ORIGINAL

Niger J Paed 2014; 41 (3):199 –203

Alex-Hart BA

Dotimi DA

Opara PI

Mothers’ recognition of newborn

danger signs and health seeking

behaviour

DOI:http://dx.doi.org/10.4314/njp.v41i3,9

Accepted: 26th November 2013

Abstract: Background: Early rec-

the mothers as danger signs of

neonatal illness, the best being fast

breathing by 66 (45.2%) mothers.

Eighty two (56.2%) mothers re-

ported that their children experi-

enced some of the neonatal danger

signs: the commonest were diffi-

cult breathing and convulsions in 8

(9.8%) cases each. Unconscious-

ness and excessive crying were

thought to be caused by evil spirits

and consultations sought with faith

healers. The major constraint to

utilization of health facilities was

cost {45(29.8%)}.

Conclusion: Mothers’ recognition

of danger signs in the newborn

was poor. Self-medication and the

use of home remedies delayed

timely consultation. The common-

est reason for non-utilization of

health facilities was lack of

money.

ognition of neonatal illnesses fol-

lowed by care-seeking and inter-

vention are key factors in improv-

ing neonatal health and survival.

Objectives: To assess mothers’

ability to recognize newborn dan-

ger signs and actions taken by

mothers in the event of neonatal

illness.

(

)

Alex-Hart BA

Opara PI

Department of Pediatrics & Child

Health

University of Port Harcourt Teaching

Hospital

P.MB 6371, Port Harcourt

Rivers State, Nigeria

Email: balaalexhart@ymail.com

Methods: The study was carried

out in three health centres in Yena-

goa Metropolis from April to May

Dotimi DA

Department of Community Health,

School of Health Technology, Ogbia,

Bayelsa State, Nigeria.

2

011. A 15 itemed Questionnaire

based on the WHO/UNICEF IMCI

programme handbook was admin-

istered to 146 mothers with infants

younger than three months. The

mothers were asked to identify

danger signs of neonatal illness

from a list of symptoms, to indicate

which of the listed symptoms their

babies experienced, to state what

actions were taken in response to

the symptoms and reasons for not

utilizing orthodox healthcare.

Keywords: Mothers, Newborns,

Danger signs, Recognition, Health

seeking.

Results: None of the listed symp-

toms was recognized by up to half

Introduction

proportion of the four million annual global neonatal

deaths . In developing countries like Nigeria, progress

4

The neonatal period (the first 28 days of life) is the most

critical period for the survival of the child . Every year

toward achieving Millennium Development Goal 4 (to

reduce by two-thirds under-5 mortality from the 1990

baseline) is being h₅ampered by slow progress in reduc-

ing neonatal deaths .

1

over 4 million babies die within this period globally;

with 98% of the deaths occurring in the developing

2

world . In developing countries, the risk of death in the

neonatal period is six times greater than in developed

countries; in the least developed countries it is over

eight times higher . In Nigeria, 241,000 child deaths

Neonatal illnesses exhibit a rapid course of progression

and can prove to be fatal if not identified and treated

correctly in a timely manner. Timely and adequate care-

seeking for illnesses as well as appropriate and timely

intervention are therefore₆_,k₇_,e₈y element in improving neo-

natal health and survival . An example of such inter-

vention is the integrated management of childhood ill-

ness (IMCI) strategy. Besides improving health workers'

skills in managing childhood illness, IMCI Strategy also

aims to improve families' care seeking behaviour. The

health workers are trained to teach the mothers about

danger signs and counsel them about the need to seek

2

occur annually within the neonatal period and these neo-

natal deaths are responsible for a quarter of the under

1

five mortality rates in the country . Nigeria ranks highest

in Africa in terms of number of neonatal deaths and sec-

1

ond highest in terms of neonatal deaths worldwide . Of

the estimated neonatal deaths which occurred in Nigeria

in 2003, 37% were due to severe infections like pneu-

monia, sepsis, neonatal tetanus and diarrheal diseases;

while preterm births and birth asphyxia accounted for

3

9

another 49% . All these problems account for a large

care promptly and adequately if these signs occur .

2

00

Despite the availability of these lifesaving interventions

in the health facilities, inad₁e₀_-q₁u₂ ate care-seeking is still

and orthodox medications administered to the neonates

at home by their caregivers without appropriate prescrip-

tions. Faith healers were herbalist and religious leaders

who engage in healing of ailments, traditional birth at-

tendants were unorthodox pregnancy and childbirth care

providers, while qualified care providers were doctors in

both private and government owned health facilities.

being reported for neonates

with more than half of

11

the neonatal deaths in Nigeria occurring at home .

Timely and appropriate care-seeking for neonatal ill-

nesses will depend partly on mothers’ recognition and

12

perception of danger signs in the neonates . The current

study therefore aims to assess mothers’ ability to recog-

nize danger signs in newborns and their health seeking

behaviours.

Data obtained included identified danger signs, illnesses

suffered by the babies during the neonatal period, ac-

tions taken by the mothers and reasons for non-

utilization of health facilities. Socio-demographic infor-

mation was also collected. The data collected were ana-

lyzed using SPSS version 17 software. Simple descrip-

tive statistics in the form of percentages were employed.

The Ethics Committee of University of Port Harcourt

Teaching Hospital and the Bayelsa State Ministry of

Health gave ethical approval.

Subjects and Methods

This was a descriptive cross-sectional study carried out

in Yenagoa Metropolis in Bayelsa State. Yenagoa Me-

tropolis is the headquarters of Yenagoa Local Govern-

ment Area and is also the seat of power of Bayelsa State

Government. Bayelsa State is located in the oil and gas

1

3

rich Niger Delta Region in Southern Nigeria . The state

has a riverine and estuarine setting. A lot of her commu-

nities are almost (and in some cases) completely sur-

rounded by water, hence making these communities

inaccessible by road. Despite the extensive petroleum

and gas activities in the state, majority of Bayelsans live

in poverty and are mainly rural dwellers. Due to the dif-

ficult terrain of the State, coupled with decades of ne-

glect by the central and state governments and the petro-

leum prospecting companies, there is lack of adequate

transportation, health, education or other infrastruc-

ture . All the functional health facilities in the state are

concentrated in Yenagoa Metropolis. Yenagoa Metropo-

lis has a general hospital, one Federal Medical Centre,

three health centres and several private hospitals. The

health centres conduct weekly immunization and antena-

tal clinics. The health centres are run by nurses, mid-

wives and Community Health Workers with no input

from doctors. Consequently they have low patronage as

majority of the people go to the bigger health facilities

with doctors.

Results

A total of 146 mothers participated in the study, with a

mean age of 29.09±6.1 years. More than one quarter {41

(28.1%)} of the mothers were between the ages of 30-34

years: 49 (33.6%) had secondary education and 58

(39.7%) were unemployed. Most of the fathers {74

(50.7%)} had tertiary education and majority {75

(51.4%)} were civil servants (Table 1).

1

3

Table 1: Bio-demographic data of parents

Mothers

Age in years

Frequency Percentage

1

2

3

5-19

0-24

5-29

0-34

5-39

5

3.5

31

39

41

20

10

21.2

26.7

28.1

13.7

6.8

≥40

Mothers’ education

Tertiary

Secondary

Primary

No education

Mothers’ occupation

Professionals

Civil servants

Skilled

42

49

27

28

28.8

33.6

18.5

19.1

The study was conducted in the three health centres in

Yenagoa Metropolis from April to May 2011. Only

women who had babies less than three months old, who

brought their babies for immunization within the study

period were recruited. A 15-item interviewer adminis-

tered questionnaire was used. Problems listed in the

questionnaire were the potentially severe conditions

mentioned in the WHO/UNICEF Integrated Manage-

ment of Childhood Illnesses (IMCI) programme hand-

6

4.1

43

5

29.5

3.4

Unskilled

34

58

23.3

39.7

Unemployed

Fathers’ education

Tertiary

Secondary

Primary

No education

Fathers’ occupation

Professionals

Civil Servants

Skilled

1

4

74

50

16

6

50.7

34.2

11.0

4.1

book . The mothers were asked to identify from a list,

what they considered danger signs of neonatal illness, to

indicate which of the listed symptoms their babies ex-

perienced and to state what actions were taken in re-

sponse to the symptoms. Similar lists of problems have

15

75

24

25

7

10.3

51.4

16.4

17.1

4.8

8

been used in other community studies . An open ended

question was used to find out their reasons for not utiliz-

ing orthodox healthcare. Questions were asked in Eng-

lish language, but sometimes interpreted in the native

languages when the mother did not understand English

language. Home remedies were taken to be concoctions

Unskilled

Unemployed

2

01

Table 2 shows the danger signs recognized by the moth-

ers. The most common danger signs recognized by the

mothers were fast breathing and convulsion. The least

recognized danger sign was movement only when

stimulated {29(19.9%)}. There was less than 50% rate

of recognition for each of the danger signs. Between one

fifth and one quarter of mothers identified milder condi-

tions like skin rashes, redness of the eyes and skin blis-

ters as danger signs.

Eighty two (56.2%) mothers reported that their babies

had some of the danger signs during the neonatal period.

The two most common potentially severe problems ex-

perienced by the neonates were convulsion and difficult

breathing each in 8 (9.8%) babies. The three most com-

mon mild problems experienced by the neonates were

high body temperature, skin rashes and skin blisters in

of the eyes and skin (neonatal jaundice) was said to be

caused by malaria. Table 5 shows the reasons for non-

utilization of health facilities. The major obstacle to

utilization of health facilities was cost of treatment {45

(30.8%)}. Others were delay in receiving treatment in

health facilities {36(24.7%)} and long distance to health

facilities {25(17.1%)}.

Table 3: Problems experienced by the neonates from 82 moth-

ers and actions taken

Potentially severe

conditions

Fre-

quency

of

Home

Remedy

Took

resort

Faith

To:

Qualified

Providers

TBAs

symp-

toms

healers

Convulsion

8

6

5

8(100)

4(50)

0(0.0)

6(75.0)

2(25.0)

3(50.0)

7(87.5)

6(100.0)

0(0.0)

Difficult breathing

Fast breathing

Excessive crying

1(12.5)

1(16.7)

0(0.0)

4

3(52.4%), 16(19.5%) and 11(13.4%) babies respec-

5

tively.

(100.0)

Pus around um-

bilicus

Yellowness of the

eyes/skin

4

3

4(100.0)

3(100.0)

0(0.0)

3(75.0)

1(33.3)

Table 2: Danger signs recognized by146 mothers

0(0.0)

Danger sign

Frequency Percentage (%)

Extreme weakness

Unconsciousness

Very small baby

Low body tem-

perature

Mild illnesses

High body tem-

perature

3

1

2(66.7)

0(0.0)

2(66.7)

1(100.0)

1(33.3)

0(0.0)

3(100.0)

0(0.0)

3(100.0)

1(0.0)

Fast breathing

Convulsion

66

57

49

45

40

39

36

35

34

33

32

31

29

45.2

39.0

33.6

30.8

27.4

26.7

24.7

24.0

23.3

22.6

21.9

21.2

19.9

Umbilical bleeding

Difficulty in breathing

Pus around the umbilicus

Unconsciousness

Skin rashes

High body temperature

Extreme weakness

Diarrhea

Excessive crying

Yellow skin/eyes

Very small baby

Redness of the eyes

Purulent eye discharge

Low body temperature

Inadequate/poor sucking

Umbilical discharge

Skin blisters

0(0.0)

43

16

25(58.1)

16

7(16.3)

0(0.0)

6(14.0)

2(12.5)

32(74.4)

4(25.0)

Skin rashes

(100.0)

Skin blisters

Redness of the

eyes

Bleeding around

umbilicus

11

9

8(72.7)

9(100.0)

1(9.0)

2(22.2)

5(45.5)

0(0.0)

3(27.3)

3(33.3)

5

4(80.0)

1(20.0)

0(0.0)

3(60.0)

Diarrhoea

Swollen eyes

Purulent eye

discharge

5

3

2

4(80.0)

3(100.0)

2(100.0)

0(0.0)

1(20.0)

0(0.0)

3(60.0)

1(33.3)

0(0.0)

Note: Figures in bracket are percentages of symptoms’ frequency.

Some mothers took more than one type of action. TBA=Traditional

Birth Attendents.

Abdominal distension

Swollen eyes

Movement only when stimu-

lated

Table 5: Reasons for non-utilization of health facilities by 146

respondents

Reasons

Frequency (%)

For most of the problems experienced by the neonates,

mothers either applied home remedies or consulted with

faith healers or qualified health care providers. There

was also multiple care seeking as shown in Table 3.

Table 4 shows what the mothers’ perceived as the causes

of their children’s problems. Seventy five percent of

those whose children had convulsion and 100% of those

whose children were unconscious or had excessive cry-

ing attributed the conditions to evil spirits. Yellowness

Cost

Delay in receiving treatment

Long distance to health facilities

Health workers are hostile

Herbs are more effective

45 (30 .8)

36 (24.7)

25 (17.1)

20 (13.7)

15 (10.3)

10 (6.8)

Some illnesses are caused by evil spirits

Note: Some mothers gave more than one reason.

2

02

Table 4: Mothers’ perceptions of the causes of the problems

experienced by the neonates

and eyes, abdominal distention, movement only when

stimulated, poor sucking and very small size were all

poorly recognized. Instead, a greater percentage of the

mothers identified relatively milder conditions like skin

rashes and skin blisters as danger signs. Since recogni-

tion of signs and symptoms of neonatal illnesses is an

important factor associated with time₁l_,₁y₈ and appropriate

Problems

Perceived causes (%)

Convulsion (n=8)

Evil spirits 6 (75 )

Fever 3 (37.5)

Difficult breathing (n=8)

Fast breathing (n=6)

Exposure to cold 8 (100)

No idea 4 (66.7)

Sickness 3 (50)

1

care seeking in developing countries . it can therefore

Excessive crying (n=5)

Pus around the umbilicus

Evil spirits 5 (100)

Bad air 3 (75)

Infection 1(25)

be assumed that poor recognition of these danger signs

will lead to delay in seeking appropriate health care and

thus poorer treatment outcome. This inability to recog-

nize danger signs in the neonates by mothers will also

impact negatively in the Integrated Management of

(n=4)

Yellowness of the eyes/

skin (n=3)

Malaria 2 (66.7)

Jaundice 1(33.3)

Extreme weakness (n=3)

Unconsciousness (n=3)

Low body temperature

Poor feeding 3 (100)

Sickness 2(66.7)

11

Childhood Illnesses (IMCI) Program in Bayelsa State .

This is because the program is based on early identifica-

tion of newborn danger Signs by caregivers, with

prompt and appropriate referral aiming at reduction in

neonatal mortality.

Evil spirits 3(100)

Sickness 1(33.3)

Cold weather (100)

(n=1)

Skin rashes (n=16)

Heat rashes 14 (87.5)

Measles 4 (25)

More than half (56.2%) of the mothers in our study said

their children had at least one illness during the neonatal

period that would have required medical care. This is

similar to the 51.2% and 56.8% reported i₁n₆ two separate

Skin blisters (n=11)

Heat 6 (54.5)

Mother ate too much rice during preg-

nancy 5 (45.5)

Redness of the eyes (n=9)

Bleeding around the um-

bilicus(n=5)

Apollo 9 (100)

Umbilical stump not well tied 5 (100)

1

0,18

but higher than 37.5% also from

studies in India

India. This disparity could be explained by demographic

differences and levels of exposure of the respondents to

information.

Diarrhoea

Spoilt breast milk 4(80)

Child drank bad water 1 (20)

High body temperature

Malaria 38 (88.4)

No idea 5 (11.6)

Germs 8 (18.6)

(n=43)

Our study agrees with previous studies which reported

multiple care seeking, sequential care seeking as wel₁l₈a_,₁s₉

symptom specific care seeking pattern for neonates.

Most mothers began by applying home remedies or con-

sulting with faith healers or doing both and only sought

care from qualified providers when symptoms persisted

or worsened. Several studies have reported that this de-

lay in seeking appropriate care and not seeking any care

Very small baby (n=3)

Swollen eyes (n=3)

Prematurity 2(66.7)

Nature 3 (100)

Apollo 2 (66.7)

Excessive crying 1 (33.3)

Purulent eye discharge

Apollo 1 (50)

Infection 1(50)

Breast milk entered the eyes 1 (50)

(n=2)

Note: Mothers offered more than one perceived cause. Apollo=

Epidemic viral conjunctivitis.

at all, contribute significantly to the large number of

20,21,22

child deaths in developing countries

.

Evidence also suggests that perceptions about illness

causation often determine when and from whom care is

1

2

Discussion

sought . In our study, unconsciousness and excessive

crying were perceived to be caused by evil spirits. The

children with these conditions were taken to faith heal-

ers and health facilities. On the other hand, our study

also showed a high rate of application of home remedies

for most neonatal illnesses irrespective of their per-

ceived causes. For instance, conditions like convulsions

and redness of the eyes were treated with home remedies

and medications from qualified health care providers.

Our study has demonstrated that there was poor knowl-

edge of newborn danger signs amongst mothers in Ye-

nagoa Metropolis as there was less than 50% rate of

recognition of each of the d₅anger signs. This is similar

1

to the report of Baqui et al who found poor awareness

of danger signs amongst caregivers in Bangladesh. It

however differs from the high level of awareness of

newborn danger signs by caregi₁v₆ ers in India reported by

9

Awasthi et al and Dongre et al respectively. It is possi-

In our study, neonatal jaundice was believed to be

caused by malaria and children with this condition re-

ceived home treatment and only 33.3% of them were

seen by qualified health care providers. To a certain ex-

tent therefore, affected babies were exposed to the risk

of bilirubin encephalopathy. For a condition like fast

breathing, majority of the mothers did not know its

cause and therefore sought help from faith healers and

qualified health care providers.

ble that lack of exposure to community intervention pro-

jects aimed at reducing neonatal mortality was responsi-

ble for poor knowledge of mothers in Yenagoa.

The two most commonly recognized danger signs were

fast breathing (45.2%) and convulsion (39%). This is

probably because these two are alarming signs and are

difficult to miss. This find₇ing is similar to that reported

1

by Juma in Dares Salaam though in that study convul-

sion was recognized by a higher proportion (92.5%) of

mothers. In the present study, other signs which signify

serious neonatal illnesses such as yellowness of the skin

Several reasons were given for non-utilization of health

facilities for neonatal illnesses. The commonest reason

was the high cost of treatment from qualified health care

2

03

providers. This is not surprising because majority of the

parents and especially the mothers were either unem-

ployed (39.7%) or were under paid civil servants. Other

reasons were delay in receiving treatment from health

facilities, far distance to the health facilities and un-

friendly attitude of the health workers.₃These reasons

utilization of health facilities was lack of money. There

is need to intensify the practice of Integrated Manage-

ment of Childhood Illnesses in Bayelsa State to improve

families care seeking behaviours.

Limitations of the study

2

have also been cited in a previous study .

Information obtained is based on the mothers’ ability to

recall past illnesses suffered by their babies during the

neonatal period.

Conclusions

Authors’ contribution

Mothers’ recognition of danger signs in the newborn

was poor in Yenegoa Metropolis. Care seeking from

multiple providers and the use of home remedies de-

layed appropriate and timely medical care seeking for

neonatal illnesses. The commonest reason for non-

All three authors participated in the study design, collec-

tion and analysis of data and writing of the manuscript.

Conflict of interest: None

Funding: None

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