Community Based Essential Newborn Care Practices and Associated Factors among Women Who Gave Birth at Home in Last Twelve Months in Amaro Woreda, Southern Ethiopia, 2019

Introduction:- Significant numbers of women are giving birth at home; in this case community based newborn care is a means of bringing life-saving care to mothers and newborns at the community level. However, practice is challenging within the Ethiopian health system. Objective:- The aim of this study was to assess prevalence of community based newborn care practices and its associated factors among women who gave birth at home in Amaro Woreda, southern Ethiopia, 2019. Methods:- Across-sectional study was conducted on 490 women in the reproductive age groups of 15-49 in Amaro district and by using simple random sampling technique individual was recruited. Data collected through face-to-face interview at household level. EpiData version 3.1 statistical software was used for entry and SPSS version 20 for was used for data cleaning, management and analysis. Bi-variate and multivariate logistic regression analysis employed for analysis of factors associated with Community based newborn care practices. Results:- A total 490 of study participants were included in the analysis and only 29% practiced community based essential newborn care. Educational status of father AOR=2.28; 95%CI:1.07-4.84 & mother AOR=0.35; 95%CI: 0.16-0.75, last delivery assisted by relative/friends AOR=3.58; 95%CI: 1.66-7.73, having awareness about Community based newborn care AOR=3.49; 95%CI: 2.11-5.77, awareness about newborn danger sign AOR=2.18; 95%CI: 1.29-3.68 and having birth preparedness and complication readiness plan AOR=3.52; 95%CI: 1.97-6.29 were an identified independent factors associated with Community based newborn care Practice. Conclusion and recommendation:- Around three-fourth (71%) of mothers were not practicing Community based newborn care. Educational status of family, awareness about


Introduction
Community based new born care (CBNC) is a means of bringing life-saving care to mothers and newborns at the community level within the Ethiopian health system (1). Through CBNC, the government aims to strengthen the primary health care unit (PHCU) and the Health Extension Program, which is a platform for community-based primary care delivery (1). Building on lessons learned from Integrated Community Case Management of childhood illness (ICCM), the implementation of CBNC used the following guiding principles to ensure rapid, high-quality implementation: government leadership and ownership, spanning the continuum of care, balance between preventive and curative care at the community level, quality service, community participation, strong health system support and phased implementation approach and partnership (2).
The goal of CBNC program is to reduce newborn mortality through strengthening the Globally, around 4 million neonatal deaths occur annually, which accounts for 38 percent of under-five mortality. A similar number of babies are still born and 99% of all neonatal deaths occur in low and middle income countries (4). As Ethiopian Demographic and Health Survey (EDHS) 2016, the neonatal mortality rate was 29 deaths per 1,000 live births. The risk of death is highest in the first 24 hours of life when more than half of deaths occur and about three-quarters of all neonatal deaths occur within the first week of life (5).
Despite Ethiopia's remarkable reductions in infant and under-5 mortality and achievement of Millennium Development Goal (MDG) four three years ahead of the deadline, the reduction in neonatal mortality has not been as impressive (1). The 2016 EDHS results show that the neonatal and infant death for the 5 years before the survey is 29 & 48 deaths per 1,000 live births, respectively. In other words, in Ethiopia 1 in every 35 children dies within the first month and 1 in every 21 children dies before celebrating the first birthday (6). Although Ethiopian government did many health interventions such as training health workers, enhancing referral system, integrating health services, implementing packages of Health Extension Program (HEP) and routine immunization, neonatal death is still high, even one of the top ten countries in Africa (7,8). The finding of studies conducted in different area of Ethiopia with regards to the level of CBNC practice documented that there is low comprehensive practices of essential new born care practices (9,10). A family community package promoting good home care of the newborn particularly cleanliness, warmth provision, and exclusive breastfeeding would have an expected reduction in the NMR of 10 to 40 percent, varying with the baseline NMR and the potential for accessing care. The effect might be greater if the package successfully addressed harmful local practices.
As the indication of EDHS 2016 the proportion of home delivery nearly 83% in Ethiopia the probability of maternal and newborn health, need more investigation for better planning and promotion on maternal and newborn health. Outreach services such as prenatal care alone have an effect of about 10 percent on NMRs, but when they are combined with a family package using community health promoters, an additional 30 percent reduction in the NMR is projected in Ethiopia (11).
As indicated on 2017/2018 annual report of Segen Area People Zone maternal and newborn health report performance of ANC 4th 63 %, and skill delivery coverage 71 %.In addition to this, specific to Amaro district government report reveals that postnatal care service coverage 68 %, and skill delivery coverage 32.09 %. Therefore, obtaining evidence on level of Community on Essential Newborn Care Practices and its associated factors will facilitate the interventional measures to avert the preventable factors of neonatal death.
Hence, this study aimed to assess community based essential newborn care practices and associated factors among women who gave birth in the last 12 months preceding the survey in Amaro woreda southern Ethiopia, 2019.

Methods And Materials Study area, Design and Period
This study conducted in Amaro district in Segen Area Peoples Zone, Southern Ethiopia. The district is located 695 km south of Addis Ababa and 465 km still south of the regional capital city Hawassa. The district has a total of population of 193,219 in which 25,505 women are in childbearing age. In the district, there are 33 rural kebele and 2 urban kebele. In the district, there are one primary hospital, seven health centers, 39 health posts and 25 private health facilities deliver health care service (21). Health Extension workers at health posts are providing maternal, child and neonatal services like ANC, PNC, Immunization, growth monitoring, outpatient therapeutic program, ICCM/CBNC and first aids. At community level, Heath extension workers are performing preventive health services through regular home to home visits and curative services at health post (22,23).
A community based descriptive cross-sectional study was conducted from January-February 2019 in Amaro district, Southern Ethiopia.

Population, Sampling Determination and Sampling Procedure
The source population was women in the reproductive age group of 15-49 years who were practicing home delivery in Amaro district. Accordingly, women of reproductive age groups who gave live birth at home in the last 12 months' period preceding the survey was taken as study population. To take adequate sample size from study population, sample size for study was determined by single population formula by consideration of a desired level of confidence (95%), margin of error (5%), non-response rate (10%), design effect (1.5), the estimated prevalence of community based essential newborn care practices (26.7%) [10].
the final sample size for this study was 495.
To make the sample is more representative; around 31% (11) out of 35 kebeles of Amaro district were selected using lottery method. Then, proportional allocation of size to kebele was made. Finally, computer random generated number was employed to recruit the mother from family folder in community health information system. However, the mothers who delivered in the health institution, mothers who are caregivers to babies whose mother is lost, those mothers who were seriously sick during data collection and mothers who recently delivered died fetus was excluded from the study.

Variables of the study and Operational definitions
Community Based Essential Newborn Care Practices is outcome , while age of mother, education of mother, education of father; sex of neonate, occupation of mother, 0ccupation of father, n umber of pregnancy, number of delivery, number of children, number of ANC visits, attendant at birth, birth preparedness plan, mothers awareness about newborn danger signs, counseling from a health extension worker (HEW) or advice from a CHV (WDA leader), exposure to media and husband involvement.
Community Based Essential New Born Care Practiced: In this study those mothers who practice all the three essential new born care practices (delayed bathing, safe cord cutting and early initiation of breast feeding within one hour of birth) are said to be practiced ( 9).
Delayed bathing: The recommended practice of bathing a new born by delaying for at least the first 24 hours of birth to reduce the risk of hypothermia(10).
Early initiation of breast feeding: The recommended practice of putting a new born to the mother's breast within one hour of birth (10).
Safe cord cutting: Safe cord cutting means practice of cutting a new born cord with help of the instrument from clean home delivery kit, a new blade or a boiled blade (15).

Data collection methods and tools
Structured questionnaires were designed in English version and translated to Amharic and local language. Pre-test was carried out on the 10% of sample size at Burji District which is one of neighbor district and necessary correction was made prior to the actual data collection. The data was collected by four BSc graduate professional in health at selected households. Training was given for data collectors and supervisor on the objectives of the study, the content of the questionnaire, issue related to confidentiality of the responses and rights of the respondents during data collection. They also have informed about proper data handling, systematic answers for respondents' questions. data was collected by using face to face interviews. Supervisors checked data for completeness daily after data collection and principal investigator also randomly cross-checked the data before entry. Finally, the overall data collection process was controlled by the principal investigator.  (Table 3).

Discussion
This study aimed to assess community based essential newborn care practices and associated factors among women who gave birth at home in the last 12 months preceding the survey in Amaro woreda southern Ethiopia. Of the total study participants included in the analysis, 142(29%) were practiced CBNC. However, 60.2 % neonate received clean cord care, 63.1% mothers initiated breast-feeding within one hour and 59.5% received appropriate bathing, which is comparable with study conducted in Southwest Ethiopia ( 18).
The prevalence of community based essential new-born care (CBNC) practice in this study is considered to be higher as compared to other studies reports from Amhara (23.1%) and Aksum (26.7%) (9,10). This discrepancy may be due to the fact that some of the former studies include both home and facility delivery.
In the current study, paternal education was found to have statistically significant association with community based essential newborn care practices.  (9,(17)(18)(19). This might be due to the fact that education in the real world has a positive significant effect to practice any healthy life for mothers and children as well families. However, in the current study mothers able to read and write were 65% less practicing CBNC than illiterate mothers. It need further investigation.
Mothers who had her last delivery at home by assisted with relatives or friends were found to be 3.58 times more likely practicing CBNC than those assisted by HW at home This may be due to poor quality of counseling by HEW or HWs results in strong peer pressure to change their view towards CBNC practice.
Having awareness about CBNC is the most important reported factors in the population (15,19). Besides of the above reported risk factors the level of practicing the community based essential new-born care (CBNC) was 3.49 times highly common among those mothers who had awareness about CBNC than those who did not informed. Neonatal danger has become a substantial problem in many developing countries like Ethiopia. In this regard, health-seeking behavior of mothers for neonatal care highly relies on their knowledge about neonatal danger sign, and it has been hardly investigated (24).
In this community-based study, individuals who had awareness about newborn danger sign were 2.18 times more likely practicing community based essential newborn care (CBNC) as compared to the counterpart. The finding in this study considered to be in line with a community based study conducted in Enugu state, South-East Nigeria and North West of Ethiopia (24,25). This finding might be due to the fact that those mothers who had a positive awareness about neonatal danger sign experienced of how to practice CBNC.
comprehensive strategy and matrix that includes shared responsibility among the woman and her family, the community, healthcare providers, facilities that serve them, and the policies that affect care for the woman and the newborn (26). Accordingly, the likelihood of Community based essential new-born care (CBNC) practice among those having birth preparedness and complication readiness plan was 3.52 more prone to practice CBNC than counterpart. This finding was in line with finding in Kofale District, South East Ethiopia (26) and it was found to be due to the fact that having birth preparedness and complication readiness plan positively affect the mothers practice to ward community based essential new born care.
Unlike many other study findings, this study did not reveal any association of community based essential new-born care (CBNC) practice with number of ANC visits during last pregnancy, number of last fetus, early PNC for last birth by HEW and counseling about CBNC in the last 12 months. This might be illustrated by variations related to study population, setting, socio-demographic, socio -economic and cultural difference.
One of the strength of this study was findings can be generalized to similar settings and population in other parts of the country since this study is primary data and a community based study.

Conclusion
In conclusion, around 71% of mother who give home birth and participated in this study were not practicing essential newborn care, which is fare lower than many other studies.
The study identified both positive and negative factors towards to CBNC practice.
Accordingly, having formal paternal educational, delivery assisted by relative or friends, having awareness about CBNC, having awareness about newborn danger sign and having birth preparedness and complication readiness plan were positively affecting an essential

Availability of data and material
The datasets used for current study is available from the corresponding author on reasonable request. divorced, single) , Others*** (Merchant and Government employee).  **Significance at p_ value <0.001, * significance at p_ value <0.05. Figure 1 Community based newborn care practice status of study participants, Amaro district