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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.
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