Congenital anomalies, or birth defects, are structural or functional abnormalities present at birth that can lead to significant health challenges, including early abortions, stillbirths, disabilities, and increased infant mortality (1). Globally, congenital disorders account for approximately 240,000 newborn deaths annually, with the majority occurring in low- and middle-income countries (2–4). In Ethiopia, the absence of a standard registry and the prevalence of unsupervised deliveries hinder the understanding and management of congenital anomalies (5, 6).

Early detection through comprehensive newborn physical examinations is essential for improving developmental outcomes and guiding timely medical interventions (4). However, standardized examination protocols and routine screening are not widely practiced in Ethiopia, resulting in many anomalies remaining undiagnosed (5, 6). This study addresses a critical gap by exploring real-world newborn examination practices and congenital anomaly detection in major Ethiopian public hospitals, aiming to inform policy and improve early detection and management.

Research questions: (a) What are current newborn examination practices in large public hospitals in Addis Ababa? (b) What barriers and facilitators influence adoption of checklist-based examinations? (c) How are documentation and communication with parents managed?

Twelve participants (pediatricians, obstetrician-gynecologists, and midwives) from four public hospitals in Addis Ababa contributed perspectives on examination practices, training, documentation, and institutional readiness. Hospitals reported between 400 and 1,100 deliveries per month (typically around 500). Results are organized into five thematic findings with illustrative quotations.

This study highlights significant gaps in neonatal examination practices, training, and documentation in major Ethiopian public hospitals. The lack of standardized protocols and routine use of structured checklists compromises the quality and consistency of neonatal care, leading to missed diagnoses and delayed interventions.

The study institutions, being the largest delivery and teaching centers in the city, play a pivotal role in shaping neonatal care standards. The absence of a unified examination protocol in these settings compromises the safety, quality, and continuity of neonatal care.

International literature supports the importance of standardized newborn examinations conducted by trained professionals, with checklists serving as valuable tools for comprehensive assessment.

The newborn physical examination is a comprehensive assessment and a cornerstone of the Universal Child Health Promotion Program (8). Its timing should correspond with the physiological adaptations that neonates undergo as they transition to extra uterine life. This examination supplements the initial general assessment typically performed by the midwife or neonatal team immediately after birth to confirm the absence of obvious abnormalities (9).

Our study reveals significant inconsistencies in the implementation of standardized protocols for newborn physical examinations. While some institutions are in the process of developing checklists to guide newborn examinations, others continue to rely on unstructured general assessments. Such variability raises concern about the adequacy of care; as critical assessments may be overlooked. This finding indicate that without standardized protocols, the quality of neonatal care is at risk, potentially resulting in missed diagnoses of congenital anomalies and other health issues.

In contrast, countries like the United Kingdom have implemented standardized newborn and infant physical examinations nationwide, though operational details may vary by region (10). Davis and Elliman (10) recommend that newborn examinations be conducted by suitably trained and competent healthcare professionals with ongoing clinical experience. This standard is not consistently met in our study institutions, as echoed by nearly all participants. Regardless of a provider's background or qualifications, the quality and content of the examination should remain consistent across all facilities. Tappero and Honeyfield (11) further highlight that inadequate knowledge and skills among healthcare providers can lead to missed minor and subtle congenital anomalies a concern echoed by our participants, who noted that such anomalies are often overlooked due to insufficient training and the absence of structured, checklist-based examinations.

Our findings also highlight concerns regarding the training and competency of healthcare providers involved in newborn examinations. Many participants noted that non-physician staff, such as midwives and neonatal nurses, often lack the necessary training to conduct thorough assessments. Most professionals working with neonates have not received targeted training in anomaly detection, resulting in inconsistencies in care and a higher likelihood of missed diagnoses. This underscores the need for regular training programs to address gaps in knowledge and practical skills. Continuous education is essential for improving detection rates of subtle anomalies that might otherwise go unnoticed. Similar findings have been reported elsewhere; for example, Kaur et al. (12) emphasized the importance of on-the-job training and accessible clinical guidelines for nurses in neonatal care. Additionally, evidence suggests that providers' skills improve with adequate training, performing a minimum number of examinations annually, and attending relevant forums (9, 13).

The use of structured checklists for infant physical examinations varied significantly across the study sites. Most participants reported reliance on gross examinations without structured approaches, which may compromise thoroughness and accuracy. Standardizing checklist use across facilities could improve clinical practice by ensuring consistent and comprehensive evaluations, ultimately enhancing detection rates for congenital anomalies. This is supported by the Queensland Clinical Guidelines (14), which emphasize the importance of checklists in newborn examinations for systematically assessing body systems and detecting conditions such as heart defects and hip dysplasia. The value of such checklists as screening tools is further supported by Rogers et al. and Poojari et al. (15, 16).

Regarding congenital anomaly detection, while major anomalies such as hydrocephalus are often identified prenatally via advanced ultrasound, subtle conditions frequently go undetected until after birth. This inconsistency can delay interventions and worsen outcomes. Our findings align with literature indicating that operator dependency and limitations in ultrasound technology contribute to low detection rates for subtle anomalies during prenatal screening. Van Nisselrooij et al. (17) noted that perinatal diagnoses may be missed due to impaired clinical skills and lack of experience. Poojari et al. (15) recommend the development and implementation of standard protocols for prenatal screening across all obstetric care facilities, while Rogers et al. (16) reaffirm the value of structured checklists for newborn anomaly detection.

Participants in our study reported commonly identified anomalies such as neural tube defects, hydrocephalus, Chiari II anomalies, and cleft lip and palate. Major anomalies like spina bifida and hydrocephalus are typically detected prenatally, consistent with findings from Jimma Medical Center, which also reported myelomeningocele, hydrocephalus and anorectal anomalies as prevalent anomalies (18).

Documentation of newborn physical examinations and congenital abnormalities is primarily electronic, though some hospitals still use paper records. However, the lack of a standardized and structured documentation approach leads to inconsistencies and incomplete records. Even though this study did not quantify documentation completeness, our findings confirm that most public hospitals' records are inconsistent, a result echoed by studies in Benin-city and elsewhere, which found poor documentation of external genital examinations and identified incomplete records as a persistent challenge in neonatal care (15, 19).

Finally, participants described challenges in communicating congenital anomaly findings to parents, including parental shock, misunderstanding, and denial. This finding is supported by the qualitative study finding done in Jordan and Saudi Arabia which stated that mothers experienced shock when they heard about their child congenital anomalies for the first time (20). Participants noted that breakdowns in communication may further delay treatment initiation and worsen parental anxiety, highlighting the need for improved counseling frameworks and sensitivity training in neonatal care settings (21, 22). These challenges further highlight the need for standardized protocols, comprehensive training, and effective communication strategies to improve neonatal outcomes.

The study's qualitative design and focus on urban public hospitals may limit the generalizability of findings to other settings, including rural or private institutions. Social desirability bias and reliance on self-reported practices without direct observation or record audits may have influenced findings. Nevertheless, triangulation of roles and sites and member checking strengthened credibility.

This study demonstrates that newborn physical examination practices at the assessed public health facilities in Addis Ababa are inconsistent and lack standardization. There is no established protocol specifying which health professionals should conduct newborn examinations, nor are there defined competency or training requirements. Documentation of examination findings is not routinely performed unless abnormalities are detected, and a comprehensive, checklist-based head-to-toe assessment prior to discharge is absent. Additionally, essential materials such as spatulas and torches for oral examinations are often unavailable in postnatal wards.

Major congenital anomalies, such as spina-bifida and hydrocephalus, are typically identified through prenatal ultrasound; however, subtle conditions frequently go undetected during both prenatal and postnatal assessments. Given that these institutions are the largest delivery and teaching hospitals in Addis Ababa, it is likely that these findings reflect practices in other public health facilities in Ethiopia.

We recommend the development and implementation of a standardized national neonatal examination checklist to guide comprehensive newborn assessments; establish mandatory protocols specifying the roles, competencies, and training requirements for healthcare providers conducting newborn examinations; initiate comprehensive training programs for healthcare providers to enhance skills in conducting thorough newborn examination with a particular focus on early detection of congenital anomalies; and, support and conduct community-based studies on the incidence of birth defects to inform data-driven interventions and policy development.