Children are most commonly vulnerable to disease, injury, and death during the neonatal period (1). Globally, nearly three million children lose their life before celebrating 1 month of life. Almost 99% of neonatal mortality occurs in low-income nations, including Ethiopia, where health care systems are weak and most of the mothers deliver at home, attended by untrained birth attendants (2, 3). Applying appropriate health interventions that are accessible, reasonable, and tolerable to mothers may prevent most of these neonatal deaths in low-income countries (4).

The World Health Organization (WHO) declared essential newborn care (ENC) as a comprehensive approach to advance the health of newborns and mothers through interventions throughout the perinatal period (during pregnancy, childbirth, and postnatal period) (1, 5). ENC comprises instant drying and covering of newborns following birth, starting skin-to-skin contact, hygienic cord care, eye care, immunization, sooner initiation of breastfeeding, and late washing. Despite the importance of ENC, its enactment was not satisfactory, especially among those delivered at home in Ethiopia (6, 7).

Globally, most neonatal deaths can be averted through standing maternal and child health curriculum which are associated to clean cord care for the prevention of sepsis, regulating temperature, and early initiation of breastfeeding (2, 8). In addition to skill enhancement and equipping health professionals, enhancing the knowledge of mothers regarding ENC is very critical to increasing the quality of ENC. Knowledge gaps and durable cultural principles influence newborn survival at the moment the neonate is at home with the mother. Therefore, the enhancement of mothers' knowledge and skills toward ENC are vital aspects to sustain life, growth, and development of neonates and reducing neonatal morbidity and mortality (9).

Evidence from research carried out in Mekelle, Ethiopia indicates that only one-third of mothers were knowledgeable regarding ENC. Good knowledge (mothers who responded correctly to at least 75% of questions) of ENC showed association with mothers who were educated, counseled during childbirth and postnatally, were knowledgeable of newborn care, and had good knowledge of newborn signs of illness (10).

However, neonatal death is still high, and the Ethiopian government has implemented various health interventions including health care provider training, improving referral systems, integrating health services, applying packages of the Health Extension Program, and regular vaccination (11). However, most women still give birth at home with untrained birth assistants, which may promote the exercise of harmful traditional practices (12). Little emphasis was given to newborn care until the placenta is delivered. This came with delays in drying or covering and delayed skin-to-skin contact with frequent positioning slightly away from the mother's side. Inappropriate knowledge of mothers and caregivers during this period could decrease the quality of newborn care, which may threaten newborn well-being, possibly increasing neonatal mortality (13).

Although a mother's knowledge of ENC is highly effective in the reduction of neonatal mortality and has been broadly encouraged, information on women's knowledge and its determinant factors toward ENC in a study setting is inadequate. Moreover, most studies have focused on health professionals' knowledge of ENC and on scanty evidence about postnatal women's knowledge of ENC in Ethiopia, particularly in rural settings, where home delivery is high. Thus, this article aimed to assess the magnitude and determinants of mothers' knowledge of ENC in rural Ethiopia.

The first few minutes and hours immediately after birth are the most critical period in the life of a newborn. Hence, preventing neonatal morbidity and mortality requires equipping mothers with accurate knowledge of newborn care to ensure proper practices. In this study, only 33.5% of mothers had good knowledge of ENC. This may result in failure to achieve the national goal of reducing neonatal mortality from 28 to 11/1,000 by 2020 (20). This result has a prodigious inference on the survival of the neonates, opposing preventable disease, and future development and productivity.

The magnitude of good knowledge of ENC in this study is in line with prior studies from Ethiopia (10, 21) despite being lower than studies conducted in Nekemte city, Ethiopia (19, 22) and Ghana (23). This could be due to the study setting variation since this study was conducted in a rural area, a place where access to health facilities and health professionals is deprived and where traditional home practice is widely exercised. Additionally, poor quality postnatal services, counseling, and inadequate home visits could aggravate this issue. Mothers with poor knowledge of ENC are more likely to use harmful traditional practices which may affect the health and growth of newborns and create a negative impact on the current global and national plan to reduce neonatal mortality by 2030 (24).

The finding on the level of good knowledge in this study is also higher than the studies conducted in India (25) and Bangladesh (26). This might be due to the study population in India consisting only of primiparous mothers, while adolescent women (aged 15–19 years) who had ever been married with noninstitutional births were the study population for the study conducted in Bangladesh. Therefore, adolescents, primiparous mothers, and mothers who delivered at home might be less knowledgeable about ENC. Moreover, differences in the socio-cultural composition of the study groups and differences in the study period might be the reason for this discrepancy.

The care of the umbilical cord always needs special attention as it can function as the entry point for infections. Almost 26.1% of the respondents in this study practiced unsafe cord care and 34.9 % of them applied butter to the cord immediately after delivery. This is supported by findings from Ethiopia (19, 27). Locally, many people believe that applying butter, animal dung, or Vaseline would lubricate the cord and prevent dryness and cord and neonatal cloth attachment (21). However, this could result to be a source of infection which later complicates the survival of the neonate. In summary, this indicates that mothers had a lack of knowledge about appropriate cord care.

Regarding breastfeeding knowledge, 75.7% of mothers stated that breastfeeding should be initiated within 1 h. Although exclusive breastfeeding should be the only source of nutrition and energy for infants up to 6 months of age, only 59% of them reported that newborns should exclusively be breastfed until 6 months. On the other hand, WHO universally recommends that colostrum, the first milk that flows within the first few days after delivery, is the perfect food for every newborn, but only 39.8% of mothers feed colostrum to their newborn in this study. This is in line with a study conducted in southern Ethiopia (21), though incongruent to others (19, 22). This incongruity could be due to service delivery of information and demonstration about effective breastfeeding techniques for breastfeeding mothers or variation in health service utilization, culture, and taboos about breastfeeding (colostrum) within various areas. Early initiation of breastfeeding is encouraged as it stimulates breast milk production and facilitates the release of oxytocin, which helps in uterine contraction and reduces postpartum hemorrhage (28). Culturally, mothers milk out the first milk from the breast before attaching the newborn to the breast because they believe that the initial breast milk/colostrum is dirty and not nutritious. Therefore, they believe that the newborn must be supplemented with pre-lacteal feeds like butter and honey (29).

Hypothermia has significant contributions to neonatal morbidity and mortality in Ethiopia (30). According to this study, the thermal care practiced among respondents included initiating newborn bathing within 24 h after delivery (41%), using a cape to cover the head of the newborn (82.7%), and the exercise of skin-to-skin contact with the mother immediately after delivery (23.9%). Although the proportion varies, similar studies were being reported (10, 19). Strong cultural beliefs could be the main reason for common thermal care malpractices. The baby is seen as dirty after delivery, particularly if the vernix was visible, leading to the stigmatization of the mother. This is due to the belief that the vernix is the result of sperm secondary to late trimester sexual practice (31).

The presence of the routine provision of ANC had a significant impact on the mother's level of knowledge about ENC, which is consistent with studies done in Mekelle, Ethiopia (10), Kenya (32), and Ghana (23). Maternal and child health care are interrelated. The more women who adhere to the continuum of maternal and childcare, the more women who will know the benefits of care, understand health appointments, and improve their communication with care providers. Therefore, we recommend that the maternal and child health services, including ANC and PNC, should be further strengthened, especially at rural community levels.

Educated mothers were more likely to be knowledgeable about ENC. The role of maternal education as an important determinant factor of a mother's knowledge of ENC has also been reported by other studies (10, 22). Education leads to an increased level of awareness regarding maternal and neonatal illnesses, health-seeking behavior, and availability of services, which may sensitize the family to decide and utilize health care provided at various health care facilities (7). The Ethiopian government assigned HEWs in each kebeles to improve maternal and child health service delivery in the district by delivering appropriate information about the different available services to the mothers at the community and household level. But this alone does not seem to be enough to increase the level of maternal knowledge. The findings from this study also revealed that there is a significant association between mothers' religion and knowledge of ENC. A similar finding was reported in Uganda (33). This implies there is a need to further study with analytical study design for future researchers.

Institutional delivery is also significantly associated with ENC. Mothers who delivered at health institutions were about four times more likely to have good knowledge of ENC when compared to mothers who delivered at home. The result was in line with a previous study reported from Ghana (23). This might be because mothers who deliver at the health facility may get better counseling regarding ENC, PNC, and danger signs. Hence, they feel quite confident about their health and the health of their newborn. This indicates that home deliveries may be missed opportunities to promote ENC's benefits for mothers and newborns. In addition, the findings suggest that there is a need to improve the quality of maternal health care services (counseling or health education and promotion) at the rural community level.

Based on this study, mothers' knowledge level of ENC was significantly low in the study area. Antenatal care visits, counseling during ANC place of delivery, delivery place, religion, and maternal educational status were factors significantly associated with the mother's knowledge of ENC. Cultural practices, such as tying the cord with unsterile materials, applying butter on the newborn cord, giving home remedies for cord infection, avoiding colostrum feeding, and home delivery practices, were common. Therefore, it is better to give special attention to ensuring that education should focus on women for antenatal care follow-up, encouraging institutional delivery, and inspiring counseling to rural and illiterate mothers.

The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author/s.

The studies involving human participants were reviewed and approved by Haramaya University, College of Health and Medical Sciences, Institutional Health Research Ethics Review Committee (IHRERC). The patients/participants provided their written informed consent to participate in this study.

TG: conceptualization, investigation, methodology, project administration, analysis, writing—original draft, and writing—review and editing. MD: conceptualization, methodology, writing—review, writing—review and editing, and supervision. AE: conceptualization, methodology, writing—original draft, and writing—review and editing. BB: investigation, methodology, writing—original draft, and writing—review and editing. TY: conceptualization, analysis, writing—review and editing, and supervision. The co-authors wrote the manuscript. All authors were involved in reading and approving the final manuscript.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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