Determinants of neonatal morbidity in Rajshahi Division of Bangladesh

Abstract

Objectives

Neonatal morbidity (NM) refers to any clinically identified health complication that occurs within the first 28 days of life after birth. It remains a significant public health challenge in low and middle-income countries such as Bangladesh. This study aimed to investigate the determinants of NM in the Rajshahi Division of Bangladesh, with a particular focus on socio-demographic characteristics, maternal health, delivery practices and breastfeeding behaviors.

Study design

A population-based cross-sectional study.

Methods

Data were collected from 475 mothers in selected hospitals using a multi-stage sampling technique. Information was collected through structured questionnaires and medical records at two time points: 3 days and 28 days after birth. Descriptive statistics summarized participant characteristics. Chi-square tests and binary logistic regression were used to explore associations between key variables and NM.

Results

The overall neonatal morbidity rate was 53.6 %. Maternal age, mode of delivery, delivery attendance and breastfeeding practices were significant determinants of NM. Infants born to mothers aged 25–29 years had significantly lower odds of NM (OR = 0.192, 95 % CI: 0.043–0.855) compared with those born to mothers aged ≥35 years. Vaginal delivery was associated with higher odds of NM than caesarean section (OR = 1.934, 95 % CI: 1.334–2.829) whereas deliveries attended by both a doctor and a nurse were associated with lower odds (OR = 0.366, 95 % CI: 0.204–0.655) of morbidity. Exclusive breastfeeding and early initiation of breastfeeding with the first hour after birth were associated with lower odds of NM compared with non-exclusive breastfeeding and delayed initiation (OR = 0.521, 95 % CI: 0.343–0.794; OR = 0.588, 95 % CI: 0.351–0.985, respectively). Furthermore, infants who were fed on demand had markedly lower odds of neonatal morbidity (OR = 0.145, 95 % CI: 0.031–0.671).

Conclusions

NM in the Rajshahi division is influenced by maternal age, delivery method, delivery attendance and breastfeeding practices. Policies and programs promoting skilled delivery attendance and optimal breastfeeding support are essential to reduce NM and improve neonatal health outcomes in this region.

1. Introduction

Neonatal morbidity (NM), defined as any clinically recognized health complication within the first 28 days of life, remains a critical public health challenge, particularly in low- and middle-income countries (LMICs) such as Bangladesh. The neonatal period is highly vulnerable time for newborns, accounting for a substantial proportion of under-five child mortality and long-term health complications [1]. Globally, nearly 2.4 million newborns died in 2020, representing approximately 47 % of all under-five deaths worldwide, many of which were preventable with timely and appropriate care [2]. Common causes of NM include sepsis, birth asphyxia, jaundice, pneumonia and complications from preterm birth all of which are often exacerbated by inadequate maternal health services, socio-economic challenges and limited access to skilled healthcare [1,3,4].

In Bangladesh, despite notable progress in reducing child mortality over the past decades, NM rates remain high with marked regional disparities. The 2020 Bangladesh Demographic and Health Survey (BDHS) reported a mortality rate of 18 deaths per 1000 live births [5]. The Rajshahi Division, situated in the northwestern part of Bangladesh, presents a unique context for studying NM due to its socioeconomic diversity, limited healthcare infrastructure and cultural practices influencing maternal and child health behaviors. These local factors may interact with maternal characteristics, delivery practices and postnatal care, including breastfeeding behaviors, to shape neonatal outcomes.

Multiple determinants contribute to NM, ranging from maternal characteristics to healthcare utilization, delivery practices and postnatal care, including breastfeeding behaviors [[6], [7], [8], [9]]. Previous studies have shown that younger maternal age, inadequate antenatal care, home deliveries and suboptimal breastfeeding practices are significantly associated with poor neonatal outcomes [[10], [11], [12]]. However, region-specific evidence for areas like Rajshahi is limited, despite the division's distinctive challenges in healthcare access and socio-cultural practices. Understanding these local determinants is essential for designing targeted interventions that address early-life inequalities and improve child health outcomes, contributing to Sustainable Development Goal 3, which aims to ensure healthy lives and promote well-being for all. This study therefore aims to identify the determinants of NM among newborns in the Rajshahi Division, focusing on maternal, socio-demographic, delivery and breastfeeding-related factors. The findings are expected to inform policy decisions and provide practical guidance for healthcare providers in implementing context-specific strategies to reduce NM in the region.

2. Methods

2.1. Study design

This study employed a cross-sectional design with short-term follow-up to identify the determinants of NM in the Rajshahi Division of Bangladesh. This Division located the northern part of Bangladesh and this region is comparatively less developed in Bangladesh. Although baseline data were collected shortly after birth, NM was assessed over the entire neonatal period (first 28 days of life) to capture clinically relevant outcomes.

2.2. Study area and population

The study was conducted in the Rajshahi Division, which is located in the northwestern region of Bangladesh. The division comprises eight districts, namely Rajshahi, Chapai Nawabganj, Naogaon, Natore, Pabna, Bogura, Joypurhat and Sirajganj. Due to logical feasibility and healthcare service coverage, three districts (Rajshahi, Bogura and Sirajganj) were selected. This region is characterized by diverse socio-economic conditions and variations in maternal and neonatal care practice that making it a relevant setting for studying NM. The study population consisted of mothers of live-born infants aged 0–3 days who received delivery or postnatal care at selected hospitals within the study area.

2.3. Sample size and sampling technique

Total number of population of the Rajshahi Division is unknown that's why to determine the sample size we used Cochran's formula [13] $n_0=Z^2.P\left(1-P\right)/e^2$ where Z = 1.96 in 95 % confidence, P = 0.5 which is assumed prevalence, and the margin of error is e = 0.05. Based on these parameters, the required sample size was approximately 385. To increase precision, 475 neonates and their mothers were included in this study. A multi-stage sampling technique was employed. In the first stage, three districts Rajshahi, Bogura, and Sirajgonj were randomly selected from the eight districts of the Division. In the second stage, healthcare facilities within these districts were randomly chosen such as Rajshahi Medical College and Islami Bank Hospital (Rajshahi), Shaheed Ziaur Rahman Medical College (Bogura) and Shahid M. Monsur Ali Medical College (Sirajgonj). In the third stage, eligible mothers who had recently delivered were randomly selected from the gynecology wards of the selected hospitals. Data collection was conducted in two phases. In the first phase, baseline information was collected from 475 mothers within 0–3 days postpartum. A follow-up at 28 days was conducted to assess NM and postnatal outcomes. During the follow-up, 2 neonatal deaths were recorded, 12 participants declined further participation and 8 could not be contacted. These cases were excluded from the final analysis, resulting in a final analytical sample of 453 participants. No imputation was performed for missing follow-up data.

2.4. Questionnaire design and data collection procedures

A self-structured questionnaire was developed based on an extensive review of relevant literature [[14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24]] (please see Appendix-I). A pilot study with 60 participants and expert review by three public health researchers ensured its reliability and validity. Data were collected between August 14 and November 15, 2024, from selected public and private hospitals across the Rajshahi Division. Information was obtained in two phases: first, within the first 0–3 days of life to capture maternal, socio-demographic and delivery-related factors, and second, at 28 days of age to assess NM and postnatal health outcomes. Eligibility criteria included mothers of live-born infants aged 0–3 days with complete medical records who provided written informed consent. Mothers with incomplete records or who declined participation were excluded to ensure ethical standards and data quality.

2.5. Variables

Outcome Variable: The primary outcome variable of this study is NM, defined as the presence of any clinically recognized health complication occurring within the first 28 days of life. NM was recorded as a binary variable (1 = “Yes,” 0 = “No”) based on physician-diagnosed conditions documented in the hospital medical records, including, but not limited to, neonatal jaundice, sepsis, respiratory distress feeding difficulties and other documented neonatal illness.

Predictor Variables: The predictor variables in this study encompassed four main domains: socio-demographic characteristics, delivery-related information, health-related factors, and anthropometric measurements. Socio-demographic data included parental age, education, occupation, family type and size, income, housing condition, and sanitation. Delivery-related variables covered mode of delivery, birth order, birth interval, antenatal and postnatal care, and prior adverse pregnancy outcomes. Health-related factors included neonatal illness history and healthcare consultation sources. Anthropometric data captured maternal and neonatal measurements such as weight, height, MUAC, and BMI. Breastfeeding practices were also assessed, including exclusivity, initiation time, colostrum and pre-lacteal feeding, and feeding frequency.

2.6. Data analysis

Data were analyzed using statistical software packages including SPSS (version 26.0) and R (version 4.0.2). Descriptive statistics were used to summarize the socio-demographic, delivery information and neonatal health outcomes. Bivariate analyses, primarily using Chi-square tests, were conducted to examine associations between key independent variables such as antenatal care visits, mode of delivery, breastfeeding practices, and family structure and NM outcomes. To identify independent predictors of neonatal morbidity, binary logistic regression models were employed, adjusting for potential confounders such as maternal education, socio-economic status, and healthcare access. Results were presented as odds ratios (ORs) with 95 % confidence intervals (CIs), and a p-value of <0.05 was considered statistically significant.

3. Results

3.1. Demographic profiles

Table 1 summarizes the socio-demographic characteristics of the study participants. Most mothers were aged 20–24 years, followed by those aged 25–29 years, while a small proportion were aged ≥35 years. Over half of the mothers had secondary-level education and nearly one-third of fathers had completed higher education. The majority of households belonged to low-income groups, lived in pucca houses and relied on tube wells for drinking water. Slightly more than half of the families were joint families. Neonatal sex distribution was nearly equal.

Table 1.

Demographic profiles of the participants (n = 453).

Variables	Frequency (%)	Variables	Frequency (%)
Age of mother		Housing status
20–24	272 (60.0)	Katcha	88 (19.4)
25–29	112 (24.7)	Tin	68 (15.0)
30–34	46 (10.2)	Pucca	246 (54.3)
35–39	17 (3.8)	Katcha- Pucca	48 (10.6)
≥40	6 (1.3)	Others	3 (0.7)
Education of mother		Family size
Primary education	35 (7.7)	Small family	178 (39.3)
Secondary education	248 (54.7)	Medium family	207 (45.7)
Higher secondary	92 (20.3)	Large family	68 (15.0)
Above	78 (17.2)	Monthly income category
Education of father		Low income	332 (73.3)
Primary education	79 (17.4)	Middle income	107 (23.6)
Secondary education	166 (36.6)	High income	14 (3.1)
Higher secondary	74 (16.3)	Monthly expenditure
Above	134 (29.6)	Low income	332 (73.3)
Occupation of mother		Middle income	107 (23.6)
Housewife	425 (93.8)	High income	14 (3.1)
Service	28 (6.2)	Source of drinking water
Occupation of father		Supply	57 (12.6)
Govt. service	48 (10.6)	Tube-well	396 (87.4)
Private service	89 (19.6)	Toilet facility
Business	99 (21.9)	Katcha	60 (13.2)
Agriculture	120 (26.5)	Slab	79 (17.4)
Others	97 (21.4)	Pucca	307 (67.8)
Sex of neonate		Open field	7 (1.5)
Male	244 (53.9)	Type of family
Female	209 (46.1)	Nuclear	206 (45.5)
		Joint	247 (54.5)

3.2. Delivery and maternal care

Delivery-related characteristics are presented in Table S1. Over half of the deliveries (55.4 %) were normal and most neonates were first-born (53.6 %). Deliveries were primarily attended by skill health personnel either jointly by doctors and nurses (44.6 %) or by nurses alone (38.9 %), while a smaller proportion (15.2 %) were assisted by traditional birth attendants. A majority (87.4 %) of mothers practiced breastfeeding during antenatal or postnatal care. Approximately half of the mothers (49.0 %) reported attending 1–3 ANC visits, while 59.2 % attended 1–3 PNC visits. Regarding reproductive history, 19.0 % reported at least one adverse pregnancy outcome, including abortion (4.9 %), miscarriage (7.5 %), stillbirth (4.0 %), or neonatal death within the first year of life (2.6 %). Birth intervals exceeding 25 months were observed in 41.1 % of cases, and 53.6 % of mothers were primiparous.

3.3. Health-seeking behavior

Overall, 53.6 % of neonates experienced at least one morbidity episode during the neonatal period (Fig. 1). Jaundice was the most frequently (14.1 %) reported condition, followed by vomiting, respiratory infections, pneumonia, and sepsis. Additionally, 18.5 % of cases were classified under miscellaneous or unspecified illnesses. In terms of health-seeking behavior, the majority of caregivers consulted specialist doctors (63 %) for treatment. Health-related officers were approached by 20.8 % of respondents, while paramedic doctors and nurses or midwives were consulted by 3.1 % and 1.8 % respectively.

Fig. 1.

Health information of the study participants whereas x-axis represents percentage values and y-axis represents the variables under three factors “child faced illness”, “health advice given by”, and “types of illness”.

A small proportion sought advice from NGO workers (3.3 %), relatives or other sources, highlighting diverse health-seeking behaviors among caregivers. Anthropometric measurements indicated that neonates had a relatively low mean birth weight, whereas maternal nutritional indicators were within normal ranges (Fig. 2).

Fig. 2.

Measurements on nutritional status of the neonatal and mothers.

3.4. Breastfeeding practices

Breastfeeding practices are summarized in Table 2. The majority of mothers (71.1 %) practiced exclusive breastfeeding, with most maintaining it for 21–28 days (66.6 %). Early initiation of breastfeeding was common, with 35.8 % of infants breastfed within the first hour and 17.7 % within 6 h of birth. Colostrum was given to 89.8 % of newborns. Among non-exclusively breastfed infants, the most common reason was the baby's illness (50.4 %). The majority of infants (67.4 %) were fed on demand.

Table 2.

Breast feeding status of the study participants is presented in frequency and percentage.

Variables	Frequency (%)	Variables	Frequency (%)
Exclusively breastfeeding		Causes of non-exclusive breastfeeding
Yes	322 (71.1)	Mother's illness	15 (11.3)
No	131 (28.9)	Baby's illness	67 (50.4)
Duration of exclusively breastfeeding		Combination of artificial milk and breast milk	25 (17.3)
1–7 days	20 (6.1)	Milk came in late	23 (18.8)
7–14 days	33 (10.1)	Baby not feeling well after fed	1 (0.8)
14–21 days	56 (17.1)	Doctor, nurse advised to take artificial milk	2 (1.5)
21–28 days	217 (66.6)	Given pre-lacteal feeding
Initiation of breastfeeding after birth		Yes	56 (12.4)
Within 1 h	162 (35.8)	No	397 (87.6)
Within 6 h	80 (17.7)	Frequency of breast feeding
Within 24 h	62 (13.7)	Less than 6 times	32 (7.1)
Within 2 days	55 (12.1)	6-8 times	33 (7.3)
After 2 days	94 (20.8)	9-11 times	60 (13.2)
Baby drink colostrum after birth		More than 12 times	11 (2.4)
Yes	407 (89.8)	Breastfeeding on demand	305 (67.4)
No	46 (10.2)	Don't remember	12 (2.6)

3.5. Associations with neonatal morbidity

NM was significantly associated with several maternal, household and feeding-related factors (Table S2). Higher morbidity was observed among neonates born to mothers aged ≥35 years (p = 0.013), those delivered vaginally (p = 0.001) and those assisted by traditional birth attendants (p = 0.002). Neonates from joint families and larger households also associated with NM (p = 0.003 and p = 0.001, respectively. Lower NM was observed among infants who initiated breastfeeding within the first hour after birth (p = 0.004). Exclusive breastfeeding was also associated with a reduced risk of neonatal morbidity (p = 0.002). Infants who were breastfed on the first day of life experienced lower morbidity compared with those who were not (p = 0.000). In addition, more frequent breastfeeding was significantly associated with reduced NM. Breastfeeding practices were significantly associated with NM. It also differed by source of drinking water, with lower morbidity among households using supply water compared with tubewell water (p = 0.007).

3.6. Logistic regression findings

Results from the multivariable logistic regression analysis are shown in Table 3. Maternal age, mode of delivery, delivery attendance and breastfeeding practices remained significant determinants of NM after adjustment. Mothers aged 25–29 years had lower odds of NM compared with those aged ≥35 years (OR = 0.192, 95 % CI: 0.043–0.855). Vaginal delivery was associated with higher odds of NM compared with caesarean section (C-section) (OR = 1.934, 95 % CI: 1.334–2.829). Delivery attended by both a doctor and a nurse was associated with reduced odds of NM (OR = 0.366, 95 % CI: 0.204–0.655).

Table 3.

Binary logistic regression analysis of NM and its associated factors.

Variables	Categories	OR	Lower limit	Upper limit
Age of mothers	20–24	0.278	0.064	1.20
	25–29	0.192	0.043	0.855
	30–34	0.194	0.035	1.067
	≥35 (ref)	1	1	1
Type of family	Nuclear	0.554	0.191	1.603
	Joint (ref)	1	1	1
Family size	Small	0.746	0.212	2.632
	Medium	0.994	0.423	2.336
	Large (ref)	1	1	1
Source of drinking water	Supply	1.381	0.578	3.303
	Tubewell	1	1	1
Mode of delivery	Normal	1.934	1.334	2.829
	Caesarian (ref)	1	1	1
Attendant on delivery	Doctor	2.187	0.241	4.889
	Nurse	0.550	0.304	0.894
	Both doctor and nurse	0.366	0.204	0.655
	Traditional birth attendants (ref)	1	1	1
Exclusively breastfeeding	Yes	0.521	0.343	0.794
	No (ref)	1	1	1
Initiation of breastfeeding after birth	Within 1hr	0.588	0.351	0.985
	Within 6hrs	0.456	0.248	0.837
	Within 24 h	1.101	0.568	2.131
	Within 2d	1.334	0.663	2.684
	After 2d (ref)	1	1	1
Duration of exclusive breastfeeding	1–7 days	1.670	0.428	6.516
	7–14 days	0.887	0.238	3.300
	14–21 days	0.367	0.099	1.365
	21–28 days (ref)	1	1	1
Frequency of breastfeeding	<6 times	0.714	0.126	4.046
	6-8 times	0.533	0.097	2.921
	9-11 times	0.723	0.141	3.719
	>12 times	0.900	0.104	6.780
	On demand	0.145	0.031	0.671
	Don't remember (ref)	1	1	1
Start breastfeeding to the child from	1st days	0.358	0.064	1.998
	2–7 days	0.828	0.147	4.650
	8–14 days	1.100	0.181	6.680
	15–21 days	2.250	0.229	5.144
	22–28 days (ref)	1	1	1

Breastfeeding practices were independently associated with NM. Exclusive breastfeeding was associated with significantly lower odds of NM compared with non-exclusive breastfeeding (OR = 0.521, 95 % CI: 0.343–0.794). Initiation of breastfeeding within the first hour after birth (OR = 0.588, 95 % CI: 0.351–0.985) and within 6 h (OR = 0.456, 95 % CI: 0.248–0.837) had lower risk of NM compared with initiation after two days. Additionally, feeding on demand was associated with substantially lower odds of NM (OR = 0.145, 95 % CI: 0.031–0.671). The regression model demonstrated good discriminatory ability, with an area under the curve (AUC) of 0.862 (Fig. 3).

Fig. 3.

The ROC curve plots sensitivity (true positive rate) against 1-specificity (false positive rate) at various threshold settings.

4. Discussion

This study investigated the key determinants of NM in the Rajshahi Division of Bangladesh, focusing on maternal, with particular emphasis on maternal characteristics, delivery related factors and breastfeeding practices. The findings highlight that NM is influenced by a combination of socio-demographic conditions, healthcare utilization and early infant feeding behaviors. By identifying modifiable risk and protective factors, this study provides important evidence to inform targeted public health interventions aimed at improving neonatal health outcomes in this region.

Maternal age emerged as a significant determinant of NM. Mothers aged 25–29 years were less likely to have neonates with morbid conditions compared to those aged 35 years and above [25]. This aligns with global evidence indicating that advanced maternal age to higher risks of pregnancy and neonatal complications, including preterm birth and low birth weight [26,27]. Younger maternal age within the optimal reproductive window is often associated with better physiological readiness and fewer comorbidities which may explain the reduced morbidity observed in this group [28]. These findings underscore the importance of maternal health interventions that consider age-specific risks, particularly in resource-limited settings. Mode of delivery was another key factor [23,29]. Neonates born through vaginal delivery had significantly higher morbidity compared to those delivered by C-section [29]. While C-section deliveries are sometimes associated with respiratory complications in neonates [30,31], our results are consistent with evidence suggesting that, in certain LMIC contexts, planned and medically supervised C-sections can reduce NM [32]. In Bangladesh, the rising trend of elective cesarean deliveries without medical indication highlights the need to balance clinical necessity with potential health benefits [33]. The presence of both a doctor and nurse at the time of delivery was associated with a reduced risk of NM [34]. This emphasizes the critical role of skilled birth attendants in ensuring safe delivery practices and immediate neonatal care which can prevent complications [35]. In settings like the Rajshahi Division where healthcare infrastructure is uneven, ensuring access to skilled personnel during childbirth is particularly vital [36].

Breastfeeding practices were strongly associated with neonatal health. Exclusive breastfeeding reduced the risk of NM [37]. This finding aligns with the WHO's recommendations and a large body of evidence that supports exclusive breastfeeding for the first six months as a major preventive strategy against infections, malnutrition and NM [38]. Exclusive breastfeeding provides essential nutrients and antibodies that are vital for neonatal immunity and development [39]. Early initiation of breastfeeding within 1 h after birth was associated with reduced odds of NM compared with initiation after two days. This finding is consistent with previous studies [[40], [41], [42]] that emphasize the protective role of timely breastfeeding in improving neonatal survival. Breastfeeding on demand also showed a protective effect, likely by promoting frequent feeding, sustaining hydration and energy levels and reducing risks of hypoglycemia and jaundice [[43], [44], [45]]. These findings suggest that promoting exclusive and responsive breastfeeding could be a feasible and low-cost intervention in local neonatal health programs.

Although familial factors such as family type and size were not statistically significant in the regression model, larger and joint families may influence caregiving practices, maternal workload and access to healthcare resources which can indirectly affect neonatal outcomes [46,47]. In the context of the Rajshahi Division, socioeconomic disparities, household crowding and limited maternal support may further compound these risks, emphasizing the need for community-level interventions that address structural determinants of health. These findings highlight the interplay of maternal characteristics, delivery practices, breastfeeding behaviors and local household and healthcare factors in shaping neonatal health outcomes [[48], [49], [50]]. Targeted strategies that improve maternal care, promote skilled delivery attendance and encourage optimal breastfeeding practices while accounting for local socioeconomic and structural conditions are essential to reduce NM in resource-limited settings like the Rajshahi Division.

4.1. Implications for policy and practice

The findings of this study have important implications for public health strategies in the Rajshahi Division and similar contexts. Encouraging institutional deliveries attended by both doctors and nurses and ensuring appropriate clinical decision-making regarding the mode of delivery may help reduce NM. Strengthening programs that support exclusive and on-demand breastfeeding as well as early initiation of breastfeeding is also essential. In addition, health education initiatives focusing on optimal maternal age, early antenatal care enrollment and evidence-based newborn feeding practices may further improve neonatal health outcomes.

4.2. Limitations

This study has several limitations. First, its cross-sectional design limits causal inference. Second, the hospital-based sample may not be representative of the wider population. Third, NM was primarily self-reported and lacked full clinical validation which may introduce measurement bias. Fourth, some follow-up responses were incomplete, potentially affecting outcome assessment. Finally, the findings are specific to the Rajshahi Division and may not be generalizable to other regions of Bangladesh.

4.3. Conclusion

This study demonstrates that NM in the Rajshahi Division of Bangladesh is influenced by maternal characteristics, delivery practices and breastfeeding behaviors. Maternal age, mode of delivery, presence of skilled birth attendants and exclusive breastfeeding were identified as significant determinants of neonatal health outcomes. Local socioeconomic and household factors, including family structure and access to healthcare, may also indirectly affect neonatal well-being. These findings emphasize the importance of promoting skilled delivery care, optimal breastfeeding practices and maternal health education to reduce NM. Further longitudinal and community-based research is recommended to validate these associations and guide context-specific interventions aimed at improving neonatal health outcomes in similar settings.

Author's contributions

All authors made significant contributions to the study. MMH and MKK conceptualized the research, designed the study and supervised the project. MMH was responsible for data collection, data management, and statistical analyses, contributed to the literature review and assisted with data interpretation. Additionally, MKK provided critical revisions and helped refine the study design and methodology. The initial draft was collaboratively written by MKK and MMH, and the final version was reviewed and approved by both for submission.

Ethical statement

This study was approved by the Institutional Animal, Medical Ethics, Biosafety and Biosecurity Committee (IAMEBBC) of the Institute of Biological Sciences, University of Rajshahi, Rajshahi-6205, Bangladesh (Approval ID: 110(16)/320/IAMEBBC/IBSc). Written informed consent was obtained from all participants prior to their inclusion in the study. The mothers were assured that their participation was voluntary and that their information would be kept confidential and used for research purposes only.

Funding

The authors received no specific funding for this work.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A. Supplementary data

The following are the Supplementary data to this article:

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.