Gaps in the knowledge and skills of Portuguese mothers associated with newborn health care

ABSTRACT Objectives: assess mothers’ parenting knowledge and skills associated with the parental competence health promotion and monitoring for newborns and infants aged up to six months and determine the key characteristics of mothers who are better prepared for parenting. Method: cross-sectional study conducted in three health centers belonging to a Local Health Unit in the Northern Region of Portugal. Data was collected using clinical interviews conducted with pregnant women or mothers with a child aged up to six months. The tool used contained 21 child health promotion and monitoring indicators associated with different assessment moments: pregnancy, 1st/2nd week, 1st/2nd month, 3rd/4th month, and 5th/6th month. Results: we assessed the knowledge and skills of 629 women. Learning needs were identified for each of the indicators. The mothers who were better prepared for parenting tended to have a higher level of schooling, resided with the child’s father, had other children, had planned pregnancy, and intended to breastfeed. Conclusions: the results showed that knowledge and skills were lacking for each of the periods assessed by this study. First-time single mothers whose pregnancy was unplanned and who did not prepare themselves for parenthood may be considered a vulnerable group.


Introduction
The mission of nursing is to facilitate transitions (1) . For both parents, having a child represents a developmental transition that requires the incorporation of new knowledge and skills to develop proficiency in child-care.
Child health promotion and maintenance, specifically healthy growth and development, requires the active participation of informed and motivated parents who assume responsibility for caring for their children.
Preparation for parenting begins during pregnancy, when parents become aware of their role in ensuring their child achieves his or her maximum health potential. Parental behavior is therefore a key factor to ensuring healthy child development from the outset of pregnancy (2)(3)(4)(5) . After birth, the child is totally dependent on parental responses to its behavior; thus, inadequate responses may negatively affect a child's health.
Good parenting is essential for ensuring a child's survival, safety and well-being (6) . Therefore, developing parental competencies plays an important role in reducing neonatal morbidity (7)(8) .
Parental competence can be defined as a set of knowledge, skills and attitudes that enable effective parenting, thus ensuring that a child achieves maximum potential growth and development (9)(10) .
By mastering parenting skills, parents change the way in which they interpret their own performance and their child's behavior. The higher the level of parenting knowledge and skills, the greater the likelihood of creating an environment conducive to healthy development and the greater the awareness of a child's needs and the likelihood of responding to these needs (11) .
By contrast, lack of parenting knowledge and skills may lead parents to underestimate their child's capacity, meaning that the child is not stimulated to achieve his/her maximum development potential. Furthermore, unrealistic expectations in relation to parenting and child development can also increase the risk of abuse and neglect (8,(11)(12) .
Given the lack of studies to sustain childbearing and parenting training programs focusing on health promotion and monitoring for newborns and infants aged up to six months, this study aimed to respond the following questions: what is the level of knowledge of mothers regarding the promotion and monitoring of their child's health? What is the association between mothers' knowledge and sociodemographic factors?
This study aimed to assess mothers' parenting knowledge and skills associated with the parental competence health promotion and monitoring for newborns and infants aged up to six months and determine the key characteristics of mothers who are better prepared for parenting.

Method
A cross-sectional study was conducted using data collected in three health centers in the Northern Region of Portugal after obtaining authorization from the Ethics Committee of the Local Health Unit.
A total of 629 participants were selected using convenience sampling based on the following inclusion criteria: (1) being a mother -pregnant or with a child aged up to six months; and (2) (9) . The IACP was developed to systematize the assessment of parental competence during pregnancy and the first six  "yes/present" permits to identify that the patient has adequate knowledge/skills. A clinical judgment "no" permits identify the identification of an opportunity to improve knowledge/skills (13)(14) .
The data collection tool was composed of two "total score"; "pregnancy score" (that included the three indicators assessed during pregnancy); "1st-2nd week score" (that included the nine indicators assessed during the 1st-2nd week); "1st-2nd month score" (that included the three indicators assessed during the 1st-2nd month); "3rd-4th month score" (that included the four indicators assessed during the 3rd-4th month); and "5th-6th month score" (that included the two indicators assessed during the 5th-6th month).   The highest score was obtained for the assessment moment pregnancy (A = 0.36; DP = 0.38), while the lowest scores were obtained for the 3rd-4th month and 5th-6th month (0.085 and 0.084, respectively).
To determine the key characteristics of mothers who are better prepared for parenting, we analyzed the association between level of knowledge and skills and the attribute variables ( Figure 2

Better-prepared mothers [Post-natal]
-Multiparous -Lives with child's father -Assumed responsibility for child care -Intention to breasfeed -Nurses and doctors as information sources -Parenting prepation during pregnancy -Nurses as information sources -Doctors and internet as information sources (1 st /2 nd month)

Discussion
Mother's are mainly responsible for child care (9.15) and therefore the quality of care is influenced by the mother's knowledge and skills regarding the health of her child.
The findings show that women who had had more than one child and resided with the child's father tended to more knowledge and skills needed child health promotion and monitoring. These findings are in line with the results of other studies that show that first-time mothers are more likely to have poor Knowledge about child development (7)(8) . Another study reported that there was no association between mothers' knowledge of child health and level of schooling and number of children (15) .
In contrast, a different study showed that mothers who had a low level of schooling were more likely to lack Knowledge about jaundice in newborns (16) .
The present study did not observe an association between mothers' knowledge and skills and age and schooling level. However, other studies have shown an association between level of knowledge of Guthrie test in the neonatal period and level of schooling (17) . Other authors reported that an association between schooling level and scores for the items recognition of warning signs, treating the umbilical stump and measuring and interpreting body temperature (8) . A study conducted in 2005 reported that schooling level was a strong predictor of mothers' knowledge (5) .
Nurses and doctors were the most commonly mentioned information sources and were these sources that had the greatest influence on the knowledge and skills of mothers, both in the pre-natal and post-natal periods. of the women had heard of the test, but were unaware of the purpose and importance of the test (19) .

Knowledge about immunization
Besides not knowing when to start the immunization A further study that interviewed 30 mothers (15 with one child and 15 with more than one child) to assess vaccination information needs and information seeking behavior showed that only four women (two with one child and two with more than one child) knew the name and purpose of the vaccine administered to their children (3) .
Another study conducted in Italy observed that only 26% of the participating mothers knew which vaccines made up the vaccination schedule (18) .

Knowledge about warning signs
Half of the mothers interviewed under the present study lacked the necessary knowledge to recognize warning signs and know when to seek healthcare services. Another study observed that mothers had a satisfactory level of knowledge of warning signs in newborns and infants in the first few months of life (7) .
Recognizing warning signs can be particularly complex given the broad spectrum of normality patterns in child health. A study conducted with 373 mothers to assess their knowledge of specific aspects of child health showed that half of the mothers were not aware that a newborn that "only sleeps and does not feed" may be ill and need urgent attention and that 25% of mothers did not know that the fact that a child "cries continually, doesn't sleep and expresses pained when moved" is a warning sign and that the child requires immediate attention (15) .
The present study also showed that almost half of the mothers (49%) lacked knowledge about jaundice.
Similar results were obtained by other studies. A study conducted with 161 mothers to assess their knowledge about neonatal jaundice showed that 53.6% of the mothers had inadequate knowledge (16) , while another study undertaken with 396 mothers who had recently given birth to determine their knowledge, attitude and behavior in relation to neonatal jaundice showed that 53% (N=203) had little knowledge about this problem (21) .
Another study highlighted that it is was worrying to find that the majority of mothers thought that jaundice in the first Day of life of a newborn is normal and simply required more frequent feeding and exposure to sunlight (15) . what is considered a fever was poor (22) . Another study showed that 35.1% of mothers thought that fever was an indication of a serious disease (15).

Knowledge about newborn weight
Weight loss or low weight gain in newborns is source of doubt for most mothers, particularly those who breastfeed. Our findings show that over half of the mothers lacked knowledge about the expected pattern of weight gain (65%) and physiological weight loss (50%).
Given that in exclusively breastfed babies milk intake is difficult to ascertain, weight is the best indicator of nutritional status in the first year of life (23) .
The results also show that over 60% of mothers did not have any knowledge about child sleeping patterns.
Similar results were found by another study involving 203 mothers, which showed that child sleeping patterns was the area in which the participants most lacked knowledge (5) .

Knowledge about oral health
The mothers also showed a lack of knowledge and skills in relation to childe oral health. Oral hygiene routine should be a routine component of parenting  (15) . A further study observed that 65% of mothers correctly answered all questions on the questionnaire regarding child development (5) . This idea is somewhat confirmed by other authors when they observe that after birth mothers and children "compete" for the attention of health professionals (25) .
This study showed some limitations in relation to The mothers who were better-prepared for child health promotion and monitoring tended to have a higher level of schooling, had other children, resided with the father of the child, and consulted nurses as information source after the birth of their child. In contrast, firsttime single mothers whose pregnancy was unplanned and who did not prepare themselves for parenthood may be considered vulnerable.

Practical implications
Nurses play a critically important role in the development of parenting skills. By identifying the main gaps in parenting knowledge and skills, the findings of this study can inform the design of parenting training programs focusing on health promotion and monitoring for newborns and infants aged up to six months.
Indeed, the systematic assessment of the learning needs identified in this study could constitute a starting point for defining the content of nursing interventions contemplated by the nursing care plan