Knowledge and practice of immediate newborn care among midwives and nurses in public health facilities of Afar regional state, Northeast Ethiopia

An institution-based cross-sectional study was conducted during April 2018 on midwives and nurses working in government health facilities in Zone one and Zone three of Afar Regional State, Northeast Ethiopia. In Zone one, there are 27 health centers and 2 hospitals, while in Zone three, there are 18 health centers and 1 hospital. In these two zones, there are 287 midwives and 326 nurses (613 nurses and midwives).

A sample size of 386 was determined using the following formula;

Assumptions: n = required sample size, \( \mathrm{z}\frac{\upalpha}{2} \) = critical value for normal distribution at 95% confidence level (1.96), P = 60% proportion of good immediate newborn care practice among health professionals [22], d = 0.05 (margin of error), and 5% for non-response.

There are five zones in the Afar regional state. Using the rule of thumb, two zones (Zone one and three) were randomly selected. All 48 public health facilities (45 health centers and 3 hospitals) found in the selected zones were included in the study. Then, the sample size was proportionally allocated for each health facility based on the number of nurses and midwives assigned on newborn care (delivery care) unit. Since the number of nurses and midwives in each of the health facility is not equal, the sample size allocated for each facility was proportionally allocated to determine the number of nurses and midwives included in the study from each facility. Finally, all randomly selected midwives and nurses who were providing immediate newborn care during data collection period were included in the study.

Data were collected using interviewer administered questionnaire and observation checklist. The questionnaire and observation checklist was adopted and modified from WHO and other related sources [11, 13, 23, 24]. The questionnaire was organized in three parts; socio-demographic characteristics, knowledge and practice of midwives and nurses on immediate newborn care. Data were collected by six public health professionals using the English version of the questionnaire and observation checklist. Data collectors and supervisors were trained for three days on the study instrument and data collection procedures. A pretest was conducted on 5% of the sample size in Zone two of Afar Regional State. Then, the questionnaire was improved and contextualized to fit the local condition and the study objective.

The dependent (outcome) variables for this study were the level of knowledge on immediate newborn care and immediate newborn care practice. Level of knowledge was assessed using 10 major questions. Nurses and midwives were considered as having adequate knowledge (coded as 1) if they respond to greater than or equal to the mean score (5.54) of the 10 knowledge-related questions. If they respond to less than the mean score of knowledge questions, considered as having inadequate knowledge (coded as 0). Good practice (coded as 1): if nurses and midwives correctly performed greater than or equal to the mean score (16.92) of the 23 practice-related questions. Poor practice (coded as 0): if they performed less than the mean score of the 23 practice questions. The independent variables were: age, sex, religion, marital status, ethnicity, educational level, monthly income, work environment (the type of health facility), experience, participation on immediate newborn care training and workload.

Data were checked for completeness and inconsistencies. Epi-info version 7.0 was used to enter, clean and code the data. Then, SPSS version 20 was used to analyse the data. Chi-Square (χ²) test of independence was used to determine the association between outcome variables (knowledge and practice) and each of the predictor variables. Before conducting the multivariable logistic regression analysis, preliminary analyses were conducted to assess multicollinearity. All correlations among the independent variables were weak to moderate. This indicates that multicollinearity was unlikely to be a problem [25]. The crude odds ratio (COR) was estimated in the univariable logistic regression analysis. Variables with p-value < 0.25 in the univariable logistic regression analysis were included in the multivariable logistic regression analysis [26, 27]. Adjusted Odds Ratio (AOR) with 95% confidence interval was estimated to assess the strength of the association. A p-value < 0.05 was used to declare statistical significance.

This study was approved by the Research Ethics Review Committee (RERC) of Samara University dated April 15, 2018, and numbered ERC0056/2018. Letter of the permission was secured from the Regional health bureau and all selected health institutions. Informed consent was taken from the study participants after informing the study subjects on study objectives, expected outcomes, benefits and the risks associated with it. Confidentiality of responses was maintained throughout the study.

Totally, 357 midwives and nurses participated in the study (estimated response rate of 92.5%). About 56% of the study participants were female. The mean (±SD) age of the study participants was 29.9 (±3.4) years (data not shown). Majority of the participants 117 (66.7%) were Ethiopian Orthodox followers, and 214 (59.9%) were diploma holders. Nearly 85% of the study participants were working in a health center, and 39% received training on immediate newborn care (Table 1).

About two-third (60.8%) of the study subjects stated that newborn should be placed on to mother’s abdomen immediately after birth, and 53.2% of the participants knew the importance of assessing breathing of newborn. Overall, 53.8% [95% CI: 48.6, 59.0%] of the participants had adequate knowledge on immediate newborn care (Table 2).

The result from the univariate analysis revealed that there was an association between respondents’ background characteristics and their knowledge on immediate newborn care. Work environment and experience, interest in providing newborn care and being received newborn care training were significantly associated with nurses and midwives’ knowledge about newborn care (Table 1).

The univariable logistic regression analysis showed that age, having an interest in providingnewborn care, receiving training, workload and environment were significantly associated with the knowledge of nurses and midwives on immediate newborn care. However, the multivariable logistic regression analysis showed that the odds of having adequate knowledge about immediate newborn care was significantly higher for nurses and midwives working in hospitals [AOR: 4.62; 95% CI (1.76,12.10)] compared to those working in health centers. Male midwives and nurses had lower odds of having adequate knowledge on immediate newborn care [AOR: 0.59; 95% CI (0.39, 0.98)] compared to females. Midwives and nurses without interest to provide immediate newborn care were less likely to [AOR: 0.29; 95% CI (0.13,0.68)] have adequate knowledge on immediate newborn care compared to those who had the interest to provide (Table 3).

Three hundred and thirty-one (92.7%), 230 (64.4%) and 282 (79%) of the study participants put on a sterile glove, clean the eyes of newborn and kept baby skin-to-skin contact with mother, respectively. The majority (80.7%) of the nurses and midwives applied tetracycline eye ointment for the prevention of ophthalmic neonatorum, but only 166 (46.5%) gave the recommended immunization (Oral Polio Vaccine (OPV₀) and Bacillus Calmette-Guerin (BCG) vaccine) immediately after birth. Overall, 62.7% [95% CI: 57.7, 67.8%] of the study participants have a good practice on immediate newborn care (Table 4).

The result from the chi-square test showed that level of education, work environment and experience, interest in providing newborn care, obtaining newborn care training were significantly associated with immediate newborn care practices of midwives and nurses. Moreover, this analysis found that nurses’ and midwives’ practice on immediate newborn care was significantly associated with their sex and marital status (Table 1).

The multivariable logistic regression analysis revealed that midwives and nurses with inadequate knowledge had lower odds of having a good practice on immediate newborn care [AOR: 0.39; 95% CI (0.25, 0.64)] compared to those having adequate knowledge. Midwives and nurses without interest to provide newborn care were less likely [AOR: 0.35; 95% CI (0.16, 0.74)] to have a good practice on immediate newborn care compared to those who had an interest. In addition, the odds of having a good practical performance on immediate newborn care were lower among midwives and nurses having work experience of lower than six years [AOR: 0.33; 95% CI (0.14, 0.78)] compared to those having six years and above experience. On the other hand, receiving newborn care training [AOR: 0.40; 95% CI (0.23,0.70) and working in hospitals [AOR: 8.56; 95% CI (2.39, 30.63)] were positively associated with good newborn care practices (Table 5).

Use of direct observation to assess the practical performance of midwives and nurses is the major strength of this study. However, there might be observation bias and the cross-sectional nature of the study does not confirm the cause and effect relationship between predictors and outcome variables.

This study showed that a significant number of nurses and midwives had inadequate knowledge and poor practice on immediate newborn care. Work environment, sex and interest in providing newborn care were statistically significant predictors for knowledge on newborn care. Moreover, it was revealed that the practice of midwives and nurses on newborn care was influenced by their knowledge, work experience, interest in providing the care, receiving newborn care training, workload and environment.

Based on these findings, priorities have to be given to create experience sharing opportunities between midwives and nurses working in hospitals and health centers. Providers’ interest should be considered as the part of the criteria to assign midwives and nurses to the newborn care unit. In addition, strengthening provision of refreshment training on regular basis coupled with strict follow up is very crucial to improve their knowledge and skills on newborn care.