Neonatal jaundice (NNJ) is a very common condition affecting 60% of term and 80% of preterm newborns, to a variable degree, around the world [1]. If severe jaundice develops, it can lead to acute bilirubin encephalopathy or kernicterus with a significant risk of neonatal mortality and long-term neurodevelopmental symptoms such as cerebral palsy, sensor neural hearing loss, intellectual difficulties, or gross developmental delays [2].

Neonatal jaundice is defined as a yellowish discoloration of the mucous membranes, skin, and sclera due to the accumulation of unconjugated, nonpolar, lipid-soluble bilirubin pigment in the skin [3]. Neonatal jaundice is the most common during the remaining weeks of neonatal age and an important condition needing medical attention; about 10% of breastfed neonates are still jaundiced within 1 month. It is a common disorder worldwide, and an estimated 75% of hospital readmissions [4]. Neonatal jaundice is primarily important because there is a relationship between the increase in unconjugated bilirubin levels and neurotoxic effects that can lead to long-term complications such as cerebral palsy, kernicterus, and hearing impairment [5].

Neonatal jaundice is an increased release of hemoglobin from the breakdown of red cells due to high hemoglobin at birth, as well as due to the reduced life span of newborn red blood cells (70–80 days) compared to that of adults (90–120 days), and reduced hepatic metabolism of bilirubin due to an immature liver and Most neonatal jaundice is a natural transition that resolves by the rest of the week with the maturing of the liver cells [6].

Neonatal jaundice may have severe side effects on the health of infants; consideration should be given to its associated factors in newborns, and kernicterus is one of the most important complications of the disease [7]. Neonatal jaundice is one of the most and nine dangerous signs of neonatal illness recognized by the World Health Organization (WHO) [8]. According to a recent review, sub-Saharan Africa and South Asia were reported as the leading contributors to an estimated 1.1 million babies who would develop severe hyperbilirubinemia worldwide, so early identification of infants at risk of severe hyperbilirubinemia is more crucial for this potentially devastating condition [9].

So, it is clear that neonatal jaundice represents a heavy burden for healthcare services. Therefore, the purpose of this study is to determine the magnitude and determinants of neonatal jaundice among neonates admitted to the NICU. Dessie town public hospitals and it is important, to reduce the risk for future neonates to develop kernicterus, for early intervention, prophylaxis, and treatment; improving prevention, early detection, and management of neonatal jaundice; and reducing neonatal deaths by strengthening newborn care and maternal health services. It may also help to create awareness to the community based and mothers, on the result finding and health professionals will give health education to mothers about different determinants of neonatal jaundice at the time of antenatal clinic and postnatal care follow up which help them to be screened and treated early. Finally, it would also be a baseline for other researchers to do qualitative and other study designs for the future to assess the magnitude and determinants of neonatal jaundice.

Study Design, Area and Setting

A health institution-based cross-sectional survey was conducted in public hospitals in Dessie Town from March 30 through April 30, 2020. The study was conducted at health facilities in Dessie Town, Ethiopia, which is located 401 kilometres from Addis Ababa, the capital city of Ethiopia, and 480 kilometres from Bahirdar, the capital city of Amhara regional state. Dessie town has a total population of 151,174, of whom 72,932 are men and 78,242 are women. The languages spoken include Amharic (94.89%), Tigrigna (3.79%), and other languages (0.67%) [10]. A total of two public hospitals have been offering the neonatal intensive care unit (NICU).

Source of Population, Sample Size Calculation and Sampling Procedures

The source populations were all neonates with their mothers' who were admitted to the neonatal intensive care unit of those hospitals.

The sample size was calculated by using a single population proportion formula with the assumption of Prevalence of neonatal jaundice being 44.6 % [11] with 95% confidence level and 5% margin of error were considered. With these assumptions, the minimum required sample size was 380, but according to the recent one-month health management information system registration data, the estimated total population in the study area was 414. This was less than 10,000. So, a correction formula was used; N= total estimated neonates with their mother in the study area during data collection time was 414 by considering 10 % none response rate of participants is added 10 % of the sample size which was 20. So the total sample size was 218 newborns.

A total sample size for the two hospitals were carried out according the client patient load in each public institutions. The individual cases of jaundice were investigated with reference to their charts.

Data Collection

Data were collected using interviewer administered questionnaires and checklists were used. The data collection tools were adopted from previous similar studies [12-14] adapted to the local context. The data collection instrument was prepared in English and translated to the local language (Amharic) by language expert who is fluent in both languages and back translated to English by another expert to ensure the language consistency and accuracy.

Data collectors were recruited based on their previous data collection experience, relevance of their qualifications, and ability to speak the local language. Training was given for three consecutive days in order to make the data collectors and supervisors familiar with the data collection tools and interview techniques. Emphasis was given to ethical considerations, the safety of participants, data collectors, and maintaining confidentiality. The data collection tools were pre-tested at Woldia general hospital out of the actual study site on 5% of the total sample size prior to actual data collection.

A field work manual was developed by the principal investigator and used by all research teams. To ensure the quality of the data and minimize inter-interviewer variation, about 5% of the respondents were re-interviewed at random by the principal investigator and supervisors and checked for consistency. In addition, daily checks and follow-up were done by the supervisors and investigator.

Operational Definitions

Prevalence of Neonatal Jaundice: The number of neonates with neonatal jaundice in the percentage of the total admitted during the data collection period.

Low birth weight: The neonatal birth weight is less than 2,500 grams.

Neonate: A neonates from birth to 28 days of age of life.

Preterm: Newborn whose gestational age is less than 37weeks.

Normal birth weight: The neonate weight is greater than 2500 grams and less than 4000grams.

Neonatal Jaundice: Neonates are diagnosed as jaundiced by physicians.

Physiological Jaundice: clinical jaundice appears after 24 hours of age and clinical jaundice resolve by 1 week in term and 2 weeks in preterm infants.

Breast Milk Jaundice: Late-onset jaundice begins after 4-7th day of life and is caused by increased reabsorption of unconjugated Bilirubin, perhaps due to an unidentified factor in human milk.

Breastfeeding jaundice: Occurs in the rest few days (2-3) days of life and is related to decreased breast milk intake and decreased frequency of feeding as well as a history of formula feeding that may indicate the occurrence of breastfeeding jaundice.

Pathological Jaundice: It is evident on the 1st day of life and clinical jaundice persists for more than 1 week in full-term infants or 2 weeks in preterm infants.

Data Analysis

The data was cleaned manually, coded, and entered into Epi Data version 4.2 and analysed by SPSS version 24 statistical software. The statistical analyses used were percentage, frequency, and bivariate and multivariate logistic regression analyses. Found to be significant at the bivariate level (P 0.05), they were selected and included in multivariate logistic regression models. Then multiple logistic regression analysis models were used to calculate the odds ratio with a 95% confidence interval to estimate the association and control confounding variables. Strength and Strength and direction of the association presented using odds ratios relative to the reference category and 95% confidence levels.

Socio-Demographic Characteristics of the Study Participants

A total of 218 clients were approached; however, 209 Newborn baby and mother pairs consented to participate in the study, constituting a response rate of 96%. The mean age of mothers was 28.68 years (SD=5.4). More than half of the respondents (60.8%) were in the age group of 20-35, and the majority of the mothers 192 (88.2%) were Amhara in ethnicity. More than three-quarters of the mothers, 188 (88.2%), were married, and 120 (54.85) were urban residents. Maternal educational status: 32(14.8%) of the respondents were unable to read and write, and more than half of the mothers were housewives (Table1).

Table 1: Socio-demographic factors for neonatal jaundice in Dessie town public hospitals, Amhara region, Ethiopia, 2019/20. (n=218).

Maternal Factors for Jaundice

More than half 146 (67.0%) of the respondents were Multi Para. Regarding mode of delivery, 202 (92.2%) were spontaneous vaginal deliveries (SVD), whereas 11 (5.1%) were C-sections (C/S). With regard to the place of delivery 118 (54%) were hospitalized and six (2.8%) were home delivery and 192 (88.2%) had No previous sibling with jaundice, 206 (94.5%)) of the mothers had ANC follow up, and also 26 (11.9%) were taking substance during pregnancy. Of which alcohol taking, herbal medication, and chat chewing were (57.7%), (15.4%) and (26.9%) respectively, and regarding chronic medical illness only (5.5%) mothers who had medical chronic illness (Table 2).

Table 2: Maternal factor for neonatal jaundice in Dessie town public hospitals, Amhara region, Ethiopia, 2019/20. (n=218).

Noted: ANC=Antenatal Care, SVD= Spontaneous vaginal Delivery and PROM= Premature rapture of membrane.

Neonatal Factor for Jaundice

More than fifty percent of neonates were male infants and the majority of the age group found between 1-7 days 164 (75.2%). The majority of neonates (68.8%) were LBW, and 146 (66.9% neonates were on breast feeding (Table 3).

Table 3: Neonatal factor for neonatal jaundice in Dessie town public hospitals Amhara region, Ethiopia 2019/20 (N=218).

Neonatal age with onset neonatal jaundice indicated that less than 1 day, 1-7 days, 8-14 days, And more than 14 days were 28 (45.4%), 19(30.6%), 11 (17.5%) and 4 (6 5%) were respectively (Figure 1).

Figure 1: Neonatal age with the onset of neonatal jaundice in Dessie comprehensive specialized hospitals Amhara, Ethiopia 2019/20.

Prevalence of Neonatal Jaundice

The Prevalence of neonatal jaundice among neonates admitted to the neonatal intensive care unit (NICU) of Dessie Town public hospitals was found to be 28.4%(62) (Figure 2).

Figure 2: The prevalence of neonatal jaundice among neonates admitted to neonates (NICU) in Dessie comprehensive specialized hospitals, Amhara, Ethiopia 2019/2020.

Factors Associated with Neonatal Jaundice

In the bivariate logistic regression analysis, where possible confounders were not controlled, assessing the independent effects of the covariate was difficult. So, enter the logistic regression technique, which was used to assess the independent effect of explanatory variables on neonatal jaundice. To avoid an excessive number of variables and unstable estimates in the final model, only variables with a P-value less than 0.25 in the bivariate analysis were taken into the multivariate logistic regression analysis and a P value less than 0.05 was taken as the level of statistical significance. In multivariate logistic regression analysis Low APGAR score, ABO-incompatibility, neonatal sepsis, prolonged labor, Rh-incompatibility, and Gestational Age < 37weeks were found to be an independent predictor of neonatal jaundice. However, birth trauma, residence, birth asphyxia, PROM, time of delivery, maternal parity, and family/sibling history were not associated with neonatal jaundice.

This study had shown that prolonged duration of labor had a significant effect on the development of neonatal jaundice. The odds of jaundice developing were about more likely to be observed in neonates who were born with a long duration of labor compared with those neonates who were born in normal labor [AOR = 3.69 (95% CI = 1.05, 12.94)]. Newborn neonates who were delivered before gestational age of 37 weeks were 3 times more likely to develop neonatal jaundice when compared to babies born at a gestational age of 37 weeks and more [AOR=3.92, 95%CI=1.89, 9.11)] and likewise, Neonates had low APGAR score < 7 eight times more likely to develop neonatal jaundice when compared to neonates who had normal APGAR score [AOR=8..36 (95%CI=1.34, 39.65)].

In this study, neonatal sepsis and ABO incompatibility had a significant association with the dependent variable. The odds of neonatal jaundice among neonates who had neonatal sepsis were three times more likely observed Neonatal jaundice compared with those neonates who had no infection was confirmed [AOR = 3.82 (95% CI = 1.67, 8.09)]. Similarly, neonates with an ABO incompatibility diagnosis were 6 times more likely to develop neonatal jaundice compared with those neonates who had no diagnosis of blood type incompatibility [AOR = 6.94 (95% CI = 1.97, 24.42)].

Table 4: Bivariate and Multivariate logistic regression analysis of maternal and neonatal factors for neonatal jaundice Neonates were admitted to NICU in Dessie town Public hospitals, Amhara region, Ethiopia 2019/20 (N=218).

(*=a variable that has statistically significant at p value <0.05 with 95%CI).

AOR=Adjusted Odd Ratio, OR=Crude Odd Ratio and PROM=Premature rapture of membrane.

Neonatal jaundice has significant importance on neonatal morbidity and mortality worldwide. The vast majority of the affected neonates reside in sub-Saharan Africa and South Asia [15]. A little bit of data was available on the prevalence and factors associated with neonatal jaundice in Ethiopia. This study aimed at assessment of prevalence and predictors of neonatal jaundice among neonates admitted to the neonatal intensive care unit in Dessie Town Of public hospitals.

In the study, the prevalence of neonatal jaundice was found to be 62 (28.4%), and this was consistent with studies conducted in India and Pakistan [16,17]. But it was lower than the prevalence of retrospective study conducted in Ethiopia, and Nigeria [11,18]. This inconsistency may be due to differences in the study area, time gaping, and methodology. This study is also lower than a study conducted in Nigeria [19]. This discrepancy between the findings may be due to the time gap between the study periods and the different study areas, study design, and the skills of data collectors. Likewise, this finding was also lower than compared to the findings from the retrospective study conducted in Sub-Saharan Africa [20]. Inconsistency may be due `to a difference in the skills of data Collectors, study area, and study design.

This study was also lower than a case-control study conducted at Bloemfontein [21]. The discrepancy of this finding might be the different study areas, study design, and skills of data collectors. This study also a little bit lower than the study conducted in Southeast Nigeria [14]. Besides the difference in methodology, time gaping, and the study setting may be the reason behind. This study also shows lower than the study was conducted in Northern Ethiopia [22]. The discrepancy of this finding might be explained by the different study areas, time gaping, and skills of data collectors, and also this study was not a consistent case-control study conducted by Gondar University [23]. This difference could be due to the different study areas, study design, and methodology reason behind.

This study had shown that neonatal sepsis had a significance effect on developing neonatal jaundice. The odds of jaundice were ten times higher among neonates who had no sepsis diagnosis compared with neonates who had no sepsis diagnosis. This finding supported as possible causes of neonatal jaundice in studies were conducted in Nigeria, South Indian, and Israel-Aiwa [16,24,25]. This might be because hemolysis, hepatocellular damage, ileus, and/or acidosis may occur as a result of sepsis. These factors may increase bilirubin production (hemolysis), decrease bilirubin removal (liver cell damage), increase reabsorption of bilirubin, or decrease liver function, which leads to accumulation of serum bilirubin in the body. This is supported by a study conducted in Iran [26].

ABO incompatibility had a significant effect on developing neonatal jaundice. The odds of jaundice were more likely developing jaundice among neonates had ABO incompatibility compared neonates who had not ABO-incompatibility. This finding was supported studies conducted in Nigeria and also south East Indian [16,19]. The possible explanation would be that the mother had an O blood group and the fetus had an A or B blood group. In this condition, some fetal RBCs cross the placenta and enter the maternal circulation, where they can cause hemolysis of infant RBCs, which leads to neonatal jaundice, and also a hemolytic disease of the Newborn when maternal IgG antibodies with specificity for the ABO blood group system pass through the placenta to the fetal circulation, where they can cause haemolysis of fetal red blood cells, which can lead to fetal anemia, which could be the result [20].

This study showed that prematurity had a significant effect on developing neonatal jaundice. The odds of jaundice were six times higher among neonates who had delivered before term gestational age compared with neonates who had delivered at an appropriate gestational age (at term weeks). This result is in line with studies done in Nigeria and Ethiopia [14,23]. Those preterm babies have immature livers with decreased ability to process bilirubin, and preterm neonates are also more likely to be stressed and, therefore, are at risk for an impaired blood-brain barrier. Further, preterm neonates often have low serum protein and thus have fewer bilirubin binding sites, increasing the likelihood of free bilirubin. Gestational age plays an important role in determining neonatal jaundice. Infants who were delivered prematurely were at higher risk to have jaundice which prone to developing jaundice due to immaturity of their bilirubin conjugating system at a higher rate of haemolysis, increased enters hepatic circulation and decreased caloric intake which leads develop jaundice [27]. This study revealed that neonates with low APGAR scores had higher odds of developing neonatal jaundice compared to those neonates who had normal APGAR scores. This finding was supported by studies conducted in Nigeria [24]. It is fact that APGAR core is the overall indicator for the state of the Newborn in the extra uterine environment and neonates with low Apgar score could be in a state of Brady cardiac asphyxia and sepsis which could be leaders to neonatal jaundice [28].

Moreover, the study revealed that prolonged duration of labour had a significant effect on the development of neonatal jaundice. The odds ratio of jaundice was about 3 times more likely developing jaundice among neonates who were born with a long duration of labour compared with those neonates who born in normal labour. This finding was in line with findings in [22] and [21]. This might be contributing to the bruising and swelling of the scalp of new-borns because of the excessive pressure applied by health attendants as a solution for prolonged labour, which, in turn, increases the risk of jaundice by raising the bilirubin level in the bloodstream, which leads to the development of neonatal jaundice.

Our finding suggests there is an association between neonatal jaundice and low Apgar scores less than 7, prematurity (gestational age< 37weeks), blood type incompatibility, prolonged duration of labour, and neonatal sepsis. It is necessary that all women be tested for the mother's blood group as early as possible during antenatal follow up and if the woman's blood group O is detected during follow-up, it should be considered an ABO setup, making early prevention and detecting neonatal jaundice mandatory. It is also important for health care providers should adhere to aseptic techniques while carrying and conducting neonatal invasive procedure and policy makers to strengthen the in availing the need of women along with comprehensive.

AAU: Addis Ababa University, ANC: Antenatal, AOR: Adjusted Odd Ratio: APGAR scores Appearance, pulse, grimace, activity, respiration, score, BMH: Boru Meda Hospital; DRH: Dessie referral hospital; COR: Crude Odd Ratio, EDHS: Ethiopian Demographic and Health Survey; G-6PD: Glucose-6-Phosphate Dehydrogenate: HMIS: Health Management Information System; LBW: Low Birth Weight; NICU: Neonatal Intensive Care Unit; NNJ: Neonatal Jaundice; Rh factors: Rhesus factor; SPSS is the Statistical Package for Social Science, and WHO is the World Health Organization.

Ethical Considerations

Ethical clearance was obtained from the institutional review board (IRB) of Addis Ababa University College of Health Sciences, School of Nursing and Midwifery. An official letter of permission was written to the respective hospitals. Consent was obtained from medical directors and the respective unit heads at each health institution. Verbal consent was obtained from each participant. In order to make an informed decision, sufficient information was given to each participant. Confidentiality was strictly maintained for each piece of information, and the interview was conducted in a strictly private setting. At the end of the interview, general information, referral, and follow-up links were made for those who needed them.

Author’s Contribution

All authors contributed equally to the conception and design of the study. MT collected, analysed, and interpreted the data. HM, TA, and YG monitored and evaluated the data. HM and TA critically revised and edited the article as well as the manuscript, participated as advisors, and helped with statistics. All authors read and approved the final content of the manuscript.

Availability of Data and Materials

The datasets were used for the study are available from the corresponding author upon needed.

Competing Interests

We declare that no financial or non-financial competing interests related to this study.

Acknowledgements

We are very grateful to Addis Ababa University for funding the study. We would like to express our most sincere thanks to the women who participated in this study for sharing this personal and important information. We also extend our thanks to all data collectors participated throughout the process.

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