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 aged 21-30 years with a mean age (+SD) of 26.44 +6.04 years. One hundred ninety-eight (40.5%), 452(90%) and 255(52.1%) mothers were unable to read and write, married and urban residents respectively. 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 was 4 or more ANC visits). One hundred eighty (36.8%) mothers started ANC follow-up before 24 weeks of gestation and 149(30.5%) started after 24 -30 weeks of gestation (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
|
< 24weeks
|
180
|
36.8
|
24 -29 weeks
|
149
|
30.5
|
30- 35 weeks
|
37
|
7.6
|
greater than 35weeks
|
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%) neonates were delivered from multiparous mothers. Four hundred forty (90%) were a singleton type and 380 (77.7%) delivered at the index hospital. About 299(61.1%) mothers were delivered by midwives, and 288(58.9%) mothers had a labor duration ranging from 4-12 hours. More than two-thirds (69.1%) of mothers were delivered through spontaneous vaginal delivery and 319(65%) 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(< 34 weeks )
|
63
|
12.9
|
Late preterm(34-36weeks)
|
97
|
19.8
|
Term(37-42weeks)
|
319
|
65.2
|
post-term(>42weeks)
|
10
|
2.0
|
Length of hospital stay
|
<3 days
|
160
|
32.7
|
4-7days
|
229
|
46.8
|
>7days
|
100
|
20.4
|
Complications during pregnancy
Eighty-one (16.6%) mothers had a complication during the current pregnancy. Preeclampsia or eclampsia account for 43(8.8%). In addition, 30(6.1%) mothers had a medical illness during pregnancy. Two hundred twenty-six (46.2%) mothers had a complication during labor with the most common complication being prolonged duration of labor in 103 (21.1%) participants (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 the 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
Three hundred six (62.6%) and 378(77.3%) of newborns were male and admitted within the first day of life respectively. More than half (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%) suffered from birth asphyxia at 5 minutes (based on the 5 minute Apgar score). Three hundred one (61.1%) newborn 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
|
Apgar score at 5 minute
|
≤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
|
Nothing per mouth
|
152
|
31.1
|
|
Exclusive Breast Feeding
|
301
|
61.1
|
|
Formula Feeding
|
36
|
7.4
|
Treatment modalities
Four hundred thirty-five (89%) 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 and causes of Neonatal Mortality
Among admitted newborns, 98(20%) died and the remaining were survived from admission to discharge in NICU (Figure2). The most common causes of neonatal mortality were complications of preterm 28(28.58%) followed by birth asphyxia 22(22.45%) and neonatal infection 18 (18.36%) (Figure3).
Predictors of Neonatal Mortality in NICU
In the multivariable 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 (AOR: 2.78, 95% CI: 1.17, 6.57) more likely to die compared with term neonates. Low birth weight babies were two times (AOR: 2.39, 95% CI: 1.04, 5.41) more likely to die when compared with normal birth weight. Furthermore, newborn with low 5 minute APGAR score was about five times(AOR: 5.18,95% CI: 2.51,10.66) more likely to die compared with 5 minutes APGAR score of greater than or equal to seven; length of stay was another variable found to be predictors of neonatal mortality. Newborn who were hospitalized for less than 3 days were nearly four times (AOR:3.63,95% CI:1.82, 7.22) more likely to die than those who were hospitalized 4-7 days; this implies that majority of deaths occurred in the first 72 hours of life. In addition, neonates with fever on admission were nearly seven times (AOR: 6.68, 95% CI: 1.34, 33.13) more likely to die compared with afebrile neonates. Moreover, neonates who did not initiate breastfeeding with in the first 24 hours were twelve times (AOR: 12.16, 95% CI: 5.98, 24.70) more likely to die than those who initiated exclusive breastfeeding within the first 24 hours of life (Table 5).
Table 5: Multivariable 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)
|
.335
|
31-40 years
|
17
|
78
|
0.97(0.53, 1.78)
|
1.85(0.76, 4.48)
|
.212
|
>40 years
|
1
|
5
|
0.89(0.10, 7.82)
|
2.40(0.23, 24.89)
|
.532
|
Marital status
|
|
|
|
|
|
Married
|
88
|
364
|
1
|
1
|
|
Single
|
9
|
19
|
1.96(0.86, 4.48)
|
1.33(0.35, 5.03)
|
.766
|
Others
|
1
|
8
|
0.52(0.06, 4.18)
|
1.62(0.15, 16.94)
|
.543
|
Parity
|
|
|
|
|
|
Multi-Para
|
50
|
233
|
1
|
1
|
|
Primi-para
|
48
|
158
|
1.42(0.91, 2.21)
|
1.94(0.93, 4.05)
|
.680
|
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)
|
.275
|
Home
|
16
|
6
|
0.35(0.08, 1.53)
|
0.26(0.03, 2.40)
|
.205
|
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)
|
.225
|
More than 12hrs
|
111
|
47
|
0.69(0.41, 1.14)
|
0.62(0.30, 1.25)
|
.184
|
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)
|
.460
|
Instrumental
|
15
|
14
|
2.78(1.24, 6.17)
|
1.34(0.40, 4.44)
|
.944
|
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)
|
.310
|
Gestational age at birth
|
|
|
|
|
|
Term (37-42weeks)
|
227
|
92
|
1
|
1
|
|
Preterm (<37weeks)
|
82
|
78
|
3.56(2.23,5.66)
|
2.78(1.17, 6.56) *
|
.020
|
Post term (>42weeks)
|
6
|
4
|
4.65(1.25,17.19)
|
4.54(0.83, 24.70)
|
.051
|
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)
|
.858
.86
|
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)
|
.092
|
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)
|
.057
|
>37.5c0
|
33
|
14
|
1.25(0.38, 4.05)
|
6.68(1.35, 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(0.93, 7.80)
|
1.71(0.47, 6.15)
|
|
|
|
|
|
|
|
|
|
*statistically significant at p ≤ 0.05; EBF: Exclusive breastfeeding; NPO: nothing per month; FF: Formula Feeding