I. INTRODUCTION

Newborn death is a global public health burden mostly concentrated in low- and middle-income countries. Neonates are a vital link in the life cycle, spanning from conception to adulthood. The neonatal stage is defined as the first twenty-eight days after birth. ${}^2$ Newborns face a higher risk of death in this period with an average globalized rate of 17 deaths per thousand live births in the year 2019. ${}^3$

Evidence shows that 2.5 million children lost their lives in the first month of life in 2018, this translates to 7,000 neonatal deaths occurring every day; most of which close to three quarters dying, with one-third of newborns dying on the first day. About $75\mathrm{\%}$ of neonate mortality occurs in the first week of life and about one million newborns die within the first 24 hours after birth. On top, 80 percent of all newborn deaths are caused by three preventable and treatable issues namely complications related to prematurity, birth complications including lack of oxygen (asphyxia) and newborn infections such as sepsis and pneumonia. Numerous lives could be saved each year by investing in quality care around the time of birth, coupled with special care for sick and small newborns. There are mainly three major causes of death in the neonatal period worldwide are infections (around $36\mathrm{\%}$ of which include pneumonia, severe sepsis, and diarrhoea), $28\mathrm{\%}$ of preterm, about $23\mathrm{\%}$ of birth asphyxia and $13\mathrm{\%}$ due to other causes.

A child born in Southern Asia and sub-Saharan Africa is ten times more likely to die in the first 28th days of life than a child born in a developed and high-income country. The first 28 days of neonate life is the most vulnerable time for survival. WHO formulated and focused the priority strategy to reduce neonatal mortality rate worldwide by following neonatal health: thermoregulation, hygienic skincare and cord care, early initiation and exclusive breastfeeding for neonates, assessment for serious health issues or need of additional care in case of low birth-weight and baby of HIV-infected mother and preventive care. Relevant care after birth is very important for the survival and wellbeing of the newly born infant. Basic objectives for neonatal care at birth include initiation of normal breathing, prevention of hypothermia, initiation of breastfeeding, protection from infection and early identification of danger signs.

Care of neonates had always been a traditionally and culturally vital role of mothers irrespective of their educational level, occupation status, family income level, family type and religion.[11]

The neonatal mortality rate per thousand live births in Nepal is 24.2. There are numerous unscientific and unhygienic health practices and social taboos in child-rearing that make the newborn extremely vulnerable.[12] Newborn care of the mothers plays a significant role in bringing down mortality and morbidity because they will have appropriate information and enough confidence to take care of their newborn baby who helps to provide quality and essential care to prevent deviation of normal health.[13] The knowledge of newborn care is directly linked with education level.[14] Out of 363 mothers, $61.70\mathrm{\%}$ of the mothers had adequate knowledge of neonatal danger signs. The mothers were educated up to secondary and more education secured good knowledge.[15] One recent study revealed that a significant association was found between the knowledge scores of primipara mothers with their residential area and education level.[16]

The Sustainable Development Goals (SDGs) have set ambitious targets for all countries. South Asia's target is set to reduce newborn deaths from 28 per 1,000 live births in 2016 to 21 per 1,000 live births by 2021.[17]

Out of 17 Sustainable Development Goals (SDGs) set by United Nations in 2015, the third goal, target (No. 3.2) states that all countries aim to put a stop to millions of avoidable deaths of newborns and under-five children by 2030. The targets achieve by reducing neonatal and under-five deaths to no more than 12 and 25 deaths per 1000 live births respectively.[18] the majority of low-income countries are far behind in achieving SDG target number 3.2 goal mostly because of slow progress in reducing neonatal death.[19] Among 518 mothers, more than half of the newborns were bathed within six hours of delivery. Around $50\mathrm{\%}$ started breastfeeding within one $1\mathrm{h}$ of birth. And $44.8\mathrm{\%}$ of them did not feed colostrum to their newborns.[20] Numerous studies show that an umbilical cord is one of the sensitive issues concerning newborn care. WHO focuses on the significance of hygiene while handling the cord and applying chlorhexidine, basically in regions where there are over neonatal mortality rates.[21] A study shows that one-third of the participants had good newborn care practice based on three composite variables such as early breastfeeding initiation $83.9\mathrm{\%}$, safe cord care $32.9\mathrm{\%}$, and thermal care $30.6\mathrm{\%}$ respectively.[22]

Mothers are the key person for providing newborn care in Nepal.[23] In the context of Nepal, lack of knowledge among primigravida mothers about the preparation for their new roles and responsibilities.[24] The health of newborns has been neglected despite the huge number of deaths due to various causes in Nepal such as preterm birth complications $31\mathrm{\%}$, intrapartum related complications $23\mathrm{\%}$, sepsis $19\mathrm{\%}$, congenital abnormalities $13\mathrm{\%}$, diarrhoea $1\mathrm{\%}$, pneumonia $6\mathrm{\%}$, other conditions $7\mathrm{\%}$.[25] A study was conducted in Nepal, among 276 primiparous mothers, $56\mathrm{\%}$ of women had moderate knowledge about newborn care, $44\mathrm{\%}$ had a low level of knowledge of breastfeeding, and $78\mathrm{\%}$ had a sufficient level of knowledge about immunisation.[26]

II. MATERIAL AND METHODS

a) Study Design, Setting and Population

A descriptive cross-sectional research design was used for this study to meet its objectives. This study was conducted at the postnatal ward Bharatpur hospital in Chitwan. The main objective of the study was to find out the knowledge on newborn care among primi postnatal mothers. The study population was primigravida postnatal mothers.

b) Sampling Technique

A descriptive cross-sectional study design was adopted to assess the knowledge of newborn care among primi postnatal mothers. The sample populations were the primi postnatal mothers who had undergone either vaginal delivery or cesarean section delivery and were admitted to the postnatal wards. The sample size was 104. A non-probability, purposive sampling technique was used. Data were collected by using structured interview methods following ethical principles. The data were collected for 6 weeks period from August ${22}^{\mathrm{nd}}$ to October $6^{\mathrm{th}}$ 2021 at Bharatpur district hospital postnatal ward, Chitwan.

c) Instrumentation

The instrument for data collection was a structured interview schedule through face to face interview method which was developed by the researcher herself by reviewing the related literature and consulting with subject experts.

d) Inclusion criteria

All primi postnatal mothers who had undergone either vaginal delivery or cesarean section delivery and were admitted to the postnatal wards were willing to participate. Others criteria was mothers who can understand English and Nepali language.

e) Outcome variable

Find out the knowledge on newborn care among primi postnatal mothers.

f) Explanatory variables

Explanatory variables were age, educational status, ethnicity, types of family, occupation, area of residence, type of delivery and duration of hospital stay etc.

g) Ethical committee approval

Ethical clearance was obtained from Manmohan Memorial Institute of Health Sciences (IRC) Kathmandu, Nepal. Data collection permission was obtained from the Bharatpur district hospital in Chitwan. The purpose of the study was explained to the participants. Verbal consent was taken from all respondents before the data collection. Privacy was maintained by using a code number for each respondent. Confidentiality was maintained by not disclosing the information to others and assured that the information will be used for study purposes only. Respondents were clearly explained that they have the choice to reject or discontinue the research study at any point during the study time.

h) Questionnaire design

Content validity of the instrument was established by consultation with the research advisor and subject experts. English questionnaire was translated into the local Nepali language to maintain simplicity and comprehensibility with the help of a language expert. Besides, pre-testing was done among $10\mathrm{\%}$ of respondents (i.e. 11 respondents) to assess the practicability of use of the instrument and was excluded from the main study. Slight modifications were done to the instrument such as arranging questions in order and adding/deleting some response categories after the pretest.

i) Data management and statistical analysis

The collected data was checked, reviewed and organized for accuracy, completeness and consistency. All collected data were analyzed by using the statistical package for social sciences (SPSS) version 20.0. Association between different variables were tested by Chi-square.

III. RESULTS

Table 1 shows the socio-demographic variables of respondents. Out of 112 respondent's majority, $50.9\mathrm{\%}$ belong to the age group 20-24 years. The present study shows that majority of the respondents were from rural areas $59.6\mathrm{\%}$. Likewise, the majority of the respondents were from janajati ethnicity $38.5\mathrm{\%}$ and $80.7\mathrm{\%}$ followed the Hindu religion. Majority of respondents $98.0\mathrm{\%}$ were literate. Among them, $38.1\mathrm{\%}$ had completed secondary level and at least $0.9\mathrm{\%}$ could read and write. Regarding the type of family, the majority $65.3\mathrm{\%}$ were living in joint families. Nearly one-third of the respondents $74.0\mathrm{\%}$ were household workers.

Table 3 shows that, $96.1\mathrm{\%}$ replied breastfeeding is one of the most important areas of newborn care, whereas only $19.2\mathrm{\%}$ replied management of illness is the meaning of newborn care. Similarly, $40.3\mathrm{\%}$

respondents knew of the newborn period, and $50.9\mathrm{\%}$ respondents knew the normal weight of the newborn.

Table 4 shows $92.3\mathrm{\%}$ had knowledge of the first feeding, $56.7\mathrm{\%}$ had knowledge of the position of breastfeeding and $47\mathrm{\%}$ of mothers said burping should be done after feeding. While asking about exclusive breastfeeding only $44.2\mathrm{\%}$ heard, $82.6\mathrm{\%}$ knew what exclusive breastfeeding and $60.8\mathrm{\%}$ knew its duration.

Table 5 shows the majority of mothers $88.46\mathrm{\%}$ of mothers knew the umbilical cord should be kept clean to prevent infection and $82.6\mathrm{\%}$ of mothers were knowledgeable about cleaning cords with warm water and cotton. In addition, $71.1\mathrm{\%}$ of mothers knew that their eyes should be cleaned using warm water and cotton. Regarding maintenance of body temperature, $44.2\mathrm{\%}$ knew an appropriate time to give baby baths after delivery and only $28\mathrm{\%}$ knew that delaying bathing after birth helps in maintaining body temperature.

Table 6 delineates that $77.8\mathrm{\%}$ had heard about immunization. Similarly, $69.1\mathrm{\%}$ of mothers were unknown about the appropriate time for BCG vaccination and $82.1\mathrm{\%}$ knew the necessity of vaccination is to prevent some diseases. Likewise, $48.0\mathrm{\%}$ had heard about newborn danger signs and $68\mathrm{\%}$ considered cord infection as a danger sign.

Table 9 shows that, there is significant association of knowledge on newborn care with mother age $(p=0.047)$, education $(p=0.03)$, ethnicity $(p=0.026)$ and occupation $(p=0.05)$.

IV. DISCUSSION

The present study found that, $50.9\mathrm{\%}$ had moderately adequate knowledge, $45.2\mathrm{\%}$ had inadequate knowledge and only $3.8\mathrm{\%}$ had adequate knowledge of newborn care. Which was in contrast to the study conducted by Bagilkar & Anuchihra (2014) where $68\mathrm{\%}$ had moderately adequate knowledge, $30\mathrm{\%}$ had adequate knowledge and only $2\mathrm{\%}$ had inadequate knowledge.[27] In the current study, only $17.3\mathrm{\%}$ mothers answered one month baby is the newborn, which was inconsistence with the study conducted in Nepal by Bhandari & Sharma (2016) where $85.3\mathrm{\%}$ know the meaning of newborn baby.[28] In this study, $69.23\mathrm{\%}$ of the respondents knew about the right time for the initiation of breastfeeding and $92.3\mathrm{\%}$ knows colostrum feeding. This result were similar to the study conducted by Mohite, Mohite, & Kakade (2012) in Bangladesh. The result that $59.6\mathrm{\%}$ had fair knowledge about breastfeeding and $82.7\mathrm{\%}$ knew about colostrum feeding.[29] A contras finding which was conducted by Pathak, Singh, Agarwal, & Kant (2021) shows that only $4.5\mathrm{\%}$ of the mothers knew about the initiation of breastfeeding to the baby within one hour after delivery. Regarding the knowledge of burping after feeding, only $45.1\mathrm{\%}$ knew burping is necessary. Whereas, the contrast finding shows that $93.5\mathrm{\%}$ knew burping after feeding is necessary.[30]

Most of the respondents $96.1\mathrm{\%}$ knew about breastfeeding is one of the important parts of newborn care which is supported by the finding of Berhea, Belachew, & Abreha, (2018) where $97.4\mathrm{\%}$ replied about breastfeeding.[31] It contradicts the findings by Chaudhary, Dhungana, & Ghimire (2013) in Nepal[32] and Berhe, et al., (2016) in North Ethiopia showing that $52.5\mathrm{\%}$ and

$63.1{\mathrm{\%}}^{33}$ were knowledgeable about breastfeeding respectively.

Regarding exclusive breastfeeding $44.2\mathrm{\%}$ had heard it while a contrast study conducted by Ahmed & Piro (2019) shows that $69.2\mathrm{\%}$ of the mothers answered about exclusive breastfeeding.[34] This study reflects that $88.4\mathrm{\%}$ of mothers knew cord should be kept clean to prevent infection and $71.1\mathrm{\%}$ knew how to keep eye-clean. This is similar to the finding of Bhandari & Sharma (2016) where the primi postnatal mothers who revealed that $56.3\mathrm{\%}$ of the answered cord should be kept clean and $88\mathrm{\%}$ had knowledge on eye care to prevent infection.[28]

Regarding immunization, though $77.8\mathrm{\%}$ of respondents had heard about it only $20.9\mathrm{\%}$ knew about the appropriate time for B.C.G vaccination which contradicts the finding in the study by Pathak, Singh, Agarwal, & Kant, (2021) which revealed that $(97\mathrm{\%})$ were fully immunized. ${}^{30}$ A study was done by Bhandari, and Sharma,2016 expressed centpercent of mothers had heard about immunization. ${}^{28}$ In the present study, $48.0\mathrm{\%}$ had heard about newborn danger signs. Where $81.73\mathrm{\%}$ of mothers thought poor sucking was a serious condition where they should seek medical help. This is in contrast to the finding of Pathak, Singh, Agarwal, & Kant, (2021) which shows that $(98\mathrm{\%}),(78\mathrm{\%}),(37\mathrm{\%}),$ (and $31\mathrm{\%}$ ) knew fever, fast breathing, chest in drawing and unable to feed respectively were the newborn danger signs. ${}^{30}$ According to the study the knowledge on newborn care is significant association with the education of the mother $(p=0.03)$ which was similar to the study conducted by Bagilkar, & Anuchihra (2014) and Sakelo, Assefa, Oljira, & Assefa (2020) were the significant association of knowledge with maternal education with newborn care. ${}^{35}$

V. CONCLUSION

Based on the finding of the present study it is concluded that the knowledge of newborn care among primi postnatal mothers is inadequate in almost half of the respondents, the adequate level of knowledge is very less in comparison to the moderately adequate and inadequate knowledge. Knowledge of breastfeeding, knowledge on eye care, and cord care were good but mothers were lacking knowledge in various aspects of newborn care and newborn danger sign. As the study was about population on primipostnatal mothers who had no experience in raring and caring for newborns. Hence, emphasizing health education regarding newborn care during antenatal visits might increase the knowledge during the postnatal period.

VI. LIMITATIONS OF THE STUDY

The study was conducted in only one district hospital in Chitwan. The finding cannot be generalized to the overall population as well as others setting.

VII. RECOMMENDATION

Health education on essential newborn care should be integrated into routine antenatal services and re-emphasized in the postnatal period to help improve maternal knowledge and essential newborn care practices.

Health intervention should be provided for primigravida in the special focus area like immunization, exclusive breastfeeding, prevent hypothermia, and cleanliness of newborn danger signs.

Funding sources

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflict of Interest: The authors do not have any conflict of interest arising from the study.

ACKNOWLEDGEMENTS

Our deepest gratitude goes to study participants, supervisors, and all maternity ward staff of Bharatpur hospital in Chitwan.