Skip to main content

Low knowledge of newborn danger signs among pregnant women in Papua New Guinea and implications for health seeking behaviour in early infancy – findings from a longitudinal study



Globally, 2.5 million babies die in the first 28 days of life each year with most of these deaths occurring in low- and middle-income countries. Early recognition of newborn danger signs is important in prompting timely care seeking behaviour. Little is known about women’s knowledge of newborn danger signs in Papua New Guinea. This study aims to assess this knowledge gap among a cohort of women in East New Britain Province.


This study assessed knowledge of newborn danger signs (as defined by the World Health Organization) at three time points from a prospective cohort study of women in East New Britain Province, factors associated with knowledge of danger signs after childbirth were assessed using logistic regression. This study includes quantitative and qualitative interview data from 699 pregnant women enrolled at their first antenatal clinic visit, followed up after childbirth (n = 638) and again at one-month post-partum (n = 599).


Knowledge of newborn danger signs was very low. Among the 638 women, only 9.4% knew three newborn danger signs after childbirth and only one knew all four essential danger signs defined by Johns Hopkins University ‘Birth Preparedness and Complication Readiness’ Index. Higher knowledge scores were associated with higher gravidity, income level, partner involvement in antenatal care, and education.


Low levels of knowledge of newborn danger signs among pregnant women are a potential obstacle to timely care-seeking in rural Papua New Guinea. Antenatal and postnatal education, and policies that support enhanced education and decision-making powers for women and their families, are urgently needed.

Peer Review reports

Key points

Patient and public involvement

  • Patients and members of the public were not involved in the design, or conduct, or reporting, or dissemination plans of the research. The study, however, was designed and conducted in close consultation with East New Britain Provincial Health authorities as part of an ongoing research collaboration, called the Healthy Mothers Healthy Babies program, in which we are working together to improve maternal and child health outcomes.

What is already known on this topic

  • Early recognition of newborn danger signs plays an important role in initiating timely care seeking. There is minimal evidence about women’s knowledge of newborn danger signs in Papua New Guinea.

What this study adds

  • Knowledge of newborn danger signs among women was low in pregnancy and after childbirth, and likely insufficient for timely newborn care-seeking. Women with higher knowledge scores were those with a previous pregnancy, higher income and a male partner who attended antenatal care with them.

How this study might affect research, practice or policy

  • This study highlighted the need for greater efforts in targeted perinatal education, particularly for first time parents, and ensuring education is effectively received and understood by pregnant women and their families. There is an urgent need to review policies that support decision-making powers for women and their families, as well as enhance antenatal and postnatal education.


Major gains have been made globally in reducing child mortality over the past three decades, with a halving of the mortality rate for children under five [1]. However, the rate of decline for neonatal mortality has been slower and neonatal deaths now make up almost half (47%) of all deaths under five, with the vast majority of these (99%) occurring in low– and middle–income countries (LMIC) [1]. In order to reach target 32 of the Sustainable Development Goals (SDG) — reduction of neonatal mortality to 12 deaths or less per 1,000 live births by 2030 [2] — a major focus is needed on reducing risk factors associated with newborn mortality and improving access to quality family–centred care.

Newborn danger signs are symptoms and clinical signs that commonly indicate severe sickness in a baby at birth or in the immediate postnatal period [3, 4]. Compared to later in infancy, recognition of newborn danger signs is often more difficult as newborn illness can present with non–specific signs and symptoms [5], and timely recognition is critical as newborn illnesses can progress very rapidly [6]. Initiation of the healthcare seeking cascade is highly dependent on the primary caregiver’s (often the mother) knowledge and recognition of neonatal danger signs [7], and a delay at this stage can increase the risk of a poor newborn outcome [8, 9]. Timely recognition of newborn danger signs can be more critical in remote settings where there may be delay in reaching healthcare facilities due to distance and limited travel means [10].

Papua New Guinea (PNG), a LMIC in the Asia–Pacific region, has a population of over 8.5 million [11] and has one of the highest neonatal mortality rates in the region at 20 deaths per 1,000 live births [12, 13]. The PNG National Health Plan (2012–2020) considers neonatal health and survival as a priority area [14] and aims to improve health outcomes for newborns through improved maternal health services, facility-based births, and enhanced capacity to provide life–saving support to the newborns. However, despite these efforts, the SDG target for NMR is unlikely to be achieved sooner than 2050 in PNG [15].

Vital to this work is evidence on women’s knowledge of newborn danger signs, yet very limited evidence is available in PNG, and the broader Pacific region [16]. Two studies from PNG have previously investigated knowledge of danger signs, one reported women’s knowledge of maternal, but not newborn, danger signs in pregnancy and childbirth [17] (among 482 women), and the other reported on a cross–sectional survey that included mother’s knowledge of newborn danger signs evaluated within two years of childbirth [18] (among 482 women). Here we provide additional insights, reporting knowledge of newborn danger signs among women at three important timepoints: early pregnancy, after childbirth, and one month postpartum. The study included a longitudinal cohort of pregnant women in East New Britain Province (ENBP) who were enrolled and followed from first antenatal clinic visit through to childbirth and the post-partum period.


Setting, population and sampling

The Healthy Mothers, Healthy Babies (HMHB) [19] research program was established in East New Britain Province (ENBP) in 2015 and consists of several primary studies and implementation projects all working towards identifying determinants of poor maternal and newborn health [20,21,22]. ENB is part of a large island in PNG’s north–east, whose population of approximately 400,000 live in a mix of highland and coastal villages, with some small towns [23]. The HMHB Prospective Observational Longitudinal Cohort Study, conducted between March 2015 and December 2018, recruited 699 pregnant women at their first antenatal clinic (ANC) with follow up after childbirth, and again at 1, 6, and 12 months postpartum; data from the first three time points (ANC1, childbirth and 1 month postpartum) were used for this study. Eligible women were those aged 16 years or more, living in the health facility catchment, and who agreed to participate and provided written informed consent. Women were enrolled by using a dice to select randomly from clinic attendees. Of the 699 enrolled, 638 (91%) were followed to childbirth, and 599 (86%) to one–month post–partum.

Study procedures

Interviews using a structured questionnaire, including both quantitative and qualitative components, were conducted in private settings at the ANC clinic, health facility after childbirth and the woman’s home (after childbirth and at one month postpartum). Questions covered demographics, obstetric history, experience of health care, health knowledge, and preferences for care, in addition to physical examinations and collection of biological samples. Interviews were administered by trained local research staff in local languages, guided by a questionnaire on an electronic tablet. Participants received routine care in accordance with PNG national guidelines, including facilitation of follow–up of any health issues disclosed in the interview. Knowledge of newborn danger signs was assessed by asking women to name (in their local language) any signs or symptoms in their newborn that would prompt them to seek urgent assessment for their baby (Supplementary Table 1). Interviewers coded these against a list based on World Health Organization (WHO) guidance on newborn danger signs [5]. Follow–up questions allowed for clarification or additional detail.

Data analysis

Data were de–identified and analysed with Stata 150 for each time point – antenatal care, after childbirth and one month postpartum. Responses to knowledge questions were calculated as simple proportions. Secondary analysis drew on international literature to describe a minimum effective knowledge level, based on the type and the number of danger signs reported. Data were analysed by the research team, referencing the eight newborn danger signs described by the WHO [5] and four signs identified by Johns Hopkins University’s Birth Preparedness and Complication Readiness (JH BPCR) Index [3]. A composite outcome measure was created and defined as: knowledge of three or more danger signs. Bi–variate and multivariable logistic regression models assessed the association between this composite outcome measure and possible determinants including: age, marital status, maternal birth province, travel time to clinic, monthly household expenditure, gravidity, education and employment status of the woman and her partner, and partner involvement at ANC (defined as partner being present in the clinic room while health worker performed assessment). Variables used in the multivariable model, to adjust for possible confounders, were decided through discussion within the research team, based on known associations in published literature. Variables with clear co–linearity were excluded. Crude and adjusted odds ratios with 95% Confidence Interval (CIs) and p–values assessed the direction and strength of the statistical association.


The sociodemographic and obstetric profile of mothers and their partners is shown in Table 1. The study assessed interview data from 699 pregnant women enrolled at their first ANC visit, followed up in the early postpartum period after childbirth (n = 638) and again at one-month post-partum (n = 599). More than half of women were aged over 25 (417/692, 602%). The median monthly household expenditure was approximately 150 Kina (~ $42USD in October 2021). Approximately 177% (123/694) of women’s male partners were present at first ANC visit. The majority of women were multigravida (522/697, 749%), married or cohabiting (663/697, 951%), and unemployed (531/699, 760%).

Table 1 Socio–demographic and obstetric variables of women at baseline (first antenatal care visit)

Frequency of clinically–significant newborn danger signs reported

Proportions of women reporting important danger signs were quantified at three time points (Table 2). At the antenatal visit, 31∙1% (215/692) of women could not name any danger signs, decreasing to 15% (87/581) at one–month post–partum. At the visit after childbirth, only one woman named all four key signs in the JHBPCR; 98% (61/625) named three or more danger signs, and 723% (452/625) named one or two danger signs (Table 3). Fever and ‘not feeding’ were the most commonly reported danger signs across all time points. Very few women named any of the four key signs identified in the JHBPCR as those essential to life–saving care–seeking, with breathing difficulties being the most common danger sign women reported (reported by 144% [90/625] at the first postpartum visit). Some trends over the three time points were apparent; more women could name one or more danger signs at later time points. A higher proportion of women named fever after childbirth and one–month post–partum than at first ANC.

Table 2 Newborn danger signs identified by women at the three different time–points
Table 3 Adequacy of pregnant and postpartum women’s knowledge of newborn danger sings

Characteristics associated with women’s knowledge of newborn danger signs after childbirth

Associations with knowledge of three clinically important danger signs shortly after childbirth were analysed using bivariate and adjusted multivariable logistic regression models (Table 4). Age, in the bivariate model only, and gravidity, in bivariate and adjusted model, both showed associations with knowledge at childbirth; where women with a history of previous pregnancies had 386–fold greater odds of reporting three or more danger signs compared to first time pregnant mothers (95% CI 125 – 1189, p = 0019). Monthly expenditure (as a proxy for wealth) had a suggestive association with knowledge across all time points. At childbirth women with monthly expenditures above 300 Kina had a 3∙08–fold (95% CI 1∙36 – 7∙00, p = 0∙007) increased odds of naming three or more danger signs, however this relationship weakened once confounders (such as women’s employment and partners’ education) were included in the multivariable model (adjusted OR 2∙26, 95% CI 0∙9 – 5∙64, p = 0∙081). It was only at one-month post-partum that associations were found with other factors such as education, greater age, or accompaniment by a partner at ANC visit (Supplementary Table 6).

Table 4 Association between women naming ≥ 3 newborn danger signs and potential determinants of knowledge, at interviews shortly after childbirth


These findings show that knowledge of clinically significant danger signs among mothers in East New Britain is inadequate for informed decision–making on care seeking in the case of serious neonatal illness. At childbirth, only one woman knew all four key danger signs that help identify life–threatening illness [3] and 17% could not report any danger signs. This is consistent with findings of studies in other resource–constrained settings such as India, Nigeria, Ethiopia, and Uganda [24,25,26,27,28,29] which identified inadequate maternal knowledge regarding newborn danger signs.

This study did not assess actual care–seeking in response to danger signs, however other studies have found that knowledge of one WHO–recognised danger sign can prompt a caregiver to initiate care–seeking [26]. Among WHO–defined newborn danger signs, fever was most frequently reported as known by women in ENBP — mirroring prior findings from PNG [18] and other settings [26, 30, 31] — followed by difficulty with feeding. Both are important danger signs, although many life–threatening newborn conditions do not present with fever [5], and this sign is not included in the JHBPCR core set. It is perhaps unsurprising that fever was mentioned by many mothers, given that febrile illness – especially related to malaria – has a prevalence in PNG 3∙5 times higher than the global average [32, 33]. However, it is concerning that other important signs in the newborn period, such as convulsions, breathing difficulties and low body temperature, were named infrequently by study participants. These are signs that are possibly not learned through general experience, as they occur less commonly, but rather need active education to raise awareness of them.

Women’s awareness of danger signs may be derived more from lived experience than from health education; noting that the number of women naming common symptoms, such as fever and cough, did increase from childbirth to one–month post–partum. This is also supported by our regression analysis, which found that at the childbirth time point, greater knowledge had a stronger association with previous experience of pregnancy, than with other factors such as education. It was only in interviews at one–month post–partum, the conclusion of the neonatal period, that we found associations with other factors such as education, greater age, or accompaniment by a partner at ANC visit (as also reported by Zaman et al. (2018) [34]).

Previous studies in PNG have suggested the need for health education to incorporate recognition of maternal and newborn danger signs [35]. These studies, in addition to our findings, highlight the need for greater efforts in targeted perinatal education, especially for first time parents and during routine postnatal care. Others have highlighted the potential of high–quality ANC education [36] and postnatal care [37] to empower women to take a more proactive role in seeking healthcare for their newborn. There is also a high rate of unplanned pregnancy and low use of family planning methods in this population [21]. Given previous pregnancy experience was associated with greater knowledge in our data, there may be opportunities for experienced mothers to share and teach first–time mothers in peer–to–peer or group education models [38]. Education at a postnatal pre–discharge discussion (for babies born in health facilities) has improved women’s knowledge of newborn danger signs in other settings [31, 39]. In responding to our findings, the ENB Provincial Health Authority supported renewed efforts to improve knowledge of maternal and newborn danger signs through a postnatal care implementation research project [40], capitalising on the postnatal period as a feasible time point for the delivery of tailored postnatal education.

Adequate knowledge and the ability to recognise danger signs may not be enough to always initiate care seeking behaviour. Family income and financial resources can play a role in maternal and child health service utilisation in PNG [41]. Our findings showed that wealthier women (using our proxy expenditure measure) had greater odds of knowing three or more danger signs, which may be suggestive of greater autonomy and household decision making powers for the mother [42,43,44]. While PNG has a free primary healthcare policy, it cannot always be applied due to facility financial constraints. Decision making powers do not always rest with the mother but can be influenced by others (such as the male partner or older women), it may be that wealthier households allow greater prioritisation and allocation of funds to the mother for out–of–pocket expenses, increasing her likelihood of service utilisation, especially in the case of illness [45].

A complete response to our findings must necessarily entail broader strengthening of access to, and receipt of quality newborn care, alongside efforts to improve antenatal and postnatal education and service delivery, reduced costs of access and a continued emphasis on the role of the partner [46,47,48,49,50], family and the wider community [51, 52]. In addition, there are currently no standardised indicator sets used in the assessment of newborn danger sign knowledge and definitions of adequate knowledge in studies and reference documents vary widely. Whilst knowledge of three or more danger signs is the most frequently reported criteria in the literature [31, 53, 54] a standardised indicator set could be a useful tool for determining adequate knowledge required to optimise newborn health outcomes.

Strengths and limitations

Strengths of this study include the use of a longitudinal cohort design allowing analysis of knowledge changes over the critical period of pregnancy, childbirth, and early postpartum periods. Limitations include that recruitment was limited to women who were already attending a healthcare facility for ANC, which covered an average of 78% of all pregnant women presenting to a health facility in ENBP during recruitment [32]. The knowledge of newborn danger signs among women who did not attend ANC is unknown. We used the reporting of newborn danger signs, without use of prompts, as an indicator of knowledge, recognising that this is not an absolute measure of knowledge or action that may be taken, and we did not assess healthcare seeking behaviour in response to knowledge.


Caregivers’ knowledge and recognitions of danger signs in the newborn period plays a vital early step towards appropriately seeking care for severe illness. Our findings demonstrate that knowledge of key newborn danger signs in East New Britain is critically low, but that knowledge does increase from early pregnancy to childbirth and that women with previous pregnancies have higher levels of knowledge. This likely reflects a learning that occurs through antenatal care and that of lived experience. These findings indicate a need to strengthen ANC and postnatal education for parents, particularly first-time parents, alongside other efforts to improve quality and access to care, and empowering partners and communities in efforts to promote newborn survival in PNG.

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available due to potential confidentiality concerns. Additional information can be made available from the Scientific Integrity Officer at Burnet Institute, (admin@, on reasonable request.



Papua New Guinea


East New Britain


East New Britain Province


Low– and middle–income countries


Sustainable Development Goals


Antenatal Care


Healthy Mothers, Healthy Babies


Maternal Newborn Health


World Health Organisation


Johns Hopkins University’s Birth Preparedness and Complication Readiness


Confidence Interval


  1. Newborns: improving survival and well-being. Fact sheet. []

  2. Sharrow D, Hug L, You D, Alkema L, Black R, Cousens S, Croft T, Gaigbe-Togbe V, Gerland P, Guillot M, et al. Global, regional, and national trends in under-5 mortality between 1990 and 2019 with scenario-based projections until 2030: a systematic analysis by the UN Inter-agency Group for Child Mortality Estimation. Lancet Glob Health. 2022;10(2):e195–206.

    Article  Google Scholar 

  3. JHPIEGO: Monitoring birth preparedness and complication readiness: Tools and indicators for maternal and newborn health. In. Johns Hopkins, Bloomberg School of Public Health, Center for Communication Programs, Family Care International. ; 2004.

  4. Awasthi S, Verma T, Agarwal M. Danger signs of neonatal illnesses: perceptions of caregivers and health workers in northern India. Bull World Health Organ. 2006;84:819–26.

    Article  Google Scholar 

  5. World Health Organization: WHO recommendations on newborn health: guidelines approved by the WHO Guidelines Review Committee. In. World Health Organization; 2017.

  6. Lawn JE, Blencowe H, Oza S, You D, Lee ACC, Waiswa P, Lalli M, Bhutta Z, Barros AJD, Christian P, et al. Every Newborn: progress, priorities, and potential beyond survival. The Lancet. 2014;384(9938):189–205.

    Article  Google Scholar 

  7. Amarasiri de Silva MW. Wijekoon A, Hornik R, Martines J: Care seeking in Sri Lanka: one possible explanation for low childhood mortality. Soc Sci Med. 2001;53(10):1363–72.

    Article  Google Scholar 

  8. Geldsetzer P, Williams TC, Kirolos A, Mitchell S, Ratcliffe LA, Kohli-Lynch MK, Bischoff EJ, Cameron S, Campbell H. The recognition of and care seeking behaviour for childhood illness in developing countries: a systematic review. PLoS ONE. 2014;9(4): e93427.

    Article  Google Scholar 

  9. Kozuki N, Guenther T, Vaz L, Moran A, Soofi SB, Kayemba CN, Peterson SS, Bhutta ZA, Khanal S, Tielsch JM, et al. A systematic review of community-to-facility neonatal referral completion rates in Africa and Asia. BMC Public Health. 2015;15(1):989.

    Article  Google Scholar 

  10. Karra M, Fink G, Canning D. Facility distance and child mortality: a multi-country study of health facility access, service utilization, and child health outcomes. Int J Epidemiol. 2016;46(3):817–26.

    Google Scholar 

  11. Papua New Guinea []

  12. Linhart C, Carter K, Sorchik R, Haberkorn G, Taylor R: Trends in Neonatal and infant moratlity for Pacific island states. . In. Noumea, New Caledonia: Secretariat of the Pacific Community.; 2015.

  13. National Statistical Office - NSO, ICF: Papua New Guinea Demographic and Health Survey 2016–18. In. Port Moresby, Papua New Guinea: NSO and ICF; 2019.

  14. National Department of Health Papua New Guinea: National Health Plan 2011–2020, Volume 1 Policies and Strategies. In. Government of Papua New Guinea; 2010.

  15. United Nations Inter-agency Group for Child Mortality Estimation. Papua New Guinea []

  16. Wilson AN, Spotswood N, Hayman GS, Vogel JP, Narasia J, Elijah A, Morgan C, Morgan A, Beeson J, Homer CSE. Improving the quality of maternal and newborn care in the Pacific region: A scoping review. Lancet Reg Health West Pac. 2020;3: 100028.

    Article  CAS  Google Scholar 

  17. Vallely LM, Emori R, Gouda H, Phuanukoonnon S, Homer C, Vallely AJ. Women’s knowledge of maternal danger signs during pregnancy: Findings from a cross-sectional survey in Papua New Guinea. Midwifery. 2019;72:7–13.

    Article  CAS  Google Scholar 

  18. Emori R, Vallely AJ, Gouda H, Siba P, Phuanukoonnon S, Mola G, Homer CE, Vallely LM. Supervised and unsupervised birth and early newborn care practices in Papua New Guinea: Findings of a maternal and infant health survey conducted in three provinces. P N G Med J. 2017;60(1/2):27–40.

    Google Scholar 

  19. Healthy Mothers Healthy Babies []

  20. Morgan CJ, Saweri OPM, Larme N, Peach E, Melepia P, Au L, Scoullar MJL, Reza MS, Vallely LM, McPake BI, et al. Strengthening routine immunization in Papua New Guinea: a cross-sectional provincial assessment of front-line services. BMC Public Health. 2020;20(1):100.

    Article  Google Scholar 

  21. Peach E, Morgan C, Scoullar MJL, Fowkes FJI, Kennedy E, Melepia P, Homiehombo P, Au L, Luchters S, Umbers AJ, et al. Risk factors and knowledge associated with high unintended pregnancy rates and low family planning use among pregnant women in Papua New Guinea. Sci Rep. 2021;11(1):1222.

    Article  CAS  Google Scholar 

  22. Scoullar MJL, Boeuf P, Peach E, Fidelis R, Tokmun K, Melepia P, Elijah A, Bradshaw CS, Fehler G, Siba PM, et al. Mycoplasma genitalium and Other Reproductive Tract Infections in Pregnant Women, Papua New Guinea, 2015–2017. Emerg Infect Dis. 2021;27(3):894–904.

    Article  CAS  Google Scholar 

  23. National Department of Health: Provincial and District Health Profiles of Papua New Guinea. . In. Port Moresby: Monitoring and Research Branch of NDOH. ; 2018.

  24. Bazzano AN, Felker-Kantor E, Eragoda S, Kaji A, Horlick R. Parent and family perspectives on home-based newborn care practices in lower-income countries: a systematic review of qualitative studies. BMJ Open. 2019;9(4): e025471.

    Article  Google Scholar 

  25. Dongre AR, Deshmukh PR, Garg BS. Awareness and health care seeking for newborn danger signs among mothers in peri-urban Wardha. Indian J Pediatr. 2009;76(7):691–3.

    Article  Google Scholar 

  26. Ekwochi U, Ndu IK, Osuorah CD, Amadi OF, Okeke IB, Obuoha E, Onah KS, Nwokoye I, Odetunde OI, Obumneme-Anyim NI. Knowledge of danger signs in newborns and health seeking practices of mothers and care givers in Enugu state. South-East Nigeria Ital J Pediatr. 2015;41:18.

    Google Scholar 

  27. Jemberia MM, Berhe ET, Mirkena HB, Gishen DM, Tegegne AE, Reta MA. Low level of knowledge about neonatal danger signs and its associated factors among postnatal mothers attending at Woldia general hospital, Ethiopia. Maternal Health, Neonatology and Perinatology. 2018;4(1):5.

    Article  Google Scholar 

  28. Mersha A, Assefa N, Teji K, Bante A, Shibiru S. Mother’s Level of Knowledge on Neonatal Danger Signs and Its Predictors in Chencha District, Southern Ethiopia. American Journal of Nursing Science. 2017;6:426.

    Article  Google Scholar 

  29. Sandberg J, Odberg Pettersson K, Asp G, Kabakyenga J, Agardh A. Inadequate knowledge of neonatal danger signs among recently delivered women in southwestern rural Uganda: a community survey. PLoS ONE. 2014;9(5): e97253.

    Article  Google Scholar 

  30. Abdulrida HN, Hassa RJ, Sabri MM: Knowledge and health-seeking practices of mothers attending primary health-care centers in Baghdad Al-Karkh sector about danger signs in newborns. . Mustansiriya Medical Journal 2018, 17(1).

  31. Kibaru EG, Otara AM. Knowledge of neonatal danger signs among mothers attending well baby clinic in Nakuru Central District, Kenya: cross sectional descriptive study. BMC Res Notes. 2016;9(1):481.

    Article  Google Scholar 

  32. Papua New Guinea National Department of Health: Sector Performance Annual Review. In.; 2018.

  33. World Health Organization: This year's World malaria report at a glance. . In.; 2018.

  34. Zaman SB, Gupta RD, Al Kibria GM, Hossain N, Bulbul MMI, Hoque DME. Husband’s involvement with mother’s awareness and knowledge of newborn danger signs in facility-based childbirth settings: a cross-sectional study from rural Bangladesh. BMC Res Notes. 2018;11(1):286.

    Article  Google Scholar 

  35. Kakazo M, Lehmann D, Coakley K, Gratten H, Saleu G, Taime J, Riley ID, Alpers MP. Mortality rates and the utilization of health services during terminal illness in the Asaro Valley, Eastern Highlands Province, Papua New Guinea. P N G Med J. 1999;42(1–2):13–26.

    CAS  Google Scholar 

  36. Fujino Y, Sasaki S, Igarashi K, Tanabe N, Muleya CM, Tambatamba B, Suzuki H. Improvement in mothers’ immediate care-seeking behaviors for children’s danger signs through a community-based intervention in Lusaka. Zambia Tohoku J Exp Med. 2009;217(1):73–85.

    Article  Google Scholar 

  37. Sacks E, Langlois ÉV. Postnatal care: increasing coverage, equity, and quality. Lancet Glob Health. 2016;4(7):e442-443.

    Article  Google Scholar 

  38. Lori JR, Ofosu-Darkwah H, Boyd CJ, Banerjee T, Adanu RMK. Improving health literacy through group antenatal care: a prospective cohort study. BMC Pregnancy Childbirth. 2017;17(1):228.

    Article  Google Scholar 

  39. Degefa N, Diriba K, Girma T, Kebede A, Senbeto A, Eshetu E, Aschalew Z, Tariku B, Zerihun E. Knowledge about Neonatal Danger Signs and Associated Factors among Mothers Attending Immunization Clinic at Arba Minch General Hospital, Southern Ethiopia: A Cross-Sectional Study. Biomed Res Int. 2019;2019:9180314.

    Article  Google Scholar 

  40. Accelerating access to postnatal care and chlorhexidine in PNG []

  41. Jayanthan J, Irava W, Anuranga C, R.P. R-E: The Impact of Out-of-Pocket Expenditures on Families and Barriers to Use of Maternal and Child Health Services in Papua New Guinea: Evidence from the Papua New Guinea Household Survey 1996 and Household Income and Expenditure Survey 2009–2010. In. RETA-6515 Country Brief. Manila: Asian Development Bank.; 2012.

  42. Amin R, Shah NM, Becker S. Socioeconomic factors differentiating maternal and child health-seeking behavior in rural Bangladesh: A cross-sectional analysis. Int J Equity Health. 2010;9:9.

    Article  Google Scholar 

  43. Kabeer N. Resources, Agency, Achievements: Reflections on the Measurement of Women’s Empowerment. Dev Chang. 1999;30(3):435–64.

    Article  Google Scholar 

  44. Nigatu D, Gebremariam A, Abera M, Setegn T, Deribe K. Factors associated with women’s autonomy regarding maternal and child health care utilization in Bale Zone: a community based cross-sectional study. BMC Womens Health. 2014;14(1):79.

    Article  Google Scholar 

  45. World Health Organization. Gender, women and primary health care renewal: a discussion paper. In. Geneva: World Health Organization; 2010.

    Google Scholar 

  46. Forbes F, Wynter K, Wade C, Zeleke BM, Fisher J. Male partner attendance at antenatal care and adherence to antenatal care guidelines: secondary analysis of 2011 Ethiopian demographic and health survey data. BMC Pregnancy Childbirth. 2018;18(1):145.

    Article  Google Scholar 

  47. Greenspan JA, Chebet JJ, Mpembeni R, Mosha I, Mpunga M, Winch PJ, Killewo J, Baqui AH, McMahon SA. Men’s roles in care seeking for maternal and newborn health: a qualitative study applying the three delays model to male involvement in Morogoro Region, Tanzania. BMC Pregnancy Childbirth. 2019;19(1):293.

    Article  Google Scholar 

  48. Holmes W, Wambo G, Gabong R, Kavang E, Luana S, Sawa A, Supsup H, Reeder JC, Cassidy S, Natoli LJ. “Because it is a joyful thing to carry a baby”: involving men in reproductive, maternal and newborn health in East New Britain, Papua New Guinea. P N G Med J. 2012;55(1–4):24–34.

    CAS  Google Scholar 

  49. Tokhi M, Comrie-Thomson L, Davis J, Portela A, Chersich M, Luchters S. Involving men to improve maternal and newborn health: a systematic review of the effectiveness of interventions. PLoS ONE. 2018;13(1): e0191620.

    Article  Google Scholar 

  50. Comrie-Thomson L, Tokhi M, Ampt F, Portela A, Chersich M, Khanna R, Luchters S. Challenging gender inequity through male involvement in maternal and newborn health: critical assessment of an emerging evidence base. Cult Health Sex. 2015;17(sup2):177–89.

    Article  Google Scholar 

  51. Syed U, Asiruddin S, Helal MS, Mannan II, Murray J. Immediate and early postnatal care for mothers and newborns in rural Bangladesh. J Health Popul Nutr. 2006;24(4):508–18.

    Google Scholar 

  52. Mason E, McDougall L, Lawn JE, Gupta A, Claeson M, Pillay Y, Presern C, Lukong MB, Mann G, Wijnroks M, et al. From evidence to action to deliver a healthy start for the next generation. The Lancet. 2014;384(9941):455–67.

    Article  Google Scholar 

  53. Abu-Shaheen A, AlFayyad I, Riaz M, Nofal A, AlMatary A, Khan A, Heena H. Mothers’ and Caregivers’ Knowledge and Experience of Neonatal Danger Signs: A Cross-Sectional Survey in Saudi Arabia. Biomed Res Int. 2019;2019:1750240.

    Article  Google Scholar 

  54. Berhea TA, Belachew AB, Abreha GF. Knowledge and practice of Essential Newborn Care among postnatal mothers in Mekelle City, North Ethiopia: A population-based survey. PLoS ONE. 2018;13(8): e0202542.

    Article  Google Scholar 

Download references


The authors would like to thank the women and infants who participated in this study, as well as the families and communities who supported them to do so. Our special thanks to the National Department of Health, the East New Britain Provincial Administration, the Provincial Health Authority, Catholic Health Services and participating health facilities (Nonga General Hospital, St Mary’s Vunapope, Kerevat rural hospital, Napapar health centre, Paparatava health centre) for enthusiastically facilitating our research team to work alongside them. Specific thanks to Mr Levi Mano and Mr Nicholas Larme, Dr Ako Yap, Mr Moses Bogandri, Mr Benedict Mode, Dr Beryl Vetuna, Dr Pinip Wapi, Dr Felix Diaku, Dr Tanmay Bagade, Dr Delly Babona, Sr Placidia Nohan, Sr Theonila Wat and Sr Rebecca Penaia who have provided invaluable support and advice throughout the planning and implementation of this work in ENB. We gratefully acknowledge the dedication and contribution by our HMHB team who worked tirelessly to implement this study, specifically we would like to thank: Dr Stenard Hiasihri, Essie Koniel, Dukduk Kabiu, Ruth Fidelis, Wilson Philip, Priscah Hezeri, Kerryanne Tokmun, Primrose Homiehombo, Rose Suruka, Benishar Kombut, Thalia Wat, Noelyne Taraba, Chris Sohenaloe, Dorish Palagat, Zoe Saulep, Elizabeth Walep, Lucy Au, Irene Daniels, Gabriella Kalimet-Tade, Noreen Tamtilik, Ellen Kavang, Wilson Kondo, Allan Tirang, Michael Palauva, Ioni Pidian, Teddy Wanahau, Eremas Amos, Bettie Matonge, Elice Adimain, Thelma Punion, Lucy Palom. Thank you to the invaluable project support from Burnet Institute Melbourne, especially: Kellie Woiwod, James Lawson, Lisa Davidson, Vivian Newton, Lisa Vitasovich and Rodney Stewart. Additional thanks to Prof Michael Toole, Prof Margaret Hellard, Prof Stanley Luchters, Alexandra Umbers and Hannah Clark.


This work was funded by the Burnet Institute with philanthropic support provided by numerous private and business donors in Australia and PNG, including the Bank South Pacific Community Grant, the June Canavan Foundation, Gras Foundation, Finkel Foundation, Chrysalis Foundation and the Stewart-Naylor Fund. Several authors receive funding from the National Health and Medical Research Council (NHMRC) of Australia (Senior Research Fellowship to JGB and Program Grant to JGB and BSC, Career Development Fellowships to FJIF and LJR, Early Career Fellowship to LMV, Postgraduate Research Scholarship to CM. MJLS received a Basser Research Entry Scholarship from the Royal Australasian College of Physicians Foundation (2018 and 2020). The Burnet Institute is supported by an Operational Infrastructure Grant from the State Government of Victoria, Australia, and the Independent Research Institutes Infrastructure Support Scheme of the NHMRC of Australia. The funders had no role in study design, implementation or analysis, or the decision to publish.

Author information

Authors and Affiliations



Study design: led by JGB, CM, BSC, FJIF, MJLS with input from WP, EK, LV, AE. Data collection: MJLS, PM, EP. Data analysis and interpretation led by DE, MJLS, AW, CM with input from all authors, and DE wrote the first draft of the manuscript. All authors critically reviewed and edited the manuscript. The author(s) read and approved the final manuscript.

Corresponding author

Correspondence to Michelle J. L. Scoullar.

Ethics declarations

Ethics approval and consent to participate

The study was led by the Burnet Institute and had ethical approval from PNG’s national Medical Research Advisory Committee (approval no. 14.27), the PNG Institute of Medical Research Institutional Review Board (approval no. 1114), and the Alfred Hospital Human Research Ethics Advisory Committee in Australia (approval no. 348/14).

Approval and support to conduct the study was obtained from the Provincial Executive Committee of the East New Britain Provincial Government, and the individual health facilities involved. Written informed consent was obtained from all subjects and all methods were performed in accordance with relevant guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Eghrari, D., Scoullar, M.J.L., Wilson, A.N. et al. Low knowledge of newborn danger signs among pregnant women in Papua New Guinea and implications for health seeking behaviour in early infancy – findings from a longitudinal study. BMC Pregnancy Childbirth 23, 71 (2023).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: