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Neonatal mortality is the major contributor to under-five mortality rates in many low and middle income countries. We examined the health practices, care-seeking behavior, and referral of sick outborn neonates to a district and regional hospital in the Upper West Region of Ghana. The study was a cross-sectional study conducted over an eight (8) month period in 2018. Data were obtained from caregiver interviews and case notes. Altogether, 153 outborn neonates were examined. Inappropriate practices including the use of enemas, cord care with cow dung, and herbal baths were found. Three babies treated this way died. The majority of caregivers sought care at a health facility. However, 67 (44%) sought care only after their babies were ill for ≥7 days, suggesting the influence of a period of confinement on health seeking. More than half, 94 (61.4%), of the facilities visited referred patients to destination hospitals without giving any treatment. Delayed care-seeking was associated with a low birth weight, using home remedies, and a maternal age of ≥30 years. Altogether, 12 neonates (7.8%) died, consisting of three males and nine females (p = 0.018). Socio-cultural factors strongly influence health seeking behavior and the health outcome of neonates in this setting. There appeared to be a limited repertoire of interventions for treating neonatal disease in primary care.
The study was carried out at the Upper West Regional Hospital (UWRH) and St. Joseph’s Hospital (SJH). The Upper West Regional Hospital doubles as a municipal and regional hospital of people living in the Upper West Region of Ghana. It serves as the main referral center for the region and surrounding towns in the Northern, Upper East Region, and Burkina Faso, which shares a border with the region on its northern side. At the end of 2016, it had nine wards and a bed capacity of 200 beds, including a neonatal unit which was created between August and December 2016. Altogether, 248 neonates were admitted with 39 deaths in the same period. There are no intensive care services. The number of deliveries at the UWRH in 2016 was 4915. St. Joseph’s Hospital in Jirapa functions as the district hospital for the people of Jirapa. It is one of the hospitals belonging to the Christian Health Association of Ghana (CHAG). The hospital had a bed capacity of 193 beds in early 2017 distributed over seven (7) wards. In 2016, the total deliveries were 1709. Until 2018 when a neonatal unit was created at the UWRH, it was the main referral center for neonatal conditions in the region. Patients from surrounding health centers, Community-Based Health Planning and Services (CHPS), compounds, and some of the district hospitals in the region were referred to the hospital. The UWRH and the St. Joseph’s Hospital are about 64.07 km apart. Figure 1 below shows the study area, towns, and health facilities. In addition, distance and access to transportation considerations influencing the choice of which referral center to go, and other factors, such as patient beliefs, past experience of family and friends, as well as the size and cadre of staff at the referral facilities, may help inform a patient to choose to which facility to send their neonate. Health facilities attended, St. Joseph’s Hospital and Upper West Regional Hospital, in Wa, Ghana. The study was a descriptive cross-sectional study which examined the profile, health seeking behavior, and outcome of outborn neonates admitted to the Upper West Regional Hospital (UWRH) and St. Joseph’s Hospital (SJH) over an eight (8) month period from 23 January to 16 October 2018. The health seeking behavior of caregivers of neonates, the referral system, and sources of delay were determined. Parents or caregivers of all the 153 consecutive outborn neonates admitted over the study period were interviewed. Although the study collected data over an eight (8) month period from 23 January to 16 October 2018, the last outborn neonate from SJH was admitted in June 2019 resulting in the low numbers of outborn neonate from SJH. These estimates were calculated from the 2016–2017 total deliveries, neonatal admissions, and proportion of admitted neonates that were outborn in the study facilities. Outborn neonates were defined as neonates born outside the Upper West Regional Hospital (UWRH) or St. Joseph’s Hospital (SJH) and admitted to these hospitals during the study period. The estimated sample size of patients recruited for the maternal interviews was based on the assumptions that 15–20% of newborns required admission, and of these, approximately 25–60% were outborn babies. Thus, outborns will form around 10% of all newborns. Therefore, for a confidence interval of 95% and allowable error of 5%, the minimum sample size was calculated to be 138 patients. Thus, we aimed at obtaining 150 outborn caregiver interviews. Caregivers of newborns admitted to the neonatal unit who delivered outside the hospital in 2018 during the study period from 23 January to 16 October 2018 were eligible for this part of the study. Those who were unavailable to provide accurate information on the referral process or unable to provide consent were excluded from the study. Data on parental health seeking behavior and the referral process were collected by administering questionnaires to caregivers and reviewing the child’s case notes. This data included information on the place the child was referred from, the health facilities visited, reasons for the choice of facility, treatments given at home and at the health facility visited, and sources of delay. Data on the duration of travel and the condition of the neonate on arrival at UWRH and SJH have been presented elsewhere. Demographic, clinical features, and social factors, such as age, sex, presenting features, diagnosis and outcome of the neonate, were also obtained. The information was obtained by trained nurses who worked in the hospitals. Some lived in the districts and could speak the dialects. The data were captured and analyzed using the Statistical Package for Social Sciences (SPSS) version 16.0 and cleaned by using standardized queries to conduct range and logic checks. Discrepant entries were identified and corrected. Frequencies, proportions, and means of study variables were computed and presented in tabular and graphical form. Comparisons and statistical inference were made using the Chi square test to assess risk factors, and the t-test was used to assess the degree of statistical significance when comparing means. Statistical significance was accepted at a 5% probability level, that is, a p-value of less than 0.05. Logistic regression was used to determine factors independently associated with delay in seeking health care for sick neonates. Caregivers were considered to have delayed care-seeking if they report to the neonatal unit after 24 h of onset of symptoms. Ethical clearance to perform this study was obtained from the Ghana Health Service Ethical Review Committee (Ethical Review Committee Protocol ID No: GHS-ERC 09/03/17). Consent was obtained before the questionnaires were administered. Permission was obtained from the facilities involved. The data were anonymized in order to not reveal patients’ identities, and the analysis was conducted in a way that the final results cannot be linked to individual patients.
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