This survey suggests that paediatricians’ views accord with various published reports that rank preterm birth/low birth weight, birth asphyxia and sepsis as the leading causes of neonatal mortality in Nigeria
[1, 16, 17]. This is reassuring as recent reports suggest that most countries in Sub-Saharan Africa are unlikely to achieve neonatal mortality rates comparable to levels currently reported in high-income countries before 2065 at the existing rate of progress
. Efforts to accelerate reduction in neonatal mortality rate such as promotion of delivery with skilled birth attendants, the ‘helping babies breathe’ global initiative for neonatal resuscitation and revision of the integrated management of childhood illness (IMCI) algorithms to improve management of neonatal infections and preterm births therefore deserve greater attention from all stakeholders at all levels of health care delivery.
However, paediatricians’ views on these priority conditions are not limited to mortality and underscore the need not to overlook the full health spectrum of these conditions especially as the vast majority of infants are delivered outside hospitals. For example, the economic burden of preterm births/low birth weight survivors in terms of immediate hospital care and long-term support are beyond the means of most families
. While the prevention of preterm births altogether remains unattainable goal worldwide, the health care system even at the tertiary level is generally ill-equipped to provide on-going care for otherwise healthy children with special needs. An integrated approach for the management of preterm/low birth weight infants is therefore essential in effectively addressing the associated immediate and long-term burden.
Perhaps the most notable finding is the comparable overall rating for sepsis and jaundice after preterm births and birth asphyxia. Evidently, the common practice of subsuming neonatal jaundice under “other conditions” in various reports on global child health seems inappropriate for Nigeria and perhaps possibly for other countries in Africa where severe jaundice has been associated with significant morbidity and mortality
[5, 9, 10, 12, 17]. Available facilities in many hospitals make it impracticable to accurately distinguish between early-onset sepsis and jaundice based on the immediate clinical signs or symptoms
[20, 21]. It is therefore not uncommon for infants with jaundice to be treated routinely for suspected sepsis as a first-line intervention until laboratory investigations confirm otherwise even though both conditions are more often unrelated in this setting.
The adverse consequences of severe jaundice and acute bilirubin encephalopathy are entirely preventable through effective clinical and surveillance protocol. Close and objective monitoring of bilirubin levels as well as prompt treatment with phototherapy is all that is needed by majority of the affected infants failing which exchange transfusion is warranted. However, the benefits of these treatments are ‐ seldom available due to the lack of requisite or functional facilities. Early hospital discharge within 48 hours of birth or delivery outside hospital often results in late presentation in hospitals. This delay is often exacerbated by poor recognition of jaundice especially by first-time mothers and the common recourse to traditional herbal therapies before seeking medical attention
. Even in hospitals with phototherapy units, lack of routine maintenance and evaluation of the irradiance levels often results in high rates of exchange transfusions
[11, 23]. The only community-based data on severe neonatal jaundice in Nigeria suggests an incidence of 55 per 1000 infants requiring phototherapy and 19 per 1000 infants requiring exchange blood transfusion
. Widespread glucose-6-phosphate dehydrogenase (G6PD) deficiency is also a principal predisposing factor to severe jaundice in Nigerian infants aggravated by (TA)n promoter polymorphism of the uridine-diphospate-glucuronosyltransferase 1A1 gene (UGT1A1)
 and possibly the active promotion of exclusive breastfeeding
. Appropriate policy initiatives embracing maternal and health professional education, provision of functional phototherapy units and bilirubin monitoring devices are evidently warranted to prevent or significantly reduce the unrecognised contributions of jaundice to neonatal mortality in Nigeria as well as the related morbidity and disability among the survivors.
While tetanus remains as a significant cause of mortality, the overall ranking below jaundice may reflect both global and national progress in curtailing its incidence largely due to improved routine tetanus toxoid immunisation and greater awareness on the importance of clean cord care in hospitals and among primary health care workers including traditional birth attendants
[1, 27–30]. Nonetheless, concerns still persist on the unacceptably high levels of tetanus-related mortality in many locations which deserve urgent attention. Traditional uvulectomy is the suspected portal of entry in majority of cases followed by the unhealed umbilical cord. The traditional practice of cutting the uvula between the third and seventh days of life as well as unhygienic handling of the umbilical cord are major contributory factors to the high incidence of neonatal tetanus. Current global efforts aimed at promoting facility-based delivery or home-delivery attended by trained midwives as well as clean birth and postnatal practices as recommended by the World Health Organisation: and immunisation of pregnant women and those of childbearing age obviously need to be intensified at all levels of obstetric/perinatal care delivery.
It is not uncommon for the term “neonatal sepsis” to be collectively used for septicaemia, meningitis and pneumonia because of the challenge of diagnosing these infections accurately in many resource-poor settings and lack of uniform clinical criteria for their evaluation. This fact is worth noting in interpreting our results. As expected, the relative importance of congenital abnormalities as a cause of neonatal deaths diminishes as other largely preventable causes of death remain prominent in contrast to the pattern in countries with well-established healthcare systems. Notwithstanding, the disability associated with this condition was rated higher than the related mortality. The ranking for diarrhoea accurately suggests a far lesser burden among neonates compared with older infants and young children worldwide. For example, diarrhoea accounts for 18% of child deaths in Africa compared to 1% of neonatal deaths
. Birth trauma was most widely cited in the category of “other conditions” which perhaps reflects on the quality and challenges of obstetric care delivered in some hospitals especially at the secondary levels.
The lower ranking for birth asphyxia in relation to hospital admissions, mortality and morbidity among residents compared with consultants warrant further investigation. Similarly, it was unclear why residents compared with consultants ranked tetanus higher and sepsis lower in terms of mortality. The views of residents as first line physicians must be balanced by cumulative experience of consultants and professors in explaining the observed differences. The lack of differences between professors and consultants should be expected as the professors are themselves consultants in tertiary clinical settings with academic distinctions.
The major strengths of this study are its novelty as well as the geographical representativeness and working experience of respondents besides the prospect of facilitating a mutually-shared awareness between policy makers and paediatricians on the priorities for newborn health in this population. The response rate would also appear satisfactory considering prevailing challenges to web-based surveys especially among busy physicians in settings with limited internet connectivity. While the lack of comprehensive demographic data on those contacted precluded comparison of respondents and non-respondents, a random interview of non-respondents for example, suggested that some individuals did not consider it necessary to participate once they ascertained that their colleagues more closely associated with neonatal care had responded resulting in some response bias. It was also not unlikely that some eligible respondents were not enlisted with PAN or were wrongly excluded during verification with potential for selection bias. Notwithstanding, the key findings accord with available literature from Africa on neonatal health and support calls to also pay attention to the optimal growth and development of the many survivors of these conditions as far as practicable. Perhaps more importantly, this study exemplifies a practical approach to overcoming the constraints of requisite data drought on some aspects of newborn health in resource-poor countries.