Ani‑Amponsah et al. International Journal for
International Journal for Equity in Health           (2023) 22:37  
https://doi.org/10.1186/s12939‑023‑01852‑3 Equity in Health
REVIEW Open Access
Hot fomentation of newborn fontanelles 
as an indigenous practice in Ghana: implications 
for policy and integrated community‑based 
health care in Covid‑19 pandemic and beyond
Mary Ani‑Amponsah1, Solina Richter2, Mariam Al‑Hassan Adam3, Evans Appiah Osei4*, Mahama Mustapha5 and 
Ezekiel Oti‑Boadi6 
Abstract 
Objective African newborns undergo numerous traditional and religious practices ranging from fontanelle fomenta‑
tion to total head shaving, scalp molding, skin scarification and ano‑genital irrigation which can negatively impact the 
health of neonates. Hot fomentation of fontanelles has been a predominant indigenous home‑based postnatal prac‑
tice in Ghana and among Africans in the diaspora. Mobility restrictions during the Covid‑19 pandemic has impacted 
direct access to facility‑based care as well as home care. The flourishing of newborn traditional practices among Afri‑
can populations during this Covid‑19 pandemic offers opportunities to rethink the provision of family healthcare sup‑
port for newborns during the ongoing pandemic and beyond. Hence, the aim of this critical review was to examine 
and describe a common indigenous practice—hot fontanelle fomentation to inform home birth support, discharge 
planning, and the delivery of optimal home‑based care support.
Study design This study is a review of literature on hot fomentation of newborn fontanelles.
Methods Literature search in CINAHL, PubMed, African Index Medicus and Scopus, was conducted and evidence 
synthesised from articles ranging from 1983–2022. Sixty articles were reviewed; however, 10 manuscripts were 
excluded prior to screening. The other 19 were exempted because they were either below 1983 or were not the best 
fit for the study purpose. In all, 31 studies were included in the study. The study was guided by Madeleine Leininger’s 
Culture Care Diversity and Universality care theory.
Results The current study identifies hot fomentation of newborn fontanelles practices in Ghana, the description of 
hot fomentation practices and the dangers associated with it. The findings and suggested ways to help overcome this 
challenge.
Conclusion There are several neonatal indigenous practices including fontanelle fomentation which pose threat to 
the health of the neonate as discussed in this study. Future research needs to investigate innovative ways of fonta‑
nelle fomentation where necessary instead of the use of hot water by mothers, especially in this Covid‑19 pandemic 
where health and mobility restrictions impact physical access to timely health care. This research will help educate 
*Correspondence:
Evans Appiah Osei
oseiappiahevans@ymail.com
Full list of author information is available at the end of the article
© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which 
permits use, sharing, adaptation, 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 changes were made. The images or 
other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line 
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory 
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Ani‑Amponsah et al. International Journal for Equity in Health           (2023) 22:37 Page 2 of 7
mothers about the dangers of fontanel fomentation and reduce the practice, especially in rural areas of developing 
countries. This could help reduce neonatal mortality and unnecessary healthcare costs.
Keywords Newborn, Hot fontanelle fomentation, Indigenous practice, Ghana, Covid‑19
Introduction it usually resolves after three to four days of birth. In 
Since December 2019, the COVID-19 pandemic, caused clinical assessment, the NAF is palpated as part of all 
by the novel coronavirus, has had a significant global newborn and infant physical examinations (NIPE); its 
impact, affecting countries such as China, Italy, Spain, measurement needs to be performed as an average of 
the United States, and the United Kingdom [1, 2]. The the anterior–posterior and the transverse measure-
pandemic has posed challenges to health systems and ments [12].
emergency response systems worldwide in managing the There are six sensitive membranous anatomical 
disease’s morbidity and mortality [1]. In Africa, COVID- structures that require delicate care during delivery and 
19-related restrictions on mobility have adversely affected after birth, with the NAF being the most prominent. 
the health and access to healthcare, especially for vulner- These structures consist of one anterior, one posterior, 
able populations [2, 3]. The Covid-19 restrictions have two sphenoid, and two mastoids [10]. After birth, the 
significantly impacted maternal and newborn healthcare six fontanelles play a crucial role in aiding the brain’s 
delivery with subsequent effects on newborn care post- expansion. The triangular-shaped posterior fonta-
delivery [4]. Traditional health practices for newborn nelle, located at the junction of the occipital and two 
care, such as head molding, nasal administration of local parietal bones, helps in the careful maneuvering of the 
medicines, ano-genital irrigation, and hot fomentation newborn during delivery by providing support to the 
of fontanelles, are commonly provided by families [5]. soft sutures, allowing for accommodation of passage 
The dissemination of indigenous newborn care practices through the birth canal [12]. The anterior fontanelle of 
is primarily done through practical demonstrations and the newborn is the largest of the six fontanelles which 
oration by traditional knowledge holders and observers. support delivery, brain expansion and development, 
However, despite being widely practiced, there is a lack of and thermoregulation, but it receives the most pressure 
literature on traditional practices, including among Afri- of heat during the hot fomentation [13].
cans in the diaspora. This critical review will examine the In Africa, including Egypt, traditional art forms 
high-risk indigenous practice of fontanelle fomentation such as carvings, craftworks, and verbal artistry have 
on newborns in Ghana. a strong presence and are more prevalent than popu-
lar writing traditions, especially concerning commu-
nity practices and the communication of our African 
Description of the newborn fontanelle identity [14–16]. Upon the birth of a newborn, the 
The newborn anterior fontanelle (NAF), also known paternal family expresses gratitude to the mother for 
as the bregmatic fontanelle, or frontal fontanelle is a bringing pride and honor to the family. The presence 
diamond or rhomboid-shaped structural membranous of the newborn reinforces marital and family bonds. 
space, measuring about 4  cm in its antero-posterior Traditionally, the primary responsibility of caring for 
dimension and 2.5 cm in its transverse diameter [6, 7]. the newborn falls under the purview of the paternal 
The word “fontanelle” is derived from the Latin word family, with grandmothers, sisters-in-law, and aunties 
‘fonticulus’ and the French word ‘fontaine’, mean- playing a vital role in the child’s physical care. Female 
ing a little fountain or natural spring [8]. The NAF is adults, particularly mother-in-laws and grandmothers, 
located between the two frontal and two parietal bones actively participate in the newborn’s physical care for 2 
of the developing skull, and it is bordered by the junc- to 3 months after delivery. Traditional practices such as 
tions of the frontal, coronal and sagittal sutures with its bathing the newborn with herbs to boost their immune 
membranous normotensive structure. The most com- system and protect them from illnesses and the evil eye 
mon causes of a large anterior fontanelle or delayed are common. Additionally, throwing the baby into the 
fontanelle closure are achondroplasia, hypothyroid- air and catching them is sometimes done to instill brav-
ism, Down syndrome, increased intracranial pressure, ery and resilience in the child. During traditional nam-
infections, dehydration and rickets [9, 10]. The ante- ing ceremonies, it is customary to touch the newborn’s 
rior fontanelle persists until approximately 18 months, tongue with alcohol and water sequentially to symboli-
when full closure is observed [11]. The molding of the cally introduce the child to truth telling and falsehood, 
fontanelles aid in delivery through the birth canal and considered essential for growth and development.
A ni‑Amponsah et al. International Journal for Equity in Health           (2023) 22:37 Page 3 of 7
Indigenous newborn practice the newborn’s head requires healing assistance. Moist 
Harmful indigenous newborn practices are noted to set heat is applied to speed up bone ossification and pro-
neonates on challenging health trajectories [17–19]. mote fontanelle closure by improving blood circulation 
The practice of fontanelle fomentation poses health [24].
threats to the newborn; however, its respective dangers The sunken and late closure of newborn fontanelle has 
have least been examined or discussed over the years. been associated with ‘asram’- the local name for a fatal 
In other African countries such as Nigeria, abdomi- newborn illness that is characterized by head enlarge-
nal scarification with razor blades following febrile ill- ment, weight loss, and obvious greenish-blackish veins 
nesses is a traditional neonatal practice that sometimes on the head and abdomen that only a traditional healer or 
lead to evisceration of intra-abdominal viscera [20]. In spiritualist can heal [25]. Asram has been well reported in 
rural Uganda, false tooth extraction performed by tra- various studies across Ghana [18, 26–29].
ditional healers to resolve fever and diarrhoea is asso- This critical analysis provides an understanding of the 
ciated with anaemia and septicaemia [21]. The use of indigenous beliefs and practices surrounding newborn 
Mahogany and Neem oil (Bornu) to the newborn fonta- fontanelles. According to these beliefs, failure of the fon-
nelle and head molding are known practices in Nigeria tanelle to close properly may allow air to enter the brain, 
but their impact on child growth and development have resulting in persistent headaches, runny nose, nasal 
not been examined [17, 22]. congestion, and other health issues that can persist into 
adulthood. As a result, traditional practices such as hot 
Methods fomentation and scalp molding are used for up to two to 
This study is a review of literature on hot fomentation three months after the child’s birth to promote healing 
of newborn fontanelles. A literature search in CINAHL, and closure of the fontanelles.
PubMed, African Index Medicus and Scopus, was con-
ducted and evidence was synthesized from articles Description of hot fermentation practice
ranging from 1983–2022. A combination of five traditional practices, including hot 
This paper utilized quantitative studies, qualita- fomentation of fontanelles, abdominal warm compress, 
tive studies, and a systematic literature review. Ini- body massage, anogenital dripping with warm water, 
tially, about 60 studies were assessed, but only 31 were and bathing, is performed twice daily for newborns in 
used for this write-up. Ten studies were excluded due Ghana. This 5-in-1 procedure is typically done in the 
to duplication and lack of peer review, while 19 stud- early morning and evening around 6:30 am and 4:30 pm, 
ies were deemed unsuitable for the study’s purpose or respectively, although the timing may vary depending on 
dated before 1983. The PRISMA FLOW in diagram  1 the climate. In hot weather, the newborn may be washed 
provides a visual representation of the criteria and with non-boiled water in the afternoon for comfort [30]. 
rationale for excluding studies. The paper’s search for Bathing is usually done as the last procedure of the five 
information and inclusion of studies utilized the key- which is carried out by a female family elder who is either 
words Newborn, Hot Fontanelle Fomentation, Indig- the grandmother, mother–in–law, sister-in-law, auntie, 
enous Practice, Ghana, and Covid-19. The details of the or trusted volunteer neighbour [31]. This sequential pro-
criteria for inclusion is in Fig. 1 below. cedure continues until about the end of the second or 
third-month post-delivery when the mother is able to 
Results do it unaided herself. The person performing the proce-
Understanding fontanelle fomentation dure wraps a cloth around her waist, and often sits on a 
In Ghana, Akans form the largest ethnic group (47.5%), low stool, extends the legs over a rubber or metallic bath 
followed by the Mole Dagbani (16.6%), the Ewes bowl or basin, and places the baby on her thighs after 
(13.9%), Ga-Dangme (7.4%), and the Mande population rolling her waist cloth backward.
(1.1%) [23]. Fontanelle fomentation (FF) is a predomi- To perform the fontanelle fomentation and associ-
nant customary practice among these ethnic groups in ated procedures, several items are required, including 
Ghana and Africans in the diaspora [24]. As a part of two buckets for hot and cold water, an extra bucket for 
home-based postnatal care in Ghana, newborns receive mixing the water, two small towels, soap, sponge, and a 
hot fomentation of the fontanelles and scalp molding to moisturizing cream such as shea butter, Vaseline, baby 
achieve a round head shape, which is considered typi- cream, or baby oil. The fontanelle fomentation is typically 
cal of Ghanaians. The practice of newborn fontanelle the first procedure performed and lasts approximately 
fomentation (NFF), especially of the anterior fonta- 25 to 30  min, with the anterior fontanelle receiving 
nelle, is based on the belief that this sensitive area of about 15  min of attention due to its larger size. During 
the fomentation, the newborn is dressed and wrapped 
Ani‑Amponsah et al. International Journal for Equity in Health           (2023) 22:37 Page 4 of 7
Fig. 1 Prisma flow diagram for study inclusion
in a cloth, positioned face to face with the caregiver who which the baby is dried and dressed. The entire 5-in-1 
places the baby on their closed thighs. The water tem- procedure can take up to one hour on average. If the 
perature for fomentation is typically 70–85 °C, with vis- umbilical cord has dropped, irrigation of the cord base is 
ible steam. The caregiver drops the small towel into the performed with warm water. However, if the cord has not 
hot water and quickly picks it up, allowing some heat dropped, it is kept dry and intact during the bath. This 
to escape for about 30 s before squeezing out the excess entire process is typically carried out twice a day in the 
water. The towel is then placed on the anterior fontanelle bedroom or living room. During the wet or rainy season 
first and then rotated to the other fontanelles and along when the environmental temperature is lower than the 
the suture lines to mold the scalp in a roundish motion. average temperature of 23—28  °C, the neonate may be 
(See Fig. 2). wiped clean in the evenings but will still undergo fonta-
The fontanelle fomentation procedure typically elic- nelle fomentation.
its a strong reaction from newborns, who cry loudly 
and continuously. Once this procedure is complete, the Leininger’s theoretical framework
abdominal warm compress, body massage with flexion The chosen theory for this paper is Madeleine Leininger’s 
and extension of the limbs, and ano-genital dripping Culture Care Diversity and Universality care theory [32]. 
with warm water are performed. Bathing from head to This theory emphasized consideration of the patient’s 
toe is the final step and takes approximately 15 min, after cultural background in order to provide the patient with 
A ni‑Amponsah et al. International Journal for Equity in Health           (2023) 22:37 Page 5 of 7
Fig. 2 Infant Head Molding – Direction of Pressure
culturally sensitive care. Knowing the patient’s values, linked to the persistent cry of the newborn during the 
beliefs, and cultural practices can help provide univer- procedure which raises ethical concerns about new-
sal care to promote patient health and well-being. This born health and safety and maternal mental health over 
theory, therefore, emphasizes the need for healthcare the span of 2 – 3  months, and beyond. These practices 
providers to have a deep understanding of the patient’s reveal the complexity of predominant culture, the lived 
culture in order to provide compassionate care [33]. This reality of newborns, and the structural drivers of subtle 
theory was applicable because it ensures that nurses but obvious health risks that impact newborns in African 
avoid judging or angering mothers because of this inher- communities [17, 18, 20, 27, 28].
ent practice. This suggests that we need to find innovative 
ways to educate mothers about the dangers involved in Discussions
this practice. It, therefore, takes patience, understanding, Indigenous practices in Ghana and Africa are predomi-
and diligence to help mothers undo this practice. nantly passed down through oral tradition, resulting 
in limited information available in ethnic and profes-
Dangers of newborn fontanelle fomentation practice sional literature. These practices are often considered 
Fontanelle fomentation, while a commonly practiced tra- cultural norms and have been in practice for many 
dition, poses potential dangers to newborns. One major years. To reverse such behavior, it is recommended 
concern is the risk of scalding from hot water, which that healthcare providers exhibit care and understand-
can result in burns to the fontanelle. Additionally, par- ing, as suggested by Madeleine Leininger. The repeated 
ents applying too much pressure to the fontanelle dur- exposure of newborns to harmful indigenous practices 
ing fomentation could lead to inflammation, internal calls for integrated healthcare and community-based 
brain tissue trauma, infection, premature fontanelle clo- approaches at all levels of newborn healthcare. Key 
sure, and excessive molding. These risks are particularly stakeholders in newborn health, including mothers, 
concerning as newborn mortality trends indicate that fathers, grandmothers, mothers-in-law, sisters-in-law, 
infections are a major cause of death. Therefore, caution grandparents, traditional birth attendants, women’s 
should be exercised when performing fontanelle fomen- groups, religious authorities, and legislative institu-
tation to avoid potential harm to the newborn [34]. Tra- tions, need to be engaged during the antenatal period, 
ditionally, mothers have very little power to intervene immediate postnatal period, and across the continuum 
during the fontanelle fomentation procedure of their to co-lead campaigns against harmful indigenous new-
newborns due to inherent patrilineal hegemony within born practices [35]. These educative health campaigns 
the Ghanaian culture. Maternal emotional trauma is can be strengthened prenatally and at birth with a 
Ani‑Amponsah et al. International Journal for Equity in Health           (2023) 22:37 Page 6 of 7
focus on the family and other home care providers in Conclusion
newborn discharge planning [36–38]. Collaborative The present study has explored the practice of hot fomen-
research related to short and long-term outcomes of tation, highlighted its associated risks, and proposed 
NFF and other harmful indigenous newborn care prac- interventions to help mothers discontinue this practice. 
tices is needed in Ghana and among African popula- To effectively promote newborn care in the context of the 
tions [39]. Newborn frontline health care providers ongoing Covid-19 pandemic, a collaborative and commu-
need to emphasize the normality of the anterior fon- nity-based healthcare approach that integrates family and 
tanelle in prenatal, discharge and post-natal education community values, cultural beliefs, and newborn care prac-
sessions and examine fontanelle fomentation practices tices is essential. This approach should be supported by 
on preterm and small for age, and sick babies in home- evidence-based research on fontanelle fomentation, policy 
based care. guidance, and the contextualization of behavioral change 
In the current Covid-19 pandemic, healthcare access strategies that align with local cultural norms and national 
to newborns in Ghana is limited due to physical distanc- health goals. By adopting this approach, the United Nations 
ing as part of mobility restrictions across urban and rural General Assembly’s Sustainable Development Goals 
communities [4]. The marginal shift from routine facil- (SDGs) to reduce the under-five mortality rate (U5MR) to 
ity-based health care associated with Covid-19 related at least 25 deaths per 1,000 live births can be achieved.
restrictions have heightened sub-optimal healthcare-
seeking behaviours of families of newborns. This calls for AcknowledgementsWe would like to extend our sincere appreciation to are the researchers whose 
feasible, sustainable and cost-effective follow up systems studies were cited in this review.
in newborn home-based care [40].
With considerations of the contextual limitations, Authors’ contributionsM.A.A, S.A, M.A.A, and E.O.A wrote the manuscript, M.A.A, M.M and E.O.B did 
indigenous practices on newborns in Ghana and other the analysis of this review. All authors worked on the manuscript for publica‑
African communities are anticipated to rise during the tion. The author(s) read and approved the final manuscript.
current pandemic. Therefore, optimising the delivery of Funding
skilled home-based care on a continuum and strength- No funding was received for this review.
ening the capacity of families in safe newborn care is 
needed as a matter of urgency in the current Covid-19 Availability of data and materialsAll datasets generated during the current study are included in the published 
pandemic [4]. Health research is needed to investigate article and its supplementary files.
the flourishing of indigenous newborn practices dur-
ing this Covid-19 pandemic. It is equally important to Declarations
focus on individual behavioural changes and the impact 
of community beliefs on behavioural change or modifica- Ethics approval and consent to participateThis was not applicable since no human participants were used, however, 
tions [19]. all information used has been duly cited and referenced. All methods were 
Implications for Policy: Policymakers need to under- performed in accordance with the relevant guidelines and regulations.
stand that knowing the deep-rooted traditional norms Consent for publication
and their importance to the people is critical for educat- Not applicable.
ing and modifying or stopping harmful traditional prac-
tices that are rooted in predominant cultural beliefs [18, Competing interestsThe authors declare no competing interests.
41]. Making available educational modules in locally-
friendly languages and images to families and health pro- Author details
1
viders, and policies that support home care follow-ups  Maternal & Child Health Department, School of Nursing and Midwifery, University of Ghana, Legon, Accra, Ghana. 2 Faculty of Nursing, ECHA 5‑2381, 
on newborn care is important. However, stringent health Edmonton Clinic Health Academy (ECHA), University of Alberta, 11405 87 
policies need to be relaxed in order to bridge the gap Avenue, Edmonton T6G 1C9, Canada. 3 Out‑Patient Department, Ashaiman Pol‑
4
between newborn traditional care providers and facility yclinic, Ghana Health Service, Accra, Ghana.  Purdue University, West Lafayette, USA. 5 Department of Child Health, Tamale Teaching Hospital, Tamale, Northern 
care providers [42]. While it is important to reduce the Region, Ghana. 6 Department of Nursing, School of Nursing and Midwifery, 
risks associated with harmful indigenous practices, there Valley View University, Accra, Ghana. 
is a need to increase newborn advocacy and protection Received: 7 August 2022   Accepted: 22 February 2023
for newborns in culturally-dominated communities [27, 
37, 41]. Whilst enlightenment campaigns and supportive 
child health policies are critical, legislation to criminalize 
harmful indigenous practices needs to be established and References
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