alexa Knowledge and Practice of Essential Newborn Care and Associated Factors among Nurses and Midwives Working at Health Centers in Jimma Zone, Ethiopia, 2016

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Journal of Nursing & Care

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Knowledge and Practice of Essential Newborn Care and Associated Factors among Nurses and Midwives Working at Health Centers in Jimma Zone, Ethiopia, 2016

Bayisa Bereka Negussie1*, Fikadu Balcha Hailu2 and Asrat Demissie Megenta3
1College of Public Health and Medical Sciences, Jimma University, Ethiopia
2Institute of Health, School of Nursing and Midwifery, Jimma University, Ethiopia
3College of Health Science, School of Nursing, Addis Ababa University, Ethiopia
*Corresponding Author: Bayisa Bereka Negussie, Neonatal Nursing Program Coordinator, Jimma University College of Public Health and Medical Sciences, Nursing And Midwifery, Jimma Oromia, Ethiopia, Tel: +251917238905 , Email: [email protected]

Received Date: Dec 17, 2017 / Accepted Date: Feb 05, 2018 / Published Date: Feb 13, 2018


Background: In Ethiopia, institutionalization of deliveries are happening at a fast pace. Assessing the knowledge and practice of midwives and nurses in these institutions is a priority in this current scenario. The initial adaptations by the baby at the time of birth should be facilitated by the midwives by giving essential newborn care. Therefore, this study is aimed to identify knowledge and performance gap on essential newborn care.
Objective: The objective of this study was to assess knowledge and practice of essential newborn care and associated factors.
Methods: Facility based cross-sectional design was conducted. Simple random sampling method was used to select the estimated 279 study participants from those who provide delivery and neonatal care. Self-administer questionnaires was distributed to participants to collect data and facilitated by data collectors. Data was entered to EpiData Manager and exported to statistical package for social sciences version 20 and analyzed. Finally, the result was illustrated in the form of text and tables.
Results: The mean knowledge score of study participants was 23.27. The study revealed that 52.2% and 47.8% of the respondents had good and poor knowledge respectively. The mean score of practice was 32.82 and 51.1% and 48.9% of the respondents had good and poor level of practice respectively. Field of study, educational level, interest to work in delivery room, in-service training was significantly associated with level of essential newborn care practice.
Conclusion and recommendation: The study population had poor knowledge and practice on some components of essential newborn care. Level of education, interest, in-service training and level of knowledge were found to be independent predictors of practice. Hence, strengthening of in-service training, priority should be given for those trained to give delivery and newborn care service, and incorporation of all components of essential newborn care in curriculum was recommended.

Keywords: Knowledge; Practice; Essential newborn care; Midwives; Nurses


The transition to extra uterine and initial adaptations are crucial to the baby's subsequent wellbeing and should be understood and facilitated by the health care providers at the time of birth and after birth by giving essential newborn care (ENC) [1]. The care health workers provide at time of birth is critical in helping to prevent complications and ensuring survival [2]. Skilled care during labour and childbirth with prompt management of complications alone can prevent about 50% of newborn mortality and 45% of intra-partum stillbirths. Combined with adequate newborn care in the postnatal period, 75% of current newborn deaths can be prevented [3]. Therefore, WHO recommends ENC; is a comprehensive strategy designed to improve the health of newborns through interventions before conception, during pregnancy, at and soon after birth and in the postnatal period [4,5]. The ENC Protocol is a series of time bound and chronologically-ordered that a baby receives at birth and it has standardized effective procedural steps: dry and stimulate, evaluate breathing, cord care, keep the newborn warm (Prevent hypothermia), initiate breastfeeding within the first one hour, administer eye drops/eye ointment, administer vitamin k intramuscularly, place the newborn’s identification bands, weigh the newborn when it is stable and warm, record all observations and treatment provided, delay bathing of the baby for 24 h after birth [6,7].

Newborns are most vulnerable during the first hours and days of life, yet this critical window of opportunity is being missed. While evidence shows that initiating breastfeeding within one hour of birth reduces the baby’s risk of death by 44%, recent data show that less than half of newborn babies worldwide receive the benefits of immediate breastfeeding. Great efforts have been made to improve neonatal death around the world over the past four decades, yet achievements have not been as expected [8]. As many as two-thirds of neonatal deaths could be saved with ENC. Simple interventions to improve in health facilities have demonstrated up to 47% reduction in newborn mortality in Tanzania [9]. Unless newborn receives appropriate basic care, they quickly fall sick and too often they die [10]. Ethiopia is one of the ten countries with the highest number of neonatal deaths globally and neonatal mortality has remained stable at around 37 deaths per 1000 live births in recent years [10,11] and in Jimma there was high status of neonatal mortality and immediate neonatal care practices were identified as one of the determinant factors [12].

Promotion of ENC is one strategy for improving newborn health outcomes [13]. This requires health systems that provide continuity of care starting from the beginning of pregnancy (and even before) and continuing through professional skilled care at birth into the postnatal period. But, the standardized procedure for providing ENC is not commonly practiced [14]. Knowledge is one of the crucial aspects of health systems to adherence to ENC practices. But, in Ethiopia hospitals health workers’ mean knowledge score for immediate newborn care was relatively low and there was performance gap on immediate ENC provided until the first hour after birth [15].

In addition to this gap, although midwives and nurses are providing primary care to women during pregnancy, labor, ENC care and the postpartum period in almost all health centers, still there is no study about knowledge and practice of ENC among midwives and nurses working at health centers in Jimma zone. Therefore, the main purpose of this study is to identify whether there is knowledge and performance gap on ENC among nurses and midwives.


Facility based cross-sectional study design was conducted in 68 health centers found in ten Districts of Jimma zone from March 9 to April 8, 2016. A total of 279 participants were participated in the study which was selected by simple random sampling from those who were actively providing delivery care after proportional allocation was made for each Districts and health centers based on the number of nurses of each health center in the selected Districts as sampling frame. A single population proportion formula was used to estimate the sample size. There was no study conducted in Jimma area on the topic. To estimate the desired sample size, the following assumptions were made: proportion of knowledge and practice of study participants on ENC was taken as 50% (p=0.5), level of significance was considered to be 5% (α=0.05), 95% confidence level (Zα/2=1.96) and margin of error to be tolerated 5% (d=0.05). Because of the source population is less than 10,000; sample size correction was made to estimate the final sample size and 10% of the sample size added for non-response rate that made the final sample size of 279.

All qualified diploma and degree nurses and midwives recruited by government who provide delivery care services at selected health centers were included whereas those who did not provide delivery care services within the last six month prior to data collection to the time of data collection were excluded.

Data was collected by distributing self-administered structured questionnaires that adopted from published articles and further modification was done based on the Ethiopian Federal Ministry of health newborn care training Participants manual [7]. The questionnaire had both closed and open ended questions and participants were completed the necessary information by themselves. Data collectors facilitated data collection process and helped the participants in case if they had any questions on the items of tool. Data collectors waited for each respondent to complete their questionnaire and immediately retrieved after they completed. After standardized study tool was adopted, tool was checked for validity by three professional experts. Pretest was done on 6% of the sample size in four health centers found in Jimma town. Reliability test was done and chrombach’s alpha coefficient was 0.84. Modification of tools was done prior to actual data collection time based on pretest results. Data collectors were two diploma nurses and one diploma midwife who know more about the topic issue. Supervisor was one degree nurse on academic status of Graduate assistant II. Detail training was given for data collectors and supervisor. Daily, supervisor and principal investigator supervised and checked the completeness and quality of data. Incomplete and inconsistent questionnaires were excluded from analysis.

Data was coded and entered to EpiData Manager and exported to SPSS version 20 and analyzed. Each correct alternative under each knowledge questions was graded as 1point and incorrect was graded as 0. Finally, it was dichotomized as good knowledge and poor knowledge based on the sum of correct responses by taking the mean score as cutoff point. Practice of essential newborn care was graded by assigning scores to Likert scale responses on a scale of 0-2 points: 0=never, 1=sometimes, 2=always. There were 24 items of practical question and the maximum total score for practice was considered to be 48. The total score was dichotomized in to good practice and poor practice based on the summed score taking the mean score as cut-off point. Bivariate analysis was done to determine candidates for multivariate analysis. Those variables which have significant association fatherly analyzed by multivariate Logistic regression to identify the independent predictors of knowledge and practice of ENC. Confidence interval of 95%was used to see the precision of the study and the statistical association was considered as significant if p-value is less than 0.05.

Before starting any steps, ethical clearance and approval was obtained from the ethical committee of Addis Ababa University. Official letter was obtained from department of Nursing and brought to Oromia regional health Bureau and then written permission was provided to Jimma Zone health Office and from there to respective Districts health offices. Oral permission was ensured from each health center managers. Finally, the data collectors gave detail explanation of the purpose and possible benefit of the study, clarified that participation is voluntary, as well as respect of the subject privacy was ensured, obtained written consent of participants and confidentiality of the data was kept.


Socio-demographic characteristics

From the total 279 estimated sample, five questionnaires were excluded as a result of incompleteness and inconsistencies and two questionnaires were not returned back, making the response rate of 97.49%. The analysis was done based on the data collected from 272 participants. Accordingly, largest proportion of the respondents were between the ages of 25 and 29 years and smallest proportion found between 40 and 44 years. The participants age ranges from 22 to 51 years with the mean of 28.86 (SD= ± 5.78) years. Two third and 3/4 of the study participants had less than six years’ experience of delivery care service. Among the study participants, 60 (22.1%) had no interest to work in delivery room, 164 (60.3%) had work load. Regarding availability of equipment and vaccines of newborn care, 125 (46.0%) and 117 (43.0%) of study subjects were responded that all equipment, vaccines and drugs respectively were available at their health institution. The study revealed that, only 101 (37.1%) of respondents were took training on new born care (Table 1).

Question Response Frequency Percent
Work experience in health care services in years 0-5 180 66.2
6-10 69 25.4
11-15 2 0.7
16-20 8 2.9
>20 13 4.8
Work experience of delivery service in years 0-5 208 76.5
6-10 46 16.9
11-15 4 1.5
16-20 5 1.8
>20 9 3.3
Interest to work in delivery room Yes 212 77.9
No 60 22.1
Availability of equipment Yes 125 46
No 147 54
Availability of drugs and vaccines Yes 117 43
  No 155 57
Work load Yes 164 60.3
No 108 39.7
In service training Yes 101 37.1
No 171 62.9
Number of in service trainings One 53 52.5
Two 35 34.7
>Three 13 12.9

Table 1: Distribution some selected factors of knowledge and practice of ENC (n=272).

Knowledge and Practice of Airway Management

Regarding measures to be taken for babies not cries immediately after delivery, 205 (75.4%) of them knew that the correct measure is calling a help and start resuscitation, whereas the remaining did not know. About position of the baby’s head to open the airway, 169 (62.1%) responded as head should be slightly extended and the remaining participants did not able to mention the correct position. Out of the responding participants, only 93 (34.2%) could identify that 40 breath per minute is the recommended breath per minute during ventilation of newborn, but the left participants could not respond in line with guideline. The average knowledge score of resuscitation domain was 60.48%(Table 2).

Variables Response Frequency Percent
Measures to be taken if the baby not cries Cover the baby and allow skin to skin contact 49 18
Call a help and start resuscitation 205 75.4
Put baby on new born table and give mother care 18 6.6
Position of baby’s head to help open the airway A flexed 66 24.3
Slightly extended 169 62.1
Hyper extended 37 13.6
The mentioned measures if baby is not breathing well after stimulation More stimulation to breath 81 29.8
Ventilation with bag and mask 191 70.2
The mentioned breath/min 30 87 32
40 93 34.2
60 92 33.8

Table 2: Knowledge on neonatal airway management (n=272).

When the respondents asked about wiping of face and eyes, 128 (47.1%) responded that they applied always whereas 58 (21.3%) of the respondents did not apply at all. Regarding Apgar score, 168 (61.8%) of the respondents took Apgar score of all delivery they conducted, 82 (30.1%) took only for some babies. Concerning airway clearance, 181 (66.5%) respondents were applied the principle of checking and sucking airway for all babies they delivered, 86 (31.6%) were applied for some babies. Majority, 201 (73.9%) were checked for breathing while drying it always, whereas 63 (23.2%) were checked only sometimes(Table 3).

Item of practice Response Frequency Percent
Wipes the eyes and face when the head is delivered No never 58 21.3
Yes, some times 86 31.6
Yes, always 128 47.1
Taking Apgar Score No never 22 8.1
Yes, some times 82 30.1
Yes, always 168 61.8
check and Sucks the air way No never 5 1.8
Yes, some times 86 31.6
Yes, always 181 66.5
Check for breathing while drying No never 8 2.9
Yes, some times 63 23.2
Yes, always 201 73.9

Table 3: Practice on neonatal airway management (n=272).

Knowledge and Practice of Thermal Protection

According to the study, 183 (67.3%) respondents knew that newborn should be bathed after 24 h of delivery, but the remaining 89 (32.7%) of the respondents did not know the recommended time for bathing. About methods of thermal protection, 136 (50.0%) were aware that immediately dry can be used and 204 (75.0%) were aware that we can use skin to skin contact whereas 12 (4.4%) responded as early bathing which is not correct method of thermal protection. Regarding newborn placement immediately after birth, majority, 210 (77.2%) knew that newborn should kept on the mother’s belly immediately after birth, but 62 (22.8%) did not know(Table 4).

Questions Response Frequency Percent
Time of newborn bathing Immediately 11 4
Within the first 24 h 78 28.7
After 24 h of delivery 183 67.3
Methods of thermal protection Immediately dry 136 50
Allow skin to skin contact 204 75
Early bathing 12 4.4
Where newborn should kept immediately after birth Beside the mother 26 9.6
With someone else 1 0.4
On the mother’s belly 210 77.2
On newborn bed/table 35 12.9

Table 4: Knowledge of thermal protection (n=272).

Regarding to thermal protection, 218 (80.1%) of the participants dried all newborn immediately after delivery with dry towel whereas 63 (23.2%) applied only for some babies. Out of the total respondents, 198 (72.8%) kept all babies on mothers belly immediately after delivery whereas 7 (2.6%) of them did not kept, 154 (56.6%) discarded wet towel and cover with dry towel for all babies while 109 (40.1%) of them applied for some babies. Majority, 235 (86.4%) of them initiated breast feeding within the first hours of delivery(Table 5).

Questions Response Frequency Percent
Drying the baby immediately with dry towel No, never 7 2.6
Yes, some times 47 17.3
Yes, always 218 80.1
Discarding wet towel and cover the baby with dry towel No, never 9 3.3
Yes, some times 109 40.1
Yes, always 154 56.6
Keeping the baby on mothers bell immediately after birth No, never 7 2.6
Yes, some times 67 24.6
Yes, always 198 72.8
Keeping skin to skin contact with the mother No, never 8 2.9
Yes, some times 95 34.9
Yes, always 169 62.1
Initiating breast feeding Within the first hour of delivery No, never 0 0.00%
Yes, some times 37 13.3
Yes, always 235 86.4

Table 5: Practice of thermal protection (n=272).

Knowledge of Breast Feeding

Regarding breast feeding, 234 (86.0%) of study participants were aware that initiation of breast feeding after delivery should be taken within the first hours of delivery, more than 3/4 were aware that colostrums has infection protection role in newborn whereas the remaining 56 (20.6%) did not aware. About duration of exclusive breast feeding, 210 (77.2%) of the respondents knew that the mother should feed exclusively for the first six months(Table 6).

Questions Response Frequency Percent
Initiation of breast feeding Within 1 h of delivery 234 86
Within 1-6 h of delivery 34 12.5
>6 h of delivery 4 1.5
Colostrum has infection protection role Yes 216 79.4
No 56 20.6
Duration of exclusive breast feeding <6 months 13 4.8
For 6 months 210 77.2
>6 months 49 18

Table 6: Knowledge of breast feeding (n=272).

Knowledge and Practice of Prevention of Infection and Cord Care

Regarding cord care, 103 (37.9%) of participants were aware that the cord of crying baby should be clamped at 2-3 min of delivery, but 169 (62.1%) did not respond correctly. About recommended care of dirty umbilical cord, 99 (36.4%) were aware that it should be cleaned with soap and water, dried and no need of bandaging, but, 63.6% responded wrongly. About the recommended cares of low birth weight babies,145 (53.3%), 192 (70%) and 46 (16.9%) could identify that breast feeding early and frequently, keeping the child warm and infection prevention respectively are the recommended cares whereas 11 (4.0%) responded as bathing often which is contradictory with WHO guidelines(Table 7).

Questions Response Frequency Percent
Time to clamp or tie the umbilical cord of a crying baby Immediately 102 37.5
1-2 min 67 24.6
2-3 min 103 37.9
Instrument to cut the cord Clean Scissor 20 7.4
New Surgical blade 66 24.3
New razor blade 6 2.2
Sterile Scissor 254 93.4
Care of dirty umbilical cord Clean with soap and water and cover with bandage 67 24.6
Clean it with soap and water, dry it and do not cover 99 36.4
Use alcohol to clean the umbilicus 103 37.9.
Clean with sterile water and apply topical antibiotics 3 1.1
Treatment of eye infection in newborn Apply nothing 7 2.6
Apply breast milk 6 2.2
Clean with sterile water 74 27.2
Apply silver nitrate/tetracycline 252 92.6
Care for Low Birth Weight Bath often 11 4
Breast feeding early and frequently 145 53.3
Keep the child warm 192 70.6
Prevent infection 46 16.9

Table 7: Knowledge of respondents on prevention of infection and cord care (n=272).

About personal protective equipment, 207 (76.1%) used sterile glove during cord care for all babies whereas 64 (23.5%) of them used some times only .Of the total respondents, only 51 (18.8%) wore clean mask for all deliveries, 123 (45.2%) of the respondents did not wear clean mask for all deliveries they conducted, 123 (45.2%) of them wore clean apron during all deliveries they conducted whereas 45 (16.5%) did not wear at all. Concerning hand washing during delivery, only 37 (13.6%) reported that they always wash their hand with soap and water before procedure whereas 133 (48.9%) did not wash their hand before all delivery they conducted. On the other hand, only 40 (14.7%) study participants ensured all mother to wash their hands before handling the baby. Regarding cord care, 87 (32.0%) waited for 2-3 min after delivery to clamp the umbilical cord of all crying babies while 126 (46.3%) clamped the cord of all crying babies within less than 2 min or immediately after baby delivered. After clamping the cord, the vast majority, 250 (91.9%) were used sterile scissor to cut the cord but, 22 (8.1%) were used sterile scissor sometimes only. Of the study participants, 118 (43.4%) reported that they gave cord care by cleaning and letting it to air dry whereas 113 (41.5%) of them applied this care only for some babies they delivered.

On eye care, more than half did not clean eyes immediately after birth whereas 85 (31.3%) were applied this care only sometimes, but few, 28 (10.3%) of them reported that they applied this care for all babies they delivered. Of the total participants, 149 (54.8%) were reported that they applied eye ointment for all newborns they delivered, 107 (39.3%) were applied sometimes. When they apply eye ointment, 178 (65.4%) applied without touching the eyes with the tip of ampule but 34 (12.5%) applied always by touching. More than three quarters of the participants reported that they weighed and recorded the weight of all babies they delivered (Table 8).

Item of practice Level of practice
No, never Yes, some times Yes, always
Put on sterile glove 1 (0.4%) 64 (23.5%) 207 (76.1%)
Wearing mask 123 (45.2%) 98 (36.0%) 51 (18.8%)
Wearing apron 45 (16.5%) 104 (38.2%) 123 (45.2%)
 Hand washing before the procedure 133 (48.9%) 102 (37.5%) 37 (13.6%)
clean eyes immediately after birth from medial to lateral side with swab soaked in sterile water 159 (58.5%) 85 (31.3%) 28 (10.3%)
Using Sterile Scissor 0 (0%) 22 (8.1%) 250 (91.9%)
Clamping the cord within 2-3 min 126 (46.3%) 59 (21.7%) 87 (32.0%)
Ensuring the mother wash her hands 145 (53.3%) 87 (32.0%) 40 (14.7%)
Giving eye ointment 16 (5.9%) 107 (39.3%) 149 (54.8%)
Not touching the eyes with the tip of the ampule 34 (12.5%) 60 (22.1%) 178 (65.4%)
Cleaning the cord and letting to air dry 41 (15.1%) 113 (41.5%) 118 (43.4%)
Weigh and record the baby’s weight 2 (0.7%) 32 (11.8%) 238 (87.5%)

Table 8: Practice of infection prevention and cord care (n=272).

As shown in Figure 1 above, nearly two third (64.0%) knew that low birth weight is weight less than 2500 g but, 60 (22.1%) defined as weight of less than 1500 g, 36 (13.2%) of them defined as less than 1000 and 2 (0.7%) defined as weight of less than 3000 g.


Figure 1: Knowledge of low birth weight (n=272).

According to the study, 104 (38.2%) of the study participants were aware that immediate newborn care should start just during birth whereas 28 (10.3%) and 138 (50.7%) responded as it should start before birth and after birth respectively and 2 (0.7%) of them responded as they do not know when it should start. The vast majority (90.1%) of the participants were aware that bleeding in newborn can be prevented by giving Vitamin K and the remaining 27 (9.9%) did not know the correct action to prevent. Regarding time of postnatal visit, 214 (78.7%) was aware that the best time of first post natal visit should be within the first 24 h of delivery(Table 9).

Variables Response Frequency Percent
Time for first postnatal visit Within the first 24 h 214 78.7
On the 3rd day 46 16.9
On the 7th day 12 4.4
Mentioned vaccines as components ENC BCG 237 87.1
OPV 261 96
TTC 49 18
Vit k 94 34.6
Rota 2 0.74
PCV 2 0.74
Pentavalent 1 0.37
Action to prevent bleeding in newborn Breastfeeding 12 4.4
Not necessary to give anything 15 5.5
Give vitamin K 245 90.1
Dose of Vitamin k for preterm babies 1 mg 107 39.3
0.5 mg 160 58.8
Other dose 5 1.8

Table 9: Knowledge of some components of post natal care and bleeding prevention in new born (n=272).

Knowledge of Newborn Danger Signs

Respondents were considered as knowledgeable if they could identify at least four out the common 11 dager signs. Accordingly, less than 1/3 could mention four and more newborn danger signs whereas more than 2/3 could identify only three and less than three .The only two danger signs those more than half of respondents, 162 (59.6%) and 139 (51.1%) of them could mention were poor suckling and difficulty breathing respectively. To lesser extent, respondents were also able to mention fever 99 (36.4%), yellow palms/sole/eyes 77 (28.3%), lethargy 70 (25.7%), convulsion 51 (18.8%), baby too small/born too early 44 (16.2%), redness/discharge at the cord 32 (11.8%) and the remaining respondents could list few danger signs; eyes red/swollen/discharge 26 (9.6%), baby feels cold 19 (7.0%), loss of consciousness 13 (4.8%).

The overall mean knowledge score of study participants was 23.27 (SD= ± 4.39) out of the total 35 points which revealed that 52.2% of the respondents had good knowledge of ENC where as 47.8% had poor knowledge. The mean score of practice of ENC was 32.82 (SD= ± 7.35) out of the total 48 points. An overall practice of ENC, 51.1% of the respondents had good level of practice and the remaining 48.9% of them had poor level of practice.

Some Factors of Knowledge and Practice of Essential Newborn Care

A cording to the study, Age, Religion, Ethnicity, marital status, work experience and work load were not found to have significant association with participants’ level of knowledge of ENC. Field of study was significantly associated with participants’ knowledge about ENC care (p=0.001). Midwives were 3.899 times more likely knowledgeable than nurses (AOR (95% CI) 3.899 (1.781-8.537)). Educational qualification was also found to have association (p<0.001).Diploma holders were 0.250 times less likely knowledgeable about ENC than degree holders (AOR (95% CI) 0.250 (0.120-0.523)). Interest to work in delivery room was statistically significant (p=0.005).Those who had interest to work in delivery room were 2.822 times more likely knowledgeable than who had no interest (AOR (95% CI) 2.822 (1.372-5.807)). Training Also found to be a factor for knowledge of ENC (p<0.001). Those participants who had at least one in-service training were 3.421 more likely knowledgeable newbornthan those did not trained at all (AOR (95%) 3.421 (1.779-6.579)Table 10).

Variables Good knowledge Poor knowledge COR(95% CI) P value AOR(95% CI) P values
Female 81 (57.0%) 51 (39.2%) 0.486 (0.300-0.780) 0.004* 1.008 (0.544-11.868) 0.979
Male 61 (43.0%) 79 (60.8%)
Nursing 76 (53.5% 115 (88.5% 6.658 (3.542-12.514) <0.001  3.899 (1.781-8.537) 0.001*
Midwifery 66 (46.5%) 15 (11.5%)
Degree 34 (23.9%) 16 (12.3%) 0.446 (0.233-0.854) 0.015* 0.250 (0.120-0.523) <0.001*
Diploma 108 (76.1%) 114 (87.7%)
No 15 (10.6%) 45 (34.6%) 4.482 (2.350-8.549) <0.001* 2.822 (1.372-5.807) 0.005*
Yes 127 (89.4%) 85 (65.4%)
No 64 (45.1%) 107 (82.3%) 5.67 (3.243-9.914) <0.001* 3.421 (1.779-6.579) <0.001*
Yes 78 (54.9%) 23 (17.7%)

Table 10: Association of socio-demographic characteristics and some selected variables.

Age, Religion, Ethnicity, marital status, work experience, work load and monthly salary were statistically insignificant with practice of ENC. Field of study was found to have significant association with their practice of ENC (p<0.001). Midwives were 4.419 times more likely practiced essential newborn care than nurses but, the association was insignificant after adjusting for possible confounder. Educational qualification was also found to have significant association with participants’ practice of ENC (p=0.003). Diploma holders were 0.287 times less likely practiced than degree holders (AOR (95% CI) 0.287 (0.126-0.650)). Interest of participant to work in delivery room was found to be a factor for practice of ENC (p=0.008). Those who had interest to work in delivery room were 3.006 times more likely practiced than who had no interest (AOR (95% CI) 3.006 (1.328-6.804)).

There was significant difference between those who trained and not trained (p=0.004). Participants who had at least one time training on ENC were 2.937 more likely practiced than those did not trained (AOR (95% CI) 2.937 (1.415-6.098)). On bivariate analysis, availability of newborn care equipment at health centers and newborn care drugs and vaccines were found to have association with ENC practice (p=0.002) and (p=0.001), respectively but after adjustment of possible confounders, both variables were statistically insignificant. The study also showed significant association between level of knowledge and level of practice of ENC (p<0.001).Those respondents who had good knowledge were 4.848 times more likely practiced than those who had poor knowledge ((AOR (95% CI) 4.848 (2.605-9.023))(Table 11).

Variable Poor practice Good practice COR(95% CI) P-Value AOR (95%CI) P-value
Female 54 (40.6%) 78 (56.1%) 0.535 (0.330-0.865) 0.011 1.025 (0.527-1.991) 0.943
Male 79 (59.4%) 61 (43.9%)        
Nursing 113 (85.0%) 78 (56.1%) 4.419 (2.470-7.905) <0.001 1.522 (0.667-3.472) 0.319
Midwifery 20 (15.0%) 61 (43.9%)        
Degree 14 (10.5%) 36 (25.9%) 0.337 (0.172-0.659) 0.001 0.297 (0.126-0.650) 0.003
Diploma 119 (89.5%) 103 (74.1%)        
No 47 (35.3%) 13 (9.4%) 5.297 (2.703-10.378) <0.001 3.006 (1.328-6.804) 0.008
Yes 86 (64.7%) 126 (90.6%)        
No 108 (81.2%) 63 (45.3%) 5.211 (3.012-9.018) <0.001 2.937 (1.415-6.098) 0.004
Yes 25 (18.8%) 76 (54.7%)        
Availability of equipment
No 85 (63.9%) 62 (44.6%) 2.199 (1.352-3.579) 0.002 0.964 (0.485-1.139) 0.916
Yes 48 (36.1%) 77 (55.4%)        
Availability of drugs and vaccine
No 90 (67.7%) 65 (46.8%) 2.383 (1.455-3.901) 0.001 1.687 (0.861-3.307) 0.128
Yes 43 (32.3%) 74 (53.2%)        
Poor 98 (73.7%) 32 (23.0%) 9.362 (5.390-16.263) <0.001 4.848 (2.605-9.023) <0.001
Good 35 (26.3%) 107 (77.0%)        

Table 11: Association of selected socio-demographic variables, personal and institutional factors with practice of essential new born care.


Knowledge is one of the crucial aspects of health systems for ENC practices and lack of knowledge may impede provision of ENC. In this study, the average knowledge and practice score about ENC were 66.48% and 68.38%, respectively. This is lower compared to study conducted in India [16,17]. The discrepancy could be due to the difference in in-service training. But this knowledge is higher than that of Khartoum [1], Tanzania [13] and Ethiopia [15]. In this study, 52.2% of the respondents had good knowledge and 47.8% had poor knowledge whereas, 51.1% had good and 48.9% had poor level of practice. This is relatively higher compared to Egypt [18], Uganda [19] and India [16]. This discrepancy in level of practice could be due to methodological difference. The slight difference in knowledge might be due to difference between study participants in which only nurses participated in case of study conducted in Egypt and it included nurse assistants in case of Uganda.

The study finding revealed that average knowledge score of resuscitation domain was lower compared to that of India [18] and Afghanistan [20]. The difference might be due to difference in inservice training on resuscitation. Lack of knowledge can impede practice of resuscitation and increase risk of death and complication of asphyxia.

Exclusive breastfeeding has a significant protective effect against infections. Early breastfeeding and keeping the baby close to the mother reduce the risk of hypothermia and hypoglycemia and delaying of breast feeding after delivery limits the opportunities for mothers and infants to benefit from early initiation. In this study, 86.0% of participants were aware the time of breast feeding initiation and 77.2% knew duration exclusive breast feeding whereas greater than 86.4% of participants initiated feeding within one hours of delivery. This is far greater compared with study conducted in Ethiopia, Tanzania [21] and MAISHA [22]. This discrepancy could be due to the difference between study settings. Hospitals with the heaviest volume of deliveries make the providers busy to consider all components of care on time and there is also time gap between the studies; now a day government focused on newborn care and giving training for midwives. This indicated that this study increased the opportunities for mothers and infants to benefit from early initiation of breastfeeding.

Thermal protection in newborn is very important. Because, it can prevent the complication of hypothermia. According to this study, 67.3% respondents knew time of newborn bathing, 77.2% knew where newborn should kept immediately after birth, greater than 72.8% kept the baby on the mother’s chest/belly, more than 80.1% dried the babies immediately with dry towel, more than 56.6% discarded wet towel and covered with dry clothes, greater than 62.1% kept the baby skin to skin contact with the mother. This is consistent with study done in Khartoum [1]. But, this study is relatively lower compared to that of Tanzania [9]. This difference might be knowledge difference between the two study group on importance of thermal protection and scarcity of newborn care equipment. On the other hand study in India revealed that, although 89% of the providers demonstrated wiping of newborn with dry cloth, 63% showed putting neonate on warm surface [17] and study in Philippine revealed that more than 90% of infants were dried [23]. The reason of this difference might be difference of educational level of study participants leads to knowledge difference. On the other hand the study finding is higher compared to study done in Ethiopia [15] and in other study in 4 regions of Ethiopia [13]. This difference might be time gap between these studies. Now a day government focused on newborn health and giving training and others may share experience from those trained to some extent. This study was far greater compared to that of Tanzania ;skin to skin contact occurred infrequently at health centers likely due in part to the traditional practice of keeping the infant separated from the mother [21].

Clean cord care is very important in preventing early neonatal infections. The precise timing of clamping and cutting the umbilical cord is important as there is some evidence of potential benefits for the baby when the cord is not clamped and cut immediately after birth [24]. This study finding showed that, only 37.9% of the study participants knew the precise time of cord clamping and 32.0% and 21.7% of the participants delayed clamping of umbilical cord for all babies and some babies they delivered respectively. This is lower compared to that of Tanzania [9]. The possible reason might be awareness difference on the importance of delayed cord clamping. But this study was consistence with that of Khartoum [1] and Ethiopia [15] and lower compared to that of Peru [25]. This great difference is as the reason of training in the case of Peru and it was post intervention result. The study revealed that, 13.6% washed their hand before all deliveries they conducted but 48.9% did not washed at all. The study finding also revealed that less than half consistently wore protective clothing other than gloves .This was lower than that of Tanzania [21]. The possible reason might be inadequate water and equipment of newborn care in the study institution. This study showed that, only 54.8% administered eye ointment for all babies they delivered, 39.3% did it only for some babies, 16.9% administered vitamin k for all babies they delivered, 59.9% administered only for some babies whereas 23.2% did not administered at all. This is consistent when compared with results of studies conducted in Egypt [18], lower than that of Philippine [21] but higher compared to that of Uganda [19]. This supports the above difference on administration of Vitamin K and eye ointment might be due to difference in availability of drugs in the study area in that of Philippine rather than knowledge gap.

Knowledge of study participants on newborn danger signs is very crucial for the survival and future well-being of the babies. But this study revealed that, less than one third could mention four and more newborn danger signs. This may impede the care they can give for the child with health problems and advice they can give for the mother.

Many factors can influence knowledge and practice of ENC. In this study, in-service training, field of study, educational qualification and interest to work in delivery room were found to be factor of knowledge level and difference in year of experience was insignificant with knowledge level which is similar with that of Uganda in which there was no statistical difference in knowledge by experience and there was difference in knowledge level based on field and level of education [19]. Similarly study in Egypt revealed that, there was a significance relationship between nurses education and their knowledge, while a negative correlation were found regarding to their years of experience [18]. On the other hand, this study showed that, educational level, interest to work in delivery room, in-service training was significantly associated with level of ENC practice. This in part due to all of these factors can increase knowledge level which can lead to increment of level of practice. Compared to that of Egypt [18], no significance difference between nurses’ knowledge and practices and the possible reason might be difference of study participants.


Despite participants had good knowledge and practice in general, they had poor knowledge and practice on some components of ENC:

The study population had knowledge gap on resuscitation domains, poor infection prevention practice and, consistently administration of Vitamin K and eye ointment was relatively low, poor knowledge and practice on precise cord clamping time which may leads to neonatal anemia, majority were not knowledgeable on identification of neonatal danger signs.

Majority of the study population had good practice on timely initiating of breast feeding and good knowledge and practice on thermal protection. Field of study, educational level, interest to work in delivery room and in-service training were independent predictors of knowledge. Level of education, interest to work in delivery room, inservice training and level of knowledge were found to be independent predictors of ENC practice.


Strengthen in-service training given to nurses and midwives on ENC including newborn resuscitation and upgrade their educational level. Give Priority for those who trained on area and for those have better educational level on the assignment of staffs working in delivery room by considering interest of staff to work in delivery room for better services, motivation should be there for those have good performance. Conduct further observational study on quality and level of ENC practice. Provide all necessary equipment, vaccine and drugs of newborn care and it is better if ministry of education incorporate all components of ENC in the curriculum for both diploma and degree program.


First of all, we would like to thank our almighty God for giving us strength and peace. Next and for most, we would like to thank Mr. Fikadu Balcha and Mr. Asrat Demissie for their unreserved and repeated constructive and valuable comments starting from the development of the proposal throughout this research report. We would like to express our heartfelt gratitude to Addis Ababa University that provided us financial support. We would also like to acknowledge Jimma zone health office, each district’s health office, each health center’s managers and each participants for their support and cooperation in providing us data and the necessary information .We do not want to wrap up without thanking Mr.Temamen Tesfaye and Mr.Sena Belina for their support during the evaluation of study tools and contribution of constructive ideas on analysis.


Citation: Negussie BB, Hailu FB, Megenta AD (2018) Knowledge and Practice of Essential Newborn Care and Associated Factors among Nurses and Midwives Working at Health Centers in Jimma Zone, Ethiopia, 2016. J Nurs Care 7: 446. DOI: 10.4172/2167-1168.1000446

Copyright: ©2018 Negussie BB, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

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