Knowledge On Neonatal Danger Signs And Associated Factors Among Mothers Who Gave Birth In The Last One Year Prior To This Study In Debre Markos Town, East Gojjam, Northwest Ethiopia 2017: A Community Based Cross Sectional Study

Birhanu Wubale Yirdaw (  Birhanuwubale@gmail.com ) University of Gondar College of Medicine and Health Sciences Marta Berta Badi University of Gondar College of Medicine and Health Sciences Temesgen Worku Gudayu University of Gondar College of Medicine and Health Sciences Animut Tagele Tamiru University of Gondar College of Medicine and Health Sciences Getie Lake Ayinalem University of Gondar College of Medicine and Health Sciences Simachew Animen Bante Bahir Dar University College of Medical and Health Sciences Samuel Abebe Dessalegni Arba Minch University College of Medicen and Health Sciences

Neonates often present with non-speci c symptoms and signs that indicate severe illness. Such signs might be present at or any time after delivery within the neonatal periods, the rst 28 days following birth. The signs include: not feeding well, convulsions, drowsy or unconscious, movement only when stimulated or no movement at all, fast breathing(60 breaths per min), grunting, severe chest in-drawing, raised temperature(> 38 °C), hypothermia(< 35.5 °C) and central cyanosis (5).
Recognizing the occurrence of these signs will results in high overall sensitivity and speci city to predict the need for seeking treatment of the new born(6).
Reducing neonatal mortality is increasingly important not only because the proportion of under-ve deaths that occur during the neonatal period is increasing as under-ve mortality declines but also because the health needed to address the major causes of neonatal deaths generally differ from those needed to address other under-ve death (7).Neonates are more prone to show subtle signs of illness, and the three major causes of neonatal deaths worldwide are infections, diarrhea (36%), pre-maturity (28%) and birth asphyxia (23%)(8-10).
Morbidity and mortality from these diseases can be reduced considerably if care is sought early. Thus, in low and middle income countries like Ethiopia, the ability of mothers to recognize the common danger signs of neonatal illness and seek appropriate care is instrumental in reducing under-ve children deaths. This is only possible if mothers' knowledge regarding the neonatal danger signs is good enough to make decision to seek health care service Methods A community based cross-sectional study was conducted from September 24 to October 16, 2017 in Debre Markos Town, which is found in East Gojjam zone, Amhara Nation Regional State. Menkorer was the former name of the town which was established in 1845 E.C. the town was established at the altitude of 2420 -2509 meters above sea level and located 300 km away from Addis Ababa, the capital city of Ethiopia and 265 km from Bahir Dar, the Amhara region capital. The town has average annual temperature of 16 0 C and average annual rain of 1308 mm 3 . The town is organized into 07 kebeles and based on 2007 E.C census the town has total population of 101, 582 of whom 52, 827 were women and 48,755 were men all allocated with an estimated area of 600 square kilometers. In the town there are 3 health centers, 7 health posts, 17 clinics, 21 drug dispensers and 01 referral hospital.
All mothers who gave birth within the last 12 months and who were living in Debre Markos town were source populations. The Study population for this study included all mothers who gave birth within the last 12 months in the selected 'kebeles' who were available during the study period. And then, all mothers who gave birth within the last 12 months in the selected 'kebeles', at household level were considered as study units.
Mothers who lived in the study area less than 6 months, mothers who had still birth for the recent delivery and those who were mentally and physically incapable to give response during the data collection were excluded.
The sample size was calculated by using the single population proportion formula with the assumption of 95 % CI, and 18.2% proportion of mothers' good knowledge on neonatal danger signs (11). Considering the design effect of cluster sampling (2) and possible non -response rate during the survey (10 %), the nal sample size required was 504.
Cluster sampling technique was used to select the study units by considering kebeles as clusters. Out of 7 kebeles (clusters) in the town; three clusters (C2, C 4 and C 5) were selected by simple random sampling by using balloting method. Then all eligible mothers in the selected clusters (521) were included in the study. Tottery method was used to select one participant when two or more eligible mothers were available in the same household.
The independent variables were categorized into three sections: socioeconomic and demographic variables; (age, marital status, parents' educational status, occupational status, economical status, religion and ethnicity), obstetrics related factors: (parity, Ante natal care, BPCR, SBA, place of birth, mode of delivery and PNC) and other health related: (woman's' autonomy on health issues, income, source of information and access to media. The dependent variable in this study was being knowledgeable or not for neonatal danger signs. Those study participants who mentioned as many danger signs as the calculated mean value (three) and above to unprompted knowledge related list of WHO identi ed danger signs.
Data was collected by face to face interview using a structured and pre-tested questionnaire. The questionnaire was rst prepared in English and translated to Amharic, and then back to English after minimal amendment was done. Five diploma midwives were allocated to collect data. Two BSc midwives from Debre Markos hospital were assigned to supervise the data collection process. Both the data collectors and supervisors were given one day training before the actual work regarding WHO neonatal danger signs, the aim of study, procedures and collection techniques going through the questionnaires, art of interviewing and ways of collecting the data.
After obtaining oral informed consent, trained data collectors interviewed mothers regarding newborn danger signs. Mothers with children under-1 year were asked to list signs they considered serious health issues and could potentially endanger the life of neonates. They were also requested to list any of these signs they have had personally experienced and the initial actions they took. The danger signs listed by mothers were organized and grouped into eight WHO recognized danger signs (12).
Every day after data collection, questionnaires were reviewed and checked for completeness and relevance by the supervisors and principal investigator and the necessary feedback was offered to data collectors in the next morning and before end up incomplete questions were complete using pre-coded and for controlling errors during data analysis, 10% of the questionnaire was double entered into the software and also frequency check was done.
Epi-Info 7 was used to input the raw data. Data cleaning was done. SPSS 20 was used for data analysis.
Chi-square and logistic regression statistical instrument was also used to establish the relationship between knowledge of WHO recognized danger signs and other explanatory variables. Results were presented in percentages, odds ratios and 95% con dence intervals where appropriate. Statistical signi cance was set or considered at p-value <0.05.
Ethical clearance was obtained from Midwifery department though delegation from institutional ethical review board of university of Gondar. Formal letter of cooperation was written for Debre Markos health o ce and respective kebeles. Following this permission was obtained. Verbal informed consent was obtained from each study participants, each respondent was informed about the objective of the study that it would contribute to improve child health. Any involvement in the study was after complete consent obtained. Any mother who was not willing to participate in the study was not forced to participate. They were also informed that all data obtained from them would be kept con dentially by using codes instead of any personal identi ers and is meant only for the purpose of the study.

Results
Socio-demographic characteristics of study participants A total of 521 mothers, who gave birth within the last one year prior to the data collection, were included in the study with 91.0% response rate. The largest proportion of respondents was between the ages of 25 and 34(59.40%). The minimum and maximum ages of the sample were 15 and 39 respectively with the mean age of 27.45 (SD ± 5.12) years (Table 1).

Obstetrics related characteristics
Among the interviewees, 269(56.9%) had attended ANC for their last pregnancy and only169 (35.7%) had four and above ANC attendance, which is the recommended number of visit. Eighty eight (18.6%) mothers gave birth at home. Of whom, 48 (54.6%) were attended by traditional birth attendants. Three hundred eighty-ve (81.4%) mothers gave their last birth at a health institution ( Table 2).

Women's knowledge of newborn danger signs
Knowledge of at least one of the de ned key danger signs was present in 72.5% of all women: however, only 37.2% could name at least two signs. Forty two (26.2%) mothers were knowledgeable about neonatal danger sign (95% CI 22.2, 30.4). At least four, ve danger signs were correctly listed by 26.2, 17.3 and 6.3% of the respondents respectively while only 3.3 and 1.0 % correctly listed up to six and seven WHO recognized danger sign respectively ( Table 3). The most commonly reported source of information was health professionals.
''Fever'' was the most commonly known danger sign and referred to by 44.6% of the participants. The least known danger signs were ''skin rash'' and ''convulsion'', stated by less than 10.0 % of the respondents (Fig. 1).
Women's' experience and health care practice One hundred twenty two (25.8 %) of the respondent had noticed one or more of the danger signs in their current child when s/he was a neonate. Of whom, 55.7 and 7.4% took their child to government hospital and private clinic immediately without any home intervention respectively. Eleven (9%) of these mothers did nothing while the remaining 34 (27.8%) did the following: gave self-medication without physician order 7 (5.7%), contact traditional healer 21(17.2%) and 6(4.9%) used other home interventions. 'Other' home interventions included sponging with cold water for fever, exposure to sunlight for jaundice, massage with oil for hypothermia, and bathing with rice water for rash ( Fig. 2 and Fig. 3).

Factors associated with mothers' knowledge about neonatal danger signs
As shown in the logistic regression analysis table, on bivariate analysis the factors found to be signi cantly associated with mothers' knowledge about neonatal danger signs were: parent higher educational achievement (mother and husband), parity, ANC practice, being prepared for birth, PNC follow up and accesses for mass media (radio and television).
From this factor variables, parent higher educational achievement, ANC practice, being prepared for birth, PNC follow up and access for television were signi cantly associated with the dependent variable in multivariate logistic regression analysis (Table 4).

Discussion
This study revealed that, the proportion of knowledgeable mothers was found to be 26.2%. This nding is in line with neonatal danger signs knowledge level reported in Afghanistan (28%) (13)and four regions of Ethiopia (29%) (14) but it is higher than the knowledge level reported in India(13.9%)(15), Ethiopia (18.2%) (11) and Ghana (20.3%)(16). The inconsistency might be because of the unprompted questions used for assessing the danger signs and time, measurement and cultural differences.
Mothers' education is an important determinant factor for the outcome variable. Mothers having secondary and tertiary level education were nearly four times (AOR=3.64, 95% CI 1.14, 11.61 and AOR=3.80, 95% CI 1.25, 11.56) more likely to be knowledgeable on neonatal danger signs as compared to mothers who can't read and write. This could, possibly, be justi ed by the fact that educated mothers acquire general knowledge about family health issues through their formal education (11). However, this nding is dissimilar from studies reported in Uganda(17) and AIJRHASS(18).The variation might be due to the deference in study setting.
Fathers' education was also a signi cant factor for mothers to be knowledgeable. The odds of being knowledgeable about neonatal danger signs was four times among mothers whose husbands attained secondary (AOR=4.22, 95% CI 1.53, 11.60) and tertiary education (AOR=4.34, 95% CI 1.52, 12.37). The best explanation for this could be fathers' status in decision-making might positively in uence mothers' knowledge on neonatal danger signs.
ANC and PNC attendance generates a superior opportunity for the mothers to be knowledgeable about danger signs of neonatal illness. Antenatal and postnatal care attendant mothers were nearly four times (AOR = 3.54, 95% CI 1.62, 7.75) and more than two times (AOR = 2.41, 95% CI 1.13, 5.14) more likely to be knowledgeable towards neonatal danger sign as compared to non-attendant mothers respectively. This could be strongly accepted as mother's exposure to ANC and PNC package increased the knowledge of the mothers concerning newborn health issues.
Having BPCRP was also found to be signi cantly associated with being knowledgeable on DSNOIs. Mothers who had BPCRP were more than two times (AOR = 2.43, 95% CI 1.20, 4.89) more likely to be knowledgeable as compared to their counterparts. This nding was supported by studies conducted in Ghana(16) and India (15). This might be due to; mothers who had BPCRP were having more exposure about child health issues.
Moreover, television accessed mothers were found to be knowledgeable on neonatal danger signs. Television accessed mothers were two times (AOR = 2.06, 95% CI 1.01, 4.21) more likely to be knowledgeable than their complement. This nding was supported by a study conducted in Ghana(16) and Gondar, Ethiopia (11). This might be due to television airtime programs which are dedicated to teach the community about health issue of mothers and children.

Limitations
Its cross-sectional nature affects the establishment of the cause and effect relationship between maternal knowledge regarding the danger signs and the factors that were identi ed. And also, the unprompted knowledge questions and relatively longer recall period might bias the true knowledge level of the mothers.

Conclusions
The proportion of knowledgeable mothers (those mothers who listed at least three WHO identi ed key danger sign of neonatal illness) was found to be low. The most commonly reported source of information about WHO identi ed DSONI was health professionals and among the DSONIs, fever was the most known and most experienced or noticed by mothers.
Mothers' and husbands' higher educational achievement, attending ANC, having BPCRP, receiving PNC package and access for television were found to be signi cantly associated with being knowledgeable on neonatal danger sign.

Recommendations
Debre Markos Zonal Health Department shall promote antenatal and post natal care package utilization for all mothers who are pregnancy or after giving birth till 6wks, especially for the rst one month. Debre Markos Zonal Education Bureau shall give a priority target for intervention modalities such as encouraging parent education, up to the level of college and above, so as to increase mothers' knowledge on DSONI.
Obstetric care providers should ensure that every pregnant and recently delivered woman needs to have a BPCRP. It would also be helpful if a supplemental qualitative research is conducted, mainly focusing on reasons why mothers do prefer to seek care for sick neonates other than health facilities. Ethical approval was obtained from the Institutional Review Board of College of Medicine and Health Science, University of Gondar. Letter of permission was obtained from Amhara National Regional Bureau and Debre Markos town administration o ce. Both written and verbal consent was obtained from study participants after the purpose of the study was explained. Written consent was received from adult nextof-kin when the respondent was less than 18 years of age and verbal assent was obtained from less than 18 years age of participants. Participants were informed that participation was voluntary and they could withdraw at any time. Personal identi ers were not included in the questionnaires to ensure participant con dentiality.

Consent for publications: Not applicable
Availability of data and material: The data sets generated during the study are available from the corresponding author upon request.
Competing interest: The authors declare that they have no competing interests Funding: This work was funded by University of Gondar for data collection. The funder had no role in study design, data analysis, and interpretations of data or writing of manuscript.
Authors' contributions BWY wrote the proposal, led study design, analyzed the data, drafted the manuscript and ensured that all authors approved the manuscript before submission.
MBB revised subsequent drafts of the paper, approved the proposal and reviewing the manuscript.
TWG revised subsequent drafts of the paper, approved the design and reviewing the manuscript.
ATT approved the design and reviewing the manuscript.
GLA involved in data analysis and reviewed of the manuscript. SAB approved the proposal and reviewed the manuscript.