Maternal Socio-demographic and ANC characteristics
A total of 489 neonates were admitted during the study period. Two hundred seventy-nine (57.1%) mothers of the neonates were ages 21-30 years with a mean age of 26.44 +6.04 years. And 198(40.5%) were unable to read and write, while 452(90%) of the mothers were married and more than half of 255(52.1%) participants were urban residents. Regarding ANC follow-up, two-third of mothers 378(77.3%) had attended at least one prenatal visit however only 116(23.7%) had received the recommended follow up for their current pregnancy (which is 4 or more ANC visits). 180(36.8%) mothers started ANC follow-up before 24 weeks of gestation and 49 ( started after 30 weeks. (Table 1).
Table 1: Characteristics of mothers whose neonates were admitted to the NICU of public hospitals in Eastern Ethiopia, 2018[n=489].
Characteristics
|
Category
|
Frequency
|
Percent
|
Age
|
less than 20 years
|
109
|
22.3
|
21-30 years
|
279
|
57.1
|
31-40 years
|
95
|
19.4
|
≥ 41 years
|
6
|
1.2
|
Education level
|
Unable to read and write
|
198
|
40.5
|
Able to read and write
|
59
|
12.1
|
Primary Education
|
111
|
22.7
|
Secondary Education
|
80
|
16.4
|
College and above
|
41
|
8.4
|
Marital status
|
Single
|
28
|
5.7
|
Married
|
452
|
92.4
|
Divorced
|
7
|
1.4
|
Widowed
|
2
|
0.4
|
Residence
|
Urban
|
255
|
52.1
|
Rural
|
234
|
47.9
|
ANC follow-up
|
Yes
|
378
|
77.3
|
No
|
111
|
22.7
|
Place of ANC follow up
|
Public
|
320
|
65.4
|
Private
|
58
|
11.9
|
Gestational age at the start of ANC follow up
|
< 24wks
|
180
|
36.8
|
24 -29 wks
|
149
|
30.5
|
30- 35 wks
|
37
|
7.6
|
greater than 35wks
|
12
|
2.5
|
Number of ANC follow up attended
|
One
|
37
|
7.6
|
Two
|
80
|
16.4
|
Three
|
145
|
29.7
|
four and above
|
116
|
23.7
|
Obstetrics characteristics
Two hundred eighty-three (57.9%) of neonates were from multiparous mothers and 90% delivered as a singleton with 380 (77.7%) delivering at the index Hospital. About 299(61.1%) were delivered by midwives, and 288(58.9%) mothers had a labor duration ranging from 4-12 hours. More than two-thirds, 338(69.1%) mothers delivered through spontaneous vaginal delivery and 319(65%) of neonates were full term at birth (Table 2).
Table 2:Obstetric characteristics of mothers whose neonates were admitted to the NICU of public hospitals in Eastern Ethiopia, 2018[n=489].
Characteristics
|
Category
|
Frequency
|
Percent
|
Parity
|
Primipara
|
206
|
42.1
|
Multipara
|
283
|
57.9
|
Type of pregnancy
|
Single
|
440
|
90.0
|
Twins
|
49
|
10.0
|
Place of delivery
|
At the index Hospital
|
380
|
77.7
|
Another hospital
|
30
|
6.1
|
Health center
|
53
|
10.8
|
Private facilities
|
4
|
0.8
|
Home
|
22
|
4.5
|
Birth attendant
|
Midwife
|
299
|
61.1
|
Physician
|
151
|
30.9
|
Nurse
|
11
|
2.2
|
Health extension workers
|
2
|
0.4
|
Traditional birth attendants
|
23
|
4.7
|
Others
|
3
|
0.6
|
Duration of labor
|
< 4hrs
|
43
|
8.8
|
4-12hrs
|
288
|
58.9
|
Greater than12 hrs.
|
158
|
32.3
|
Amniotic fluid status during labor
|
Clear
|
360
|
73.6
|
Meconium stained
|
107
|
21.9
|
Bloodstained
|
22
|
4.5
|
Mode of delivery
|
Spontaneous Vaginal
|
338
|
69.1
|
Cesarean section
|
122
|
24.9
|
Instrumental Delivery
|
29
|
5.9
|
Gestational age at birth
|
Very preterm
|
63
|
12.9
|
Late preterm
|
97
|
19.8
|
Term
|
319
|
65.2
|
post-term
|
10
|
2.0
|
Length of hospital stay
|
<3 days
|
160
|
32.7
|
4-7
|
229
|
46.8
|
>7
|
100
|
20.4
|
Complications during pregnancy
Eighty-one (16.6%) of mothers had a complication during the current pregnancy with preeclampsia or eclampsia 43(8.8%), being the most common. In addition, 30(6.1%) mothers had medical illness during pregnancy. Two hundred twenty-six (46.2%) of the mothers had a complication during labor with the most common complication being prolonged duration of labor in 103 (21.1%) of the women. (Table 3).
Table 3: Obstetric and Labor complications among mothers whose neonates were admitted to the NICU of public Hospitals in Eastern Ethiopia, 2018[n=489].
Characteristics
|
Category
|
Frequency
|
Percent
|
Obstetric complications during current pregnancy
|
Yes
|
81
|
16.6
|
No
|
408
|
83.4
|
Preeclampsia or eclampsia
|
43
|
8.8
|
Chorioamnionitis
|
8
|
1.6
|
Premature rupture of membrane
|
18
|
3.7
|
Ant partum hemorrhage
|
17
|
3.5
|
Other
|
1
|
0.2
|
Medical illness during pregnancy
|
Yes
|
30
|
6.1
|
No
|
459
|
93.9
|
Diabetes mellitus
|
5
|
1.0
|
Hypertension
|
8
|
1.6
|
Tuberculosis
|
1
|
0.2
|
Cardiac disease
|
1
|
0.2
|
Anemia
|
14
|
2.9
|
Human immunodeficiency virus
|
3
|
0.6
|
Others
|
2
|
0.4
|
Complication during labor
|
Yes
|
226
|
46.2
|
|
No
|
263
|
53.8
|
|
Prolonged labor
|
103
|
21.1
|
|
Premature rupture of membrane
|
62
|
12.7
|
|
Fetal distress
|
84
|
17.2
|
|
Cord prolapsed
|
8
|
1.6
|
Neonatal Characteristics
The majority of newborns, 306(62.6%) were males and 378(77.3%) were admitted within the first day of life. More than half 274(56.4%) of the neonates had a normal birth weight (2500-3999grams). Three-fourths of the neonates, 350(71.6%) were hypothermic upon admission, and 133(27.2%) of neonates suffered from birth asphyxia at 5 minutes (based on the 5 minute Apgar score). And 301(61.1%) initiated exclusive breastfeeding in the first hour (Table 4).
Table 4: Characteristics among neonates admitted to the NICU of public Hospitals in Eastern Ethiopia, 2018[n=489].
Variable
|
Category
|
Frequency
|
Percent
|
Sex of the newborn
|
Male
|
306
|
62.6
|
Female
|
183
|
37.4
|
Age of neonate on admission
|
≤ one day
|
378
|
77.3
|
>one days
|
111
|
22.7
|
Birth weight
|
< 1000grams
|
8
|
1.6
|
1000-1499 grams
|
33
|
6.7
|
1500-2499 grams
|
145
|
29.7
|
2500-3999 grams
|
274
|
56.0
|
≥ 4000 grams
|
29
|
5.9
|
Temperature at admission(0c)
|
< 36.5
|
350
|
71.6
|
36.5-37.5
|
92
|
18.8
|
>37.5
|
47
|
9.6
|
Score at Apgar5thminutes
|
≤3
|
7
|
1.4
|
4-6
|
126
|
25.8
|
7-10
|
251
|
51.3
|
Unknown
|
105
|
21.5
|
Initiation of Feeding in 1st hour with
|
NPO
|
152
|
31.1
|
|
EBF
|
301
|
61.1
|
|
Formula Feeding
|
36
|
7.4
|
Treatment modalities
Four hundred thirty-five (89%) of neonates had received antibiotics and 416(85.1%) had intravenous fluids as therapeutic treatment while only 72(14.7%) utilized the kangaroo mother care (figure 1).
The proportion of neonatal deaths
Among admitted newborns, 98(20%) died and the majority of deaths occurred within the first day of life (Figure2).
Cause of Neonatal Mortality
The most common cause of neonatal mortality was prematurity 48(49%) followed by birth asphyxia 37(37.8%) and infection 32(32.6%) among the neonates admitted to the NICU as shown in (Figure3).
Predictors of Neonatal death
In the multivariate logistic analysis, low 5 minute APGAR score, low birth weight, preterm birth, length of hospital stay, febrile illness and feeding status were independent predictors of neonatal mortality. Being preterm was almost three times more likely to die as compared with term neonates (AOR, 2.78 [95% CI: 1.17, 6.57]). Low birth weight babies were two times more likely to die when compared with normal birth weight (AOR, 2.39 [95% CI: 1.04, 5.41]). Furthermore, neonates with low 5 minute APGAR score was five times more likely to die as compared with 5 minutes APGAR score of greater than or equal to seven (AOR, 5.18[95% CI: 2.51, 10.66]); length of staying was another variable found to be predictors of mortality(AOR,3.63 [95% CI:1.82, 7.22]). Neonates who were hospitalized for less than 3 days were more likely to die than those who were hospitalized 4-7 days; this implied that majorities of deaths occurred in the first 72 hours of life. In addition, neonates with fever on admission were seven times more likely to die as compared with afebrile neonates on admission (AOR, 6.68 [95% CI: 1.34, 33.13]). Moreover, neonates who did not initiate breastfeeding with in the first 24 hours were twelve times more likely to die than those who initiated exclusive breastfeeding within the first 24 hours of life(AOR, 12.16 [95% CI: 5.98, 24.70](Table 5).
Table 5: Multivariate analysis for Predictors of Neonatal Mortality among neonates admitted to NICU of public hospitals, Eastern Ethiopia, 2018[n=489]
Neonatal mortality
|
|
|
Characteristics
|
Died
|
Improved
|
COR
|
AOR
|
P value
|
Maternal Age
|
|
|
|
|
|
21-30 years
|
51
|
228
|
1
|
|
|
<20 years
|
29
|
80
|
1.62(0.96, 2.73)
|
1.50(0.67, 3.34)
|
-
|
31-40 years
|
17
|
78
|
0.97(0.53, 1.78)
|
1.85(0.76, 4.48)
|
|
>40 years
|
1
|
5
|
0.89(0.102, 7.818)
|
2.40(0.23, 24.89)
|
|
Marital status
|
|
|
|
|
|
Married
|
88
|
364
|
1
|
1
|
|
Single
|
9
|
19
|
1.96(0.86, 4.48)
|
1.33(0.35, 5.03)
|
|
Others
|
1
|
8
|
0.52(0.06, 4.18)
|
1.62(0.15, 16.94)
|
-
|
Parity
|
|
|
|
|
|
Multi-Para
|
50
|
233
|
1
|
1
|
|
Primi-para
|
48
|
158
|
1.42(0.91, 2.21)
|
1.94(0.93, 4.05)
|
-
|
Place of delivery
|
|
|
|
|
|
Inborn (in this hospital)
|
253
|
127
|
1
|
1
|
|
Other facility
|
46
|
41
|
0.56(0.29, 1.09)
|
0.50(0.17, 1.51)
|
|
Home
|
16
|
6
|
0.35(0.08, 1.53)
|
0.26(0.03, 2.40)
|
-
|
Duration of labor
|
|
|
|
|
|
4 -12 hrs
|
177
|
111
|
1
|
1
|
|
less than 4 hrs
|
27
|
16
|
0.80(0.35, 1.81)
|
0.45(0.12, 1.63)
|
-
|
More than 12hrs
|
111
|
47
|
0.69(0.41, 1.14)
|
0.62(0.30, 1.25)
|
|
Mode of delivery
|
|
|
|
|
|
Spontaneous vaginal
|
221
|
117
|
1
|
1
|
|
Cesarean section
|
79
|
43
|
1.23(0.73, 2.05)
|
1.00(0.47, 2.10)
|
-
|
Instrumental
|
15
|
14
|
2.78(1.24, 6.17)
|
1.34(0.40, 4.44)
|
|
Length of hospital stay
|
|
|
|
|
|
4-7 days
|
172
|
57
|
1
|
1
|
|
<3 days
|
68
|
92
|
4.03(2.43, 6.67)
|
3.63(1.82, 7.22) *
|
.000
|
>7 days
|
75
|
25
|
0.77(0.35, 1.63)
|
0.61(0.23, 1.58)
|
|
Gestational age at birth
|
|
|
|
|
|
Term
|
227
|
92
|
1
|
1
|
|
Preterm
|
82
|
78
|
3.56(2.23, 5.66)
|
2.78(1.17, 6.56) *
|
.020
|
Post term
|
6
|
4
|
4.65(1.25, 17.19)
|
4.54(0.83, 24.70)
|
|
Birth weight
|
|
|
|
|
|
2500-3999 grams
|
211
|
86
|
1
|
1
|
|
Less than 2499 grams
|
77
|
86
|
3.46(2.17, 5.49)
|
2.39(1.04, 5.49) *
|
.040
|
> 4000 grams
|
27
|
2
|
0.23(0.03, 1.73)
|
0.67(0.06, 6.80)
|
|
APGAR at 5th minutes
|
|
|
|
|
|
7-10
|
188
|
63
|
1
|
1
|
|
≤ 6
|
68
|
65
|
5.62(3.32, 9.47)
|
5.18(2.51, 10.66) *
|
.000
|
Unrecorded
|
59
|
46
|
1.33(0.67, 2.60)
|
2.50(0.82, 7.54)
|
|
Temperature on admission
|
|
|
|
36.5 –37.5c0
|
64
|
28
|
1
|
1
|
|
<36.5c0
|
218
|
132
|
3.37(1.56, 7.23)
|
2.75(0.97, 7.78)
|
|
>37.5c0
|
33
|
14
|
1.25(0.38, 4.05)
|
6.68(1.345, 33.13) *
|
.020
|
Initiation of Feeding
|
|
|
|
|
|
EBF
|
237
|
64
|
1
|
1
|
|
NPO
|
53
|
99
|
16.71(9.32, 29.94)
|
12.16(5.98, 24.70) *
|
.000
|
FF
|
25
|
11
|
2.69(0.930, 7.80)
|
1.71(0.47, 6.15)
|
|
|
|
|
|
|
|
|
|
*statistically significant at p ≤ 0.05; EBF: Exclusive breastfeeding; NPO: nothing per month; FF: Formula Feeding