According to the World Health Organization (WHO), the early newborn period is the most critical for survival for a neonate [
The majority of neonatal deaths in developing countries occur at home, up to two-thirds of which can be prevented if timely and efficient health measures are taken [
Preventing mortalities by enhancing the child health in the community is at the principal of the approach named Integrated Management of Childhood Illness (IMCI), which was developed by UNICEF and the WHO in 1992 to prevent or detect and treat the top childhood killers [
Immediate recognition of the danger signs mentioned in IMCI is the first and most important clue a mother or a caregiver could perceive to seek medical attention. The danger signs recognized by WHO could indicate a severe disease or a local infection. The danger signs for a severe disease are refusal of feeds, convulsions, fast breathing, fever, low body temperature, severe chest in-drawing, and movement only when stimulated or no movement at all. The signs of local infection are umbilical redness or draining pus and skin pustules [
In Saudi Arabia infant mortality rate is 13 deaths per 1000 live births in 2015 [
A community-based cross-sectional study was conducted in Riyadh City of Saudi Arabia to investigate the knowledge of Saudi mothers and caregivers towards the WHO neonate's danger signs. In 2013, the literacy rate, among adult females (% of females 15 and above), is 91.37 [
All mothers who delivered during the past two years or have nursed a baby in the past two years (in case of caregivers) were considered in the sampling process. Caregivers included grandmothers, grandfathers, fathers, or “nannies” (other female relatives). Women that were unable to provide information during the data collection period were excluded.
Face to face interviews were conducted with the mothers at the PHCCs by trained research assistants using a structured questionnaire that was piloted for ambiguity before the study began. The interview was designed after an in-depth literature review [
The information collected included the sociodemographic characteristics of the neonate and the mothers/caregivers including age, gender of the neonate, area of residence, education level, monthly income, occupation, and number of children or number of children nursed by caregivers. Information on the reproductive history of pregnant women and mother’s knowledge, experience, and response for the neonate’s danger signs was also collected. Participants were asked to list the signs they would consider to be serious health problems and might threaten the neonate's life. They were also asked to list any of the signs that they experienced personally with their neonate, the actions they took, the help they sought from the healthcare institution, and reasons for not utilizing the services of any healthcare facility. They were requested to recall the time from noticing the danger sign(s) and presentation to the health care facility, promptness of care received in the health facility, and outcome of their neonate’s illness. The signs were clustered according to the Nine [
Informed consent was obtained before each participant’s enrollment, the identity of the participant was kept confidential, and the institutional review board approval was obtained from the Directorate of PHCCs, Ministry of Health, Riyadh, and from King Fahad Medical City, Riyadh, Saudi Arabia.
Based on the infant mortality and fertility rates, the estimated population of neonates at risk is 200,000 across Saudi Arabia. Estimated sample size of (N = 1425) for the study was calculated with the assumptions of precision = 1.00 %, prevalence = 1.25 %, population size = 200,000, and 95% Confidence interval specified limits of 0.25%-2.25% (these limits equal prevalence plus or minus precision).
Data analysis was done using Stata (version 12) software. Percentages and frequencies were used to describe the sociodemographic characteristics. Frequencies and percentages (95% Confidence Intervals-CI) were computed for the mother’s knowledge and experience of neonate danger signs (9 items). A total score (total number of correct spontaneous answers to nine items with a minimum score of zero and maximum of nine) was computed to measure the mother’s knowledge about the danger signs and a mother's knowledge was considered to be satisfactory if she had the knowledge of at least 3 danger signs (i.e., a score of 3 or above) [
The sociodemographic characteristics of 1428 women included in the analysis are described in Table
Participants’ characteristics (N=1428).
Variables | Frequency (%) |
---|---|
| |
18-25 | 327 (22.9) |
26-30 | 411 (28.8) |
31-40 | 587 (41.1) |
40-50 | 102 (7.2) |
| |
1-6 | 596 (42.1) |
7-12 | 489 (34.5) |
13-18 | 145 (10.2) |
19-24 | 187 (13.2) |
| |
Mother | 1397 (97.8) |
Health caregiver | 31 (2.2) |
| 727 (51.7) |
| 1298 (90.9) |
| |
Central | 239 (16.7) |
West | 238 (16.7) |
East | 521 (36.5) |
South | 192 (13.4) |
North | 238 (16.7) |
| |
Illiterate | 152 (10.6) |
Primary school | 87 (6.1) |
Middle School | 188 (13.2) |
Secondary School | 533 (37.3) |
Bachelor | 430 (30.1) |
Higher Education | 38 (2.7) |
| |
0-5000 | 557 (49.6) |
6000-10000 | 432 (38.5) |
10000 and above | 134 (11.9) |
| |
Government | 170 (11.9) |
Private Sector | 66 (4.6) |
Unemployed | 1192 (83.5) |
| |
1-3 | 881 (62.4) |
4-5 | 387 (27.4) |
≥6 | 145 (10.3) |
Participants’ knowledge of neonate’s danger signs is summarized in Table
Participants' knowledge (recognition) of the neonatal danger signs.
Danger Signs | Frequency (%) | 95% CI |
---|---|---|
Not feeding since birth or stopped feeding | 657 (46.0) | 43.4-48.5 |
Convulsion | 261 (18.2) | 16.3-20.3 |
Fast breathing | 156 (10.9) | 9.3-12.5 |
Severe chest indrawing | 137 (9.6) | 8.1-11.1 |
Fever ≥ 37.5°C | 445 (31.2) | 28.8-33.6 |
Hypothermia ≤ 35.5°C | 71 (5.0) | 3.8-6.1 |
Weakness or lethargy | 171 (12.0) | 10.3-13.7 |
Yellow soles | 688 (48.2) | 45.6-50.8 |
Sign of local infection | 530 (37.1) | 34.6-39.6 |
knowledge of at least 3 of the above danger signs | 535 (37.5) | 34.9-40.0 |
The majority 68.8% (95% CI: 66.3-71.2) of the participants had experienced at least one of the danger signs with their baby. In this study, the frequently reported danger signs were sign of jaundice 27.1% (95% CI: 24.8-29.4), not feeding since birth or stopped feeding 24.7% (95% CI: 22.4-26.9), sign of local infection 19.3% (95% CI: 17.2-21.3), and fever 18.6% (95% CI: 16.6-20.6). Experiences of the other danger signs, listed in Table
Participants' experience of the neonatal danger signs.
Danger Signs | Frequency (%) | 95% CI |
---|---|---|
Not feeding since birth or stopped feeding | 352 (24.7) | 22.4-26.9 |
Convulsion | 93 (6.5) | 5.2-7.8 |
Fast breathing | 54 (3.8) | 2.8-4.8 |
Severe chest indrawing | 59 (4.1) | 3.1-5.2 |
Fever ≥ 37.5°C | 266 (18.6) | 16.6-20.6 |
Hypothermia ≤ 35.5°C | 15 (1.1) | 0.5-1.6 |
Weakness or lethargy | 59 (4.1) | 3.1-5.2 |
Yellow soles | 387 (27.1) | 24.8-29.4 |
Sign of local infection | 275 (19.3) | 17.2-21.3 |
Experience of at least one of the above danger signs | 982 (68.8) | 66.3-71.2 |
About 635 (44.5) of the mothers/caregivers sought medical care, of whom 285 (46.9%) sought private hospital and 217 (35.7%) sought PHCCs. The time lapse between occurrence of the neonatal danger signs and seeking the help of the medical care was (10.4±12.1 hours). Out of the 592 of the mothers/caregivers who reported the final outcome of their neonates' experience with danger signs, one baby death was reported and 9 babies developed complications (Table
Seeking the medical care subsequent to experience of neonatal danger signs.
| 635 (44.5) |
| |
Private hospital | 285 (46.9) |
PHCCs | 217 (35.7) |
Governmental Hospital | 106 (17.4) |
| 10.4 (±12.1) |
| |
Resolved | 582 (98.3) |
Complicated | 9 (1.5) |
Died | 1 (0.2) |
Data presented as number (%) and mean (±SD).
Adequate mother's and/or caregiver’s knowledge of neonate danger signs is important for reducing infant mortality and morbidity. In this study, we assessed mother’s knowledge of the key danger signs of infants. Slightly more than one-third of the women appeared to have a satisfactory knowledge of the neonate danger signs (knowledge of at least three signs) and the proportion of women with knowledge of each frequently reported danger sign was even less than fifty percent. The majority reported that they have had an experience of at least one danger sign with their baby, which is corroborated with the proportion of women that appeared to know at least one danger sign. Previous studies in different setting have revealed varied differences in women’s knowledge of neonatal danger signs. The proportion of women knowing at least one danger sign in this study is congruent with several studies [
In present study, the proportion of mothers who reported at least three danger signs was low (37%), which was lower than the proportion reported (81%) in Iraq by Abdulrida et al. (2015) [
In this study, a low level of mothers’ knowledge of the neonate’s danger signs was observed even though the majority of the women had attended the recommended > 4 visits of antenatal care; this led to an idea that the antenatal care providers may not have proper resources and facilities to educate mothers about the neonate danger signs. It is also possible that the low level of mothers’ knowledge could be contributed to their socioeconomic circumstances such as lack of higher educational achievement, low income, and access to social activities. Previous studies in different settings have identified factors that are significantly associated with mothers' knowledge of neonate’s danger signs [
Mothers with sound economic status are expected to have access to better health care services and other resources such as exposure to media especially television to learn about the neonate’s health [
In our study, less than half of the mothers/caregivers reported seeking medical facilities for danger signs management. In study done in Iraq, it was revealed that 25.4% of the mothers sought medical facilities for danger signs management [
In study conducted in Pakistan, it was showed that 69.4% had sought private sector and 11.7% sought government sector [
Parts of the strengths of this study include the high number of participating women and being conducted in community-based settings across the five regions of Riyadh, the capital of Saudi Arabia. The study was rigorously conducted using multistage sampling techniques, recruiting a large sample of women, and including women from a wider geographical area in Riyadh. The questionnaires were completed by a research assistant in a face to face interview of the mother or care provider at PHCCs, which ensured the accuracy of the information collected. As reported in a study of clinical signs of younger infants [
Although the participants' experience of the neonatal danger signs is high, the proportion of mothers/caregivers knowing at least three danger signs is still low in this community-based study. Therefore, in Saudi Arabia, the public health and educational policymakers are required to consider developing interventions strategies for increasing mother’s knowledge and awareness of neonatal danger signs to reduce infants' mortality and morbidity. Such strategies should focus on training of health care workers and establishing a rigorous supportive supervision for quality assurance and sustained health education by utilizing maternal child health booklets as interventions modalities followed by continuous evaluation to confirm the validity of these interventions.
The data used to support the findings of this study are available from the corresponding author upon request.
The authors declare that they have no conflicts of interest.
The authors would like to thank the Research Center, King Fahad Medical City, Riyadh, Saudi Arabia, for providing the research fund to conduct this study.