Factors Associated with Maternal Knowledge of Newborn Care among Postnatal Mothers Attending a Rural and an Urban Hospital in Egypt

The aim of this study was to assess mothers' knowledge on newborn care as well as factors associated with poor knowledge. The study setting was two maternity hospitals, one urban and other rural, which were randomly selected from the maternity hospitals in Alexandria and El Behera governorates. A convenience sample of 422 mothers of newborns was selected from the previously mentioned settings. A structured interview questionnaire was designed and utilized by the researchers to collect the data. Maternal knowledge on newborn care was assessed and a knowledge score was created by allocating 1 point for each correct response. Knowledge score was classified as 'good', 'satisfactory' and 'poor' scores. The study results showed that 59.5% of mothers had either satisfactory or good overall knowledge. More than half of the mothers (55.7%) demonstrated a poor knowledge about some breastfeeding practices, mainly on initiation of breastfeeding (43.7%), proper attitude towards hypogalactia (42.7%), giving pre-lacteal feeds (38.4%), non-timed lactation (19.9%) and only 17.7% correctly identified the duration of exclusive breastfeeding. Mothers demonstrated satisfactory and good knowledge about the newborn warning signs (67.8%), with more than 70% of mothers recognizing 8 of 9 symptoms and/or signs that needed the urgent attention of a healthcare provider. According to multivariate analysis, rural women (odds ratio (OR)= 1.62; 95% CI 1.43-2.12), primiparae (OR= 1.77; 95% CI 1.53-2.72), mothers with lower family monthly income (OR=2.04; 95% CI 1.33-3.32) and those who never attended schools (OR=2.00; 95% CI 1.28-3.11) were more likely to have poor knowledge. In conclusion, mothers had satisfactory or good levels of knowledge about care of the umbilical cord and recognition of dangerous signs, but knowledge about breastfeeding was poor. Maternal education programs should place more emphasis on first-time mothers and those having lower socio-economic level as evident by lower monthly family income and lack of education.


INTRODUCTION
The first 28 days of life are usually considered the most serious and vulnerable period for the neonate.This is called the neonatal period and it showed the highest Bull High Inst Public Health Vol.40 No.2 [2010]   incidence of morbidity and mortality, accounting for 40% of all deaths in underfive children.Three quarters of neonatal deaths occur in the first week, highlighting the need for early care. (1)though infant mortality has fallen in many developing countries over the past two decades, the rate of fall is slowing.
One reason is the contribution of neonatal mortality, which has remained fairly steady over this period. (2)(5)(6) In Egypt, according to 2008 Egyptian Demographic and Health Survey (EDHS), under-five mortality was 28 deaths per 1.000 births, while the neonatal mortality rate was 16 deaths per 1.000.This indicates that around 58% of early childhood deaths in Egypt are taking place during the first month of life.A large differential in under-five mortality by urban-rural residence in Egypt is particularly noteworthy. (7)However, very little is known about the natural history of neonates born in rural areas in many developing countries because most of them are never seen by a physician. (8)e World Health Organization guidelines for essential newborn care encompass cleanliness, thermal protection, initiation of breathing, early and exclusive breast feeding, eye care, immunization, management of illness and care of low birth weight infants. (9)proving knowledge of mothers and family members about essential newborn care plays an important role in achieving a reduction in neonatal morbidity and mortality. (10,11)14) Signs of newborn illness are nonspecific and include poor sucking, lethargy, fever or hypothermia, respiratory distress and convulsions.Some of these may be difficult to differentiate from the spectrum of normal behavior. (15)men acquire knowledge about caring for their newborns during pre-conception, antenatal and postnatal periods through various channels of communications. (16)nce most newborns are discharged from the health facility early, families should be able to recognize signs of newborn illness and bring these to the attention of a health professional. (17)onates in communities in developing countries are cared for at home mostly in rural settings and often in inadequately protected environments. (18)ile an increasing proportion of births in rural Egypt occur in facilities, a woman's family-especially her mother-typically provides support and share traditional knowledge before, during and after birth. (19)ailable literature in developing

Study design and settings
The study was conducted using a crosssectional descriptive design.The associations between poor knowledge and each independent variable were examined by odds ratios (OR) and 95% CI.
P value of <0.05 was taken as the cut-off level of significance in the present study.

DISCUSSION
Although infant mortality rates have dropped considerably in many developing countries, the rate for neonates and in particular, early neonatal mortality have declined more slowly and in some regions have remained static. (20)Maternal health knowledge appears to be a crucial skill in improving neonatal care and survival.
According to the results of the present cord is generally recognized in some developing countries. (21,22)is is in agreement with Senarath et al.
in their study in Sri Lanka who reported that only 21.7% of interviewed mothers answered that surgical spirit should not be applied to the stump. (22)or maternal knowledge about the cord has been reported by Fayed (2008) (23) in her study conducted in Behera, Egypt.
The fact that using antimicrobial agents is beneficial for cord care has been supported by Mullany and Darmstadt (2007) in their study in rural areas in Nepal. (24)They found that without using antimicrobial agents, neonates were at higher risks of infections to umbilical stump.mortality by up to one third. (26,27) he

Promotion of Breast Feeding Intervention
Trial, showed that gastrointestinal infections and atopic eczema were significantly reduced by early promotion of breast feeding. (28)reover, the unique nutritional and antibody properties of colostrum and the disadvantages to those infants not fed with colostrum are now well recognized and documented. (29)rtunately, in the present study, unsatisfactory knowledge about some aspects of breastfeeding. (23)Knowing about breastfeeding on demand and the advantages of colostrums had similarly been recognized by the majority of mothers in a study in Sri Lanka. (22)Delayed initiation of breast feeding, discarding colostrums and giving pre-lacteal feeds to almost all neonates are still highly recognized in Northern India. (31)e lack of specificity of the clinical manifestations of various neonatal morbidities have been noted, resulting in difficulty in making a definitive diagnosis, delay in seeking care and resultant high mortality. (31) the present study, mothers' awareness with danger signs was generally satisfactory.In contrast, in a study in Bangaladesh, there was poor awareness of danger signs. (32)though the majority of mothers in our study recognized fever as a warning sign, only three quarters of them knew that hypothermia may be a sign of serious illness in newborns.Similar gap in knowledge between fever and hypothermia has been documented elsewhere. (22,31) lst emphasizing the due importance of recognizing danger signs, healthcare providers also need to explain the interpretation of benign signs to mothers and family members.Hypothermia is a more common sign of serious illness than fever in newborns, and this should be highlighted during educational sessions.
Luckily, decreased frequency of urination (non passage of urine for 48 hours) has been recognized by more than half of mothers, although it has been recognized only by 5% of mothers in Northern India. (31)terestingly, a recent Brazilian study emphasized a limited knowledge on basic Bull High Inst Public Health Vol.40 No.2 [2010]   prenatal care.The study also found that when the danger signs that require taking the child to a health service are not readily recognized, the risk lies in seeking medical care too late, when little can be done for the child. (33)alysis of the predictors of poor maternal knowledge indicated that first time mothers, illiterate and mothers living in families with lower monthly family income, as well as those from rural residence had poor knowledge on newborn care than others.Senarah et al. (2007) highlighted that primiparous mothers are unprepared to care for themselves and their babies. (22) addition, maternal literacy, poor socioeconomic status and residence in rural areas had been documented to have an impact on different aspects of infant's health, as evidenced by a large scale randomized controlled trial from Pakistan. (34)eparation of mothers before they give birth is fundamental to the promotion of many neonatal practices.In our study it was seen that only 60% of the women had received any advice on neonatal care during antenatal period and only 41.1% had this advice from a healthcare providers.
Support and counseling should be available routinely during ante-natal care, to prepare mothers; at the time of birth to help them initiate breastfeeding; and in the postnatal period to ensure that breastfeeding is fully established.
Worth noting that, the majority of mothers in the present study acquired some of their knowledge from relatives and friends.This is supported by findings of Fayed (2008)   who mentioned that mothers' main source of information on neonatal care was nonprofessional persons, namely mothers and mothers-in-law. (23)This was confirmed by Barton (2001)

Essa
et al., 356 study, maternal knowledge about caring of umbilical cord was satisfactory in some elements such as utilizing surgical spirit and the range of time required for the stump to fall.Applying something to the figures, however, may indicate a better breastfeeding practices among rural Respondents often identified more than one source or type of information.N= 230, as 153 respondents did not receive any advice on neonatal care.

Figure 1 :
Figure 1: Sources of knowledge on newborn care to the mothers during the antenatal period.

Table 1
shows that, of the total 422 mothers interviewed, 48.6% were of an urban residence and the remaining were from rural residence.Women's age ranged from 17 to 38 years, with an average of 25.18 years (±3.81 years).Among the mothers, 36.7% never attended school while 8.8% of them were graduates.The majority of the mothers (91.1%) were housewives.Most of the mothers (64.4%) belonged to families that had a per capita

Maternal knowledge on breastfeeding, care of the umbilical cord and warning signs of newborn
Knowledge of the mothers in various aspects of neonatal care was analyzed as shown in Table 2. Approximately 93.9% of responding mothers were aware that the umbilical stump should be left uncovered without any dressing, whilst 58.9% correctly answered that 'surgical spirit' (a commercially available preparation of 70% isopropyl alcohol) should not be applied on the umbilical stump.Only 24.7% of the mothers correctly identified the range of time when the stump falls off.instead, showed poor knowledge on some aspects of breastfeeding such as time of initiation of breastfeeding (43.7%), proper attitude towards hypogalactia (42.7%), giving pre-lacteal feeds (38.4%) and nontimed lactation (19.9%).Only 17.7% of the mothers correctly identified the duration of exclusive breastfeeding.