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Mothers’ perception of neonatal jaundice in Lagos,

Nigeria: An urgent need for greater awareness
V C Ezeaka, MBBS, MPH, FWACP (Paed); E N Ekure, MB BCh, FWACP (Paed); I B Fajolu, MBBS, FMCPaed;
B N Ezenwa, MBBS, MPH, FMCPaed; P E Akintan, MBBS, FMCPaed

Department of Paediatrics, Lagos University Teaching Hospital, Nigeria

Corresponding author: V C Ezeaka ([email protected])

Background. Neonatal jaundice remains a leading cause of preventable brain damage, mental handicap, physical disabilities and early death
among infants. The high mortality and morbidity from neonatal jaundice is exacerbated by the poor understanding and mismanagement
of this common neonatal problem by the general populace, leading to dangerous delays and complications.
Objective. To assess the knowledge of pregnant women on the causative factors, treatment modalities and sequelae of neonatal jaundice.
Methods. Data were obtained from all consecutive women who attended the antenatal clinic of the Lagos University Teaching Hospital,
Nigeria, from January 2013 to April 2013, using a pretested questionnaire focusing on knowledge of neonatal jaundice and its causes,
treatment and complications.
Results. The study participants numbered 395, of whom 213 (53.9%) were within the age range of 30  -  39  years. Only 101 (25.6%)
participants gave a correct definition of neonatal jaundice. The highest proportion of those who did not give a correct definition were from
the lower socioeconomic groups V and IV (χ2=12.08, p=0.017). Participants who did not know the causes numbered 313 (79.2%), while
325 (82.2%) participants chose ineffective treatment options. Furthermore, 296 (74.9%) respondents, especially those with a low level of
education, did not identify the complications correctly (χ2=12.61, p=0.006).
Conclusion. Women in the study showed inadequate knowledge of and misconceptions regarding neonatal jaundice, which must be
addressed in order to reduce significantly the devastating consequences of this common condition. We advocate for improved female
literacy and mass health enlightenment programmes.

S Afr J Child Health 2016;10(4):227-230. DOI:10.7196/SAJCH.2016.v10i4.1190

Neonatal jaundice remains a leading cause of preventable brain postnatal follow-up health visits, there is a crucial need for mothers
damage, mental handicap, physical disabilities and early death among to be duly educated on the early detection of neonatal jaundice and
infants.[1-7] This hyperbilirubinaemia results from a predisposition the avoidance of precipitating factors. Mothers, who are usually the
to bilirubin production in the newborn and their limited ability to primary caregivers of the newborns, must possess basic knowledge
excrete it. Infants, especially preterms, have higher rates of bilirubin pertaining to the aetiology and complications of neonatal jaundice,
production than adults because they have red cells with a shorter and must be given skills in its early diagnosis and management.
life span, a higher rate of haemolysis, inadequate caloric intake Most studies on neonatal jaundice in Nigeria have dwelt mainly on
with increased enterohepatic circulation, and an underdeveloped clinical research concentrating on the medical aetiological factors[2-4,7,8]
conjugating system.[1,4,8] and on the management of neonatal jaundice by healthcare staff.[16,17]
Apart from causing neonatal deaths and chronic handicapping In view of the real need for early detection and prompt institution of
conditions such as cerebral palsy, severe unconjugated hyper- appropriate therapy, the present study aims to assess the perception
bilirubinaemia usually causes deafness, speech disorders, learning of caregivers on the causative factors, treatment modalities and
disabilities and mental retardation.[1-4,6-8] Several studies in Nigeria complications of neonatal jaundice. To our knowledge, this is the first
have shown neonatal jaundice to be one of the most common study on the assessment of mothers’ knowledge of neonatal jaundice
neonatal emergencies in the referral centres,[3,9-11] and some reports in Lagos, Nigeria, and it will help to provide baseline data for the
have shown that severe neonatal jaundice and kernicterus contributed formulation of effective interventional measures.
to about a half of all cases of cerebral palsy.[2,12-14] Furthermore, it has
been reported that even moderate neonatal hyperbilirubinaemia may Methods
lead to mild neurological damage, which may not be obvious during This cross-sectional study was carried out at the Lagos University
the neonatal period, but manifests only in later life.[15] Teaching Hospital (LUTH), Nigeria, from January 2013 to April
The high mortality and morbidity from neonatal jaundice is 2013. LUTH is a 750-bed tertiary hospital offering maternal and child
exacerbated by the poor understanding, and mismanagement, of health services to all ethnic, religious and socioeconomic populations
this common neonatal problem by the general populace, leading of Nigerians within and outside Lagos State. The hospital is a referral
to dangerous delays and complications.[11,16-18] The experience has centre for general hospitals, maternity facilities and private hospitals,
been that the caregivers do not usually detect this potentially within Lagos and its neighbouring states.
serious condition early, and in many situations the healthcare Data were obtained from all consecutive women who attended
providers and the mothers are misguided about the conventional the antenatal clinic of the institution during the study period using
modalities of management, such that these infants consequently a pretested questionnaire. Questionnaires were administered after
develop kernicterus. In view of the high two-thirds prevalence obtaining informed consent from the mothers. Ethical approval was
of home deliveries in our environment, the widespread practice obtained from the Ethical Committee of the institution. The first section
of early hospital discharge for the approximately one-third of the of the questionnaire included personal data, sociodemographic data,
mothers who deliver in the health facilities[19] and the lack of effective educational level attained and obstetric data of respondents.

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The next section of the survey instrument IV and V occupy the lowest rungs of the to mosquito bites while 3  (0.8%) participants
aimed to assess the knowledge of the socioeconomic ladder. attributed the cause to yellow fever. However,
mothers regarding the definition of neonatal The SPSS version 17.0 (IBM Corp., only 39 (9.9%) participants correctly identified
jaundice and what it entails, possible causes, USA) statistical software was used for data the causes as blood incompatibility between
treatment modalities, complications and how entry, validation and analysis. Pearson’s χ2 mother and baby, infection in baby and
to detect neonatal jaundice in the newborn, statistic was used to examine the association prematurity. Of these, 13  (33.3%) correctly
using closed- and open-ended questions between categorical variables. Differences, identified one cause, while 20  (51.3%) and
of multiple choice types. The mothers associations and relationships were said to be 6  (15.4%) correctly identified two and three
were encouraged to seek clarification on statistically significant when p≤0.05. causes, respectively.
any of the questions from the attending Fig. 1 shows that in answer to the
interviewer but discussion among them was Results question on how neonatal jaundice should
discouraged while they were filling in the The number of respondents who participated be effectively treated, 70  (17.8%) of the
questionnaires. To avoid bias the interviewer in the study was 395. Most of them were participants said they had no knowledge. Of
only interpreted the question into the local within the age range of 30 - 39 years (Table 1). the 325 (82.2%) participants who mentioned
language if mothers sought clarification, and Of the 395 participants interviewed, 101 treatment options, 114  (35.1%) incorrectly
then without further explanations. (25.6%) correctly defined neonatal jaundice chose the use of ampiclox syrup, 87 (26.8%)
Social classification criteria designed by as a yellowish discoloration of the eyes and chose exposure to natural sunlight, while
Olusanya et al.[20] were used. These comprise skin owing to accumulation of bilirubin, only 31  (9.5%) correctly identified the use
five social classes (I  -  V) according to while 294 (74.4%) mothers did not know of a specific phototherapy machine, and
a scoring system based on the mother’s the correct definition of neonatal jaundice. 20 (6.2%) chose exchange blood transfusion
education and her husband’s occupation. Table 2 shows the participants’ definition (EBT) as modalities of treatment. A
Social classes I and II represent the elites, of neonatal jaundice based on social combination of both phototherapy and
class III is the middle class while class classification. The results are statistically exchange blood transfusion was chosen by
significant (χ2=12.08, p=0.017). 18 (5.5%). Other treatment options reported
Regarding the question on knowledge of the by the subjects were the use of unripe pawpaw
Table 1. Sociodemographic
characteristics of respondents causes of jaundice in the newborn, 313 (79.2%) water (28 (8.6%)), use of herbal medications
participants answered that they did not know (11  (3.4%)), glucose water (7  (2.2%)) and
Frequency, the causes, 43  (10.9%) gave varied incorrect varied combinations (9 (3.1%)).
Variables n (%)
answers in different combinations, 27  (6.8%) Furthermore, to the question about
Total 395 (100.0) respondents attri-buted the newborn jaundice knowledge of complications of neonatal
Age range (years)
15 - 19 3 (0.8) 40
20 - 29 167 (42.3) 35
Percentage, %

30 - 39 213 (53.9) 30

25
≥40 12 (3.0)
20
Ethnicity 15
Ibo 170 (43.0) 10
Yoruba 161 (40.8) 5
Hausa 12 (3.0) 0
rs
py
py

aw
ht
x

Others 52 (13.2)
T
clo

he
EB
lig

ra
ra

wp

Education level
pi

Ot
he
he
un
Am

Pa

ot
t
ls

to

No formal education 6 (1.5)

ot
ra

ph
tu

Ph

Primary 22 (5.6)
Na

T+

Secondary 170 (43.0)

EB

Tertiary 197 (49.9)

Fig. 1. Treatment options chosen by respondents.
Social class
I 126 (31.9)
Table 2. Participants’ definition of neonatal jaundice by social classification
II 145 (36.7)
Correct definition, Incorrect definition,
III 62 (15.7) Social class n (%) n (%) Total, n (%)
IV 43 (10.9) Total 101 (100.0) 294 (100.0) 395 (100.0)
V 19 (4.8) I 46 (36.5) 80 (63.5) 126 (100.0)
Parity II 30 (20.7) 115 (79.3) 145 (100.0)
0 153 (38.7) III 14 (22.6) 48 (77.4) 62 (100.0)
1 - 5 228 (57.7) IV 8 (18.6) 35 (81.4) 43 (100.0)
≥6 14 (3.5) V 3 (15.8) 16 (84.2) 9 (100.0)

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jaundice, 99 (25.1%) respondents correctly identified brain damage,

Table 3. Respondents’ knowledge of the complications of
mental retardation, hearing impairment, delayed development and neonatal jaundice by education level
convulsions in the baby as complications singly and in combinations,
while 296 (74.9%) participants did not correctly identify the Educational Correct Incorrect Total,
level knowledge, n (%) knowledge, n (%) n (%)
complications. Of these 296 respondents, 263 (88.9%) did not think
they knew the complications, while 33  (10.9%) respondents gave Total 99 (25.1) 296 (74.9) 395 (100.0)
incorrect answers such as sickle cell anaemia, blindness and damage No formal
to the blood. These results are shown in Table 3 and are statistically education 0 (0.0) 6 (100.0) 6 (100.0)
significant (χ2=12.61; p=0.006).
Primary 1 (4.5) 21 (95.5) 22 (100.0)
Regarding information received about neonatal jaundice,
185  (46.8%) had never received any such information, 89  (22.5%) Secondary 36 (21.2) 134 (78.8) 170 (100.0)
admitted they had some information from health workers (either Tertiary 62 (31.5) 135 (68.5) 197 (100.0)
nurse or doctor), 68 (17.2%) were informed by friends and relatives
and only 16  (4.05%) received information from the mass media
(television and radio). Various combinations of the above options status, while overall a quarter of the respondents correctly identified
were given by 37 (9.4%) of the respondents. brain damage, mental retardation and delayed development as
complications. This poor understanding of the dangers of jaundice
Discussion on the brain of the newborn infant further trivialises the mother’s
Neonatal jaundice is the most common neonatal emergency and management of this silent crippling condition.
a significant contributor to neonatal morbidity and mortality in Neonatal jaundice occurs in most newborns and the hallmark of
developing countries. However, in spite of its high prevalence, it effective treatment is early identification and appropriate therapy.
is apparent from the present study that the mothers, who are the In developed countries, the menace of newborn jaundice has
primary caregivers, have a poor understanding of this common, received better priority and attention. In the USA, the national
potentially lethal condition. healthcare organisations including the Centers for Disease
The finding that as many as 75% of the respondents could Control, the Joint Commission for the Accreditation of Healthcare
not describe correctly what neonatal jaundice entails is rather Organizations and the American Academy of Pediatrics issued
disheartening, since this translates to undue delays in identification alerts to all accredited hospitals and public health professionals
and seeking appropriate care. The end result may be the development that all healthy infants are at potential risk of kernicterus if their
of severe brain damage in the affected baby. This corroborates studies newborn jaundice is unmonitored and inadequately treated.[6]
by Ekanem et al.[16] and Ogunfowora et al.,[17] although their studies However, in many developing countries, compared with many
centred on primary healthcare workers. The result that many of the conditions that require advanced pharmacological strategies,
mothers described newborn jaundice as malaria in the newborn is newborn jaundice seems to be overshadowed, and has lost the
further evidence of this poor knowledge. Furthermore, the result attention that it deserves as a condition that has potentially
that this knowledge gap is significantly wider in mothers from the deleterious consequences.
lower socioeconomic group, who have poorer educational status, Intensive health education campaigns on neonatal jaundice
underscores the urgent need for improved female education and should be instituted at antenatal clinics, immunisation clinics,
mass health enlightenment programmes on newborn jaundice. paediatric clinics, well-baby clinics and in all health centres in the
In the same light, >75% of the participants did not correctly identify community. This is to ensure that mothers are duly educated at every
the causes of neonatal jaundice despite the fact that blood group opportunity about the causes of neonatal jaundice. Areas in which
incompatibility, prematurity, infections and glucose-6-phosphate to concentrate in jaundice education should include the possible
dehydrogenase deficiency have been reported by several authors in triggers of haemolysis that are commonly used in the homes, such
Nigeria as common aetiological factors.[3,7,8] Furthermore, certain as menthol and naphthalene balls, how newborn jaundice can be
agents commonly used by the mothers in their homes, such as identified early and effective treatment options for neonatal jaundice.
naphthalene balls, herbal drinks and drugs, have been documented This is especially pertinent as many newborns are usually discharged
to be icterogenic, causing an increase in the prevalence and severity home <48 hours after birth, when the jaundice is not yet evident.
of neonatal jaundice.[7,8] Some respondents attributed the cause to These new mothers are left at the mercy of grandmothers and
yellow fever in the newborn. Therefore, while continuous research neighbours who recommend local remedies such as pawpaw water
on clinical patterns and technologically advanced therapeutic options and herbal medications. The mass media should be involved in mass
remain very relevant, there should be a major focus on formulating mobilisation campaigns to help avert this apparent lack of awareness
appropriate preventive and interventional strategies in the community. as the present study has shown that only a negligible proportion
More than half of the respondents incorrectly chose the use of of the respondents received information about neonatal jaundice
ampiclox syrup (a combination of ampicillin and cloxacillin antibiotic), from that source. Increased knowledge about the predispositions
glucose drinks, unripe pawpaw water and exposure to sunlight, which and consequences of severe hyperbilirubinaemia by the mothers
have all been shown to be totally unreliable. Sadly, these same therapeutic is imperative for the institution of early appropriate care, thereby
options are among those chosen by primary healthcare workers from reducing significantly the menaces from the devastating disabilities
previous studies in Nigeria >2 decades ago.[16] It is imperative that the of this condition in our communities.
healthcare system be strengthened, and better provision made for
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