Prevalence and Associated Factors of Jaundice Among Neonates Admitted to Neonatal Intensive Care Units at Public Specialized Hospitals in Bahir Dar City,Northwest Ethiopia

Abstract

Background. Neonatal jaundice is more common and complicated in low and middle-income countries. However, there is no adequate evidences on the prevalence of neonatal jaundice and associated factors in Ethiopia. Methods. An institution-based cross-sectional study was conducted from 15 April to 15 June 2021 among 340 neonates admitted to neonatal intensive care unit at public specialized hospitals in Bahir Dar city. Results. The prevalence of neonatal jaundice was found to be 38.8%. Conclusion. The prevalence of neonatal jaundice was relatively high. Being male, prematurity, maternal Rh negative, neonatal Rh positive, maternal blood type AB, and ABO incompatibility were predictor variables of neonatal jaundice. Therefore, healthcare facilities in Bahir Dar city should provide opportunities for testing blood groups and Rh factors of all women early during antenatal care follow-up. Moreover, the treatment of neonatal jaundice has to be easily accessible in all primary health care units of the district.

Background

Neonatal Jaundice (NNJ) is the yellow discoloration of the skin, sclera, and mucosa caused by excess accumulation of bilirubin in the tissue and plasma. ¹ NNJ is a very common clinical problem worldwide, occurring in up to 60% of term and 80% of preterm newborns in the first week of life. ² Globally, every year, about 1.1 million babies would develop severe hyperbilirubinemia, and the majority reside in sub-Saharan Africa and South Asia. ² According to the global burden of disease study in 2018, NNJ ranked seventh on the list of causes of mortality in the first 6 days of the neonatal period. ³ NNJ is also accountable for 70% of neonatal morbidity and 10% of mortality. ⁴

In Ethiopia, more than one-third of childhood death occurs within the first 28 days of age, which made among the top 10 countries with jaundice-related neonatal mortality. ⁵ NNJ is the most common clinical cause of hospital admissions that requires close attention, evaluation, and treatment, ⁶ which accounts for 75% of hospital readmissions to the neonatal intensive care unit (NICU) in the first week of life.^7,8

Rhesus (Rh) incompatibility, ABO incompatibility, sepsis/infection, prematurity, birth trauma, family history of jaundice in siblings, and lack of breastfeeding are the main statistically significant factors associated with NNJ.^9,10 To overcome the aforementioned problems, various interventions and prevention methods have been implemented so far including, antenatal care follow-up and screening, rapid and reliable diagnostic tools, maternal and healthcare provider education, feeding or hydration, effective phototherapy, exchange transfusion, intravenous immunoglobulin and phenobarbitone.^11-13 The problem is more common and complicated in low- and middle-income countries, which has remained very high in sub-Saharan Africa.^14,15

Some similar studies have been conducted in Ethiopia.^1,4,10 However, this research focuses on Bahir Dar City, a region with unique cultural and social factors where traditional remedies are often practiced.^8,16,17 This preference can influence the management of neonatal jaundice and lead to delays in seeking appropriate care. Moreover, The prevalence of NNJ in Ethiopia varies from 13.3% in St. Paulos Hospital Millenium Medical College to 44.9% in Tikur Anbessa specialized Hospital among admitted neonates.^9,10 Localized studies are crucial for understanding regional variations in prevalence and associated factors. Furthermore, access to healthcare facilities and trained personnel is limited in the study area, which poses significant challenges for the effective management and prevention of neonatal jaundice. Knowing the burden will be an input for improving prevention, early detection, reducing the risks and overall management of pathological jaundice to reduce neonatal deaths by strengthening newborn care, which is one of priority issue in Ethiopian health policy. Therefore, this study aimed to assess the prevalence and factors associated with NNJ admitted to NICU at public specialized Hospitals in Bahir Dar city, northwest Ethiopia. Insights from this study will provide a comprehensive understanding of neonatal jaundice in a specific setting, which can lead to improved management, prevention, and overall neonatal care.

Methods and Materials

Study Design, Setting, and Population

An institution-based cross-sectional study was conducted from 15 April to 15 June 2021 at specialized hospitals in Bahir Dar city, the capital city of Amhara regional state. The city has 6 sub-cities, a total of 6 hospitals (2 public and 4 private hospitals), 10 health centers and a total population of 406,434. ¹⁸ The hospitals under study have a total of 32 NICU beds and experience approximately 865 admissions per month. All neonates admitted to NICU at specialized hospitals of Bahir Dar city during the study period were included in the study. Neonates with incomplete records of either of (blood group, Rh-factor, bilirubin level) and maternal charts with incomplete records of either of (blood group, Rh-factor screening tests) and neonates who didn’t have a mother (an attendant) and neonates of readmission during the data collection period were excluded from the study.

Population

All neonates in Bahir Dar city were the source population while those neonates admitted to NICU at specialized hospitals of Bahir Dar city were the study population.

Sample Size and Sampling Procedures

The sample size was calculated using single population proportion formula by considering that a previous study has demonstrated the prevalence of neonatal jaundice was 28.4% ¹⁹ with an assumption of a 95% confidence interval (CI), 5% margin of error, and 10% non-response rate, then the final sample size of 344 study participants were selected by using a systematic random sampling technique. Then neonates were selected at each second interval on the registration of NICU among the admitted neonates.

There are 2 public specialized hospitals in Bahir Dar city that provide NICU services. Then, proportional allocation was done to each hospital based on the neonates flow per 2 months from the previous 2 months’ data of NICU in each hospital.

Variables and Measurements

The dependent variable was neonatal jaundice while maternal and neonatal socio-demographic characteristics, neonatal factors, and obstetric factors were the independent variables.

Operational Definitions

Neonatal jaundice: A yellowish discoloration of the white part of the eyes and skin in a newborn baby due to high bilirubin levels (levels above 5 mg/dl within the first 24 hours). ²⁰

Pathological jaundice: Is the focus of this study and is defined as the onset of neonatal jaundice within the first 24 hours of life and/or a serum bilirubin level exceeding 5 mg/dl within 24 hours. ²¹

ABO incompatibility: is a blood type mismatch between the mother and baby that can lead to jaundice and other issues in the newborn. ²¹

Birth injury (trauma): Sustained during the birth process (labor and delivery), which includes either (caput succedaneum, cephalohematoma, or subgaleal hemorrhage). ²²

Hypoglycemia: Usually between 30 and 50 mg/dl (1.7-2.8 mmol/l). ²³

Prolonged labor: Occurs when the duration of the first and second stages of labor combined is greater than 20 hours for a woman’s first pregnancy (nulliparous) and greater than 14 hours for women who have previously given birth (multiparous) ²⁴ and/or diagnosed as prolonged labor by health professionals.

Poor feeding: A neonate sucks or feeds 0 to 4 times per day.

Moderate feeding: A neonate sucks or feeds 5 to 7 times per day.

Satisfactory feeding: A neonate sucks or feeds 8 to 12 times per day.

Low birth weight: Birth weight of the neonate 1500 to 2500 g.

Very low birth weight: Birth weight of the neonate <1500 g. ²⁵

Data Collection Tools and Procedures

The data was collected by using pretested structured interviewer-guided questionnaires and checklists. The data collection tool was developed by reviewing different literature.^9,19 The interviewer-guided questionnaires comprise 3 parts; socio-demographic characteristics of both the neonate and the mother, obstetric as well as neonatal related factors while the checklist contains a neonatal and maternal medical chart.

All neonatal data were taken from the admission book of the NICU after a full investigation was completed, and the diagnosis was confirmed. The data collection tool was first prepared in English, translated to Amharic (the local language) then retranslated to English to check for its consistency. The data was collected by 2 BSc nurses and 1 BSC nurse supervisor.

Data Quality Assurance and Control

Both data collectors and supervisors were trained by the principal investigator about the data collection techniques. Before the actual data collection, a pretest was conducted on 5% of the study population at Debark general hospital with similar characteristics to those in the study. Every day, all questionnaires were reviewed and checked at the end of the data collection and any errors were corrected accordingly by the principal investigator, supervisor, and data collectors.

Data Processing and Analysis

Data were cleaned, entered into Epi Info version 7, and exported to SPSS version 25 statistical software for analysis. A scatter plot was used to identify outliers and the model fitness was checked using the Hosmer-Lemeshow goodness of fit test which was the significance value (P = .83) and multicollinearity was checked by multicollinearity diagnosis with small inter-correlations or variance inflation factors (VIF = 1.67) was taken. Binary logistic regression analysis was computed to identify associating factors with NNJ. Variables with a P-value of less than .25 during bivariable regression were entered into multivariable logistic regression using the backward likelihood ratio. Then an Adjusted Odd Ratio (AOR) with a 95% confidence interval (CI) and P-value < .05 were considered to declare the significant factors and strength of association. Descriptive statistics such as frequency, percentages, mean, and standard deviation were presented in the form of texts and tables.

Results

Maternal and Neonatal Socio-Demographic Characteristics

A total of 340 neonates were participated in this study. The mean age of their mothers was 27.14 (SD: ±5.3) years and about 41.8% were within the range of 25 to 29 years. Almost all of the mothers 98.2% were orthodox in religion, 97.1% were married, and 57.4% were urban dwellers (Table 1).

Table 1.

Socio-demographic Characteristics for NNJ Among Neonates Admitted to NICU at Public Specialized Hospitals in Bahir Dar City, Northwest Ethiopia, 2021(n = 340).

Socio-demographic variables	Frequency (n)	Percent (%)
Maternal age
15-19	11	3.2
20-24	93	27.4
25-29	142	41.8
30-34	50	14.7
35-39	32	9.4
40-44	12	3.5
Maternal residence
Urban	195	57.4
Rural	145	42.6
Marital status of the mother
Single	6	1.8
Married	330	97
Divorce	2	0.6
Widowed	2	0.6
The religion of the mother
Orthodox	334	98.2
Muslim	5	1.5
Protestant	1	0.3
Occupation of the mother
Government employee	48	14.1
Private employee	15	4.4
Housewife	96	28.2
Farmer	126	37.1
Merchant	23	6.8
Daily laborer	32	9.4
The educational level of the mother
Unable to read and write	144	42.4
Can read and write	9	2.6
Primary (1-8)	43	12.6
Secondary (9-12)	72	21.2
Diploma and above	72	21.2
Neonatal sex
Female	145	42.6
Male	195	57.4
Neonatal age on admission
Less than 24 hours	189	55.6
1-7 days	116	34.1
8-14 days	16	4.7
15-28 days	19	5.6

Obstetric Related Factors

More than half 55.3% of the respondents were primi para and nearly half were spontaneous vaginal delivery (SVD). Nearly two-thirds were delivered at the hospital, 8.5% had prolonged labor but only 1.8% had a previous history of a sibling with jaundice, and 8.2% had a chronic illness during their current pregnancy, of which 7.4% were hypertension (Table 2).

Table 2.

Obstetric-related Factors for NNJ Among Neonates Admitted to the NICU of Public Specialized Hospitals of Bahir Dar City, Northwest Ethiopia, 2021(n = 340).

Obstetric related factors	Frequency (n)	Percent (%)
Parity
Primi para	188	55.3
Multi para	152	44.7
Place of delivery
Home	15	4.4
Health center	103	30.3
Hospital	222	65.3
Mode of delivery
SVD	169	49.7
Episiotomy	51	15.0
Cesarean section	76	22.4
Instrumental delivery (Forceps + Vacuum)	44	12.9
Chronic illness
Had no any	312	91.8
Diabetic mellitus	1	0.3
Hypertension	25	7.4
Asthma	2	0.6
Maternal blood group
A	101	29.7
B	65	19.2
AB	28	8.2
O	146	42.9
Prolonged labor
No	311	91.5
Yes	29	8.5
Maternal Rh factor
Rh positive	299	87.9
Rh negative	41	12.1
Previous NNJ siblings history
No	334	98.2
Yes	6	1.8
Had ANC follow-up
No	14	4.1
Yes	326	95.9
Time of first ANC visit
Within 1-3 months	168	49.4
Within 4-6 months	126	37.1
Within 7-9 months	32	9.4
ANC screening status (HBsAg test)
Negative	336	98.8
Positive	4	1.2
Syphilis (VDRL) test
Negative	324	95.3
Positive	16	4.7
RVI test
Negative	337	99.1
Positive	3	0.9

Neonatal Factors

Among the selected neonates, 40.9% were premature with a gestational age of 28 to 36 weeks, more than one-fourth (30.9%) were low birth weight, and 16.2% were twins. Neonatal sepsis predominantly occurred in three-fourth (76.2%) of neonates, of which, the early onset of neonatal sepsis accounts for more than three-fourth (68.2%) of neonates. In this study, more than one-fourth (25.9%) develop hypoglycemia, 10.9% had birth trauma, 32.6% had predominantly neonatal blood type “A” and the majority 91.2% were with positive Rhesus (Table 3).

Table 3.

Neonatal Factors for NNJ Among Neonates Admitted to the NICU at Public Specialized Hospitals of Bahir Dar City, Northwest Ethiopia, 2021(n = 340).

Neonatal factors	Frequency (n)	Percent (%)
Gestational age
28-36 weeks	139	40.9
37-42 weeks	178	52.3
>42 weeks	23	6.8
Singleton or twin
Singleton	285	83.8
Twin	55	16.2
Twin A	28	50.9
Twin B	27	49.1
Birth weight
Very low birth Wt (<1500 gm)	32	9.4
Low birth Wt (1500-2499 gm)	136	40.0
Normal birth Wt (2500-4200 gm)	168	49.4
Obese (>4200 gm)	4	1.2
Had neonatal sepsis
No	81	23.8
Yes	259	76.2
Type of neonatal sepsis
EONS	232	89.6
LONS	27	10.4
Hypoglycemia
No	252	74.1
Yes	88	25.9
Had birth trauma (birth injury)
No	303	89.1
Yes	37	10.9
Type of birth trauma (birth injury)
Caput succedaneum	17	46.0
Cephalohematoma	8	21.6
Subgaleal hemorRhage	12	32.4
Neonatal blood group
A	111	32.6
B	75	22.1
AB	17	5.0
O	137	40.3
Neonatal Rh factor
Rh-positive	310	91.2
Rh-negative	30	8.8
ABO-incompatibility
No	309	90.9
Yes	31	9.1
Rh-incompatibility
No	329	96.8
Yes	11	3.2
Methods feeding
Exclusive breastfeeding	304	89.4
Formula feeding only	8	2.4
Mixed feeding	28	8.2
Feeding status
Poor	62	18.2
Moderate	174	51.2
Satisfactory	104	30.6
Age at onset of jaundice
<24 hours	17	12.9
1-7 days	111	84.1
8-14 days	3	2.3
>14 days	1	0.7
Total serum bilirubin level on admission in mg/dl
5-8	15	11.4
8-15	45	34.1
15-20	40	30.3
>20	32	24.2
Direct serum bilirubin level on admission in mg/dl
<0.00.3	5	3.8
0.3-1	66	50
1-2	39	29.5
>2	22	16.7
Bilirubin encephalopathy (Kernicterus)
No	116	87.9
Yes	16	12.1
NNJ management
Phototherapy	100	75.75
Both phototherapy and exchange blood transfusion	32	24.24
Conditions at discharge
Improved	293	86.2
Died	44	12.9
Referred	1	0.3
Against medical (disappeared)	2	0.6

Abbreviations: EONS, early onset of neonatal sepsis (within 7 days); LONS, late onset of neonatal sepsis (8-28 days).

Prevalence of Neonatal Jaundice

The prevalence of NNJ among neonates admitted to the NICU of public specialized hospitals of Bahir Dar city was found to be 38.8% (95% CI = 34, 44).

Factors Associated With Neonatal Jaundice

In the multivariable logistic regression model, neonatal male sex, prematurity, maternal Rh negative, neonatal Rh positive, maternal blood group AB, mode of delivery, and ABO incompatibility were significantly associated with NNJ.

Accordingly, NNJ among males was 2 times more likely to be at risk compared to females (AOR = 2.15; 95%CI = 1.27, 3.63). Moreover, neonates with a gestational age of 28 to 36 weeks were nearly 8 times more likely to develop NNJ compared to those with a gestational age of greater than 42 weeks (AOR = 7.64; 95% CI = 2.04, 28.60). Likewise, neonates born from mothers with Rh-negative were 6 times more likely to develop NNJ compared to Rh-positive mothers (AOR = 6.29; 95% CI = 2.37, 16.71). Similarly, mothers who had blood group “AB” were 79% less likely at risk to develop NNJ than mothers with blood group “A” (AOR = 0.21; 95% CI = 0.06, 0.72).

Likewise, neonates who were delivered by instrumental delivery (forceps, vacuum) were nearly 3 times more likely to develop NNJ than neonates who were delivered by SVD (AOR = 2.91; 95% CI = 1.32, 6.42). Moreover, neonates with Rh positive were 6 times more likely to develop NNJ than neonates who were Rh negative (AOR = 6.36; 95% CI = 1.92, 21.08) and neonates who had ABO incompatibility were 15 times more likely to develop NNJ compared to those who had no ABO incompatibility (AOR = 15.33; 95% CI = 4.99, 47.09) (Table 4).

Table 4.

Bivariable and Multivariable Logistic Regression Analysis of Maternal, Neonatal, and Obstetric-Related Factors of NNJ Among Neonates, Admitted to the NICU at Public Specialized Hospitals in Bahir Dar City, Northwest Ethiopia, 2021(n = 340).

Variables	Neonatal jaundice		COR (95% CI)	AOR (95% CI)	P-value
	Yes (n)	No (n)
Neonatal sex
Male	87	108	1.79 (1.14, 2.81)	2.15 (1.27, 3.63)	.004*
Female	45	100	1	1
Gestational age
28-36 weeks	70	69	4.82 (1.56, 14.89)	7.64 (2.04, 28.60)	.003*
37-42 weeks	58	120	2.30 (0.75, 7.06)	2.25 (0.61, 8.36)	.23
>42 weeks	4	19	1	1
Maternal blood group
A	42	59	1	1
B	22	43	0.72 (0.38, 1.38)	0.63 (0.31, 1.30)	.21
AB	4	24	0.23 (0.08, 0.73)	0.21 (0.06, 0.72)	.01*
O	64	82	1.10 (0.66, 1.83)	0.69 (0.38, 1.27)	.23
Maternal Rh factor
Rh-negative	23	18	2.23 (1.15, 4.31)	6.29 (2.37, 16.71)	<.001*
Rh positive	109	190	1	1
Neonatal Rh factor
Rh positive	123	187	1.54 (0.68, 3.46)	6.36 (1.92, 21.08)	.003*
Rh-negative	9	21	1	1
Mode of delivery
SVD	66	103	1	1	.81
Episiotomy	21	30	1.10 (0.58, 2.07)	1.10 (0.51, 2.35)	.27
C/Section	23	53	0.68 (0.38, 1.21)	0.69 (0.35, 1.34)	.01*
Instrumental delivery	22	22	1.56 (0.80, 3.04)	2.91 (1.32, 6.42)
ABO-incompatibility
Yes	26	5	9.96 (3.72, 26.68)	15.33 (4.99, 47.09)	<.001*
No	106	203	1	1

Abbreviations: COR, crude odds ration; AOR, adjusted odds ratio, CI, confidence interval.

*

Statistically significant at P-value <.05.

Discussion

In this study, the overall prevalence of neonatal jaundice (NNJ) was 38.8% (95% CI = 34, 44). The finding of this study was relatively consistence with a study conducted in Kenya ²⁶ and Ethiopia ⁹ where the prevalence of NNJ was reported to be 34.4% and 44.9% respectively.

However, the prevalence of NNJ in this study was lower than a study conducted at Bloemfontein, South Africa where the NNJ prevalence was 55.2% ²⁷ and a comparative cross-sectional study conducted in Kelantan, Malaysia 63%, ²⁸ This variation might be due to differences in study designs in which the previous studies used retrospective chart review, geographical areas, time gap, and sociocultural parameters among study populations.

In contrast, the prevalence was higher than a study conducted in Benin 20.19%, ²⁹ and specific studies in Ethiopia like Dessie town public hospitals (13.3%), ¹⁰ and University of Gondar Comprehensive Specialized Hospital (28.4%). ¹⁹ The discrepancy in prevalence rates could be due to several factors, including differences in study population characteristics, methodological approaches, or regional variations in disease incidence. Variations in diagnostic criteria, data collection methods, or sample sizes between studies can also contribute to differences in reported prevalence rates.

This study had shown that the odds of developing jaundice among male neonates was 2 times higher as compared to female neonates. This finding was in line with studies conducted in Ghana ³⁰ and Nigeria.^31,32 The higher odds of developing jaundice among male neonates could be attributed to biological differences, such as variations in bilirubin metabolism or liver function between genders.

In this study, prematurity was found to have a significant effect on developing neonatal jaundice. Neonates who were delivered before term (<37 weeks) were nearly 8 times more likely to develop NNJ compared to those with a gestational age of greater than term and above. This finding was in line with studies done at Tikur Anbessa Specialized Hospital in Addis Ababa and public hospitals in Dessie town.^9,19 This might be related to preterm neonates having immature livers had decreased ability to conjugate the excess bilirubin level.

The result of this study indicated that the maternal Rh factor had a significant effect on NNJ. Neonates born from mothers with Rh-negative were 6 times more likely to develop NNJ as compared to neonates born from Rh-positive mothers. The increased likelihood of neonatal jaundice (NNJ) in neonates born to Rh-negative mothers is likely due to Rh incompatibility. When an Rh-negative mother carries an Rh-positive fetus, her immune system may produce antibodies against the fetal red blood cells, leading to hemolysis. This destruction of red blood cells results in elevated bilirubin levels and a higher risk of jaundice in the newborn.

This finding revealed that 12.1% of mothers were Rh-negative, out of which 6.8% of Rh-negative mothers’ neonates developed neonatal jaundice (NNJ). This finding is consistence with studies conducted in Ethiopia.^1,33,34 The finding that 6.8% of Rh-negative mothers’ neonates developed neonatal jaundice (NNJ) likely reflects Rh incompatibility issues, where the Rh-negative mothers had a higher risk of producing antibodies against Rh-positive fetal blood cells, leading to jaundice in their newborns. According to this finding, neonates who were Rh-positive were 6 times more likely to develop NNJ than those neonates of Rh negatives. This may be due to the hemolytic disease of the newborn (HDN), where Rh-positive neonates are more prone to hemolysis caused by maternal antibodies in cases of Rh incompatibility. This condition leads to elevated bilirubin levels and a higher risk of jaundice.

In this study, neonates with maternal blood group AB had 79% lower odds of developing NNJ as compared to neonates from maternal blood group A. This might be due to lower incidence of blood group incompatibility. Blood group AB mothers have fewer naturally occurring antibodies against other blood groups compared to blood group A mothers, which reduces the likelihood of hemolysis and subsequent jaundice in their neonates. However, a study in Ethiopia identified maternal blood group O as a significant risk factor for neonatal jaundice (NNJ). ³⁵ This is because maternal blood group O can have naturally occurring anti-A and anti-B antibodies that cross the placenta and cause hemolysis in neonates.

This finding also indicates that the mode of delivery significantly affects neonatal jaundice (NNJ). Neonates delivered instrumentally (using forceps or vacuum) had nearly 3 times higher odds of developing jaundice compared to those delivered by safe vaginal delivery (SVD). This finding was supported by a population-based cohort study conducted in Australia, ³⁶ Iran, and Japan.^36,37 The similarity is likely due to common risk factors associated with instrumental deliveries, such as increased trauma or bruising, which can elevate the risk of neonatal jaundice (NNJ) across different populations.

In this study, ABO incompatibility had a significant effect on developing neonatal jaundice. The odds of developing jaundice among neonates who had ABO incompatibility was 15 times higher as compared to those who had no ABO incompatibility. This finding was supported by the study conducted in Mekkha ³⁸ The significantly higher odds of neonatal jaundice in cases of ABO incompatibility is due to hemolysis caused by maternal antibodies against fetal blood group antigens. This hemolysis leads to elevated bilirubin levels and an increased risk of jaundice in affected neonates. This results in hemolytic disease of the newborn, where maternal IgG antibodies specific to the ABO blood group system cross the placenta and cause hemolysis of fetal red blood cells. This hemolysis is a major cause of severe hyperbilirubinemia, acute bilirubin encephalopathy, and kernicterus. ³⁹

Limitations of the Study

The limitation of this study was that it didn’t detect the contribution of G-6PD deficiency due to the inaccessibility of routine screening for the enzyme deficiency in the study area. In addition, the data registered on the neonatal and maternal medical charts might have reliability insufficiency and this might be another limitation of this study.

Conclusions

The overall prevalence of neonatal jaundice at public specialized hospitals in Bahir Dar city, was high. Being male, prematurity, maternal Rh negative, neonatal Rh positive, maternal blood group AB, mode of delivery, and ABO incompatibility were significantly associated with NNJ. It is recommended that healthcare facilities in Bahir Dar city should provide opportunities for testing the blood groups and Rh factors of all women as early as possible during ANC follow-up. Moreover, healthcare workers working in the delivery room are better to give great care to avoid birth trauma during instrumental delivery. The treatment of NNJ currently given only in referral and specialized hospitals has to be easily accessible and available in primary hospitals and health centers of the district. Service accessibility for G-6PD screening also has to be considered.