the approximately four million global neonatal deaths that occur annually, 98% occur in developing countries, where most newborns die at home while they are cared by mothers, relatives, and traditional birth attendants (World Health Organization (WHO) and Save the Children, 2011). During the neonatal period, exclusive breastfeeding and hypothermia management (Hill et al., 2010) could prevent more than 70% of current deaths through essential newborn care. According to Nepal’s National Neonatal Health Strategy (2009), hypothermia (less than 36.5°C) is the fourth leading cause of neonatal death, and 16% of hypothermic neonates die during the first week after birth. Knowledge of newborns is essential for primiparous mothers, who must be well-informed of the needs and proper care of their babies. Mothers have to have correct knowledge, and act proper to raise healthy children (Salam, 1995). It is Correspondence address: Shrestha Sharmila, Division of Nursing Sciences, Faculty of Human Health Sciences, Tokyo Metropolitan University, 7-2-10 Higashiogu,Arakawa-ku, Tokyo 116-8551, Japan. Email: [email protected] Received 18 July 2014; revision received 3 November 2014; accepted 7 November 2014
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known that some infants are unhealthy because of mothers’ lack of knowledge or wrong and traditional applications (Kabakus et al., 2000; Atiyeh & El-Mohandes, 2005). Gupta et al. (2010) stipulated that correct knowledge and practices regarding newborn care were lacking among mothers. In Nepal, the common reasons behind harmful practices were lack of awareness and traditional cultural practices (Devkota & Bhatta, 2011). Primiparous mothers had poor level of knowledge about newborn-care issues (Senarath et al., 2007). In Nepal, newborn-care practices are not satisfactory and there are some unacceptable practices, such as taboos and superstitions associated with caring for the newborns, which adversely affect their health. This study, therefore, sought to identify the actual and exact need of primiparous mothers regarding newborn care. Moreover, it helps to determine primiparous mothers’ lack or level of knowledge for planning the process of educating mothers to improve infant health. Tinker and Ransom (2003) argued that millions of newborn deaths could be avoided if more resources were invested in proven low-cost interventions designed to address newborn needs. There are multiple demographic variables that affect maternal knowledge on newborn care. A mother’s educational level is an important factor affecting her infant’s health. Lande et al. (2004) showed that while an increase in the mother’s education level improves the quality of infant care, a decrease in her education level increases the doi: 10.1111/nhs.12193
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possibility of growth deficiencies, feeding problems, and even mortality in infants. Knowledge of newborns can decrease anxiety (Sercekus & Mete, 2010). Women attending antenatal classes experienced less anxiety during the postnatal period (Ip et al., 2009; Ferguson et al., 2013). Childcare responsibilities and lack of knowledge and preparation are sources of frustration and fatigue for new mothers (Kanotra et al., 2007). Conversely, if mothers are unable to respond to their infant’s cues and to appropriately give care, they will eventually develop negative feelings about the maternal role (Tessier et al., 1992). In Nepal, joint family (i.e. with in-laws and their families) is common, and women have less power and autonomy than men even in making decisions about their own health care and, women often have unequal access to food, education, and health care.
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primiparous mothers. The expectation was that women with low educational level and poor socioeconomic status, living with joint family, with no previous experience regarding newborn care would have a poor level of knowledge about care of the newborn. In addition, they would expect an inverse relationship between newborn-care knowledge and anxiety among primiparous mothers.
METHODS Design This investigation was a cross-sectional, correlation study of the level of knowledge about newborn care and its relationship with selected demographic variables among primiparous mothers.
Traditional newborn-care practices in Nepal Traditional practices cannot be neglected in considering the achievement of better neonatal care in developing countries, such as Nepal. Cultural beliefs and practices are important in the care of Nepalese women and their babies during the postpartum period. They are transmitted intergenerationally from mothers to daughters in order to ensure the health of new mothers and their babies. Nepal is predominantly rural, where household newborn-care practices are poor, and some are harmful (Yadav, 2007). Traditional beliefs and practices, such as separating newborns from their mothers immediately after birth and the application of harmful substances to the cord could also adversely affect neonatal survival (MoHP (Ministry of Health and Population), USAID, ICF Macro, New ERA., 2011). In Nepal, bathing a baby soon after birth is widely prevalent to purify the baby, because the baby’s body is coated with vernix, which is considered dirty. (Gurung, 2008). It is quite common to give prelacteal feeds, such as honey, sugar, and ghee, to newborn babies instead of colostrum. In traditional culture, colostrum is regarded as unholy, and sucking colostrum is believed to make babies sick (McKenna & Shankar, 2009). In rural areas of Nepal, the majority (73%) of births take place at home, and of these, 55% of women are assisted by relatives and traditional birth attendants (Nepal Family Health Program (NFHP) & New ERA, 2010). Approximately half of pregnant women have received the World Health Organization’s (WHO) recommended four antenatal care (ANC) visit ,and 85% have only one ANC visit (Joshi et al., 2014). Nepal is a small, landlocked country, with a population of 30 million (Index Mund, 2013) and more than 60 ethnic groups. The people of Nepal are poor, and communication systems and infrastructure are lacking resulting in a lack of access to healthcare for many people (MoPH et al., 2011). The gross national product per head was only approximately $US1300 per annum in 2012 (Index Mundi, 2013). The literacy rate of women was 48.3%, and 73% for men in 2010 (Index Mundi, 2013). The total fertility rate is 2.36 births per woman (Index Mundi, 2013). In this study, we explored the knowledge level of newborn care and investigated the relationship between newborn-care knowledge and selected demographic variables among © 2015 Wiley Publishing Asia Pty Ltd.
Participants The participants were recruited from a central-level referral hospital of a maternity and women’s hospital, located in Kathmandu, Nepal. The inclusion criteria for participation were pregnant women who were married, primiparous with a single and uneventful pregnancy, between 38 and 42 weeks of gestation, and able to speak and read the Nepali language. Those who fulfilled the eligibility criteria were approached for participation while they were in the outpatient department for ANC checkup. A total of 276 women participated in this study.
Outcome measures Newborn-care Knowledge Questionnaire Maternal knowledge of newborn-care was measured by the Newborn-care Knowledge Questionnaire (NKQ), which was developed by the researcher. The researcher adopted newborn questions from the Nepal Demographic and Health Survey (MoPH, 2011) and reviewed these based on the relevant literature (Beck et al., 2004; Kinzie & Gomez, 2006; Malata et al., 2007; Weiner et al., 2011). The questionnaire was examined by experts in midwifery, and modifications were made based on their advice.The draft questionnaire was again reviewed by educational midwives, and then the tool was pretested. The test–retest technique was used for reliability of the tool. The NKQ had acceptable test–retest reliability (r = 0.78) and internal consistency (Cronbach’s α = 0.76). The NKQ consists of four sections and a total of 23 items, requiring a single answer for each question, with an assigned “1” score for correct answers and “0” for incorrect answers. The questionnaire consists of the following knowledge areas: maintenance of body temperature (items 1–7), breastfeeding (items 8–15), infection prevention (items 16–20), and immunization (items 21–23). The sum of the scores comprises the newborn-care knowledge score of the participants. The highest possible score is 23 (100%), and knowledge levels are categorized as low (< 50%), moderate (50–75%), and adequate (> 75%).
Newborn-care knowledge in Nepal
State-Trait Anxiety Inventory for Adults (STAI-AD) The Nepali versions of the State-Trait Anxiety Inventory for Adults (STAI-AD) were used to measure maternal anxiety during the antenatal period, which was developed by Spielberger et al. (1983). The STAI-AD has been adapted to more than 30 languages for cross-cultural research and clinical practice. Anxiety is measured on a four-point Likert-type scale, with scores ranging from 1 (no) to 4 (totally). The total score for state anxiety varies from 20 to 80, and is categorized as mild (20–39), moderate (40–59), and severe (60–80); (Norouzia et al., 2013). Cronbach’s alpha was 0.86 in this study. The Educational variable was classified based on three levels: primary (1–5 class), secondary (5–10 class), and college (above 10 class), and the score was classified as low (primary) = 1, middle (secondary) = 2, and high (college) = 3. Total income per month was categorized as low (≥ $US56) middle ($US157–261), and high ($US < 261), and the score was classified as low = 1, middle = 2, and high = 3.
Ethical considerations The study was approved from the Ethical Committee of Tokyo Metropolitan University and the study venue. All participants were assured that their data would be kept confidential, their participation was voluntary, and that they could withdraw at any time.
Data-collection procedures The researcher approached eligible women at the antenatal clinic to identify potential candidates. The women were informed the nature of the study and were invited to participate. This resulted in a total of 276 respondents. They were requested to complete the NKQ, STAI-AD, and demographic questionnaires in the waiting room of the ANC clinic. The data were collected with the help of two research assistants who were registered nurses in Nepal. They were trained in study procedures by the first author before the commencement of the study.
Data analysis Descriptive statistics were used to analyze the demographic information. Participants’ knowledge level on newborn care was analyzed with descriptive statistics.The χ2-test, Spearman rank correlation, and logistic regression analysis were used to analyze the relationship between newborn-care knowledge and selected demographic variables. An alpha level of 0.05 was used.
RESULTS The 276 participants ranged in age from 18 to 37 years, with approximately two-thirds aged 21–30 years. More than half (61%) lived in joint families. Mean household income per month was $US201.24 (standard deviation = $US50.44, 100 rupees [Nepalese rupee] = $US1.05). A total of 135 (49%)
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Table 1.
Participant knowledge of care of the newborn (n = 276)
Variables Maintain body temperature Breastfeeding Infection prevention Immunization
Total score
Minimum score obtained
Maximum score obtained
Mean
Standard deviation
7
1
7
3.88
1.23
8 5
0 0
7 5
3.53 3.13
1.26 1.42
3
0
3
2.33
0.84
participants were educated up to secondary level, 87 (32%) up to college level education, and 54 (20%) up to primary level. In our study, 133 (48%) participants had previous experience of newborn care and 143 (52%) did not.
Level of Nepalese primiparous mothers’ knowledge of newborn care Of the 276 participants, 107 (39%) had low, 130 (47%) had moderate, and 39 (14%) had an adequate level of newborncare knowledge. Participants’ mean and percentage of their total score on the NKQ was 12.88 (56%). Mean knowledge score for maintenance body temperature was 3.88 ± 1.23, for breastfeeding it was 3.53 ± 1.26, for infection prevention it was 3.13 ± 1.42, and for immunization it was 2.33 ± 0.82 (Table 1). This finding indicated that participants had a good knowledge of immunization compared with the other components. Participants’ correct response on NKQ components are shown in Table 2. In this study, a small proportion of respondents (n = 36, 13%) had knowledge about the maintenance of body temperature to prevent hypothermia whilst 96 (34.8%) had knowledge of skin-to-skin contact between baby and mother as one of the most effective methods to maintain newborn body temperature. Only 110 (39.9%) participants had knowledge of delaying bathing. However, 270 (97.8%) knew how to cover the baby. The majority of participants (n = 225, 81.5%) had knowledge of early breastfeeding, even though 132 (47.8%) planned to give prelacteal feeds to their newborns. Only 12 (4.3%) knew that the first breast milk, colostrum, contains antibodies, and only 53 (19.2%) knew about the purpose of burping after breastfeeding. The results showed that 204 (73.9%) participants had knowledge of the best technique of umbilical cord care, even though 224 (88.8%) planned to apply some substance to it. The majority of the participants (n = 206, 74.6%) had knowledge of signs and symptoms indicating that the newborn was in danger, but only 116 (42%) had knowledge of signs of infection. The analysis revealed that low-income women were nine (95% confidence interval [CI] = 8.30–97.98) times more likely to have a low level of newborn-care knowledge, and middle-income women were 7.65 (95% CI = 1.93–30.28) times more likely. Women who had a primary level of education were 9.18 (95% CI = 2.39–35.22) times more likely to © 2015 Wiley Publishing Asia Pty Ltd.
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Table 2. Participants’ correct knowledge components (n = 276)
responses
on
Knowledge components Maintain body temperature
Breastfeeding
Infection prevention
Immunization
Average weight Skin-to-skin contact to maintain body temperature Maintain body temperature to prevent hypothermia Best timing for first baby bath Wrap baby immediately after bath Clothes used for summer season Best technique to cover body First breastfeeding starting time Colostrum containing antibiotics Frequency of breastfeeding Will give prelacteal feeding Method of burping after feeding Purpose of burping Reasons for baby crying Age to start solid foods Danger signs for normal baby Signs of infections Best technique for umbilical cord care Plan to apply something for healing the umbilical cord Sign of umbilical cord infection Aim of immunization Bacillus Calmette–Guerin vaccine vaccine prevents tuberculosis Oral polio vaccine can be given immediately after birth
newborn-care
n
%
121 96
43.8 34.8
36
13.0
110 262
39.9 94.9
176 270 225 12 37 132 137 53 109 269 206 116 204
63.8 97.8 81.5 4.3 13.4 47.8 49.6 19.2 39.5 97.5 74.6 42.0 73.9
244
88.4
95 245 177
34.4 88.8 64.1
222
80.4
have a low level of newborn-care knowledge, and those with a secondary level of education were 3.24 (95% CI = 1.41– 7.42) more likely. Women with moderate anxiety were 2.53 (95% CI = 1.17–6.83) and 1.69 (95% CI = 0.83–4.17) times more likely to have a low- and middle-level knowledge of newborn care indicating that women with higher income and education had adequate knowledge of newborn care, and those with a low income and education had poor knowledge of newborn care.
Relationship between newborn-care knowledge and selected demographic variables There were significant associations between newborn-care knowledge and anxiety (χ2 = 64.91, P < 0.00), household income (χ2 = 22.19, P < 0.00), and education (χ2 = 17.87, P < 0.001), but no significant association between previous experience about newborn care and newborn-care knowledge (χ2 = 0.24, P = 0.88) and types of family (χ2 = 0.64, P = 0.73) (Table 3). There was a positive correlation between newborn-care knowledge, household income (r = 0.26, P < 0.00), and education (r = 0.25, P < 0.00), but no correlation between previous experience with newborn © 2015 Wiley Publishing Asia Pty Ltd.
care(r = 0.29, P = 0.64) and types of family (r = 0.02, P = 0.67) (Table 4). There was a negative correlation between newborn-care knowledge and anxiety (r = −0.46, P < 0.00). As indicated by the results, maternal anxiety, education, and socioeconomic status had an inverse and significant correlation with maternal knowledge on newborn care.
DISCUSSION There are a lack of studies in Nepal that have rigorously assessed maternal knowledge of newborn care. The acquisition of knowledge of newborn care by primiparous mothers is commonly viewed as a key strategy to improve maternal and infant health. Overall, mothers’ knowledge of newborn-care issues was not adequate in the study sample. Among the four components of newborn-care knowledge, participants had higher knowledge of immunization and lower knowledge of breastfeeding compared to other components of the questionnaire. The majority of the participants knew about early breastfeeding, but few knew of the frequency for breastfeeding and that colostrum contains antibodies. Colostrum is discarded because of a belief that its thickness and viscosity make it difficult for newborn to swallow. This finding supported previous studies (Gupta et al., 2010 & Sreeramareddy et al., 2006) Some mothers discarded colostrum, as they perceived that it caused disease (Dessalegn & Shikur, 2013). Prelacteal feeding is common in developing countries. In Nepal, it is common practice to give prelacteal feeds instead of colostrum. Our study also revealed that prelacteal feeding is widespread. In the southern part of Nepal, 80.4% of newborns receive prelacteal feeds within the first two weeks of life (Karas et al., 2012). In Tanzania, prelacteal food is also given to newborns before initiating breastfeeding (Mrisho et al., 2008). A study conducted by Chaudhary et al. (2011) showed that all participant mothers knew that they had to breastfeed their babies, but did not know the appropriate timing for breastfeeding and colostrum feeding. Mothers’ knowledge of early breastfeeding was an important predictor of healthy breastfeeding practices (Tuladhar, 2010). Similarly, Gupta et al. (2010), in a study in India, found that more than one-third (36.6%) of mothers initiated breastfeeding within one hour of birth, and 30.2% initiated breastfeeding after one day. Our study revealed that few respondents had knowledge of delayed bathing and the maintenance of body temperature to prevent hypothermia.This finding supported previous studies (Sreeramareddy et al., 2006; Gupta et al., 2010). Nepal is a predominantly rural country, where household practices of newborn care reflect impoverishment, with some being harmful (Yadav, 2007). Mrisho et al. (2008) reported that newborns were dipped into cold water to make them cry. Bathing newborns soon after birth makes them more vulnerable to hypothermia and interferes with their suckling ability. In this study, primiparous mothers had inadequate knowledge of skin-to-skin contact (kangaroo mother care). A study conducted by Samuel et al. (2011) also indicated that
Newborn-care knowledge in Nepal
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Table 3. Relationship between knowledge about newborn care and study variables
Variables Antenatal anxiety Total income
Education
Previous experience with newborn care Type of family
Categories
Low n
Mild Moderate Low Middle High Primary (1–5) Secondary(6–10) College (> 10) Yes No Joint Nuclear
62 45 30 74 3 29 58 20 50 57 64 43
Newborn-care knowledge Moderate Adequate n n 124 6 25 90 15 22 60 48 63 67 82 48
Table 4. Spearman correlation coefficient among demographic variables and newborn-care knowledge (n = 276)
Measures Anxiety Household income Education Previous experience about newborn care Type of family
Newborn-care knowledge r P-value −0.46** 0.26** 0.25** 0.29 0.02
< 0.00 < 0.00 < 0.00 0.64 0.67
**Correlation is significant at the 0.01 the level (two tailed).
primiparous mothers had a lack of knowledge about kangaroo mother care. Respondents knew about the best techniques of umbilical cord care, even though a large proportion (80.1%) planned to apply some types of substance to the umbilical cord to promote healing in line with existing traditional beliefs and practices in the community. A study conducted by Padiyath (2010) found that participants had comparatively poorer knowledge in the areas of umbilical cord hygiene. Approximately 41% of newborns received an application of substances, such as oil, herbal paste, and ash, on their cord stump (MoPH et al., 2011). This kind of practice has also been noted in other South Asian countries, such as Bangladesh, India, and Pakistan (Khadduri et al., 2008; Moran et al., 2009; Gupta et al., 2010). Maternal education has the potential to serve as a strong influence on mothers’ choices to break away from harmful traditional beliefs and practices. Community awareness must be intensified to make people aware of newborn care. In our study, participants had satisfactory knowledge on immunizations. A study conducted by Devkota and Bhatta (2011) in Nepal also showed that 65% of participants vaccinated their babies. In Nepal, 87% of children between the
39 0 1 29 9 3 17 19 20 19 22 17
Total n 225 51 56 193 27 54 135 87 133 143 168 108
χ2-value
P-value
64.91
< 0.00
22.19
< 0.00
17.87
0.001
0.24
0.88
0.64
0.73
ages of 12 and 23 months were fully immunized by the time the survey was conducted (MoPH, 2011). Education helped to prepare mothers to cope with new situations during pregnancy and the postpartum period. Socioeconomic status is an important factor influencing newborn health and illness. Poor education and low socioeconomic status are linked with poorer child health (Department for Children, Schools and Families, 2007). Women who have a higher level of educational and good economic status have adequate newborn-care knowledge, and those who do not have low newborn-care knowledge. This study also supported Lande et al, (2004) that an increase in a mother’s educational level improves the quality of infant care. A similar study showed that knowledge of breast milk was highly associated with a mother’s education (Banu et al., 2012). Previous studies have suggested that parents’ socioeconomic status is associated with child survival (Kabir et al., 2001; & Hossain & Islam, 2008). Mothers with more education were found to have adequate knowledge of breast milk, as compared to mothers with lower levels of education and those who were illiterate (Banu et al., 2012). Women with lower levels of education and income are vulnerable, and this finding strongly indicates that these women should be followed more closely by health professionals. In this study, no significant relationship existed between previous experience with newborn care, types of families, and newborn-care knowledge. Maternal education and awareness have a strong influence on mothers’ capacity to break away from traditional beliefs and practices that could be harmful to newborns. The significant findings in this study suggest that women who have low anxiety have adequate knowledge of newborn care, and those who have moderate-to-severe anxiety have poor knowledge of newborn care. Lower levels of newborn-care knowledge predicted higher levels of anxiety. A study conducted by Sercekus and Mete (2010) showed that knowledge of newborns decreased anxiety. Research suggests that an increase in a mother’s educational level improves the quality of infant care; therefore, © 2015 Wiley Publishing Asia Pty Ltd.
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continuing education and guidance are necessary requirements for maternal and newborn health (Lande et al., 2004).
Limitations and future research There were several limitations in this study. First, the study was conducted in a hospital with a sample of only primiparous mothers due to time and personnel constraints. Therefore, a replication of the study should be conducted in other hospitals and community settings with primiparous and multiparous mothers. Only one central hospital was chosen for data collection, so there is a need to collect data from different hospitals and communities and different geographic areas. The small sample size in our study limits our ability to draw conclusions about the level of maternal knowledge on newborn care in primiparous mother in Nepal. The NKQ was a newly-developed questionnaire and needs to be used in various studies in different counties, especially in developing countries. Future studies should be conducted with a larger sample size, include different health centers, and that long-term follow-up care should be arranged. Future research could include a replication of the study with a larger and more diverse sample of primiparous and multiparous mothers from several different hospitals and communities.
Conclusions This study represents a small step towards being able to detect knowledge level among primiparous mothers about newborn care. This research helps to address the actual and specific learning needs of primiparous mother regarding newborn care and it identifies areas which should be targeted in primiparous mothers’ education in order to improve infant health. Of particular significance, is that there was a positive relationship between newborn-care knowledge and maternal education and socioeconomic status among primiparous mothers. There was an inverse relationship between newborn care knowledge and anxiety. As a whole, participants had a moderate level of knowledge related to newborns, and good knowledge of immunization. Participants had low knowledge about colostrum containing antibodies, the frequency of breastfeeding, and the maintenance of body temperature for newborns to prevent hypothermia. Maternal education and socioeconomic status had a significant, positive association with knowledge about newborn-care. Maternal education and economic status was positively associated with newborn-care knowledge. A lower level of education of the mother is a risk factor for newborn health, so these women should be followed more closely by nurses.
Implications Maternal education and awareness can serve as a strong influence in helping mothers to break away from traditional beliefs and practices that could be harmful to newborns. Therefore, education and awareness about newborn care are essential for developing countries, such as Nepal. These © 2015 Wiley Publishing Asia Pty Ltd.
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health-promotion activities could decrease maternal and neonatal mortality and morbidity. The findings of our study strongly suggest that continuing maternal-education programs in Nepal requires close attention and ongoing monitoring to ensure that the mothers’ knowledge gaps who care for the next generation are addressed. This study is likely to contribute to improving the health and well-being of mothers and newborns. It could also help in the development of intervention for policy makers and nurses during the antenatal and postnatal periods. Future research on maternal newborn care is needed to test nursing interventions and measure healthcare outcomes. Finally, neonatal issues in Nepal deserve more attention from researchers in order to identify local problems and plan effective strategies to correct them.
CONTRIBUTIONS Study Design: SS (Sharmila Shrestha), KA. Data Collection and Analysis: SS, SS. Manuscript Writing: SS (Sharmila Shrestha), KA, MAP, AS.
REFERENCES Atiyeh GN, El-Mohandes A. Preventive healthcare of infants in a region of Lebanon: Parental beliefs, attitudes and behaviors. Matern. Child Health J. 2005; 9: 83–90. Health Reports, 10, 57–67. Banu B, Hasnin S, Khanom K. All effects of education level of father and mother on perceptions on breastfeeding. J. Enam Med. Coll. 2012; 2: 67–73. Beck D, Ganges F, Goldman S, Long P. 2004. Care of newborn reference manual. Washington, DC: save the Children Federation. [Cited 17 Sep 2013.] Available from URL: http://fmp.ueh.edu.ht/ PDF/Care_of_Newborn_SNL.pdf. Chaudhary RN, Shah T, Raja S. Knowledge and practice of mothers regarding breast feeding: a hospital based study. J. Health Renaiss. 2011; 9: 194–200. Department for Children, Schools and Families. 2007. Children and young people today: evidence to support the development of the children’s plan. [Cited 29 Aug 2013.] Available from URL: https://www.education.gov.uk/publications/eOrderingDownload/ Childrenandyoung_people_today.pdf. Dessalegn T, Shikur M. Maternal knowledge of optimal breastfeeding practices and associated factors in rural communities of Arba Minch Zuria. Int. J. Nutr. Food Sci. 2013; 2: 122–129. Devkota MD, Bhatta MR. Newborn-care practices of mothers in a rural community in Baitadi, Nepal. Health Prospect 2011; 10: 5–9. Family Health Division. Nepal National Neonatal Health Strategy. Kathmandu: Department of Health Services, Ministry of Health, 2009. Ferguson S, Davis D, Browne J. Does antenatal education affect labour and birth? A structured review of the literature. J. Women Birth 2013; 26: 5–8. Gupta P, Srivastava VK, Kumar V et al. Newborn-care practices in urban slums of Lucknow city, UP. Indian J. Community Med. 2010; 35: 82–85. doi: 10.4103/0970-0218.62570. [Cited 29 Aug 2013.] Available from URL: http://www.ijcm.org.in/text.asp?2010/35/1/ 82/62570. Gurung G. Practices on immediate care of newborn in the communities of Kailali district. J. Nepal Med. Coll. 2008; 10: 41–44. Hill Z, Tawiah-Agyemang C, Manu A et al. Keeping newborns warm: beliefs, practices and potential for behaviors change in rural Ghana. Trop. Med. Int. Health 2010; 12: 42–49.
Newborn-care knowledge in Nepal
Hossain M, Islam M. Socio-economic variables affecting infants and children mortality in Bangladesh. Internet J. Health 2008; 9: 118– 125. Index Mundi. 2013. World data atlas. [Cited 17 Nov 2013.] Available from URL: http://www.indexmundi.com/Nepal/population.html Ip WY, Tang CSK, Goggins WB. An intervention to improve women’s ability to cope with childbirth. J. Clin. Nurs. 2009; 18: 2125–2135. Joshi C, Torvaldsen S, Hodgson R, Hayen A. Factors associated with the use and quality of antenatal care in Nepal: a population-based study using the demographic and health survey data. BMC Pregnancy Childbirth 2014; 14: 94. Kabakus N, Acik, Y, Aygun, AD. Opinions and attitudes of Turkish mothers about febrile illness of their children. Turk. J. Pediatr. 2000; 43, 56–62. Kabir A, Islam MS, Ahmed MS, Khalique BMA. Factors influencing infant and child mortality in Bangladesh. Int. J. Serving Int. Community Med. Sci. 2001; 1: 292–295. Kanotra SD, Angelo D, Phares TM, Morrow B, Barfield W, Lansky A. Challenges faced by new mothers in the early postpartum period: an analysis of comment data from the 2000 pregnancy risk assessment monitoring system (PRAMS) survey. J. Matern. Child Health 2007; 11: 549–558. Karas DJ, Mullany LC, Katz J, Khatry SK, Darmatadt GL, Tielsch JM. Home care practices for newborns in rural southern Nepal during the first 2 weeks of life. J. Trop. Pediatr. 2012; 58: 200– 207. Khadduri R, Marsh DR, Rasmussen B, Bari A, Nazir R, Darmstadt GL. Household knowledge and practices of newborn and maternal health in Haripur district, Pakistan. J. Perinatol. 2008; 28: 182–187. Kinzie B, Gomez P. 2006. Basic maternal and newborn-care: a guide for skilled providers. Maternal and Neonatal health. [Cited 30 Aug 2013.] Available from URL: http://www.accesstohealth.org. Lande B, Andersen LF, Veierod MB et al. Breast-feeding at 12 months of age and dietary habits among breast-fed and nonbreast-fed infants. J. Public Health Nutr. 2004; 7: 495–503. Lucen A, Bilkis B, Kazi AR, Khurshida K. Factors associated with knowledge about breastfeeding among female garment workers in Dhaka City. J. Public Health 2012; 1: 249–255. Malata A, Hauck Y, Monterosso L, McCaul K. Development and evaluation of a childbirth education programme for Malawian women. J. Adv. Nurs. 2007; 60: 67–78. McKenna KM, Shankar RT. Practice of pre-lacteal feeding to newborns among Hindu and Muslim families. J Midwifery Women’s Health 2009; 54: 78–81. Ministry of Health and Population (MoPH), United States Agency for International Development (USAID), ICF Macro, & New ERA. 2011. Nepal Demographic and Health Survey 2011–2012. Moran AC, Choudhury NU, Zaman Khan N et al. Newborn-care practices among slum dwellers in Dhaka, Bangladesh: a quantitative and qualitative exploratory study. Kathmandu, Nepal: Ministry of Health and Population, USAID, ICF Macro, and New ERA, Calverton, Maryland. BMC Pregnancy Childbirth 2009; 9: 54.
353
Mrisho M, Schellenberg JA, Mushi AK, Obrist B, Mshinda H et al. Understanding home-based neonatal care practice in rural southern Tanzania. Trans. R. Soc. Trop. Med. Hyg. 2008; 102: 669– 678. Nepal Family Health Program (NFHP) & New ERA. 2010. A midterm survey for NFHP II: Family Planning, Maternal, Newborn and Child Health situation in rural Nepal. Kathmandu, Npal: NFHP & New ERA: Nepal. Norouzia F, Keshavarza M, SeyedFatemib N, Montazeric A. The impact of kangaroo care and music on maternal state anxiety. J. Complement. Ther. Med. 2013; 21 (5): 468–472. Padiyath MA. Knowledge attitude and practices of neonatal care among postnatal mothers. J. Curr. Pediatr. Res. 2010; 14: 147–152. Salam CM. Mothers’ perception of infant care and self-care competence after early postpartum discharge. Int. J. Childbirth Educ. 1995; 10: 30–40. Samuel BN, Priscilla NLW, Regina O et al. Perception and practice of Kangaroo Mother Care after discharge from hospital in Kumasi, Ghana: a longitudinal study. BMC Pregnancy Childbirth 2011; 11: 99. Senarath, U., Fernando, D., Vimpani, G., & Rodrigo, I. Factors associated with maternal knowledge of newborn care among hospitaldelivered mothers in Sri Lanka. Trans. Roy. Soc. Trop. Med. Hyg. 2007; 101 (8): 823–830. Sercekus P, Mete S. Turkish women’s perceptions of antenatal education. Int. Nurs. Rev. 2010; 57: 395–401. Spielberger CD, Gorsuch RL, Lushene R, Vagg PR, Jacobs GA. 1983. State-trait anxiety inventory for adults: manual, instrument and scoring guide consulting. Palo Alto, California: Psychologists Press Mind Garden. Sreeramareddy CT, Joshi HS, Sreekumaran BV, Chuni N. Home delivery and newborn-care practices among urban women in western Nepal: a questionnaire survey. BMC Pregnancy Childbirth 2006; 6: 27. Tessier R, Piche C, Tarabulsy GM, Muckle G. Mothers’ experiences of stress following the birth of a first child: identification of stressors and coping resources. J. Appl. Soc. Psychol. 1992; 22: 1319–1339. Tinker A, Ransom E. Healthy mothers and healthy newborns: “The Vital Link”. Washington, DC: Population Reference Bureau, 2003. Tuladhar S. 2010. The determinants of good newborn-care practices in the rural areas of Nepal. University of Canterbury, Health Sciences Centre, master thesis. [Cited 21 Aug 2013.] Available from URL: http://ir.canterbury.ac.nz/handle/10092/5061. Weiner EA, Billamay S, Partridge JC, Martinez MA. Antenatal education for expectant mothers results in sustained improvement in knowledge of newborn-care. J. Perinatol. 2011; 31: 92–97. World Health Organization and Save the Children. 2011. Newborn Deaths Decrease but Account for Higher Share of Global Child Deaths. Joint Press Release 30 August 2011. [Cited 30 Aug 2013.] Available from URL: http://www.who.int/mediacentre/. Yadav S. Newborn-care: traditional practices in Nepal. Stud. BMJ 2007; 15: 293–336.
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