|Year : 2016 | Volume
| Issue : 3 | Page : 743-748
Mothers' perception toward neonatal jaundice in Kafr El-batanoon village, Menoufia, Egypt
Dalia M Allahony1, Nagwa N Hegazy2, Zeinab A Kasemy3, Eman M Bahgat4
1 Department of Pediatrics and Neonatology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Family Medicine, Faculty of Medicine, Menoufia University, Menoufia, Egypt
3 Department of Public Health, Faculty of Medicine, Menoufia University, Menoufia, Egypt
4 Kafr El-batanoon Unit, Department of Family Medicine, Menoufia, Egypt
|Date of Web Publication||23-Jan-2017|
Eman M Bahgat
Kafr El-batanoon Unit, Department of Family Medicine, Shebin Elkom, Menoufia, 32721
Source of Support: None, Conflict of Interest: None
The aim of this study was to evaluate the knowledge, attitude, and practice of the mothers toward neonatal jaundice (NNJ).
NNJ is a significant cause of neonatal morbidity worldwide and accounts for 75% of hospital readmissions in the first week of life. Severe NNJ can lead to irreversible brain damage or even death in otherwise healthy newborns. Because of early discharge of mothers from the hospitals, the responsibility of mothers in recognizing jaundice has increased. Mothers therefore play a vital role in the early identification and prevention of complication.
Materials and methods
This cross-sectional study was carried out on 265 mothers who attended Kafr El-batanoon primary health care for antenatal care or for their babies' vaccinations. The mothers were interviewed using a predesigned questionnaire to assess their knowledge, practice, and attitude toward NNJ. Data were analyzed using SPSS version 13.
The results showed that only 18.9% of mothers had good knowledge about NNJ. Mother's knowledge was significantly influenced by their level of education, age, parity, and previous history. About 48.0% of participants had good attitude toward NNJ and its management. However, 95.8% of mothers expressed their willingness to seek medical advice if their babies develop NNJ; only 25.3% had a good practice and stated that they would seek medical attention within the first 24 h of jaundice, which was significantly influenced by their age, parity, occupation, and history.
Participants attending Kafr El-batanoon Unit had adequate idea about recognition of NNJ. However, their knowledge of causes, danger signs of complications, complications, and treatment were poor, with common misconceptions. Their attitude toward the management of NNJ was apparently positive, whereas practice was poor. Knowledge and practice of mothers were significantly influenced by their age, parity, and history of NNJ in previous babies. Therefore, it is recommended that healthcare providers should give more health education on NNJ to the mothers during antenatal care visits.
|How to cite this article:|
Allahony DM, Hegazy NN, Kasemy ZA, Bahgat EM. Mothers' perception toward neonatal jaundice in Kafr El-batanoon village, Menoufia, Egypt. Menoufia Med J 2016;29:743-8
|How to cite this URL:|
Allahony DM, Hegazy NN, Kasemy ZA, Bahgat EM. Mothers' perception toward neonatal jaundice in Kafr El-batanoon village, Menoufia, Egypt. Menoufia Med J [serial online] 2016 [cited 2020 Sep 20];29:743-8. Available from: http://www.mmj.eg.net/text.asp?2016/29/3/743/198793
| Introduction|| |
Jaundice is the yellowish discoloration of the skin, sclera, and/or mucous membranes caused by tissue deposition of bilirubin  . It is a significant cause of neonatal morbidity worldwide and is estimated to be present in 60% of term neonates and 80% of preterm babies .
About 5-10% of all newborns require intervention for pathological jaundice. It is a common disorder worldwide and accounts for 75% of hospital readmissions during the first week of life  .
In Egypt, severe neonatal hyperbilirubinemia accounted for 33% of total admissions to the outborn neonatal ICU (NICU) in 2006, with about 10 cases of kernicterus occurring each year  . In a study in Shebin Elkom, Menoufia, on neonatal jaundice (NNJ), a total of 25/46 newborns (54.3%) developed significant hyperbilirubinemia in the first 5 days of life, and the prevalence of severe hyperbilirubinemia in Menoufia was 17% according to another study , .
In neonates, jaundice tends to develop because of two factors: the breakdown of fetal hemoglobin and the relatively immature hepatic metabolic pathways, which are unable to conjugate. Hence, the excretion of bilirubin occurs as quickly as in an adult. This causes an accumulation of bilirubin in the blood, leading to the symptom of jaundice. A bilirubin level of more than 85 mmol/l (5 mg/dl) manifests NNJ  .
Most cases are benign; however, if bilirubin levels reach a critical value it may lead to serious central nervous system sequelae and disabilities, especially in the developing countries. Furthermore, it may be a sign of serious neonatal disease or anomaly, and hence must be carefully evaluated and efforts must be directed toward the prevention of progression to serious complications  .
The serious complication of hyperbilirubinemia is kernicterus or even neonatal death in severe cases. It is due to the severe accumulation of unconjugated bilirubin in the brain tissue  .
There is no cure for kernicterus, but it is preventable if jaundice is recognized early and effective therapy commenced promptly  .
Nowadays, because of early discharge of mothers and neonates from the hospitals, the responsibility of mothers in recognizing jaundice has increased. Mothers therefore play a vital role in the early identification and prevention of complication  .
It is suggested that the mother, as the primary caretaker, should have a clear understanding of how to recognize NNJ and how to respond appropriately, as early recognition and prompt treatment decrease the likelihood of development of the potentially permanent complication  .
Therefore, mothers should be adequately educated about the care of jaundiced baby and early identification of danger signs and also its complications. It helps in effective treatment and also in the prevention of jaundice complications  .
| Materials and methods|| |
This cross-sectional study was carried out in Kafr El-Batanoon village primary healthcare unit, Shebin Elkom district, Menoufia governorate. The study included mothers who attended for antenatal care and those who came for vaccination sittings of their babies. The sample size required for the study was calculated using the formula for sample size determination for an infinite population in a descriptive study: [(Zα0) 2 × P (1 − P)]/(ME) 2 . The prevalence of severe hyperbilirubinemia in Menoufia governorate was 17% according to a previous study  and comprised 265 participants.
Ethical clearance was obtained from the Ethics and Research Committee before commencement of the study, and permission to conduct the study was obtained from the Head of Kafr El-batanoon primary healthcare unit.
The antenatal clinics were held on Thursdays and vaccination sittings of BCG, 2, 4, and 6 months of life were held on Mondays and Wednesdays when the mother was interviewed individually. Individual informed consent was obtained verbally from the respondents after the purpose of the survey was explained to them and confidentiality was assured.
Data were collected using a structured, researcher-administered questionnaire. The first part was for sociodemographic data, which were collected and scored using Al-Gilany's socioeconomic status scale for health research in Egypt  . There was one question on the idea of the respondents about NNJ. Past history and family history were also assessed. The second part comprised 34 question for assessing the mother's knowledge on the diagnosis, causes, danger signs of complication, complications, and treatment of NNJ, with answers scored as correct = 1 and incorrect = 0; participants with at least 60% correct answers were considered as having good knowledge. The third part included three questions as regards the attitude of mothers toward NNJ and its treatment; participants with at least 60% positive answers were considered as having positive attitude. The fourth part was for practice, which comprised three questions. At the end of the entire data collection period of the research, a health education talk was given by the researcher to the participant mothers, with adequate clarification.
Data collected were analyzed using Statistical Package for Social Science (SPSS) version 13 (SPSS Inc., Chicago, Illinois, USA). The χ2 -test and Student's t-test were used to test association between the sociodemographic characteristics of the respondents and their knowledge, attitude, and practice toward NNJ. The level of significance was set at P value less than 0.05.
| Results|| |
A total of 265 expectant mothers who attended the antenatal clinic and vaccination sitting at Kafr El-batanoon primary healthcare unit were interviewed. About 58.9% of mothers had an experience of NNJ in their previous babies. Most of the mothers (79.2%) had an idea about NNJ as a yellowish discoloration of the skin and sclera of the newborn.
Most mothers (64.9%) knew about prematurity as a cause of NNJ, whereas only 30.9% knew about infection and 11.7% about disparity between the mother's blood group and that of the baby. In all, 134 (50.6%) mothers have a misconception that increased ultrasound examination during pregnancy may be a cause of NNJ ([Table 1]).
|Table 1 Respondents' knowledge of causes, complications, and methods of treatment of neonatal jaundice |
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Only 21.5% of mothers were aware that severe NNJ can cause brain damage, which is the main complication of NNJ, and only 1.5% knew about hearing loss, which is a common sequel ([Table 1]).
As regards treatment, 82.3% of mothers knew about phototherapy and only 23% knew about blood exchange transfusion. The majority of mothers believe in drugs and direct exposure to neon lamp as a treatment for NNJ (88.3 and 71.7%, respectively), which is a common wrong belief ([Table 1]). Generally, maternal knowledge was poor; 81.1% of mothers had poor knowledge, whereas only 18.9% had good knowledge ([Figure 1]).
|Figure 1: Total score of participants' knowledge about neonatal jaundice (NNJ).|
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There was a statistically significant association between age, parity, occupation, education, and socioeconomic level of mothers, and their knowledge about NNJ. An overall 74% of mothers had good knowledge and had a university education. An overall 74% of them were multipara, whereas no one from nulliparous mothers had a good knowledge. There was a significant relation between history of NNJ in previous babies of mothers and their knowledge; 76% of mothers with good knowledge had a past history ([Table 2]).
|Table 2 Relation between sociodemographic data, history of neonatal jaundice in previous babies, and respondent's knowledge (n=265) |
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A majority of the expectant mothers (95.8%) expressed their willingness to seek medical attention if their babies were to develop NNJ, whereas only 25.3% of mothers stated that they would seek medical advice in the first 24 h of jaundice and were considered as having good practice ([Table 3] and [Figure 2]).
|Figure 2:; Total score of participants' practice with neonatal jaundice (NNJ).|
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There was a statistically significant association between age and parity of mothers and their practice with NNJ; 73.1% of mothers with good practice were multipara. However, there was no significant relation between education and socioeconomic level of mothers and their practice. There was also a statistically significant association between history of NNJ in previous babies of mothers and their practice with NNJ; 70.1% of mothers with good practice had a past history with NNJ ([Table 4]).
|Table 4 Relation between sociodemographic data, history of neonatal jaundice in previous babies, and practice of mothers toward neonatal jaundice (n=265) |
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About 49.1% of mothers agreed that NNJ is a worrisome condition. The majority of mothers (82.3%) had a positive attitude toward phototherapy as a treatment of NNJ, whereas only 21.1% agreed for blood exchange transfusion. An overall 48% had a positive attitude and 52% had a negative attitude toward NNJ and its treatment ([Table 5] and [Figure 3]).
|Table 5 Respondents' attitude toward neonatal jaundice and its treatment |
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|Figure 3: Total score of participants' attitude toward neonatal jaundice (NNJ) and its treatment.|
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| Discussion|| |
The present study shows that, although the majority of mothers had an idea about NNJ, their knowledge of important aspects of the condition is poor. This is in agreement with reports from similar studies in South Western Nigeria, Port Harcourt, and Malaysia with 189 (100%) respondents, 225 (88.2%) mothers, and 400 (93.8%) respondents, respectively, being aware of NNJ [3, 4, 5, 6, 7, 8, 9, 10, 11, 12] .
This is in agreement with the report from a study in Iran where the knowledge of the mothers was insufficient about the causes, complication, harmful symptoms, and prevention of the condition. Inadequate knowledge about the causes, treatment, complications, and danger signs of NNJ coupled with various misconceptions about the condition may adversely affect the actions of the mothers in the prevention of some of the causes of NNJ, such as neonatal sepsis - as may occur from poor umbilical cord hygiene - and hemolysis - as may occur in G6PD-deficient babies when menthol is applied to the umbilical cord. Second, it may also result in a delay in seeking medical attention for NNJ, hence contributing to the development of kernicterus  .
However, in a similar study in Nigeria, the knowledge of the mothers was adequate in the aspect of recognition, treatment, and complications of NNJ. However, the knowledge of the expectant mothers on causes and the danger signs of complications of NNJ were inadequate. The difference in findings may be as attributed to the fact that the Nigerian study was conducted in a tertiary healthcare facility situated in Benin City where a high literacy level was observed, with 61% of mothers having tertiary education, whereas this study was conducted in a rural village. Second, it may be attributed to the higher prevalence of severe hyperbilirubinemia (56.6%) and a high rate of exchange blood transfusion in Nigeria, which may improve knowledge of the mothers about the complications and treatment of NNJ  .
Maternal knowledge about causes was poor in general and 50.6% of mothers have a misconception that increased ultrasound examination during pregnancy may be a cause of NNJ.
As regards knowledge about complications, it was found that only 21.5% of mothers were aware that severe NNJ can cause brain damage, which is the main complication of NNJ, and only 1.5% knew that hearing loss is a common sequel; this low incidence may be attributed to the fact that hearing affection would be discovered later in the childhood, and hence parents cannot detect that severe hyperbilirubinemia in infancy is the cause.
In a similar study in Malaysia, it was found that, although about 70% of them were aware that severe jaundice can cause brain damage and death, only a small percentage (38%) were aware that hearing loss is a common sequel .
The present study revealed that placing a jaundiced infant, either naked or fully dressed, directly under the neon lamp is a common belief and practice among a large proportion of the mothers. Moreover, administering medications such as vitamins or liver enzyme activators is believed to be a treatment for NNJ.
In another study aimed to understand the reasons for late presentation of cases of severe neonatal hyperbilirubinemia, it was found that 87 of these parents (79.8%) were advised to 'place the infant under neon light' at home, and 15 infants were prescribed a variety of medications, including vitamins before admission, which led to additional delay in implementing proper treatment of severe neonatal hyperbilirubinemia. It was found that placing babies under neon lamps at home is a very ineffective form of phototherapy. Furthermore, prescription of vitamins and other medications for NNJ was not only useless but may also have given parents false reassurance that their jaundiced infant was being treated  .
In the study conducted in Malaysia it was found that placing a jaundiced infant, either naked or fully dressed, directly under the sun was a common practice among Malaysian mothers (48.4%), and that many of them were not aware that this was not a safe and effective practice. Many were not aware that sunning a jaundiced infant in such a manner increased the risk for dehydration, sunburn, and worsened the severity of jaundice .
Similar findings were reported in a study in Nigeria, in which 17.8% of mothers still believe in exposure to sun light as a treatment for NNJ  .
A majority of the expectant mothers (95.8%) expressed their willingness to seek medical advice if their babies developed NNJ, but only 25.3% of mothers stated they would seek medical advice during the first 24 h of jaundice. In the Nigerian study, although the women in the study agreed that a newborn with jaundice should be taken to the hospital within 24 h of development of the condition, studies have shown that most babies present late in the hospitals after complications have set in  .
Similarly, in another Nigerian study, of the 75 newborns who had acute bilirubin encephalopathy, 73 had developed the condition before presentation at the hospital. It has been shown that exposures of bilirubin levels higher than 20 mg/dl even for less than 6 h, between 6 and 12 h, and more than 12 h result in neurological disorders in 2.3, 18.7, and 26% of cases, respectively, and this emphasizes the importance of early seeking of medical advice to detect the severity of NNJ .
This study revealed that the majority of mothers (82.3%) had a positive attitude toward phototherapy as a treatment of NNJ, whereas only 21.1% agreed for blood exchange transfusion as a treatment, as the majority of mothers believe that the condition is not serious to this extent and some of them reject BET for fear of the procedure and infection. In addition, mothers who rejected phototherapy, did so for fear of NICU admission or because of a bad experience with NICU admission in a previous baby.
Similarly, in a study in Iran, only 2.7% of the mothers agreed to undergo exchange blood transfusion, and 38.5% agreed to undergo phototherapy for the management of NNJ  .
It was shown in this study that the level of education of the respondents, age, and parity of the mothers had a significant influence on their knowledge about the condition. An overall 74% of mothers with good knowledge were multipara, whereas all nullipara (primigravida) had poor knowledge and some of them had not heard before about NNJ.
There was also a significant association between past history of NNJ in previous babies of mothers and their knowledge. In a study in Iran, it was observed that the knowledge was significantly associated with a history of NNJ, child's birth rank, and the mother's age .
The poor knowledge and practice of mothers toward NNJ may be a cause of the significant delay in presentation to the hospital, which occurred at a mean age of 9.4 days. In the Egyptian study of WHO, of the 130 infants, 14 had signs of acute bilirubin encephalopathy at the time of hospital admission. The delay in seeking treatment was further compounded by faulty medical advice, where before admission a wide range of treatments were utilized. Most of these treatments led to an additional delay in implementing the proper treatment of severe neonatal hyperbilirubinemia, such as placing babies under neon lamps at home, which was suggested by many medical practitioners, and prescription of vitamins or liver enzyme activators for NNJ. Moreover, this may be a cause of wrong knowledge of the mothers, as mothers receive their information from medical practitioners through direct or indirect ways .
Thus, there is an urgent need to develop comprehensive educational and training programs for healthcare workers throughout the country on the neurotoxic potential of bilirubin, the exposure-time factor, and how to avoid it.
| Conclusion|| |
This study revealed that expectant mothers attending Kafr El-batanoon primary healthcare unit had an adequate knowledge in the aspect of recognition of NNJ. However, the knowledge of the expectant mothers on causes, the danger signs of complications, complications, and treatment of NNJ were poor with common misconceptions. Their attitude toward the management of NNJ was apparently positive, whereas practice was poor. Knowledge and practice of mothers were significantly influenced by their age, parity, and history of NNJ in previous babies. Poor knowledge and practice of the mothers toward NNJ may be a cause of the significant delay in the presentation of severe NNJ and occurrence of complication. Thus, healthcare providers should continuously educate the mothers during antenatal care on NNJ, with special focus on the causes and danger signs of complications of NNJ.
The authors would like to acknowledge the contribution of the head, residents, and nursing staff in Kafr El-batanoon primary healthcare unit.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]