TPB is considered as a useful model to predict human behavior and widely used in areas of health [16–19]. In this study the proportion of pregnant women who correctly know about neonatal care showed that knowledge were lacking for some items. Therefore the efforts should be made to increase it, and health workers in health centers should play a leading role.
Similarly in a study in Nepal participants had a moderate level of knowledge on newborn care (56%), and among its four components, participants had lowest knowledge in breastfeeding (44%) and adequate knowledge (78%) of immunization. Maternal education and socioeconomic status had a significant, positive association with newborn-care knowledge [20]. In another study in Kenia 28%, Ethiopia 18.2% and in Himalayas 52% of women had adequate knowledge about neonatal care [13–15]. The results of this study are consistent with our study.
Therefore the health educator and midwife in health centers should be provided for women regarding an importance knowledge and improve women’s motivation for neonatal care.
A systematic review of 30 studies by Schaaf et al. indicated that low socioeconomic status have a significant influence on neonatal care and increased risk of preterm birth [21]. Some causative factors on neonatal care includes deficiency of knowledge, poverty, adverse environmental conditions, access to quality health care, maternal health behaviors such as smoking or illicit drug use, and maternal stress [22].
In this study finding showed that correlation between mothers’ knowledge, intention behavior, age and level of education. In this study mother with higher education were more knowledge about neonatal care. Similarly in the study with Memon et al. about knowledge, attitude, and practice among mothers about newborn care in Sindh, Pakistan indicated that among the study sample, more than half of the newborns were bathed within six hours of delivery. Around 50% started breastfeeding after 1 h of birth. A substantial proportion (45%) of mothers gave pre-lacteal feeding and 44.8% of them did not feed colostrom to their newborns. Mothers with no education had less significant KAP score about newborn care as compared to those who had higher education [23].
According to this study health worker and midwife in health center and spouse were the most subjective norm that influence on the knowledge, attitude of mothers about neonatal care.
This finding is consistent with the results of other studies for example in Vietnam showing that Fathers' support can influence mothers' breastfeeding decisions and behavior [24].
Therefore health worker and midwife need to gain the knowledge, attitudes, and adequate skills to deliver culturally competent care, including tools on how to effectively communicate with pregnant mothers or families from diverse cultural, socioeconomic, and level of education. Application of culturally appropriate communication is crucial. This will in turn help elicit helpful dialogue with pregnant women and families that will encourage them to ask questions in health centers and communicate their concerns more clearly to ensure the best delivery of the highest quality of neonatal care for every pregnant women. Beside the health worker, delivery health information through Mass-medias such as televisions, radio and booklet about neonatal care would change the women’s misconception that would improve their service utilization.
This study also revealed that attitude towards neonatal care was positive associated with intention to neonatal care. Respondents who had a positive attitude towards neonatal care more likely to have intention than those who had a negative attitude. A similar result was reported in China which identified attitude women towards cervical cancer screening as the most significant factor that affects intention [25].
More than half of the mothers interviewed under the present study lacked the necessary knowledge to baby visit after birth, bathing the baby, baby holding temperature. Another study in China observed that 48.2% of the participants reported practicing neonatal care and range of score for each scale was knowledge 0–16 (M = 9.62), perceptions 28–103 (M = 79.99), barriers 17–85 (M = 65.40) and practice 11–55 (M = 34.44) [26].
In this study knowledge about neonatal jaundice 33% had inadequate knowledge but in study Amegan et al. about awareness, perception and preventive practices about neonatal jaundice in mothers in Accra showed that 92.6% did not know the causes of jaundice or had the wrong information and there was no significant association with their level of education [27]. In study Goodman et al in Nigeria showed that 68.9% of the mothers had a poor level of knowledge about neonatal jaundice. In this study age and educational qualification did not show any statistically significant relationship with knowledge about neonatal jaundice [28].
With considering neonatal jaundice is a preventable cause of neonatal morbidity and mortality. Therefore an improving pregnant mothers' knowledge will help with early recognition of neonatal jaundice, prompt and appropriate intervention.
According to this study considerable number of mothers lacked knowledge (73%) the proper temperature of the baby's room. These findings are considered low when compared with a study conducted in North Ethiopia, where 99.3% of the participants had the knowledge about temperature of the baby room [29]. This difference could be related to the difference in study participants in two countries Iran and Ethiopia.
This study revealed that the proportion of mother having adequate knowledge about benefits of breastfeeding (86%) and colostrum's (74%) which is almost similar with the findings in study in Jimma (66.4%) [30]. On the other hand, knowledge of the study participants in this study is slightly higher compared with study in Uganda (47%) [31]. This might be due to slight variation in the tools used and socio-economic variable in participant in countries
In study of Chhetri et al. about newborn care practices at home finding showed that initiation of breastfeeding was practiced by only 40% of mother. Among neonates, 65% were given colostrums and hand washing was practiced by 62.5% before touching the baby. For thermal care, burning charcoal (75%) was mostly used. The study revealed association between newborn care and mother education and per capita income of family [32].
According this study 40% of pregnant women knowledge about bathing the baby. In the study in Pakistan (32%) and Southern Tanzania (60%) of respondents stated that they bathed their newborns within six hours after birth [33–34].
The results also show that over 47% of mothers did not have any knowledge about take care of the baby's umbilical cord, 60% did not have any knowledge about how to bathing the baby.
In contrast another study in Jordan [35] and Arab society [36] which showed that neonatal care in mothers most lacked knowledge.
The mothers also showed a lack of knowledge about to visit the baby on the days after birth by health care (59%). Based on this study health workers at health centers must have been knowledge enough to advise pregnant women to have visit neonatal after birth.
In this study intention behavior for neonatal care was 4.4 score. Similarly in study Andre et al. about influential factors in influenza vaccination during pregnancy showed that, 76% of pregnant women had received the influenza vaccination. Intention of women for vaccination was the desire for neonatal protection, the common reasons for not being vaccinated were not receiving information on vaccination or safety concerns [37].
In this study 22% of mothers don’t know recognizing danger sign in neonatal. Welay et al in study indicated that a knowledge score of neonatal danger signs was found 32.9%. Mothers educated to secondary level and mothers whose husband educated to college and above were 4.9 times more likely to know about neonatal danger signs [8].
This study tested the applicability of the knowledge and perceived behavior control R2 = 32% in the prediction of neonatal care intentions. In fact the findings of this study show partial support for the predictive ability of the theory of planned behavior in predicting intentions in pregnant women for neonatal care.
In Wang study about predicting women's intentions to screen for breast cancer R2 = 8.3% in the prediction of breast cancer screening intentions [38]. Sun et al in another study about predicting iron consumption intention in women showed that the model explained 35–55% of the variance of behavioral intention [39].
In fact TPB assumes that attitude, subjective norms, and perceived behavioral control lead to the development of a behavioral intention and so the behavioral intention is the immediate antecedent of behavior [40].
Our study findings reflected that perceived behavior control were significant construct of TPB to intention behavior for neonatal care among mothers. The present study had some limitations. The research is a cross-sectional study, and all independent and dependent variables were measured in a single point of time. All variables were self-reported, which may lead to misclassification due to recall and reporting bias. This limitation was resolved by allocating sufficient time and explicit expression of the objectives of study, and gathering information along with interviewing. Further research with larger and more diverse samples was suggestion.
Regardless of these limitations, this study has advantages. One of the strengths of the present study is that the design of the protocol based on theory center for asses neonatal care.
Cognition is a critical process to practice good health behavior. Theoretical based research can help to understand the cognition elements better. The TPB constructs of perceived control behavior and attitude explain significant to increase intention behavior among pregnant women about neonatal care.
Finally, it can be said that this study show support for the predictive ability of the TPB in predicting for neonatal care therefore the design of educational intervention should be based on intention and knowledge as the most important predictors of maternal behavior