Knowledge on Time to Newborn First Bath among Post Paritum Women, Southwest Ethiopia

Strength and limitation of the study

A. The study was conducted at multiple health institutions, increasing the generalizability of the findings to the entire population.
B. This study used a multivariate logistic regression analysis to regulate all likely confounders.
C. Since this is a cross-sectional study, it may not show cause and effect relationship.

Thermal control remains poor in newborns owing to immaturity of the thermoregulatory centre and newborn become vulnerable to hypothermia especially premature babies, intrauterine growth retardation and LBW babies, and even normal babies [1]. Bathing is a regular occurrence for all newborn infants. While bathing practices and skin care have traditionally been based on culture, regional customs and anecdotal experience [2].

World health organization (WHO) recommends that bathing should be delayed until 24 hours of birth, and bathing a newborn within the first 24hours of delivery is a bad practice [3]. Even though there is enough evidence to support the benefits of delayed newborn bathing, it is the most poorly practiced component of the essential newborn care package, especially in sub-Saharan Africa including Ethiopia [4,5]. Bathing the neonate should be delayed until their temperature is stable above 36.5 ℃ usually after the first 24hrs, unless there is a risk of infection (e.g. maternal HBV or HIV positive) from the mother [6]. The community around the world consecrates a new-born baby through different ways and the Community still preserved the ritual of infant bathing as a symbol of welcoming the baby as a way to integrate the baby within society [7,2].

Every newborn requires basic care provided by the mother at home such as warmth, feeding support, skin-to-skin care, proper hygiene and identification of danger signs. Mothers as close care givers of neonates are supposed to be knowledgeable about thermoregulation of their neonates but most women had no knowledge that in hypothermia [8,9]. Standard safety precautions should be used when bathing infants. Such practices include wearing gloves until after the infant’s first bath to prevent from infections [2,3].

The study conducted in Bawku Municipality, Ghana, knowledge on delayed bathing was low as more than half of the respondents, 55% did not know that newborns are not supposed to be bathed until after 24hours of delivery [10]. Another study conducted in in Nepal indicates that, only nine (9%) post-partum women have knowledge in delay bathing to keep newborn warm [11].

A cross-sectional study conducted in Rwanda states that approximately 97% of mothers had in adequate knowledge about neonatal hypothermia and only 56% knew the time of bathing the newborn [12]. In eastern Ethiopia around 12.5% of women reported that time of the first bath should be before 24 hrs. and 3% of mothers were don’t know the first time of bath [13]. Mostly mothers with primipara status had no knowledge of hypothermia and practicing early newborn bathing [14].

Additionally, a community based cross-sectional study conducted at Adigrat, Tigray, Ethiopia indicates that55 % of mothers reported that baby should be bath after 24 hours of delivery [15]. The prevalence of neonatal hypothermia in Southwest Ethiopia was 50.3% as early newborn bathing was a highly associated indicator for this complication of the newborn [16].

Knowledge of newborn bathing time is significant predictors of good newborn care practices [10]. Knowledge gap about first bathing and hygiene practices among postnatal mothers leads to early newborn bathing [17], and knowing the correct first bathing time was significantly associated with good newborn care practices of mothers [18]. Although the early first newborn bath is highly practiced by postpartum women in Ethiopia, little attention has given to determine maternal knowledge on time to newborn bath. Therefore, this study aimed to assess knowledge on time to newborn first bath among postpartum women who gave birth in the last six months in Jimma town/ southwest Ethiopia.

Study design, area, and period

This cross-sectional study was conducted at the Jimma town public health institutions from July 15 to August 4, 2021. The town is located in the Jimma zone, in the southwestern part of Ethiopia, and is approximately 352km away from Addis Ababa the capital city of Ethiopia. The town has five public health centres and two public hospitals (one referral and one district). The referral hospital, Jimma Medical Center (JMC) is one of the oldest public hospitals in the country it was established in 1937 by Italian invaders. The hospital provides service to 15-20 million residing in Oromia, Gambella, and southwest regions even for neighbouring South Sudan with 1800 staff members including 550 nurses with 32 intensive care units and 800 beds. It provides many services under many departments, such as paediatric ward, medical ward, surgical ward, maternity ward, obstetrics, gynaecology ward, maternal and child health (MCH) ward, operating room (OR), emergency outpatient department (OPD), delivery room, psychiatric clinic, dental and eye clinics, laboratory service, ultrasound and other imaging studies. Shanan Gibe Hospital is also one of the district hospitals in Jimma town, which provides many services under departments such as medical, paediatric surgical, maternity, obstetrics and gynaecology, maternal and child health, operating room, and emergency outpatient department.

Population

All postpartum women who gave birth in the last six-month and come for newborn immunization to Jimma town public hospitals were the source population whereas all sampled postpartum women who gave birth in the last six-month and come for immunization to Jimma town public hospitals during the data collection period were considered as the study population.

Inclusion and exclusion criteria

Women who came for immunization and were present in the hospital during the data collection period were included while; Caregivers who brought infants to immunization mothers to assist mother and women unable to speak and participate were excluded.

Sample size determination

The sample size was determined by using a single population proportion formula considering the following assumptions: 95% confidence level, margin of error (0.05) and proportion (P) of knowledge on newborn first bath was considered as 50% since there is no previous study and the ample was calculated as follows:

After adding a non-response rate of 5% (19.2~20), the final sample size was 404.

Sampling technique and procedure

The average number of women who were coming for child immunization at each facility in the month proceeding the data collection period, which was approximately 557 from hospitals (A total of 314 and 243), From JUMC and Shenen Gibie Hospital respectively and samples, were proportionally allocated to each hospital. A systematic sampling method was used to select study participants who attended newborn immunization during the data collection period. Participants’ card numbers were used to systematically select study participants at every K^TH interval taking K=N/n=557/404) = 1.37 which is approximately two.

Variables of the study

Dependent variable: The dependent variable was maternal knowledge on “Timing of newborn first bath” dichotomized good knowledge and poor knowledge. The independent variables of the study included:
A. Maternal and Neonatal sociodemographic characteristics: (Sex of neonate, maternal age in years, Ethnicity, Religion, Marital status, educational status, maternal residency, Maternal Occupation,).
B. Gynecology and obstetrics related characteristics: Obstetricrelated characteristics: (Gravidity, parity, Place of delivery, Type of pregnancy, Preparedness for delivery, problem, Presentation, Mode of delivery).
C. Maternal knowledge and practice related characteristics :( KMC, postnatal care follows up during last birth, ANC during last pregnancy, Number of visits, early breastfeeding initiation, and maternal knowledge about newborn bathing technique and Hypothermia and maternal practice of neonatal bath).

Operational definitions

Knowledge on newborn bath: know the appropriate time for bathing the newborn after birth. Mothers were asked if they did know the appropriate time for first bathing newborn after birth and they were considered at the have good knowledge if they answered appropriate time for first bathing newborn was 24hours or more, while the women were considered having poor knowledge if they answered appropriate time for first bathing newborn was below 24hrs.
Early bathing practice: The immersion of all or part of the body of a newborn in water or some other liquids for cleansing or refreshment before 24hrs. after delivery.

Data collection procedures

Data were collected using a structured and pretested questionnaire through face-to-face interviews, which was adapted after reviewing different of literatures. All primary data were obtained from postnatal mothers. The tool was first prepared in English and then translated into local languages, Afan-Oromo and Amharic and retranslated back to English to check its consistency. Two BSc midwives were collecting the data and they were trained for one day about the objective of the study before they go-to actual data collection. One MSc clinical midwife was assigned as a supervisor in each hospital.

Data quality assurance

To ensure the quality of data, different measures were undertaken. The questionnaire was initially prepared in English then translated to the local language (Afaan Oromo), then translated back to English. Before actual data collection, a pretest was conducted on 5% of the total samples in another setting. Based on pretest result corrections were made before using it for the main study. One day of training was given to the data collectors. During the data collection period, the data were checked for completeness and consistency of information by the principal investigator.

Data processing, analysis, and presentation

The collected data were coded and entered into Epi data 4.4.2.2.1and exported to SPSS version 25 for analysis. Hosmer and Lemeshow test were done to confirm the model of fitness, and the model has been fitted. Bi-variate and Multivariable analysis were done between maternal knowledge of timing of first newborn bath and independent variables. In bivariate logistic regression, the variables which had a p-value of less than 0.25 was considered as candidate variable for multivariable logistic analysis. In multivariable analysis, those variables which had a p-value of less than 0.05 were considered statistically significant with the outcome variable. The finding of the data was presented by using text, tables, figures, and graphs.

Patient and public involvement

Study participants were not involved in the development of the research question or design, or conduct, or reporting, or implementation or dissemination plans and evaluation.

This study used to measure the level of knowledge towards timing of first newborn bath among postpartum women, from the total sample of four hundred four (404) women, three hundred seventy-six (376) of them were agreed and involved in the study and gave a response rate of 93.1%.

Maternal and neonatal socio-demographic characteristics

In this study, approximately three hundred twenty-four (86.17%) of the mothers were in the age group of 20-34 years. Majority of the newborns brought for immunization during data collection period were female which accounted for two hundred one (53.46%). Approximately ninety-three (24.73%) of the respondents had completed primary schools (Table 1).

Table 1:Socio-demographic characteristics of mothers and their neonates at Jimma town public hospitals, Southwest Ethiopia, 2021.

Gynaecology and obstetrics related characteristics

In this study, Majority (61.17%) of women was multigravidas and approximately three hundred fifty-five (94.41%) women had a single tone pregnancy. Approximately three hundred thirty-one (88.03%) of respondents had ANC follow up during the recent pregnancy and only three hundred twenty (85.11%) women had birth preparedness plan (PBR). Only eighty-five (22.61%) respondents had post-natal follow up during the recent pregnancy (Table 2).

Table 2:Maternal gynecology and obstetrics related characteristics at Jimma town public hospitals, southwest Ethiopia, 2021.

Maternal knowledge and practice related characteristics

In this study, majority of women had good knowledge towards neonatal hypothermia, which accounted for (61.7%). Only one hundred five respondents had practiced kangaroo mother care, which accounts (27.93%). Approximately 268(71.28%) women had initiated breast-feeding within one hour (early initiation) (Table 3).

Table 3:Maternal knowledge and practice related characteristics at Jimma town public hospitals, southwest Ethiopia, 2021.

Maternal knowledge on timing of newborn first bath

Approximately 124(32.98 % (95% CI: 28.39-37.91) were having poor knowledge on time to first newborn bath, while 252 (67.02 %) mothers had good knowledge on time to bathing (Figure 1).

Figure 1:Maternal knowledge on Timing of newborn bathing among mothers at Jimma town public hospitals, southwest Ethiopia, 2021.

Factors associated with maternal knowledge on timing of newborn bath

In this study, ANC follow up during pregnancy, maternal parity and mode of delivery were variables significantly associated with maternal knowledge on timing of newborn bath with p-value less than 0.05.

Women who had ANC follow up in the recent pregnancy were had 3.35 times more knowledgeable on timing of newborn bath than women who didn’t have ANC follow up in recent pregnancy (AOR:3.35 (95% CI:1.77-6.336).

The odds of timing of newborn bath knowledge were 68.4% less likely among primipara women than their counterparts (AOR: 0.316(95% CI: 0.197-0.505). Mothers who gave birth through the vaginal mode of delivery were 49.1% less likely to have good knowledge on timing of newborn bath than mothers who delivered using cesarean section (AOR: 0.509(95% CI: 0.251-1.031) (Table 4).

Table 4:Factors associated with maternal knowledge on timing of newborn bath among the mothers at Jimma town public hospitals, Southwest Ethiopia, 2021.

Background

This Cross sectional study was conducted to assess the maternal knowledge on time to newborn first bath and its associated factors among postpartum women, southwest Ethiopia.

General finding

It is a well-known fact that the knowledge towards timing of newborn bath has directly been related to morbidity and mortality of neonates. Despite education for women on the benefits of delayed bathing, many mothers were still requesting to have their newborn bathed as soon as possible. In this, study mothers, who had poor knowledge on time to first newborn bath accounted for 67.02%.

This study revealed that there is significant relationship between ANC follow up, mode of delivery and maternal parity with maternal knowledge on time to newborn first bath. In this study women who had ANC follow up in the recent pregnancy were 3.35 times more knowledgeable on timing of newborn bath than women who didn’t have ANC follow up in recent pregnancy (AOR:3.35 (95% CI:1.77-6.336).

Timing of newborn bath knowledge were 68.4% less likely among prime-para than multifarious women (AOR: 0.316(95% CI: 0.197-0.505). Moreover, in this study mothers who gave birth through the vaginal mode of delivery were had 49.1% less likely have knowledge on timing of newborn bath than mothers who delivered using cesarean section (AOR: 0.509(95% CI: 0.251- 1.031).

Comparison with similar studies

In this, study mothers, who had poor knowledge on time to first newborn bath accounted for 67.02%.Our study finding is slightly lower than the study conducted in Bawku Municipality ,Ghana, 55% [10],in Rwanda 56% [12], and study conducted at Adigrat, Tigray, Ethiopia indicates that55 % of mothers reported that baby should be bath after 24 hours of delivery [15].The possible reason for this discrepancy may be from the difference on Scio-demographic and other characteristics.

In this, study mothers, who had poor knowledge on time to first newborn bath accounted for 32.98 %,( 95% CI: 28.39-37.91), the proportion of this study finding higher than the study conducted in Nepal, only nine (9%)(11).The study conducted in eastern Ethiopia around 12.5% of women knew that time of the first bath should be before 24 hrs. and 3% of mothers were don’t know the first time of bath [13], while the finding was lower than the study conducted in Ibadan, Nigeria, where inadequate knowledge on bathing was (76%) [19], this discrepancy may be this discrepancy may be because there is the socio-cultural difference and maternal and difference in neonatal health care service.

Women who had ANC follow up in the recent pregnancy were 3.35 times more knowledgeable on timing of newborn bath than women who didn’t have ANC follow up in recent pregnancy (AOR:3.35 (95% CI:1.77-6.336). This is consistent with a study conducted in Southeastern Ethiopia [20] and Southern Ethiopia [21]. This might be because ANC follow-ups may increase the chance to obtain more information related to thermal care and time to newborn bath from health professionals. This might indicate the need to improve the counselling given to mothers during ANC and PNC, with emphasis on the appropriate time of newborn bath.

The odds of timing of newborn bath knowledge were 68.4% less likely among primipara than multifarious women (AOR: 0.316(95% CI: 0.197-0.505). The finding was in agreement with studies done Southern Ethiopia [21] and Harer [14]. The possible explanation might be those mothers who gave birth more than two times might have multiple exposures to the healthcare providers that enable them to have awareness about time to newborn bath and safety principles on thermal care as compared with those primi-parous mothers. Therefore, prim parous women should ask for help from healthcare professionals when they have doubts about their or their newborn’s well-being, which might prevent neonatal and maternal morbidity.

Mothers who gave birth through the vaginal mode of delivery were had 49.1% less likely have knowledge on timing of newborn bath than mothers who delivered using cesarean section (AOR: 0.509(95% CI: 0.251-1.031). This may be that women delivered with cesarean section may have a longer hospital stay at the hospital and adequate time to contact with health care providers; this may lead to increase maternal understanding about newborn care including time to bath. The findings of this study will have significant contribution to achieve the sustainable development goals and every newborn action plan that targets to achieve 12 or fewer neonatal mortality per 1000 live births worldwide by 2030 and it is the only study in Ethiopia that will help as base line to conduct further observational studies.

Policy implication and future research

Currently, some trials running aim to implement techniques for promotion of level of knowledge among mothers on first timing of newborn bath and to decrease neonatal mortality related with proper bathing technique in Ethiopia. However, the current study’s findings indicated that maternal knowledge was low on timing of newborn first bath different due to different associated factors. This highlights that mothers with poor knowledge on timing of newborn bath are at a higher risk of leading their neonates for different comorbidities and related mortalities. Thus, the government of Ethiopia needs to strengthen existing trials and strategies to increase the level of maternal knowledge and decrease mortalities in neonates by preventing predictive factors.

In addition to governmental organizations, other nongovernmental organizations should pay attention to fill knowledge gap in mothers for newborn bath. Additional attention should be given to mothers who didn’t have ANC follow up in recent pregnancy, prime-para mothers, and mothers who gave birth through the vaginal mode of delivery.

The maternal knowledge on time to newborn first bath is still a public problem and ANC follow up, vaginal mode of delivery and maternal parity were associated factors with maternal knowledge. Therefore, Education on delayed bathing should add to the prenatal class curriculum. Labor and delivery midwives should promote delaying a newborn’s first bath during the admission process. Women should be potentially educated on the timing of first bath three times: during prenatal classes and postnatal periods, finally upon provision of discharge education to the home before the women leaving the postpartum unit.

Ethical consideration

Before data collection official letter was obtained from the Jimma university review board and official permission was asked from Jimma medical center. The entire respondents were asked their permission before data collection. In addition, the confidentiality of the information was assured and the privacy of the study participants was respected to ensure confidentiality the names of respondents were not written on the consent form.

Acknowledgment

First, we would like to thank Jimma University Institute of Health, Faculty of Health Science, and School of Midwifery for allowing us to do this research paper. Secondly, we would like to thank Jimma Medical Center and Shanan Gibe Hospital administrators for their absolute cooperation. It is also our pleasure to thank the data collectors, supervisors, and participants for their kind cooperation.

Author contributions

Conceptualization: B.F, Y.D. T.B, and A.Y; methodology: B.F and Y.D; software: T.B and A.Y Validation: B.F and A.Y; formal analysis B.F; investigation: Y.D. T.B, and A.Y; data curation: B.F. and T.B; writing-original draft preparation and writing-review and editing, all authors; supervision, Y.D. and, B.F. All authors have read and agreed to the published version of the manuscript.

Funding

The authors declare that no financial funding was received for the study, authorship, and publication of this article.

Data availability statement

The raw data file could be provided for research purposes only, upon request via e-mail of the corresponding author.

Conflicts of Interest

The authors declare no conflict of interest.

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