Boadu et al. BMC Pediatrics(2024) 24:586
https://doi.org/10.1186/s12887-024-05050-0

BMC Pediatrics

RESEARCH

Open Access

Caregivers’ experiences on preterm infants’management in a tertiary care facility
in Ghana: a qualitative exploratory study
Mary Boadu1, Senoo-Dogbey Vivian Efua2,3* , Ohene Lilian Akorfa2 , Armah Deborah4 and Irene Owusu Darkwa2
Background Preterm birth is a process that fundamentally alters parental or caregiver roles, particularly in the early
weeks of childbirth. Caregiver experiences can be distressing due to struggles with an unfamiliar and potentiallythreatening environment of the Neonatal Intensive Care Unit (NICU). These experiences can affect the developmentof parenting or caregiving roles to a greater extent. Supporting caregivers of preterm infants through education andinformation sharing can significantly improve neonatal outcomes. This study sought to explore the experiences ofcaregivers with hospitalized preterm infants regarding the education and information they received from healthcare
workers on the care of preterm infants.
Method An exploratory descriptive qualitative study that explored caregivers’ experiences with the management ofpreterm infants hospitalized at the Level III Neonatal Intensive Care Unit (NICU) of a tertiary level facility with an annual
delivery of almost 7500 and a bed capacity of 26. The study utilized a deductive approach and a purposive samplingtechnique to recruit 16 caregivers who participated in an in-depth interview using a piloted semi-structured interview
guide. The interviews were audio-recorded, transcribed, and analyzed using thematic analysis.
Findings The study identified three major themes, which were (1) preterm infant feeding and keeping infants warm,(2) routine procedures and activities at the NICU, and (3) preparation towards homecare after discharge. Seven (7)sub-themes were generated. Caregivers were satisfied with the education and information they received on infant
feeding and keeping the infant ward. They also had adequate education that prepared them for home care of thepreterm infant. Caregivers did not receive timely information and education on the health status of their infants andthe care processes of the NICU. They felt they were left out as they were not involved in decision-making. Regarding
the care of the preterm infant. The inadequate flow of information and use of medical terminologies were a greatsource of worry and frustration for participants. The study showed that although the NICU staff were willing to offer
health education to caregivers, information giving and education were not structured and hence did not address all
the needs of the caregivers.
Conclusion Healthcare providers caring for preterm infants include caregiver education in their routine NICU
activities and procedures. These processes start from the period of admission till discharge. Their education sessions
primarily focus on breastfeeding, keeping the infant warm and adequate preparation of caregivers for preterm infant
home care. This notwithstanding there are gaps in caregiver education and information on routine procedures in*Correspondence:
Senoo-Dogbey Vivian Efua
efuvivi@yahoo.co.uk; vesenoo-dogbey@ug.edu.gh
Full list of author information is available at the end of the article© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0
International License, which permits any non-commercial use, sharing, 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 you modified thelicensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images orother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to thematerial. 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 http://
creativecommons.org/licenses/by-nc-nd/4.0/.

Boadu et al. BMC Pediatrics(2024) 24:586

Page 2 of 11

the NICU as well as information on the health needs of the infant. Participants are not fully involved in the decisionmaking processes and the use of medical terminologies compound caregivers’ frustrations and anxieties. It is
important to develop structured educational programs tailored to address the information needs faced by caregivers
to ensure optimal health outcomes for their preterm infants.
Keywords Caregivers, Education, Healthcare workers, Hospitalization, Infants, needs, preterm

Introduction
Preterm birth is a major public health problem due to its
medical, economic, and social impact. Although there
have been great strides to increase preterm survival
rates globally, the rate of survival remains minimal in
Low- and Middle-Income Countries (LMICs) [1–4]. The
challenges associated with preterm births are multifaceted. At the individual level, the condition is associatedwith long-term physical, and neurodevelopmental challenges in early life and may extend throughout the life
course [2, 5, 6]. At the health system level, preterm births
result in significant costs to health systems with the total
cost for providing initial hospital care in Ghana being
GH$212,776.96 ($35,462.83) [7]. Similarly, at the familylevel, preterm births have significant socioeconomic consequences for the affected families as well since caregivers experience considerable psychological and financial
hardships. These processes fundamentally alter maternal, parental, or caregiver roles, particularly in the early
weeks of childbirth [8, 9].
Ghana like other Sub-Saharan African countries has
a high neonatal mortality rate of 23 per 1000 LBs whichis unacceptably high [1–4] even though the country has
developed, disseminated and implemented the National
Newborn Health Strategy and Action Plan [7]. The
action plan outlines strategies for preventing neonatal
deaths by increasing access to quality neonatal care anda healthy start for neonates. Unfortunately, the Ghanaian health system is challenged with inadequate healthinfrastructure required for the care of preterm infants[7] since there are limited number of Standard Neonatal
Care Units (SNCUs) and Neonatal Intensive Care Units(NICU) in the country. There is also an inadequate number of neonatologists, paediatricians and specialist paediatric nurses who have the needed skills, knowledge andcompetencies to provide specialist care and services topreterm infants. However, health professionals such as
doctors and nurses have been trained in basic skills inmanaging preterm infants at all levels in the healthcaredelivery system with the limited resources available tothem [7].
Furthermore, studies performed in Ghana have shownthat neonatal care and survival interventions are directed
at meeting the physiological and health needs of the neonates with little attention to the caregivers. This situation
is of great concern as it has been reported that preterm
infant caregiver experiences can be distressing due tostruggles with an unfamiliar and potentially threatening NICU environment, which affects the developmentof parenting or caregiving roles to a greater extent [10].
According to Govindaswamy et al., (2019), the mostimportant need of caregivers of hospitalized preterm
infants is timely and appropriate information and education. Hence optimum support from healthcare personnel
in the NICU can address these challenges significantly [8,11–13].
The negative experiences of caregivers are compoundedby the lack of information and education on the processes
at the units and the health needs of their infants [14, 15].
There are efforts to help caregivers of preterm infants in
Ghana; nonetheless, these support services provided are
insufficient in meeting caregivers’ needs, furthermore,
the forms of education they are given are mostly inadequate [14, 15].
Secondly, studies that involved caregiver education
have mostly been performed in heterogeneous populations where there is extensive social security and uniquehealthcare systems that are different from the Ghanaian
context. This paper therefore focuses on the experiencesof caregivers with hospitalised preterm infants regarding
the education and information they received from thehealthcare providers to optimize the survival of their preterm infants.

Methods
Research design

The study used an Exploratory Descriptive Qualitative
Design (EQD) to explore the experiences of caregivers
through face-to-face in-depth interviews. Caregivers’
educational needs during their infant’s hospitalization
at the NICU were studied using EQD above design toenable us to describe what the phenomenon entails in the
Greater Accra Regional Hospital.
The study setting

The study was conducted in the Neonatal Intensive Care
Unit (NICU) of the Greater Accra Regional Hospital.
This study setting was chosen for the study because thehospital is situated in the heart of the city of Accra, andcaters for individuals from various backgrounds anddiverse locations. The facility also serves as a referral
centre for many maternal and child cases coming fromthe various districts within the region and beyond. Total
deliveries recorded in 2022 and 2023 were 7504 and 7151

Boadu et al. BMC Pediatrics(2024) 24:586

respectively. The NICU at the Greater Accra Regional
Hospital is classified as a level III intensive care unit andhence manages newborns and preterm infants requiring
regular nursery care, intensive care, and comprehensive
care for seriously ill infants. The unit has a bed capacityof 26 with an average daily in-patient rate of 26 neonates.
About 75–100 neonates are admitted to the unit permonth. The unit is managed by one neonatologist (supported by house officers) two paediatric specialists and 23
registered nurses giving a permanent staff strength of 26.
The nurses in the unit run a double shift system (Day andnight duties) with an average nurse-patient ratio of 1:8
for each shift. Families are occasionally involved in thecare of their sick infants through scheduled visitations.
Study population and recruitment

Caregivers whose infants were born before the 37 weeks
of gestation and hospitalized at the NICU of the Greater
Accra Regional Hospital for one week and beyond wererecruited into this study. We operationalized caregivers in this study as biological parents, grandparents, andany significant other whose infant was hospitalized in the
NICU during the study period. Mothers who sufferedmajor complications of pregnancy and were not strong
physically and emotionally stable were excluded from thestudy.
Participant recruitment, sample size technique, andsampling

The study employed a homogenous purposive samplingtechnique where the researcher used personal judgment
in choosing the cases that answered a set of researchquestions to achieve the stated objectives [16]. The purposive sampling also involved the selection of study participants with unique characteristics such as knowledge
and experiences built over time. In this study, the uniquecharacteristic is having a preterm infant being hospitalized in the NICU. Caregivers with the above-statedunique experience were approached as they came toeither breastfeed or see their preterm infants. The study
aims, and procedures were discussed with them andthose who showed interest in participating in the study
were recruited after they consented and signed the written informed consent form. The sample size was determined by data saturation. According to Boddy [18],sample size determination in the interpretivism paradigm
does not deal with larger samples compared to positivism but rather an in-depth inquiry into the phenomenon
under study. After interviewing the 16th participant, werealised that the information obtained from subsequentinterviews was just like what had already been provided
by the participants interviewed earlier. Therefore, wewere not able to obtain or identify any new themes hence

Page 3 of 11

data saturation was attained, and we ended the interviews on the 16th participant.
Data collection instrument

We developed a semi-structured interview guide purposely for this study. The data collection tool comprised
four separate sections, namely, the background information of the participants, questions on feeding and warmthfor the infant (2) routine procedures at the NICU (3)home care of the preterm infant, and (4) danger signs.
The questions were open-ended to accommodate probing to get in-depth information from the participants.
The tool was subjected to validity procedures with expert
review followed by piloting on two caregivers whose
preterm infants were hospitalized in another secondarylevel health facility in the Greater Accra Region.
Data collection procedure and techniques

The research was conducted according to the institutional ethical guidelines of Ghana Health Service andthe standard ethical practices for conducting research.
Approval was sought from the medical director as well as
the nurse manager of the institution. The research team
had an introduction and a short orientation to the NICU
which made it possible for the researchers to become
familiar with the unit, staff, and caregivers whose infants
were hospitalized. Potential participants were all given
information on the overall aim of the study and the procedures involved before and during data collection. Concerns by participants were addressed to their satisfaction,and those who expressed interest in the study were given
written consent forms to sign as evidence of willingness
to freely. Participants were recruited sequentially, andthe interviews followed the same pattern until the 16th
participant was interviewed. All the interviews wereconducted by the Principal Investigator however trained
research assistants took field notes and did the audio
recordings during the interview sessions.
The interaction with the participants was done throughin-depth interviews using open-ended questions. Nonverbal cues, gestures, and observations were noted
and written in the field notes book. All interviews wererecorded using an audio tape recorder. Each interview
session lasted for 40–45 min.
Ethics approval and consent to participation

Ethical clearance was obtained from the Institutional
Review Board of the Ghanaian Health Service with thenumber GHS-ERC:028/02/23. An introductory letterfrom the principal investigator’s institution was sent tothe study site for authorization to undertake the study.
The purpose of the study was explained to the participants, and their informed consent was sought throughadministering consent forms for them to sign. The

Boadu et al. BMC Pediatrics(2024) 24:586

Page 4 of 11

Nurse-In-charge permitted the use of the nurses’ officefor the in-depth interviews and this made it possible forprivacy to be ensured during all the interview sessions.
The audio recorder used to capture the information was
only accessible to the study team. All identifiable information, including audiotapes and field notes kept underlock and key to ensure confidentiality.
Methodological rigor

This study aligned with Guba and Lincoln‘s (1986) principles of trustworthiness in research [17]. To ensure
credibility, we built trust with all our study participants
right from the recruitment phase and this paved the way
for successful interactions for in-depth information to
be obtained. A comprehensive field note was taken, andmember checking was performed on every participant
to ensure that the data were not mixed. Dependability, as
described by Polit and Beck et al. (2017), is the “stabilityof data over time and conditions” [18]. In this study, an
audit trail of events and procedures was kept. To ensure
credibility, we carefully reported all the methodologicalprocesses that the research went through to allow for replication by other researchers. Confirmability was ensured
such that the meanings of the data collected were notaltered by prejudicial means, knowledge, and experiencesof the researcher [17]. This was ensured by immediatelytranscribing interviews to avoid mixing of data.
Data analysis

Data collection and analysis were performed concurrently. The audio recordings were played and listened tocarefully by the research team and played to the interviewee to reaffirm what was said or captured. Audios
were transcribed, and the researcher then used thematic
analysis to analyze the data. Thematic analysis is theprocess whereby patterns (themes) within the data areorganized, analyzed, and described in detail [19]. During this process, each aspect of the data, including words,
phrases, statements, and sentences made by the participants that depicted education or teaching, was analyzed.
Using the Braun, & Clarke, (2006) principle of thematic
analysis, the transcripts were read over and over. Transcript familiarization elicited similar and contrasting ideas and thoughts that were combined to develop
themes and categories. Field notes were used to support
the themes, as for the categories they were coded andsub-categories assigned. The authors confirms that alldata generated or analysed during this study are includedin this article.

Results/Findings
Sociodemographic characteristics of participants

Sixteen (16) caregivers whose infants were hospitalized at
the NICU participated in this study. All participants were
Ghanaians who lived in Accra; three (3) biological fathers
and thirteen (13) biological mothers participated in the
study. Out of this number, thirteen (13) were Christians
and three (3) Muslims. For the mode of deliveries, ten(10) were by caesarean section and six (6) spontaneousvaginal deliveries. Ten (10) infants were males, and nine(9) were females, including three (3) sets of twins. Detailsof the demographic data of the participants are presented
in Table 1.
Themes and Sub-Themes Based on the responses ofcaregivers, three themes were identified. These areas
included feeding and ensuring warmth for their infants,
information and education on the routine activities at
the NICU and education to prepare them for the care of
the infant after discharge. Seven sub-themes were identified from the main themes (Table 2). The themes are

Table 1 Sociodemographic characteristics of participants
Age of Participant
37
34
26
29
33
30
33
33
30
28
32
37
35
39
30
38

Relationship with Infant
MotherFatherMotherMotherMotherMotherFatherFatherMotherMotherMotherMotherMotherMotherMotherMother

Employment status
Employed
Employed
Employed
Unemployed
Employed
Employed
Employed
Employed
Employed
Employed
Employed
Employed
Employed
Employed
Employed
Employed

Duration of Hospitalization
14 days
7 days7 days21 days
8 days7 days9 days7 days
5 days10 days
7 days28 days
7 days9 days20 days
11 days

Gestation
30 weeks
34 weeks
29 weeks
30 weeks
30 weeks
32 weeks
34 weeks
32 weeks
32 weeks
34 weeks
32 weeks
25 weeks
32 weeks
32 weeks
30 weeks
31 weeks

Boadu et al. BMC Pediatrics(2024) 24:586

Page 5 of 11

Table 2 Theme and subthemes
THEMESa. Preterm infant feeding and keeping the infant warm

b. Routine procedures and activities at the NICU

c. Preparation towards care of the infant at home after discharge

supported by verbatim quotations from participants,
to ensure anonymity numbers were assigned to eachparticipant.
Preterm infant feeding and keeping the infant warm

Preterm infant feeding and keeping the infant warm
generated two subthemes which include education onbreastmilk expression, positioning and benefits, and education on keeping the infant warm.
Education on breastfeeding: breastmilk expression,
positioning during feeding and benefits of breastmilk

Most of the participants narrated how the healthcare
workers taught them how to breastfeed their infants andcup-feeding. For some mothers, it was about the position of the baby and good posture during breastfeeding
to avoid back pain. Another participant who was a firsttime mother of a preterm infant in an incubator narrated
how she was taught mechanical breastmilk expression bybreast massage.
“When you start breastfeeding, they educate youon how to sit well and position the baby to suck sothat the baby will be well latched on the breast. The
nurses told me to rest my back on the chair to avoid
back pains. They also taught me to part the baby’sback to remove air” P1.
“They also told us that the breastmilk will help thebaby to be strong and healthy so when I enter, I do
my best to get breastmilk for my baby.” P15.
“The nurses taught me how to express, so the firstday, one nurse said the baby has to start eating so
she wanted me to express breastmilk. Even if it’slittle I should try. Therefore, she taught me how tomechanically express breastmilk by massaging thebreast. She showed me a room for expression, told
me to wash my hands and take the sterilized bottle
prepared for that purpose”. P3.

SUBTHEMES
1. Education on breastfeeding:• breastmilk expression and cup feeding,• Positioning of caregiver and infant during feeding• Benefits of breastmilk
2.Education on Keeping the infant warm
3 Education on NICU ward rounds• Type of routine NICU activities• Purpose of ward rounds• Health providers involved in ward rounds and their roles
4. Education on infants’ state of health needs, and medical care
5. Education on infants’ health needs• Hygiene, thermoregulation, feeding and elimination needs
6. Education on danger signs and follow-up visits
7. Evaluation of caregiver skills and competencies• Observation of caregiver in performing preterm infant care

Education on keeping the infants warm

Participants gave experiences about the education
received on keeping their infants warm and the benefits
that made it easy for them to comply. According to participants, the education and information received were
beneficial as they were empowered and gained confidence in their ability to care for the newborn at home.
A 29-year-old hairdresser with a 1.4 kg infant expressed
how the education assisted her in bonding with theinfant.
“I have received help from all the health workers
here. They told me that the baby is now learning toadapt to the environment and that the baby can
become too cold and lose body heat. The nurse said I
need to take charge of that temperature control task
until the baby is grown to do that. It is all about covering up very well when we are discharged finally.
One of the nurses even helped to teach me how to tie
the Kangaroo Mother Care (KMC) cloth when I put
my baby on my chest” P10.
“When we were moved to that ward, a nurse, and adoctor helped me to position my baby and tie him
on my chest. They taught me that if I do it, it will
help my baby to keep warm and protect him from
infection, it will also help me to be able to breastfeed
well”. P9.
“They taught us that when the babies are preterm,
sometimes the preterm infants may have breathing difficulties. Therefore, when the baby is tied likethat in front of you when you breathe then, the baby
also responds. They also said that the KMC prevents
infection because there is less touching of the baby bydifferent individuals. It also makes them feel warm
like he is in your womb. They told us that the KMC
creates that bond between the mother and child.
Because the baby now recognizes her mother’s body

Boadu et al. BMC Pediatrics(2024) 24:586

smell and makes them recognize that we are theirmothers”. P4.

Routine procedures and activities at the NICU

Two subthemes were also derived from this section. This
includes education on NICU ward rounds and educationon the infant’s state of health, needs and overall medical
care.
Education on NICU ward rounds, the purpose of the rounds
and health providers involved in the ward rounds

One of the routine activities in NICU is doctors’ andnurses’ rounds. During these rounds, doctors and nurses
review and discuss the preterm infants’ progress and planfor daily and weekly care. Sometimes multi-professionalrounds inclusive of dieticians, therapists, and pharmacists are done.
For the participants, the multi-professional rounds
were unusual and new which resulted in anxiety andfear as they thought their infants were in distress. For
example, a 33-year-old first-time father said he had
never experienced this, and since the infant was not in astable condition, he got frightened at the sight of many
health workers around the baby. The nurses subsequently
explained what the rounds meant to the caregivers, toallay anxiety. However, according to the narratives of theparticipants, the information regarding the multi-professional ward rounds was not timely.
“The other day when we came, the nurse, and thedoctors were all over and around my baby. In addition, when we got there, I got so worried because they
were busily working on him. All of them were goingto and fro and I didn’t get anybody to ask what wasgoing on, initially because they were busy. so, I got
very worried.P4.
‘This scene truly scared me because I thought something had happened to the baby so I looked at mywife and she was very heartbroken, anxious and you
could see it in her eyes. Then the nurses called us andsat my wife and me down. They spoke to us at length,
then we understood all that they were doing’’.P2.
‘The information I got from the interaction with thenurses was that it was nothing to be afraid of andthat the specialist and the entire care team werediscussing the care of the baby and doing a routine
checkup on him. I wouldn’t be that scared if I knew
that’s what happens here”.P8.
One participant lamented and expressed her dissatisfaction openly about her not being adequately educated onward rounds and then not being part of decisions thatwere taken regarding her preterm infant.

Page 6 of 11“The doctors also take care of him[baby], but I
don’t know what they do for him. When they comearound, we are not allowed in so we don’t know what
happens. As soon as they come to do their rounds,
they will tell you to go out when they finish you cancome. After the rounds when I enter and ask them,
all they say is they have seen him and made decisions regarding the care of my baby and if there is aprescription they give it to me.
They didn’t tell me all that they discussed about mybaby during the ward rounds. I realized they spent
a lot of time there, but they did not go into detailabout what was done and said about my baby. They
only said that they would continue with the current
treatment”. P9.

Education on infants’ state of health, needs, and medical care

The health needs of preterm infants admitted to the
NICU vary and include temperature instability, feeding
difficulties, low blood sugar, infections, and breathingdifficulties. The care of these vulnerable individuals iscomplex, and each infant requires specific care to meethis or her individual needs. The participants said they
were eager to learn and understand their infant’s specifichealth needs and the overall care rendered. However,some of the caregivers expressed their frustrations andlamented about the inadequate flow of communication at
the NICU. They reflected that they did not receive timely
information regarding changes in their infants’ state ofhealth, and that made them very uncomfortable. Few ofthe participants had this to share.
“Because this is the NICU and she is in the incubator, I most of the time want to know if she has beentaken off the oxygen and how the breathing is andthen the level of the jaundice’’P2.
‘’I only observed that she was removed from the
incubator, I was not told the improvement or gains
that were made but I just knew maybe she got better.
The nurse did not explain to me what happened andwhat next would be done for my baby’’P5.
I observed in the later part of the day that her eyes
were yellowish. Then when I went in again, she was
put under the machine. I was extremely worried, but
I was waiting for answers from them, and they still
did not tell me anything. So, this afternoon I asked
the nurse what was wrong with my baby, and she
said, they knew what that was and they were working on it. She also said they were progressing verywell”. P2.
The participants also admitted that they had difficulty
getting information from the right people as the medical

Boadu et al. BMC Pediatrics(2024) 24:586

terminologies used by the healthcare providers did
not give them a better understanding of their infants’condition.
“My son was suffering from jaundice, and it was anextreme case and for a layman and a teacher, whenit comes to the technical and medical issues, I don’t
get it just like that. The health workers used their
medical terminologies and technical words thatmade it very difficult for me to comprehend.’’P3.
Some of the caregivers also gave an account of how thenurses gave them an explanation of some specific processes involved in the care of their infants. The healthcare
workers described the procedure for taking the infant off
oxygen and explained the use of the gadgets and equipment used on their infants.
“. So, what they told me was that they take her off
the oxygen for some time and monitor her and put
it back to see if she can breathe without it. However,
I was told that her respiration is irregular but apartfrom that she is doing well”. P11.
“I didn’t understand why monitors were being
plugged on my baby. But the nurse explained to me
that this is for monitoring the heartbeat, this is formonitoring the temperature, and this cage is keeping
the baby warm, and so forth.” P3.

Preparation towards care of the infant at home after
discharge

In this study, participants revealed that they were adequately prepared for discharge, and that helped themto build confidence in caring for their preterm infants
at home after discharge. For some of the caregivers, theeducation started right from the day their infants wereadmitted and for some others, it started when the healthcare providers noticed improvement in the condition of
their infants. Three subthemes emerged from the above
theme, and these include (1) education on medicationand general care at home, (2) education on danger signsand (3) assessment of caregivers’ competencies.
Education on infants health, hygiene, thermoregulation,
feeding and elimination needs

The healthcare workers offered education to the caregivers throughout hospitalization. The education encompasses baby hygiene, administration of medications,and ensuring warmth and feeding. The NICU staff alsoemphasized the prevention of infection. Before theirdischarge, a father described how he and his wife wereprepared to be able to care for their infant at home.
A participant expressed his satisfaction with how the

Page 7 of 11

teaching was done with the main goal of helping him
build confidence and have high self-efficacy towards thecare of the baby at home. Below are narratives shared bysome of the participants.
“The NICU staff started educating my wife and I
since the very day they noticed an improvement in
the baby’s condition. They taught us how to take careof the baby, and how to handle him in terms of giving drugs and cleaning him up. I believe I can do allthat they said’’.P10.
‘The education on feeding and keeping the baby
warm started right from the second day. The nurse
also taught me how to give the medications at home.
She said we will be discharged tomorrow. She said
I should wash my hands very well before I feed thebaby and before I give the medication’’P12.
The way she talked about it over and over, I thinkthese are all important. I am committed to going by
her advice. I can take care of the baby, now I know,even though the baby is very small’’ P4.

Education on danger signs and follow-up visits

Early recognition of the danger signs in preterm infants
facilitates early and positive care-seeking by caregivers. The danger signs in preterm infants could indicate
a severe disease or a local infection. These signs include
refusal of feeds, convulsions, fast breathing, fever, lowbody temperature, severe chest in-drawing, and movement only when stimulated or no movement at all. In
this study, caregivers were given education on the danger
signs to expect and when to report to the facility. Manyof the caregivers had an idea of how the infant would
behave if unwell. A few participants who were discharged
emphasized how their confidence had been built throughthe education they acquired at the NICU. Some participants narrated the following.
“They taught us how to study them for danger signs
and to report early when something like that happens. We were also told that we have to become used
to the care of our infant so that when we get home,
we will be able to care for them.” P4.
“The nurses came around and talked to us during
breastfeeding. They told us about any danger signs
we should expect when we go home and that weshould report quickly to the nearest clinic.” P1.
‘Right from the day we came here, the staff have beenteaching us how to identify that the baby is unwelland in danger. The nurse said they are danger signs
that we should be looking out for at home and reportto the hospital the moment we see even one of thesesigns’’P5.

Boadu et al. BMC Pediatrics(2024) 24:586‘’They also told us about the need to bring the baby
back when we see those signs. My baby was very welltaken care of, aww they did very well”. P13.

Page 8 of 11

time, reduced costs of care, reduced hospital readmissions, and most importantly a significant reduction in the
demand for 24-hour emergency care units [20].
Preterm infant feeding and keeping the infant warm

Evaluation of caregiver skills and competencies

At the time of discharge, caregivers should independently and confidently care for their infant; provide
medications, nutritional supplements, and any special
medical care; recognize signs and symptoms of illness
and respond appropriately, especially in emergencies;
and understand the importance of infection control measures and a clean environment. In this study, the caregivers narrated the type of assessment they underwent
regarding the level of competence on the aforementioned
topics before they were discharged. According to them,
the healthcare workers ensured that the caregivers werecompetent to care for the preterm infant before discharge
from the NICU. This was done by observing the mother’s capabilities during infant feeding and KMC sessions.
To determine the effectiveness of the education and theinformation caregivers received, they were evaluatedthrough a series of questions.
“Therefore, in that ward, the nurses and doctors
monitor the baby and also observe the mother to be
sure that she can take care of the baby if they aredischarged’’.P 4.
The nurses told us that whatever they have taught
us to do are the things we are to do. We should not
do it anyhow. After the teaching, they then ask us torepeat what they said to know whether we are capable of handling them when we go home. P9.

Discussion
This present study involved caregivers with preterm
infants who were hospitalized for various health issues
at the NICU of the Greater Accra Regional Hospital. The
study explored the experiences of the caregivers regarding the education and information they received fromhealthcare providers on caring for their preterm infants.
There has been a slight increase in the survival rate ofpreterm infants globally, especially in developed countries, despite this strive, there is still the possibility of thedevelopment of morbidities in preterm infants necessitating intensive care admissions and treatment [20].
Apart from medical interventions that promote the survival of preterm infants in the NICU, education, andprovision of information to caregivers and the entire
family of the preterm infant have shown positive results.
For example, there is evidence that the implementationof education and information-giving strategies for caregivers has advantages including reduced hospitalization

In this study, caregivers acknowledged the educational
guidance provided by the healthcare workers regarding preterm infant feeding practices. Additionally, theteachings on breastfeeding and its components, adept
identification of infant feeding cues, and the fulfilmentof their infants’ nutritional requirements were regarded
as immense support from healthcare workers. This finding is consistent with studies that outlined essential
premature infant feeding components and educational
packages that meet the needs of the mother [15, 21, 22].
According to researchers, caregiver education on infant
feeding enhances parental empowerment, which helps
them actively participate in their infants’ care resulting in
better health outcomes for preterm infants [23].
The caregivers in this study were satisfied with the education they had on how to keep their preterm infants
warm. This finding falls in line with what was reported by
Apedani et al. and Negarandeh et al. [24, 25]. It was, also
found that caregivers with stable infants who were transitioning from the ICU were allowed to perform skinto-skin care thereby promoting bonding. This finding
corroborates the study by Vizzari et al., [28] conductedin an Italian NICU, where the healthcare workers allowedskin-to-skin contact when infants were clinically stable[26]. The best neonatal outcomes are achieved when skinto-skin contact also known as Kangaroo Mother Care
(KMC) is practised well, as the benefits include prevention of infection because of limited handling, increased
breastfeeding, and improved maternal role identity [27].
Routine procedures and activities at the NICU

Our study also found that the caregivers were eager toreceive information and understand their infant’s specific health needs as well as the overall care processes,
and the actions taken to address the needs of the preterm
infants. However, they did not receive timely educationand information regarding changes in their infants’ stateof health and the actions taken to ensure the survival of
the preterm infants. There was inadequate flow of information and the medical terms and unfamiliar medical
language used by healthcare providers made caregivers frustrated. In another related study, half of the study
participants were dissatisfied with the information theyreceived regarding the health state and care of their preterm infants [28]. This finding aligns with observations
that healthcare workers in the NICU have interactions
and communication challenges with caregivers of preterm infants [29].

Boadu et al. BMC Pediatrics(2024) 24:586

The purpose of communication between staff andcaregivers in the NICU is to share information withcaregivers about the infant’s health state, treatment, andinvolvement in decision-making regarding the care of
their infants. In this study however, the participants feltthat they were not adequately educated on some of theprocedures and routines of the NICU. For example, thecaregivers were not familiar with ward rounds which are
undertaken on daily basis, caregivers also felt left out indecision-making involving their infants. This finding
is similar to that of Caldwell et al. [30–34] who foundthat caregivers recognize the value of ward rounds andtherefore should be involved. Including them in this routine fosters a strong relationship between the caregiverand child as well as with the healthcare team. Caregivers feel comfortable speaking directly to the healthcare
team about their concerns as this allows them to ask forclarifications.
Preparation towards care of the infant at home, after
discharge

Caregivers who participated in this study attested tobeing satisfied with the education they had received
before the discharge of their infants. According to theparticipants, the education gave them confidence in theirability to care for the preterm infant and this finding
resonates with that of Shillington et al. [33] who emphasized the importance of caregiver preparation before
discharge of the infant from the hospital to the homeenvironment. Griffith et al. [34] described support forparents and families post-NICU discharge as importantin providing education related to infant care and overall health. Our findings on the need for information andeducation to caregivers before going home are similar toother studies where mothers who received educational
guidance exhibited contentment and satisfaction. This
educational guidance encompassed topics such as infant
home care, administration of medications, KMC practices, and breastfeeding [21, 24]. A successful transition
from the NICU to the home environment is elemental
for the long-term health and well-being of the preterm
infant. Caregivers educated on their infants’ care areknowledgeable about the infants’s needs. Caregivers areusually emotionally distressed about taking care of theinfant at home due to fear of the infant not surviving [30].
Through information and education fatalities that might
have occurred at home are alleviated [25, 33].
Study limitations

The design of this study did not permit for the assessmentof the educational programmes available hence conclusions were based on self-report only. Data from othersources would have allowed for triangulation to enhance

Page 9 of 11

the validity of the findings. This study was performed in asingle facility hence findings cannot be generalized.

Conclusion
The significance of caregiver education on preterm
infant care cannot be overstated. Empowering caregivers through education and information on practical skills
will enhance infant health outcomes and strengthen thebond between caregivers and their infant and healthcare providers. Therefore, health professionals should
welcome caregivers and the family and provide conditions for active participation in the care of the infant.
In the Ghanaian context, it is imperative to develop andimplement tailored educational programs that address
the challenges faced by caregivers. In doing so, there isthe creation of a more supportive environment that leads
to improved survival rates and overall preterm healthoutcomes.
Based on the findings of our study we recommend
the adoption of the family-centered care concept which
is becoming a model for providing care in the NICU,
and this model should be well embraced to provide theneeded support for caregivers and families.
Implications for practiceThe study findings indicate that the healthcare workers
in the NICU possess a positive attitude towards parent
teaching and education. Nevertheless, there is a needfor a well-coordinated and tailored approach to meetthe specific needs of caregivers. Additionally, healthcare
workers must engage in open and timely communication
with caregivers, which plays a pivotal role in providing
support across the continuum of care.
Abbreviations
NICU	Neonatal Intensive Care Unit
EQR	Exploratory Qualitative Design
KMC	Kangaroo Mother Care
Acknowledgements
We acknowledge the Neonatal Intensive Care Unit staff of the Greater Accra
Regional Hospital for their support. We are also immensely grateful to all
our study participants for their voluntary participation and the time they
committed to this study.
Author contributions
B.M; Conceptualization, Methodology, Data collection, Data Analysis. Writing,Original draft, preparation of manuscript. S-D V. E; Methodology, Supervision,
Writing, Original draft preparation of manuscript. O.L. A; Methodology,
Supervision, Writing, Original draft preparation of manuscript. A, D; Writing,original draft preparation of manuscript.
Funding
This research received no funds or grants from public, private, or nonprofit
agencies.
Data availability
The authors confirms that all data generated or analysed during this study areincluded in this article.

Boadu et al. BMC Pediatrics(2024) 24:586

Page 10 of 11

Declarations
Ethics approval and consent to participate
Ethical clearance was obtained from the Institutional Review Board of the
Ghana Health Service with the number GHS-ERC:028/02/23. An introductory
letter from the principal investigator’s institution was sent to the studysite for authorization to undertake the study. The purpose of the study
was explained to the participants, and their informed consent was sought
through administering and signing of consent forms. All the participants inthis study were adults above age 18 and therefore consent to participate was
not sought from parents or legal gurdians as would have been the case forparticipants who are minors.
Privacy was ensured during the interview sessions. The audio recorder wasused to capture the information and was only accessible to the study team. All
identifiable information, audiotapes and field notes were kept under lock andkey to ensure confidentiality.
Consent for publication
Not Applicable.
Competing interests
The authors declare no competing interests.
Author details
1
Ghana Health Service, Madina Polyclinic, Accra, Ghana
2
Department of Public Health Nursing, School of Nursing and Midwifery,
University of Ghana, Legon, Accra, Ghana
3
Ghana Institute of Management and Public Administration, Greenhill
Achimota, Ghana
4
Department of Maternal and Child Health, School of Nursing andMidwifery, University of Ghana, Legon, Accra, Ghana
Received: 1 April 2024 / Accepted: 3 September 2024

11.

12.

13.

14.

15.

16.
17.
18.
19.
20.
21.
22.

References
1. World Health Organization. Preterm birth. In: Key Facts [Internet]. 2023
[cited 24 Mar 2024] pp. 1–4. Available: https://www.who.int/news-room/fact-sheets/detail/preterm-birth
2. Ohuma EO, Moller AB, Bradley E, Chakwera S, Hussain-Alkhateeb L, Lewin A,
et al. National, regional, and global estimates of preterm birth in 2020, withtrends from 2010: a systematic analysis. Lancet. 2023;402:1261–71. https://doi.org/10.1016/S0140-6736(23)00878-4.
3. Perin J, Mulick A, Yeung D, Villavicencio F, Lopez G, Strong KL, et al. Global,
regional, and national causes of under-5 mortality in 2000–19: an updated
systematic analysis with implications for the Sustainable Development
Goals. Lancet Child Adolesc Heal. 2022;6:106–15. https://doi.org/10.1016/
S2352-4642(21)00311-4.
4. Chawanpaiboon S, Vogel JP, Moller AB, Lumbiganon P, Petzold M, Hogan D, etal. Global, regional, and national estimates of levels of preterm birth in 2014:a systematic review and modelling analysis. Lancet Glob Heal. 2019;7:e37–46.
https://doi.org/10.1016/S2214-109X(18)30451-0.
5. Mwaniki MK, Atieno M, Lawn JE, Newton CRJC. Long-term neurodevelopmental outcomes after intrauterine and neonatal insults: a systematic review.
Lancet. 2012;379:445–52. https://doi.org/10.1016/S0140-6736(11)61577-8.
6. Cassiano RGM, Gaspardo CM, Linhares MBM. Neonatal stress and behavior
problems in preschool children born preterm. 2023;28: 500–11. https://doi.
org/10.1177/13591045221098521
7. Ofosu W, Ahenkorah B, Akporlu J, Suntaa AS. Cost of initial care for preterm
infants at Bolgatanga Regional Hospital, Ghana. Texila Int J Acad Res.
2023;10:45–55. https://doi.org/10.21522/tijar.2014.10.03.art005.
8. Govindaswamy P, Laing S, Waters D, Walker K, Spence K, Badawi N. Needs andstressors of parents of term and near-term infants in the NICU: a systematic
review with best practice guidelines. Early Hum Dev. 2019;139:1–6. https://doi.org/10.1016/j.earlhumdev.2019.104839.
9. Heydarpour S, Bakteari Z, Maryam K. Factors affecting maternal role adaptation in mothers of preterm infants hospitalized in the intensive care unit: aqualitative study. J Qual Res Heal Sci. 2017;16:132–46.
10. Maharjan R, Shrestha M, Pokharel N, Rai G, Karna B, Chaudhary K, et al.
Stress and coping strategies among mothers ’of neonates, admitted in

23.
24.
25.

26.

27.

28.
29.
30.

31.
32.

neonatal intensive care unit. Asian J Nurs Educ Res. 2015;5:363. https://doi.
org/10.5958/2349-2996.2015.00073.7.
Ohene LA, Power KJ, Raghu R. Health professionals’ perceptions and practiceof family centred care for children injured in road traffic accidents: a qualitative study in Ghana. J Pediatr Nurs. 2020;53:e49–56. https://doi.org/10.1016/j.
pedn.2020.02.005.
De Bernardo G, Svelto M, Giordano M, Sordino D, Riccitelli M. Supporting
parents in taking care of their infants admitted to a neonatal intensive care
unit: a prospective cohort pilot study. Ital J Pediatr. 2017;43:1–11. https://doi.
org/10.1186/s13052-017-0352-1.
Rajabzadeh Z, Moudi Z, Abbasi A, Miri-Aliabad G. The effect of family-centered educational supportive intervention on parental stress of prematureinfants hospitalized in the NICU. Med - Surg Nurs J. 2021;9. https://doi.
org/10.5812/msnj.111847.
Abukari AS, Acheampong AK, Aziato L. Experiences and contextual practices
of family-centered care in Ghanaian nicus: a qualitative study of families
and clinicians. BMC Health Serv Res. 2022;22:1–9. https://doi.org/10.1186/
s12913-022-08425-0.
Lomotey AY, Bam V, Diji AKA, Asante E, Asante HB, Osei J. Experiences ofmothers with preterm babies at a Mother and Baby Unit of a tertiary hospital:a descriptive phenomenological study. Nurs Open. 2020;7:150–9. https://doi.
org/10.1002/nop2.373.
Anderson C. Presenting and evaluating qualitative research. Am J ofPharmaceutical Educ. 2010;74(Artic 141 Spec):2010–74.
Guba EG, Lincoln YS. Epistemological and methodological bases of naturalistic inquiry. 1982; 1–7.
Polit DF, Beck CT. Nursing research:Generating and assessing evidence fornursing practice. 10th ed. Philadelphia: Wolters Kluwer Health; 2017.
Braun, Clarke V. Using thematic analysis and psychology. Qual Resaerch
Psychol. 2006;3:77–101.
Chiodi LC, Del Angelo Aredes N, Scochi CGS, Fonseca LMM. Health educationand the family of the premature baby: an integrative review. ACTA Paul
Enferm. 2012;25:969–74.
Umberger E, Canvasser J, Hall SL. Enhancing NICU parent engagement andempowerment. Semin Pediatr Surg. 2018;27:19–24. https://doi.org/10.1053/j.
sempedsurg.2017.11.004.
Zainal K, Zakaria SM, Muhammad Aun NS. The domain of challenges andcoping mechanisms amongst caregivers of autistic children. Int J Acad Res
Bus Soc Sci. 2021;11:946–57. https://doi.org/10.6007/ijarbss/v11-i6/10225.
Waddington C, van Veenendaal NR, O’Brien K, Patel N. Family integrated care:
supporting parents as primary caregivers in the neonatal intensive care unit.
Pediatr Investig. 2021;5:148–54. https://doi.org/10.1002/ped4.12277.
Negarandeh R, Hassankhani H, Jabraeili M, Abbaszadeh M, Best A. Health carestaff support for mothers in NICU: a focused ethnography study. BMC Pregnancy Childbirth. 2021;21:1–13. https://doi.org/10.1186/s12884-021-03991-3.
Apedani D, Koduah A, Druye A, Ebu I. Experiences of mothers with preterm
babies on support services in neonatal intensive care unit of a mission
hospital in Ghana. Int J Afr Nurs Sci. 2021;15:100366. https://doi.org/10.1016/j.
ijans.2021.100366.
Vizzari G, Morniroli D, Consales A, Capelli V, Crippa BL, Colombo L, et al.
Knowledge and attitude of health staff towards breastfeeding in NICU
setting: are we there yet? An Italian survey. Eur J Pediatr. 2020;179:1751–9.
https://doi.org/10.1007/s00431-020-03678-5.
Cañadas DC, Carreño TP, Borja CS, Perales AB. Benefits of kangaroo mothercare on the physiological stress parameters of preterm infants and mothersin neonatal intensive care. Int J Environ Res Public Health. 2022;19. Available:
https://pubmed.ncbi.nlm.nih.gov/35742429/
Wigert H, Dellenmark MB, Bry K. Strengths and weaknesses of parent-staff
communication in the NICU: a survey assessment. BMC Pediatr. 2013;13.
https://doi.org/10.1186/1471-2431-13-71.
Strandås M, Fredriksen STD. Ethical challenges in neonatal intensive care nursing. Nurs Ethics. 2015;22:901–12. https://doi.
org/10.1177/0969733014551596.
Alinejad-Naeini M, Peyrovi H, Shoghi M. Emotional disorganization: theprominent experience of Iranian mothers with preterm neonate: a qualitative
study. Health Care Women Int. 2021;42:815–35. https://doi.org/10.1080/0739
9332.2020.1797040.
Shillington J, McNeil D. Transition from the neonatal intensive care unit tohome: a concept analysis. Adv Neonatal Care. 2021;21: 399–406. https://doi.
org/10.1097/ANC.0000000000000835.
Maghaireh DF Al, Kawafha MM Al, Khatijah LA, Chong MC. A systematic
review of qualitative studies exploring parental experiences in the Neonatal

Boadu et al. BMC Pediatrics(2024) 24:586

intensive care unit. J Clinial Nurs. 2016;25:2745–56. https://doi.org/10.1111/
jocn.13259.
33. Waddington C, van Veenendaal NR, O’Brien K, Patel N. Family integrated care:
supporting parents as primary caregivers in the neonatal intensive care unit.
Pediatr Investig. 2021;5:148–54. https://doi.org/10.1002/ped4.12277.
34. Pavlyshyn H, Sarapuk I, Casper C, Makieieva N. Kangaroo mother care can
improve the short-term outcomes of very preterm infants. J Neonatal Perinatal Med. 2021;14: 21–8. https://doi.org/10.3233/NPM-200455.

Page 11 of 11

Publisher’s note

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