neonatal sepsis and related system challenges in health facilities of Gushegu and Nkwanta South districts

statistics, logistic regression and thematic coding which revealed systemic delays and care deficiencies.

monthly income. In Gushegu, only 43% had formal education, and used travel times longer than two

hours. The facilities had no CRP and blood culture testing. In Gushegu, recovery rates were 52% and

64% in Nkwanta South; mortality rates were 20% and 14%, respectively. Late presentation (>48 hours)

tripled adverse outcomes (OR = 2.8); delayed antibiotics (>6 hours) quadrupled mortality risk (OR =

3.9); delayed referrals (>12 hours) doubled it (OR = 2.1). Only 31% of health workers had recent

training.

neontates with sepsis. Tiered multi-faceted interventions—community education, standardisation of

middle-income countries experience a disproportionate burden of these neonatal deaths (UNICEF, 2023). In

Ghana, it is one of the leading causes of newborn deaths. It is a crisis that is even more serious in the rural

parts of the country, such as Northern Ghana, where there are limited healthcare centers, putting further

burdens on the prevention and treatment of infections (Ghana Health Service, 2022). While nationwide, there

have been considerable progress, there remain deficiencies in the assessment, referral and clinical management

of newborns.

As these routine diagnostic instruments — including blood cultures and C-reactive protein (CRP) tests — are

scarce, health workers in many rural communities generally make do with clinical judgment alone. The

shortcomings in these resources can result in delayed treatment and misdiagnosis, which is particularly

harmful to newborns. These barriers — from poorly trained birth attendants, to poor infection control, lack of

focused interventions and inform public health policy recommendations to improve neonatal care. By

filling systemic and clinical gaps, this research serves the wider goal of eliminating preventable neonatal

mortality by 2030 in Ghana, which responds to national and global health priorities. Neonatal sepsis

continues its status as the leading cause of preventable neonatal deaths in Ghana, accounting for up to

59% of neonatal admissions in tertiary healthcare institutions (Craymah et al., 2024).

Neonatal sepsis also remains a major cause of preventable neonatal death in Ghana, largely due to lack of

diagnostic capacity and proper facilities in some rural districts. In these rural districts, the prevalence of sepsis

equipment (Konlan et al., 2024). Conversely, urban areas are reporting fewer admissions for hospitalizations

those at Ho Teaching Hospital have associated early neonatal deaths with a delay in diagnosis and inefficient

referral systems (Afeke et al., 2021). Systemic barriers in the Northern and Oti Regions—such as poor

documentation, inadequate referral coordination, and the lack of standardized protocols—also inhibit clinical

progress in these areas (Konlan et al., 2024; GHS, 2023). At the district level, due to the problem of lacking

capacity to confirm sepsis diagnoses, many local clinics have turned to empirical treatments, which also

generate evidence to improve care, reduce mortality, and inform policy reforms that strengthen health systems

This research is based on two related theoretical models which help to explain the systemic and clinical

issues in neonatal sepsis of rural Ghana. The first is the Health Systems Framework formulated by the

World Health Organization (WHO, 2007) that encompasses six basic elements for a working health

system: service delivery, health workforce, health information systems, access to essential medicines,

financing and leadership/governance. These factors present a systematic perspective on systemic

disruptions, especially those of infrastructure and human resources, elements that are essential for

neonatal survival. The second model is the Three Delays Model by Thaddeus and Maine (1994) that

assigns delays to a mother and baby, in a patient’s treatment, according to three stages—delays in

recognizing illness, delays in reaching appropriate care, and delays in receiving adequate treatment. Such

delays are often magnified by low caregiver readiness, lack of transport, and inadequately equipped

health facilities. By linking them together, the study highlights how systemic weaknesses, such as service

delivery and workforce shortages, access to medicines, and governance challenges, are causative of

systemic delays are experienced at the point of contact when making clinical decisions as well as

diagnosing patients in the north of Ghana.

The conceptual framework we have generated in this study relates systemic health system challenges to

clinical outcomes in neonatal sepsis. At the core of this framework is the function of diagnostic capacity,

the presence and use of laboratory testing (including blood cultures) and C-reactive protein (CRP)

analyses. The lack of laboratory infrastructure in rural Ghana frequently necessitates the use of clinical

guidelines by healthcare providers, which are applied inconsistently owing to differences in training,

experience and resource availability. These constraints direct provider behaviours that lead to differences

in disease recognition and treatment implementation. As a result, delays in diagnosis and treatment are

not simply pragmatic but entrenched in more systemic impediments. With that being said, the framework

does highlight the importance of timely, standardized, and well-supported clinical interventions to

improve neonatal outcomes. A significant research gap is the absence of data on how diagnostic

limitations impact clinical decision-making and outcomes. We have limited knowledge of how clinical

There is strong empirical and clinical evidence that show a critical need to address the burden of neonatal

sepsis that currently remains a leading cause of neonatal deaths in Ghana and sub-Saharan Africa.

Worldwide, about 30% of neonatal mortality occurs from sepsis according to UNICEF (2023), illustrating

its serious impact on child survival. For example, neonatal sepsis has been identified by the Ghana Health

Service (GHS, 2022) as one of the most significant contributors to neonatal mortality, especially in rural

found high case fatality rates, particularly among neonates born outside health facilities or treated late for

care. It highlighted the impact of late diagnosis, poor laboratory support, and inconsistent clinical

protocols on these findings. Enyew et al. (2025) reinforced the systemic issues of weak referral systems,

poor infection control, and insufficient staff training as significant contributors to poor neonatal

outcomes. These results are consistent with international regional observations indicating infrastructure

inadequacies, supply chain disruptions and governance failures as the ongoing barriers to improved

neonatal care (Camara et al., 2024; Wudu et al., 2025). For instance, Camara et al. (2024) highlighted

inadequate collaboration on infection control policies in rural clinics, and Wudu et al. (2025) noted that

frequent stockouts of critical antibiotics and diagnostic reagents are paramount in obstructing patients’

access to appropriate treatment in a timely manner. However, much less is known about the way

aim is to offer insights into health system enhancements and policy-relevant ideas that may improve

neonatal sepsis care in emerging geographies.

This study was conducted in rural health facilities in Gushegu (Northern Region) and Nkwanta South (Oti

Region), known high neonatal mortality settings due to insufficient diagnostics and delayed care (GHS, 2023).

The facility selection was based on geography, level of service delivery and neonatal cases. Gushegu and

Nkwanta South were also situated with a projected population of approximately 154,456 and 135,735 (GSS

2021). This registered some 5,390 live births a year in Gushegu and 4,725 live births in Nkwanta South; there

was a crude birth rate 35/1,000. (Crude Birth Rate (Per 1,000 People) falls 2.02% to 25.4 births in Ghana in

2024, 2024)

kits. For diagnostic capacity and outcomes, a mixed-methods approach was used (Creswell & Plano Clark,

2021). Collecting and analyzing statistical features and interview data were conducted over a period of 9

months to obtain contextual knowledge (Creswell & Hirose, 2023). The participants comprised health

facilities, frontline health workers, caregivers and newborn records.

Stratified sampling was utilized to guarantee rigorous methodological rigour and transparency. Stratified

sampling was the best response to assess the diversity in facilities, as the sample was recruited using

geographic location, service (service level and neonatal case volume) as its criterion, and further credibility

was also promoted with the implementation of the findings. According to these criteria, ten selected facilities

and centers were set forth to be included. Power calculations and access were factored in, accounting for 322

neonatal records. Additionally, 20-25 health workers and 15-20 caregivers completed interviews, which were

at saturation, to reflect a range of experiences and insight (Bouncken, Czakon, & Schmitt, 2025). Data

collectors were trained for two days on purpose, ethical approach of the study performed and data collection

study, as well as stratified sampling across facility types and location, increasing the ability to generalize

findings to other similar rural settings (Bengtsson, 2022; Creswell & Hirose, 2023). For qualitative data,

double-encoding was used to mitigate bias as two researchers coded transcription with one another

independently and talked about and resolved any differences. In order to enhance the credibility of interviews,

Quantitative analysis used SPSS (version 29) and STATA (version 18) and detailed a descriptive statistics,

cross-tabulation, and multivariate logistic regression approach to examine whether there was a causal

association between diagnostic delay, timing of treatment, and neonatal outcome. These results were visually

presented in tables and graphs able to show trends in admissions and rates of mortality, as well as referral

timelines by district. Qualitative data were collected using semi-structured interviews, which were complete

a general financial insecurity. Travel time to health facilities was also much longer in Gushegu at an

average of 2.1 hours, as opposed with 1.6 hours in Nkwanta South.