High incidence of neonatal danger signs and its implications for postnatal care in Ghana: A cross-sectional study

PLoS ONE, Volume 10, No. 6, Year 2015

Interpretation

Background: Reducing neonatal mortality is a major public health priority in sub-Saharan Africa. Numerous studies have examined the determinants of neonatal mortality, but few have explored neonatal danger signs which potentially cause morbidity. This study assessed danger signs observed in neonates at birth, determined the correlations of multiple danger signs and complications between neonates and their mothers, and identified factors associated with neonatal danger signs. Methods: A cross-sectional study was conducted in three sites across Ghana between July and September in 2013. Using two-stage random sampling, we recruited 1,500 pairs of neonates and their mothers who had given birth within the preceding two years. We collected data on their socio-demographic characteristics, utilization of maternal and neonatal health services, and experiences with neonatal danger signs and maternal complications. We calculated the correlations of multiple danger signs and complications between neonates and their mothers, and performed multiple logistic regression analysis to identify factors associated with neonatal danger signs. Results: More than 25% of the neonates were born with danger signs. At-birth danger signs in neonates were correlated with maternal delivery complications (r = 0.20, p < 0.001), and neonatal complications within the first six weeks of life (r = 0.19, p < 0.001). However, only 29.1% of neonates with danger signs received postnatal care in the first two days, and 52.4% at two weeks of life. In addition to maternal complications during delivery, maternal age less than 20 years, maternal education level lower than secondary school, and fewer than four antenatal care visits significantly predicted neonatal danger signs. Conclusions: Over a quarter of neonates are born with danger signs. Maternal factors can be used to predict neonatal health condition at birth. Management of maternal health and close medical attention to high-risk neonates are crucial to reduce neonatal morbidity in Ghana. This cross sectional study was conducted as part of a situational analysis of the Ghana Ensure Mothers and Babies Regular Access to Care (EMBRACE) Implementation Research Project [21], a collaboration between the Ghana Health Service (GHS), the University of Tokyo, and the Japan International Cooperation Agency (JICA). GHS oversees three Health Research Centres (HRC) located in the three different eco-epidemiological zones of the country: Navrongo HRC in the Upper East region; Kintampo HRC in the Brong-Ahafo region; and Dodowa HRC in the Greater Accra region. Each of the HRCs runs a Health Demographic Surveillance System (HDSS) covering a total of six districts, which were examined in this study. The HDSS collects data from whole communities over time, monitors new health threats, tracks population changes, and assesses policy interventions. This study recruited 1,500 pairs of women and their neonates through the HDSS databases of the three HRCs. Two-stage random sampling was subsequently conducted to select 500 eligible pairs of women and their neonates from each HRC site. The target women were all aged between 15 and 49 years, had a resident membership at the study sites on the date of the survey, and got pregnant and delivered a live or stillborn baby between January 2011 and April 2013. If a woman got pregnant and delivered twice or more between January 2011 and April 2013, information pertaining to the most recent pregnancy was used. If a woman had a multiple birth, one child was randomly selected for the interviews. Of the 16 women who had delivered twins, six provided data for both neonates; thus, we randomly selected and excluded data from one of the neonates, as well as the duplicated maternal data (n = 6). Data from the mother-neonate pairs were also excluded from the dataset due to missing key data (n = 3) and miscarriage (n = 1). Thus, data from a total of 1,490 pairs of women and their neonates were used for the analysis, including 13 stillbirths and 15 neonatal deaths within six weeks postpartum. During the data collection period, trained interviewers visited the homes of the selected women and conducted face-to-face interviews. Using structured questionnaires, the women were asked about their socio-demographic characteristics; utilization of antenatal care (ANC), delivery care, postnatal care (PNC), and medical care; complications that they experienced from the latest pregnancy up until six weeks postpartum; and the danger signs and complications that their neonates showed at birth and within the first six weeks. To ensure validity of the data on the utilization of health and medical care, and history of complications and danger signs, the interviewers asked these questions without prompt, followed by with-prompt, and they were cross-checked with maternal health record book. In addition, the HDSS database was used to acquire information on household assets. Potential determinants of neonatal danger signs were categorized into four domains: 1) maternal factors, 2) family factors, 3) antenatal factors, and 4) delivery factors based on the conceptual frameworks of Kayode [6] and Mosley [22]. Maternal factors included age, educational level, marital status, and parity. Family factors included wealth quintile rank, ownership of a valid national health insurance card, family support, and means of transportation to access an ANC clinic. Wealth quintiles were established via principal component analysis based on the ownership of the following household asset items: electricity, source of cooking fuel, toilet facility, sewing machine, radio, television, cooking device, fridge, motorbike, car, and mobile phone. Family support was assessed based on four items that would likely affect a woman’s decision to take her sick neonate to a health facility: financial resources to pay for care, a caretaker for other children, a companion to accompany the woman and her neonate to a health facility, and encouragement from family members to visit a health facility. Antenatal factors included the total number of antenatal clinic visits and the reception of the following essential antenatal care services: education on complications, nutrition and family planning, tetanus toxoid immunization, intermittent preventive treatment for malaria, and HIV testing. Delivery factors included health complications experienced during delivery and place of delivery. Neonatal danger signs at birth were measured through maternal recall and review of the maternal health record books. The assessed danger signs included cold body, very small size, inability to suck, not crying, fever, difficulty in breathing, preterm birth, and bleeding [23]. Descriptive analyses were performed to examine background characteristics of the women and their neonates, incidence of maternal complications, incidence of danger signs and complications among neonates, and utilization of PNC and health facility visit for treatment. Pearson’s correlation coefficients were calculated to assess the correlations between number of danger signs and complications that women and their neonates had during different periods (i.e. pregnancy, delivery, and postnatal periods). A multiple logistic regression analysis was performed to identify factors associated with neonatal danger signs at birth. In this model, the cluster robust estimate of variance was used to allow within-cluster correlations at the sub-district level. Ethical approval was obtained from the Research Ethics Committee of the Graduate School of Medicine, the University of Tokyo, the Ethics Review Committee of Ghana Health Service, the Institutional Review Board of Navrongo Health Research Centre, the Institutional Ethics Committee of Kintampo Health Research Centre, and the Institutional Review Board of Dodowa Health Research Centre. These ethical oversight bodies approved the following procedure of informed consent. Written informed consent was obtained from all participants before the start of the interviews. If an eligible participant was between 15 and 17 years of age, written informed consent was obtained from their parents for study participation in advance. Participant confidentiality was strictly enforced.

AI Digest

Study Justification:

– Reducing neonatal mortality is a major public health priority in sub-Saharan Africa.
– Previous studies have focused on determinants of neonatal mortality, but few have explored neonatal danger signs that can cause morbidity.
– This study aims to assess danger signs observed in neonates at birth, determine correlations between danger signs and complications, and identify factors associated with neonatal danger signs.

Study Highlights:

– More than 25% of neonates in Ghana are born with danger signs.
– Danger signs in neonates at birth are correlated with maternal delivery complications and neonatal complications within the first six weeks of life.
– Only 29.1% of neonates with danger signs received postnatal care in the first two days, and 52.4% at two weeks of life.
– Maternal age, education level, and antenatal care visits are factors associated with neonatal danger signs.

Study Recommendations:

– Management of maternal health is crucial to reduce neonatal morbidity.
– Close medical attention to high-risk neonates is necessary.
– Increase access to postnatal care for neonates with danger signs.
– Improve antenatal care services, particularly for younger mothers and those with lower education levels.

Key Role Players:

– Ghana Health Service (GHS)
– University of Tokyo
– Japan International Cooperation Agency (JICA)
– Health Research Centres (HRC) in Navrongo, Kintampo, and Dodowa
– Research Ethics Committee of the Graduate School of Medicine, University of Tokyo
– Ethics Review Committee of Ghana Health Service
– Institutional Review Board of Navrongo Health Research Centre
– Institutional Ethics Committee of Kintampo Health Research Centre
– Institutional Review Board of Dodowa Health Research Centre

Cost Items for Planning Recommendations:

– Training and capacity building for healthcare providers
– Infrastructure and equipment for maternal and neonatal care
– Outreach and awareness campaigns for postnatal care
– Monitoring and evaluation of interventions
– Data collection and analysis
– Collaboration and coordination between stakeholders

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is rated 7 because it provides detailed information about the study design, data collection methods, and analysis. However, it does not mention the specific statistical tests used to calculate correlations and perform logistic regression analysis. To improve the evidence, the abstract could include the specific statistical tests used and provide more information about the sample size and representativeness of the study population.

Abstract

This cross sectional study was conducted as part of a situational analysis of the Ghana Ensure Mothers and Babies Regular Access to Care (EMBRACE) Implementation Research Project [21], a collaboration between the Ghana Health Service (GHS), the University of Tokyo, and the Japan International Cooperation Agency (JICA). GHS oversees three Health Research Centres (HRC) located in the three different eco-epidemiological zones of the country: Navrongo HRC in the Upper East region; Kintampo HRC in the Brong-Ahafo region; and Dodowa HRC in the Greater Accra region. Each of the HRCs runs a Health Demographic Surveillance System (HDSS) covering a total of six districts, which were examined in this study. The HDSS collects data from whole communities over time, monitors new health threats, tracks population changes, and assesses policy interventions. This study recruited 1,500 pairs of women and their neonates through the HDSS databases of the three HRCs. Two-stage random sampling was subsequently conducted to select 500 eligible pairs of women and their neonates from each HRC site. The target women were all aged between 15 and 49 years, had a resident membership at the study sites on the date of the survey, and got pregnant and delivered a live or stillborn baby between January 2011 and April 2013. If a woman got pregnant and delivered twice or more between January 2011 and April 2013, information pertaining to the most recent pregnancy was used. If a woman had a multiple birth, one child was randomly selected for the interviews. Of the 16 women who had delivered twins, six provided data for both neonates; thus, we randomly selected and excluded data from one of the neonates, as well as the duplicated maternal data (n = 6). Data from the mother-neonate pairs were also excluded from the dataset due to missing key data (n = 3) and miscarriage (n = 1). Thus, data from a total of 1,490 pairs of women and their neonates were used for the analysis, including 13 stillbirths and 15 neonatal deaths within six weeks postpartum. During the data collection period, trained interviewers visited the homes of the selected women and conducted face-to-face interviews. Using structured questionnaires, the women were asked about their socio-demographic characteristics; utilization of antenatal care (ANC), delivery care, postnatal care (PNC), and medical care; complications that they experienced from the latest pregnancy up until six weeks postpartum; and the danger signs and complications that their neonates showed at birth and within the first six weeks. To ensure validity of the data on the utilization of health and medical care, and history of complications and danger signs, the interviewers asked these questions without prompt, followed by with-prompt, and they were cross-checked with maternal health record book. In addition, the HDSS database was used to acquire information on household assets. Potential determinants of neonatal danger signs were categorized into four domains: 1) maternal factors, 2) family factors, 3) antenatal factors, and 4) delivery factors based on the conceptual frameworks of Kayode [6] and Mosley [22]. Maternal factors included age, educational level, marital status, and parity. Family factors included wealth quintile rank, ownership of a valid national health insurance card, family support, and means of transportation to access an ANC clinic. Wealth quintiles were established via principal component analysis based on the ownership of the following household asset items: electricity, source of cooking fuel, toilet facility, sewing machine, radio, television, cooking device, fridge, motorbike, car, and mobile phone. Family support was assessed based on four items that would likely affect a woman’s decision to take her sick neonate to a health facility: financial resources to pay for care, a caretaker for other children, a companion to accompany the woman and her neonate to a health facility, and encouragement from family members to visit a health facility. Antenatal factors included the total number of antenatal clinic visits and the reception of the following essential antenatal care services: education on complications, nutrition and family planning, tetanus toxoid immunization, intermittent preventive treatment for malaria, and HIV testing. Delivery factors included health complications experienced during delivery and place of delivery. Neonatal danger signs at birth were measured through maternal recall and review of the maternal health record books. The assessed danger signs included cold body, very small size, inability to suck, not crying, fever, difficulty in breathing, preterm birth, and bleeding [23]. Descriptive analyses were performed to examine background characteristics of the women and their neonates, incidence of maternal complications, incidence of danger signs and complications among neonates, and utilization of PNC and health facility visit for treatment. Pearson’s correlation coefficients were calculated to assess the correlations between number of danger signs and complications that women and their neonates had during different periods (i.e. pregnancy, delivery, and postnatal periods). A multiple logistic regression analysis was performed to identify factors associated with neonatal danger signs at birth. In this model, the cluster robust estimate of variance was used to allow within-cluster correlations at the sub-district level. Ethical approval was obtained from the Research Ethics Committee of the Graduate School of Medicine, the University of Tokyo, the Ethics Review Committee of Ghana Health Service, the Institutional Review Board of Navrongo Health Research Centre, the Institutional Ethics Committee of Kintampo Health Research Centre, and the Institutional Review Board of Dodowa Health Research Centre. These ethical oversight bodies approved the following procedure of informed consent. Written informed consent was obtained from all participants before the start of the interviews. If an eligible participant was between 15 and 17 years of age, written informed consent was obtained from their parents for study participation in advance. Participant confidentiality was strictly enforced.

Materials

N/A

Innovations

Based on the information provided, here are some potential innovations that could be recommended to improve access to maternal health:

1. Mobile health (mHealth) interventions: Develop and implement mobile phone-based applications or text messaging services to provide pregnant women and new mothers with information and reminders about antenatal care, postnatal care, danger signs to watch out for, and available healthcare services.

2. Community health workers: Train and deploy community health workers to provide education, support, and basic healthcare services to pregnant women and new mothers in remote or underserved areas. These workers can help identify danger signs, provide referrals, and ensure follow-up care.

3. Telemedicine: Establish telemedicine networks to connect healthcare providers in urban areas with pregnant women and new mothers in rural or remote areas. This can enable remote consultations, diagnosis, and treatment, reducing the need for travel and improving access to specialized care.

4. Maternal health clinics: Set up dedicated maternal health clinics in areas with high maternal mortality rates. These clinics can provide comprehensive antenatal care, postnatal care, and emergency obstetric services, ensuring that women receive the care they need during pregnancy and childbirth.

5. Financial incentives: Implement financial incentives, such as conditional cash transfers or vouchers, to encourage pregnant women to seek antenatal care, deliver in healthcare facilities, and attend postnatal care visits. This can help overcome financial barriers and improve access to essential maternal health services.

6. Strengthening referral systems: Improve the coordination and effectiveness of referral systems between primary healthcare facilities and higher-level facilities. This can ensure that pregnant women with complications are promptly referred to appropriate facilities for specialized care.

7. Quality improvement initiatives: Implement quality improvement initiatives in healthcare facilities to enhance the provision of maternal health services. This can include training healthcare providers, improving infrastructure and equipment, and implementing evidence-based protocols for maternal care.

8. Health education campaigns: Conduct targeted health education campaigns to raise awareness about the importance of antenatal care, postnatal care, and recognizing danger signs during pregnancy and childbirth. This can empower women and their families to seek timely and appropriate care.

It is important to note that the specific recommendations for improving access to maternal health should be tailored to the local context and healthcare system in Ghana.

AI Innovations Description

Based on the information provided, the recommendation to improve access to maternal health and reduce neonatal danger signs in Ghana is to focus on the following areas:

1. Strengthening postnatal care: The study found that a significant number of neonates with danger signs did not receive postnatal care in the first two days or at two weeks of life. Improving access to postnatal care services and ensuring that all neonates receive timely and appropriate care is crucial. This can be achieved by increasing awareness among mothers about the importance of postnatal care, providing training to healthcare providers on neonatal danger signs, and ensuring that postnatal care services are available and accessible to all women.

2. Enhancing maternal health management: The study found that maternal delivery complications were correlated with neonatal danger signs. Therefore, it is important to focus on improving maternal health management during delivery. This can be done by strengthening the capacity of healthcare providers to manage delivery complications, ensuring that all deliveries are attended by skilled birth attendants, and promoting the use of evidence-based practices during delivery.

3. Targeting high-risk neonates: The study identified several factors associated with neonatal danger signs, including maternal age less than 20 years, maternal education level lower than secondary school, and fewer than four antenatal care visits. Identifying high-risk neonates based on these factors and providing targeted interventions and support can help reduce neonatal morbidity. This can include providing additional antenatal care visits for high-risk mothers, offering educational programs for young mothers, and implementing strategies to improve access to education for women.

4. Strengthening the healthcare system: To effectively address the issue of neonatal danger signs and improve access to maternal health, it is important to strengthen the healthcare system as a whole. This can include improving infrastructure and equipment in healthcare facilities, ensuring an adequate supply of skilled healthcare providers, and implementing quality improvement initiatives to enhance the overall quality of care provided.

By implementing these recommendations, it is possible to improve access to maternal health and reduce neonatal danger signs in Ghana, ultimately leading to a reduction in neonatal morbidity and mortality.

AI Innovations Methodology

Based on the information provided, here are some potential recommendations to improve access to maternal health:

1. Strengthen postnatal care services: Increase the availability and accessibility of postnatal care services, particularly in the first two days and two weeks after birth. This can be done by improving the capacity of healthcare facilities, training healthcare providers, and raising awareness among mothers about the importance of postnatal care.

2. Enhance antenatal care utilization: Promote early and regular antenatal care visits, with a focus on reaching women who are younger, have lower education levels, and have fewer than four antenatal care visits. This can be achieved through community outreach programs, education campaigns, and removing barriers to accessing antenatal care services.

3. Improve maternal health management: Strengthen the management of maternal health during delivery, particularly for high-risk pregnancies. This can involve providing specialized care for women with complications, ensuring access to emergency obstetric services, and promoting skilled birth attendance.

4. Address socio-economic factors: Address socio-economic factors that contribute to poor maternal health outcomes, such as poverty, lack of education, and limited access to healthcare services. This can be done through targeted interventions that address these underlying determinants of health.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define indicators: Identify key indicators to measure access to maternal health, such as the percentage of women receiving postnatal care within the recommended timeframes, the number of antenatal care visits, and the incidence of maternal and neonatal danger signs.

2. Collect baseline data: Gather baseline data on the selected indicators from the target population. This can be done through surveys, interviews, or data collection from healthcare facilities and health records.

3. Implement interventions: Implement the recommended interventions, such as strengthening postnatal care services, enhancing antenatal care utilization, improving maternal health management, and addressing socio-economic factors. Ensure that these interventions are implemented consistently and monitored closely.

4. Monitor and evaluate: Continuously monitor the implementation of the interventions and collect data on the selected indicators. This can involve regular data collection, surveys, and interviews with healthcare providers and beneficiaries.

5. Analyze data: Analyze the collected data to assess the impact of the interventions on access to maternal health. Compare the baseline data with the post-intervention data to identify any changes or improvements.

6. Draw conclusions and make recommendations: Based on the analysis of the data, draw conclusions about the effectiveness of the interventions in improving access to maternal health. Identify any gaps or areas for improvement and make recommendations for further action.

7. Repeat the process: Continuously repeat the process to assess the long-term impact of the interventions and make adjustments as needed. This iterative approach allows for ongoing monitoring and improvement of access to maternal health services.

Author

Dima Health

Statistics:

Citations: 13

Identifiers:

DOI: 10.1371/journal.pone.0130712

Research Areas:

Community Interventions, Environmental, Food Security, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Countries:

Ghana

Study Design:

Cohort Study, Cross Sectional Study, Grounded Theory

Study Approach:

Quantitative

Participants Gender:

Female