healthmedicinet

Socio-demographic characteristics

From the total of 3682 pregnant women enumerated and interviewed at the initial stage,
3612 pregnant women were included in the analysis at the baseline and enrolled to
the follow up study after excluding 70 incomplete questionnaires. After excluding
incomplete questionnaires, abortion cases, missed-to-follow up, maternal deaths and
stillbirths, a total of 3463 live births happened and included in the analysis of
this study making a response rate of 95.9 %. Of the total 3463 respondents, 75.1 %
were from rural residence. Majority (63.8 %) of the mothers were in the age group
of 20-29 years. Oromo was the dominant ethnic group (87.6 %) and Muslim was the leading
religion (87.2 %). More than half (54.0 %), have not attended any formal education
(Table 3).

Table 3. Socio-Demographic characteristics of Respondents, Jimma Zone, Southwest Ethiopia,
September 2012-April 2013 (n?=?3,463)

Neonatal care practices

Among the components of neonatal care practices during pregnancy, 53.8 %, 23.8 %,
41.9 % and 43.0 % received TT, planed for birth, received ANC and received adequate
information on neonatal care, respectively. Among the elements of neonatal care during
labor and delivery, 17.5 % and 95.0 % received skilled care and social support during
labor, respectively.

Among the components after birth, 96.5 % received immediate thermal care, 64.1 % started
breastfeeding within one hour of birth, 86.5 % got clean cord care, 91.5 % on exclusive
breast-feeding, 56.5 % got bathing at appropriate time (after 6 hours of birth) and
8.1 % received vaccination (BCG and Polio-0) on the date of birth. By using these
parameters, composite index was produced by using PCA and mean score was determined.
Accordingly, 59.5 % (95 % CI: 57.6 %, 61.3 %) of neonates scored above or equal to
the mean score and labeled as received good neonatal care (Table 4).

Table 4. Neonatal care practice in Jimma Zone, Southwest Ethiopia, September 2012-December
2013 (n?=?3,463)

The qualitative finding was also supplemented the quantitative one in that still there
are problems in the coverage of some of the neonatal cares. The qualitative part particularly
focused on breastfeeding, thermal care, cord are and neonatal immunization. According
to the opinions of most of the respondents, previously there were problems in newborn
feeding practices that most mothers do not start breast-feeding immediately. They
also used to give fresh butter to the newborn to swallow with the assumption that
he/she will not cry during the childhood. Now a days, the HEWs are educating the mothers
and every mother gives breastfeeding immediately.

Concerning thermal care, mixed practices were reported by majority of the respondents.
As repeatedly mentioned, during home delivery, almost all newborns are wrapped with
clean new towel and put in front of mothers or someone caries them carefully. However,
almost all mothers and newborns are washed just immediately or within thirty minutes
by cold water. This is because of lack of knowledge about the importance of delayed
bathing.

A 28 years old FGD discussant said, “I gave birth to my child two months back by the help of traditional birth attendant.
Just immediately, as the placenta was out, she washed me and my newborn with cold
water. As to me, this is what all women in our community practice….”

A key informant TBA added, “…Both the mother and the newborn are contaminated with dirty blood. How can they
stay with it for long hours? That is why we encourage immediate wash of both the mother
and the newborn….”

Concerning cord care, majority of the respondents had the view that previously, the
mothers reuse rather blades to cut umbilical cord and put butter on umbilical stamp.
But now, every woman knows its drawback and no such practices. Regarding to immunization,
as reported by the majority, vaccination is the major problem of neonatal care. As
most reported, previously mothers had no adequate knowledge and do not accept child
immunizations. But now, every woman knows its benefits. However, the neonates are
not getting appropriately because of many reasons from service providers. The major
reported problems were unavailability of vaccines and when available, the providers
do not open for few neonates.

A 24 years old FGD discussant stated, “…I had taken my neonate two times to the health centre, but he never received the
vaccine. On first day, the provider said, ‘I can’t open the vaccine for less than
10 children’ and appointed me for a week. Again after a week, he said, ‘no vaccine
at all! Come another day!’ I never went there again…”

A HEW added, “…we have been facing problems of open vial policy. We are not supposed to open BCG
vial unless there are 10 neonates. We used to appoint mothers to bring on same day
to open. But, they do not come on same day at same time. As a result, many neonates
are not getting the BCG vaccine….”

Factors affecting neonatal care practice

To evaluate the applicability of the mixed-effects multilevel linear regression model,
the ICC (?) was calculated in the empty-model and it was found to be 0.332 indicating
that 33.2 % of the variation was contributed by between cluster variations. The test
of the preference of log likelihood versus linear regression was also strongly significant
(P??0.0001). Then, the final full model was run by including all the cluster level
and individual level variables and the ICC (?) became 0.157. This again indicated
that 15.7 % of the variation was attributed to cluster level variables suggesting
the preference of multilevel analysis. The preference of log likelihood versus linear
regression was again strongly significant (p??0.0001) (Table 5).

Table 5. Parameter coefficients and test of goodness-of-fit of the mixed effect multilevel
model, in Jimma Zone, Southwest Ethiopia, September 2012-December 2013 (n?=?3,463)

After adjusting in the final two-level mixed-effects linear regression model, predictors
of neonatal care practice existed both at the cluster level as well as at the individual
level. Among the higher (cluster) level variables, place of residence was found to
have statistically significant association with neonatal care practice. Being in urban
residence was found to increase the neonatal care practice significantly (? =0.86;
95 % CI: 0.45, 1.23).

Among the lower level (individual) variables, maternal education, husband’s occupation,
wealth quintiles, birth order and inter-birth interval were identified as predictors
of neonatal care practice. Maternal education of primary (? =0.21; 95 % CI: 0.10,
0.32) and secondary or above (??=?0.76; 95 % CI: 0.55, 0.98) were found to increase
the neonatal care practice significantly as compared with illiterate mothers. Mothers,
whose husbands were employed (??=?0.54; 95 % CI: 0.30, 0.77) or merchants (??=?0.28;
95 % CI: 0.09, 0.47) had higher neonatal care practice as compared to those whose
husbands were farmers.

Wealth quintiles of second (??=?0.18; 95 % CI: 0.03, 0.31), third (??=?0.30; 95 %
CI: 0.15, 0.46), fourth (??=?0.41; 95 % CI: 0.25, 0.56) and fifth (??=?0.30; 95 %
CI: 0.14, 0.46) also increased neonatal care practice significantly as compared to
the lowest (poorest) wealth quintile. Similarly, inter-birth interval of 2-4 years
(??=?0.20; 95 % CI: 0.01, 0.39) and above 4 years (??=?0.34; 95 % CI: 0.10, 0.58)
increased neonatal care practice significantly as compared to interval of??2 years.
Birth order had inverse relationship with neonatal care practice. Birth order of 2
^d
-4
^th
(??=?-0.30; 95 % CI: -0.52, -0.09) and above 4
^th
(??=?-0.43; 95 % CI: -0.68, -0.19) significantly reduced neonatal care practice as
compared to first-order neonates (Table 6).

Table 6. Multilevel analysis of factors affecting neonatal care practice, in Jimma Zone, Southwest
Ethiopia, September 2012-December 2013 (n?=?3,463)

The qualitative part also supplemented the quantitative one and the reasons for poor
neonatal care were themed as low awareness, low-socio economy, costs and unavailability
of transportations. Majority of the respondents had the feeling that most of the women,
particularly in the rural areas, are illiterate and have no adequate knowledge about
the risks of neonatal health problems and importance of neonatal care.

The other major problems repeatedly raised by most of the respondents as barriers
to the neonatal care were unavailability of roads and means of transportation and
costs of transportation and services to take them to health facility for preventive
and curative services. The respondents also emphasized that majority of rural women
are poor and give special emphasis to their daily work for family survival and give
less attention to the neonatal care.

A 36 years old TBA expressed her sorrow as, “…many women face problem because of road and transportation unavailability. The community
has been trying to carry women after complication in labor. Now, they are helping
by burying women because of repeated occurrences and loss of hope….”

A 30 years old FGD discussant mother added, ‘….Lack of transport is our serious problem. I know one woman in my neighborhood.
She had labor at home for more than a day. We tried to take her to health facility,
but no any car around. As a result, we had no options except waiting her till the
dead fetus came out ….”