Knowledge, Attitudes, and Practices Regarding Neonatal Danger Signs among Mothers in a Tertiary Care Hospital in Senegal ()
1. Introduction
The neonatal and immediate post-neonatal periods represent the most critical phases of the maternal and child health continuum, accounting for nearly half of global child mortality. In 2022, approximately 2.3 million neonatal deaths were recorded worldwide [1]. In sub-Saharan Africa, neonatal mortality remains among the highest; the region had an estimated rate of 26 deaths per 1000 live births in 2023 [2]. In Senegal, although progress has been made, neonatal mortality remains high [3].
Most of neonatal deaths in Low- and Middle-Income Countries (LMICs) occur at home, in contexts where signs of neonatal illness are not recognized, and newborns are not referred to health facilities [4]. Neonatal danger signs, as defined by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF), constitute major warning signals indicating a high risk of neonatal morbidity and mortality, necessitating early therapeutic interventions [5].
Therefore, their early recognition in newborns by mothers or caregivers constitutes a major determinant of survival, particularly in resource-limited settings where access to specialized care is often delayed. In many African countries, maternal knowledge remains limited due to social, cultural, educational, and economic factors that influence both the identification of danger and the timeliness of healthcare-seeking behavior [4].
In Senegal, few studies have documented the level of maternal knowledge regarding neonatal danger signs and mothers’ responses to these symptoms. We conducted this study with the objectives of assessing mothers’ level of knowledge and practices regarding neonatal danger signs and determining the role of healthcare workers in providing information on these signs.
2. Methods
2.1. Study Setting
This study was conducted in the Maternity and Pediatrics departments of the Abass NDAO Hospital in Dakar. This is a tertiary referral hospital located in the Southern Health District of the Dakar region.
2.2. Study Design, Period, and Population
We conducted a cross-sectional study over a six-month period from September 18th, 2023, to March 19th 2024. We included all mothers who delivered vaginally or via cesarean section and had a newborn aged less than 28 days, who had been discharged and subsequently returned for a postnatal consultation or for the hospitalization of their newborn.
We excluded mothers hospitalized in the maternity ward, mothers whose newborns were admitted to the neonatology unit, mothers whose newborns had died, and mothers presenting for post-operative care without their newborn.
2.3. Ethical Considerations
Verbal informed consent was obtained individually from each mother during the interview to minimize potential bias and ensure the integrity of the survey. The objectives of the study were clearly explained to the participants.
2.4. Data Collection
Data were collected via face-to-face interviews with mothers and recorded using the KoboToolbox software. The data collected included:
Sociodemographic, parental, and family characteristics: Maternal age, education level, parental occupation, marital status, and the number of children in the household.
Obstetric and delivery history: Data regarding the pregnancy and childbirth.
Neonatal signs at discharge: Breastfeeding, stools, breathing, movements/reflexes, crying patterns, and jaundice.
Knowledge of danger signs: Including advice received from healthcare personnel and/or prior personal knowledge.
Maternal attitudes and practices: Reactions and actions taken regarding danger signs.
2.5. Operational Definitions
The neonatal danger signs assessed in the survey included: fever/hyperthermia, respiratory distress/fast breathing, apathy, lethargy, convulsions, refusal to breastfeed, vomiting/abdominal distension, constipation, jaundice, low weight, umbilical redness, and purulent umbilical discharge.
Maternal knowledge was categorized as follows:
Good knowledge: Identification of at least 7 danger signs.
Satisfactory knowledge: Identification of 4 to 6 danger signs.
Poor knowledge: Identification of fewer than 4 danger signs.
Maternal knowledge was categorized based on the WHO guidelines for essential newborn care. Out of the 12 danger signs assessed, the threshold for ‘Good knowledge’ was set at 7 or more signs (≥58%). This cut-off was selected to ensure that mothers classified as having ‘Good knowledge’ could identify the majority of critical warning signals requiring immediate referral, distinguishing them from those with only a fragmented awareness or insufficient knowledge.
2.6. Data Management, Sampling and Statistical Analysis
Data analysis was performed using R (version 4.3.2) and SPSS (version 28.0.1) software. Descriptive analysis was conducted to assess the distribution of study variables. Figures and tables were generated using Microsoft Excel. Qualitative (categorical) variables were expressed as frequencies and percentages. Quantitative (continuous) variables were reported as means, medians, and standard deviations. The Chi-square test was used to assess associations between variables, with statistical significance defined as p < 0.05.
The sample size of N = 200 represents a comprehensive capture of eligible mothers attending postnatal consultations or pediatric hospitalization units over the six-month study period (September 2023-March 2024). This duration was selected to account for seasonal variations in hospital admissions. With this sample size, the study achieves a 95% confidence level with a margin of error of approximately 7%, ensuring that the findings are representative of the patient population served by this tertiary referral hospital.
3. Results
3.1. Sociodemographic and Obstetric Characteristics
A total of 200 mothers were interviewed. Among the 200 deliveries, there were 109 female and 91 male newborns (45.5%). The mean maternal age was 27.77 years, with the 20 - 30 age group being the most represented (n = 130; 65%). The majority of mothers had received formal education (91%), with 29% having attained a higher education level. Regarding marital status, 92.5% were married, 6.5% were single, and 1% were widowed. More than half of the mothers (n = 113; 56.5%) lived in extended family homes. Antenatal care (ANC) was provided by a midwife in 63% of cases and by a gynecologist in 37% of cases. Most mothers (88.5%; n = 177) had adequate antenatal care with more than three ANC visits, while 11.5% (n = 23) had inadequate follow-up. Deliveries were attended by a midwife in 52% of cases and by a gynecologist in 48% of cases (Table 1).
Table 1. Sociodemographic, obstetrical characteristics, and postnatal information of mothers (N = 200).
Variables |
Categories |
Count (n) |
Percentage (%) |
Newborn gender |
Female |
109 |
54.5 |
Male |
91 |
45.5 |
Mothers’ residence |
Urban (Dakar) |
128 |
64 |
Outside Dakar |
53 |
26.5 |
Peri-urban |
19 |
9.5 |
Mothers’ age |
Under 20 years |
11 |
5.5 |
20 - 30 years |
130 |
65 |
|
30 - 40 years |
53 |
26.5 |
Over 40 years |
6 |
3 |
Education level |
No schooling |
17 |
9 |
Quranic school |
26 |
13 |
Primary |
19 |
10 |
Secondary |
80 |
41 |
Higher education |
58 |
29 |
Marital status |
Married |
185 |
92.5 |
Single |
13 |
6.5 |
Widow |
2 |
1 |
Living environment |
Family house |
113 |
56.5 |
Apartment |
87 |
43.5 |
Number of children |
1 child |
99 |
49.5 |
2 - 3 pregnancies |
81 |
40.5 |
4 pregnancies |
20 |
10 |
Pregnancy follow-up |
By midwife |
126 |
63 |
By gynecologist |
74 |
37 |
Birth attendant |
Midwife |
104 |
52 |
Gynecologist |
96 |
48 |
3.2. Maternal Knowledge of Danger Signs
Of the 200 mothers surveyed, 126 (63%) reported receiving advice from healthcare personnel after delivery, while 37% stated they received no advice. Only 7.5% of mothers had received specific information regarding danger signs (Figure 1).
The danger signs most frequently identified by mothers were fever, refusal to breastfeed, hypothermia (cold body), and abdominal distension (Table 2). Nearly two out of three women (63%) demonstrated poor knowledge of danger signs (Figure 2). However, most danger signs were perceived as serious by more than 80% of mothers (Figure 3).
Table 2. Distribution according to the level of knowledge of danger signs by mothers.
Categories |
Count (n) |
Percentage (%) |
Hot body/Hyperthermia |
138 |
69 |
Refusal to breastfeed |
76 |
38 |
Cold body/Hypothermia |
70 |
35 |
Abdominal distension/bloating |
59 |
29.5 |
Vomiting |
36 |
18 |
Apathy |
36 |
18 |
Difficulty breathing |
31 |
15.5 |
Fast breathing |
29 |
14.5 |
Convulsions/Seizures |
20 |
10 |
Jaundice |
15 |
7.5 |
Lethargy |
12 |
6 |
Base of the cord is red |
9 |
4.5 |
Purulent discharge from umbilicus |
6 |
3 |
Figure 1. Distribution according to the types of advice received.
Figure 2. Mothers’ level of knowledge of danger signs.
Figure 3. Mothers’ attitude towards newborn danger signs.
3.3. Attitudes and Practices
Regarding maternal practices in response to danger signs, the vast majority of mothers indicated they would seek care at health facilities, which constituted the primary point of care for almost all participants. However, practices were more heterogeneous for certain specific signs. Home monitoring was frequently reported, particularly for excessive sleep, constipation, and jaundice (Table 3).
Table 3. Distribution according to mothers’ practices regarding signs of danger of the newborn.
Signs |
Advice from relative |
Pharmacy |
Health facility |
Monitoring |
Remedy |
Traditional healer |
Fever |
0.5% |
2.5% |
73.5% |
0% |
0% |
0% |
Difficulty breathing |
2% |
0.5% |
97% |
0% |
0% |
0% |
Fast breathing |
0% |
0.5% |
99% |
0.5% |
0% |
0% |
Apathy |
1% |
2% |
87% |
9% |
1% |
0% |
Sleeps continuously |
2% |
0% |
63.5% |
32.5% |
1% |
1% |
Convulsions |
1% |
0% |
93% |
5% |
0% |
1% |
Jaundice |
1% |
0% |
85% |
13.5% |
0.5% |
0% |
Tense abdomen/vomiting |
1% |
0.5% |
92.5% |
5% |
1% |
0% |
Refusal to breastfeed or not feeding well |
1% |
1.5% |
92.5% |
4.5% |
1.5% |
0% |
Constipation |
0.5% |
2.5% |
70% |
19.5% |
7.5% |
0% |
Not gaining weight |
1.5% |
2% |
84% |
7% |
5.5% |
0% |
Redness of umbilicus |
0.5% |
7.5% |
89.5% |
1.5% |
1% |
0% |
Purulent discharge from umbilicus |
0% |
3.5% |
96% |
0.5% |
0% |
0% |
3.4. Factors Associated with Knowledge Levels
A statistically significant association was found between poor knowledge of danger signs and the following factors: age group 20 - 30 years, higher education level, living in an extended family home, and being married (Table 4).
Furthermore, having more than three ANC visits, receiving antenatal care from a midwife, and initiating breastfeeding between 1 and 12 hours after birth were significantly associated with poor knowledge of neonatal danger signs (Table 5).
Table 4. Sociodemographic factors associated with knowledge of danger signs.
|
Poor knowledge |
Satisfactory knowledge |
Good knowledge |
P-value |
n |
% |
n |
% |
n |
% |
|
Mothers’ age |
<20 years |
8 |
4% |
3 |
1.5% |
0 |
0% |
0.000 |
20 - 30 years |
82 |
41% |
43 |
21.5% |
5 |
2.5% |
30 - 40 years |
33 |
16.5% |
18 |
9% |
2 |
1% |
Over 40 years |
3 |
1.5% |
3 |
1.5% |
0 |
0% |
Education level |
No schooling |
13 |
6.5% |
3 |
1.5% |
1 |
0.5% |
0.000 |
Quranic school |
14 |
7% |
12 |
6% |
0 |
0% |
Primary |
13 |
6.5% |
6 |
3% |
0 |
0% |
Middle school |
24 |
12% |
16 |
8% |
1 |
0.5% |
Secondary school |
24 |
12% |
14 |
7% |
1 |
0.5% |
Higher education |
38 |
19% |
16 |
8% |
4 |
2% |
Mothers’ origin |
Urban |
74 |
37% |
48 |
24% |
6 |
3% |
0.2014 |
Peri-urban |
12 |
6% |
7 |
3.5% |
0 |
0% |
Outside Dakar |
40 |
20% |
12 |
6% |
1 |
0.5% |
Mothers’ occupation |
Unemployed |
73 |
36.5% |
35 |
17.5% |
2 |
1% |
0.4245 |
Informal sector |
32 |
16.0% |
23 |
11.5% |
3 |
1.5% |
Formal sector |
21 |
10.5% |
9 |
4.5% |
2 |
1% |
Housing type |
Family house |
66 |
33% |
42 |
21% |
5 |
2.5% |
0.000 |
Apartment |
60 |
30% |
23 |
11.50% |
2 |
1% |
Others |
0 |
0% |
2 |
1% |
0 |
0% |
Marital status |
Single |
10 |
5% |
3 |
1.50% |
0 |
0% |
0.000 |
Married |
115 |
57.5% |
64 |
32% |
6 |
3% |
Widows |
2 |
1% |
0 |
0% |
0 |
0% |
Type of marriage |
Monogamy |
5 |
2.50% |
66 |
33% |
40 |
20% |
0.000 |
Polygamy |
2 |
1% |
49 |
24.50% |
24 |
12% |
Others |
0 |
0% |
11 |
5.50% |
3 |
1.50% |
Table 5. Pregnancy follow-up and delivery factors associated with knowledge of danger signs.
|
Poor knowledge |
Satisfactory knowledge |
Good knowledge |
P-value |
n |
% |
n |
% |
n |
% |
|
ANC (Visits) |
1 |
2 |
1% |
0 |
0% |
0 |
0% |
0.000 |
2 |
3 |
1.5% |
3 |
1.5% |
0 |
0% |
3 |
10 |
5% |
5 |
2.5% |
0 |
0% |
>3 |
111 |
55.5% |
59 |
29.5% |
7 |
3.5% |
Healthcare provider |
Gynecologist |
39 |
19.5% |
31 |
15.5% |
4 |
2% |
0.000236 |
Midwife |
87 |
43.5% |
36 |
18% |
3 |
1.5% |
Place of delivery |
Health center |
4 |
2% |
1 |
0.5% |
1 |
0.5% |
0.3707 |
Clinic |
2 |
1% |
5 |
2.5% |
0 |
0% |
Hospital |
118 |
59% |
60 |
30% |
7 |
3.5% |
Health post |
2 |
1% |
0 |
0% |
0 |
0% |
Time spent in hospital |
1 to 10 days |
126 |
63% |
63 |
31.5% |
7 |
3.5% |
0.679 |
11 to 20 days |
0 |
0% |
2 |
1% |
0 |
0% |
>20 days |
0 |
0% |
2 |
1% |
0 |
0% |
Advice received |
Breastfeeding |
57 |
28.5% |
19 |
9.5% |
34 |
17% |
0.402 |
Vaccination |
42 |
21% |
9 |
4.5% |
37 |
18.5% |
PNC date |
55 |
27.5% |
12 |
6% |
0 |
0% |
Birth control |
10 |
5% |
15 |
7.5% |
2 |
1% |
Danger signs |
10 |
5% |
3 |
1.5% |
2 |
1% |
Others |
5 |
2.5% |
2 |
1% |
1 |
0.5% |
Parity |
1 child |
69 |
34.5% |
26 |
13% |
4 |
2% |
0.3165 |
2 - 3 children |
46 |
23% |
32 |
16% |
3 |
1.5% |
>=4 |
11 |
5.5% |
8 |
4% |
1 |
0.5% |
Time to breastfeeding |
1 h - 12 h |
70 |
35% |
21 |
10.5% |
2 |
1% |
0.0002473 |
13 h - 24 h |
18 |
9% |
9 |
4.5% |
1 |
0.5% |
25 h - 36 h |
1 |
0.5% |
0 |
0% |
0 |
0% |
37 h - 48 h |
16 |
8% |
12 |
6% |
2 |
1% |
>48 h |
21 |
10.5% |
25 |
12.5% |
2 |
1% |
PNC: post natal consultation.
4. Discussion
In our study, the most represented age group was 20 - 30 years, accounting for 65% of the sample. This proportion is slightly higher than that reported by Okawa et al. in Ghana in 2015 (50.5%) [6]. This finding can be explained by the predominantly young population in Senegal, where this age group corresponds to the peak childbearing age [3].
Our cohort is characterized by a high level of schooling, a profile generally more favorable than those observed in many studies across sub-Saharan Africa [7]. However, despite the majority of mothers having a good level of education, nearly two-thirds (63%) demonstrated insufficient knowledge. These results corroborate data reported in several resource-limited settings, where maternal knowledge of danger signs remains low despite high utilization of health services. In Ethiopia, studies conducted between 2020 and 2023 showed that the percentage of mothers with good knowledge ranged from 20% to 40%, depending on education levels and access to care [8]. In Nigeria, Ekwochi et al. reported that knowledge of three or more of the nine WHO-recognized signs was very low (0 - 30.3%) across the studied communities [9]. Similarly, in an Ethiopian study, only 36.5% of mothers had “good” knowledge of neonatal danger signs, and correct recognition was associated with education, media exposure, birth preparedness, and delivery in a health facility [10] [11].
In our study, the analysis of associated factors showed that higher education and the 20 - 30 age group were significantly associated with poor knowledge (p = 0.000). This suggests that, even in an urban and educated setting, formal academic instruction does not substitute for targeted health education.
Indeed, although adherence to the health system is strong—with 88.5% of mothers attending more than three Antenatal Care (ANC) visits and 99% delivering in a formal facility (attended by a midwife or gynecologist)—the communication process appears to be deficient. Only 7.5% of mothers stated they had received specific information regarding danger signs. Furthermore, the statistically significant association between having attended more than three ANC visits or having been followed by a midwife and possessing poor knowledge of neonatal danger signs (p = 0.000 and p = 0.000236, respectively) highlights a systemic gap in the quality and content of prenatal and postnatal education in Senegal. The majority of mothers in resource-limited countries are insufficiently prepared to identify neonatal complications, contributing to the persistence of high neonatal mortality despite the availability of care. This contrasts with WHO protocols for essential newborn care, which mandate that counseling on danger signs be a systematic component of both prenatal and postpartum management [12]. The counter-intuitive negative correlation between higher maternal education, frequent ANC attendance, and knowledge levels points to a specific “competence assumption” bias in provider-patient interactions. Healthcare professionals may inadvertently assume that educated mothers are already health-literate, leading them to omit basic counseling on danger signs. Conversely, the high frequency of ANC visits among mothers with poor knowledge suggests a ‘ritualization’ of care, where the focus remains strictly on obstetric monitoring (e.g., pre-eclampsia screening) at the expense of anticipatory neonatal guidance. This indicates that without a structured, mandatory educational curriculum embedded into prenatal visits, high healthcare utilization does not translate into improved neonatal health literacy
Insufficient knowledge of neonatal signs remains a critical issue, as early detection is key to reducing neonatal morbidity and mortality. In our series, recognition was better for the most overt signs: fever/hyperthermia (69%) and refusal to breastfeed (38%). This hierarchy of recognition, where visible signs are better known, is a trend observed in comparative studies conducted in other resource-limited settings. In Kenya, a study reported that fever was the most frequently identified sign in newborns (~73.9%) [13]. Similarly, in a study at a tertiary hospital in Uganda, only 14.0% of mothers had satisfactory knowledge (≥3 signs spontaneously recognized) at discharge; fever (73.6%) and refusal to breastfeed (38.8%) were among the most cited [14].
Conversely, knowledge of more insidious signs or those specific to severe infections—such as jaundice, convulsions, lethargy, or purulent umbilical discharge—was low in our study. In a survey in eastern Ethiopia, authors reported that specific signs like lethargy or convulsions remain poorly recognized [15]. In Saudi Arabia, a qualitative study focused on knowledge reported major difficulties for mothers in identifying enough signs, particularly those that are less obvious (lethargy, convulsions, jaundice, etc.) [16].
The poor recognition of jaundice and neurological signs is concerning, as it may delay the diagnosis and treatment of severe pathologies, which are direct causes of preventable sequelae and death in Low- and Middle-Income Countries (LMICs). In developed countries, public health campaigns focus on the early recognition of these subtle signs through systematic prenatal and postnatal education programs, easy access to information (internet, media, prenatal classes), and strong involvement of healthcare professionals in parental counseling to prevent irreversible complications [17].
Maternal attitudes were generally very positive, as more than 80% considered neonatal danger signs to be serious. Regarding practices, health facilities were the primary point of care for almost all mothers, which constitutes a major asset of the Senegalese system. In Ghana, Gyaase’s study reported that 77.2% of mothers stated they would go to the hospital as soon as a neonatal danger sign was identified [18].
However, recourse to the advice of family members, marabouts (traditional healers), or the use of traditional remedies, although present in small proportions in our study, is nonetheless responsible for delays in management. Moreover, poor knowledge of danger signs was associated with living in an extended family home and being married, indicating that these mothers rely more on advice from their social circle than on structured medical information.
Furthermore, the persistence of home monitoring (“watchful waiting”) observed for certain signs (excessive sleep, constipation, and jaundice) remains worrisome. This waiting period observed in maternal practices is a key determinant of neonatal survival, as studies show that delays in care-seeking significantly increase the risk of infant mortality [19].
The significant association between polygamy and maternal knowledge observed in our study (p < 0.05) likely mirrors the dynamics seen in extended family households. In polygamous settings, the hierarchy of care often shifts from the biological mother to older co-wives or the paternal grandmother, who act as the primary decision-makers regarding newborn health. This ‘collective mothering’ structure can dilute the impact of hospital-based education, as traditional beliefs held by senior household members—such as home monitoring for jaundice or using traditional remedies—often supersede the medical advice given to the young mother. Consequently, even if a mother attends antenatal care, her ability to implement that knowledge is constrained by the domestic power dynamic, reinforcing the need for inclusive health education strategies that target the entire family unit rather than the mother in isolation.
Our results argue for the systematic integration of a module on neonatal danger signs into prenatal care programs, birth preparedness sessions, and postnatal visits in Senegal. Additionally, training midwives and community health workers in parental education is essential, as they are best positioned to reach mothers in the immediate postpartum period. Experience from other resource-limited countries demonstrates that such simple but systematic interventions can significantly improve maternal knowledge and reduce consultation delays [10].
Finally, our study has limitations: it relies on a self-reported questionnaire, which may introduce social desirability bias, and does not directly assess the quality of practices (actual consultation times, real-world behavior in case of danger, neonatal outcomes). These limitations do not detract from the value of the findings but should encourage further research, such as clinical practice audits, interventional studies (impact of an education program), and longitudinal follow-up of newborns.
5. Conclusions
In Senegal, despite high healthcare utilization and favorable sociodemographics, maternal knowledge of neonatal danger signs remains suboptimal, notwithstanding a high perception of severity. This underscores a significant discrepancy between the quantity of maternal care accessed and the quality of health education delivered.
Improving early detection of neonatal illnesses and reducing mortality requires immediate action: the integration of systematic maternal education into the entire perinatal continuum of care is imperative. This must be supported by adapted educational tools and reinforced training for healthcare providers.