Maternal and Child Health Journal

, Volume 16, Issue 3, pp 677–684 | Cite as

Family Socio-Demographic Factors and Maternal Obstetric Factors Influencing Appropriate Health-Care Seeking Behaviours for Newborn Jaundice in Sagamu, Nigeria

Article

Abstract

Poor care-seeking behaviour of families may be responsible for the high prevalence of complications of newborn jaundice in the developing world. To examine the influence of family socio-demographic characteristics and maternal obstetric factors on health care-seeking behaviours for newborn jaundice and the inter-relationship between this behavior and severity of newborn jaundice. Mothers whose babies were referred to a Nigerian tertiary hospital with jaundice were studied in a cross-sectional survey for appropriate health-care seeking behaviours as well as the need for exchange transfusion and the occurrence of kernicterus in their babies. Out of 182 mother-baby pairs, 127 (69.8%) mothers recognized jaundice in their infants, 34.1% delayed care for ≥48 h, 40.6% sought medical care in orthodox health facilities while 20.9% did not seek care outside the home. In all, 61.5% mothers administered various medications to jaundiced babies. Appropriate health care-seeking behaviours were recorded among 28.6% mothers. Low maternal education had a significant relationship with delayed health care-seeking and the use of home remedies for newborn jaundice. A significantly higher proportion of babies who had home remedies had delayed care. Delayed care for ≥48 h was also significantly associated with high Total Serum Bilirubin on admission, higher requirement for exchange transfusion and higher occurrence of kernicterus. Intensive health education of families may help improve their health care-seeking behaviours for neonatal jaundice.

Keywords

Care-seeking behaviour Exchange transfusion Jaundice Kernicterus Newborn Social factors 

Introduction

Although newborn jaundice is primarily, a clinical entity, its public health importance lies in the associated social implications. These are linked with the numerous neuro-developmental disorders arising from bilirubin-induced encephalopathy. Encephalopathy occurs when free bilirubin permanently stains specific parts of the brain like the basal ganglia, cerebellum and brainstem nuclei. The long term effects of this encephalopathy, otherwise known as kernicterus, among the survivors include chronic handicapping conditions like cerebral palsy, deafness, speech defect and seizure disorders [1]. Practitioners in the developing world still encounter kernicterus frequently [1] whereas it has been described as a re-emerging disease in most parts of the developed world. This re-emergence of kernicterus had been variously attributed to factors such as poor adherence to universal guidelines on the management of jaundice, early discharge of babies from nurseries before jaundice could be detected, rise in breastfeeding practices, poor knowledge of the early signs of bilirubin encephalopathy and lack of parental information about the dangers of newborn jaundice [2, 3].

Overall, the problems of kernicterus impinge on the social status of a family. Caring for a kernicteric child requires assistance in almost every aspect of living [4]. In the developed world, sophisticated facilities for rehabilitation are available and children with kernicterus are less dependent in terms of communication, mobility and feeding. Therefore, the care givers have minimal responsibilities with respect to the care of such children. On the other hand, the situation is a lot different in most parts of the developing world where rehabilitation is highly limited and social support is almost non-existent. Thus, most children with cerebral palsy default from follow-up care at the out-patient clinics in parts of the developing world [5]. Thus, the care of kernicteric children in under-resourced parts of the developing world may result in a care giver dropping out of a job in order to give maximum attention to the affected child, reducing family finances and placing strain on the family structure and functions [4].

The aforementioned implications of this preventable condition make it a public health issue. Prevention of bilirubin encephalopathy can be achieved through prompt identification of at-risk babies and effective treatment [6, 7]. In the developing world, the burden of effectively reducing the prevalence of bilirubin encephalopathy rests on a lack of adequate assessment of babies for hyperbilirubinaemia and dearth of effective treatment facilities [8]. The former appears to be more important because most babies are delivered outside hospitals. A substantial number of jaundiced babies in the developing world can be prevented from developing encephalopathy using the basic facilities available if they are brought to the hospital early enough [8].

Delay in seeking appropriate care for newborn illnesses in Ghana was reported to be due to factors like previous negative experiences with health services, complex decision making processes, and preferences for traditional medicine as well as recognition of some types of illnesses as “not for hospital.” [9] Delay in presentation has been suggested to be a plausible reason for the high prevalence of severe hyperbilirubinaemia and bilirubin encephalopathy among babies delivered outside tertiary hospitals in the developing world [1]. Therefore, stringent efforts should be made to prevent delay in making diagnosis and in treating newborn jaundice [10]. Health-care seeking models have demonstrated that delay in seeking appropriate care may lie in poor recognition of the severity and import of disease conditions, lack of knowledge about how to seek care and social and economic impediments to seeking appropriate health care [11]. Studies abound in the developing world about mother’s knowledge, beliefs and attitudes about jaundice [12, 13] but the literature is sparse about factors which may influence their care-seeking behaviours for affected babies even after recognizing the need to seek care.

Increasing knowledge about the need for early identification, early commencement of effective treatment and consequence of severe jaundice are pivotal to the planning and implementation of interventions required to minimize the burden of kernicterus [14]. Therefore, the objective of the present study is to examine the influence of family socio-demographic characteristics and maternal obstetric factors on health care-seeking behaviours for newborn jaundice and the inter-relationship between this behavior and severity of newborn jaundice.

Methods

This study was a descriptive, cross-sectional survey conducted between January 2008 and February 2010 in the Newborn Unit of the Olabisi Onabanjo University Teaching Hospital (OOUTH), Sagamu, Ogun State in southwestern Nigeria. This unit provides specialist neonatal care to newborn babies delivered in the hospital and to those referred from other government-owned hospitals and privately-owned health facilities in at least three states of the federation.

The subjects were consecutive referred term and preterm infants. Inclusion criteria included the presence of jaundice alone or in addition to other disease conditions. Mother-baby pairs with incomplete family socio-demographic data and those delivered in our hospital were excluded from the study. Institutional ethical approval was obtained and the babies who met the inclusion criteria were enrolled after the parents or care givers had given informed consents.

The data collected in the study included neonatal parameters like age, sex and weight on admission. Babies were classified into term (≥37 weeks of gestation) and preterm (<37 weeks of gestation). The estimated gestational age was determined using the Modified Ballard method [15] for babies presenting within the first 48 h of life. For babies older than 48 h, the maternal last menstrual period and the physical features of the babies were used to determine the estimated gestational age. The age (in hours) at observation and documentation of jaundice were also recorded. Delay in presentation was defined as the interval between observation and documentation of jaundice greater than 47 h as previously observed [16]. Maternal bio-social and obstetric parameters such as age, parity, place where antenatal care was received, place of delivery and history of jaundice in the previous children were recorded. The socio-economic classification was done using the educational qualification and occupation of both parents [17]. Scores (1–5) were allotted to groups of occupation and educational qualification for each parent. The highest educational qualifications were scored 1 while the lowest educational qualifications were scored 5. Similarly, the most highly paid jobs scored 1 while the least paid jobs were scored 5. The scores for both parents were summed and averaged. The average score (to the nearest whole number) for each family was equivalent to the socio-economic classes I to V. Thus, classes I and II were uppermost, class III formed the middle class while classes IV and V were the lowermost.

For each baby, the Total Serum Bilirubin (TSB) on admission was plotted on the recommended normogram for the prediction of risk of severe hyperbilirubinaemia to determine the degree of risk of severe hyperbilirubinaemia in relation to age in hours [7]. The subjects were grouped based on maternal age, (<25 and ≥25 years), maternal parity (1 or >1), family socioeconomic status (lower classes or the others), place of antenatal care (orthodox or non-orthodox), place of delivery (orthodox or non-orthodox) and parental education (tertiary/senior secondary or less). For the purpose of this study, primary health centres, private clinics and general hospitals were classified as orthodox health facilities while traditional birth homes, churches and unregistered health posts were classified as non-orthodox health facilities [18]. Outcome variables included the use of home remedies (medications and herbal mixtures) and delay in presentation for ≥48 h. Appropriate health care-seeking behaviour for neonatal jaundice was defined as delay period <48 h without the use of home remedies. The measures of severity included the occurrence of kernicterus and the need for exchange transfusion.

The data were processed with SPSS 15.0 software using descriptive and inferential statistics. Using bivariate analysis, mother-baby pairs in the various groups were compared for the above-stated outcome variables. Proportions were compared with Risk Ratio (RR) and statistical significance was established when the values of 95% Confidence Interval (CI) excluded unity.

Results

General Characteristics of 182 Mother-Baby Pairs

The babies were aged 12–240 h at presentation. Age distribution of the babies showed that 105 (57.7%), 61 (33.5%) and 16 (8.8%) were aged ≤72 h, 73–168 h and >168 h, respectively. There were 120 (65.9%) males and 62 (34.1%) females. The estimated gestational age varied between 28 and 44 weeks; there were 103 (56.6%) preterm babies and 79 (43.4%) term babies.

The places of delivery were private clinics (46.1%), traditional birth homes (20.8%), general hospitals (13.7%), churches (10.4%), residential homes (8.2%) and primary health centres (0.5%). One hundred and twenty-seven (69.8%) mothers recognized jaundice in their infants while the remaining 55 (30.2%) did not. These 55 mothers presented on account of pemphigus neonatorum (21; 38.2%), bleeding from the cord (18; 32.7%), vomiting (11; 20.0%) and milk aspiration (5; 9.1%). Eighty-four (46.2%) babies were admitted primarily with jaundice while 98 (53.8%) were admitted with other conditions including jaundice. Total Serum Bilirubin (TSB) on admission fell in the high risk zone, high intermediate risk zone and low intermediate zone on the recommended age-related normogram for 118 (64.8%), 23 (12.6%) and 41 (22.6%) babies, respectively.

Sixty two (34.1%) mothers delayed seeking appropriate care for their jaundiced babies. The period of delay was 48–96 h among 48 (77.4%) babies, 120–168 h and >168 h among 7 (11.3%) babies each. None of the babies had delay of 97–119 h. One hundred and forty four (79.1%) sought care outside the home while 38 (20.9%) did not seek care outside the home but administered various medications to their babies. In addition, 74 (40.6%) sought medical care at the places of birth (private clinics, primary health centres and general hospitals). Overall, 112 (61.5%) mothers administered various medications and other substances to treat their jaundiced babies at home. These home remedies included Ampiclox® {a proprietary brand of ampicillin and cloxacillin combination} (70; 40.7%), water extract of unripe pawpaw (32; 17.6%), multivitamins (32; 17.6%) and glucose drinks (20; 11.0%) in various combinations.

The mothers were aged 18–41 years. The distribution by age was as follows: 42 (23.1%) were aged <25 years while 140 (76.9%) were aged ≥25 years. The levels of maternal education were as follows: no formal education (7; 3.8%), primary education (43; 23.6%), junior secondary education (27; 14.8%), senior secondary education (70; 38.5%) and tertiary education (35; 19.3%). Similarly paternal educational qualifications were as follows: primary (25; 13.7%), junior secondary education (20; 11.0%), senior secondary education (64; 35.1%) and tertiary education (73; 40.1%).

Sixty-one (33.5%) mothers were primiparous while 100 (54.9%) and 21 (11.5%) were multiparous and grandmultiparous, respectively. One hundred and twenty-one mothers provided information with regards to occurrence of jaundice in an older child; out of these 59 (48.8%) were affirmative while 62 (51.2%) denied history of jaundice in an older child.

Appropriate Health Care-Seeking Behavior for Jaundice

Out of 182 mothers, 52 (28.6%) had appropriate care-seeking behaviours with respect to their jaundiced babies while the remaining 130 (71.4%) did not. Table 1 shows the comparison of mothers with and without appropriate health care-seeking behaviours in relation to socio-demographic characteristics and some maternal obstetric factors. Compared to mothers who had inappropriate care-seeking behaviours, significantly higher proportions of mothers who had appropriate care-seeking behaviours were primiparous (48.1%), had high education (92.3%) and belonged to socio-economic classes I to III (59.6%). The fathers of this group of babies were also significantly highly educated (88.5%). On the other hand, maternal age, utilization of orthodox prenatal and delivery services and history of jaundice in an older child had no significant influence on appropriate care-seeking behaviours.
Table 1

Socio-demographic characteristics and appropriate health care-seeking behavior for neonatal jaundice

Indices

Appropriate behavioura (n = 52)

Inappropriate behaviourb (n = 130)

RRc (CId)

Maternal age

 <25 years

13 (25.0)

29 (22.3)

1.1; (0.66–1.81)

 >25 years

39 (75.0)

101 (77.7)

Maternal parity

 1

25 (48.1)

36 (27.7)

1.8; (1.17–2.88)*

 >1

27 (51.9)

94 (72.3)

Maternal education

 Highe

48 (92.3)

57 (43.8)

8.8; (3.31–23.37)*

 Low

4 (7.7)

73 (56.2)

Paternal education

 Highe

46 (88.5)

91 (70.0)

2.5; (1.15–5.50)*

 Low

6 (11.5)

39 (30.0)

Socioeconomic status

 Lowf

21 (40.4)

74 (56.9)

0.6; (0.39–0.98)*

 High

31 (59.6)

56 (43.1)

History of jaundice

 Yesg

11/27 (40.7)

48/94 (51.1)

0.8; (0.49–1.31)

Place of prenatal care

 Orthodoxh

37 (71.1)

97 (74.6)

0.8; (0.54–1.46)

 Non-orthodox

15 (28.9)

33 (25.4)

Place of delivery

 Orthodoxh

32 (61.5)

78 (60.0)

1.0; (0.65–1.68)

 Non-orthodox

20 (38.5)

52 (40.0)

KEY: figures in parentheses are percentages of the respective total

aAppropriate health care-seeking behaviour

bInappropriate health care-seeking behavior

cRisk ratio

d95% confidence interval

eSenior secondary/tertiary education

fSocio-economic classes IV and V

gHistory of jaundice in an older child

hGeneral hospitals, primary health centres and private clinics

* Statistically significant

In Table 2, only low maternal education (50.9%) was significantly associated with the use of home remedies while the mothers who administered home remedies or not were similar in terms of age, parity, socio-economic status, history of jaundice in an older child and utilization of orthodox prenatal care and delivery services. There was no relationship with fathers’ education. In addition, there was no significant association between use of home remedies and preterm birth {62/112 vs. 41/70; RR = 0.9, CI = 0.72–1.20} or between use of home remedies and the co-existence of jaundice with other disease conditions {52/112 vs. 32/70; RR = 1.0, CI = 0.73–1.40} (Data not presented in Table 2).
Table 2

Socio-demographic characteristics in relation to use of home remedies

Indices

Use of home remedies (n = 112)

Non-use of home remedies (n = 70)

RRa (CIb)

Maternal age

 <25 years

26 (23.2)

16 (22.9)

1.0; (0.77–1.32)

 >25 years

86 (76.8)

54 (77.1)

 

Maternal parity

 1

32 (28.6)

29 (41.4)

0.7; (0.61–1.04)

 >1

80 (71.4)

41 (58.6)

 

Maternal education

 Highc

55 (49.1)

50 (71.4)

0.7; (0.56–0.89)*

 Low

57 (50.9)

20 (28.6)

 

Paternal education

 Highc

81 (72.3)

56 (80.0)

0.8; (0.67–1.09)

 Low

31 (27.7)

14 (20.0)

 

Socioeconomic status

 Lowd

61 (54.5)

34 (48.6)

1.1; (0.89–1.38)

 High

51 (45.5)

36 (51.4)

 

History of jaundice

 Yese

41/80 (51.3)

18/41 (43.9)

1.2; (0.78–1.75)

Place of prenatal care

 Orthodoxf

84 (75.0)

50 (71.4)

1.0; (0.82–1.41)

 Non-orthodox

28 (25.0)

20 (28.6)

 

Place of delivery

 Orthodoxf

68 (60.7)

42 (60.0)

1.0; (0.80–1.28)

 Non-orthodox

44 (39.3)

28 (40.0)

 

KEY: figures in parentheses are percentages of the respective total

aRisk ratio

b95% confidence interval

cSenior secondary/tertiary education

dSocio-economic classes IV and V

eHistory of jaundice in an older child

fGeneral hospitals, primary health centres and private clinics

* Statistically significant

Furthermore, significantly higher proportions of babies with <48 h delay in the documentation of jaundice belonged to primiparous mothers (25.0%), mothers with high education (82.5%), mothers in high socio-economic classes (57.5%) and fathers with high education (86.6%) as shown in Table 3. There was no significant relationship between delay for ≥48 h and maternal age, history of jaundice in an older child and utilization of orthodox prenatal care and delivery services. However, term babies {39/62 vs. 40/120; RR = 1.9, CI = 1.40–2.63} and babies with jaundice not co-existing with other diseases were significantly more likely to be delayed for ≥48 h {55/62 vs. 29/120; RR = 3.6, CI = 2.64–5.10} (Data not presented in Table 3).
Table 3

Socio-demographic characteristics in relation to delay in presentation

Indices

Delay <48 ha (n = 120)

Delay ≥48 hb (n = 62)

RRc (CId)

Maternal age

 <25 years

30 (25.0)

12 (19.9)

1.1; (0.88–1.40)

 >25 years

90 (75.0)

50 (80.1)

Maternal parity

 1

47 (39.2)

14 (22.6)

1.3; (1.05–1.56)*

 >1

73 (60.8)

48 (77.4)

Maternal education

 Highe

99 (82.5)

6 (9.7)

3.5; (2.39–4.99)*

 Low

21 (17.8)

56 (90.3)

Paternal education

 Highe

104 (86.6)

33 (53.2)

2.1; (1.42–3.20)*

 Low

16 (13.4)

29 (46.8)

Socioeconomic status

 Lowf

51 (42.5)

44 (70.9)

0.6; (0.55–0.84)*

 High

69 (57.5)

18 (29.1)

History of jaundice

 Yesg

28/48 (58.3)

31/73 (42.5)

1.3; (0.96–1.97)

Place of prenatal care

 Orthodoxh

89 (74.2)

45 (58.4)

1.0; (0.81–1.31)

 Non-orthodox

31 (25.8)

17 (41.6)

Place of delivery

 Orthodoxh

78 (65.0)

32 (41.6)

1.2; (0.97–1.53)

 Non-orthodox

42 (35.0)

30 (58.4)

KEY: figures in parentheses are percentages of the respective total

aInterval between observation and documentation of jaundice <48 h

bInterval between observation and documentation of jaundice ≥48 h

cRisk ratio

d95% confidence interval

eSenior secondary/tertiary education

fSocio-economic classes IV and V

gHistory of jaundice in an older child

hGeneral hospitals, primary health centres and private clinics

* Statistically significant

Measures of Severity of Jaundice

In Table 4, significantly higher proportions of babies of mothers with high education (68.5%) and high socio-economic status (61.8%) as well as higher proportion of babies of fathers with high education (84.3%) did not require exchange transfusion. However, there was no significant association between requirement for exchange transfusion and maternal age, parity, history of jaundice in an older child or utilization of orthodox prenatal care and delivery services.
Table 4

Socio-demographic characteristics in relation to the requirement for exchange transfusion

Indices

EBT requireda (n = 93)

EBT not requiredb (n = 89)

RRc (CId)

Maternal age

 <25 years

24 (25.8)

18 (20.2)

1.1; (0.85–1.58)

 >25 years

69 (74.2)

71 (79.8)

Maternal parity

 1

31 (33.3)

30 (33.7)

0.9; (0.73–1.34)

 >1

62 (66.7)

59 (66.3)

Maternal education

 Highe

44 (47.3)

61 (68.5)

0.6; (0.50–0.87)*

 Low

49 (52.7)

28 (31.5)

Paternal education

 Highe

62 (66.7)

75 (84.4)

0.6; (0.50–0.86)*

 Low

31 (33.3)

14 (15.6)

Socioeconomic status

 Lowf

61 (65.6)

34 (38.2)

1.7; (1.28–2.39)*

 High

32 (34.4)

55 (61.8)

History of jaundice

 Yesg

29/62 (46.8)

30/59 (50.8)

0.9; (0.64–1.33)

Place of prenatal care

 Orthodoxh

68 (73.1)

66 (74.2)

0.9; (0.71–1.34)

 Non-orthodox

25 (26.9)

23 (25.8)

Place of delivery

 Orthodoxh

59 (63.4)

51 (57.3)

1.1; (0.84–1.53)

 Non-orthodox

34 (36.6)

38 (42.7)

KEY: figures in parentheses are percentages of the respective total

aExchange transfusion needed to regulate serum bilirubin

bExchange transfusion not needed to regulate serum bilirubin

cRisk ratio

d95% confidence interval

eSenior secondary/tertiary education

fSocio-economic classes IV and V

gHistory of jaundice in an older child

hGeneral hospitals, primary health centres and private clinics

* Statistically significant

Table 5 depicts the relationship between family social variables and the occurrence of kernicterus in their babies. Significantly higher proportions of babies of mothers with multiparity (69.6%), low education (50.9%), low socio-economic status (92.4%) as well as babies of fathers with low education (34.2%) had kernicterus. On the other hand, maternal age, history of jaundice in an older child and utilization of orthodox prenatal care and delivery services were not significantly associated with the development of kernicterus.
Table 5

Socio-demographic characteristics in relation to the occurrence of kernicterus

Indices

ABE present (n = 79)

ABE absent (n = 103)

RRa (CIb)

Maternal age

 <25 years

22 (27.8)

20 (19.4)

1.4; (0.84–2.44)

 >25 years

57 (72.2)

83 (80.6)

Maternal parity

 1

24 (30.4)

37 (35.9)

0.8; (0.60–0.97)*

 >1

55 (69.6)

66 (64.1)

Maternal education

 Highc

33 (41.7)

72 (69.9)

0.5; (0.38–0.74)*

 Low

46 (58.3)

31 (30.1)

 

Paternal education

 Highc

52 (65.8)

85 (82.5)

0.63; (0.46–0.87)*

 Low

27 (34.2)

18 (17.5)

 

Socioeconomic status

 Lowd

73 (92.4)

22 (21.4)

11.1; (5.11–24.30)*

 High

6 (7.6)

81 (78.6)

History of jaundice

 Yese

29/55 (52.7)

30/66 (45.5)

1.1; (0.81–1.67)

Place of prenatal care

 Orthodoxf

52 (65.8)

82 (79.6)

0.69; (0.50–1.06)

 Non-orthodox

27 (34.2)

21 (21.4)

Place of delivery

 Orthodoxf

44 (55.7)

66 (64.1)

0.82; (0.59–1.14)

 Non-orthodox

35 (44.3)

37 (35.9)

KEY: figures in parentheses are percentages of the respective total

aRisk ratio

b95% confidence interval

cSenior secondary/tertiary education

dSocio-economic classes IV and V

eHistory of jaundice in an older child

fGeneral hospitals, primary health centres and private clinics

* Statistically significant

There was similarity in the proportions of babies with and without home administration of remedies who had exchange transfusion {60/112 vs. 33/70; RR = 1.1, CI = 0.84–1.54} and kernicterus {50/112 vs. 29/70; RR = 1.1, CI = 0.76–1.52}. Instructively, a significantly higher proportion of babies who had home administration of remedies also had delay ≥48 h {52/112 vs. 10/60; RR = 2.8, 1.53–5.07}. Similarly, a significantly high proportion of babies with delay ≥48 h had kernicterus {44/62 vs. 35/120; RR = 2.4, CI = 1.76–3.35} and required exchange transfusion {44/62 vs. 49/120; RR = 1.7, CI = 1.33–2.29}.

Discussion

This study has shown that health care-seeking behavior with respect to newborn jaundice was poor in close to three-quarter of the families studied in this Nigerian population. This implies that three out of four jaundiced babies delivered outside the teaching hospital in this population are at risk of mismanagement and severe morbidities. It also justifies the relevance of this study in this population and calls for stringent efforts at improving the practice and attitude of families to jaundiced infants. The exclusion of in-born babies from this study eliminated bias arising from the routine counseling of mothers and assessment of their babies in our hospital. It is instructive that more than two-thirds of the mothers studied recognized jaundice in their babies and this was markedly higher than 36.5% reported from India in 2006 [19].

The administration of drugs and other remedies to jaundiced babies at home was widely practiced in this population similar to reports from Ghana [9] and India [19] in respect of neonatal illnesses generally. The wide use of home remedies might have stemmed from the cultural belief that every illness deserves drug treatment. Unfortunately, the mothers inadvertently administered drugs with no pharmacologically proven bilirubin clearance efficacy to jaundiced infants. Examples of such drugs include glucose drinks, a proprietary combination of ampicillin and cloxacillin and multivitamins. These agreed with previous Nigerian studies which reported the belief of mothers in the use of such medications to treat neonatal jaundice [12, 20].

The widespread use of home remedies might explain the lack of significant association between the use of home remedies and the requirement for exchange transfusion as well as the distribution of kernicterus among the infants studied. There was also no significant relationship between the use of home remedies and level of TSB on admission. Although, this observation suggests that the remedies applied may not be icterogenic, this deserves further in-depth research. It is essential to conclusively determine the effects of these agents on serum bilirubin. Nevertheless, only high maternal education was associated with non-use of home remedies whereas paternal education and family socio-economic status had no such influence. This highlights the relevance of maternal educational empowerment to child health and improved child survival.

Delay in presentation in our hospital significantly influenced severity of jaundice at presentation. Most of the babies who had delayed presentation also had high Total Serum Bilirubin (TSB) on admission, required exchange transfusion and developed kernicterus. Obviously, delay in seeking appropriate care increases the severity of jaundice and puts the affected infants at risk of complications. It, therefore, implies that there should be no delay when newborn babies are observed to be jaundiced. Unfortunately, mothers in the population studied often take neonatal jaundice for granted except when it is associated with another illness or when jaundice makes the infant unwell. Little wonder, jaundice not co-existing with other illnesses was significantly associated with delay more than 48 h in the present study. Interestingly, the use of home remedies was associated with delay in presentation for more than 48 h. This suggests that the use of home remedies also delays prompt health care-seeking. Therefore, discouraging the use of home remedies would encourage earlier health care-seeking for neonatal jaundice and ultimately improve the outcome in newborn jaundice.

High maternal and paternal education and high family socio-economic status were significantly associated with early presentation of jaundiced babies in our hospital. This agreed with previous reports that high maternal education and family socio-economic status are associated with good health care seeking behaviours [11, 21] probably because families with such characteristics have better access to health information and could utilize such information optimally. Similarly, high maternal education and high socioeconomic status have been shown to be related to good child health indices like breastfeeding practices [21, 22]. Therefore, the focus of health education and counseling in this respect should be families with low socio-economic status. Apart from using the mass media, community groups and religious groups should also be used as platforms on which to provide the health education. Emphasis should be on the fact that every jaundiced infant requires estimation of TSB to decide whether further care is required or not. It is also essential to emphasize that with or without other signs of illnesses like fever, poor cry or poor activity, jaundice could also be a major illness and should not be taken for granted as mere skin discolouration.

It is instructive that contrary to expectation, the utilization of orthodox health facilities for prenatal care and delivery did not positively influence any of the indices of appropriate health care-seeking behaviors for jaundice or be associated with reduced severity of jaundice at presentation in the hospital. This finding was similar to previous reports from a similar Yoruba community in southwest Nigeria where utilization of orthodox prenatal care and delivery services did not influence appropriate breastfeeding practices [21]. The observation made in the present study may suggest that mothers who utilized orthodox prenatal care facilities were probably not equipped with enough information about jaundice before delivery or that their babies were not appropriately assessed for jaundice after birth. This observation calls for the integration of a detailed approach to the care of neonatal hyperbilirubinaemia into training programmes for health workers as previously reported from Sri Lanka [23]. Studies have shown that some cadres of health workers actually had poor knowledge of the management of neonatal jaundice [24]. Such health workers would benefit from structured training programmes on the management of newborn jaundice.

Similarly, health facilities providing prenatal care and delivery services should be encouraged to adopt routine assessment of newborn babies for jaundice after birth and after discharge from the health facilities. This is provided in the National Institute for Health and Clinical Excellence (NICE) guidelines on routine postnatal infant care in the UK [25] and can be adapted to local practices in other parts of the world. In these guidelines, health workers need to be trained to assess newborns for jaundice (and assess serum bilirubin where facilities are available) prior to discharge from the nursery. Health information materials should be made available to mothers to increase their knowledge and vigilance about jaundice. Timely follow-up of newborn babies should also be arranged to detect jaundice appearing after discharge, monitor the progress of jaundice of existing jaundice and encourage re-admission into the hospital if need be.

The role of maternal age in appropriate health care-seeking behaviours had earlier been demonstrated [11]. The relatively older mothers tended to seek care for their ill children late and within home. Similarly, the observations made in this study showed that most of the mothers who had inappropriate health care-seeking behaviours and whose babies had severe jaundice warranting exchange transfusion or developed kernicterus were relatively older although without statistical significance. Maternal multiparity was also significantly associated with the occurrence of kernicterus in their jaundiced babies. It is attractive to postulate that these groups of mothers are more likely to be independent in their actions and decision making and so, less compliant with health instructions. Therefore, health education drives aimed at improving home care for jaundiced babies should focus on mothers who are older than 25 years and multiparous amongst other characteristics.

A limitation of this study is the fact that it is hospital-based. It would also be interesting to know the socio-demographic profile of mothers who do not seek hospital care for their jaundiced infants. It may also be important to assess mothers’ knowledge about possible causes and sequelae of jaundice and subsequently relate the level of knowledge to their health care-seeking behavior. These should be considered in subsequent studies of this nature.

In conclusion, poor recognition of jaundice may no longer be a significant problem in this population. Rather, failure to promptly seek appropriate health care for jaundice is an issue which deserves stringent attention. Educational empowerment of families may improve the health care-seeking behaviour for neonatal jaundice. Counseling of expectant mothers about good care-seeking behavior for newborn jaundice should be incorporated into routine health talks at the antenatal, immunization and postnatal clinics. The mass media, offering wider coverage, can also be used to discourage the use of home remedies for newborn jaundice. With improved appropriate health care-seeking behavior for jaundice, the opportunity for effective treatment of newborn jaundice would be adequately used. Furthermore, the burden of severe hyperbilirubinaemia and bilirubin encephalopathy would be minimized.

Notes

Acknowledgments

The assistance of Dr Dodondawa Oluwo and other interns who worked in the Neonatal Ward of the Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria during the period of study is deeply appreciated.

Conflicts of Interest

None declared.

References

  1. 1.
    Ogunlesi, T. A., Dedeke, I. O. F., Adekanmbi, A. F., Fetuga, M. B., & Ogunfowora, O. B. (2007). The incidence and outcome of bilirubin encephalopathy in Nigeria: A bi-centre study. Nigerian Journal of Medicine, 16, 354–359.PubMedGoogle Scholar
  2. 2.
    Ebbesen, F. (2000). Recurrence of kernicterus in term and near-term infants in Denmark. Acta Paediatrica, 89, 1213–1217.PubMedCrossRefGoogle Scholar
  3. 3.
    Hansen, T. W. (2000). Kernicterus in term and near-term infants—the specter walks again. Acta Paediatrica, 89, 1155–1157.PubMedCrossRefGoogle Scholar
  4. 4.
    Bhutani, V. K., & Johnson, L. H. (2003). Newborn jaundice and kernicterus—health and societal perspectives. Indian Journal of Pediatrics, 70, 407–416.PubMedCrossRefGoogle Scholar
  5. 5.
    Ogunlesi, T. A., Ogundeyi, M. M., Ogunfowora, O. B., & Olowu, A. O. (2008). Socio-clinical issues in Cerebral Palsy in Sagamu, Nigeria. South African Journal of Child Health, 2, 120–124.Google Scholar
  6. 6.
    Dixon, K. T. (2004). Newborn jaundice and kernicterus. Greater awareness and action needed. Advance for Nurse Practitioners, 12, 43–46.PubMedGoogle Scholar
  7. 7.
    American Academy of Pediatrics Subcommittee on Hyperbilirubinaemia. (2004). Management of Hyperbilirubinaemia in the Newborn Infant 35 or more weeks of Gestation. Pediatrics, 114, 297–316.CrossRefGoogle Scholar
  8. 8.
    Owa, J. A., & Ogunlesi, T. A. (2009). Why we are still doing so many exchange blood transfusions for neonatal jaundice in Nigeria. World Journal of Pediatrics, 5, 51–55.PubMedCrossRefGoogle Scholar
  9. 9.
    Bazzano, A. N., Kirkwood, B. R., Tawiah-Agyemang, C., Owusu-Agyei, S., & Adongo, P. B. (2008). Beyond symptom recognition: Care-seeking for ill newborns in rural Ghana. Tropical Medicine and International Health, 13, 123–128.PubMedCrossRefGoogle Scholar
  10. 10.
    Shapiro, S. M. (2010). Kernicterus and newborn jaundice online. Available at http://www.kernicterus.org. Accessed on 7th Feb 2010.
  11. 11.
    Ogunlesi, T. A., Olanrewaju, D. M. (2010). Socio-demographic characteristics and appropriate health care-seeking behaviours for childhood illnesses. Journal of Tropical Pediatrics. doi:10.1093/tropej/fmq009.
  12. 12.
    Ogunfowora, O. B., Adefuye, P. O., & Fetuga, M. B. (2006). What do expectant mothers know about neonatal jaundice? International Electronic Journal of Health Education, 9, 134–140.Google Scholar
  13. 13.
    Khalesi, N., & Rakhshani, F. (2008). Knowledge, attitude and behavior of mothers on neonatal jaundice. Journal of Pakistan Medical Association, 58, 671–674.Google Scholar
  14. 14.
    Bhutani, V. K., Johnson, L. H., Maisels, M. J., Newman, T. B., & Phibbs, C. (2004). Kernicterus: Epidemiological strategies for its prevention through systems-based approaches. Journal of Perinatology, 24, 650–652.PubMedCrossRefGoogle Scholar
  15. 15.
    Ballard, J. L., Khoury, J. C., Wednig, K., et al. (1991). New Ballard score, expanded to include extremely premature infants. Journal of Pediatric, 119, 417.Google Scholar
  16. 16.
    Ogunlesi, T. A., Ogunfowora, O. B. (2010). Predictors of acute bilirubin encephalopathy among term Nigerian infants with moderate-to-severe hyperbilirubinaemia. Journal of Tropical Pediatrics. doi:10.1093/tropej/fmq045.
  17. 17.
    Ogunlesi, T. A., Dedeke, I. O. F., & Kuponiyi, O. T. (2008). Socio-economic classification of children attending specialist health facilities in Ogun State. Nigerian Medical Practitioner, 54, 21–25.CrossRefGoogle Scholar
  18. 18.
    Ogunlesi, T. A. (2005). The pattern of utilization of prenatal and delivery services in Ilesha, Nigeria. The Internet Journal of Epidemiology, 2(2). Available at http://www.ispub.com last accessed on the 13th April 2010.
  19. 19.
    Awatshi, S., Verma, T., & Agarwal, M. (2006). Danger signs of neonatal illness: Perceptions of caregivers and health workers in northern India. Bulletin of the World Health Organization, 84, 819–826.CrossRefGoogle Scholar
  20. 20.
    Eneh, A. U., & Ugwu, R. O. (2009). Perception of neonatal jaundice among women attending children out-patient, immunization clinics of the UPTH, Port Harcourt. Nigerian Journal of Clinical Practice, 12, 187–191.PubMedGoogle Scholar
  21. 21.
    Ogunlesi, T. A. (2010). Maternal socio-demographic factors and the initiation and exclusivity of breastfeeding in a Nigerian semi-urban setting. Maternal and Child Health Journal, 14, 459–465.PubMedCrossRefGoogle Scholar
  22. 22.
    Wamani, H., Astrom, N., Peterson, S., Tylleskar, T., & Tumwine, J. K. (2005). Infnat and young child feeding in Western Uganda: Knowledge, practices and socioeconomic correlates. Journal of Tropical Pediatrics, 51, 356–361.PubMedCrossRefGoogle Scholar
  23. 23.
    Senarath, U., Fernado, D. N., & Rodrigo, I. (2006). Newborn care practices at home: Effect of a hospital-based intervention in Sri Lanka. Journal of Tropical Pediatrics, 53, 113–118.PubMedCrossRefGoogle Scholar
  24. 24.
    Ogunfowora, O. B., & Daniel, O. J. (2006). Neonatal Jaundice and its management: Knowledge, attitude and practice of community Health Workers in Nigeria. BMC Public Health, 6, 19. doi:10.1186/14712458-6-19.PubMedCrossRefGoogle Scholar
  25. 25.
    Sellwood, M., & Huertas-Ceballos, A. (2008). Review of NICE guidelines in routine postnatal infant care. Archives of Disease in Childhood. Fetal and Neonatal Edition, 93, 10–13.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  1. 1.Department of PaediatricsOlabisi Onabanjo University Teaching HospitalSagamuNigeria
  2. 2.Department of Nursing ServicesOlabisi Onabanjo University Teaching HospitalSagamuNigeria

Personalised recommendations