Knowledge, attitude, and practice among mothers about newborn care in Sindh, Pakistan

Each year nearly 7.7 million children under five years die around the world; out of which approximately 3.1 million of the newborns die during the neonatal period and almost all these (99%) deaths occur in the developing countries [ 1]. According to the World Health Organization estimation, neonatal deaths account for 45% of the under-five deaths [ 2]. More than one-third of these deaths take place in the first 24 h of birth, whereas three-quarter of the neonatal deaths takes place in the first seven days of birth [ 3, 4].

Among the17 Sustainable Development Goals (SDGs) set by United Nations in 2015, the 3rd goal, target (No. 3.2) states that all countries aim to put a stop to millions of avoidable deaths of newborns and under-five children by 2030. The targets to achieve are: reduction in neonatal mortality and under-5 mortality to no more than 12 and 25 deaths per 1000 live births respectively [ 5]. Majority of low-income countries are far behind achieving this goal mainly because of slow progress in reducing neonatal death [ 6].

In Pakistan, despite the reduction in under-five and infant mortality rate, there is almost no change in neonatal mortality for the last two decades (from 56 to 46 per 1000 live births) [ 7]. Pakistan ranks third among the top ten countries with high incidence of neonatal deaths [ 8]. At these mortality levels, 1 in every 14 Pakistani children is unable to survive before the first birthday, while 1 in every 11 dies before the age of five [ 9]. The increasing evidence suggests that early newborn care practices impact neonatal mortality and morbidity. The burden of neonatal mortality and morbidity can be reduced by practicing essential newborn care (ENC) practices [ 10]. Many studies have been done on the newborn care topics in Pakistan and in developing countries but most of them only focus on newborn care practices [ 11– 14].

In Pakistan, mothers are the primary caregiver to newborns hence the care is mostly dependent on their level of knowledge, attitude, and practice (KAP) about newborn care. Therefore, this study aims to investigate the KAP of mothers about newborn care and its related factors to achieving optimum newborn care.

The sample consisted of 528 participants and had an overall response rate of 98.1%. The mean age of the mothers was 28.8 ± 5.8 years. 55.5% of the participants belonged to the age range of 20–29 years. Around 66% of the participants resided in the rural areas and 53% of respondents lived in joint families. 64.9% had no education at all, whereas only 14.1% studied up to secondary level. 66% of these women were housewives while 34% had outdoor occupations. 20% of the working mothers were farmers. (Table  1).

The mean KAP scores for these mothers were 5.48 (out of 11) for the scale of Knowledge, 3.14 (out of 5) for the scale of Attitude and 4.60 (out of 9) for the scale of Practice.

Respondents’ knowledge varied for different aspects of newborn care as per WHO guidelines; 57% of the participants had correct knowledge regarding skin to skin contact, whereas 55% knew about the correct timing of newborn’s first bath, 54.6% had accurate knowledge about initiation of breast milk, 57.6% knew about pre-lacteal feed and 55.6% of the participants could respond correctly about giving colostrum to their newborns. Only 1.4% of the subjects informed that chlorhexidine should be applied on the umbilical cord and the rest reported that any type of oil, dettol, common powder, and antimony could be used. Around 73.4% of study subjects knew that breastfeeding should be given on demand. More than half of the participants 51.0% were aware about six months duration of exclusive breastfeeding. (Table  2).

Study participants were assessed on their attitude about newborn care, out of total sample unit, 59.5% perceived that skin to skin contact is a preventive method from getting cold to a baby. Most of the respondents 61.0% did not accept delaying bathing of their newborns babies. Majority of the participants 88.4% preferred to use a new blade for cord cutting. Around 68.1% believed that prelacteal feeding should not be administered and 41.1% had a negative attitude on regarding colostrum feeding as shown in Table 2.

More than half of the respondents stated that they bathed their newborns within six hours of delivery. Around 50% of subjects breastfed newborns after one hour of their birth. 44.8% stated that they did not feed colostrum to their newborns. Approximately 45% of the mothers reported that they gave pre-lacteal feed to their newborns. Among these, 15.4% of respondents gave animal/formula milk, 24.5% gave honey/sugar and 5.2% gave fresh butter/ghee. Majority of mothers 65.1% breastfed their babies on demand. (Table 2).

This study provides a holistic picture depicting knowledge, attitude, and practices in mothers about newborn care, to help design evidence- based interventions in order to achieve SDG goal 3 related to newborn survival in Pakistan.

With respect to thermal protection, WHO has recommended preventive measures such as skin to skin contact, immediate placement of baby on mothers chest and delayed bathing with the gap of minimum six hours after birth are very important for a newborn as these can prevent the neonatal complication of hypothermia. The early bathing is known to be a leading risk factor for neonatal morbidity such as hypothermia and mortality [ 19, 20].

According to this study, 57% of the mothers had knowledge about Kangaroo care (skin to skin contact) and 57.1% practiced skin to skin contact with their babies. However, these findings are considered low when compared with a study conducted in North Ethiopia, where 99.3% of the participants had the knowledge and 72.1% practiced skin to skin contact with their babies [ 21]. This difference could be related to the difference in study participants. As in above-mentioned study participants were midwives because of their qualification and positions they may have a better understanding about the importance of skin to skin contact.

As far as the bathing time is concerned, in the present study, more than half (51.8%) of the respondents reported that they bathed their newborns within six hours. If compared to the study done in District Matiari, Pakistan, where 32% of respondents stated that they bathed their newborns within six hours, the current study’s statistics are quite high [ 13].

According to a study done in Nepal, cultural beliefs were related to early newborn bathing. Majority of the participants reportedly believed that early bathing of their newborns cleans the dirty coating of Vernix present on the baby. Hence, the study population has a custom of early bathing to clean and purify the baby instantly [ 22]. Almost the same reason can be held responsible for early bathing practices for newborns found in District Badin. Despite this, the practice percentage is much lower in Badin if compared with 78.5% people in Gilgit, 82% people in Karachi , Pakistan and 60% people in Southern Tanzania [ 11, 14, 23]. The difference seen here can be due to a difference in socio-cultural characteristics in different regions.

An umbilical cord is another sensitive issue concerning newborn care. WHO stresses the importance of hygiene while handling the cord and applying chlorhexidine, especially in regions where there are higher neonatal mortality rates [ 24]. Unhygienic deliveries and unsafe cord cutting and caring practices cause tetanus and sepsis which are two leading reasons for maternal and neonatal illnesses and deaths [ 19, 25].

The importance of applying Chlorhexidine was stated by Imdad A. et al. in Pakistan; he demonstrated a significant reduction in a number of cases of umbilical cord infections among newborns delivered at home [ 26]. In the current study, 65.4% of the respondents stated that the umbilical cord was cut by a new blade. Nearly 26.9% of respondents reported using traditional substances on the cord, whereas, only 1.5% used chlorhexidine. However, these findings were not consistent with a study conducted in urban areas of Rohtak Haryana located in the neighboring country India, where a new blade was used in 88.6% of the deliveries and 40% of the mothers used traditional substances on the cord [ 12]. The differences observed might be due to study settings and the difference in a socio-cultural background of the participants.

According to WHO, breast milk is the best way of feeding babies and supplying them with nutrients essential for their healthy growth and development [ 27].

Regarding the knowledge of breastfeeding, our study found out that 54.6% of the mothers knew that breastfeeding should be initiated within an hour of the baby’s birth. 57.5% knew that pre-lacteal feed should not be given to neonates and 55.6% of them stated that colostrum should be given to their newborns. These figures did not match with the ones found in a study done in Ethiopia; the respondents there had higher knowledge about breastfeeding. Around 80.9% stated in that study that breastfeeding should be initiated within the first hour of birth, 95.9% stated that pre-lacteal feed should not be given to the newborns and 96.4% stated that colostrum should be given to the newborns [ 28]. The possible explanation for such a stark difference in responses might be because the study in Ethiopia was conducted in urban areas as compared to this one done in rural areas that make a difference in the information about newborn care.

In this present study around half (50%) of the participants initiated breastfeeding within one hour of birth, 54.8% of them did not give any pre-lacteal feed and 55.2% administered colostrum to their newborns. This finding is higher than the findings in a study done in district Matairi, Pakistan which shows that breast milk was initiated within one hour by 41%, pre-lacteal feed was not given by 52.1% respondents and colostrum was given by 44% mothers [ 13]. This difference might be due to awareness interventions in the study community by various organizations working on child health.

According to the result of the multivariate analysis, among socio-demographic and other related factors such as maternal age, education, and place of residence had significant associations with the Knowledge and Practice score of mothers. Mothers within the age group of 20–39 had on average higher knowledge and practice score on newborn care as compared to women who were forty or above. This figure appeared to be consistent with another study done in Ethiopia [ 24]. The suggested possible explanation for the above result could be that mothers with young age may have better awareness regarding the benefits of newborn care practices. While older mothers may have more traditional influence or come from the traditional cohort, therefore, were less likely to have knowledge and practice in comparison to young mothers. Mothers’ education level was found to be significantly associated with the KAP of newborn care. Respondents with no formal education had lesser score than those mothers who had higher education. This finding is consistent with studies done at Tamil Nadu, in southeastern India and Kanchipuram district, India [ 18, 29]. A probable explanation for this finding might be that a highly educated mother could have a better understanding or awareness about the importance of newborn care. Thus, giving these mothers confidence to take the right decisions to take care of their newborns, resulting in better knowledge and accurate practices. In this study, there was no significant association of mothers’ occupation with KAP of mothers about newborn care. This finding is similar to the study done at Mandura District, Northwest Ethiopia, In which no association between mothers occupation and mothers practice of newborn care was found [ 30]. This inconsistency could be because of the difference in socio-demographic conditions of the respondents in the study area. Urban resident mothers were associated with the practice of newborn care than who were living in rural areas. This is in line with the two studies done in Ethiopia [ 30, 31]. A probable reason for this difference might be easy access to healthcare services and better education in urban areas as compared to rural areas. In our study, the socioeconomic status of the respondents had no association with the practice of newborn care. This finding is also similar to the study done in Ethiopia [ 31]. The reason behind this could be that health care provider disseminates information about the importance of newborn care house to house irrespective of socioeconomic status.

Since the study is cross-sectional it may not be strong enough to demonstrate a causal relationship between dependent and independent variables due to the nature of the study. Similar studies done on KAP of newborn care are limited in our country to make comparative discussion. The information on KAP of newborn care was collected from the mothers who had given live birth during the past twelve months prior to the start of this survey. Hence, there might be some recall bias that affected the quality of data.

The findings of this study showed gaps in knowledge and practice for newborn care. High-risk factors were identified in this study such as immediate bathing, application of traditional substances on the umbilical cord, delayed initiation of breastfeeding, discarding colostrum and giving pre-lacteal feed to newborns; these all need immediate attention of MNCH programs in Sindh province. Moreover, this study has also revealed many socio-demographic factors which have significant effects on the mothers’ KAP regarding newborn care. These factors included education level of mother and place of residence. Therefore, information gained from this study can be used as a baseline to provide input for developing feasible and sustainable behavioral change and educational interventions. Community-based programs are expected to address the poor practices to improve neonatal outcomes. Furthermore, it is recommended to conduct qualitative research to explore the reasons and beliefs associated with unsafe newborn care practices.