Neonatal care practice and associated factors among mothers of infants 0–6 months old in North Shewa zone, Oromia region, Ethiopia

Worldwide, the magnitudes of neonatal mortality are estimated to be about 3 million due to insufficient care. The burden of neonatal mortality is high in Ethiopia as compared to high and middle-income countries. The study aimed to assess the neonatal care practice and associated factors among mothers of infants 0–6 months old in Northern Shewa, Ethiopia. A community-based cross-sectional study design was undertaken on a mother living in the North Shewa zone from September 2019 to June 2020. Neonatal care practice was assessed by World Health Organization (WHO) minimum neonatal care package indicators. Over the study period, a total of 245 (62.0%) mothers had a good neonatal care practice. Being urban areas [AOR 5.508, 95% CI 2.170, 13.984], having ANC follow-up [AOR 3.042, 95% CI 1.031, 12.642], lack of adequate information [AOR 0.123, 95% CI 0.054, 0.282] and post-natal care (PNC) [AOR 5.779, 95% CI 2.315, 14.425] were predictors of good neonatal care practice. In our study, there was moderate neonatal care practice among mothers. Therefore, all elements of neonatal care packages should be studied at large.

Study participants and eligibility criteria. All mothers of infants aged 0-6 months residing at least for 6 months in the catchment area during the data collection period were included in this study while, mothers who were unable to communicate because of seriously ill or impaired cognition were excluded from the study.
Study variables and outcome measures. The dependent variable was neonatal care practice, which was assessed by WHO core elements. This neonatal care package has 12 that are scored as "Yes" or 'No' questions. This element contains immunization from tetanus, preparation of mother to manage complications, antenatal care (ANC), Information on neonatal care, Skilled care at birth, Immediate thermal care, breast-feeding initiation, caring of cord, only breastfeeding of the neonate, washing of newborn, Vaccination during birth, and Infection prevention 10 . The WHO core elements of neonatal danger signs were used to identify the level of knowledge of mothers about neonatal danger signs. Mothers who had mentioned ≥ 3 out of twelve newborn danger signs had good knowledge and those who scored < 3 was classified as poor knowledge 16 .
Sample size determination and technique. The sample size was calculated by the single population proportion formula whereas, N is the sample size 95% is CI, d is the level of precision, and p is the magnitude of neonatal care practice which is 0.59 (p = 0.59) 17 .
where Z = critical value for normal distribution at 95% confidence level which equals to1.96 (Z value at α = 0.05); P = Proportion of neonatal care practice (59.5%) from the previous study. d = 0.05 (5% margin of error); and by considering the design effect of 1.5 the sample size becomes 552. After adding the non-response rate of 10% the total sample size was (552 × 10%) + 552 = 607. A multi-stage clustered sampling technique was used to identify the study participants. First, the zone was stratified to woredas and four woredas were selected by simple random sampling from the total number of woredas. In the second stage kebeles within the selected woreda were selected randomly. Finally, each household in the selected kebeles was selected by systematic random sampling.
Data collection process and management. A structured questionnaire was developed which was adapted from related literature for neonatal care practices. The tool was developed in English and converted to the local languages ' Afan Oromo' to ensure the clarity of questions for the respondents. A pretest was conducted in Bishoftu town out of the study area by taking 5% of our sample size that was not included in the actual study population before the actual data collection takes place. Data were collected by eight (8) B.Sc. nurses and the data collection process was supervised by the principal investigators. Before starting data collection, orientation was given to data collectors for 2 days about the data collection and how to handle the data, and the content of the instrument. The data collectors collected the information through face-to-face interviews of mothers at the house level.
Data processing and analysis. The data were entered into a computer using EPI-info 3.5.4 software to avoid any errors. Analysis was done using statistical software for social sciences (SPSS) 24.0. Descriptive data were explained as frequency and percentage. Multivariable logistic regression was used to analyze the variable and the variables with a p-value of less than 0.05 were considered a statistically significant association.

Operational definitions.
• Good neonatal care practices Those who scored above or equal to the mean score out of 12 items of minimum neonatal care package listed by WHO 10 . • Poor neonatal care practices Those who scored less than the mean scores out of 12 items of minimum neonatal care package listed by WHO 10 . • Good knowledge of newborn danger signs Mothers who had mentioned ≥ 3 out of twelve newborn danger signs 16 . • Poor knowledge of newborn danger signs Mothers who had scored < 3 was classified 16 .
Ethical approval and informed consent. Ethical clearance was obtained from the ethics review board of Salale University with the reference number SU13/2018. A permission letter was provided to the North Shewa zonal administration office, and in turn to the selected woredas and kebeles in the district, for proceeding with data collection. Informed consent was obtained from all the participants. Additionally, informed consent was www.nature.com/scientificreports/ obtained from a parent/or legal guardian for participants who are under 18 years of age and have no formal education. To ensure confidentiality, the name and other identifiers of participants and health care professionals were not recorded on the data collection tools. All methods were performed following the relevant guidelines and regulations. The study was performed per the Declaration of Helsinki. The study was registered researchregistry.com with a unique reference number of "researchregistry5882".  www.nature.com/scientificreports/ ers who wrapped their baby before delivery of the placenta, most of them used dry and clean cloths accounted about 188 (47.59%). Concerning Cord care, a new string or thread was the most used material to tie the cord for 182 (46.1%) of births. On another hand in most of the respondents 16 (4.05%), the blade was commonly used to cut the cord after delivery of their recent baby while in 7 (1.77%) of mothers' the scissor was used to cut the cord.

Consent for publication.
Regarding their breastfeeding, out of total respondents, only 204 (51.6%) mothers reported that their newborns were breastfed within the first hour after delivery,73 (18.5%) between 1 and 6 h, 62 (15.7%) between 6 and 24 h, 56 (14.2%) were after 24 h. About 258 (65.3%) mothers reported that they bathed their newborn child for the first time after 24 h of birth. Of the total respondents' most of the mothers 269 (68.1%) reported that their newborns were given vaccination (BCG and Polio-0) on their first day of birth (Table 3).
Factors associated with neonatal care practices among mothers. Residence of mother, educational status of the mother, mother's occupation, husband's educational status, family monthly income, ANC follow up, number of ANC follow-up, information on neonatal care, birth preparedness, and complication readiness, having PNC service and maternal knowledge on neonatal danger sign were factors associated with neonatal care practice among mothers on bivariate analysis.
In multiple logistic regressions, mothers who lived in urban areas were 5.5 times more likely to have good neonatal care practices when compared to mothers who lived in rural areas. [AOR 5.508, 95% CI (2.170, 13.984)]. Mothers who had ANC follow-up in their last pregnancy were 3 times more likely to have good neonatal care than mothers who did not attend ANC follow-up [AOR 3.042, 95% CI (1.031, 12.642)]. www.nature.com/scientificreports/ Mothers who did not get adequate information from a health worker or HEW on neonatal care before or following their delivery were 0.12 less likely to have good neonatal care practices as compared to mothers who had to get adequate information on the newborn issues [AOR 0.123, 95% CI (0.054, 0.282)].
A mother who had birth preparedness & complication readiness in their last pregnancy was 5.3 times more likely to have a good neonatal care practice as compared to others [AOR 5.311, 95% CI (2.055, 13.723)] (Table 4).

Discussion
Neonatal care and their health can be improved by a multidisciplinary approach in Ethiopia 14 . The magnitude of neonatal care practice in our study area was 62.0%, which was almost like the previous study done in southwest Ethiopia (59.5%) 17 , but it was relatively higher than the study conducted in Addis Ababa, Ethiopia (29%) 18 .
Most of the elements of the neonatal care practice along the continuum of care were somewhat good. This finding was almost higher than a previous study done in southwest Ethiopia 17 . This may be described relatively by a good knowledge of mothers regarding neonatal health and neonatal care that increases its utilization.
Neonatal care practice was higher among mothers from the urban area as compared to their counterparts. Mothers who lived in urban areas were 5.5 times more likely to have good neonatal care practices when compared to mothers who lived in rural areas [AOR 5.508, 95% CI (2.170, 13.984)]. This was consistent with other prior studies conducted in Southwest Ethiopia 17,19,20 . This is due to the ease of access to information for mothers from urban areas.
Similarly, this study revealed that mothers who had ANC follow-up in their last pregnancy were 3 times more likely to have good neonatal care than their counterparts [AOR 3.042, 95% CI (1.031, 12.642)]. This was also consistent with other prior studies done in Nepal 21 . This is due to ANC follow-up which insights into mothers' neonatal care practice.
Mothers who did not get adequate information from a health worker or HEW on neonatal care before or following their delivery were 88% less likely to have good neonatal care practices as compared to mothers who had to get adequate information [AOR 0.123, 95% CI (0.054, 0.282)]. This was almost consistent with other prior studies done in Nepal 21 , and East Gojjam, Ethiopia 22 . This may be due to the reason that getting adequate information on neonatal care and other newborn issues is very important for mothers to increase their awareness and practices toward their newborn care.
This study revealed that mothers who had birth preparedness and complication readiness were 5.3 times more likely to have good neonatal care practices as compared to others [AOR 5.311, 95% CI (2.055, 13.723)]. Similarly, Table 4. Multivariate logistic regression analysis result of factors associated with neonatal care practice among mothers of infants 0-6 months in North shewa zone, Oromia region, Ethiopia (N = 395). CI confidence interval, COR crude odd ratio, AOR adjusted odd ratio. *p-value < 0.05.  21 . This is due to the PNC services of mothers, as they are expected to get essential information and be counseled about every aspect of newborn issues which helps them to have good practices toward their newborns.
Strength and limitations of the study. As the strength, the determinants of neonatal care practice at both the community and individual levels were studied. As a limitation since the study was cross-sectional it may not be strong enough to demonstrate a causal relationship between dependent and independent variables due to the nature of the study. Similar studies were done on neonatal care practice and associated factors among mothers are limited in our country to make comparative discussion. In addition, neonatal care practices were determined based on mothers' reports, which might have been forgotten. Therefore, precaution should be given while interpreting the findings.

Conclusion
The study showed that almost there was moderate neonatal care practice among mothers in the study area. Besides this, the big difference was founded in the coverage of the components of the neonatal care package. Place of residence, attending ANC follow-up, receiving information/counseling before, or following delivery from a health worker or HEW, and birth preparedness and complication readiness (BPCR) were found to be determinants of neonatal care practice. Therefore, Policymakers and healthcare providers need to create awareness in the community to improve the coverage of the neonatal care package components before, during, and after birth. Community-based programs are expected to address the poor practices to improve neonatal outcomes. Besides this, improving antenatal care follow-up, and family planning service is recommended to assure good newborn care practices among mothers. Furthermore, it is recommended to conduct qualitative research to explore the reasons and beliefs associated with poor neonatal care practices.