Caregivers perception of common neonatal illnesses and their management among rural dwellers in Enugu state, Nigeria: a qualitative study.

BACKGROUND: Neonatal mortality continues to be a challenge in Nigeria, where low-quality care, caregivers' ignorance of signs of neonatal illnesses, and prevalent use of unorthodox alternatives to health care predominate. Misconceptions originating and propagating as traditional practices and concepts can be linked to adverse neonatal outcomes and increased neonatal mortality. This study explores the perceptions of causes and management of neonatal illness among caregivers in rural communities in Enugu state, Nigeria. METHODS: This was a cross-sectional qualitative study among female caregivers of children residing in rural communities in Enugu state. A total of six focus group discussions (FGDs) were conducted; three in each of the communities, using an FGD guide developed by the researchers. Using pre-determined themes, thematic content analysis was used to analyze the data. RESULTS: The mean age of respondents was 37.2 ± 13.5 years. Neonatal illnesses were reportedly presented in two forms; mild and severe forms. The common causes of the mild illnesses reported were fever, jaundice, eye discharge, skin disorders, and depressed fontanelle. The severe ones were convulsion, breathlessness/difficulty or fast breathing, draining pus from the umbilicus, and failure-to-thrive. The caregivers' perceptions of causes and management of each illness varied. While some believed these illnesses could be managed with unorthodox treatments, others perceived the need to visit health centers for medical care. CONCLUSIONS: Caregivers' perception on the causes and management of common neonatal illnesses in these communities is poor. Obvious gaps were identified in this study. There is a need to design appropriate interventions to dispel the myths and improve the knowledge of these caregivers on neonatal illnesses towards adopting good health-seeking behaviours.

Assessment of breastfeeding techniques in Enugu, South-East Nigeria.

Background: Good breastfeeding technique is important in ensuring adequate milk delivery and preventing breastfeeding problems. Exclusive breastfeeding rate is quite low, and requisite skills regarding proper positioning and attachment of an infant while breastfeeding appears lacking among mothers in Nigeria. This study was undertaken to assess breastfeeding techniques of mothers attending the well-child clinics of two tertiary hospitals in southeast Nigeria. Materials and Methods: This cross-sectional descriptive study of 396 mother and child pairs who attend the well child clinics of two tertiary hospitals in Enugu (Enugu state University Teaching Hospital and University of Nigeria Teaching Hospital) between September 2018 and February 2019. An interviewer administered, well-structured pro forma was used to collect data while mothers were observed closely as they breastfed and scored using the World Health Organization criteria. Data were analyzed using SPSS version 22. Results: Most of the mothers studied (357; 90.2%) attended ante-natal care, and 365 (92.2%) of the deliveries were assisted by a health worker. Only 194 (49%) of mothers practiced good breastfeeding techniques. Maternal age (20-30 years) (P < 0.001, odds ratio [OR] 0.464), attendance to antenatal clinic (P < 0.001; OR 8.336), health education and demonstration on breastfeeding techniques before and after delivery (P = 0.001) and maternal level of education (χ2 = 13.173, P = 0.001) but not parity (P = 0.386; OR 1.192) were significantly associated with good breastfeeding techniques. Conclusion: There are suboptimal breastfeeding techniques among mothers. Increased awareness creation and regular demonstration of breastfeeding techniques are needed.

RésuméContexte: Une bonne technique d'allaitement est importante pour assurer une livraison adéquate du lait et prévenir les problèmes d'allaitement. Exclusive le taux d'allaitement est assez faible, et les compétences requises en ce qui concerne le positionnement et l'attachement appropriés d'un nourrisson pendant l'allaitement semblent manqué chez les mères au Nigéria. Cette étude a été entreprise pour évaluer les techniques d'allaitement des mères qui fréquentent les cliniques hôpitaux tertiaires dans le sud-est du Nigeria. Matériaux et méthodes: Cette étude descriptive transversale de 396 couples de mères et d'enfants assister aux cliniques pour enfants de deux hôpitaux tertiaires à Enugu (Hôpital universitaire d'Enseignement de l'Université d'Enugu et Université du Nigeria Enseignement hôpital) entre septembre 2018 et février 2019. Un intervieweur administré, bien structuré pro forma a été utilisé pour recueillir des données les mères ont été observées de près au fur et à mesure qu'elles allaitaient et scorelaient selon les critères de l'Organisation mondiale de la santé. Les données ont été analysées à l'aide du SPSS version 22. Résultats: La plupart des mères étudiées (357; 90,2 %) soins prénatals, et 365 (92,2 %) des livraisons ont été assistées par un travailleur de la santé. Seulement 194 (49%) des mères pratiquaient de bonnes techniques d'allaitement. Âge maternel (20­30 ans) (P 0,001, rapport de cotes [OR] 0.464), présence à la clinique prénatale (P 0,001; OU 8.336), éducation à la santé et démonstration sur les techniques d'allaitement avant et après (P = 0,001) et le niveau d'éducation maternel (2 = 13,173, P = 0,001) mais pas la parité (P = 0,386; OR 1.192) ont été significativement associés avec de bonnes techniques d'allaitement. Conclusion: Il existe des techniques d'allaitement sous-optimales chez les mères. Création accrue de sensibilisation et une démonstration régulière des techniques d'allaitement sont nécessaires.

Snakebite in children in Nigeria: A comparison of the first aid treatment measures with the world health organization's guidelines for management of snakebite in Africa.

Background: Snakebite and envenomation remains a public health problem with significant morbidity and mortality in children in developing countries. The World Health Organization (WHO) in 2010 developed guidelines for the prevention and management of snakebite in Africa. Aim: The aim of this study was to compare the pattern of first aid treatment among children presenting with snakebite/envenomation with the 2010 WHO guideline for the prevention and clinical management of snakebite in Africa. Patients and Methods: All children who presented with snakebite over a 7-year period in a teaching hospital in Enugu, Nigeria. The first aid treatment given to these children was obtained and was compared with the provisions of the WHO guideline for the prevention and clinical management of snakebite in Africa (2010). Data collected were analyzed using SPSS version 22. Results: Five (71.4%) of the snakebites occurred in the rainy season and in the dark involving the lower limbs in 85.7% of cases. Six (87.5%) of the patients received one form of first aid before presentation to a health facility. None received first aid interventions in line with the WHO recommendation. Topical application of herbal concoctions to the site of the bite (37.5%) was the most common intervention. One (14.3%) of the children was promptly brought to the health facility following snakebite. The interval from bite to presentation to the health facility ranged from 1 to 12 h (median 5 h: 43 min). Conclusion: Huge gaps still exist in the first aid treatment given to snakebite victims compared to the WHO guidelines.

RésuméContexte: La morsure de serpent et l'envenomation demeurent un problème de santé publique avec une morbidité et une mortalité importantes chez les enfants des pays en développement. L'Organisation mondiale de la Santé (OMS) a élaboré en 2010 des lignes directrices pour la prévention et la gestion des morsures de serpent en Afrique. Objectif: L'objectif de cette étude était de comparer le modèle de traitement des premiers soins chez les enfants présentant des morsures de serpent/envenomation avec la directive 2010 de l'OMS pour la prévention et la prise en charge clinique des morsures de serpent en Afrique. Patients et méthodes: Tous les enfants qui se sont présentés avec des morsures de serpent sur une période de 7 ans dans un hôpital d'enseignement à Enugu, Nigeria. Le traitement de premiers soins accordé à ces enfants a été obtenu et a été comparé aux dispositions de la ligne directrice de l'OMS pour la prévention et la prise en charge clinique des morsures de serpent en Afrique (2010). Les données recueillies ont été analysées à l'aide de la version 22 du SPSS. Résultats: Cinq (71.4%) des morsures de serpent se sont produites pendant la saison des pluies et dans l'obscurité impliquant les membres inférieurs dans 85,7% des cas. Six (87,5 %) des patients ont reçu une forme de premiers soins avant d'être présentés à un établissement de santé. Aucun d'entre eux n'a reçu d'interventions de premiers soins conformément à la recommandation de l'OMS. Application topique des concoctions à base de plantes sur le site de la morsure (37,5%) était l'intervention la plus courante. Un (14,3%) des enfants a été rapidement amené à l'établissement de santé à la suite d'une morsure de serpent. L'intervalle allant de la morsure à la présentation à l'établissement de santé variait de 1 à 12 h (médiane 5 h : 43 min). Conclusion: Il existe encore d'énormes lacunes dans le traitement des premiers soins accordé aux victimes de morsures de serpent par rapport aux lignes directrices de l'OMS.

Evaluation of Wait Time in the Children's Emergency and Outpatient Units of a Tertiary Hospital in Southeast Nigeria.

BACKGROUND: Promptness of intervention in the emergency room (ER) or outpatient unit is a major determinant of outcome in acutely ill children. Time is, therefore, of the essence in trying to reduce complications and mortality associated with children. METHODS: This was a cross-sectional study conducted in the children ER and the children outpatient unit of the Enugu State University Teaching Hospital (ESUTH), Enugu, Southeast Nigeria. Waiting time defined as the time between arrival and doctor consultation was calculated. RESULTS: A total of 248 respondents were enrolled during the study period. In the emergency unit, majority (67.5%) of the respondents' sick children were attended to almost immediately, while 13.3% and 19.3% waited for ≤10 and >10 min, respectively, before being attended to by a doctor. The mean waiting time in the emergency unit was approximately 9.27 ± 29.2 min (95% confidence interval [CI]: 2.90-15.65 min) with a range of 0-56 min. In the outpatient unit, the mean waiting time was 12.67 ± 15.3 min (95% CI: 10.31-15.01 min) with a time range of 5-245 min. Eighty-five (51.5%) of the 165 respondents waited for <10 min, 60 (36.4%) waited for between 10 and 30 min, while 20 (12.1%) waited for >30 min before their sick children were attended by a doctor. CONCLUSION: The mean waiting times reported in this study in the emergency and outpatient units of the ESUTH were within acceptable standards. However, there were cases where the waiting time in both children's units was exceptionally long. There is need for continued monitoring and evaluation of waiting times in these units for prompt attention to patients.

Hypertension in Children: Could the Prevalence be on the Increase?

BACKGROUND: In children particularly in the developing world, there is a tendency to downplay the role of primary hypertension in their health. In adults, a number of factors have clearly been associated with the incidence of hypertension. Knowledge of the prevalence of hypertension and its associated factors among children in our environment is important and could inform the need for lifestyle changes and routine blood pressure (BP) checks in children so as to reduce BP-related health risks. AIM: The aim of this study is to document the prevalence of hypertension and its risk factors among children in Enugu, Nigeria. MATERIALS AND METHODS: Children aged 6-17 years attending the outpatient clinic of a tertiary hospital, were enrolled for the study. Their socioeconomic status (SES), weight, height, BP, and dipstick urinalysis were measured using standardized methods. Adherence to Mediterranean diet was assessed using the Mediterranean Diet Quality Index (KIDMED). The prevalence of hypertension and the influence of these factors on their BP were analyzed. RESULTS: Forty-six (9%) of the 491 participants had hypertension. Of these 46 hypertensive children, 72% were females while a significantly higher proportion 57% (P = 0.006), were in the age group 13-17 years. While age, gender, and the presence of protein in urine were significantly associated with hypertension in these children; body mass index, diet, family history of hypertension, and SES were not. CONCLUSION: The prevalence of hypertension in children in this environment is high and appears to be increasing. There is need for routine BP and urinalysis check for all children in our clinics and wards.

Cancer Mortality in the Niger Delta Region of Nigeria: A Case Study of the University of Port Harcourt Teaching Hospital.

AIM: The aim of this study is to determine the pattern of cancer mortality (CM) seen in the University of Port Harcourt Teaching Hospital (UPTH) which is a cancer reference center in the Niger Delta Region. METHODOLOGY: This is a 6-year retrospective study of cancer-related deaths in UPTH using patients' admission registers in all the wards and emergency units. Furthermore, the death certificates of cases were reviewed. RESULTS: Three hundred and sixteen cases of cancer-related deaths occurred, involving 174 females and 142 males, in a female-to-male sex ratio of 1.2:1. All age groups were affected, with age group 40-49 years accounting for the majority (20.6%). CM was seen in all the systems, except the central nervous system. Cancers of the gastrointestinal tract and its accessory organs (liver and gall bladder) caused most mortality (27.9%), in a female-to-male ratio of 0.8:1. The single most involved organ in CM is the female breast (20.6%), distantly followed by mortality due to prostate cancers and hematolymphoid cancers which accounted for 9.2% each. Colorectal cancers accounted for 7.3% of cancer deaths and ranked 4th. Cancers of both cervix and stomach each accounted for 5.7% of mortality. The major histologic diagnoses were carcinomas (adenocarcinoma; 36.7%, invasive ductal carcinoma; 20.3%, squamous cell carcinomas; 8.2% and hepatocellular carcinomas; 4.4%). Leukemias and lymphomas accounted for 9.2% of cases, whereas sarcomas accounted for 5.1% of cases. CONCLUSION: Infection-related and noninfection-related cancers cause most mortality in UPTH. The 5th decade was the most commonly affected, while female breast was the single most involved organ. Breast, prostate and hematolymphoid malignancies are common causes of CM with death from breast occurring earliest. Majority of the deceased were educated, working-class urban dwellers. More advocacies on public acceptance of cancer screening and cancer preventive lifestyles as well as governments' improvement on workforce training and treatment infrastructure will improve the current CM profile in Port Harcourt.

Pattern of Congenital Anomalies in Newborn: A 4-Year Surveillance of Newborns Delivered in a Tertiary Healthcare Facility in the South-East Nigeria.

Congenital abnormalities are important causes of morbidity and mortality in children and significantly add to the burdens on healthcare in developing countries. Unfortunately, there remains a paucity of information on congenital birth defects in most developing countries. This is a 4-year prospective study that assessed the patterns and predictors of congenital anomalies among newborns at the Enugu State University Teaching Hospital, Nigeria. In total, 5830 deliveries were recorded, of which 38 had congenital anomalies, giving an incidence rate of 6.5/1000 live births. Fifty-two newborns were enrolled as nested controls. Factors significantly associated with congenital anomalies were low birth weight (p = 0.009), low socio-economic class (p = 0.011), lower maternal educational attainment (p = 0.009), parity of ≥ 5 (p = 0.002), febrile illness (p = 0.001) and the use of local concoction in index pregnancy (p = 0.009). More than half of the anomalies reported involved the musculoskeletal system. Occurrence of congenital anomalies may be prevented by curtailing risk factors identified in this study.

Incidence and Predictors of Mortality Among Newborns With Perinatal Asphyxia: A 4-Year Prospective Study of Newborns Delivered in Health Care Facilities in Enugu, South-East Nigeria.

Fatalities from perinatal asphyxia remain high in developing countries, and continually assessing its risk factors will help improve outcomes in these settings. We explored how some identified risk factors predict mortality in asphyxiated newborns, to assist clinicians in prioritizing interventions. This was a 4-year prospective study conducted at the Enugu State University Teaching Hospital, Enugu, Nigeria. All newborns who met the study criteria that were admitted to this facility in this period were enrolled and monitored. Data collected were analysed with SPSS Version 18. A total of 161 newborns with perinatal asphyxia were enrolled into the study with an in-hospital incidence rate of 12.81 per 1000 birth and a case fatality rate of 18%. Overall, the APGAR scores were severe in 10%, moderate in 22%, mild to normal in 68%, whereas the SARNAT stages were III in 24%, II in 52%, and I in 25%. In terms of mortality, 66.7%, 22.2%, and 11.1% mortalities were, respectively, observed with SARNAT scores III, II, and I (P = .003), whereas the findings with APGAR were 31.2% (severe), 25.0% (moderate), 25.0% (mild), and 18.8% (normal) (P = .030). Fatality outcome was more correlated with SARNAT (R = .280; P = .000) than APGAR (R = -.247; P = .0125). The SARNAT score significantly differentiated between the degrees of asphyxia in newborns based on gestational age at delivery (P = .010), place of delivery (P = .032), and mode of delivery (P = .042). Finally, it was noted that newborns that were female (P = .007), or born outside the hospital (P = .010), or with oxygen saturations <60% (P = .001), or with heart rate <120 (P = .000), and those with respiratory rate <30 (P = .003), all have significantly higher likelihood of deaths from asphyxia. Therefore, predictors of neonatal mortality from perinatal asphyxia in our centre include being female and being born outside the hospital, as well as low oxygen saturations, heart rates, and respiratory rates at presentation.

Delays in healthcare delivery to sick neonates in Enugu South-East Nigeria: an analysis of causes and effects.

BACKGROUND: In most parts of the world, neonatal mortality rates have shown a slower decline when compared with under-5 mortality decline. A sick newborn can die within minutes if there is a delay in presentation, thus early diagnosis and treatment are essential for the survival of a critically ill newborn. This study investigated factors responsible for delays in healthcare services for the sick newborn and maternal socio-demographic variables that influence these delays in Enugu, South-East Nigeria. METHODS: This was a community-based descriptive study. A total of 376 respondents were randomly selected from 4 of the 17 local government areas of Enugu State. Mothers and/or caregivers that were nursing or had nursed a child in the previous 2 years were enrolled. Self-reported data on delays encountered during healthcare for sick newborn were collected using pretested structured questionnaire. Chi-square and multivariate logistic regression were used to determine the association between causes of delays in newborn healthcare services, maternal socio-demographics and relationships with newborn mortality. RESULTS: Delays in reaching healthcare facilities accounted for the most common delays encountered by respondents, 78.0%, in this study, followed by delays at household level, 24.2% and delays at health facility level 16.0% (P = 0.000). Mothers with knowledge of ≥3 WHO recognized danger signs compared with those with ≤2 were significantly less likely to delay at household (level 1: 40.7 versus 59.3%) (P = 0.017) and reaching healthcare service (level 2: 19.9 versus 80.1%) (P = 0.028). Delays at health facility level (level 3) occurred more at tertiary health facilities (59.0%), secondary health facilities (39.1%) and primary healthcare facilities (19.7%) compared with private health facilities (13.5%) (P = 0.000). CONCLUSIONS: Delays in seeking healthcare at all levels especially those related to transporting the sick newborn to the hospital are a contributor to newborn mortality in Nigeria. Improving access to healthcare could potentially reduce mortality in the sick newborn.

Danger Signs of Childhood Pneumonia: Caregiver Awareness and Care Seeking Behavior in a Developing Country.

Background. Efforts to reduce child mortality especially in Africa must as a necessity aim to decrease mortality due to pneumonia. To achieve this, preventive strategies such as expanding vaccination coverage are key. However once a child develops pneumonia prompt treatment which is essential to survival is dependent on mothers and caregiver recognition of the symptoms and danger signs of pneumonia. Methods. This community based cross-sectional study enrolled four hundred and sixty-six caregivers in Enugu state. It aimed to determine knowledge of caregivers about danger signs of pneumonia and the sociodemographic factors that influence knowledge and care seeking behaviour of caregivers. Results. There is poor knowledge of the aetiology and danger signs of pneumonia among caregivers. Higher maternal educational attainment and residence in semiurban area were significantly associated with knowledge of aetiology, danger signs, and vaccination of their children against pneumonia. Fast breathing and difficulty in breathing were the commonest known and experienced WHO recognized danger signs while fever was the commonest perceived danger sign among caregivers. Conclusion. Knowledge of danger signs and health seeking behaviour among caregivers is inadequate. There is need for intensified public and hospital based interventions targeted at mothers to improve their knowledge about pneumonia.

Knowledge of danger signs in newborns and health seeking practices of mothers and care givers in Enugu state, South-East Nigeria.

BACKGROUND: According to UNICEF, 40% of all under-5 deaths occur within the first month of life and half of these within the first few days of life. Many of these deaths are related to late recognition of neonatal illness, delays in decision to seek care at household level and subsequent late intervention at healthcare facilities. Knowledge of mothers about the danger signs in newborn is imperative to reduce these delays and preventable deaths. AIM: This study aimed to assess the perception of mothers and/or care givers of danger signs in newborns and their knowledge of the WHO recognized danger. A secondary aim was to explore the socio-demographic factors of mothers that influence knowledge of the WHO recognized danger signs and the health seeking behaviors of these mothers and/or care-givers. METHODS: This was a community based descriptive and analytical study which used a multistage sampling technique to select 376 mothers and/or care-givers from four communities in 4 of the 17 Local Government Areas (LGA) of Enugu State. Logistic regression and chi-square was used in testing associations between variables. RESULTS: Knowledge of more than three of the nine WHO recognized danger sign was poor (0.0-30.3%). Majority of the mothers had knowledge of one (i.e. fever) WHO recognized danger sign (95.2%). Knowledge of the WHO signs was not significantly associated with maternal socio-demographic variables considered in this study. Healthcare seeking behaviour was significantly determined by knowledge of at least one WHO recognized danger sign (OR 4.6 CI 1.1-18.7, P = 0.032). Cough, diarrhea and the excessive crying were the most perceived and experienced non-WHO recognized dangers signs among respondents. CONCLUSION: There is urgent need to strengthen the teaching and training of expectant mothers across all maternal socio-demographic variables on these danger signs and the most appropriate measures to take when they occur.

Out-of-pocket cost of managing sick newborns in Enugu, southeast Nigeria.

BACKGROUND: Neonatal illnesses usually require long hospital stays and specialized care and/or facilities, which usually results in huge medical bills. With more than 70% of people in Nigeria living on less than US$2 per day, these bills are not affordable to many families' livelihoods. AIM: This study aims to determine the average cost of managing neonatal illnesses in Enugu in southeast Nigeria and the proportion of family income spent on these illnesses. It further seeks to ascertain the cost of various components in the management of neonatal diseases. METHODS: This is a longitudinal and descriptive study involving 106 newborns admitted to the sick baby unit of the Enugu State University Teaching Hospital and the out-of-pocket medical expenditure in the management of their illnesses. RESULTS: A hundred and six newborns participated in the study. All (100%) medical bills were out-of-pocket payments, and 103 (97.2%) of these were catastrophic health expenditure (more than 10% of total family monthly income). The average duration of hospital stay and cost of managing a neonatal illness was 12.86±8.81 days and ₦36,382±19,389.72 (US$223±119), respectively. This expenditure amounted to 157%, 71%, and 25% of total monthly family income for the low, middle, and upper socioeconomic class families, respectively, with a mean percentage of 85%. Families with a total monthly income of less than ₦10,000 (US$61), ₦10,000-49,999 (US$61-306), and ₦50,000-100,000 (US$306-612) and more than ₦100,000 (US$612) on average spent 683%, 108%, 54%, and 20% of their monthly income on their newborn's illness. Hospital and utility bills compared with bills accruing from drug and laboratory investigations account for a significantly larger proportion of total cost incurred in neonatal sepsis (₦23,499±14,987 [US$144±92], P=0.001), low birth weight (₦39,863±24,003 [US$224±147], P=0.001), severe anemia (₦40,504±13,923 [US$248±85], P=0.001), transient tachypnea of the newborn (₦10,083±1,078 [US$62±7], P=0.001), birth asphyxia (₦24,398±14,096 [US$149±86], P=0.001), and meningitis (₦26,731±7,675 [US$164±47], P=0.001), whereas cost for laboratory investigations was significantly higher for neonatal jaundice (₦11,690±3,169 [US$72±19], P=0.001). There was a strong positive correlation between duration of hospital stay and total medical cost incurred (r=0.897, P=0.001). CONCLUSION: Health expenditure on neonatal illness is high and leads to catastrophic expenditure for the majority of households in the state. There is a need for effective health insurance schemes to help subsidize and cushion this disastrous and impoverishing health expenditure on families for improved neonatal survival in Nigeria.