Nigerian Journal of Paediatrics

Availability and distribution of phototherapy services and health care providers for neonatal jaundice in three local government areas in Jos North Central Nigeria

Niger J Paediatr 2018; 45 (1): 1 – 5

ORIGINAL

Toma BO

CC – BY Availability and distribution of

Diala UM

Ofakunrin AOD

phototherapy services and health

Shwe DD

care providers for neonatal

Abba J

jaundice in three local government

Oguche S

areas in Jos, North - Central

Nigeria

DOI:http://dx.doi.org/10.4314/njp.v45i1.1

Accepted: 31th January 2018

Abstract : Background: Severe

health facilities. Most (10; 71.4%)

neonatal jaundice remains com-

of the hospitals with phototherapy

Toma BO

(

)

mon in Nigeria. Phototherapy is

were located in Jos-North LGA.

Diala UM, Ofakunrin AOD

the most commonly used in-

There were 38 phototherapy units

Shwe DD, Oguche S

hospital treatment for neonatal

in all the 14 hospitals that offered

Department of Paediatrics,

hyperbilirubinaemia.

phototherapy, consisting of 8

University of Jos/ Jos University

Objectives: To describe the avail-

(21.1%) light emitting diodes

Teaching Hospital, Jos, Nigeria.

ability and distribution of photo-

(LED) and 30(78.9%) conven-

Email: gabosetoma@gmail.com

therapy services as an essential

tional units of which 25(83.3%)

neonatal service in hospitals in

were locally fabricated. In all the

Abba J

Jos, North-Central Nigeria.

hospitals that provided photother-

APIN, Jos University Teaching

Methods: This was a cross-

apy, jaundiced neonates were man-

Hospital, Jos, Nigeria

sectional study of all secondary

aged by physicians of whom only

and tertiary level health facilities

12% were fulltime paediatricians.

in Jos-North, Jos-South and Jos-

All hospitals that offered photo-

East Local government Areas

therapy had laboratory facilities to

(LGAs) between January and

assay bilirubin.

March 2015.

Conclusions: Phototherapy ser-

Results: There were 30 (90.9%)

vices in Jos, Nigeria are inade-

secondary and three (9.1%) terti-

quate and are concentrated in the

ary health facilities. Twenty –

urban private sector. An increase

eight (84.8%) were privately

in phototherapy services especially

owned. Fourteen (42.4%) of the

in secondary public facilities is

33 hospitals provided photother-

needed.

apy services, of which 11 (78.6%)

were private. Phototherapy ser-

Key words : Health Care Provider,

vices were available in all the

Hyperbilirubinaemia, Jos, Neona-

tertiary facilities and in only 11

tal Jaundice, Nigeria, Phototherapy

(36.7%) of the secondary level

Introduction

In Nigeria, NNJ accounts for 9 – 45% of neonatal ad-

with mortality rates of 5- 14%.

9,11,12

missions^9-12

Studies

Jaundice is common in the newborn affecting 60 – 80%

have reported the prevalence of kernicterus in Nigeria to

range from 2.3 to 3.4%

13,14

of newborns in the first week of life. Neonatal jaundice

of neonatal admissions with

(NNJ) although usually benign, can become severe and

sometimes up to 30% of admitted jaundiced neonates

having features of kernicterus.

12, 15

may result in adverse outcomes when unmonitored or

This is in addition to

other long term complications like hearing loss.

untreated in a timely manner. Severe hyperbilirubinae-

mia (SH) occurs in 8 – 9% of infants during the first

week of life. It is associated with substantial mortality

The therapeutic modalities for NNJ include photother-

and long‑ term morbidities especially in low - and

apy (PT), exchange blood transfusion (EBT) and intra-

middle‑ income countries (LMICs). 4 Kernicterus, a com-

venous immune globulin (IVIG), depending on its sever-

plication of severe hyperbilirubinaemia occurs world -

ity and etiology. Phototherapy is the most commonly

wide,

5,6

although the burden appears to be greater in

used treatment and with its widespread use, the need for

LMICs. The persistent occurrence of kernicterus has

exchange blood transfusion (EBT) for infants with neo-

natal jaundice is decreased. It is non- invasive and has

been attributed to a health systems failure in neonatal

fewer complications compared to EBT. Phototherapy

services.

3,8

is therefore an essential neonatal service that should be

A list of all health care facilities in the three Local Gov-

readily available. The World Health Organization

ernment Areas in Jos was obtained from the Plateau

(WHO) in an interagency list of priority medical devices

State Ministry of Health (SMOH). The secondary and

needed to provide essential interventions for reproduc-

tertiary level facilities were visited by the researchers to

tive, maternal, newborn and child health in LMICs,

ascertain the availability and types of phototherapy

listed phototherapy as a priority medical device at the

units/ devices which were sighted and tested. Other rele-

district level hospital.

vant information like cadre of health care personnel who

managed jaundiced infants, availability of laboratory

To the best of our knowledge, published data on avail-

diagnosis of serum bilirubin (SB) in the health facilities

ability and distribution of PT in Nigeria, especially in

was also documented. In addition, the total births and

north-central Nigeria particularly at the secondary level

other demographic data for the LGAs were obtained

of care, is at best, very scanty . The few studies on pho-

from the National Population Commission (NPC).

totherapy are focused on irradiance levels, which were

Ethical approval for the study was obtained from the Jos

found to be generally inadequate. Knowledge of the

University Teaching Hospital (JUTH) Research and

availability and distribution of phototherapy services

Ethics Committee (JUTH/DCS/ADM/127/XIX/5822)

will guide health systems planning and will aid reduc-

and permission to carry out study was obtained from the

tion of morbidity and mortality from NNJ. We therefore

owners of the hospitals.

undertook this study to describe the availability and dis-

tribution of phototherapy services in secondary and terti-

The data obtained was entered into a Microsoft excel

ary health institutions in three Local Government Areas

sheet and was analyzed using EPI info 7.2. Simple ratios

(LGAs) in Jos metropolis as an essential neonatal ser-

and proportions were calculated, while comparison of

vice.

proportions was done using Chi square or Fisher exact

Test as appropriate. A p-value of <0.05 was considered

statistically significant.

Methods

We undertook a cross sectional descriptive study in Jos

Results

North, Jos South and Jos East Local government Areas

(LGAs) in Jos metropolis, Plateau State, North – Central

There were a total of 33 health facilities in the three

Nigeria between January and March 2015. It was part of

LGAs. These consisted of 30 (90.9%) secondary and

a larger study. The study area co – hosts the capital city

three (9.1%) tertiary level facilities. Five (15.2%) of the

of Plateau State and is a cosmopolitan area with some

facilities were public, while the remaining 28 (84.8%)

suburban outskirts. The 3 LGAs span an area of 1,821

were privately owned (inclusive of seven faith-based

Km with a combined population of 951,173. Plateau

facilities). All the health facilities offered obstetric and

State is located in Nigeria’s middle belt, with an area of

perinatal care services.

26,899 Km with subdivisions into 17 LGAs and an esti-

Fourteen (42.4%) of the 33 hospitals provided photo-

mated population of 3.9 million people. Jos North and

therapy services; 11 (78.6%) of which were privately

Jos South LGAs are predominantly cosmopolitan, while

owned. Phototherapy services were available in all the

Jos East is predominantly rural. The health care system

tertiary health institutions and in only 11(36.7%) of the

is organized into primary, secondary and tertiary levels

secondary level facilities. Most (10; 71.4%) of the hos-

of care in line with the Nigerian national health system

pitals with phototherapy were located in JNLGA (Table

structure. Healthcare is provided by Government

1).

(public) and private or non-governmental institutions.

There are three tertiary hospitals in the study area which

Table 1: Availability of phototherapy services by type and

receive referrals from the rest of the state and neighbor-

level of facility and local government areas in Jos metropolis,

ing states. Secondary health facilities are generally de-

Nigeria

signed to serve people with services that are more com-

Characteristics

Phototherapy

plex, technically demanding and specialized than those

Total N

present

Absent

(%)

n (%)

available at primary care facilities, but not as specialized

as those provided by tertiary facilities. Their range of

Type of hospital

services includes diagnostics, treatment (including pho-

Public

5 (100)

3 ( 60)

2 (40)

0.63

totherapy services, ideally), care, counselling and reha-

Private

28 (100)

11 (39.3)

17 (60.7)

Level of care

bilitation. They often have only one family physician or

Secondary

30 (100)

11 (36.7)

19 (63.3)

0.07

a non-physician practitioner; with limited laboratory

Tertiary

3 (100)

0 ( 0)

services. Tertiary facilities usually have at least, one

Local Govt. Area

specialist and technical equipment and capacity to pro-

*JNLGA

19(100)

10 (52.6)

9 ( 47.4)

0.37

†

vide complex clinical care interventions to patients re-

JSLGA

13( 100)

4 (30.8)

9 (69.2)

‡

ferred from the primary or secondary facilities The

JELGA

1(100)

0(0)

1 (100)

2014 total live births (home & hospital) in the 3 LGAs

was 49,407 giving 950 births /week.

*JNLGA: Jos North Local Government Area;

†

JSLGA: Jos South Local Government Area;

‡

JELGA: Jos East Local Government Area

The total number of phototherapy units/devices in all the

In all the 14 hospitals that offered phototherapy services,

14 hospitals that offered phototherapy was 38, consist-

the jaundiced neonates were managed by trained physi-

ing of 8 (21.1%) light emitting diodes (LED) and 30

cians who were mainly concentrated in JNLGA. There

(78.9%) conventional units using ‘blue light’. Twenty

were only three (12%) full time trained paediatricians

five (83.3%) of the conventional units were locally fab-

involved in the management of jaundiced babies in Jos

ricated, while five (16.7%) were imported. Fourteen

metropolis and they were all in the tertiary facilities,

(36.8%) of the phototherapy units were in the tertiary

Table2.

hospitals, while the remaining 24 (63.2%) were in

All the 14 hospitals that offered phototherapy had labo-

11secondary level hospitals.

Most of the units (27;

ratory facilities to assay bilirubin in the jaundiced

71.1%) were in the private health facilities and were

babies.

concentrated in JNLGA (29; 76.3%). The remaining 9

(23.7%) were in JSLGA.

Table 2: Distribution andcadre of physicians providing care for jaundiced neonates in hospitals in Jos metropolis, Nigeria

Characteristics

Full time

Part time pae-

Full time

Medical

Total

paediatri-

trainee paedia-

diatricians

family physi-

trainee family

officers

n (%)

cians

tricians

n (%)

cians

physicians

n (%)

Total

3 (12)

10 (40)

3 (12)

4 (16)

2 (8)

25(100)

type of hospital

Public

Private

Level of care

Tertiary

Secondary

Local Govt.

Area

Jos North

Jos South

Jos East

charge. In the USA, the American Academy of Pediat-

rics (AAP) Subcommittee on Hyperbilirubinemia rec-

ommended that all nurseries and services treating infants

Discussion

should have the necessary equipment to provide inten-

sive phototherapy. Similarly, the WHO recommended

This study aimed at describing the availability and dis-

phototherapy as a priority medical device needed to pro-

tribution of phototherapy services in secondary and terti-

vide essential interventions at district level hospitals for

ary health facilities in Jos metropolis. Our findings

reproductive, maternal, newborn and child health in

LMICs.

showed that less than half of all the health institutions

The findings in our study do not meet these

offer phototherapy services. Also, we found that all terti-

standards. If this is the status in the capital of the state,

ary health care facilities provided phototherapy services

the situation may be worse in the peripheral rural areas.

with fulltime specialist paediatricians or family physi-

There was a lack of data to compare our study with, as

cians providing care. A large proportion of the secon-

most of the studies on phototherapy are on irradiance

dary facilities (which were mostly public) did not have

and not availability or distribution. Nevertheless, the

phototherapy. Physicians managed the jaundiced babies

number of devices in our study (38 devices in 14 hospi-

in the hospitals in Jos; however, the number of fulltime

tals) appears to be fewer than that in these studies. For

example, Owa et al evaluated phototherapy irradiance

specialist paediatricians providing care for jaundiced

babies is relatively small. Furthermore, most of the pho-

in 63 devices in the newborn units of twelve secondary

totherapy services were concentrated in private health

and tertiary hospitals in Nigeria. However, the areas

were not specified. Similarly, Cline et al evaluated the

institutions and were mainly in the Jos North LGA. This

followed the pattern of distribution of other specialist

irradiance 76 PT devices in 16 hospitals selected by con-

services, providers and resources, where there was a

venience sampling across 4 Nigerian states and the Fed-

concentration of these in the more cosmopolitan Jos

eral Capital Territory. The sampled 16 urban and semi-

North and parts of Jos South LGA.

urban hospitals included both public and private facili-

ties, but the distribution of these hospitals were not

The fact that less than half of all the institutions offer

stated. The number of phototherapy devices in our study

phototherapy services is unsatisfactory considering the

also appears to be fewer than the report by Ferreira, et

al. in Maceio, Brazil where the authors evaluated the

fact that all these hospitals take deliveries, and also

serve as referral hospitals to the primary health clinics in

irradiance of 36 phototherapy devices in 6 maternity

these LGAs, the rest of the state and neighbouring

wards.

states. Phototherapy should be readily available and ac-

cessible to families after delivery in view of the fact that

Another way of assessing availability of phototherapy in

NNJ is a major cause of readmission of babies after dis-

our study may be by comparing the number of babies

that may develop jaundice to the total number of photo-

not surprising as the Paediatric Association of Nigeria

therapy devices. Based on the total live births(49,407

(PAN) in a previous publication found that the number

births/year or 950 births/week) in the 3 LGAs and as-

of paediatricians in Nigeria is grossly inadequate; and

suming that 8 – 10%

[3]

of these infants may have severe

there was also an uneven distribution of paediatricians

hyperbilirubinaemia; this will give 76 – 95 neonates

with more in the southern states.

[26]

It was also found that

requiring treatment per week. This gives an average of 2

higher child-to-paediatrician ratio was significantly as-

-3 jaundiced neonates / phototherapy unit/ week. This

sociated

with higher under-fives

mortality rates

implies that either 1-2 jaundiced babies will be without

(U5MR). The paucity of paediatricians involved in the

phototherapy/ week, or 2-3 babies will have to share the

management of jaundiced babies in our study may result

same PT unit; a practice which is discouraged. These

in increased morbidity and mortality from NNJ as even

figures may be higher if we include babies from other

amongst practitioners, paediatricians were found to man-

age jaundiced babies better. There is therefore a need

parts of the state and neigbouring states since these hos-

pitals are referral centres.

for more trained paediatricians and to promote their dis-

tribution to the various areas within the LGAs. Addi-

The reduced availability of phototherapy services in our

tionally, in view of the high burden of NNJ in Nigeria,

study may be due to limited resources which may be

there is a need to train other health workers/ new born

presumed by the finding that most of the devices were

practitioners on NNJ.

locally fabricated. Or on the other hand, it may be due to

the fact that NNJ may not have been made a priority by

This study is limited by the relatively small sample size

the health policy makers. Unavailability of phototherapy

of the hospitals surveyed. A more elaborate picture of

may result in delay in treatment of babies with NNJ,

the status of phototherapy services will have been sur-

high rates of EBT and increased neonatal mortality in

mised if we had studied all the health facilities in the

addition to long term sequelae.

state, however, this was limited by funding. Also, we

did not assess the irradiance of the phototherapy devices

Another finding of our study was that the phototherapy

to determine their effectiveness. This should be an area

services were mainly available in the private health in-

for further study. The actual number of jaundiced babies

stitutions. This implies that the private sector is a signifi-

in the population was not determined. The fact that we

cant contributor to neonatal health services and so

did not have literature to compare our findings with may

should be carried along in health related programmes. It

also limit its application. However, in spite of these

also corroborates the fact that government alone cannot

limitations, the findings of this study will have applica-

provide all the health care for the entire population.

tion for health planning for neonatal services.

Government therefore must provide an enabling envi-

ronment for the private sector to complement its efforts.

The disadvantage of this may be that these services

though available physically, may not be accessible to the

Conclusion

general population because of cost. Thus the Govern-

ment still needs to ensure that these facilities are avail-

Phototherapy services in Jos are inadequate and are

able in the public health facilities and should be accessi-

mainly concentrated in the urban private sector. There

ble to all. The fact that all the tertiary facilities in Jos

are few full time paediatricians involved in the care of

provided phototherapy services is therefore commend-

babies with NNJ.

able.

Concerted efforts should be made to ensure that all sec-

ondary level health facilities should offer phototherapy

Most of the phototherapy services were concentrated in

with distribution especially to JELGA and to the public

the urban JNLGA. This appears to be due to the avail-

facilities. The need for more paediatricians and their

ability of health care delivery personnel, electricity and

distribution to the secondary public sector and suburban

other social amenities in urban areas as compared to

areas is advocated. These may reduce jaundice related

suburban and rural areas. The use of solar powered pho-

neonatal morbidity and mortality.

totherapy devices or filtered-sunlight phototherapy may

be an alternative in areas with poor electricity supply.

Conflict of Interest: None

There were few fulltime trained paediatricians involved

Funding: None

in the management of jaundiced babies in Jos. This is

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