International Journal of Science and Healthcare Research

Vol.4; Issue: 4; Oct.-Dec. 2019

Website: www.ijshr.com
Original Research Article ISSN: 2455-7587

Knowledge, Attitude and Practice on Identification of Newborn Danger

Signs and Associated Factors Among Mothers attending Postnatal Clinics
at Dessie Referral Hospital, North East Ethiopia, 2019
Mulugeta W/Selassie1, Tarikua Afework1, Prem Kumar2
1
Lecturer, Department of Pediatrics and Child Health Nursing, College of Medicine and Health Sciences
(CMHS), Wollo University, Dessie, Ethiopia
2
Asst. Professor, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
Corresponding Author: Prem Kumar

ABSTRACT 5.148, 30. 31) were positive predictors for

newborn danger sign practice.
Background: Globally every year, 2.7million Conclusion and Recommendation: The
neonates die during the neonatal period. In magnitude of newborn danger sign practice in
Ethiopia Neonatal, mortality is higher among these specific setting found to be good but the
many African region and other undeveloped mothers knowledge and attitude towards
countries. Recognition and early sought of newborn danger sign is poor. Promotion of
medical care towards neonatal danger sign has intensive education program on at all level,
many implications for decreasing neonatal integrating it with post-natal and child health
morbidity and mortality. Despite the importance service and focusing on urban and low
of, early sought of medical care towards socioeconomic status mothers is recommended.
neonatal danger sign the practice is low in
Ethiopia. Key Words: Newborn, Danger Signs, PNC
Objective: To assess knowledge, attitude and Attendant Mothers.
practice on neonatal danger sign and associated
factors among PNC attendant mothers in Dessie INTRODUCTION
referral Hospital, North East Ethiopia. “Newborn” and “neonatal” are terms
Method: A Facility-based cross-sectional study that refer to the first 28 days of life.
employed. The data collected from 340 mothers Mortality risk during the neonatal period is
from March to April 2018 by consecutive
highest at the time of birth and decreases
sampling technique. The data collection tool
was adapted from WHO, Neonatal Health and it over the subsequent days and weeks. Up to
was collected by using Interview based 36% of neonatal deaths occur within the
structured questionnaire. Descriptive statistics, first 24 hours of birth and nearly 73% in the
binary and multivariable logistic regression first week of life. [1] Some of repeatedly
analysis employed to identify the factors reported neonatal danger signs include not
associated with Newborn danger sign practices. able to feed, movement only when
Variables with a p-value < 0.05 identified as stimulated, low or high temperature,
statistically significant factors. respiratory rate over 60 breaths per minute,
Result: The proportion of good newborn danger severe chest in drawing and history of
sign practice was 220 (92.8%) in Dessie convulsion. Recognizing the occurrence of
Referral Hospital. 58(17.1%) of respondents
these signs will results in high overall
were knowledgeable and 146(42.9%) of mothers
had favorable/positive attitude towards newborn sensitivity and specificity to predict the need
danger sign. Mother’s income between >1500 for seeking treatment of the new born. [2,3]
Birr/month 8.194(AOR: 95% CI: 2.583, Globally, the three main causes of
25.995), Mothers who live in rural side4.210 newborn deaths are direct preterm
(AOR: 95% CI: 1.41, 12.576), Mothers who has complications (36% of neonatal deaths
instrumental delivery 9.843 (AOR: 95% CI: worldwide), severe infection (23%), and

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Vol.4; Issue: 4; October-December 2019
Mulugeta W/Selassie et.al. Knowledge, Attitude and Practice on Identification of Newborn Danger Signs and
Associated Factors Among Mothers attending Postnatal Clinics at Dessie Referral Hospital, North East
Ethiopia, 2019
intra-partum-related complications (23%). About one third (32%) of all mothers and
globally, approximately 630,000 newborns newborns globally do not receive skilled
die each year because of severe infections. care at birth [15] and evidence has shown that
Over 1800 newborns die every day due to about three quarters of all babies born
complications of childbirth, plus many more outside a health facility do not receive an
stillbirths. [4] Over 80% of premature babies early postnatal care visit following delivery.
[16]
are born as moderate to late preterm births
and most of these do not need intensive care
in order to survive. Up to 58% of premature OBJECTIVE
babies can be saved globally through the To assess knowledge, attitude and practice
provision of cost-effective care that can on neonatal danger sign and associated
feasibly delivered in low-resource settings. factors among PNC attendant mothers in
[5]
Dessie referral Hospital, North East
Previous studies have shown that Ethiopia from March to April 2018.
neonatal death affected by various factors.
Maternal factors associated with neonatal METHODOLOGY
death include young maternal age, primi-or Study area: This study conducted in Dessie
grand-multi parity, short birth intervals, Town, south Wollo Zone, one of the 11Th
maternal health complications, and not Zones in the Amhara regional state,
breastfeeding.[6–12] Neonatal factors Ethiopia
associated with their death were preterm Study Period: The study conducted from
birth, low birth weight, multiple births, and March to April 2019.
male gender.[6–10,13–14] The lack of Study Design: Institution-based cross-
appropriate care during pregnancy, delivery, sectional study design employed.
and the postpartum period respectively, [9–11] Source of population: Post-natal Mothers of
and residence in rural or poor socio- newborn (alive) who were attending in
economic community were also associated Dessie referral Hospital, 2019.
with neonatal death. [2-6] While many studies Study population: Randomly selected Post-
have examined factors contributing to natal Mothers of newborn (alive) who were
neonatal mortality in resource-limited attending in Dessie referral Hospital during
settings; few studies have focused on data collection period considered as a study
neonatal danger signs and complications. population.
These abnormal health conditions could Eligibility criteria
eventually lead to life-threatening Inclusion criteria: Randomly selected Post-
[3]
complications or death. The health of natal Mothers of newborn (alive) who are
mothers and their babies closely linked that attending in Dessie referral Hospital and
the delivery of effective interventions has a willing to participate in the study were
triple return on investment with the potential included in the study.
to avert 71% of newborn deaths, 33% of Exclusion criteria: Mothers of newborn
stillbirths, and 54% of maternal deaths at who are seriously ill, mental problem or
full coverage. It is estimated that, improving unable to communicate were excluded.
MNH services could prevent up to three out Sampling Technique& Sample size:
of four newborn deaths, specifically through Consecutive sampling technique used to
the increased coverage and quality of select 340 samples.
preconception, antenatal, intra-partum, and Variables
postnatal interventions. [5] Increasing access Dependent Variable
to maternal and newborn health (MNH)  Mothers practice on newborn danger
services and to lifesaving medical sign
commodities may be the single most  Mothers knowledge on newborn danger
important way to improve these statistics. sign

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Vol.4; Issue: 4; October-December 2019
Mulugeta W/Selassie et.al. Knowledge, Attitude and Practice on Identification of Newborn Danger Signs and
Associated Factors Among Mothers attending Postnatal Clinics at Dessie Referral Hospital, North East
Ethiopia, 2019
 Mothers perception/attitude towards Data cleaning performed to check
newborn danger sign for accuracy, consistencies, and values. The
Independent Variables data undergo rigorous daily checking to
 Maternal and husbands demographic identify and correct errors. The investigators
variable(maternal age, educational status were enter the data using Epi Data version
,occupation, religion, marital status) 3.02 and exported to SPSS 20 statistical
 House hold character(income, family package for analysis. Descriptive statistics
size) was used to describe socio-demographic and
 Health care service utilization(ANC economic characteristics of the study
utilization, place of delivery and PNC) population and KAP on newborn danger
 Health service accessibility(distance sign. Then bivariate logistic regression
from home) techniques was done to see the crude
Data collection instrument and method association between the independent
The data collection tool was adapted variables and the dependent variable and the
from WHO, Neonatal Health. The adapted strength of association will be expressed in
questionnaire was modified and odds ratio (OR). Eventually, result from
contextualized to fit the local situation and bivariate analysis of p<0.2 will be moved to
the research objective. The questionnaire multivariate analysis and done through step
was prepared first in English, translated into wise multivariate logistic regression
Amharic, and then back into English by technique to control the effects of
fluent speakers of both languages to check confounding and to identify predictors of
its consistency. The data collected through appropriate practice on newborn danger
face-to-face interview using semi structured sign. A P value of < 0.05 was e used as the
questionnaires. After review of the criterion for statistical significance.
instruments all suggested a revision made Ethical Consideration
before administer in the actual study. Three Ethical clearance secured from
data collectors and two supervisors recruited Wollo University College of medicine and
to participate in the study. The selection health science department of pediatrics and
criteria for data collectors were those child health nursing research and ethical
individual who had Diploma in nursing. The review committee to Dessie referral
supervisors should have BSc degree in Hospital. Permission letters obtained from
nursing. Dessie referral Hospital. After giving clear
Data quality assurance and deep understanding about the aim of the
Deep orientation given for data study, written consent obtained from each
collectors for one day to ensure the respondent before the interview conducted.
completeness and consistency of
information during data collection. The RESULTS
investigators made a thorough check before A total 340 mothers were interviewed which
receiving the filled questionnaire from each made the response rate of 100%.
data collector and in the meantime; they are Socio-demographic characteristics of
randomly select the questionnaire to study population
crosscheck its completeness and errors on The mean age of respondents were
spot and there was meeting at the end of 25.15 (± 4.33 SD). About sixty-Eight
data collecting time for discussion. Data percent of respondents were urban and106
analysis started by sorting and performing (31.2%) were rural residents. A majority,
quality control checkup on field. Pretest 162(47.6%) of the women were in age
(5%) done at Dessie Health center in order group of 18-24, 340 (100%) were married,
to check the consistency and reliability of 206 (60.6%) were Muslim by religion, 322
the questionnaire. (94.7%) were Amhara by Ethnicity and 209
Data processing and analysis (61.5%) were Housewife by occupation.

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Vol.4; Issue: 4; October-December 2019
Mulugeta W/Selassie et.al. Knowledge, Attitude and Practice on Identification of Newborn Danger Signs and
Associated Factors Among Mothers attending Postnatal Clinics at Dessie Referral Hospital, North East
Ethiopia, 2019
About 109 (32.1%) of the women and 133 Regarding maternal health service
(39.1%) of their partner did attended utilization; of the total respondents
secondary education and Higher education 338(99.4%) mothers were attending ANC;
respectively. A majority of husband were 211(62.1 %) utilized ANC four and more
self-employed by occupation (Table 1) times, 116(34.1%) had gotten Newborn
Table 1: Socio-demographic variable
danger sign Counseling at ANC
Socio-demographic variable Frequency Percentage Clinic, 329(96.8%) delivered their
(N=340) child at Government health facility and their
Age of Mother
18-24 year 162 47.6 delivery was assisted by health professional
25-29 year 120 35.3 and 188(55.3%) delivered through normal
30-34 year 46 13.5
35-39 year 10 2.9 spontaneous. 195(57.4%) mothers were
40-45 year 2 .6 don’t attending PNC (Table 2).
Family Size
<=3 211 62.1
Table 2: Maternal Health service utilization characteristics of
>=4 129 37.9
mothers of Newborn in Dessie Referral Hospital, North East
Mothers Marital status Ethiopia, 2018 (N=340)
Married 340 100 Variable Frequency Percent
Mothers Educational Status (N=340) (%)
Unable to read & write 49 14.4 Health Extension package graduate
Informal education 31 9.1 Yes 35 10.3
Primary education 86 25.3 No 305 89.7
Secondary education 109 32.1 Ever gone for medical purpose
Higher education 65 19.1 Yes 316 92.9
Mothers Religious status No 24 7.1
Orthodox 132 38.8 ANC follow up
Protestant 2 .6 Yes 338 99.4
Muslim 206 60.6 No 2 .6
Mothers Ethnicity Attending ANC service(N=338)
Tigre 1 .3 <=3 times 127 37.4
Amhara 322 94.7 >= 4 times 211 62.1
Oromo 17 5 Newborn danger sign counseling
Mothers occupation during ANC visit(N=338)
House wife 209 61.5 Yes 116 34.1
Gov’t work 77 22.6 No 222 65.5
private work 26 7.6 Place of delivery
Farmer 28 8.2 Health facility 329 96.8
Mothers Monthly income Home 11 3.2
<500 Birr 229 67.4 Delivery attendant
500-1000 Birr 8 2.4 Health professional 329 96.8
1001-1500 Birr 8 2.4 TBA 11 3.2
>1500 Birr 95 27.9 Mode of delivery
NO_ of children CS 96 28.2
<=3 308 90.6 Spontaneous vaginal delivery 188 55.3
>=4 32 9.4 Instrumental delivery 56 16.5
Husband Educational Status PNC follow up
Unable to read & write 46 13.5 Yes 145 42.6
Informal education 34 10 No 195 57.4
Primary education 52 15.3
Secondary education 75 22.1
Higher education 133 39.1 Knowledge of mother on Newborn
Husband occupation
private work 118 34.7
danger sign
Gov’t work 117 34.4 Only 58(17.1%) of respondents were
Farmer 72 21.2 knowledgeable about Newborn danger sign.
Other 33 9.7
Residence More than 155(45.6%) of the mothers
Urban 234 68.8 mentioned none of key danger sign. The
Rural 106 31.2
Neonate Sex most common danger sign recognized by
Male 215 63.2 mothers were; one hundred forty seven
Female 125 36.8
(43.2%) Poor sucking/Unable to feed,
55(16.2) fever, 54(15.9%) Frequent
Maternal health service utilization Vomiting and 53(15.6) fast breathing. Only,
characteristics 104(30.6%) of mothers had heard the term

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Vol.4; Issue: 4; October-December 2019
Mulugeta W/Selassie et.al. Knowledge, Attitude and Practice on Identification of Newborn Danger Signs and
Associated Factors Among Mothers attending Postnatal Clinics at Dessie Referral Hospital, North East
Ethiopia, 2019
Newborn danger sign and the most common
source of information was health
professionals (19.4%).

Fig3: Source of information about newborn danger sign

among mothers of newborn in Dessie Referral Hospital in
2019(N=340)

Attitude of Mothers towards Newborn

danger sign
Fig2: Knowledge of mother on Newborn danger sign in Dessie
Referral Hospital, North East Ethiopia, 2019 (N=340) Only 146(42.9%) of mothers had
favorable/positive attitude towards newborn
Table: 3 Knowledge of mothers on components of Newborn danger sign.
danger sign in Dessie Referral Hospital, North East Ethiopia,
2019 (N=340)
Variable Frequency(n=340) Percentage
Poor sucking/Unable to feed
Yes 147 43.2
No 193 56.8
Convulsion
Yes 23 6.8
No 317 93.2
Fast Breathing
Yes 53 15.6
No 287 84.4
Chest in drawing
Yes 23 6.8
No 317 93.2
Fever
Yes 55 16.2 Fig4: Attitude of mothers towards newborn danger signs at
No 285 83.8 Dessie Referral Hospital, North East Ethiopia, 2019 (N=340)
Hypothermia
Yes 12 3.5
No 328 96.5 Mothers practice on Newborn danger
Unconsciousness sign at Dessie Referral Hospital
Yes 9 2.6
No 331 97.4
Jaundice
Yes 6 1.8
No 334 98.2
Frequent Vomiting
Yes 54 15.9
No 286 84.1

Fig 5: Practice of mothers on newborn danger signs at Dessie

Referral Hospital, North East Ethiopia, 2019 (N=237)

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Vol.4; Issue: 4; October-December 2019
Mulugeta W/Selassie et.al. Knowledge, Attitude and Practice on Identification of Newborn Danger Signs and
Associated Factors Among Mothers attending Postnatal Clinics at Dessie Referral Hospital, North East
Ethiopia, 2019
Among 237 mothers who got sick sickness/illness, majority of 78(32.9%)
their newborns the general proportion of newborns was experienced poor
appropriate practice for newborns danger sucking/unable to feed followed by
sign was 92.8% and 17(7.2%) of them 48(20.25%) fast breathing and 31(13.1%)
sought non-medical care for neonatal danger Hypothermia. Among 237 mothers who got
signs. Among 17 mothers who sought non- sick their newborns 221(93.2%) were taken
medical care, 10(4.2%)was taken no action action within 24 hours and 16(6.8%) were
and 4(1.7%) of mothers sought spiritual care taken action lately (>24 hr).
and 3(1.3%).Among 237 newborns who got

Fig6: Newborn danger sign experienced in Dessie Referral Hospital, North East Ethiopia, 2019 (N=237)

Fig7: Health seeking practice among mothers of newborn in Dessie Referral Hospital, North East Ethiopia, 2019 (N=237)

Bivariate analysis and multivariate The binary logistic regression

analysis analysis showed that mothers who live in
Factors associated with Newborn danger rural side, mother’s income >1500
sign practice Birr/month, both mothers and their husband
civil servant by occupation and Newborn

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Vol.4; Issue: 4; October-December 2019
Mulugeta W/Selassie et.al. Knowledge, Attitude and Practice on Identification of Newborn Danger Signs and
Associated Factors Among Mothers attending Postnatal Clinics at Dessie Referral Hospital, North East
Ethiopia, 2019
started immunization were significantly newborn danger sign as compared to those
associated with Newborn danger sign Husbands self employed by occupation.
practice (p < 0.05). In multiple logistic regression
Mothers who live in rural side were analysis; Mother’s income between >1500
3.061 (95%CI: 1.119, 8.377) times more Birr/month, mothers who live in rural side,
likely to have good practice on newborn mothers who has neonatal death history and
danger sign as compared to those mother mothers who has instrumental delivery were
who lives in urban. Mother’s income >1500 important predictors of newborn danger sign
Birr/month were 7.128 (95%CI: 2.364, practice.
21.492) times more likely to have good Mother’s income between >1500
practice on newborn danger sign as Birr/month were 8.194(AOR: 95% CI:
compared to those mothers whose income 2.583, 25.995) times more likely to have
were <500 birr/month. Civil servant mothers good practice on newborn danger sign.
were 3.109(95% CI: 1.036, 9.33) times Mothers who live in rural side were4.210
more likely to have good practice on (AOR: 95% CI: 1.41, 12.576) times more
newborn danger sign as compared to likely to have good practice on newborn
Housewife once. Civil servant Husbands danger sign. Mothers who has instrumental
were 4.778(95% CI: 1.281 – 17.819) times delivery were 9.843 (AOR: 95% CI: 5.148,
more likely to have good practice on 30.31) times more likely to have good
practice on newborn danger sign.

Table4: Factors associated with newborn danger sign practice among mothers of newborn attend in Dessie referral Hospital,
northeast Ethiopia, 2019
Variable Danger sign Practice Crude OR (CI; 95%) Adjusted OR (CI: 95%)
Good (%) Poor (%)
Residence
Urban 150(68.2) 7(41.2) 1 1
Rural 70(31.8) 10(58.8) 3.061(1.119,8.377)* 4.210(1.410,12.576)*
Mothers occupation
House wife 143(65) 7(41.2) 1 1
Gov’t work 46(20.9) 7(41.2) 3.109(1.036, 9.33)* .326(.068,1.561)
Private work 21(9.5) 1(5.9) .973(.114,8.308) .270(.023,3.133)
Farmer 10(4.5) 2(11.8) 4.086(.748,22.303) 2.373(.306,18.435)
Mothers Monthly income
<500 Birr 162(73.6) 5(29.4) 1 1
1001-1500 Birr 5(2.3) 1(5.9) 6.48(.634,66.214) 5.746(.538,61.419)
>1500 Birr 50(22.7) 11(64.7) 7.128(2.36,21.49) * 8.194(2.583,25.995) *
Husband occupation
Private work 86(39.1) 3(17.6) 1 1
Gov’t work 66(30) 11(64.7) 4.778(1.28,17.82) * 3.016(.671,13.552)
Farmer 43(19.5) 2(11.8) 1.33(.215,8.281) .399(.030,5.336)
Others 25(11.4) 1(5.9) 1.147(.114,11.512) .710(.056,8.942)
Immunization status
Started immunization 21(9.5) 6(35.3) 5.169(1.735,15.399) * 2.783(.796,9.726)
Not started 199(90.5) 11(64.7) 1 1
Newborn death history
Yes 56(25.5) 16(94.1) 46.857(6.075,61.418) 9.843(5.148,30.33) *
No 164(74.5) 1(5.9) 1 1
Mode of delivery
Cs 43(19.5) 16(94.1) 1 1
SVD 134(60.9) 0(0) 0.000(.000,0.00001) 0.000(.000,0.00001)
Instrumental delivery 43(19.5) 1(5.9) .063(.008,.492)* 0.062(.008,.492) *
Foot note:* means has statistical significance in binary and ** means has statistical significance in multivariate logistic regression

DISCUSSION danger sign found to be 92.8%, which

The Facility based study has indicated that appropriate newborn danger
attempted to identify the extent and factors sign practice was good in the study setting.
associated with newborn danger sign This figure is consistent with (90.56%), in
practice in Dessie Referral Hospital. The India. [20] While the proportion of
study revealed that practice of newborn appropriate newborn danger sign practice in

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Vol.4; Issue: 4; October-December 2019
Mulugeta W/Selassie et.al. Knowledge, Attitude and Practice on Identification of Newborn Danger Signs and
Associated Factors Among Mothers attending Postnatal Clinics at Dessie Referral Hospital, North East
Ethiopia, 2019
Dessie Referral Hospital to be higher than could be due to that those mothers being
the study done in Esera District, South West poor economic status might perceive that
Ethiopia(58.4.5%), Tenta District, North sought medical care is costly and
Eastern Ethiopia (41.3%), Jeldu District, ineffective.
South West Ethiopia(74.6%) and in Nigeria.
[17,21-23]
The difference might be because this CONCLUSION
study conducted in facility setting with The magnitude of newborn danger
populations who has better health seeking sign practice in these specific setting found
behavior. But the above study were to be good but the mothers knowledge and
conducted in community based setting. attitude towards newborn danger sign is
The study revealed that knowledge poor. Mother’s income >1500 Birr/month,
of mothers on newborn danger sign found to Mothers who live in rural side, Mothers who
be 17.1%, which indicated that mother’s has instrumental delivery were positive
newborn danger sign knowledge, was very predictors for newborn danger sign practice.
poor in the study setting. This figure is
consistent with in Gondar Town (18.2%), Recommendations
[19]
while the proportion of mother’s The findings from this study are
knowledge on newborn danger sign in intended to inform policy makers, planners,
Dessie Referral Hospital to be lower than other health professionals, mothers and
the study done in India (95.2%) and in community leader about newborn danger
Ghana (77.2%). [17,18] The difference might sign knowledge, attitude and practices. They
be because this study was included both can initiate policies and programs that
rural and urban residence. The population respond to the community needs, which will
character affects the health service and in turn improve coverage of skilled newborn
information access. This in turns leads to care and reducing neonatal morbidity and
negative effect on knowledge of newborn mortality. Therefore, any interested
danger sign. researcher shall conduct further study on
The study revealed that attitude of quality of ANC and PNC in focus of
mothers towards newborn danger sign found newborn danger sign to assess whether
to be 42.9%, which indicated that attitude of health professionals appropriately advise
mothers towards newborn danger sign, was and provide health information concerning
poor in the study setting. This figure is newborn danger sign and shall consider
consistent with in India (39%), Tenta further follow up study in community based
District, North Eastern Ethiopia (42.6%) inappropriate newborn danger sign practice.
and in Esera District, South West Ethiopia
(50.6%). [20,21,23] ACKNOWLEDGEMENT
Mother’s income >1500 Birr/month, First and for most our deepest thanks goes
Mothers who live in rural side, Mothers who to Wollo University and Dessie Referral
has instrumental delivery were positive Hospital postnatal unit for the chance to
predictors for newborn danger sign practice. conduct this research. Secondly, to our data
Mother’s income between >1500 collectors as well as our study participant
Birr/month were 8.194(AOR: 95% CI: for their commitment to be engaged in this
2.583, 25.995) times more likely to have study.
good practice on newborn danger sign. This
figure is consistent with in Esera District, Conflict of interest: Nil
South West Ethiopia those mother monthly
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Associated Factors Among Mothers attending Postnatal Clinics at Dessie Referral Hospital, North East
Ethiopia, 2019
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