in Dairy R OPEN ACCESS Freely available online

es

Advances in Dairy Research

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earch
ISSN: 2329-888X

Research Article

Assess the Level of Knowledge and Health-Care Seeking Behavior about

Who Recognized Neonatal Danger Signs and Associated Factors among
Mothers in Gasera District, Ethiopia
Fikadu N. Dessalegn1, Tilahun E. Wanamo2*, Debebe W3
College of Medicine and Health Sciences, Department of Public Health, Goba Referral Hospital, Madda Walabu University, Bale Goba,
1,3

Ethiopia; 2*College of Medicine and Health Sciences, Department of Public Health, Goba Referral Hospital, Madda Walabu University,
Bale Goba, Ethiopia

ABSTRACT
Background: Globally, in 2015 there were an estimated 2.7 million neonatal deaths which represents 45% of all
deaths among children under five. In Ethiopia, according to WHO neonatal mortality rate is still high 29 per
1,000 live births. The majority of these new born deaths occur at home where a few families recognize signs of
newborn illness and delays in decision to seek care at household level. However, different studies focus mostly on the
prevalence of neonatal death and essential newborn care practice disregard of mother’s knowledge about neonatal
danger sign and their health care seeking behavior which is one of the critical delays in neonatal illness.
Objective: This study was intended to assess the level of knowledge and health care seeking behavior about WHO
recognized neonatal danger signs and associated factors among mothers in Gasera district, Ethiopia.
Methods: A community based cross sectional study design using quantitative supplemented with qualitative methods
was conducted from March 12 to April 10, 2017. Stratified multistage sampling and purposive sampling method
was used for quantitative to select 501 mothers and qualitative method respectively. Data entering and coding
were performed with Epidata 3.1 and analyzed by SPSS version 20 using descriptive, bivariate and multivariate
techniques. Thematic qualitative data analysis was also used.
Results: Mothers who had knowledge of neonatal danger signs were found to be 26.0%. The odds of having
good knowledge was positively associated with husband’s formal education (AOR=2.33, 95% CI 1.24, 4.53), birth
preparedness (AOR=3.04, 95% CI 1.68, 5.52), health extension workers home to home visit (AOR=5.45, 95% CI
2.78, 10.7), receiving family health card (AOR=7.52, 95% CI 4.10, 13.82), PNC follow up (AOR=2.52, 95% CI
1.30, 4.92) and television access (AOR=3.15, 95% CI 1.55, 6.40). About 182(55.8%) of the mother sought medical
treatment for their newborn while only 31.3% sought immediate medical treatment within 24 hour. Likewise, the
odds of having good health care seeking behavior for neonatal illness was statistically positively associated with
maternal knowledge towards neonatal danger sign (AOR=2.56, 95% CI 1.18, 5.54), family income (AOR=2.10, 95%
CI 1.15, 3.81), PNC follow up (AOR=2.24, 95% CI 1.24, 4.05), and receiving family health card (AOR=3.04, 95%
CI 1.38, 6.70).
Conclusion: This study showed maternal knowledge about neonatal danger signs and health seeking behavior
was low. Therefore, intervention modalities focusing on increasing access to PNC service, advocating the use of
television, provision and use of integrated family health booklet for health information, and HEWs home to home
visit was recognized.
Keywords: Neonatal danger sign; Health care seeking behavior; Gasera District
Acronyms and abbreviation
ANC: Antenatal Care; AOR: Adjusted Odd Ratio; CBNC: Community Based Newborn Care; CI: Confidence
Interval; COR: Crude Odd Ration; CSA: Central Statistical Agency; EDHS: Ethiopia Demographic and Health
Survey; ENC: Essential Newborn Care; ETB: Ethiopian Birr; FMOH: Federal Ministry of Health; HEW: Health

Correspondence to: Tilahun E. Wanamo, College of Medicine and Health Sciences, Department of Public Health, Goba Referral Hospital, Madda
Walabu University, Bale Goba, Ethiopia, Email: tilahunjimma2008@gmail.com
Received: September 09, 2021, Accepted: September 25, 2021, Published: October 02, 2021
Citation: Wanamo TE, Dessalegn FN, Debebe W (2021) Assess the Level of Knowledge and Health-Care Seeking Behavior about Who Recognized
Neonatal Danger Signs and Associated Factors among Mothers in Gasera District, Ethiopia. J Adv Dairy 9:583.
Copyright: © 2021 Wanamo TE, et al. This is an open access article distributed under the term of the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Extension Worker; IMNCI: Integrated Management of Neonatal and Childhood Illnesses; IMR: Infant Mortality
Rate; MCH: Maternal and Child Health; NMR: Neonatal Mortality Rate; PNC: Post Natal Care; PPS: Probability
Proportional to Size; SPSS: Statistical Package for Social Scientists; SRS: Systematic Random Sampling; WHO:
World Health Organization; WorHO: Woreda Health Office

INTRODUCTION child deaths in 2015, almost 1 million occur in the first day of life
and close to 2 million take places in the first week i.e. Deaths are
Background more concentrated among newborns [3]. This is an urgent call for
an increasing focus on newborns for the reason that the neonatal
Newborn danger signs refer to presence of clinical signs that would period is the most critical time for the survival of an infant [8].
indicate high risk of neonatal morbidity and mortality, and the need
for early therapeutic intervention. The danger signs are; stopped Early identification of a sick newborn still, has some problems. The
feeding well, history of convulsions, fast breathing (breathing rate clinical features are nonspecific e.g. whether the illness is of infective
>60/min), severe chest in-drawing, no spontaneous movement, or metabolic origin; the signs do not help us in differentiating the
fever (temperature >37.5°C), low body temperature (temperature cause and can be a manifestation of almost any newborn disease.
<35.5°C), any jaundice in first 24 hour of life, or yellow palms and The distinction between variation of normal behavior and early
soles at any age [1,2]. signs of illness becomes more difficult in low birth weight and
preterm infants. Neonates are more prone to show subtle signs
Globally, the two regions of sub-Saharan Africa and South Asia of illness. Lethargy or difficulty feeding are sometimes the only
has both the highest proportion of neonatal deaths and one of the signs present, which may not be readily recognizable and illness
highest overall under-five mortality rates as well as in South Asia may advance quickly [9,10]. Furthermore, there is overlap in signs
neonatal mortality is considerably higher than expected relative to and symptoms of the three major causes of death – sepsis, birth
the global pattern [3]. asphyxia and complications of prematurity [10,11], as well as with
The major causes of neonatal mortality in 2015 were prematurity, other conditions such as hypoglycemia and hypothermia.
birth-related complications (birth asphyxia) and neonatal sepsis, The modified three delays model responsible for newborn death
while leading causes of child death in the post-neonatal period were shows that household and health facility related delays were the
pneumonia, diarrhea, injuries and malaria. Thus, achievement major contributors to late presentation, treatment initiation and
of sustainable development goals (SDG target 3.2) for child subsequent newborn deaths in many developing countries. These
survival depends on more effectively addressing neonatal deaths, delays especially at the household level are predominantly serious
particularly early deaths in the first week of life [4]. because once there is a delay in the recognition of the danger signs
In the first 28 days the majority of newborn deaths could be of newborn illnesses there are automatically delays at all other levels
prevented with key interventions around the time of birth i.e. Initiation of appropriate treatment and/or referral to a better
and improved care for small and sick newborns [3]. Integrated resourced hospital etc. [12]. For that reason, reducing neonatal
Management of Newborn and Childhood Illness (IMNCI) morbidity and mortality requires immediate caregiver’s recognition
developed by the World Health Organization (WHO) focuses on of suggestive danger signs in the neonates and visiting the nearby
assessment of general danger signs in the examination of children clinic [13].
presenting with illness at health care centers [1,2]. World Health
The vast majorities of newborn deaths are preventable, with 73%
Organization in 2013 strongly recommended specific danger signs
occurring within seven days of birth, and requires many of the
that should be assessed during each postnatal care contact and
corresponding investments in health systems that are needed to
the new born should be referred for further evaluation if any of
improve maternal health outcomes [14]. Early identification of
the signs are present. The family should also be encouraged to
new born danger signs by caregivers with prompt and appropriate
seek health care early if they identify any danger signs in-between
referral serves as backbone of the programs aiming at reduction in
postnatal care visits [1].
neonatal mortality [15].
Globally, in 2015 an estimated 5.9 million children under 5 years
Although, Ethiopian Demographic Health Survey 2016 [16]
of age died, with a global under-five mortality rate of 42.5 per 1000
showing improvement in under-five child mortality, the knowledge
live births. There were 2.7 million neonatal deaths (deaths within
of mothers and caregivers on newborn illness is low and different
the first 28 days of life), with a global neonatal mortality rate of
studies focus mostly on the prevalence of neonatal death and
19 per 1000 live births which represents 45% of all deaths among
newborn care practice disregard of mothers/caregivers knowledge
children under five. A similar number of babies are still born [5,6].
The majority of these new born deaths occur at home where a few of neonatal danger sign and their health care seeking behavior
families recognize signs of newborn illness and nearly all neonates which is one of the critical delays for newborn survival.
are not taken to health facilities when they were sick [7]. The newborn cannot explain or express their discomfort and
In most regions, success in tackling later childhood diseases means therefore identification as well as diagnosis of illness may be
a larger share of the neonatal period. As global rates of under- delayed if parents are not intelligent, observant, and concerned.
five mortality have fallen, neonatal deaths now account for a Early detection of neonatal illness is an important step towards
rising proportion of the remaining burden of under-five deaths. improving newborn survival. Maternal recognition of neonatal
In 1990, neonatal deaths represented 40% of global under-five illness, one of major barriers for optimal care-seeking among
deaths, compared with 45% today. Of the estimated 5.9 million neonates during the early neonatal period, was also poor [13].

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Mothers are the primary caregivers of the newborn. Consequently, in an infant who was feeding well earlier, are very important and
the knowledge of the mothers regarding newborn danger signs has sensitive indicators of neonatal illness. Temperature instability is
a great influence on the health of the newborn [17]. Expansion a very important danger signs in neonates. Convulsions happen
of Community Based Newborn Care (CBNC) by health extension because of sudden, abnormal electrical activity in the brain.
workers (hews) in Ethiopia is ongoing and expected to contribute Breathing difficulties indicate serious illness in the new born. An
to a decrease in neonatal mortality. However, there is still a gap increased respiratory rate (more than 60 per minute) and chest
in availing quality health services such as counseling for newborns retractions indicate a serious problem. It could be due to pneumonia,
health in many facilities and at each service [18]. hyaline membrane disease, heart failure or malformation. Jaundice
in the newborn may be physiological, but when it appears on the
In Ethiopia, the ministry of health has integrated mother and child
first day of life or the skin staining is up to palms and soles or it
information in one booklet (family health card) which is provided
persists beyond 2 weeks of life, needs investigation and appropriate
to the mother during antenatal clinic and hews use for health
treatment. Hyper-bilirubinemia in the first week could lead to
education. Information on danger signs have been in cooperated
kernicterus and severe disabilities [9].
in the family health card for the care provider to advice the mothers
and also for the mothers to read. However, various studies in Knowledge about neonatal danger signs
developing countries have demonstrated that despite availability
of information on neonatal danger signs on family health card Mother’s knowledge of the danger signs of newborn complications
maternal knowledge on the equivalent remain very low [19,20]. is an essential step in the recognition of complications and a way
towards reducing neonatal mortality. It is very important to check
Generally neonates and young infants often present with non-
the newborn for the danger signs of illness as the actions taken
specific symptoms and signs that indicates severe illness. These signs
to help the newborn are crucial to ensure prompt and safe care.
might be present at or after delivery or in a newborn presenting
It is also need to teach the mother to look for these signs in the
to hospital or develop during hospital stay. Since most babies are
newborn and advise her to seek care promptly if she observes any
born at home or are discharged from the hospital in the first 24
one of the danger signs [22].
hours, increasing community awareness of the danger signs of
newborn and improving care seeking of newborn care is of critical Studies in different countries reported the inconsistency of finding
importance for improving newborn survival. related to level of mothers’ knowledge and related factors about
neonatal danger signs. Study done in Tamil, Nadu India shows,
In Ethiopian mothers were recognized as caretakers for the majority
18% of the women were not aware of even one danger sign of
of neonates [16], and mothers need to know the danger signs of
sick newborn. They can explain these signs to others or family new born [23] while other studies shows three and above neonatal
member in a simple language so as to enable them to identify the danger signs were mentioned among 13.9%, 28.1% and 29.3%
danger signs and to seek early and prompt medical help. Therefore, of mothers included in the study from India [12,19,24] and four
improving maternal knowledge concerning neonatal danger sign is regions of Ethiopia respectively [25].
a key entry point. A study conducted in Uganda on inadequate knowledge of
Early determination of health care seeking behaviors of mothers neonatal danger signs among recently delivered women showed
on neonatal danger signs could save the new-born during life that knowledge of at least one of the defined key danger signs
threatening complications. Therefore, understanding the factors was present in 58.3% of all women: however, only 14.8% could
related to health care seeking behavior for neonatal danger signs are name at least two signs. “Fast or difficulty breathing” was the most
critical for countries like Ethiopia with alarmingly high neonatal commonly known danger sign and referred to by almost 30% of the
mortality. Despite the fact that health-seeking behavior plays a women [20]. Poor suckling or feeding and fever were the newborn
critical role in reducing neonatal morbidity and mortality, studies danger signs that were frequently mentioned. The knowledge levels
on the area are limited and inconsistent. Hence, this study was on the rest of the danger signs among the respondents were very
carried out to assess mothers’ knowledge and health care seeking low [19,20]. The least known danger signs were “convulsions”,
behavior about neonatal danger signs. “movement only when stimulated” and “hypothermia”, stated by
less than 5% of the respondents [20,24].
LITERATURE REVIEW The study done in Kenya shows majority of mothers 84.5%
identified less than three neonatal danger signs. Hotness of the
New born danger Signs body (fever) was the commonly recognized danger sign by 74.9%
The “WHO recognized dangers signs” based on WHO definition postnatal mothers, and 46.6%, 40.1%, 35.3% and 5.8% identified
were categorized as follows: i) Not feeding since birth or stopped difficulty in breathing, poor sucking, jaundice and lethargy/
feeding; ii) Convulsion; iii) Respiratory rate of 60 or more (fast unconsciousness as new born danger signs respectively. Only 11.1%
breathing); iv) Severe chest in drawing (difficulty in breathing); and 9.7% identified convulsion and hypothermia as new born
v) Temperature of ≥ 37.5 degree centigrade (fever/hot to touch); danger signs respectively [26].
vi) Temperature ≤ 35.5 degree centigrade (hypothermia/cold A study conducted in South-East Nigeria reported that knowledge
to touch); vii) Only moves when stimulated or not even when of more than three of the nine WHO recognized danger sign was
stimulated (weakness or lethargy); viii) Yellow soles/yellowness poor (30.3%). Majority of the mothers had knowledge of one (i.e.
(sign of jaundice); ix) Umbilicus redness or draining pus, skin boils, Fever) WHO recognized danger sign (95.2%). Cough, diarrhea and
or eyes draining pus (sign of local infection) [21]. the excessive crying were the most perceived and experienced non-
In a full-term baby poor sucking/stopped feeding well, especially WHO recognized dangers signs among respondents [27].

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According to study conducted in Mangalore, India on knowledge education and sensitization, women should be taken through
on warning signs of newborn illness among 70 mothers, reported danger signs prior to their discharge from hospital so that they can
that it was found that 62% had good knowledge and 36% of easily detect signs and rush to health care facilities as and when
the samples had average knowledge. One percent of the samples necessary [19].
had excellent knowledge and one percent of samples had poor
These studies from Uganda, Ghana, and India reported the positive
knowledge [28].
effect of birth preparedness, exposure to TV/Radio, and older age
A study conducted in Northern India on the perception of care of mother to improve the knowledge of maternal and newborn key
giver and health worker about the danger signs of neonatal danger signs [20,24,34]. Women were more knowledgeable than
illness with 200 mothers reported that more than one-third of men [35]. In contrast, studies elsewhere have shown that there
the caregivers recognized fever, irritability, weakness, abdominal had been absence of relationship between educational status of
distension/vomiting, slow breathing and diarrhea as danger signs mother, birth order, and place of birth, ANC, access for skilled
in neonates. Seventy-nine (39.5%) of the caregivers had seen a sick birth attendance, wealth, and parity [20,28].
neonate in their own family in the past 2 years. Continuous crying
Furthermore, study conducted in Uganda on inadequate knowledge
was reported as a common manifestation of neonatal illness and
of neonatal danger signs among recently delivered women and a
this was supported by the findings of eight key informant interviews
study conducted in South-East Nigeria on knowledge of the WHO
with caregivers who had experienced adverse neonatal events [12].
signs showed that there is no significant association seen between
Study conducted in rural Wardha India and peri-urban Wardha, knowing at least one danger sign and any socio-demographic
India reported the awareness of mothers regarding newborn danger characteristic were found [20,27].
signs was found to be poor. About 67.2% mothers knew at least one
Along with, the utilization of the MCH booklet was found to be
newborn danger signs. Poor sucking, low birth weight, lethargy/
insufficient by the mothers attending well baby clinic and only
unconsciousness, rapid/difficulty in breathing were known as
59% of them were explained the contents of the booklet by the
danger signs to 34.4%, 25.8%, 25.5%, 10.3% mothers respectively,
health care providers and up to 33.5% of the mothers did not read
while hypothermia and convulsions were referred as danger signs
the instructions in the MCH booklet [26].
by only 10.3% and 8.6% mothers respectively [24].
The study done in North West Ethiopia reports that the odds of
Although Ethiopia has taken great initiative to empower the
having good knowledge was positively associated with mother’s
community to improve neonatal and infant health services at the
(AOR=3.41, 95% CI 1.37, 8.52) and father’s (AOR=3.91, 95%
grass root level, maternal knowledge level about neonatal danger
CI 1.23, 12.36) higher educational achievement. Similarly, the
signs, which is a key entry point to improve neonatal health, was
odds of having good knowledge about neonatal danger signs was
found to be low (18.2%). This indicates that nearly 80% of mothers
higher among antenatal care (AOR=2.28, 95% CI 1.05, 4.95) and
were more likely to delay in deciding to seek care which could
postnatal care attendant mothers (AOR=2.08, 95% CI 1.22, 3.54).
intern fires the death of neonates [29].
Besides, access to television was also associated with mothers’ good
Factors associated with mother’s knowledge about knowledge about neonatal danger signs (AOR=3.49, 95% CI 1.30,
neonatal danger signs 9.39) [29].

Home-based neonatal health interventions have promoted Health care seeking for neonatal danger signs
recognition of danger signs through prenatal interventions Health care seeking behavior is not only a matter of knowledge
[1,30,31], and Community Health Workers (CHWs) assessed about the cause and treatment of the disease, but also of perceived
neonates using IMCI algorithms through post-natal routine home seriousness and duration, cultural practices and socio-economic
visits [30,32]. status. Delay in recognition of the problem and the decision to
The high mortality and morbidity rates have been attributed to a seek care is one of the three delays in maternal and newborn health
significant break in the continuum of care in the service-delivery care. Physical distance, financial and cultural barriers to seeking
strategy after delivery. Care during post natal clinic is critical for care are compounded when there is a delay in recognizing illness
both the mother and baby to provide the mother with important and taking the decision to seek care, especially in rural settings [36].
information on how to care for herself and her child [33]. Such a delay, even if short, can be fatal because neonatal illness
generally presents less obviously and progresses more quickly than
The study done in Kenya shows, information on neonatal dangers
in older infants [31].
was not provided to 57.2% of the postnatal mothers during their
antenatal clinic attendance by the health care providers while A study in South-East Nigeria reported that healthcare seeking
education level, PNC accompaniment by spouse, danger signs behavior was significantly determined by knowledge of at least
information to mother, explanation of MCH booklet by care one WHO recognized danger sign (OR 4.6 CI 1.1-18.7). The study
provider during ANC and mother read MCH Booklet were factors also revealed that less than half (47.7%) presented to the hospital
positively associated with improved knowledge of neonatal danger immediately these signs were noticed and about one in four (23%)
sign [26]. did not present to the hospital at all following the delays at the
household level [27].
Study in the East Mamprusi district of the Northern Region of
Ghana, which sought to explore women knowledge of neonatal Poor care seeking contribute significantly to high neonatal
danger signs, revealed that the poor knowledge was due to the high mortality in developing countries. A study conducted to identify
illiteracy rate among women, and probably explains why neonatal care-seeking patterns for sick newborns in rural Rajasthan, India,
mortality is still high. This study suggests that as part of health reported that 70% of mothers mentioned at least one medical

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condition during the neonatal period that would have required the need for hospitalization of a new born in the first week of life
medical care. However, only 63 (31%) newborns with any reported and recognizing the occurrence of these signs will results in high
illness were taken to consult a care provider outside home, while overall sensitivity and specificity to predict the need for seeking
about half of these to an unqualified modern or traditional care treatment of the new born [2].
provider. In response to hypothetical situations of neonatal illness,
A study conducted in rural Rajasthan, India showed that perceptions
families preferred home treatment as the first course of action for
of ‘smallness’, not appreciating the conditions as severe, ascribing
almost all conditions, followed by modern treatment if the child
the conditions to the goddess or to evil eye, and fatalism regarding
did not get better. For babies born small and before time, however,
surviving newborn period were the major reasons for the families’
the majority of families did not seem to have any preference for
decision to seek care. Mothers were often not involved in taking
seeking modern treatment even as a secondary course of action
this critical decision, especially first-time mothers. Decision to seek
[37].
care outside home almost always involved the fathers or another
A study conducted in Northern India on the perception of care male member. Primary care providers (qualified or unqualified) do
giver and health worker about the danger signs of neonatal illness not feel competent to deal with the newborns [37].
shows 23% of respondents sought health care and administered
Healthcare-seeking behavior for the newborn is influenced by
medicines for neonatal illness. According to the study the preferred
many factors [7,32]. Common barriers discouraging seeking care
health-care provider was either a local medical doctor (60.7%),
for the newborn from formal health facilities include lack of
followed by a traditional healer (19.6%) while the remainders were
money and lack of reliable transport to the facility [24,38], faith in
treated with home remedies. Modern medicines were administered
supernatural causes and remedy was sought from traditional faith
to 78.3%, while the rest used indigenous medicine and traditional
healer, ignorance of parents [24] and abusive language by health
homemade medicines, either alone or in combination with modern
personnel were mentioned as barriers to neonatal care-seeking [38].
medicine [12].
In other study areas, seclusion (restriction) of both mother and
Study conducted in Wardha India also showed that majority baby was reported to be 40 days and families often perceive this as
of mothers (87.4%) responded that the sick child should be way to protect the child against witchcraft [38].
immediately taken to the doctor but only 41.8% of such sick
Furthermore, study in South Asia shows that the reasons families
newborns got treatment either from government hospital 21.8%
seek initial care from locally available unqualified practitioners,
or from private hospital 20% and 46.1% of sick babies received no
such as traditional healers are traditional beliefs (for example, the
treatment [24].
influence of evil spirits and harmful effects of allopathic treatments),
However, a study conducted in peri-urban Wardha, India reported lack of understanding of the problem, costs of treatment and
that all sick newborns with danger signs were taken to the doctor perceived lack of quality of health services [34].
and only two mothers consulted faith healer for treatment [24].
However, a study done in Lusaka, Zambia on access to a health
Study conducted in Southern Tanzania and study in South Asia facility and care-seeking for danger signs in children: before and
Bangladesh reported that mothers discuss issues related to childcare after a community-based intervention shows long distance to the
with their female friends, husbands, aunts and other close female health facility and low-household income negatively influenced
relatives. Traditional healers are widely believed to be able to heal caregivers’ appropriate and timely care-seeking practices at baseline,
sick neonates and are therefore often consulted. Unlike most health but 3 years later, after the implementation of a community-based
facilities they treat on credit, accept payment in kind (exchange of intervention, distance and household income were not significantly
goods for services) and payment rates can be negotiated. Babies related to caregivers’ care-seeking practices [41].
with pneumonia, convulsions and any illness associated with spirits
Improving newborn care and newborn health outcomes in Ethiopia
and witchcraft are usually taken to traditional healers. Evil spirits
will likely require a multifaceted approach. Given low facility
were reported as a source of childhood illness in nearly all FGD
delivery rates, community-based promotion of preventive newborn
and in-depth interviews [34,38,39]. Only after these remedies
care practices, which has been effective in other settings, is an
have failed to alleviate the problem do they seek care from health
important strategy. For this strategy to be successful, the coverage
facilities [34].
of counseling delivered by HEWs and other community volunteers
Factors associated with health care seeking for neonatal should be increased [25].
danger signs In Ethiopia, regarding care seeking for newborns, the problem
gets more pronounced. There are multiple cultural attitudes and
The most effective strategies to reduce mortality are those that practices that make care seeking for newborn more challenging
treat the causes of early mortality. Various factors influence the e.g. low awareness and knowledge about newborn danger signs,
women ability to seek care for their neonates. It has been noted seclusion of mother and newborn influenced by traditional beliefs
that women’s utilization of maternal and neonatal health services that they require protection from cold, wind, direct sunlight and
are often influenced by perceived socio-cultural, economic and evil eye, and also seclusion of the newborn until spiritual blessing
health system factors operating at the community, household and and naming by a spiritual leader will occur through the ritual
individual level as well as within the larger social and political known as ‘hamechisa’ (East Shewa). Local conceptions of newborn
environments and health care infrastructure [40]. illnesses, inadequate recognition of danger signs, utilization of
In a multicenter study by Young Infants Clinical Signs Study traditional therapy, and lack of financial resources, transportation
Group (YICSG) it was noted that assessment of danger signs and appropriate treatment constrain or delay utilization of health
resulted in a high overall sensitivity and specificity for predicting facilities for newborn illnesses [42].

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According to the study on assessment of ICCM implementation Inclusion and exclusion criteria
strength and quality of care in Oromia, Ethiopia reasons given by
HEWs for why caretakers do no seek appropriate care for newborn Mothers or caregivers those who were not mentally and physically
illness, 30% mentioned that the community is not aware of services capable of being interviewed were excluded.
in nearby health post; 23% cited distance from the health post
Sample Size Determination and Sampling Procedure
as the reason; 13% wanted injections (they did not know HEWs
give curative ICCM/CBNC); and 11% stated that the health post Quantitative study: Sample size was determined by using single
was not always open [8,43]. Moreover, other study in Gedeo zone population proportion formula. Where, N= minimum sample size
of SNNP shows residences, educational status of the respondent; required for the study, Z=standard normal distribution (Z=1.96)
delivery and family size were predictors of treatment seeking with confidence interval of 95% and α=0.05, P= prevalence/
behavior of mother’s from health center to new born [44]. population proportion D=design effect (D=1.5), E=is a tolerable
margin of error (E=0.05).
Conceptual framework
Sample size for first objective: Based on the following assumptions:
This is the conceptual frame work constructed specifically for this 95% confidence level, finding 29.3% mothers who had knowledge
study by the investigator through reviewing and adopting related of three or more neonatal danger signs (good knowledge) from
different literatures. previous study done in 4 regions of Ethiopia [25] and a 5% margin
of error.
METHODS
N1=(1.96)2 * 0.293 *(1-0.293) =318, (0.05)2
Study area and period Multiplying with 1.5 design effect the minimum sample required
The study was conducted in Gasera district, Bale zone, Ethiopia for first objective was 477. Taking, 5% non-response rate N1 =501.
from March 12 to April 10 2017. Gasera district is located in the Sample size for Second objective: Using 95% confidence level,
south eastern part of Ethiopia at 484 km away from the capital finding proportion of 20% mothers who were decided to seek
Addis Ababa and 54 km from Robe Town. It is one of the medical care immediately for neonatal illness from previous study
eighteen districts found in the zone. Currently, the district has done in Northwest Ethiopia [29] and a 5% margin of error.
21 rural and 3 urban kebeles (the smallest administrative units)
N1= (1.96)2 * 0.20 *(1-0.20) =246, (0.05)2
with total households of 20,826 and total population of 99,963
of which 48,724 were female. Based on Gasera district health With the above inputs, multiplying with 1.5 design effect the
office report, estimated total number of women of reproductive minimum sample required for second objective was 369. Taking,
age (15-49 years) and pregnant women in the district were 22,092 5% non-response rate N2 =387.
and 3,469, respectively. There are estimated total number of 3,469
Taking the largest sample size from the first objective, the minimum
and 3,219 live births and surviving infants respectively. A total of
sample required for quantitative study was Nf=501
34 health institutions were available in the district: 24 government
health facilities (5 health centers, and 19 functional health posts), Qualitative study
8 private clinics and 2 private pharmacy/drug shop (unpublished
Gasera District health office report, 2016/17). The sample size of qualitative method was determined at saturation
of idea.
Study design
Sampling technique and procedure
Community based cross sectional study design was conducted.
Sampling procedure of quantitative study: All Kebele of Gasera
Source population district was stratified into urban (n=3) and rural ones (n=21).
Roughly half of the Kebele in each stratum, i.e. one urban and
Source populations were all mothers of less than one year child in
eleven rural Kebele were selected by simple random sampling. The
Gasera district
district was implementing Community Health Information System
Study population (CHIS) and existing Health Post Family Folder (family-centered tool
designed for HEW to be used for data collection, documentation,
The study populations were sampled mothers of children less than and management) was used to identify households with mothers
one year of age during data collection period in selected kebeles of or caregivers who had child less than one year prior to the survey.
Gasera district. Finally 501 mothers who had child less than one year were selected
using the Health Post Family Folder (sampling frame) through the
Sampling unit simple random sampling technique with proportionate allocation
to size. Data collectors used name of Kebele, their house numbers,
List of all household who had mother or caregivers of less than one
and health extension workers for guidance.
year child in the kebele.
Sampling procedure of qualitative Study: For the qualitative study
Study units purposive sampling technique was used to select participants for
the in-depth interview and focus group discussion (FGD). The
Study units were selected mothers or caregivers of less than one
participants for in-depth interview were 6 tradition birth attendants
year old child in the households.
and 17 mothers who had experienced neonatal illness in the last

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one year. The maximum numbers of participants for in-depth care seeking questions and then categorized as having
interview was decided at the idea saturation. A series of four focus health care seeking behavior (if participants necessitate
group discussions were carried out among purposefully selected seeking care at the health facility) or not having health care
community health workers (health development arms), mothers seeking behavior (if participants do not initiate care at the
of small baby and elderly women with eight to ten participants health facility.
in each group. The focus group discussions kept on till new ideas
• Mother or caregiver: Mother of the baby or caregiver of
mentioned and were stopped as repetition of idea occurs
the baby.
Variables in the study • Knowledgeable on key danger signs of newborn: In this
research a mother was considered knowledgeable (had good
Dependent variables: Knowledge about neonatal danger signs
knowledge) if she can mention at least the three WHO
Neonatal illness health care seeking behavior of mothers/caregivers recognized nine danger signs for newborn spontaneously
[2,33].
Independent variable:
• Not knowledgeable on key danger signs of newborn:
Socio-demographic and economic factors
Mother who did mention less than three WHO recognized
• Age of mother and child nine danger signs for newborn spontaneously [2,33].
• Place of residence • Well birth prepared: defined as having taken at least 3 of
• Maternal marital status the 4 actions (bought childbirth materials, saved money,
identified transport, identified skilled provider or health
• Occupation of mother and father, facility).
• Family income
Data collection instrument and procedure
• Ethnicity and Religion
Data collection instrument: Quantitative data supplemented
• Mother and Father educational level with qualitative data was used. Quantitative data was collected
• Distance from the nearest health facility from selected kebeles starting from March up to April, 2017
by using a structured interview-administered pre-tested Afan
• Source of information (exposure to Media) Oromo questionnaire. Structured questionnaire was prepared
Health service utilization factors using literatures used in this study and related studies done in
different countries. The questionnaire was prepared in English
• Number of children (parity) language and then translated to Afan Oromo (local language) and
• Birth preparedness re-translated back to English to check for any inconsistencies. It
includes five main segments: - socio-demographic factors, obstetric
• Place and assistant of delivery
characteristics, maternal and child health service utilization status,
• ANC follow-ups and PNC services knowledge on neonatal danger signs and health care seeking
behavior for neonatal illness.
• ANC follow-ups and PNC services accompaniment by
spouse For qualitative data a semi-structured interview guide and
discussion guide consisting of specific questions that was used to
• HEWs home to home visit
gather as much information as possible was designed and used to
• Know about nearby HEWs treat newborn illness conduct an in-depth interview and focus group discussion. Semi-
• Mother’s awareness about free of charge CBNC treatment structured Afan Oromo interview guide and discussion guide was
by HEWs at HP used and translated back to English. Eleven elements of interview
guide and eight components for FGD were used.
• Family health booklet availability and accessibility
Data collection procedure
• Decision making
Quantitative data: The purpose of the study was briefly introduced
Operational definition for each of the study participants and data were collected after
• Neonatal period: refers to the first 28 days of life (divided obtaining a verbal informed consent. The data were collected by
into early neonatal period (first 7 days) and late neonatal trained twelve diploma graduate nurses who are fluent in speaking
period (days 8-28). local language and two public health degree supervisors. Two visits
were made for absences in the first visit. The data were collected
• Neonatal danger signs: refer to the presence of WHO in the quietest corner of mother’s house where there was no noise
recognized neonatal clinical signs that would indicate high and disturbance. The data collection process had taken an average
risk of neonatal morbidity and the need for early therapeutic of 20 minutes.
intervention.
Qualitative data: A discussion guide was prepared, consisting of
• Health care seeking behavior for neonatal illness: Mother's/ specific questions that were used to gather as much information as
caregiver's first response for visiting health institutions for possible. The investigator conducted the in-depth interview using a
medical treatment when their newborn has got neonatal simple checklist questions to be covered to collect the suggestion of
illness. It was measured by looking for answers to health the participants. The points were manually written.

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For FGDs the investigator was the moderator, and accompanied Ethical consideration
by two assistants (2 health professionals for each FGD) who were
the note taker and recorder. Sitting arrangement was in a circular Prior to data collection appropriate ethical clearance was obtained
manner to allow all participants see each other during focus group from the Ethical Review Committee of Madda Walabu University
discussion. The moderator had introduced himself as well as the Goba Referal Hospital. Letter of permission was obtained from
note taker and recorder. After the introduction, the discussion was Gasera district administrative and health office. The participants
begun. All participants were encouraged to air their views and were were informed about the right not to participate or withdraw at any
treated equally. Each discussion was stopped at the point of idea time. Confidentiality of information was maintained by omitting
saturation. any personal identifier from the questionnaires. Finally, verbal
consent was requested from every study participant included in the
Data quality control study during data collection time after explaining the objectives
of the study. For this very purpose, a one page consent letter was
Data quality was assured through careful questionnaire design, attached to the cover page of each questionnaire stating about the
pretest and training. One day training about the purpose of the general objective of the study and issues of confidentiality which
study, the questionnaire in detail, the data collection procedure, were discussed by the data collectors before proceeding with the
the data collection setting and the rights of study participants interview.
in detail was given for the data collectors and supervisors. The
questionnaire was prepared in English version and translated in RESULTS
to Afan Oromo version and back to English version to check its
consistency. After each day of data collection, the collected data Five hundred-one mothers consented to participate in this study
were checked for completeness and consistency by holding a out of which 497 were successfully interviewed giving a recruitment
meeting with the data collectors. The questionnaire was pre-tested fraction of 99.2%.
on 5% of the total sample size in Sambitu kebele, Sinana district,
which had similar socio-demographic characteristics with Gasera Socio-demographic characteristics
district to minimize ambiguity of words applicability to the local Of the total respondents, 449 (90.3%) were rural resident and 48
context. Finally, the completeness of the questionnaire was checked (9.7%) were urban resident. The mean age of respondents was
before entering data into computer software program and before 25.34 (SD ± 5.1) years and the mean age of infants was 16.1 (SD ±
analysis and interpretation. 12.8) weeks. Majority of the respondents 415 (83.5%) were Oromo
by ethnicity, 317 (63.8%) Muslim, 437 (87.9%) currently in marital
Data analysis
union, 380 (76.5%) were house wife, 184 (37.0%) were attended
Data were entered to Epi Data version 3.1 and then exported to elementary school. Regarding respondent’s husband, 181 (36.4%)
SPSS version 20.0 for analysis. The completeness and consistency of and 351 (70.6%) were educated to elementary and occupationally
the data were checked and cleaned. Descriptive statistics was used to farmers, respectively. The mean of the estimated monthly family
describe the study population in relation to relevant variables and income of the participants was 1734.56 (SD ± 1387.70) ETB. Less
measures of central tendency were also determined. Bivariate and than half, 42.9% and 19.9% of the mothers had access to a radio
and the television, respectively (Table 1).
multivariable logistic regression was done to assess any significant
relationship between each independent variable and outcome Obstetric and maternal health service characteristics
variable. Crude and adjusted odds ratios were used to ascertain
any associations between the dependent and independent variables Among the interviewees, majority, 452 (90.9%) were attended
while significance were determined using a 95% confidence ANC for their last pregnancy, of whom, 336 (74.4%) attended
interval. For not losing the most important variables, independent four and greater than four times. Nearly, more than half (54.3%)
variables with a p-value of less than 0.25 at the bivariate level were mothers were gave their last child birth at home and 130 (48.1%)
included in a multivariable logistic regression model. However, were attended by traditional birth attendants, while the rest, 140
any significant association was determined at a p-value of less than (51.9%) were by their families. Mothers who lost their children
0.05 in the multivariable logistic regression model controlling for were 76 (15.3%) of whom, more than half 43 (56.6%) were lost
potential confounding variables. The results were presented as odds at neonatal age. Majority, 360 (72.4) of mother had four and less
children with 26.2% being first time mothers. Less than half,
ratios (OR) with 95% confidence intervals (CI). Finally results were
(41.0%) of the mothers were well birth prepared whereas only
compiled and presented using tables, graphs and texts.
17.5% were accompanied by their spouses to the antenatal and/
Qualitative data which were from an in-depth interview and FDG or postnatal care clinic. Only one fourth of the mothers were
were transcribed by arranging the record according to forwarded got health extension worker home to home visit during their last
questions and translated to English. Then thematic data analysis pregnancy and/or post-natal period (Tables 2 and 3).
method was used. The notes and the transcribed tape recorded
audio data were compiled and coded. The coded data were
Access and utilization of family health booklet
organized into themes and when necessary the information was Mothers were asked whether they had ever got family health booklet
presented verbatim in the results. Subsequently comparison and the presence of the booklet at the home was observed. Only
was done on the responses of different respondents to identify 131 (26.4) mothers had been provided with the standard family
similarities and differences. Finally, information was linked to its health booklet of whom, majority, 92 (70.3%) received during the
congruence with data obtained from quantitative findings. ANC clinic. However, only 88 (67.2%) of them were explained the

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Table 1: Socio-demographic characteristics of the respondents in Gasera Merchant 50 10.1

District, Ethiopia, (n=497) March 12 to April 10.
Daily labor 5 1.0
Variable Frequency Percent Others*** 2 0.4
Residence Total Family Income (ETB), (n=459)
Urban 48 9.7 ≤1500 285 62.1
Rural 449 90.3 >1500 174 37.9
Mother Age (years) Radio
≤20 101 20.3 Yes 213 42.9
21-25 166 33.4 No 284 57.1
26-30 152 30.6 Radio Listening Frequency (n=213)
>30 78 15.7 Always 15 7.0
Child Age (weeks) Often 39 18.3
<4 weeks 119 23.9 Sometimes 102 47.9
5-24 weeks 246 49.5 Rarely 36 16.9
>24 weeks 132 26.6 Never 21 9.9
Child Sex Television
Male 245 49.3 Yes 99 19.9
Female 252 50.7 No 398 80.1
Religion Television Listening Frequency
Orthodox 174 35.0 (n=99)
Muslim 317 63.8 Always 41 41.4
Protestant 6 1.2 Often 46 46.5
Ethnicity Sometimes 12 12.1
Oromo 415 83.5 Distance from Nearest Health Facility
Amhara 80 16.1 <1 hr 232 46.7
Others* 2 0.4 ≥1 hr 265 53.3
Marital Status *include Welayita **include student & daily laborer ***include student.
Married 437 87.9
Not married 16 3.2 Table 2: Obstetric characteristic of mothers in Gasera District, Ethiopia,
(n=497) March 12 to April 10.
Divorced/separated 34 6.8
Widowed 10 2.0 Variable Frequency Percent
Educational Status of the Mother Age at First Pregnancy
(year)
Unable to read and write 175 35.3
<20 328 66.0
Read and write 82 16.5
20-29 167 33.6
Grade1-8 184 37.0
≥30 2 0.4
Grade 9-12 25 5.0
Number of Pregnancy
College and above 31 6.2
1 121 24.3
Educational Status of the Father
2-4 209 42.1
Unable to read and write 122 24.6
≥5 167 33.6
Read and write 109 21.9
History of Abortion
Grade1-8 181 36.4
Yes 48 9.7
Grade 9-12 38 7.6
No 449 90.3
College and above 47 9.5
Parity
Occupation of the Mother
1 130 26.2
Housewife 380 76.4
2-4 204 41.0
Farmer 44 8.9
≥5 163 32.8
Government employee 45 9.1
History of Still Birth
Private employee 11 2.2
Yes 25 5.0
Merchant 15 3.0
No 472 95.0
Others** 2 0.4
Total Number of
Occupation of the Father
Children
Farmer 351 70.6
≤4 360 72.4
Government employee 71 14.3
>4 137 27.6
Private employee 18 3.6

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Experienced Child Death (loss) contents of the booklet by the health care providers and only 89
Yes 76 15.3 (17.9%) of them did read the instructions in their family health
booklet. Among the mothers only up to 23.5% were ever informed
No 421 84.7
about neonatal danger signs by care providers (Table 4).
Age of Child at Death (n=76)
Within 1 month 43 56.6 Maternal knowledge about neonatal danger signs
Between 1 and 11
19 25.0 Of the total respondents, only 129 (26.0%) mothers were
month
Between 12 month and knowledgeable about neonatal danger sign.
14 18.4
5 years When asked to list those signs, 88 (17.7%) had no knowledge of
Planned Pregnancy of Last Child any and listed none. One hundred-fifty (30.2%) of the mothers
Yes 296 59.6 listed correctly at least one of the WHO recognized danger signs.
No 201 40.4 Two, three, four and five danger signs were correctly listed by 130
(26.2%), 79 (15.9%), 32 (6.4%) and 16 (3.2%) of the respondents,
Table 3: Maternal and child health (MCH) service utilization status of respectively while only 2 (0.4%) correctly listed up to six WHO
mothers in Gasera District, Ethiopia, (n=497) March 12 to April 10. recognized danger signs (Table 5).
Variable Frequency Percent Fever and poor feeding (unable to suckle) were the most commonly
ANC Follow Up mentioned neonatal danger signs 247 (49.7%) and 186 (37.4%),
Yes 452 90.9 respectively whereas coldness (hypothermia) and jaundice were the
No 45 9.1 least known danger signs 16 (3.2%) and 17 (3.4%), respectively
ANC Visit Frequency (n=452) (Figures 1 and 2). Mothers also mentioned signs perceived as
dangers signs which are not WHO recognized. They include but
<4 visit 116 25.6
were not limited to diarrhea, frequent crying, vomiting, cough and
≥4 visit 336 74.4
abdominal colic.
Place of Delivery
Health center 201 40.4 Most of the in-depth interview participants mentioned fever,
diarrhea, abdominal distension, abdominal colic, tonsillitis,
Hospital 26 5.3
headache, persistent vomiting, unable to suck, fast breathing,
Home delivery 270 54.3
frequent crying and cough, as the neonatal danger signs.
Home Delivery Assistant
(n=270) A 28 years old mother said that “newborn only express its hunger,
TBA 130 48.1 pain, and discomfort by crying, therefore, crying is a major sign of
Family 140 51.9
Table 4: Family Health Booklet availability and utilization for mothers in
PNC Follow Up Gasera District, Ethiopia, (n=497) March 12 to April 10.
Yes 225 45.3
Variable Frequency Percent
No 272 54.7
Received Family Health Booklet 131 26.4
PNC Visit Frequency (n=225)
Time Family Health Booklet
<3 visit 194 86.2 Received (n=131)
≥3 visit 31 13.8 During ANC 92 70.3
ANC and/ or PNC During delivery 13 9.9
Accompanied by Spouse
During PNC 26 19.8
Yes 87 17.5
Explanation received on content of
No 410 82.5 family heath booklet from the care 88 67.2
Birth Preparedness Practices* provider (n=131)
Saved money 196 39.4 Read all the instructions in the
89 17.9
Arranged transportation 267 53.7 family health booklet (n=131)
Identified skilled birth attendant 287 57.7 Received information on neonatal
117 23.5
Buying delivery materials 347 69.8 danger signs from care providers

Not birth prepared 77 15.5 Time Information Received on

Neonatal Danger Signs from Care
Birth Preparedness Status Providers (n=117)
Well birth prepared 204 41.0 During ANC 70 59.8
Not well birth prepared 293 59.0 During delivery 19 16.3
HEW Home to Home Visit During PNC 22 18.8
Yes 126 25.4 Other* 6 5.1
No 371 74.6
*include during Integrated Refreshment Training (IRT), during polio
*multiple response campaign, during sick baby clinic, during pregnant mother’s conference.

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Table 5: Knowledge about neonatal danger signs among mothers in Gasera of the mothers 338 (68.0%) responded that the cause of neonatal
District, Ethiopia, (n=497) March 12 to April 10. illness was evil spirit (eye) or devil and followed by 209 (42.1%)
Variable Frequency Percent coldness and 170 (34.2%) lack of hygiene (Figure 3). Only 81
Source of Information about Neonatal (16.3%) of the respondents know that nearby health extension
Danger Sign* worker treat and refer neonatal illness, of whom 30 (37.0%) did not
Health Extension Worker (HEW) 97 32.4
Other health professionals** 74 24.7
Reading family health booklet and/or
63 21.1
posters
Mass media 75 25.1
Family/neighbor/friends 120 40.1
Community health worker (health
64 21.4
development army)
Others*** 3 1.0
Knowledge Level of Newborn Danger
Signs
None 88 17.7
One 150 30.2
Two 130 26.2
Three 79 15.9
Four 32 6.4
Five 16 3.2
Six 2 0.4
Figure 1: Conceptual frame work for knowledge and health seeking
Seven 0 - behavior of mothers about newborn danger signs, 2017.
Eight 0 -
Nine 0 -
Perceived Cause of Neonatal Illnesses*
Poor hygiene 170 34.2
Hunger 57 11.5
Coldness 209 42.1
Evil spirit(eye),devil 338 68.0
Trauma/injury 118 23.7
Others**** 110 22.1
Don’t know 83 16.7
Nearby HEW’s Treat Newborn Illness
Yes 81 16.3
No 416 83.7 Figure 2: The danger signs in Rural and Urban areas of Gasera District.
Nearby HEW’s Treat Newborn Illness
Free of Charge
26%
Yes 51 63.0
Knowled
No 30 37.0
geable
*multiple responses, **include Midwife, Nurse, Health Officer and Doctor,
***include Training, ****include bad odor, mother disease (amoeba), if
mother eat leafy vegetables, giving the baby butter, birth defect, keeping
in the sun (hotness), giving other foods or drinks other than breast milk,
home delivery, something left in the abdomen during birth, baby stay in
the blood during birth, ‘mitch’, tonsillitis.

any problem the newborn developed”. In addition, a 41 years old

traditional birth attendant said that “the newborn baby frequently
cry because of abdominal colicky pain which is, beginning, from
maternal sickness (ameba) and as well if something left in baby’s 74% Not
abdomen immediately after birth”. Knowled
The most common reported source of information (57.1%) was
geable
health professionals (health extension workers plus other health Figure 3: Maternal level of knowledge on neonatal danger signs in Gasera
professionals) followed by family and friends (40.1%). Majority, District, Ethiopia, (n=497) March 12 to April 10.

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know that treatment by health extension worker is free of charge. discussant mentioned major reason for delay for health care seeking
Majority, of the focus group discussants besides mentioned lack was newborn cannot be given any medication, the new born would
of cleanliness, mother’s health condition, amount of breast milk be got better, lack of awareness about neonatal illness, use home
mother produce, giving other foods or drinks other than breast treatments and use of culturally believed treatments. A 26 years old
milk, lack of care and warmth, exposure to cold weather, home mother said that “I will never take my sick newborn for medical
delivery, inappropriate positioning and holding a newborn, birth treatment except it is get worse because the small baby can’t abile
defect and keeping in the sun (hotness) as cause for neonatal illness. to take injection”.
A 29 years old mother said that “newborn need care unless they
A number of FGD discussants mentioned seclusion of both
easily develop diseases.” The other, old aged (66 years old), mother
mother and baby up to 40 days due to the norm so called “ulma”.
said that “evil spirit (eye) and/or devil, bad odor, if mother eat leafy
Accordingly, the mother wouldn’t go out of home further up 40
vegetables, if baby stay in the blood during birth and if something
days even if she and/or her baby become ill.
left in the baby abdomen after birth the baby became ill.”
Factors associated with maternal knowledge about neonatal
Neonatal danger signs health care seeking behaviors danger signs
Three hundred and twenty six (65.6%) of the respondent had After controlling for other socio demographic factors, health
previously noticed one or more of the danger signs in their current service utilization status, and maternal obstetric factors; husband
newborns or children when they were neonates. educational status, PNC follow up, birth preparedness, health
extension worker home to home visit, receiving family health
Of the 326 mothers who have experienced the perceived and
booklet and mothers’ access for television service were the factors
WHO recognized danger signs in their newborns only 182 (55.8%)
that significantly affect maternal knowledge.
mothers took their child to the nearby health institution for
medical treatment immediately without any home intervention Husband’s with formal education was about 2.33 times
(Figure 4). Only 7 (3.8%) got initial neonatal treatment and referral (AOR=2.33, 95% CI 1.24, 4.35) more likely to mention at least
from nearby health extension workers while majority 107 (58.8%) three neonatal danger signs as compared to husbands with no
go treatment from health center and/or government hospital. For formal education. PNC service utilization was another statistically
those who sought medical treatment, majority 125 (68.7%) were significant independent variable for knowledge about neonatal
presented delayed to the health facility more than 24 hours after danger signs. A mother having at least one PNC service was
recognition of the danger signs. about 2.52 times more likely to know danger signs occurring in
newborn (AOR=2.52, 95% CI 1.30- 4.92). Similarly, mothers
Most FGD and in-depth interview participants label the newborn
who got health extension worker home to home visit during their
illness as ‘mitch’, and massage them with a local herb and have
ANC and/or PNC were more likely (AOR= 5.45, 95% CI 2.78,
them inhale the smoke from burning the leaves, rather than seeking
10.70) knowledgeable compared to their counterparts. ‟Before
medical care. A 27 year old mother of small baby said that “babies
health extension program had started; the community had poor
experiencing breathing problems and difficult of passing stool have
knowledge and attitude towards newborn; for example there was
collapsed intestines from either fallen or not being carried properly
bad attitude that if newborn died we say no matter don’t worry the
and would take to ‘wogesha’ for treatment”.
GOD took itself and it will give again the other health extension
Among the 144 (44.2%) mothers who did not present to the health worker bought a great deal improvement especially during home to
facility at all, the most frequent reasons for not taking newborn home visit…..”. (In-depth interviewee, TBA)
to the health facility given by the respondents included; perceived
Moreover, mothers well birth preparedness, receiving family health
no effective treatment is available at health institution (43.1%),
booklet from health providers and access to television had positive
thought symptoms is not serious (poor recognition of signs of
influence on maternal knowledge of newborn danger sign. Those
illness) (31.9%), symptoms resolved without treatment (23.6%),
who were well birth prepared during their last pregnancy were three
lack of money (15.3%) and long distance or lack of transportation
times more likely (AOR=3.04, 95% CI 1.68, 5.52) had knowledge
(12.55%). Others include perceived fear of evil eye or devil (9.0%),
about neonatal danger signs as compared to their complements.
seclusion of both mother and baby with believe/culture/traditional
Correspondingly, mothers who had received family health booklet
and/or religious faith (7.6%), and lack of decision autonomy to
from health providers were 7.52 times (AOR=7.52, 95% CI 4.10,
seek healthcare for newborn (3.5%) (Table 6).
13.82) more likely had good knowledge about neonatal danger
Most of the in-depth interview participants and focus group signs as compared to those who did not received. As well, mothers’
access to television increased their knowledge about neonatal
300
Frequency danger signs nearly by three times (AOR=3.15, 95% CI 1.55, 6.40)
247
250 (Table 7).
186
200
frequency

137
150
100 72 85 Factors associated with health care seeking behavior for
62 46
50 16 17 newborn danger signs
0

The independent variable child sex was statistically significant

for neonatal illness medical health care seeking; as compared to a
woman having female child, a woman having male child was more
likely (AOR=1.86, 95% CI 1.09, 3.17) seek medical care. Mothers
Figure 4: Different neonatal danger signs mentioned by mothers in Gasera who had PNC follow up were more likely to seek medical care for
District, Ethiopia, March 12 to April 10.

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Table 6: Neonatal illness health care-seeking behavior of respondents in Gasera District, Ethiopia, March 12 to April 10.
Variable Frequency Percent
Experienced Neonatal Illness with the Current Child 326 65.6
Neonatal Illness Experienced* (n=326)
Fever(hot to touch)ª 143 43.9
Diarrhea/loose stool 49 15.0
Continuous excessive crying 60 18.4
Breathing difficultyª/cough 86 26.4
Fast breathingª 29 8.9
Lethargy/unconsciousness/weaknessª 18 5.5
Inability to feed/suckleª 73 22.4
Vomiting 68 20.8
Abdominal colic 30 9.2
Skin pustule/boil/rashª 55 16.9
Convulsionª 14 4.3
Tonsillitis 14 4.3
LBW/prematurity 2 0.6
Abdominal distention 6 1.8
Cold bodyª 1 0.3
Jaundiceª 1 0.3
Bulging fontanel 1 0.3
Source of Medical Treatment (n=182)
Government health institution (health center or hospital) 107 58.8
Health post 7 3.8
Private clinic 56 30.8
Pharmacy/drug store 12 6.6
Reason for Not Seeking Medical Treatment* (n=144)
Perceived sickness is incurable 7 4.9
Symptoms is not serious (poor recognition of signs of illness) 46 31.9
Symptom resolved without treatment 34 23.6
Do not know where it could be treated 5 3.5
No effective treatment is available at health institution 62 43.1
Perceived lack ability of primary care providers in the health centers in treating
11 7.6
newborn illness
Lack of money (cost) 22 15.3
Long distance/lack of transportation 18 12.5
Seclusion of both mother and baby due to fear of evil eye or devil and culture 24 16.6
Decision making problem 5 3.5
Other*** 14 9.7
Time Took to Seek Medical Treatment for Sick Newborn (n=182)
Within 24 hr 57 31.3
More than 24 hr 125 68.7
Reason for Delayed Health Care Seeking for Newborn* (n=125)
Did not know that it is a danger sign (poor recognition of signs of illness) 37 29.6
Health facility is far and/or lack of transportation 32 25.6
Lacked money 16 12.8
Thought the child would get better 89 71.2
Wanted to try home remedies first 16 12.8
Absence of responsible person at the home 7 5.6
Newborn didn’t taken to outside in believe/cultural 8 6.4
ªWHO recognized danger signs in newborn (52), *multiple responses, **include Home treatment, Traditional (spiritual) healer, left to God, done nothing,
***include health facility cannot treat evil eye, injection could not give for small baby, tonsillitis can't treated at health facility.

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Table 7: Factors associated with mother’s good knowledge about neonatal danger signs, Gasera District, Ethiopia, March 12 to April 10.
Knowledge of Neonatal Danger Sign
Factor Variables COR (95% CI) AOR(95% CI)
Knowledgeable Not knowledgeable
Mother Age (years)
≤20 12 89 0.23 (0.11, 0.49) 0.32 (0.11,1.01)
21-25 43 123 0.59 (0.33, 1.05) 0.54 (0.22,1.35)
26-30 45 107 0.71 (0.40, 1.26) 0.72 (0.29,1.77)
>30 29 49 1.00 1.00
Mother Education
Not formal education 48 209 1.00 1.00
Formal education 81 159 2.22 (1.47,3.35) 1.28 (0.52,3.13)
Father Education
Not formal education 37 194 1.00 1.00
Formal education 92 174 2.77 (1.79,4.27) 2.33 (1.24,4.35)**
Television Access
Yes 63 36 8.80(5.41,14.33) 3.15 (1.55,6.40)**
No 66 332 1.00 1.00
Distance from Nearest Health
Facility
<1 hr 76 156 1.95 (1.30, 2.93) 1.15 (0.61,2.17)
≥1 hr 53 212 1.00 1.00
ANC Follow Up
Yes 117 335 6.25(1.48,26.45) 1.11 (0.19,6.58)
No 12 33 1.00 1.00
Place of Delivery
Home 24 246 1.00 1.00
Health facility 105 122 8.82(5.38,14.45) 1.62 (0.65,4.04)
PNC Follow Up
Yes 105 120 9.04(5.52,14.82) 2.52(1.30,4.92)**
No 24 248 1.00 1.00
Birth Preparedness
Well prepared 91 113 5.40 (3.48, 8.38) 3.0 (1.68, 5.52)**
Not well prepared 38 255 1.00 1.00
HEW Home Visit
Yes 79 47 10.79(6.75,17.2) 5.45(2.78,10.7)**
No 50 321 1.00 1.00
Received Family Health Booklet
Yes 92 39 20.9 (12.6,34.7) 7.52(4.1,13.82)**
No 37 329 1.00 1.00
** Significant with multiple logistic regression at p-value ≤0.05
** Significant with multiple logistic regression at p-value ≤0.05

Table 8: Factors associated with respondent’s healthcare seeking behavior for newborn with danger signs, Gasera District, March 12 to April 10. (n=326).
Medical Health Seeking Behavior
Factor Variables Not Treatment COR (95% CI) AOR (95% CI)
Treatment Sought
Sought
Child Sex
Female 80 84 1.00 1.00
Male 102 60 1.78 (1.15,2.77) 1.86 (1.09, 3.17)**
Mother Education
No formal education 84 91 1.00 1.00
Formal education 98 53 2.00 (1.28,3.13) 1.42 (0.67,2.97)
Father Education
No formal education 75 79 1.00 1.00

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Dessalegn FN, et al. OPEN ACCESS Freely available online

Formal education 107 65 1.73 (1.11,2.79) 0.76 (0.44,1.32)

Total Income
≤1500 89 104 1.00 1.00
>1500 79 28 0.30 (0.18,0.51) 2.10 (1.15, 3.81)**
Television
Yes 79 27 3.32 (1.99,5.54) 1.71 (0.93,3.15)
No 103 117 1.00 1.00
PNC Follow Up
Yes 149 82 3.41 (2.07, 5.63) 2.24 (1.24, 4.05)**
No 33 62 1.00 1.00
Planned Pregnancy
Yes 139 100 1.42 (0.87, 2.32) 0.88 (0.47, 1.67)
No 43 44 1.00 1.00
Place of Delivery
Home 35 66 1.00 1.00
Health facility 147 78 3.55 (2.17, 5.82) 1.46 (0.58, 3.67)
Birth Preparedness
Not well prepared 90 100 1.00 1.00
Well prepared 92 44 2.32 (1.47, 3.67) 0.48 (0.44, 1.59)
Distance from HF
<1 hr 92 53 1.75 (1.12, 2.74) 0.96 (0.55, 1.68)
≥1 hr 90 91 1.00 1.00
HEW Home Visit
Yes 66 14 5.28 (2.82, 9.90) 1.34 (0.58, 3.09)
No 116 130 1.00 1.00
Received Family Health
Booklet
Yes 75 16 5.60(3.08, 10.19 3.04 (1.38, 6.70)**
No 107 128 1.00 1.00
Received Information on
Danger Signs
Yes 65 11 6.71(3.38, 13.33 1.53 (0.45, 5.49)
No 117 133 1.00 1.00
Know Nearby HEW’s Treat
Newborn Illness
Yes 45 8 5.58(2.54, 12.29 0.64 (0.17, 2.38)
No 137 136 1.00 1.00
Knowledge Status of
Newborn Danger Signs
Not knowledgeable 110 130 1.00 1.00
Knowledgeable 72 14 6.07(3.24, 11.36 2.56 (1.18, 5.54)**
** Significant with multiple logistic regression at p-value ≤0.05

newborn illness than those who cannot had PNC during their last signs of neonatal illness and their health seeking behavior towards
child (AOR=2.24, 95% CI 1.24, 4.05). Similarly, mothers who neonatal illness. Accordingly, only 26.0% of the participants had
received family health booklet from health care providers were knowledge about newborn danger signs. This finding is slightly
three times (AOR=3.04, 95% CI 1.38, 6.70) likely to seek neonatal lower than the finding from community based study conducted
medical health care than their counterparts. Furthermore, neonatal in South-East Nigeria [27], in which knowledge of three and more
danger sign knowledgeable mothers were nearly three times newborn danger signs was (30.3%). This discrepancy could be
(AOR=2.56, 95% CI 1.18, 5.54) more prone for neonatal illness attributed to difference in setting. When asked to list those signs,
medical care seeking than not neonatal danger sign knowledgeable 88 (17.7%) had no knowledge of any and listed none, which was
counterparts. Also, family monthly income has positive significant consistent with the study done in Nadu India, where 18% of the
association with health care seeking (Table 8). women were not aware of even one danger sign [23].
Even though, the Ethiopia Ministry of Health has integrated family
DISCUSSION
health card (booklet) which incorporate information on neonatal
This study was tried to assess mother’s knowledge about danger danger signs for the care provider to advice the mothers and also

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Dessalegn FN, et al. OPEN ACCESS Freely available online

for the mothers to read, efforts to increase awareness of the danger health in this community is very low (26.0%), which does not give
signs among health care givers and the parents, this study showed more educated mothers much of an advantage.
that only 131 (26.4%) mothers received it of whom only 89 (17.9%)
The study also confirmed that PNC follow up practice creates a
read all the instructions on the booklet. The reasons for low
good opportunity for the mother to have good knowledge towards
(26.0%) maternal knowledge on newborn danger signs in the study
neonatal danger sign. Postnatal care attendant mothers were two
area could also be due to small number of mothers received and
times more likely to mention at least three neonatal danger sign as
read instructions on the booklet. This finding is also supported by
compared to their counterparts. However, this finding is different
other studies where despite availability of information on neonatal
from the study conducted in Uganda [20]. The possible reason for
danger signs on family health booklet maternal knowledge on the
the discrepancy could be PNC packages contain information about
equivalent remain very low [19,20].
neonatal danger signs.
In this study majority of the mothers (76.5%) had not received any
Surprisingly, despite a high ANC attendance and health facility
information from the health care workers any time else regarding
delivery among study participants, increased knowledge of
neonatal dangers signs and this is in line with the study done in
newborn danger signs was not detected neither among women
Kenya [26], where only 42.8% received information on neonatal
attending the recommended number of ANC visits nor among
danger signs from care provider during ANC follow up.
women using skilled birth attendant at delivery. This finding is
In the present study the awareness of mothers in Gasera district in line with the studies done in India [28]. This gives rise to great
regarding new born danger signs was found to be poor which is concern; as previous studies conducted in Northern Ethiopia [29]
in line with neonatal danger signs knowledge level reported in indicates, by providing structured counseling during ANC and
Tamil Nadu, India [23]. However, compared to previous studies advice during delivery, knowledge of events and danger signs in
conducted in four regions of Ethiopia [25] and Ghana [19], it is all phases of pregnancy and neonatal period improved. In view of
lower although it is higher than the level reported in India [24], this finding, the extent and quality of the information given to
Northern Ethiopia [29] and Kenya [26]. The discrepancy might be women at ANC and/or delivery with regard to newborn’s health
because of most of the previous studies considered other WHO and what danger signs to look needs significant improvement. This
recognized neonatal danger signs in their studies where as in the study adds further concerns about the quality of ANC service in
current study only the nine WHO recognized neonatal danger study area.
signs answered by a mother were used to assess knowledge status
Furthermore, knowing at least three of those signs was significantly
which might be the reason for this discrepancy, and also possibly
associated with being well prepared for birth. This is consistent
it could be because of time, study setting and cultural differences.
with the study done on inadequate knowledge of neonatal danger
The study further showed that husband education was a significant signs among recently delivered women in Rural Uganda [20].
predictor of mothers’ knowledge about neonatal danger signs.
This study also shows significant association between neonatal
The odds of knowledge about neonatal danger signs were nearly
danger sign knowledge and receiving family health booklet. An
two times good among mothers whose husbands attended formal
increased exposure to media especially television was also increased
education and this finding is consistent with study done in
the knowledge of mothers on neonatal danger signs. Mothers
Northern Ethiopia [29]. This might be due to the fact that males
those who had television access were three times more likely
are decision makers so that if they had education, they can make or
knowledgeable than their counterpart and this supports the study
support mothers to seek care for newborns by which mothers know
conducted in Northern Ethiopia [29] and Ghana [45]. This could
newborn danger signs. Whereas, study in Uganda [20] and Kenya
be television contains a segment of airtime devoted to teach the
[26] shows dissimilarity, possibly due to the cultural differences.
community about health issue of mothers and children.
The study also recognized that health extension workers home
This study also showed that, out of 326 mothers who experienced
to home visit creates a good opportunity for the mother to have
neonatal danger signs, about 55.8% of mothers sought medical
good knowledge towards neonatal danger signs. Health extension
care for their newborn danger signs. This finding was higher than
home to home visited mothers were outlying about five times
the study done in Enugu state, Nigeria (47.7%) [27] lower than
more likely to mention at least three neonatal danger signs as
studies in peri-urban of India (92%) [46] and Pakistan (81.1%)
compared to their counterparts. Indeed, this positive association
[47]. These discrepancies might be due to the difference in social
was what the Ethiopia's health policy expects from health extension
environment that does not encourage health care seeking behavior
workers by implementing integrated health extension package for
towards neonatal danger signs and differences in accessibility of
routine home to home visit especially visit for pregnant mother
health facilities.
and newborn child. Thus, this finding further strengthens the
argument that HEWs contribution at community level improves The study revealed that knowledge of at least three danger signs
newborn survival. in the newborn considerably increased the likelihood of mother
to seek care in health facilities nearly three times. This is aligned
Absence of association between maternal education and
with the study done in Nigeria [27]. However this study shows only
increased knowledge of newborn danger signs in this study was
31.3% of mothers with sick newborn sought medical treatment
unanticipated. Besides, in previous studies this particular absence
immediately within 24 hr. The implication of poor knowledge
of association was noticed in the study conducted in Uganda [39]
was reflected in the fraction of mothers with experience of these
and Kenya [26]. On the contrary, most of the previous studies
signs in their sick newborn who sought care in health facilities
found knowledge of neonatal danger signs was significantly higher
immediately the danger signs were observed in this study
among educated women [27] and [29]. The possible explanation
for this inconsistency is that the overall understanding of newborn Mothers who had PNC follow up were 2.24 times more likely to

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Dessalegn FN, et al. OPEN ACCESS Freely available online

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