Perinatal asphyxia is defined as the inability of the newborn to initiate and sustain enough respiration after delivery and is characterized by a marked impairment of gas exchange [
Perinatal asphyxia is caused by a lack of blood flow or gas exchange to the fetus during late pregnancy, during, or after birth as a neonate. When placental (before birth) or pulmonary (immediate after birth) gas exchange is decreased or stopped altogether, there is partial (hypoxia) or complete (anoxia) lack of oxygen to the vital organs. This causes progressive hypoxemia and hypercapnia. If the hypoxemia is severe enough, the tissues and vital organs (muscle, liver, heart, and ultimately the brain) will develop an oxygen debt. Anaerobic glycolysis and lactic acidosis will ensue. Neonatal hypoxic ischemic encephalopathy refers to the neurologic sequelae of perinatal asphyxia [
The diagnosis of perinatal asphyxia is made when the umbilical cord arterial pH is <7, the APGAR (Appearance, Pulse, Grimace, Activity, and Respiration) score is 0-3 at the fifth minute, and there are central nervous system manifestations like seizures, lethargy, coma, hypotonia, or hypertonia and multisystem organ dysfunction [
The incidence of perinatal asphyxia in developed countries is 2 per 1000 live births, but the rate is 10 times greater in developing countries where there is no adequate access to maternal and neonatal care. Of those asphyxiated neonates, 15-20% will die in the neonatal period and around 25% of survivors will have permanent neurologic deficits [
According to the World Health Organization, perinatal asphyxia is one of the three common causes of under-five child mortality (11%) following preterm birth (17%) and pneumonia (15%) [
In Ethiopia, neonatal mortality accounts for 29/1000 live births. Many of these deaths occur during the first 48 hours of age, and still, the reduction in mortality is low [
Despite this high mortality and morbidity associated with perinatal asphyxia, the prevalence and associated factors of perinatal asphyxia are not well studied in Ethiopia and there is no report on the prevalence and associated factors of perinatal asphyxia in the study area so far. Therefore, this study is aimed at assessing the prevalence and associated factors of perinatal asphyxia among newborns admitted to Ayder Comprehensive Specialized Hospital in Tigray region.
Ayder Comprehensive Specialized Hospital is found in the Tigray region Mekelle town, which is around 778 km from the capital city Addis-Ababa. It started as a referral and specialized medical center in 2008 GC. It delivers clinical service to more than a population of 8 million in the catchment areas of Tigray, Afar, and southeastern parts of the Amhara regional state. It provides a broad range of medical services to both in- and outpatient for all age groups. It also serves as a teaching hospital to several medical, dental medicine, nursing, midwifery, public health, pharmacy, anaesthesia, and medical laboratory students in both undergraduate and postgraduate programs. It is the second largest hospital in the nation and has more than 500 inpatient beds in the four major departments (internal medicine, pediatrics, gynaecology and obstetrics, and surgery and other specialties). The pediatrics and child health department has 18 specialists (general pediatricians) and six subspecialists. There are 43 residents in the department and 30-40 medical interns rotating every three months.
The NICU (neonatal intensive care unit) ward provides service for approximately 200 neonates per month with a total of 43 beds and one room for KMC (kangaroo mother care). There are 65 BSC nurses, 1 neonatologist, 1 general pediatrician, 4 residents, and 8 interns. It is equipped with 4 radiant warmers, 6 incubators, 5 phototherapy devices, and two mechanical ventilation machines.
Institution-based cross-sectional study design was used and data collected to include neonates seen from January 1, 2016, to December 30, 2017.
The source population was composed of all neonates admitted to Ayder Comprehensive Specialized Hospital.
All neonates admitted to Ayder Comprehensive Specialized Hospital, NICU ward, during the study period and who fulfilled the inclusion criteria were included in the study.
Inclusion criteria include all newborns admitted to Ayder Comprehensive Specialized Hospital with
Neonates were excluded if they are suffering from major congenital anomalies or syndromes, e.g., NTD (neural tube defect), have incomplete documentation (no maternal or fetal measurement parameters), are kept for observation, and have mothers who took general analgesia.
The sample size was determined by using a single proportion formula. The sample size determination formula is
The dependent and independent variables are provided in Table
Neonates are newborn infants who are less than 28 days.
Perinatal asphyxia is the inability of the newborn to initiate and sustain adequate respiration after delivery.
APGAR score is a score used as a part of early assessment of a newborn.
Perinatal asphyxia is considered when the 5th APGAR score is <7 or a neonate did not cry or needed resuscitation.
HIE (hypoxic ischemic encephalopathy) is a central nervous system dysfunction during the neonatal period, and it is due to ischemic and hypoxic insult.
Prolonged labor is the total duration of
Congenital malformation is a physical defect present in a newborn at birth that results in central nervous system depression.
Prestructured data collection format was used to collect the information. Data was collected by medical interns. Relevant information was obtained which includes neonatal information (gender, gestational age, birth weight, and APGAR score), maternal information (age, parity of mothers, residence, place of delivery, mode of delivery, and problems during pregnancy or labor).
Data were entered into SPSS (Statistical Package for the Social Sciences) version 20 (Armonk, NY: IBM Corp), cleaned, coded, and checked for normality and completeness before analysis. Descriptive statistics was used to determine the prevalence of birth asphyxia and sociodemographic as well as obstetrics history. Bivariate and multiple binary logistic regression analysis was carried out to identify the associated factors of PNA. Variables with a
Ethical clearance was obtained from the Institutional Review Board (IRB) of the College of Health Sciences of Mekelle University. Permission was taken from Ayder Comprehensive Specialized Hospital medical director offices; a support letter from the chief clinical director was obtained.
A total of 3403 neonates were admitted to the NICU during the study period, and a total of 282 neonate medical records were collected using a standardized random sampling approach and 267 (94.7%) neonate medical records had complete data, and 15 patients were omitted due to incomplete data. Of the 267 neonates, 48 had perinatal asphyxia, giving us a prevalence of 18%. Majority of the study neonates’ mothers (62.2%,
Study variables.
Dependent | Independent |
---|---|
Perinatal asphyxia | Age of the mother |
Residence | |
Age of neonates at admission | |
Sex of newborn | |
Gestational age in weeks | |
Birth weight in grams | |
Parity | |
ANC follow-up (antenatal care follow-up) | |
Birth history | |
Comorbidities (diabetes, preeclampsia) | |
Type of labor (spontaneous or induced) | |
Duration of labor | |
Place of delivery | |
PROM (premature rupture of membranes) | |
MSAF (meconium-stained amniotic fluid) | |
Fetal presentation | |
Mode of delivery | |
APGAR score (Appearance, Pulse, Grimace, Activity, and Respiration) | |
Duration of hospital stay |
Majority of the mothers (60.3%,
Among the mothers of neonates with PNA, 52.1% (
Sociodemographic and clinical characteristics of mothers and neonates at ACSH, Ethiopia, January 1, 2016–December 30, 2017 (
Variables | Perinatal asphyxia | ||
---|---|---|---|
Yes (48), |
No (219), |
||
Age of mothers | |||
<20 | 2 (4.2) | 11 (5) | 13 (4.8) |
20-35 | 28 (58.3) | 138 (63) | 166 (62.2) |
>35 | 18 (37.5) | 70 (32) | 88 (33) |
Residence of mothers | |||
Urban | 23 (47.9) | 131 (59.8) | 154 (58.8) |
Rural | 25 (52.1) | 88 (40.1) | 113 (42.2) |
Sex of neonates | |||
Male | 28 (58.3) | 129 (58.9) | 157 (58.8) |
Female | 20 (41.7) | 90 (41.1) | 110 (41.2) |
Age of neonate at admission | |||
0-72 h | 47 (98) | 174 (79.5) | 221 (82.2) |
3-7 days | 1 (2) | 20 (9.1) | 21 (7.8) |
>7 days | 0 (0.0) | 25 (11.4) | 25 (10) |
Weight | |||
≥4000 | 2 (4.16) | 13 (5.9) | 15 (4.5) |
2500-3999 | 37 (77.1) | 121 (55.3) | 158 (59.2) |
1500-2499 | 10 (20.8) | 72 (32.9) | 82 (30.7) |
1000-1499 | 2 (4.2) | 10 (4.6) | 12 (5.6) |
Parity | |||
Nulliparous | 20 (41.7) | 86 (39.3) | 106 (39.7) |
Multipara | 28 (58.3) | 133 (60.7) | 161 (60.3) |
ANC follow-up | |||
Yes | 48 (100) | 215 (98.2) | 263 (98.5) |
No | 0 (0.0) | 4 (1.8) | 4 (1.5) |
Place of delivery | |||
Tertiary hospital | 28 (58.3) | 129 (58.9) | 157 (58.8) |
Primary and general hospitals | 6 (12.5) | 41 (18.7) | 47 (17.6) |
Health center | 13 (27.1) | 44 (16.4) | 57 (21.3) |
Home delivery | 1 (2.1) | 5 (2.3) | 6 (2.2) |
Previous birth history | |||
Abortion | 2 (4.2) | 18 (8.2) | 20 (7.5) |
Still birth | 1 (2.1) | 7 (3.2) | 8 (3) |
Neonatal death | 1 (2.1) | 4 (1.8) | 5 (1.9) |
None | 44 (91.7) | 190 (86.8) | 234 (87.6) |
Comorbidity | |||
Preeclampsia | 7 (14.6) | 10 (4.6) | 17 (6.4) |
DM | 0 (0.0) | 6 (2.72) | 6 (2.2) |
None | 41 (87.4) | 202 (92.2) | 244 (91.4) |
Type of labor | |||
Spontaneous | 42 (87.5) | 193 (88.1) | 235 (88) |
Induced | 6 (12.5) | 24 (11.0) | 30 (11.2) |
Augmented | 0 | 2 (0.9) | 2 (0.8) |
Duration of labor | |||
Normal | 40 (83.3) | 210 (95.9) | 251 (94) |
Prolonged | 8 (16.6) | 9 (4.1) | 17 (6.4) |
PROM | |||
Yes | 1 (2.1) | 9 (4.1) | 11 (4.1) |
No | 46 (97.9) | 210 (95.9) | 256 (95.9) |
MSAF | |||
Yes | 8 (16.6) | 14 (6.4) | 22 (8.2) |
No | 40 (83.3) | 205 (93.6) | 245 (91.8) |
Fetal presentation | |||
Cephalic | 46 (95.8) | 212 (96.8) | 258 (96.6) |
Noncephalic | 2 (4.2) | 7 (3.2) | 9 (3.4) |
Mode of delivery | |||
C/S | 16 (33.3) | 78 (35.6) | 94 (35.2) |
SVD | 30 (62.5) | 134 (61.2) | 164 (61.4) |
Instrumental | 2 (4.2) | 7 (3.2) | 9 (3.4) |
Gestational age | |||
Preterm | 9 (18.8) | 67 (30.6) | 76 (28.4) |
Term | 38 (79.2) | 141 (64.4) | 179 (67) |
Postterm | 1 (2.1) | 11 (5.0) | 12 (4.6) |
Abbreviations: PROM: premature rupture of membrane; MSAF: meconium-stained amniotic fluid; ANC: antenatal care.
Thirty-three neonates (68.75%) had a score of 4–6 at the 5th minute, and 27.15% (
Clinical status of asphyxiated neonates, January 01, 2016–December 30, 2017 (
Clinical factors | Frequency | % |
---|---|---|
Perinatal asphyxia | ||
Yes | 48 | 18.0 |
No | 219 | 82.0 |
SARNAT stage of PNA | ||
Stage I | 9 | 18.75 |
Stage II | 26 | 54.17 |
Stage III | 13 | 27.1 |
APGAR score at the 5th minute | ||
0–3 | 2 | 4.2 |
4–6 | 33 | 68.75 |
Needed resuscitation (did not cry) | 13 | 27.1 |
Abbreviation: PNA: perinatal asphyxia.
Nine PNA neonates (18.8%) developed seizure. Of those neonates who had seizure, 66.7% (
In bivariate regression analysis, residence, gestational age, preeclampsia, place of delivery, birth weight, presence of meconium, and duration of labor were significantly associated factors of PNA (Table
Bivariate and multivariable logistic regression model showing predictors of birth asphyxia among babies admitted in ACSH, January 1, 2016–December 30, 2017.
Characteristics | PNA | Non-PNA | At 95% CI | At 95% CI | |
---|---|---|---|---|---|
COR | AOR | ||||
Preeclampsia | |||||
No | 41 | 209 | Ref. | Ref. | |
Yes | 7 | 10 | 3.57 (1.28-9.91) | 7.94 (2.22-28.37) | 0.001 |
Residence | |||||
Urban | 23 | 131 | Ref. | Ref. | |
Rural | 25 | 88 | 1.79 (1.150-0.98-3.25) | 1.7 (0.87-3.37) | 0.114 |
Preterm | 9 | 67 | Ref. | Ref. | |
Term | 38 | 141 | 0.50 (0.23-1.09) | 0.67 (0.22-2.02) | 0.486 |
Postterm | 1 | 11 | 1.48 (0.17-12.84) | 2.87 (0.26-32.47) | 0.393 |
Place of delivery | |||||
Tertiary hospital | 28 | 129 | Ref. | ||
Primary and general hospitals (district) | 6 | 41 | 1.13 (0.46-2.8) | 0.84 (0.29-2.4) | 0.75 |
Health center | 13 | 44 | 0.61 (0.29-1.27) | 0.58 (0.23-1.47) | 0.255 |
Home | 1 | 5 | 0.99 (0.11-8.85) | 1.02 (0.1-10.34) | 0.98 |
Birth weight | |||||
2500-399 g | 34 | 124 | Ref. | Ref. | |
1500-2499 g | 10 | 72 | 1.97 (0.92-4.23) | 1.59 (0.57-4.41) | 0.372 |
1000-1499 g | 2 | 10 | 1.37 (0.28-6.56) | 2.65 (0.28-25.01) | 0.395 |
≥4000 g | 2 | 13 | 1.78 (0.38-8.28) | 0.56 (0.18-5.12) | 0.96 |
MSAF | |||||
Yes | 8 | 14 | 2.92 (1.15-7.44) | 4.17 (1.34-12.98) | 0.014 |
No | 40 | 205 | Ref. | Ref. | |
Duration of labor | |||||
Normal | 40 | 210 | Ref. | Ref. | |
Prolonged | 8 | 9 | 4.7 (1.7-12.82) | 5.19 (1.73-15.63) | 0.003 |
Abbreviation: MSAF: meconium-stained amniotic fluid.
Neonates born to mothers with prolonged duration of labor were 5 times more likely to have PNA (
Neonates who were born with meconium-stained amniotic fluid were 4 times more likely to have perinatal asphyxia as compared to those neonates delivered with clear amniotic fluid (
In the present study, the prevalence of perinatal asphyxia was found to be 18%, which is higher than in developed countries, the latter of which has reduced it to less than 0.1% [
In this study, more males than females were affected by perinatal asphyxia (58.3%). This is consistent with the report from Bangladesh (60.8%) [
The case fatality rate of perinatal asphyxia was 37.5%. This is comparable with the study conducted in Sri Lanka which was 40.6% [
The disparity could be attributable to the difference in hospital setup (some may be better equipped) and the difference in health care provider skills and birth asphyxia severity. Although this study has reported high fatality rate, perinatal asphyxia has contributed to a low overall neonatal mortality rate (6.7%,
Most of the neonates with stage III perinatal asphyxia (84.6%) died. This is higher than the reported 66.7% from Enugu, southeast Nigeria [
The current study revealed that the odds of developing perinatal asphyxia was 4 times higher in neonates of mothers who had meconium-stained amniotic fluid than those without meconium-stained amniotic fluid. Such was demonstrated in the general hospitals of Tigray [
The odds of developing perinatal asphyxia was 5.19 times higher in a newborn whose mother had prolonged duration of labor. This is consistent with reports from different hospitals in Ethiopia including general hospitals in Tigray, Dessie, and Dire Dawa [
Neonates born to mothers who had preeclampsia were 7.94 times more likely to have perinatal asphyxia than neonates from mothers without preeclampsia. This is in agreement with studies done in universities in Nigeria [
As this study has shown high prevalence and also alarmingly significant mortality in neonates with PNA, good obstetric interventions and proper care of neonates in the neonatal intensive care unit are mandatory.
This is the first PNA study in our hospital, and it was able to show the prevalence, associated factors, and outcome of asphyxiated neonates. The study was designed with random sampling technique. Moreover, neonates were included from both rural and urban areas of residence.
This study had some important limitations because it was conducted in a tertiary care hospital where significant numbers of patients were referred being critical; therefore, this prevalence may not reflect the overall prevalence of the community.
Furthermore, this study does not show cause-and-effect relationships because of the cross-sectional study design.
Measurement of fetal or neonatal arterial blood gas would give a stricter and more precise definition of PNA but our hospital’s setup could not give such services because of resource constraints.
In conclusion, the prevalence of perinatal asphyxia was high. The case fatality rate of perinatal asphyxia was alarmingly high. Prolonged labor, presence of meconium-stained amniotic fluid, and preeclampsia were predictors of perinatal asphyxia. Early detection and intervention of high-risk mothers should be carried out by health care providers, and mothers should be monitored with partograph during labor.
All important data are included in the manuscript.
The authors declare that there is no conflict of interest regarding the publication of this paper.
We are grateful to Dr. Abraha Gebreegziabher who helped us in proofreading and editing the manuscript.