Evaluating the Efficacy of the Newborn Communication, Health, Feeding, and Swallowing Education Program (N-CHFSEP) for First-Time Mothers in Mangalore taluk, Dakshina Kannada district, Karnataka, India: A Preliminary Study

Participants

The sample size was calculated using the formula: $\mathrm{n}=\frac{{\mathrm{Z}}_{1-\frac{\mathrm{\alpha }}{2}}^2\times \mathrm{pq}}{{\mathrm{d}}^2}$ ; where Z = 1.96, standard normal at 5% level of significance; p = 0.47%, q= 1-p, d=0.1 (Varghese et al., 2020). The study followed a single-arm pre-post study design similar to other educational interventional studies (Maharjan et al., 2022; Matovelo et al., 2022). A total of 98 primiparous mothers [mean age (in years): 26.03 ±3.79] were recruited for the study.

Seventy-six (77.6%) of them belonged to a joint family, while 22 (22.4%) were from a nuclear family. These mothers comprised homemakers (62%), homemakers after having resigned from their jobs due to pregnancy (11%), working in educational sectors (8%), and other private/government sectors (19%). The educational qualifications indicated mothers have completed their basic formal education (38%), higher secondary education (19%), diploma (35%), graduation (35%), and postgraduation (3%).

The inclusion criteria included (1) inpatient primiparous mothers without any prior obstetric history, (2) mothers having given birth to healthy newborns through various delivery methods [vaginal, assisted vaginal (including vacuum, forceps, or cesarean)], and (3) mothers proficient in English or Kannada (a South Indian language spoken in the state of Karnataka). The exclusion criteria included (1) primiparous mothers delivering twins/triplets with significant history of obstetric, medical, or psychological problems, and (2) mothers who were health professionals. Multiparous mothers were excluded due to their experience in caring for newborns. Mothers with obstetric complications were excluded as that may affect their ability to participate in the educational program or effectively express their attitudes. All participants were recruited from Government Lady Goschen Hospital (a government hospital exclusive for maternity care), and Kasturba Medical College Hospital (a multidisciplinary speciality centre) of the Mangalore taluk, Dakshina Kannada district.

Procedure

The present study was conducted in 2 phases. Phase 1 included the development of an (a) attitude questionnaire, (b) parent education program, and (3) feedback questionnaire; while Phase 2 included the administration of the questionnaires and the education program on the participants, followed by data analysis of the retrieved data.

Phase 1: Development of the tools.

Content Validation

The AQ, FQ, and N-CHFSEP were subjected to content validation by an expert panel to evaluate their adherence to established scientific facts and the grammatical accuracy of the designed statements. The panel included three primiparous mothers who were professionally qualified speech-language pathologists (SLPs) and three primiparous mothers who were professionally qualified paediatricians, each of them having a minimum of five years of clinical experience. All experts received a copy of the developed questionnaires (AQ and FQ) and N-CHFSEP. Each expert reviewed the tools (item-wise) on a 3-point Likert rating scale (0 being inappropriate, 1 being modifications required, and 2 being appropriate). For the N-CHFSEP validation, the panel evaluated the suitability of the milestones to appear under the corresponding age (0-6 months). Following the content validation by SLPs and the pediatricians, the content validation index (CVI) was calculated at both the item and scale level for the AQ, N-CHFSEP, and FQ respectively. The Item level CVI (I-CVI) was computed by dividing the number of experts who rated the items as one or two by the total number of experts. Scale level CVI (S-CVI) was then calculated by averaging the I-CVI scores for AQ, and FQ. The resulting S-CVI scores were 0.95 for AQ, 0.90 for N-CHFSEP, and 1.0 for FQ. The I-CVI scores for the N-CHFSEP fell below the desired level (0.78), indicating insufficient agreement among experts and, hence demanding a revalidation. The same expert panel participated in this process to obtain an I-CVI score of 1.

The AQ, FQ and N-CHFSEP underwent grammatical modifications (e.g. ‘The child … ….’ to ‘My baby … ….’) to enhance their comprehensibility for mothers. Based on expert advice, the N-CHFSEP was revised to highlight potential warning signs using the checklist released by the Centers for Disease Control and Prevention (CDC) within each month and across the 6 months. Furthermore, the program was revised to incorporate recommendations for fostering the child's communication abilities and holistic growth. Specific suggestions were made to include illustrations of certain elements in the N-CHFSEP, to facilitate better comprehension of the presented content. The SLPs provided valuable input, including guidance on breastfeeding practices, as well as identifying red flags related to communication and feeding milestones. The pediatric experts suggested the reorganization of milestones by months and repeating specific items in their respective months. Additionally, it was recommended to develop a pamphlet on the N-CHFSEP which would serve as a carry-home resource for mothers. Following the incorporations of the modifications the final N-CHFSEP was ready for administration.

Translation

The AQ, N-CHFSEP, and FQ were translated into Kannada (one of the common regional languages spoken in the Mangalore taluk). The AQ, N-CHFSEP, and FQ underwent both forward and backward translations which were performed by a bilingual translator proficient in both Kannada and English, with expertise in the subject matter. Following the completion of both forward and backward translations, a final Kannada version of the AQ, N-CHFSEP, and FQ was ready for administration. A pilot study was conducted on two Kannada-speaking participants to assess the comprehensibility, clarity, and cultural relevance of the finalized translated AQ, N-CHFSEP, and FQ. This continuous process of forward and backward translation contributed significantly to the questionnaire's accuracy and cultural appropriateness.

Phase 2: Administration of the tools and data analysis

The data collection took place in the postnatal ward through one-on-one interactions. Participants were recruited by reviewing their medical records based on the inclusion and exclusion criteria. The data was collected from each of the participants on the second day following their delivery due to the discomfort commonly experienced by the mothers on the first-day post-delivery. Safety and hygiene were strictly adhered to by following hand hygiene protocols and by wearing surgical masks (as per WHO guidelines) before approaching the participants at their bedside. Efforts were made to facilitate participants to be seated in a comfortable position, enhancing effective interaction. The researcher obtained written informed consent from the participants followed by their socio-demographic details. Each participant was oriented to the study goals and objectives and was provided with comprehensive information pertaining to the questionnaires and the education program they will be subjected to. They were actively encouraged to seek clarifications on any uncertainties pertaining to the items within the questionnaire. The study commenced by providing each participant with the AQ which required them to read the questions and mark their level of confidence across each item, followed by the presentation of the N-CHFSEP, during which the examiner verbally presented the participants with the program, further to which a printed version of the N-CHFSEP was provided, after which the AQ was re-administered. Subsequently, feedback regarding the N-CHFSEP was obtained from the participants using the FQ. All verbal responses from the mothers were recorded using a digital voice recorder (Sony ICD-UX560F Stereo IC recorder 4 GB). The total administration spanned a duration of 25-30 minutes.

The digital voice recordings of the primiparous mothers' responses towards the AQ and FQ administration were transcribed and subjected to quantitative analysis. All open-ended questions were subjected to qualitative analysis by categorizing the verbatim into comprehensive themes to examine the responses received. Descriptive statistics (quantitative data) were performed using SPSS version 25.0. The continuous variables were analyzed using mean and standard deviation while the discrete variables were analyzed using frequency and percentage. The efficacy of the N-CHFSEP was estimated by comparing the pre and post-AQ scores and analyzing the FQ responses. A paired sample t-test was performed to determine the confidence levels (before and after intervention) of primiparous mothers across domains of communication skills, feeding-swallowing skills and general newborn health. Chi-square tests were carried out to determine the relationship between the demographics of the primiparous mothers and their confidence levels under each domain (communication skills, feeding -swallowing skills and general newborn health).

Comparison of confidence levels of primiparous mothers following administration of the N-CHFSEP

Table 2 represents the results of a paired sample t-test conducted to compare the effect of N-CHFSEP on confidence levels of primiparous mothers.

Effect of age, education, family type, and occupation on the confidence levels reported by primiparous mothers before and after the administration of the N-CHFSEP

The chi-square correlation values between age, education, family type, and occupation towards the total pre-post-test measures of communication skills, feeding-swallowing skills and general infant health are represented in Table 3.

Concerns of primiparous mothers towards newborn health and development

Following the administration of the AQ (pre-test), a variety of responses were obtained from primiparous mothers through open-ended questions pertaining to concerns on newborn care and development as well as their perceived importance of communication with the newborn. Figure 5 represents the identified concerns of primiparous mothers about newborn development.

Figure 5. Concerns of primiparous mothers on newborn health and development.

Perspectives of primiparous mothers towards the importance of communication skills during infant development

A certain proportion of primiparous mothers (5%) reported that communication with their infants will (1) obtain better responses from the newborn, (2) facilitate in general and intellectual development of the newborn, (3) develop social skills, (4) encourage play behaviours in newborns, and (5) improve mother-child bonding. However, a few mothers (2%) reported that communication with their newborns may not necessarily be important in the early years but becomes crucial only when the child becomes older. Additionally, some mothers (3%) reported to be unaware of the importance of communication with the newborn.

Feedback of primiparous mothers towards the N-CHFSEP

The results of the FQ revealed 67%, 32% and 1% of primiparous mothers to strongly agree, agree, and neutrally agree respectively towards the effectiveness of the education program. Following the administration of the FQ, a variety of responses were gathered from the open-ended question (Item no. 6). Several mothers (50%) reported that N-CHFSEP benefitted them by (1) providing additional information on communication skills, (2) offering a comprehensive view on the timelines of the developmental process, (3) emphasizing the importance of hearing, (4) addressing feeding concerns, and (5) providing insights into the newborn health. In addition, the programme was effective in (6) establishing the common disbelief that typically male children may verbally communicate much later than female children, and (7) understanding the behaviours to be observed during their newborn development. Others expressed a need for specific details pertaining to (8) fever management, (9) troubleshooting lactation failure and its effect on the baby, (10) details on avoidance of the type of feeds for the infant, and (11) developmental aspects beyond 6 months were reported by 8%, 15%, 5%, and 5% of the mothers respectively.

Newborn communication skills

Considering the questions (in AQ) pertaining to communication skills, 89 (for Item 1) and 84 (for Item 2) primiparous mothers reported having a pre-existing understanding (pre-AQ administration) of these skills, attributing this to their exposure to a variety of informational sources (educational programs, books, social media platforms, etc.) which may have helped them prepare well in advance for judging their newborn communication skills. Australian researchers reported variability in the knowledge of primiparous mothers on early communication development to often rely on friends and social media for information, which was mostly unfortunately deemed unreliable according to maternal reports (Williams et al., 2014). Catering to the perspectives of primiparous mothers towards the importance of communication skills in the current study, it was reported that communication with newborns helps them to obtain responses, facilitating in general and intellectual development of their newborn, developing social skills, encouraging play behaviours, and improving mother-child bonding. However, a few mothers reported that communication with their newborns may not necessarily be important in the early years but becomes crucial only when the child becomes older. Additionally, some mothers reported to be unaware of the importance of communication with the newborn. As per the concerns obtained (AQ-Item 18) from the participants of the current study, certain mothers reported to incorrectly estimate the developmental milestones in newborns which was in line with reports (Huang et al., 2005). Several mothers also reported a lack of communication between healthcare professionals regarding newborn language development (Suskind et al., 2018). However, the evident increase in the confidence levels (p<0.05) of the primiparous mothers in identifying the newborn communication skills in the current study (AQ-Item 1 and 2), can be attributed to the increased awareness these mothers would have received by the N-CHFSEP. As per the N-CHFSEP, the domains specified pertaining to communication development tapped upon milestones including the presence of a social smile, recognition of the mother, patterns of vocalization and babbling and communicative behaviours. The provision of such information may have imparted new knowledge on their newborn communication behaviours leading to increased confidence levels (p <0.05) as reported in Table 2. A randomized control trial done to study the effectiveness of educating parents on infant language development, parents were found to have enhanced knowledge about early language environments and caregiver responsiveness using a newborn program, in conjugation with a newborn hearing screening program (Suskind et al., 2018).

Ninety-two mothers reported a heightened increase in the confidence levels in identifying their newborns hearing abilities (AQ-Item 3) prior to the education program. This could be attributed to their awareness of the existing policies and implementation of newborn hearing screening programs available in Indian hospitals (Jatto et al., 2018) (including the one in which the participants of the current study were admitted for delivery). Following the N-CHFSEP delivery to the participants of the current study, an increase in their confidence levels (p <0.05) for Item 3 was observed. The N-CHFSEP items pertaining to this aspect (on hearing loss) were directed to the knowledge and understanding of the timeline when their baby would ‘appear to listen and pay attention to sounds’, ‘localization of the speaker’, and ‘recognizing and responding to their name call’. An increase in the early detection of hearing loss with a corresponding improvement in language skills, behaviours, and the quality of life of infants due to universal newborn hearing programs has been reported (Edmond et al., 2022).

Newborn feeding-swallowing skills

Considering the questions (in AQ) pertaining to feeding-swallowing skills, 89 (for Item 4) and 93 (for Item 12) primiparous mothers reported having a pre-existing understanding (pre-AQ administration) of these skills. This may be attributed to various factors such as (1) their personal experiences in observing feeding newborns within the family circle, (2) mothers prior to delivery may have self-educated themselves about feeding skills from other support networks, and (3) the availability of lactation counsellors in hospitals offering mothers with practical assistance and opportunity to discuss feeding related concerns during the hospital stay. This aligns with previous findings in India, which reported 40% of the mothers to have received antenatal education on breastfeeding practices, while 61% were educated by family and friends (Sultania et al., 2019). The study also reported that most mothers had good knowledge about breastfeeding and the nutritional advantages of the same, while only 45% of the mothers practiced the knowledge they gained through these sources. As per the concerns obtained (AQ-Item 18) from the participants of the current study (as indicated in Figure 5), certain mothers reported concerns about breastfeeding knowledge and support. These included concerns towards deciding the feeding position, feeding duration, feeding schedule, feeding precautions, post-feeding management, aspiration management, and the type of feeds. The evident increase in the confidence levels (p<0.05) of the primiparous mothers (in the current study) in identifying newborn feeding schedules and understanding of exclusive breastfeeding for six months (AQ-Item 4 and 12), can be attributed to the adequate information provided in N-CHFSEP such as ‘exclusive breastfeeding’, ‘burping’, ‘feeding duration’ and ‘schedule’, and ‘awareness on the usage of formula feeds’. This provision of information likely complemented their existing knowledge of newborn feeding and swallowing skills. Moreover, practical demonstrations by lactation counsellors further reinforce their understanding, contributing to an increase in their confidence levels as reported in Table 2. This finding is consistent with the findings of a systematic review done on the effectiveness of educational programs related to breastfeeding and supportive programs for primiparous mothers. The studies reported the mothers to have increased breastfeeding knowledge and self-efficacy, thereby increasing the frequency of breastfeeding (Wong et al., 2021).

Newborn general health

Considering the questions (in AQ) pertaining to newborn health (AQ-Items 10, 11, 13 and 14), primiparous mothers reported having a pre-existing understanding (pre-AQ administration) of these skills. This may be attributed to the information provided on newborn hygiene and health status by the health professionals during their follow-up visits during the post-pregnancy/natal period. These heightened confidence levels may also be attributed to the significant role played by caregivers demonstrating and providing practical training on newborn care skills and the availability of educational cards such as Mother Child Protection Cards helping mothers to track newborn development, immunization schedules, and its importance. These findings were reaffirmed in another South India study, where 99.5 % of first-time mothers were aware of the importance of immunization for their children from various sources (Kumar et al., 2015). Some concerns expressed by the participants of the current study (AQ-Item 18), were regarding their child’s future education, selection of high-quality products to ensure child safety, precautions towards general health, weight gain, and bathing care. Following the N-CHFSEP delivery to the participants of the current study, an increase in their confidence levels (p <0.05) for Items 10,11, 13 and 14 was pertaining to newborn health observed in the mothers. This could be attributed to the N-CHFSEP which included adequate information on identifying the appropriate vitamin supplements, newborn hygiene practices, and post-immunization effects. Though the mothers were confident and aware of these aspects for their newborns, the N-CHFSEP supplemented their knowledge by providing comprehensive information on the administration timeline and schedules on the same. This aligns with previous research indicating the effectiveness of flipchart-assisted maternal education in improving breastfeeding practices, hygiene skills, and temperature maintenance in newborns after the educational intervention (Eluri et al., 2022). Considering the mothers confidence levels in independently identifying developmental milestones and precautions towards hypothermia (AQ-Items 15 and 16), there was an increase in the number of mothers (91 and 92 mothers respectively) exhibiting heightened confidence levels following the N-CHFSEP delivery, compared to AQ-Items 10, 11, 13 and 14. This could be attributed to the N-CHFSEP, which provided adequate information offered in the child-rearing practices such as monthly milestones, and suggestions to prevent hypothermia. In contrast to many educational programs that do not emphasize comprehensive monthly milestones, especially those that are not verbally presented to these mothers, the N-CHFSEP (in the current study) was provided via a one-to-one educational session, which was advocated by previous research as well (Khresheh et al., 2011). The findings of the current study were consistent with a previous study done in the USA, where the researchers found a higher score in newborn care knowledge and maternal confidence after the provision of a newborn class program (Gozali et al., 2020).

Warning signs

There was an increase in the mother’s confidence levels post N-CHFSEP delivery in independently identifying the warning signs (AQ-Items 5 and 7) during the infant’s communication development. This may be attributed to the aspects of N-CHFSEP which included warning signs on ‘social smile’, ‘types of child response’, ‘attentional skills’, and ‘patterns of vocalizations’ along with the corresponding timelines, thereby helping them identify potential issues in newborn development. Previous studies have proclaimed a potential lack of awareness among caregivers on implementing communication strategies (Skeat et al., 2010). The N-CHFSEP provided mothers with strategies to be used at home to increase communication skills in newborns, thereby increasing their confidence levels. Considering the questions (in AQ) pertaining to the warning signs (AQ-Items 8 and 9) in feeding-swallowing skills, there was a decrease in the number of mothers (77 and 81) reporting to be confident (before N-CHFSEP) compared to items 4 and 12 (89 and 93). This decrease may be attributed to various factors such as lack of previous experiences in newborn care, fear of misinterpretation of potential warning signals, increased stress levels during the early motherhood period, limited access to antenatal and postnatal services, and information overload during the post-pregnancy period. These factors may have led mothers to a state of confusion, making it difficult to distinguish and retain essential information related to newborn care feeding skills. This contradicts to the findings of an earlier study conducted in Punjab which reported 49.6% of urban mothers to have a good knowledge of newborn danger signs (Singh et al., 2021). The current study mothers were provided with adequate information on neonatal danger signs such as ‘struggling to swallow’, ‘feeds coming out of the baby’s nose immediately after being fed’, ‘vomiting of a large amount of feeds’, ‘coughing immediately after feeds’, ‘baby appearing dull and unable to take feeds’, and ‘forehead sweating immediately after feeds’. This was in line with a previous South Indian study, which included newborn feeding and health danger signs (Thomas & Devi, 2020). The study demonstrated the effectiveness of a structured teaching program in improving the knowledge of postnatal mothers on newborn danger signs including those related to feeding and newborn health.

Factors influencing mother’s confidence levels

The factors influencing the confidence levels of primiparous mothers (in the current study) could be attributed to the timing of intervention (provided second day of post-delivery), the expertise and the training provided by the health care professionals (SLP and Paediatrician), and the structure of the provided education program (monthly milestones, suggestions and danger signs), all of which being reiterated in previous studies (Ben-Sasson et al., 2022). Most participants in the current study were recruited from Government Lady Goschen Hospital, Mangalore which is exclusive for maternity care, encompassing a team of health care professionals from various disciplines. Studies have emphasized the significance of healthcare professionals as the primary source of information when queried about the benefits of postpartum educational programs (Gozali et al., 2020). Additionally, the hospital (in the current study) offered several instructional resources in Kannada and English such as public awareness posters on early newborn care skills and Mother Child Protection cards supplementing their confidence levels.

The age, education, occupation, and family type of the participants (in the current study) had a significant effect (p<0.05) on the confidence levels pre and post N-CHFSEP administration. The maternal age (18-25 and 26-35 years) presented an effect (p <0.05) on the confidence levels in communication skills, feeding-swallowing skills, and newborn health as reported in Table 3. The higher confidence levels observed among both young and older mothers could be attributed to their inclination to use social media and mobile applications (Ben-Sasson et al., 2022), which are generally free and readily available sources of information about newborn care. Such applications enable mothers to get information on monthly milestones, paediatric weight gain, vaccination charts, reminders on health checkup days, etc. Access to such information could contribute to increased confidence levels in managing various domains of communication skills, feeding-swallowing skills, and newborn health. Applications such as the Baby Buddy App provided easily accessible and reliable pregnancy information aiding first time mothers to effectively communicate with healthcare professionals (Bailey et al., 2022).

Maternal education levels presented a significant effect (p <0.05) on the confidence levels pre and post N-CHFSEP administration as reported in Table 3. The higher educational levels (Degree, <=10^th Std, <=12^th Std) were observed to have an effect (p <0.05) on the confidence levels of newborn communication skills and general health whereas the lower education level (<=10^th standard) specifically presented a significant effect (p <0.05) on the confidence levels in feeding-swallowing skills. This could be attributed to a deeper understanding of newborn care among highly educated mothers because of their formal education and exposure to various informational resources. Researchers found mothers with no formal education to score less than those who had higher education (Memon et al., 2019). Higher levels of education may cause an urge among these mothers to obtain evidence-based resources from reliable websites and scientific journals. This inclination may prompt them to seek clarification from qualified healthcare professionals when needed.

According to the results reported in Table 3, a significant effect (p <0.05) on maternal confidence levels on overall newborn care and development was observed among those who belonged to a joint and a nuclear family type. With a joint family structure generally comprising grandparents (experienced caregivers) or extended families, it becomes natural for first-time mothers to absorb traditional methods of newborn care along with practical demonstrations, thereby boosting their confidence levels. Regular interaction and discussions by these caregivers provide mothers with practical suggestions and solutions in various aspects of newborn care. The joint family type facilitates obtaining collective information on effective parenting strategies and decision-making during certain newborn practices such as feeding, hygiene practices, and newborn health practices, reassuring the first-time mothers in the process. Surprisingly, first time mothers from nuclear families, undertake greater responsibilities towards newborn care even without the presence of extended family members. These mothers get trained themselves to become competent in newborn care practices. The provision of N-CHFSEP in the current study may have addressed these maternal concerns by equipping them with monthly milestones, newborn care suggestions, and monthly warning signs, thereby causing a positive effect on their confidence levels.

Maternal occupations such as homemakers and others (government and private officials) were found to have a significant effect (p<0.05) on the confidence levels towards communication and feeding-swallowing skills as reported in Table 3. However studies have not found any significant association between mothers’ occupation and newborn care (Memon et al., 2019; Tegene et al., 2015). Homemakers generally get opportunities to engage in interactions with their newborns thereby fostering newborn language development and communication skills. Their consistent presence at home provides opportunities for monitoring newborn care and interventions when required. Although being a homemaker is highly advantageous, there do exist challenges such as feeling isolated, lacking professional advice, and feeling financial constraints, making them less confident in newborn practice in the process. Access to resources such as government-sponsored healthcare programs or childcare services, could positively impact their ability to prioritize development of feeding skills. The provision of N-CHFSEP might have complemented and enhanced the caregiving practices of both homemakers and government officials.

The path forward

With the implementation of N-CHFSEP in the current study, the primiparous mothers received a comprehensive education on various aspects of newborn skill development. The observed increase in confidence levels following N-CHFSEP suggested the program to effectively complement the mother’s knowledge and understanding, thereby contributing to improved confidence and awareness regarding newborn care. This understanding is crucial for the implementation of comprehensive educational interventions addressing the specific needs of primiparous mothers as it may lead to enhanced maternal and infant health outcomes. As per the obtained feedback (FQ-Item 6) from the current study participants, the N-CHFSEP provided mothers with additional information in various aspects regarding communication skills, emphasizing the importance of hearing, and corrected misconceptions. Studies have found feedback of educational programs to have positive outcomes such as encouraging mothers to interact and read with their infants in a responsive manner. These mothers reported being willing to recommend the education program to others and apply the knowledge with their newborns at home (Suskind et al., 2018). A study on the NewBorn Class program reported that it benefitted approximately 58% of the mothers by providing comprehensive knowledge for first-time mothers, and providing information on medical topics such as feeding, diaper rash, and developmental skills (Gozali et al., 2020). A total of 38 (39%) mothers provided a feedback on the N-CHFSEP program. Although certain mothers claimed to be already aware of the developmental expectations of the newborn (from the MCP card they received from the hospital), others demanded additional information on fever management, troubleshooting lactation failure and its effect on the baby, details on avoidance of the type of feeds for the infant, and developmental aspects up to 1 year of infant’s age (for which they were willing to have an additional consultation post 6 months). Although some mothers reported to lack the awareness of monthly milestones and felt boys spoke later than girls, many admitted they now know the importance of communication and hearing. Furthermore, some mothers highlighted the need for hands-on application of the information provided, thereby suggesting N-CHFSEP to be supplemented with practical demonstrations to enhance their confidence levels. Although the developed N-CHFSEP showed a significant positive change (pre and post-administration) in the attitude levels of the mothers, having a control group (mothers without receiving the intervention program) and comparing them to an experimental group (mothers receiving the intervention program) would have increased the validity of the tool. The current study findings cannot be generalized to multiparous mothers and mothers from diverse cultural or family backgrounds. Furthermore, the effectiveness of N-CHFSEP was determined immediately after the administration, leaving uncertainty about information retention up to 6 months post-intervention. The N-CHFSEP included information on neonatal care from only two disciplines (SLP and Pediatrics), suggesting the possible inclusion of additional members (such as fathers, grandparents, lactation counsellors, psychologists, Accredited Social Health Activist workers, nurses, etc.) to provide a more comprehensive understanding of various aspects of newborn health and development. Since the current work is a preliminary study, it would therefore be interesting if future studies would consider controlling the above-mentioned factors (and feedback from mothers) with a larger sample size to further derive a highly valid educational program.