Hyperbilirubinemia, characterized by elevated levels of bilirubin in the blood, is a common condition in neonates, particularly in the first week of life. It manifests as jaundice, which is the yellowing of the skin and sclera due to the deposition of bilirubin. [1 This condition affects more than 50% of term and up to 80% of preterm infants globally, making it a significant public health concern. [2]

In Ethiopia, the prevalence of neonatal jaundice ranges from 37.3% to 44.9%, indicating a substantial burden on the healthcare system [3]. Neonatal jaundice, a leading cause of neonatal morbidity and mortality, can lead to severe complications like kernicterus and even death, especially in low-resource settings like Ethiopia where healthcare access and maternal education are limited[4,5].

The Ethiopian government is aiming to reduce neonatal mortality rates from 28 per 1,000 live births to 11 per 1,000 live births by 2035 by addressing neonatal health issues like hyperbilirubinemia. [6].

Several risk factors for neonatal jaundice have been identified, including prematurity [7], maternal age [8,9], low birth weight [10], glucose-6-phosphate dehydrogenase deficiency (G6PD) [11], genetics [12], sex [13], drugs, race [14], polycythemia [10], maternal diabetes [15], oxytocin induction [8,11], delayed bowel movement, family history of physiological jaundice [13], breast milk, weight loss [16], blood-group incompatibilities [17], and other hemolytic diseases [18].

This research aims to investigate the incidence, risk factors, and knowledge gaps related to neonatal jaundice in Harari region, Ethiopia. The findings will provide valuable insights for healthcare providers and policymakers to develop targeted interventions to improve neonatal care and reduce the burden of hyperbilirubinemia in the country.

Study Design, Area, Period and Population

An institution-based cross-sectional study was carried out at Hiwotfana specialized referral hospital in Harar from April 1 through April 30, 2024.the hospital is situated in the Harari regional state and is about 525 kilometers from capital city Addis Ababa & the target population include neonates (0-28 days old) diagnosed with hyperbilirubinemia and their mothers

Sample Size

sample size was determined using the formula n = (Z/2)2p (1-p)/d2, where n is the number of study participants, Z is the value of the standardized normal distribution curve for the 95% confidence interval (1.96), P is magnitude of neonates with hyperbilirubinemia in Black Lion Hospital Ethiopia, which was 44.9 %, and d is the desired precision of the estimate (the margin of error between the sample and population, 5%) = 0.05 = (1.96)2(0.449)(0.551)/ (0.05)² = 380. The total sample size was 418 after adding 10% of the non-respondent rate

Data Collection

Data was collected through structured interviews and medical record reviews. Clinical Data: Information on the neonate's birth weight, gestational age, sex, and any underlying health conditions will be gathered from medical records. Maternal Data: A questionnaire was administered to mothers, covering: Demographic information (age, education level, socioeconomic status), Knowledge about jaundice (signs, causes, management), Previous experiences with neonatal jaundice. Data Collectors were trained on data collection methods and ethical considerations.

Data Analysis

Data was analyzed using statistical software SPSS .Descriptive statistics used to summarize demographic and clinical characteristics. Chi-square tests was used to assess associations between maternal knowledge and risk factors for hyperbilirubinemia. Multivariable logistic regression was used to identify independent risk factors associated with hyperbilirubinemia.

Ethical Considerations

Ethical approval was obtained from the Harar Health Science College Ethics and Research Committee, (Ref. Number HHSC-217/2024). Informed Consent was obtained from administrative body of the hospital and the mothers or guardians. Confidentiality of the data has been kept throughout the study.

Demographic Characteristics

A total of 400 mothers with their neonate pairs participated in the study, making the response rate of 95.69%. The age of mothers included in this study ranged from 18 to 40 years. The mean age of the mother were 27.3 (SD ± 3.86). Of the respondents, 311(77.75%) were married, 299(74.75%) were from urban areas (See Table 1).

Table 1: Socio-demographic characteristics of study participants in Hiwot-fana specialized referral Hospitals, Harar, Ethiopia.

Obstetric and Clinical Characteristics of the Mother

Among mothers included in the study, 17 (4.25%) mothers had a previous history of a child with neonatal jaundice. Among participant mothers, 102 (25.5%) had a complication during pregnancy. The commonest complication was PROM, 53 (13.25%). Regarding mode of delivery, 299 (74.75%) gave birth via spontaneous vaginal delivery (See Table 2).

Table 2: Obstetric and clinical characteristics of the mothers in Hiwot-fana specialized referral Hospitals, Harar, Ethiopia.

Neonatal Characteristics

Among neonates included in the study, 211 (32.75%) were female, regarding birth asphyxia 191 (47.75%) had where the rest do not had, regarding their gestational age, 157 (39.25%) were preterm neonates (gestational age < 37 weeks). Among neonate 231 (37.75%) had ABO incompatibility (See Table 3).

Table 3: Neonatal Characteristics of study participants’ in Hiwot-fana specialized referral Hospitals, Harar, Ethiopia.

Prevalence of Hyperbilirubinemia

The overall prevalence of hyper-bilirubinemia among the studied neonates was found to be 34% (136 out of 400 neonates). Among neonates with hyper bilirubinemia, 353 (88.25%) were treated by phototherapy, 31 (7.75%) blood transfusion and 16 (4%) both method. From a total of 136 neonates with hyper bilirubinemia, 14 (10.6%) neonates were developed complications. From the neonates who developed complications 7 (50 %) developed encephalopathy (kernicterus), 4 (28.57%) developed hemolytic disease and 3 (21.42%) developed Anemia. Among the neonates with hyper bilirubinemia 117 (86.02%) were Improved from their illness and discharged, 5 (3.67%) were referred, 4 (2.94%) died and 10 (7.35%) singed against medical advice

Maternal Knowledge on Hyper Bilirubinemia

The knowledge assessment revealed that only 30% of mothers were aware of the signs of jaundice, while 25% correctly identified the potential complications associated with untreated hyper bilirubinemia.

Table 4: Maternal knowledge on hyper bilirubinemiain Hiwot-fana specialized referral Hospitals, Harar, Ethiopia.

Risk Factors Associated With Hyper Bilirubinemia

Variables considered for multivariate logistic regression analysis were those with a p-value<0.5 in bi-variate analysis and those significantly associated with bi-variable analysis were; residence, sex, gestational age and neonatal Sepsis. After controlling confounding variables using multiple logistic regressions; only gestational age was significantly associated with hyper bilirubinemia

The multivariate logistic analyses showed that preterm babies were four more likely to develop hyper bilirubinemia than term babies (AOR = 3.55; 95% CI: 1.184-6.104).

Table 5: Bi variate and Multi variate analysis result.

Prevalence of Hyper Bilirubinemia

In this study, 34.46 % of neonates encountered jaundice. This finding is in line with the study conducted in Southeast Nigeria (35.0 %) [19]. However, it is lower than the studies conducted in Iran (70.0 %) [20], South Africa (55.2 %) [21], Myanmar governmental hospitals (46.0 %) [22], Black Lion Specialized Hospital, Ethiopia (44.9 %) [23], and Mekelle (37.3 %) [24]. On the other hand, this finding is higher than the studies conducted in India (13.0 %) [25.26], St. Paulous hospital, Ethiopia (13.3%) [27], Egypt (16 %) [28], southwest Oromia, Ethiopia (20.5 %) [29] and Uganda (22.7 %) [30]. the discrepancies might be due to methodology

This high prevalence underscores the importance of early detection and management, as untreated hyper bilirubinemia can lead to severe complications, including kernicterus and long-term neurological damage.

Maternal Knowledge

A concerning finding of this study is the low level of maternal knowledge regarding hyper bilirubinemia. Only 30% of mothers recognized the signs of jaundice, and only 25% were aware of the potential complications. This lack of awareness can lead to delays in seeking medical care, resulting in worsened outcomes for affected neonates. The findings suggest an urgent need for educational programs aimed at mothers, focusing on the identification of jaundice, its implications, and the importance of timely medical intervention.

Risk Factors

In this study, multivariate logistic analyses showed that preterm babies were four more likely to develop hyper bilirubinemia than term babies (AOR = 3.55; 95% CI: 1.184-6.104).This finding is consistent with studies conducted in India [31], Rwanda [32], The cause lies in the reduced efficiency of the immature liver and gastrointestinal system in metabolizing bilirubin.

Interestingly, while the study did not find a significant association between gender and hyperbilirubinemia, previous research has indicated that male infants are often more affected. This discrepancy could be attributed to local genetic or environmental factors that warrant further investigation

This study has several limitations. The cross-sectional design limits the ability to establish causal relationships between risk factors and hyper bilirubinemia. Additionally, the reliance on self-reported knowledge may introduce bias, as mothers may overestimate their understanding of the condition.

The study identified, high prevalence of hyper bilirubinemia and a significant association between hyper bilirubinemia and factors such as prematurity and low birth weight. Additionally, maternal knowledge regarding jaundice was notably low, highlighting a critical area for public health intervention. These results underscore the need for enhanced educational programs for mothers and healthcare providers to improve awareness and management of hyper bilirubinemia among neonates in the study area. Future longitudinal studies are needed to explore these associations further and assess the effectiveness of educational interventions

The authors would like to acknowledge the participants, data collectors and respective hospital administrators

Conflicts of Interest

The author declare no competing interests.

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