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.

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 etal. 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 etal. 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.

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.