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ORIGINAL ARTICLE
Year : 2019  |  Volume : 8  |  Issue : 4  |  Page : 232-237

Determinants of neonatal mortality among newborns admitted to neonatal intensive care unit Adama, Ethiopia: A case–control study


1 Department of Pediatrics and Child Health, Adama Hospital Medical College, Ethiopia
2 Department of Midwifery, College of Health Sciences, School of Nursing and Midwifery, Addis Ababa University, Addis Ababa, Ethiopia

Date of Submission25-Feb-2019
Date of Decision24-Jun-2019
Date of Acceptance01-Sep-2019
Date of Web Publication04-Oct-2019

Correspondence Address:
Asst. Prof. Roza Teshome Kassa
Department of Midwifery, College of Health Sciences, School of Nursing and Midwifery, Addis Ababa University, Addis Ababa
Ethiopia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcn.JCN_23_19

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  Abstract 


Context: The majority of problems during the early neonatal period are causally related with the fetal life or the birth process; while most problems during late neonatal life are acquired. Aims: This study aims to assess the determinant factors of neonatal mortality among newborns admitted to neonatal intensive care unit of Adama Hospital Medical College (AHMC). Setting and Design: An institutional-based retrospective case–control design was conducted at AHMC. Subjects and Materials: A total of 300 neonates study participants were recruited. Medical record review was employed to collect data. Statistical Analysis Used: Data were entered, cleaned, and analyzed by SPSS version 20 statistical package. Descriptive summaries using frequencies and proportions were used. Binary and multivariable logistic regressions were used. Results: Antenatal care, gravidity, and parity were significant factors to neonatal death. It was found that neonates who were born from mothers who had no antenatal care No single visit) had 2.7 times at risk of death (crude odds ratio = 2.7 95% confidence interval = 1.3, 5.6 adjusted odds ratio = 1.5 P = 0.008). Neonates who were delivered by assisted vaginal delivery were 5.9 times at risk of death than neonates who were delivered by singular value decomposition. It was found that asphyxia and neonatal death have a strong association. Conclusions: Antenatal follow-up, assisted vaginal delivery, cesarean delivery, gestational age, birth weight, sepsis, and asphyxia were significant neonatal risk factors for neonatal death. Most of these factors may be prevented and manageable by good antenatal care, intrapartum care, and neonatal care.

Keywords: Adama, Ethiopia, neonatal mortality, risk factors


How to cite this article:
Kolobo HA, Chaka TE, Kassa RT. Determinants of neonatal mortality among newborns admitted to neonatal intensive care unit Adama, Ethiopia: A case–control study. J Clin Neonatol 2019;8:232-7

How to cite this URL:
Kolobo HA, Chaka TE, Kassa RT. Determinants of neonatal mortality among newborns admitted to neonatal intensive care unit Adama, Ethiopia: A case–control study. J Clin Neonatol [serial online] 2019 [cited 2019 Dec 8];8:232-7. Available from: http://www.jcnonweb.com/text.asp?2019/8/4/232/268582




  Introduction Top


The majority of problems during the early neonatal period are causally related with the fetal life or the birth process; while most problems during late neonatal life are acquired.[1] The neonatal mortality rate (NMR) is defined as the number of neonatal deaths (during the first 28 completed days of life) per one thousand live births in a given year or another period.[2]

Globally, about 6.6 million children die before their fifth birthday each year. About 5 million of this occurs in the 1st year of life, and nearly 3 million die within the first 28 days of birth. This indicates that 44% of under-five deaths and 60% of infant deaths are accounted by the neonatal mortality.[3] The average NMR has fallen by more than a quarter over 20 years, from 33.2 to 23.9/1000 live births, or an average of 1.7%/year.[4] The greatest risk of this death was at the very beginning of life, 31.9% happened in the early neonatal period, and 9.7% in the late neonatal period.[5] The highest numbers of deaths were registered in South-central Asian and sub-Saharan African countries.[5],[6]

More than 98% of these deaths occur in developing countries. Sub-Saharan Africa has the highest risk of death in the 1st month of life and among the regions showing the least progress in reducing the NMR. Most of these deaths are caused by infectious diseases, pregnancy-related complications, and delivery-related complications, including intrapartum asphyxia, birth trauma, and premature birth which can easily be prevented.[7],[8]

Ethiopia's NMR, one of the highest in the world, declined much more slowly. Newborn deaths remain a major challenge: newborns account for more than 40% of under-five deaths. NMR changes from 2000, 2005, to 2014 were 39, 37, and 28, respectively.[9]

Several studies from developing countries have shown that neonatal mortality is influenced by physical accessibility to health facility antenatal care, domestic violence during pregnancy, pregnancy complications, tetanus toxoid immunization for the mothers, place of delivery, delivery complications, breastfeeding within the 1st h of delivery, postnatal care, birth weight, gestational age, birth spacing, sex of the child, previous history of neonatal death, household wealth, maternal age, and educational status of the mothers.[10],[11]

Causes of neonatal death vary by country and region with the availability and quality of health care; therefore, understanding neonatal mortality in relation to these factors is crucial. This is because there are highly feasible and cost-effective interventions that could avert NM, and this can only be achieved if countries adopt locally relevant and focused interventions that are guided by study findings. This study is aimed to determine the determinants of neonatal death among neonates admitted to neonatal intensive care unit (NICU) of Adama Hospital Medical College (AHMC), Adama, Ethiopia.


  Subjects and Materials Top


This study was conducted in Adama town, neonatal intensive care unit of AHMC. Adama Hospital is a teaching referral hospital of the region. The catchment population of the hospital is estimated to be 5 million. An institutional-based retrospective case–control design was conducted. The sample size of this unmatched case–control study was calculated using StatCalc in Epi-info 7 (Epi infoTM, CDC, Atlanta, US) by the following assumptions: level of confidence 95%, 80% power, proportion of sepsis in controls 40%, odds ratio (OR) of two, and proportion of sepsis in cases 57%. This gives the total sample size of 300 neonates: 100 cases and 200 controls.

Medical record review was done using structured data abstraction tool to collect the desired data among neonates admitted to NICU of AHMC from January 2015 to March 2016. Cases were defined as neonates who were died within 7 days of birth (early neonatal deaths) and before 28 days. Controls were defined as neonates who were registered as alive/improved. Cases were selected retrospectively until the desired sample size achieved, and two controls were obtained for every case. Data were entered, cleaned, and analyzed by SPSS version 20 statistical package (IBM Corporation, Armonk, NY). Binary and multivariable logistic regressions were used. Adjusted odds ratio (AOR) and unadjusted odds ratio at 95% confidence and significance at P < 0.05 were considered.


  Results Top


Socio demographic characteristics

A total of 300 study participants were recruited in this study. From these, 100 cases were recorded as neonatal death and 200 controls were alive/improved and discharged neonates. Out of total study participants, 192 (64%) were male [Table 1].
Table 1: Related maternal obstetric status and neonatal condition during birth, Adama Hospital Medical College, 2017

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Related maternal obstetric conditions

Among cases, 68 (68%) of their mothers had no antenatal care and 19 (19%) had more than four African National Congress (ANC) visits. Among controls, 97 (48.5%) of their mothers had no ANC, and 65 (32.5%) of them had more than four ANC visits. From 200 controls, 2 (1%) of maternal HIV status was positive [Table 1].

Related neonatal conditions at birth and after birth

From a total of 300 participants, 136 (45.3%) neonates had a birth weight range from 2500 g up to 4000 g and 156 (52%) had <2500 g. Out of the total, 158 (52.7%), 58 (19.3%), and 84 (28%) were delivered by singular value decomposition (SVD), assisted vaginal delivery, and caesarean section (CS), respectively.

Among cases, for only 13 (13%) neonates, breastfeeding was initiated within the first 1 h while this figure rose to 38 (19%) for the control group [Table 2].
Table 2: Neonatal conditions during birth and after birth-related risk factors of neonatal death, Adama Hospital Medical College, 2017

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Identified neonatal problems

The most common identified problem was neonatal sepsis 182 (60.7%). Thirty-two (10.7%), 24 (8%), and 4 (1.3) were diagnosed with prematurity, asphyxia, and jaundice, respectively [Figure 1].
Figure 1: Distribution of identified neonatal problems among cases and controls, Adama Hospital Medical College, 2017 (original)

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Risk factors of neonatal death

The risk factors were classified into three. These were maternal factors, neonatal factors, and delivery factors. These factors were analyzed by binary logistic regression and multiple logistic regression method.

Maternal factors affecting neonatal outcomes

Maternal ANC visits during pregnancy, gravidity, parity, maternal HIV status, maternal HIV treatment, were assessed. Antenatal care, gravidity, and parity were significant factors to neonatal death. It was found that neonates who were born from mothers who had no antenatal care no single visit had 2.7 times at risk of death (Crude odds ratio [COR] = 2.7 95% confidence interval [CI] = 1.3, 5.6 AOR = 1.5 P = 0.008) [Table 3].
Table 3: Maternal obstetrics and delivery related risk factors of neonatal death, Adama Hospital Medical College, 2017

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Mode of delivery as a risk factor for neonatal death

Among control groups, 126 (63%), 23 (11.5%), and 51 (25.5%) neonates were delivered by SVD, assisted vaginal delivery, and CS, respectively. From 100 cases, 32 (32%), 35 (35%), and 33 (33%) neonates were delivered by SVD, assisted vaginal delivery, and CS, respectively. It was found that there was a significant association between mode of delivery and neonatal death. Neonates who were delivered by assisted vaginal delivery were 5.9 times at risk of death than neonates who were delivered by SVD (COR = 5.9 95% CI = 3.1, 11.5 AOR = 4.8 P = 0.000) [Table 3].

Neonatal factors

Factors which were classified as neonatal factors were birth weight, gestational age, and problem identified during birth or after birth.

From the control group, 72 (36%) of neonates had a birth weight of <2500 g. Of 100 cases, 60 (60%) neonates had a birth weight of <2500 g. It was found that birth weight is a significant risk factor for neonatal death (COR = 2.7 95% CI = 1.6, 4.7 AOR = 1.3 P < 0.000) [Table 2].

Among cases, 48 (48%) of neonates were preterm whereas 38 (19%) of controls were preterm. It was revealed that being preterm neonate is a risk for death. Neonates who were preterm were more likely (3.9 risks) for death (COR = 3.9, 95% CI = 2.3, 6.7 AOR = 3.2 P = 0.000) [Table 2].

Of 100 cases, 48 (48%) of neonates were preterm and of 200 controls, 38 (20%) neonates were preterm. It was revealed that gestational age is a significant risk factor for neonatal death. Neonates who were preterm had more likely 3.9 risks for death than who were term neonates (COR = 3.9 95% CI = 2.3, 6.7 AOR = 3.3 P = 0.000) [Table 2].

From cases, 14 (14%) neonates and 10 (5%) were diagnosed with asphyxia. It was found that asphyxia and neonatal death have a strong association. Neonates who had asphyxia had 3.9 risks of death than who had no (COR = 3.1 95% CI = 1.3, 7.3 AOR = 3.9 P = 0.009) [Table 2].


  Discussion Top


This study showed that antenatal care was significantly associated with neonatal death. Neonates who were born from mothers who had no pregnancy follow-up had an odds ratio of 2.7. It was also a significant factor in a case–control study conducted in Kenya which revealed that neonates who were born from mothers who had 0–1 ANC visits had OR of 5.9 than who had more than four ANC visits (COR = 5.9, 95% CI = 3.1–11.6, AOR = 5.4, P = 0.001).[10] A study conducted in Indonesia also revealed antenatal care is a protective factor for neonatal death (COR = 0.9, 95% CI = 0.85–095, P = 0.000).[12] A community-based study conducted in India showed also less OR of neonates who were born from mothers who had more than four visits than who had no antenatal care (COR = 0.89, 95% CI = 0.82–0.98 P = 0.001).[13] It might be explained as antenatal care during pregnancy can prevent maternal complication that can affect the fetal life. Low or no ANC attendance can result in poorer follow-up of fetal condition and failure to prevent, detect, and treat the maternal complication. ANC interventions are generally thought to be effective in improving maternal and infant outcomes.[14] The association between ANC interventions and neonatal mortality is particularly important in a poor resource setting like Ethiopia, where there is an urgent need to prioritize the interventions that yield maximum benefit in terms of neonatal and maternal health outcomes.

In this study, operative deliveries were a risk factor for neonatal death. Neonates who were delivered by assisted vaginal delivery had higher OR than who were delivered by SVD (COR = 5.9 95% CI = 3.1, 11.5 AOR = 4.8 P = 0.000). This was a comparable result with a study conducted in west Gojjam Ethiopia which revealed that SVD is a protective factor for neonatal death than cesarean delivery (COR = 0.34 95% CI = 0.11–1.10).[15] A similar study by Gardella et al. used Washington state birth certificate data linked to hospital discharge records to compare perinatal outcome in 3741 vaginal deliveries by both vacuum and forceps, 3741 vacuum deliveries, 3741 forceps deliveries, and 11,223 spontaneous vaginal deliveries. The study found that the sequential use of vacuum and forceps was associated with significantly increased risk of both neonatal and maternal injury.[16] In all instances, the potential risks and benefits of a vacuum-assisted delivery must be weighed against the available alternative, including continued expectant management, like oxytocin augmentation delivery.[15]

Birth weight <2500 g was the other associated factor with neonatal death in this study. It had 2.7 times risk for neonatal death. Similarly, a study conducted in Indonesia low birth weight was a significant risk factor for neonatal death (COR = 6.27, 95% CI = 4.15–9.46, P < 0.00).[12] A case–control conducted in Kenya also showed low birth weight had 6.7 times risks for neonatal death (COR = 6.6, 95% CI = 4.5–9.8, P = 0.001).[10] Similarly, low birth weight had 6.27 OR in a study done in Indonesia (COR = 6.27, 95% CI = 4.15–9.46, P < 0.00).[13] A prospective study done in Jimma Ethiopia showed that low birth weight had a risk of death by 3.37 times.[17] However, low birth weight itself is a consequence of either preterm birth or intrauterine growth restriction resulting in small for gestational age births or a combination of the two: low birth weight per se is not thought to be on the causal pathway to neonatal mortality.[18]

In this study, preterm neonates had 3.9 risks for death. Similarly, in a study conducted in West Gojjam Ethiopia gestational age less than 37 weeks is a significant risk factor for neonatal death (COR = 16.07, 95% CI = 3.58–72.2).[15] Preterm birth is a direct cause of mortality but also aggravates the effect of another risk because of intrauterine growth retardation, which has been shown to increase the risk of mortality and morbidity.[19],[20],[21] These findings have public health importance when thinking about the potential of interventions that focus on reducing intrauterine growth retardation, or on reducing prematurity in this setting.


  Conclusions Top


Antenatal follow-up, assisted vaginal delivery and cesarean delivery were identified as maternal and 4 delivery related factors for rightneonatal death. Interventions that focus on educating mothers on the importance of antenatal clinic attendance, as well as ensuring screening, detection, monitoring, and management of maternal conditions during the antenatal period, could help reduce NMR. Gestational age, birth weight, sepsis, and asphyxia were also significant neonatal risk factors for neonatal death. Most of these factors may be prevented and are manageable by good antenatal care, intrapartum care, and neonatal care.

Ethics approval and consent to participate

The study was conducted after obtaining ethical clearance from Ethical Review Board of AHMC. Consent to participate was not required. Client records were treated confidentially, and the name of clients was not included in the data collection.

Availability of data and materials

The authors confirm that all data underlying the findings are fully available. All the necessary data were included in the paper. However, the raw data set in SPSS can be obtained by E-mail request.

Acknowledgments

We would like to thank AHMC for funding this study. Our heartfelt thanks to AHMC staffs, data collectors, and study participants.

Financial support and sponsorship

This study was supported by Adama Hospital Medical College.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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United Nations. The Millennium Development Goals Report. New York: United Nations; 2015.  Back to cited text no. 6
    
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UNICEF WHO, The World Bank, United Nations Population Division. Levels and Trends in Child Mortality: Estimates Developed by the UN Interagency Group for Child Mortality Estimation (UNIGME). New York, USA: UNICEF, WHO, the World Bank; 2013.  Back to cited text no. 7
    
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Yego F, D'Este C, Byles J, Nyongesa P, Williams JS. A case-control study of risk factors for fetal and early neonatal deaths in a tertiary hospital in Kenya. BMC Pregnancy Childbirth 2014;14:389.  Back to cited text no. 10
    
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Singh A, Kumar A, Kumar A. Determinants of neonatal mortality in rural India, 2007-2008. PeerJ 2013;1:e75.  Back to cited text no. 13
    
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Singh A, Pallikadavath S, Ram F, Alagarajan M. Do antenatal care interventions improve neonatal survival in India? Health Policy Plan 2014;29:842-8. doi:10.1093/heapol/czt066.  Back to cited text no. 14
    
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