Background: Low Birthweight (LBW) is a significant risk factor for neonatal mortality globally. LBW neonates have a higher risk of death from illness and complications compared to normal weight newborns. This paper examined the perceptions and management of low-birth-weight newborns in two large urban slums in the southern part of Ghana.

Methods: The data used for this paper comes from a concurrent mixed methods cross sectional study conducted in (Ashaiman and Sodom and Gomorrah) in Accra, Ghana. The quantitative survey was conducted among 279 randomly sampled mothers aged 15-49 years with live neonates 0 - 28 days old. Focus group discussions (14) and In-depth interviews (13) were conducted with women of reproductive age with live newborns aged 0-28 days, slum based traditional birth attendants, care givers, community leaders and public health managers who were purposively sampled. Descriptive analyses was conducted to describe care practices for low birthweight newborns. Bivariate and multiple logistic regression analyses were used to assess factors associated with health seeking for low birthweight at a 95% confidence level. Qualitative interviews were tape-recorded, transcribed, coded, and analysed thematically.

Results: Prevalence of low birth weight in the slums was high at 30%. Generally 2.5% of the babies were very large, 9.7% were larger than average and 77.8% were of average weight. About 9% were smaller than average while 1.1% were very small. The median weight at birth was lower for Sodom and Gomorrah at 2.9 (2.5,3.2), than Ashaiman 3.0 (2.6,3.2). Perceptions of small for gestational age and low birthweight babies were varied. While some believed the babies were cursed, others said their mothers were promiscuous, either attempted an abortion or ate foods that were prohibited during pregnancy. Yet, others perceived them to be possessed with evil spirits an must be exorcised.

In a binary logistic regression, mothers with no ANC visits (COR: 9.82, 95% CI: 4.24-22.73, p<0.001), and those who had attained between 1-4 ANC visits (COR: 5.61, 95% CI: 2.94-10.72, p<0.001), were significantly more likely to give birth to babies with low birth weight compared to those mothers who made 4 or more ANC visits. Again, mothers who did not receive iron folate supplementation during pregnancy were two times significantly more likely to give birth to low-birth-weight babies (AOR: 2.39, 95% CI: 1.01-5.63, p<0.05), compared to mothers who received iron folate tablets. Similarly, mothers who were not counselled on newborn danger signs during pregnancy were 2.9 times significantly more likely to give birth to low-birth-weight babies (COR: 2.87, 95% CI: 1.64-5.03, p<0.001) compared to those who were counselled on newborn danger signs.

Conclusion: Prevalence of low birthweight (roughly 30.5%) was high in the slums. Interestingly, none of these newborns received prolonged skin-to-skin care. Addressing low birth weight in Ghana’s urban slums requires strengthening ANC services and improved counselling during ANC services and home visits.

• Small for gestational age

• Low birth weight

• Antenatal care

• Kangaroo Care

Adimazoya EA, Ganle JK (2025) Perceptions and Management of Small for Gestational Age and Low Birthweight Newborns in Two Urban Slums in Southern Ghana: Evidence from a Concurrent Mixed Methods Study. Ann Pregnancy Care 7(1): 1018.

ANC: Antenatal Care; BCG: Bacillus Calmette-Guérin; FGD: Focus Group Discussion; GAR: Greater Accra Region; KMC: Kangaroo Mother Care; KBTH: Korle Bu Teaching Hospital; LBW: Low Birth Weight; MICS: Multiple Indicator Cluster Survey; SP: Suphurdoxine Pyrimethamine; WHO: World Health Organisation.

Small for Gestational Age (SGA) and Low Birthweight (LBW) remain a major public health threat to newborn survival globally. Sub-Saharan Africa and South Asia together harbour about 60% of the world’s SGA babies [1]. The World Health Organisation (WHO) defines low birth weight as the birthweight of a live born infant less than 2500 grams irrespective of the gestational age [2], while SGA are babies that might have grown healthily but are constitutionally small, or might have suffered intrauterine growth restriction due to placental insufficiency (e.g. pre eclampsia or placental malaria), fetal reasons (such as multiple births), environmental exposures or nutritional factors especially driven by maternal pre-pregnancy nutritional status [3]. Traditionally LBW has been identified as a risk factor for neonatal morbidity and mortality, accounting for over 20 million deaths of newborns globally each year [4]. Small babies face the greatest risk of death in utero, during the neonatal period and throughout childhood [5]. Being born small is often attributed to either preterm birth or small for gestational age or a combination of both conditions.In 2012 alone, an estimated 800,000 neonatal deaths were linked to babies born too small for their gestational age [6]. Again in that year, more than 80% of neonatal deaths in sub -Saharan Africa were of small babies - 65% of them attributable to preterm and 19% due to term small for gestational age [7]. Two thirds of the SGA neonatal deaths were of term low birthweight babies. Preterm births i.e. babies born too early (<28 weeks’ gestation) have the highest risk of neonatal death especially if without specialized newborn care [8]. Every year an estimated 15 million babies are born preterm (i.e., before 37 completed weeks of gestation), and this number is rising [9]. Size at birth is a strong predictor of long-term health [10]. Babies born preterm and SGA have the highest risk for stunting in childhood [11]. while the prevalence of cardiovascular diseases, obesity and insulin resistance or type 2 diabetes have been linked to preterm and SGA births [12,13]. Studies show that Infants born with a weight less than 2.5 kgs face a higher risk of malnutrition and childhood morbidities such as diarrhoea and pneumonia [14], which are also the leading causes of neonatal and child mortality [15]. Poor maternal nutrition, micro nutrient and iron deficiencies during pregnancy increases the risk of adverse pregnancy outcomes such as low birthweight, preterm birth, perinatal and infant mortality, postpartum hemorrhage and spontaneous abortion [16,17]. Despite investments in interventions to reduce the prevalence of low birth weight, progress has been especially slow in sub-Saharan Africa, where the risk of dying within the first 28 days after birth for small for gestational age and low birthweight infants is high [6,7]. The survival of small for gestational age and low birth weight infants in the first 28 days of life is very critical, because of vulnerability to infections and illness and the critical care required by mothers, caregivers and skilled attendants. This vulnerability is linked to the stress of delivery and the transition and adaptation from uterine life to ex-utero with the associated exposures to infections and other dangers [18]. The behaviour of mothers, care givers and skilled attendants immediately after birth and the quality of care provided for small for gestational age and low birthweight babies are therefore very crucial for their survival and growth [8]. Over the last decade, Ghana experienced rapid urbanization, resulting in the spread of slums across major cities. It is estimated that 39.7% of the 5.4 million urban population are now residing in slums [19]. Health outcomes of preterm, small for gestational age and low birth weight babies are even worse in poor urban slums [20,21]. Most slums lack neonatal intensive care units and appropriate health infrastructure for proper management of small for gestational age and low birthweight babies [20,21]. In 2018, the Ashaiman Municipality and the Ashiedu-Keteke Sub Metropolitan areas recorded neonatal mortality rates that were higher than the national average of 25 deaths per thousand live births [22,23]. The Government of Ghana recognizing the challenge of the high neonatal mortality burden launched several pro newborn initiatives including the Ghana National Newborn and Child Health Advocacy and Communication Strategy (2015-2019), the Ghana SDG Acceleration Framework and Country Action Plan and the Ghana National Newborn Health Strategy and Action Plan (2019-2023). Despite these initiatives, neonatal mortality has stagnated, clearly suggesting an urgent need for research into the contributory factors fueling the high neonatal deaths, particularly care for small for gestational age and low birthweight newborns. Small for gestational age and low birth weight newborns are especially vulnerable in urban slum neighborhoods due to the overcrowding, insanitary and poor housing conditions that characterize these areas, but also inadequate infrastructure, equipment and personnel to manage these conditions in slum neighborhoods. Yet, the few studies conducted in urban slums thus far have focused on the social and economic vulnerabilities rather than population health [24-26], neglecting maternal newborn and child health. Therefore, this study explored the perceptions and management of small for gestational age and low birthweight newborns in two large urban slums in the southern part of Ghana.

Study Design and Population

The data used for this paper comes from a concurrent mixed methods cross sectional study. The quantitative survey was conducted among 279 mothers aged 15-49 years with live neonates 0- 28 days old. The qualitative study was conducted among women of reproductive age with live newborns aged 0-28 days, slum based traditional birth attendants who delivered a live baby between January 1st and June 30th 2020, care givers, community leaders and public health managers at national, regional, and sub national level.

Study Area And Sampling

The study was conducted in two large urban slums (Ashaiman and Sodom and Gomorrah) in Accra. These slums are similar, ethnically diverse, mostly poor, barely educated and generally unemployed. Their residents are mostly engaged in odd, non-permanent jobs including female head porterage popularly called Kayayei. They also have poor access to healthcare. The sample for the quantitative survey was 279 women of reproductive age 15-49 years with live births 0-28 days old, who resided in either Ashaiman or Sodom and Gomorrah for at least a year prior to recruitment. Women whose babies did not survive 28 days were excluded. Mother-baby pairs recruited for the qualitative research were also excluded from the survey and vice versa to avoid potential bias and confounding of the findings.We conducted a household survey of newborn mother pairs using multi-stage stratified simple random sampling. The 2010 Ghana Population and Housing Census (PHC) [27], formed the sample frame. According to the 2010 PHC, the average size of urban Enumeration Areas (EAs) is (185 households); slightly larger than the average size of rural EAs (114 households) [27]. The sampling frame contained information about the EA’s location, type of residence and estimated number of residential households. In each study location, we randomly sampled twenty (20) EAs of clusters of slum settlements, giving a total of 40 EAs. Given that the average size of an urban EA is 185 households, sampling 20 EAs in each study location was sufficient to obtain at least 140 respondents from each site. In the second stage, a household listing was carried out in all selected EAs to identify women with newborn mother pairs that met the study inclusion criteria. The results of the household listing in each EA subsequently served as a sampling frame for selecting individual respondents in the third stage. A community level enumeration of all women with newborns aged 0-28 days was undertaken using a simple Enumeration Tool. The tool comprised basic information of the participants’ name, community, length of stay in the slum, contact number, house address, and whether the woman had a live newborn aged 0-28 days old. Following the identification and enumeration of potentially eligible women and newborns in each EA, we further screened to eliminate mothers who did not meet the study’s inclusion criteria after which a register of all eligible respondents in each EA was created [26]. The total sample size of 280 was proportionately allocated among the twenty EAs in each study site ensuring that EAs with higher numbers of potentially eligible respondents were sampled more into the survey. Each of the potentially eligible respondents in each EA was given a unique number identifier (e.g., 001 … 00n). The numbered lists were exported into a google-based random number generator programme, where the required number of participants from each study location were randomly selected. Participants who were literate were given a participant’s information sheet to help them make an informed decision. Non-literate participants received explanation about the study from trained research assistants in a language that they understood.For the qualitative arm, we conducted 14 focus groups comprising 121 females and 17 males (8-10 per group) and 13 in-depth interviews following guidelines proposed by Guest et al and Francis et al [28,29]. Recruitment of participants was purposive, and continued until saturation was reached on major issues that the qualitative component explored [30,31]. We used the homogenous, expert and maximum variation or heterogenous purposive sampling methods [32], to select participants.

Instruments and data collection

The quantitative data were collected electronically on mobile android devices using the Computer Assisted Personal Interview (CAPI). CAPI is a dependable telemetry device that transmits data to a base station’s computer.The data management software (Datacol) facilitated real time data collection. The Datacol application was used to capture and transfer the data to an online central data storage server for live data monitoring, data cleaning and analysis. Data collection was based on face-to-face interviews. Upon successful completion of an interview, the data was saved on the mobile device and a new questionnaire automatically opened up for the next interview. The data was collected by trained professional nurses and midwives. Qualitative data were collected using semi -structured open ended interview guides. Discussions in the FGDs lasted between thirty minutes and 1 hour. All discussions were conducted in one of three local dialects Twi, Ewe and Dagbani depending on the dialect that was mostly spoken and understood by the participants. The in-depth interviews lasted between forty-five minutes and one hour. Discussions and interviews were tape-recorded and notes were taken to document observations about the interview content, the participants and the context. Prior to data collection, all data collection tools were pre-tested and refined based on the pre-test results. We also trained two supervisors and ten data collectors from January 2- 4, 2020. The training offered a hands-on approach on use of the Datacol application, interviewing skills, interpretation of the questions, response categories and anthropometry. The training also covered skills in diagnosing neonatal sepsis, diarrhea, Acute Respiratory Tract Infections (ARI), ethics and compliance with research issues on human subjects.

Variables

The primary outcome considered included weight at birth (i.e. normal birthweight, low birthweight or larger than normal birthweight). The independent variables included socio-demographic factors such as maternal age, marital status, education, ethnicity, religion, parity, sex of newborn, age of newborn, occupation of mother, income or socioeconomic status, mothers’ age at birth, migration status, ANC attendance, timing of first ANC visit, home or facility delivery, delivery type, caesarean or normal spontaneous vaginal delivery, counselling received on birth preparedness and facility delivery, counselling received on breastfeeding, appropriate thermal care including skin-to skin and Kangaroo care.

Analysis

The quantitative data set was exported to SPSS version 25.0 for cleaning and generation of derived variables using Stata IC Version 16. Data analysis was done in three stages - descriptive statistics, bivariate and multi-variable logistic regression. Socio-demographic background characteristics and categorical variables were described using frequencies and percentages. The mean, standard deviation, median and inter-quartile range were used as summary statistics for normally distributed continuous and skewed variables. In bivariate analysis, various outcome variables were described across independent variables using frequencies and percentages, while the Pearson’s chi - square test was performed to assess the significance of association between categorical independent variables and categorical outcome variables. The Fischer’s exact test was used to assess associations in situations where the assumptions of the Pearson’s chi-square test was violated. A simple binary logistic regression model was used to estimate the crude odds ratios of the outcomes across all the independent variables at 95% confidence interval. A multiple binary logistic regression model was then used to estimate the adjusted odds ratios and their corresponding confidence interval. To select variables into the final adjusted regression model, all variables that had overall p-values of 0.200 and below were first fitted together in a single model. Afterwards, any variable with a p-value greater than 0.3000 was dropped. This step was carried out in an iterative process until the model no longer had a variable with a p-value above 0.300. This process allowed for a reduction of the number of variables in the model to avoid over-fitting and multicollinearity, as well as under-fitting. In the final model, all variables with p-values below 0.05 were considered statistically significant. The qualitative data were analyzed thematically. This involved a number of steps. The audio recordings were transcribed verbatim in the local languages, and translated into English. Back translations were done on selected transcripts to check the accuracy of the translations and to verify inconsistencies. All the transcripts and interview notes were read and reviewed thoroughly, and notes made on hard copies of the transcripts. A preliminary coding structure and code book was developed which led to the next phase. In the second phase, we exported all the transcripts into NVivo 12.x64 windows, where the data were both deductively and inductively coded. Data coding continued until theoretical saturation was reached (i.e., where no new concepts emerged from successive coding of the data). The completed code structure was then applied to develop and report themes with verbatim quotes.

This section presents the results of the study findings. It is divided into three parts, the first describes the socio-demographic background characteristics of the participants, the second describes the key themes around perceptions and management of small for gestational age and low birthweight newborns in the slums (covering summaries of both quantitative and qualitative findings) and lastly the factors associated with low birthweight in the slums.

Socio –demographic characteristics of respondents

Table 1 presents the socio-demographic characteristics.

Table 1: Socio –demographic characteristics of respondents.

Maternal characteristics of respondents

Table 2 also shows maternal characteristics of the survey respondents.

Table 2: Maternal Characteristics of Respondents.

Characteristics of Newborns

Of the 279 newborns (50.2%) were males. There were slightly more male neonates (52.3%) in Ashaiman compared to Sodom & Gomorrah (47.9%). Also, (63.4%) of the newborns were aged 7-28 days (late neonates). Nearly one third (30.5%) of the neonates weighed less than 2.5 kilograms. Again, (85.7%) of the newborns were vaccinated at birth. Of those neonates that were immunized, (86.4%) were vaccinated against BCG while (77.4%) were immunized against poliomyelitis.

Prevalence of Small for Gestational Age (SGA) and Low birth weight newborns

Generally, 2.5% of the babies were very large, 9.7% were larger than average, and 77.8% were of average weight. About 9% were smaller than average while 1.1% were very small. Thus 69.5% of the babies were classified as normal birthweight while 30% had low birth weight at birth. The median weight at birth for the newborns was lower for Sodom and Gomorrah at 2.9 (2.5,3.2) than Ashaiman 3.0 (2.6,3.2) (Table 3).

Table 3: Birthweight of newborns in Ashaiman and Sodom and Gomorrah.

Community Perceptions and Care for Low-Birth Weight Newborns

From the qualitative findings, community perceptions about small for gestational age and low birth weight babies were varied and mixed. While some believed the babies were cursed, others said their mothers were either promiscuous and attempted abortion or ate foods that were prohibited during pregnancy. As one traditional birth attendant posited in focus group discussions: They said if you eat ripe plantain, you can have a premature baby. Plantain causes waist pain and so eating ripe plantain while pregnant can cause contractions and you may give birth at 7 months and so is oranges and, even for oranges it is okay but for plantain, it is not good for you to eat more plantain when you are pregnant (51-year-old Traditional Birth Attendant, FGD, Sodom and Gomorrah).

A caregiver in Ashaiman said

Most people in the community tag such children as “nsuoba”, [ meaning spirit child] but I don’t think so. Sometimes it has to do with the kind of food you were eating when you were pregnant and not because the baby is “nsuoba” (35-year-old caregiver, FGD, Ashaiman). For some mothers in both Ashaiman and Sodom and Gomorrah, giving birth to preterm or low birthweight babies is not a spiritual phenomenon, but due to previous unsuccessful attempts at aborting an unwanted pregnancy or due to inadequate nutrition during pregnancy. A young mother in Ashaiman shared her insights thus: As for me, I don’t think that such children are “nsuoba”; I think it is due to an unsuccessful abortion attempt or due to the lack of proper food during pregnancy (22-year-old mother, FGD, Ashaiman).

This view was shared by a Community Leader in Sodom and Gomorrah

There are some women who attempt to terminate pregnancies when they are pregnant, but they are unable to. When you take medicine to abort a pregnancy and you are not successful, that can also deform the baby and make it small (49-year-old community leader, FGD, Sodom and Gomorrah). In the communities where this study was conducted, small for gestational age and low birthweight babies are sometimes perceived as spirit children and not human beings. During FGDs, some community members reported that for such babies they are usually taken to the mallams and left there, while others reported that the children are taken to prayer camps for pastors to exorcise the evil spirits in them. Mallams are reported to prepare some concoctions for the babies to drink, neutralizing the evil powers in them. It is believed that these babies must be treated with care otherwise they could trigger the death of their parents. As one caregiver in Ashaiman intimated: Like when you see that the child is not a human being you can take the child to a mallam and leave the child there; If you don’t want to leave the child there; they can perform rituals for you (31-year-old Caregiver, FGD, Ashaiman).

This assertion was supported by a Community Leader in Sodom and Gomorrah;

When someone gives birth to a low-birth-weight baby you look for a herbalist to make medicine for the child, so if it is not an evil eye that was cast on the baby; then the baby will be normal again (45-year-old community leader, FGD, Sodom and Gomorrah). Only a few women reported that they will send their low-birth-weight babies to the health facility for treatment. For most women, low birth weight is not a condition that can be treated in a health facility, besides they are always ashamed carrying such babies in public because of stigmatisation. This situation has implications for how small for gestational age and low birthweight newborns are perceived and treated in the slums. It is clear that this condition is perceived as “one not for hospital” and treatment will most likely be sought outside allopathic or biomedicine. Factors associated with birthweight and health care seeking during pregnancy In bivariate analysis, we found that all the 11-healthcare seeking behaviours during pregnancy were statistically associated with birthweight. (i.e., p<0.05) (Table 4).

Table 4: Bivariate analysis of healthcare seeking during pregnancy and low birthweight.

To further determine the strength and direction of each of these associations, we controlled for confounders in a multiple regression model and odds ratios were estimated (Table 5).

Table 5: Factors associated with low birthweight (Logistic regression model).

Due to multicollinearity between mother seeing a health professional for ANC, place ANC was received, gestational age at first ANC, and the number of ANC visits made, we added only the number of ANC visits made to the regression model. In the regression model, mothers with no ANC visits (COR: 9.82, 95% CI: 4.24-22.73, p<0.001) and those who had attained between 1-4 visits (COR: 5.61, 95% CI: 2.94 10.72, p<0.001) were significantly more likely to give birth to a low-birth-weight baby compared with those who made 4 or more ANC visits. When potential confounders were controlled for in a multiple logistic regression model, the number of ANC visits no longer significantly affected low birth weight. Similarly, the crude odds of a woman having a low-birth-weight baby were significantly higher among mothers who had no tetanus toxoid injections (COR: 9.94, 95% CI: 4.76-20.78, p<0.001) and among mothers who had only 1 tetanus toxoid injection (COR: 2.98, 95% CI: 1.44-6.17, p=0.003) compared to mothers who had 2 or more tetanus toxoid injections during pregnancy. The association between number of tetanus toxoid injections received by mothers prior to delivery and low birth weight was however no longer statistically significant after controlling for potential confounders. In the unadjusted binary logistic regression model, the crude odds of low birth weight were significantly higher among mothers who did not receive any SP/Fansidar during pregnancy (COR: 4.98, 95% CI: 2.72-9.11, p<0.001) compared to mothers who received 3 or more SP/ Fansidar during pregnancy. After controlling for potential confounders, the number of SP/Fansidar received during pregnancy became insignificant relative to the occurrence of low-birth weight. Again, mothers who did not receive iron folate tablets during pregnancy (COR: 5.88, 95% CI: 3.37-10.25, p<0.001) had a higher odds of low birthweight compared to those who received iron folate tablets supplementation during pregnancy. Compared to mothers who received iron folate tablets during pregnancy, the adjusted odds of low birthweight among mothers who did not take iron folate tablets was 2 times higher (AOR: 2.39, 95% CI: 1.01-5.63, p<0.05) compared to those who received iron folate tablets during pregnancy. Similarly, the crude odds of low birthweight among mothers who did not receive counselling on pregnancy and newborn danger signs during pregnancy were 2.9 times higher (COR: 2.87, 95% CI: 1.64-5.03, p<0.001) than those who received counselling on newborn danger signs.

Finally, the results show that newborn mothers who received counselling on birth preparedness and facility delivery were less likely than those who never benefitted from counselling on birth preparedness and facility delivery to give birth to babies of low-birth-weight (COR: 3.18, 95% CI: 1.81-5.60, p<0.001). However, in the adjusted binary logistic regression model, receipt of iron folate tablets, receiving counselling on pregnancy and new-born danger signs and receipt of counselling on birth preparedness and facility delivery were all no longer significantly associated with low-birth weight after controlling for potential confounders.

The study found a high prevalence of low birth weight in the slums (about one third of the newborns roughly 30.5%) had birthweights less than 2.5 kilograms. Interestingly, none of these newborns received prolonged skin to skin or kangaroo mother care. The WHO recommends prolonged skin -to-skin care for mother and baby soon after birth especially small for gestational age and low birthweight babies [33]. The high prevalence of low birthweight in the study sites reflect the level of maternal nutrition, micronutrient and iron deficiency and inadequate counselling for pregnant women and postpartum mothers in the slums. We also found that mothers of newborns with no ANC visits were more likely than those who had completed 4 or more ANC visits prior to giving birth to their index child to give birth to babies with low birthweight. This finding suggests that mothers who had greater contacts with health professionals may have received adequate health information, advice and counselling on appropriate behaviours’ that may likely equip the mothers with behaviours and skills about giving birth to babies of low birth weight, acknowledging that adequate health service contacts especially ANC visits offer opportunities for health promotion messages and counselling on adequate nutrition during pregnancy, birth preparedness and the need to at least complete 4 or more ANC visits prior to giving birth. In a binary logistic regression, we found that mothers with no ANC visits (COR: 9.82, 95% CI: 4.24-22.73, p<0.001) were 4 times significantly more likely than those who had attained between 1-4 ANC visits (COR: 5.61, 95% CI: 2.94 10.72, p<0.001) to give birth to babies with low birthweight compared with mothers who had made 4 or more visits. This persisted after controlling for potential confounders in a multiple logistic regression model. These findings are similar to those reported in previous studies in Ghana and sub-Saharan Africa. In a review of ANC attendance and LBW of institutional births in sub–Saharan Africa, Weyori and colleagues found a statistically significantly association between ANC and LBW in sub -Saharan Africa with women who had more than eight or more ANC visits being at a lower risk of giving birth to children with low birth weight [34]. The findings are also similar to a study in the Wa East District of the Upper West region of Ghana where a prevalence of 24.5% LBW was reported [35]. These findings have implications for nutrition counselling for expectant mothers and ANC visitation. Perceptions of the phenomenon of small for gestational age and low birthweight babies are varied and diverse. While others perceive women who give birth to low birthweight babies as cursed, promiscuous or had attempted an unsuccessful abortion, others believe the mothers had eaten prohibited foods such as plantain and oranges while pregnant or the babies were spirit children (nsuoba). It is recommended that the Ghana Health Service and Health Non-Governmental organisations should collaborate to strengthen delivery of ANC services in urban slums to include universal access to micronutrient and iron folate supplementation to improve maternal health of urban slum women and promote achievement of the target of at least eight contact visits for ANC by all pregnant women. Interventions must include the promotion and consumption of diverse locally available micronutrient and iron rich foods during pregnancy, strengthen nutrition counselling skills of service providers and encourage peer to peer counselling among pregnant women to improve nutritional and neonatal health outcomes especially small for gestational age and low birth weight. The findings of this study should however be interpreted with certain limitations in mind. First, only two of Ghana’s urban slums were covered in this study. The findings may therefore not be generalisable to the rest of the country, nor to other countries with different contexts. Second, the study collected first-hand information from the respondents; however given the potential for recall bias, much depended on the respondents ability to recall services received and provided in their most recent birth. Additionally, there may be limitations resulting from social desirability bias, as some respondents may have provided responses in order to look good in the eyes of the researcher and to be perceived to be doing what they perceive to be right for their babies regardless of the reality. Third, the cross-sectional design of the study means that causality cannot be determined in this study. Finally, translation errors and errors resulting from interpretation of concepts in the qualitative data could likely affect the study findings. However, we believe these errors, if at all, have been kept to the minimum given the data quality measures we implemented including rigorous training of research assistants and back-to-back translation of some transcripts. Taken together, the results in this study shed light on important areas of small for gestational age and low birthweight care practices needing urgent attention in Ghana’s urban slums.

Overall, prevalence of low birth weight (30.5%) was generally high. The perception of small babies and low birthweight newborns as spirit children (nsuoba) and the stigma associated with managing such children has implications for caring for and treating the condition. It is likely such children may not get the needed care as caregivers may turn to mallams and herbalist for treatment because of the belief that the children’s condition is spiritual Factors that were positively associated with low birthweight were age of the mother, educational attainment, marital status, use of ANC services. Therefore, to address the challenge of small for gestational age and low birth weight in Ghana’s urban slums requires strengthening ANC services and improved counselling of pregnant mothers. Specifically, we recommended that routine counselling on early and complete attendance at ANC at least meeting the recommended eight contacts with health professionals prior to delivery should be intensified during prenatal clinics focusing on primigravida mothers. Additionally, counselling on birth preparedness, skilled delivery and iron folate supplementation during pregnancy should be intensified. Finally, we recommend the Ghana Health Service should work with civil society and the private sector, and faith-based leaders to launch a vigorous social and behaviour change communication campaign on care for the small/sick neonate and devise messages to dispel the myths and misconceptions surrounding small for gestational age and low birth weight newborns.

Ethics approval and consent to participate

Ethical clearance was obtained from the Ghana Health Service Ethics Review Committee registration number GHS –ERC: 024/05/19). The study was conducted in accordance with the terms of the Helsinki Declaration. All study participants either thumb printed or signed informed consent forms before participating in the study. All interviews were conducted in private rooms, while focus group discussions were held in open spaces in either churches or classrooms. All participants were assured of confidentially. They were informed that participation was voluntary and they could refuse to answer any sensitive question/s or withdraw from the study at any point without any consequences. All ethical protocols regarding the handling of newborn babies such as taking their weights and temperature was adhered to in accordance with guidelines on research with human subjects.

Consent for publication

All participants gave consent for the study’s findings to be published. All authors also consented to the publication of this manuscript.

Availability of data and material

The dataset (s) supporting the conclusions of this article are available from the lead author upon request.

Competing interests

The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article

Funding

The authors received no specific funding for this work.

Authors’ Contribution

EAA designed the study, developed data collection tools, collected data, analysed, and prepared the draft manuscript. JKG provided scientific advice on the design, data collection, and analysis. All authors read and approved the final manuscript.

The authors acknowledge the staff of the Ghana Health Service, Dr. Isabella-Sagoe Moses, National Coordinator of Newborn Care at the Family Health Division, Dr. George Amofah, Former Deputy Director General, Dr. Linda Vanotto and Dr (Mrs) Charity Sarpong, Former Regional Directors of Health Services, Greater Accra, Dr. Patrick Amo-Mensah, Medical Director for Usher Polyclinic and Head, Ashiedu-Keteke Sub -Metropolitan Area, Mrs., Patience Ami Mamata, Municipal Director of Health Services, Ashaiman Municipality, the staff, midwives, nurses, Community Health Officers, the mother infant pairs in both slums, the community leaders, caregivers and slum based traditional birth attendants who volunteered information and made the study possible. We are also grateful to Williams Kwarah, Emmanuel Ofori Yartey, Peter Ntim Ofori, Noah Cudjoe, and Anthony Pharin for leading the data collection. Finally we thank Yakubu Alhassan for cleaning the quantitative data.

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