Study population

Demographics, socio-economic characteristics, birth situations, and laboratory data on 647 admitted neonates are summarized in Table 1 including their association with ABE. Every characteristic listed, except for sex and gravida, is strongly associated with the presence of ABE in this population. The neonates with ABE tended to be older, weigh less, have higher admission TSB levels, and have risk factors for hemolysis. Their mothers tended to be younger, had received fewer antenatal visits, were more likely to have had birth outside a hospital, and had a birth attendant other than a physician or midwife.

Table 1 Descriptive statistics and associations with ABE.Associations with type of maternal instruction

Demographics, socio-economic characteristics, birth situations, and laboratory data on the 647 admitted infants are summarized again in Table 2, this time with the association of each characteristic with type of maternal jaundice instruction. As before, every characteristic listed, except for sex and gravida, is strongly associated with the type of maternal instruction that was received in this population.

Table 2 Descriptive/Laboratory data and associations with maternal jaundice instruction.Unadjusted association of maternal instruction with ABE

Maternal instruction and frequency of ABE are strongly associated (chi-squared test, p < 0.001) as shown in Table 2. There is a marked reduction of ABE if mothers received combined antenatal with postnatal reinforcement compared with no instruction, and a lesser reduction in ABE if instruction is provided only after birth, the current standard of care. The association remains strong when neonates with mild ABE (bilirubin induced neurological dysfunction (BIND) scores 1–3) were excluded leaving 55 patients with moderate to severe ABE (p < 0.001, not shown). The association also remains strong if only patients with four or more clinic visits are included (p < 0.001, not shown).

The strong association between maternal instruction and ABE, however, could be due in part to confounding because of the strong associations among ABE, maternal instruction, and socio-economic associated risks (Tables 1, 2), particularly birth site, birth attendant and receipt of antenatal care. These potential confounding factors were examined more closely.

Impact of antenatal care

The number of prenatal visits is strongly associated with frequency of ABE (Table 1, p < 0.001). The number of prenatal visits is also strongly associated with type of maternal instruction (Table 2, p < 0.001). Mothers who had no prenatal visits were more likely to have received no instruction, while those who had four or more visits were more likely to have received both antenatal and postpartum instruction. This is expected since the antenatal instruction was delivered at prenatal visits.

Impact of birth site

The frequency of ABE varies strongly with type of birth site. Newborns admitted for jaundice following out-of-hospital birth had a higher percentage of ABE than infants born in a hospital (Table 1). The association is strong whether the comparison is done using three levels, hospital, clinic and home/other (Table 1, p < 0.001), or using two levels, hospital vs. out-of-hospital (p < 0.001, not shown). Birth site is also strongly associated with type of maternal instruction (Table 2, p < 0.001). Mothers who gave birth in a hospital were much more likely to have had both antenatal and postpartum instruction, while those who gave birth at home were more likely to have had no instruction.

Impact of birth attendant

The frequency of ABE varies strongly with type of birth attendant. Births of neonates with ABE were less likely to have been attended by a physician or midwife, and more likely to have been attended by a community health worker, traditional birth attendant (TBA) or family member, as shown in Table 1 (p < 0.001).

The type of birth attendant is also strongly associated with type of maternal education (Table 2p < 0.001). Mothers whose birth was attended by a physician or midwife were more likely to have had both ante- and postpartum instruction, while those attended by a CHEW, TBA, or family member were more likely to have had no instruction.

Adjusted association of maternal instruction with ABE

Because both frequency of ABE and maternal jaundice instruction type are strongly associated with number of prenatal visits, birth site, and birth attendant, as shown above, the potential for confounding is high. Multiple logistic regression models were therefore used to estimate the effect of maternal instruction type on the odds of ABE after controlling for number of prenatal visits, birth site, birth attendant, and center.

In the adjusted model, type of jaundice instruction was strongly associated with ABE (Type III ANOVA test, p < 0.001). Number of prenatal visits (Type III ANOVA test, p = 0.001), birth site (Type III ANOVA test, p = 0.028), and birth attendant (Type III ANOVA test, p = 0.029) were also associated with ABE. Study site, which was strongly associated with ABE before adjustment (Table 1, chi-square test, p < 0.001), was no longer associated with ABE after adjusting for the other factors (Type III ANOVA test, p = 0.236).

The results for the type of jaundice instruction for both unadjusted and adjusted regression models are shown in Table 3. Looking at the effect of no jaundice instruction the unadjusted odds of having ABE at admission are 2.046 times higher in neonates whose mothers received no jaundice instruction, compared to those whose mothers received the standard postpartum instruction (p = 0.022). After controlling for number of prenatal visits, birth site, birth attendant, and center, however, the adjusted odds of ABE for no instruction are only 1.201 times higher (20.1% larger) in neonates whose mothers received no jaundice instruction, compared to those whose mothers received the standard postpartum instruction, and are no longer statistically significant (p = 0.637). The apparent strong effect of no instruction on ABE before adjustment may be due to the strong interrelationships among no instruction, few prenatal visits, out-of-hospital birth, and not being attended by a physician or midwife.

Table 3 Odds ratios for acute bilirubin encephalopathy (ABE) in admitted neonates as a function of the type of jaundice instruction the mother received.

In contrast, the effect of adding antenatal instruction to postpartum instruction is beneficial and remains strong even after adjustment. The unadjusted odds of having ABE at admission are 0.059 times as large (94.1% smaller) in infants whose mothers received both antenatal and postpartum instruction, compared to those whose mothers received the standard postpartum instruction only, and this reduction is statistically significant (p < 0.001). This association remains strong even after controlling for number of prenatal visits, birth site, birth attendant, and center: the adjusted odds of ABE are 0.104 times as large (89.6% smaller) in infants whose mothers received both antenatal and postpartum instruction, compared to those whose mothers received the standard postpartum instruction only, and this reduction is statistically significant (p < 0.001). This result indicates that adding antenatal instruction to postpartum instruction significantly reduces the odds of ABE, compared to the standard postpartum instruction, over and above the effects of number of prenatal visits, birth site, and birth attendant. Regardless of birth attendant type, type of birth site or number of prenatal visits, adding antenatal instruction to postpartum instruction reduces the odds of ABE in admitted infants by about 90% on average.

Does maternal instruction increase the number of admissions?

TSB levels were below study guidelines for phototherapy (12 mg/dL) in 30.7% of admissions when mothers received any training and 14.4% if mothers did not receive instruction (p < 0.001). If the 2022 American Academy of Pediatrics (AAP) phototherapy guidelines2 had been followed, 329/647 (50.8%) would have been admitted “unnecessarily” but would have included four cases of ABE. When only those subjects meeting study treatment guidelines were analyzed, ABE occurred in 4/236 (1.7%), 16/63 (25.4%), and 63/184 (34.2%) in combined, postnatal only, and no instruction groups respectively. Although incidences increased in all groups, differences remained very significant (p < 0.001) and conclusions did not change.