​Results: The temperatures of the water used in the baths of the baby doll.

Twenty-seven women were involved: 11 women from urban areas and 16 women from rural areas. They were from different tribes and regions in Ghana. None of them had secondary school level of education. In terms of educational background, this sample can represent most of the population in Ghana since, even for pupils who finished secondary school education, 62% of them fail to reach the 50% score in the three core subjects of English, math, and integrated Science [27]. The women who cannot finish senior secondary school learn trades such as seam-stressing or goods-trading.

We asked women who had had a lot of experience in bathing babies to demonstrate it on a life-size baby doll. Most of the women felt relaxed saying, “If it is on a doll, so there is not a problem.” Nevertheless, some women refused to demonstrate the massage for fear of disclosure to the local maternity clinic.

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Description of the massage on the head of the doll.

During the bath, the woman poured hot water in a bucket, and after dipping a towel in it, and squeezing it she put it on the head of the doll for a few seconds (in most cases it was between 5 and 10 seconds). She repeated this process for several minutes. The length of time taken to massage the head of the doll was different for each woman and varied from 4 to 20 minutes. The average of the length of time was 10.3 minutes (stdev=3.8). In some baths, the hot water in the bucket was topped up with fresh hot water every 5 or 10 minutes. In the process of massaging the head of the doll some heat was lost between the water in the bucket and the soaked towel on the head of the doll. Although the woman determines, and so can change, the temperature of the water in the bucket, it is the temperature of the soaked towel on the head of a baby that directly affects the head in a real bath. Hence both measurements were taken with a laboratory thermometer at intervals of one minute. For each bath or woman, the average temperature of water in the bucket (Table 1) and between the towel and the head of the doll were calculated (Table 2), and they were compared to find the lost of heat (Figure 1). Table 1 represents the average temperatures of water in the bucket recorded from 27 baths or women in order according to the range of temperatures of hot water for bath determined by the American Academy of Paediatrics [170]. Table 2 represents the average temperatures between the towel and the head of the doll recorded from 27 baths or women in order according to the range of temperatures that cause damage to tissues in condition of hyperthermia [9, 10, 11].

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Table 1: The average temperatures of water in the buckets.

 

 

 

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Only one woman out of the 27 women used water whose average temperature was 37.2 degrees Celsius, which is the temperature of lukewarm water (highlighted in green) and it is the desirable temperature for bathing a baby [131]. The average temperature of each of the baths done by nine women was in the range from 42.0 to 47.9 degrees Celsius. This range was not higher than the temperature recommended by the American Academy of Paediatrics, that is, hot water should not be hotter than 49 degrees Celsius (highlighted in yellow) [170]. However, bathing in water with a temperature of 49°C can cause second and third degree burns in adults after a few minutes of bathing [171]. Babies have more sensitive skins and therefore would be more vulnerable to burns and physiological damage at such a temperature. This is why the recommendation is that hot water should not be used alone, but it should be mixed with cold water resulting in a reduced temperature closer to the ideal temperature of 39°C for an adult bath [9]. The average temperature of each of the baths done by majority of the women was in the range of 50.1 to 65.3 degrees Celsius. These temperatures can cause skin burns to adults that have thicker skin than babies [171]  (highlighted in red). Such condition would be far more dangerous to babies. 

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Table 2: The average temperatures between the towel and the head of the doll.

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In only 3 baths the head of the doll was exposed to a temperature which does not cause any physiological changes in the head (highlighted in green). The threshold temperature value of damaging cells is 38.5 degrees Celsius [11]. In 24 baths (89% of the baths, pink and red highlighted) a real baby would have suffered brain damage [9]. In the 8 baths highlighted in pink, the head of the doll was exposed to temperatures that are widely accepted as starting to cause damage. In the 16 baths highlighted in red, the head of the doll was exposed to temperatures that cause irreversible or permanent brain damage [10]. The higher the temperatures used, the more severe the physiological changes would be in the brain.

The temperature of water used in the bucket varied greatly between the women. We wanted to see how this affects the temperature measured between the head and the towel. This was important because the only indicator the women used to determine the desirable heat of the water is by the touch of their hand.

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​Figures 1: Comparison between the temperature of water in the bucket, and the temperature between the towel and the head of the doll.

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Figure 1 shows how much the temperature dropped from the time the towel was dipped in the water to the time it was placed on the head of the doll.

The temperature of the water in the bucket which is represented by the total height of the column (blue + orange) ranged from 39.2 (column number 27) to 65.3 degrees Celsius (column number 1). Even though the temperature of the water in the bucket varied greatly (a range of 26.1°C), the temperature between a towel and the head of the doll (blue) did not vary as much. It ranged from 35.8 (column number 27) to 47 degrees Celsius (column 16), which is a range of 11.2°C. As the temperature of the water in the bucket is lower (toward the right side of the graph), the difference between the temperature of the water in the bucket and the temperature between the towel and the head of the doll smaller (orange). Pearson correlation coefficient between the temperature of the water in the bucket and the lost of heat until the towel was placed on the head of the doll was rxy=0.92, which means that there was a positive correlation. As the temperature of the water in the bucket dropped, so the lost of the heat was smaller.

There could be two reasons for that:

1. The women measure the level of the heat of the water and towel by the touch of their hands. Through years of experience, the community of the women reached some consensus of what heat is required to the massage of the head of a baby. Even if a woman uses very hot water in the bucket, she shakes the towel to cool it to the desired heat. However, in a few baths such as bath 16, the woman did not shake and cooled the towel long enough, resulting in a higher temperature of the towel applied to the head of the doll than was expected. 

2. Hot water loses heat faster than cool water. If we have two buckets with the same quantity of water, and the temperature in bucket A is 60 degrees Celsius and in bucket B is 40 degrees Celsius, the temperature in bucket A will drop faster than in bucket B. This phenomenon is called the Mpemba effect [135].

The physical effect (the Mpemba effect) is important for the campaign against the use of the hot water on the head of a baby. Many times, the instruction from the hospital is ‘Do not use very hot water’. The women then lower the temperature of the water. However, as the temperature of the water is low, the rate of losing its heat is also low. It means that the women should only use lukewarm water. A temperature of lukewarm water is 37 degrees Celsius and the heat that starts to cause changes in the brain is 38.5 degrees Celsius and above [13, 41]. The difference between 38.5 and 37 degrees Celsius is only 1.5 degrees Celsius. This difference is difficult to detect and manage. The feeling of temperature of water by hand is not sufficient and therefore, not recommended.

In the discussion about the reasons the women massage the head of a baby with hot water on "Why the practice is done"    page, and in the discussion about the traditional knowledge of the herbalist on "The traditional  knowledge of the herbalist" page, it can be seen that according to the view held by the women and the herbalist, the massage of the head has to be done with hot water because it helps in closing the fontanelles (soft spots) and the sutures (cracks) that are seen as wounds in the head. The massage and the heat have each different effect. The massage puts pressure on the cranial bones that may shift one bone toward the other. This is unnecessarily action and there is no need to mold the shape of the head as it will be molded naturally with time. The heat can cause brain damage. In all, it is useless to instruct the women to massage the head of a baby with lukewarm water. The main target of instruction to the women should rather be: Do not massage the head of a baby at all, but rather use room temperature water to wash it lightly without applying any pressure on the head.