Prevalence and Predictors of Birth Asphyxia Among Neonates in Bangladesh: A Cross-Sectional Study

doi:10.21203/rs.3.rs-2186700/v1

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Prevalence and Predictors of Birth Asphyxia Among Neonates in Bangladesh: A Cross-Sectional Study

https://doi.org/10.21203/rs.3.rs-2186700/v1

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Birth asphyxia is a severe clinical problem worldwide that contributes to neonatal mortality and morbidity. This study aimed to explore the prevalence of birth asphyxia and its associated risk factors among neonates attending in a selected Bangladeshi tertiary level public hospital. This descriptive cross-sectional study was conducted in Shaheed Suhrawardy Medical College & Hospital, Dhaka, from January to December 2019. A systematic sampling technique was selected for the study sample. Data were collected by conducting a face-to-face interview with the selected respondents. The validated APGAR score measured neonates’ health status. Among the 377 neonates, 11.93% had birth asphyxia.This study found a significant association (p = 0.039) between neonate’s health/asphyxia status and the young age (15 to 20 years) of mothers. In addition, term period (p = 0.03), low birth weight (p = 0.007), Caesarean section ((C-section) (p = 0.017)), abortion and prolonged labor duration (> 12 hours) were strongly associated with birth asphyxia in neonates. The study concludes that the young age of mothers, term period, low birth weight, C-section delivery, abortion, and longer labor duration were significantly associated with the birth asphyxia. It is recommended to raise extensive awareness among the husbands and other family members. Notably, parental training bears a pivotal role to play in maintaining and restoring maternal as well as neonatal health.

Health Policy

Hospital Medicine

Birth Asphyxia

Neonates

Prevalence

Predictors

Neonatal Mortality

Maternal Health

Bangladesh

Perinatal asphyxia (PA) or neonatal hypoxia- ischemia (HI) is defined as an interim status of the interruption of oxygen availability that refers to a perilous metabolic challenge, even when the situation does not head to a fatal result [1–2]. Different parameters set by the clinicians are used in order to investigate and foretell the prognosis for the state of perinatal asphyxia, including non reassuring foetal heart rate patterns, prolonged labour, meconium-stained fluid, low 1-minute Apgar score, and mild to moderate acidemia, defined as arterial blood pH less than 7 or base excess greater than 12 mmol/L [3]. Globally, it has become a serious clinical problem worldwide that contributes to significant neonatal mortality and morbidity [4] which is one of the prime reasons of neonatal deaths within the first week of life [5]. As per the statsitics of WHO, birth asphyxia accounts for yearly 4 million deaths, representing 38% of all deaths of children under 5 years of age. It was estimated that 3% of all infants (3.6 million) suffer from moderate to severe birth asphyxia in the developing countries, of which 23% (840,000) die, and approximately the same number develop serious sequelae [6]-[7]. Notably, it is strongly associated with 1.1 million intrapartum stillbirths [8]. In effect of having asphyxia at birth, the survivors may have the possibility to generate neurological complications like mental disorders, cerebral palsy, epilepsy, and developmental delay [9].

In Bangladesh, the neonatal mortality rate (NMR) is estimated as 32 per 1000 live births where the leading causes of neonatal death e.g., birth asphyxia (21%), low birth weight (11%), and severe infection (34%) [10]. It was evident that an increased level of incidence of birth asphyxia from 29–36%, with a mortality of around 25% was explored in the annual reports of Dhaka Medical College & Hospital, a tertiary level hospital in Bangladesh located in the capital city, from 2001 to 2007 [11]-[12]. Additioanlly, another study conducted in the context of Dhaka found an incidence of birth asphyxia to be 9.76 per 1000 live births [13]. Each year, Birth Asphyxia was responsible for 16% of the total under-five years children mortality [14].

There are very few clinical studies avalilable in terms of birth asphyxia in Bangladesh. Several studies conducted on the basis of hospital data mentioned that neonatal deaths are caused by different factors including birth asphyxia which is one the prime predictors [15–17]. To the best level of knowledge among the authors, no study has yet to conduct on exploring the predictors and the prevalence on birth asphyxia in the context of Bangladesh. On that ground, the aim of this study was to assess the prevalence and predictors of birth asphyxia status among neonates attending a public tertiary hospital in Bangladesh.

The present descriptive cross-sectional study was conducted in Shaheed Suhrawardy Medical College & Hospital, Dhaka, Bangladesh, from January to December 2019. The study population were all neonates delivered through normal delivery or surgery diagnosed with or without perinatal asphyxia during data collection. Considering 56.9% [18] prevalence of perinatal asphyxia, 5% margin of error, and a 95% confidence interval, our ultimate sample size was 377. A systematic sampling technique was selected for the study sample. First, a list of babies was collected from the hospital record book. Then, every 2nd participant from the serial of the list was considered for an interview until the desired calculated sample size of 377 was obtained. The inclusion criteria were the mothers whose delivery was done at the hospital during the data collection period. Exclusion criteria were seriously sick mothers admitted at ICU and who were not interested in participating to the study.

The principal investigator developed the questionnaire, which other authors reviewed. The questionnaire was finalized after pre-testing. Pretesting was undertaken to check for validity, appropriateness, and consistency of the variables used in the study. The questionnaire was initially prepared in English and then translated into Bengali, and again back-translated to English to check the appropriateness of translation. The Bengali version of the questionnaire was pre-tested in the eight mothers attended Dhaka Medical College Hospital, Dhaka to get feedback on the questions’ suitability, appropriateness, and sequencing. After the pretesting done, some minor amendments were done. Data were collected by the assigned enumerators through face-to-face interviews by using a semi-structured questionnaire. The baby’s health status was measured by the validated APGAR score, which quantifies the health state from Medical Records. The APGAR score is based on a total score of 1 to 10, with scores of 7–9 denoting normal and good health in newborns [19].

The study was approved by the ethical committee of the faculty of allied health sciecens of Daffodil International University. The survey involved collecting very personal information. So, the reason and significance of the study was explained to the respondents and written consent was taken from them before interview. They were assured that the information obtained would be used for research purpose only. They were assured of the secrecy of information obtained and ambiguity of the study subjects.

The completeness and accuracy of the data were checked thoroughly. Data were entered, cleaned, and analyzed using Statistical Package for Social Sciences (SPSS) version 22.0. Descriptive statistics, like frequencies and proportions, were used to summarize the data. We set the statistical significance (p-value) of < 0.05. The statistical measurements like chi-square test was performed in order to figure out the degrees of association between the outcome (neonate’s asphyxia status using APGAR scores), and the independent variable (sociodemographic factors, neonates characteristics, obstetric history).

A: Health status by using APGAR score

The pie chart in Fig. 1 visualizes the neonate’s health status distribution using the APGAR score. The findings revealed that 88.07% of neonates were healthy with no asphyxia according to their APGAR score, and the rest of the 11.93% had it.

B: Association of the neonate’s health/asphyxia status by using APGAR scores with the mother’s socio-demographic factors

Table 1 illustrates a significant association between neonate health/asphyxia status and the young age group (15 to 20 years) in mothers. For the other socio-demographic factors, no associations were significant.

Table 1

Association of the neonate’s health/asphyxia status by using APGAR scores with mother’s socio-demographic factors (n = 377)
Variables	Healthy/No asphyxia (332)	Unhealthy/Birth asphyxia (45)	P value
Age group (Years)
15–20	21	13	0.039
21–25	51	9
26–30	65	7
31–35	91	7
35–40	81	2
> 40	23	7
Mean	24.03 years
Educational status
No education	48	9	0.635
Up to primary	92	6
Up to SSC	64	4
Up to HSC	35	14
Graduate and above	93	12
Residence
Rural	96	21	0.432
Urban	236	24	0.432
Place of delivery
Home	49	19	0.235
Hospital	283	26	0.235

C: Association Of The Neonate’s Health/asphyxia Status By Using Apgar Scores With Characteristics Of Neonates

Table 2 illustrates that there is a strong significant association of health/asphyxia status with gestation period (term), birth weight (< 2500g), and mode of delivery (C-section), while no significant association was found with the sex of neonates.

Table 02

Association of the neonate’s health/asphyxia status by using APGAR scores with characteristics of neonates (n = 377)
Variables	Healthy/No asphyxia (332)	Unhealthy/Birth asphyxia (45)	P value
Sex
Male	190	25	0.68
Female	142	20	0.68
Gestation period
Preterm	38	11	0.03
Term	271	27
Post term	23	7
Birth weight
< 2500 g	97	33	0.007
≥ 2500 g	235	12	0.007
Mode of delivery
Vaginal	88	10	0.017
C-section	244	35	0.017

D: Association Of The Neonate’s Health/asphyxia Status By Using Apgar Scores With Obstetric History

Table 3 illustrates that abortion is positively associated with neonate’s asphyxia status. Likewise, a strong association exists between neonate’s health/asphyxia status and labor duration exceeding 12 hours which is statistically significant. However, no significant association was observed between asphyxia status and obstetric history.

Table 3

Association of the neonate’s health/asphyxia status by using APGAR scores with obstetric history (n = 377)
Variables	Healthy/No asphyxia (332)	Unhealthy/Birth asphyxia (45)	P value
Abortion history
None	319	17	0.032
Abortion	13	28	0.032
Birth history
Still birth	49	8	0.067
Live baby	283	37	0.067
Gestation period
> 37–41 weeks	271	34	0.127
> 41 weeks	61	11	0.127
Medication during pregnancy
Medicated	256	31	0.156
No medication	76	14	0.156
Fetus presentation
Cephalic	283	26	0.235
Breech	49	19	0.235
Induction
Syntocinon	40	13	0.157
None	292	32	0.157
Labor duration
≤ 12 hours	299	16	0.012
> 12 hours	33	29	0.012
Referral
Referred	28	6	0.119
Not referred	304	39	0.119

About four to nine million newborn babies develop with birth asphyxia and acute effects like cerebral palsy, epilepsy and developmental delay [9]. In effect, the combination of hypoxia and ischemia of the brain and other vital organs, the key manifestations of asphyxia are created that occurs because of the combination of vasodilatation and vasoparalysis [9].

Basically, Birth asphyxia occurs when a baby is cut off from oxygen before, during, or right after birth. The objective of this descriptive cross-sectional study was to assess the status of birth asphyxia and associated predictors among neonates attending a public tertiary hospital in Dhaka. It is found in this study that the level of prevalence of perinatal asphyxia was 11.93%, which is higher than that of developed countries, the latter of which reduced it to less than 0.1% [20]. In vietnam, the prevalence of birth asphyxia was explored as 2% [21] Similar to our findings high prevalence rate was observed in the public hospitals in terms of Tigray, 22.1% [22]. In the context of India, it was found as 6.6% [23]. A study conducted exploring the situation in the context of Tanzania was figured out as 11.5% [24]. The Nigerian context of birth asphyxia was 12.8% [25]. As per the findings of this study, young maternal age (15–20 years) was one of the leading predictors for developing birth asphyxia, as mentioned in a prior study [26]. Along with the issue of young maternal age, primigravidity is considered as one of the key predictors of birth asphyxia [27]-[30]. No association between the variables like dwelling status, educational attainment, place of delivery and the status of birth asphyxia was figured out in the present study which is also the findings of the studies conducted in different context [18], [31].

The findings of this study reported that no association between the sex of the neonates and their asphyxia status, which was similar to an earlier study performed [18]. It was found that birth asphyxia was significantly higher in the case of delivery than in pre-and post-term babies, which was mentioned in the studies conducted in different context [32], [33]. The present study addressed that birth asphyxia was a result of one of the significant health conditions, low-birth-weight which is also consistent with other similar type of studies [4], [26], [34]. Additionally, the current study revealed that birth asphyxia was larger among the newborns whose mother had a history of having a prolonged duration of delivery. This result is similar with the findings figured out in different studies conducted in different hospitals namely, Dire Dawa, Tigray, Dessie; in the country of Ethiopia [22], [35], [36]. In order to save neonates from birth asphyxia, parental training plays an instrumental role that can be held in the community clinics located across the rural areas for each 6000 population [37]. Additionally, healthy sexual and reproductive health has also a greater role in preventing this health condition where training on misuse of digital media among the parents is a significant issue [38]. Notably, majority of the parents do practice self-medication which sometimes lead to death. So, parents especially, mothers need to be very cautious in this regard [39]. As the pregnant mothers suffer substantially due to the ignorance of the family members as well as the relatives, it needs to be incorporated into the trainings and awareness campaign for the sake of healthy neonates [40]. In a nutshell, health status of the neonates depends on multi-factorial social and behavioral aspects of public health.

For this study, the data was collected considering the issue of reliability. However, the conduction of this study was not free from the limitations. The findings of this study does not represent the whole Bangladesh as it was only confined to a tertiary level hospital based in the capital city, Dhaka. Additioanlly, the sample size was not large enough to cover the greater population with the ability to generalize the findings. This research recommends to conduct large-scale level study in order to figure out the more viable, more acceptable, and more representative findings.

In conclusion, it is said that 88.07% of neonates were healthy and had no asphyxia, and the rest, 11.93% were unhealthy and had birth asphyxia. The young age group of mothers was significantly associated with neonate’s health or asphyxia status. There was a significant association between health or asphyxia status and the term period, low birth weight, and C-section delivery. No significant association was found with the sex of neonates. Last but not the least, abortion and prolonged labor duration were also risk factors revealed in this study. In a nutshell, health status of the neonates depends on multi-factorial social and behavioral aspects of public health. This study recommends the following issues;

To raise extensive community awareness regarding ‘SAY NO’ to early marriage.
To make sure all the anti-natal follow-ups in the near by hospitals or clinics.
To maintain health-related records properly.
To disseminate abortion related knowledge among the mothers and newly married couples.
To closely monitor the personal health measurements including weight.
To make sure the parental training immediately after the marriage ceremony where the parents will be taught about the followings; the strategies of sexual behaviours on how to maintain a quality sexual life and how to make sure a good reproductive health of both husband and wives by the prescriptions of the physicians based on the required medical investigations; how to wisely decide regarding abortion issue; aftermath of miscarriage and its effect on the reproductive health of mother and the relationship between husband and wife, wife and other family members; the nutritional aspects before conceiving a child for the mother; the essentials of nutritious food intakes during pregnancy preparation, during the pregnancy period, and during the post-pregnancy period; the importance of birth-spacing and family planning as per the health of both mother and the neonates; the extended cooperation and warmth from the family members keeping free from all sorts of psychological issues; how to prevent the sexual and reproductive health related misuse of digital media; how to give importance to the opinion of a pregnant mothers is also a key game-changing component of maternal mental health that needs to be taught as well.

Morales, P., Bustamante, D., Espina-Marchant, P. et al. Pathophysiology of perinatal asphyxia: can we predict and improve individual outcomes?. EPMA Journal 2, 211–230 (2011). https://doi.org/10.1007/s13167-011-0100-3
Herrera-Marschitz M, Morales P, Leyton L, Bustamante D, Klawitter V, Espina-Marchant P, et al. Perinatal asphyxia: current status and approaches towards neuroprotective strategies, with focus on sentinel proteins. Neurotox Res. 2011;19:603–27.
MacLennan A. A template for defining a causal relation between acute intrapartum events and cerebral palsy: international consensus statement. BMJ. 1999;319:1054–9.
Pitsawong C and Panichkul P. Risk factors associated with birth asphyxia in Phramongkutklao Hospital. Thai J Obstet Gynaecol. 2012; 19(4):165–171. 2.
Bryce J, Boschi-Pinto C, Shibuya K, and Black RE. WHO estimates the causes of death in children. Lancet. 2005; 365(9465):1147–1152.
Birth Asphyxia - Summary of the previous meeting and protocol overview. Available from: http://www.curoservice.com/health_professionals/news/pdf/10-09-2007_birth asphyxia02.pdf
State of the World’s Children, UNICEF; 2009.
Lawn JE, Manandhar A, Haws RA and Darmstadt GL. Reducing one million child deaths from birth asphyxia-a survey of health systems gaps and priorities. Health Res Policy Syst. 2007; 5:4.
Haider BA, Bhutta ZA: Birth asphyxia in developing countries: current status and public health implications. Curr Probl Pediatr Adolesc Health Care. 2006, 36 (5): 178–188. 10.1016/j.cppeds.2005.11.002.
Bangladesh Demographic and Health Survey (BDHS). 2011.
Annual Report, Dhaka Medical College, 2001.
Annual Report, Dhaka Medical College, 2007.
Bhuiyan SJ. Incidence, risk factors and immediate outcome of Asphyxia Neonatorum in hospitalized neonates: Dept. of Paed IPGMR [Dessertation]. Dhaka: BCPS; 1996.
Rahman AE, Hossain AT, Siddique AB, Jabeen S, Christi MJ, Dockrell DH, Nair H, Jamil K, Campbell H, Arifeen SE. Child mortality in Bangladesh – why, when, where and how? A national survey-based analysis. J Glbo Health 2021;11:04052
State of World’s Newborns, Bangladesh: Saving Newborn Lives Initiatives; Sept 2001.
Khatoon SA, Kawser CA, and Talukder MQK. Clinical spectrum and outcome of birth asphyxiated babies in the neonatal unit of IPGMR: A study of 122 cases. BJCH. 1989; 13: 7–15.
Chowdhury MAKA, Banu K, Rahman M and Rahman M. Birth asphyxia- a prospective study in Dhaka Shishu Hospital. DS (Child) HJ. 1996; 12: 18–22.
Solayman et al. Prevalence of Perinatal Asphyxia with evaluation of Associated Risk Factors in a Rural Tertiary Level Hospital;KYAMC Journal; Vol 8, No 1, July, 2017.)
Apgar Score. Medline Plus. https://medlineplus.gov/ency/article/003402.htm#:~:text=The%20Apgar%20score%20is%20based,newborn%20is%20in%20good%20health
Saving Newborn Lives. The state of the world’s newborn: a report from Saving Newborn Lives. Washington, DC: SAVE the Children; 2001.
Kruse, A.Y., Ho, B.T., Phuong, C.N. et al. Prematurity, asphyxia and congenital malformations underrepresented among neonates in a tertiary pediatric hospital in Vietnam. BMC Pediatr 12, 199 (2012). https://doi.org/10.1186/1471-2431-12-199
Gebreheat G., Tsegay T., Kiros D., et al. prevalence and associated factors of perinatal asphyxia among neonates in general hospitals of Tigray, Ethiopia, 2018. BioMed Research International. 2018;2018:7. doi: 10.1155/2018/5351010.5351010
Babu BV, Devi SS, Kumar BK. “Birth asphyxia–Incidence and immediate outcome in relation to risk factors and complications”. Int J Res Health Sci 2014; 31; 2(4):1064–71.
Simiyu IN, Mchaile DN, Katsongeri K, Philemon RN and Msuya SE. Prevalence, severity and early outcomes of hypoxic ischemic encephalopathy among newborns at a tertiary hospital, in northern Tanzania. BMC Pediatrics 2017; 17:13. https://doi.org/10.1186/s12887-017-0780-5 PMID: 28086760
Ekwochi U, Asinobi1 NI, Osuorah CD, Ndu IK, Ifediora C, Amadi OF, et al. Incidence and Predictors of Mortality Among Newborns With Perinatal Asphyxia: A 4-Year Prospective Study of Newborns Deliv ered in Health Care Facilities in Enugu, South-East Nigeria. Clinical Medicine Insights: Pediatrics 2017; 11: 1–10.
Shabnam Mostari et al. Exploring the Factors Associated with Birth Asphyxia among the Newborn Infants at a Rural Hospital in Bangladesh. Asian Journal of Research in Nursing and Health 1(1): 1–9, 2018; Article no.AJRNH.45726
Pitsawong C, Panichkul P: Risk factors associated with birth asphyxia in Phramongkutklao Hospital. Thai J Obstet Gynaecol. 2012, 19 (4): 165–171.
Lee AC, Mullany LC, Tielsch JM, Katz J, Khatry SK, LeClerq SC, Adhikari RK, Shrestha SR, Darmstadt GL: Risk factors for neonatal mortality due to birth asphyxia in southern Nepal: a prospective, community-based cohort study. Pediatrics. 2008, 121 (5): e1381-e1390. 10.1542/peds.2007 – 1966.
Nayeri F, Shariat M, Dalili H, Adam LB, Mehrjerdi FZ, Shakeri A: Perinatal risk factors for neonatal asphyxia in Vali-e-Asr hospital, Tehran-Iran. Iran J Reprod Med. 2012, 10 (2): 137–140.
Onyearugha CN, Ugboma HA: Fetal outcome of antepartum and intrapartum eclampsia in Aba, southeastern Nigeria. Trop Dr. 2012, 42 (3): 129–132. 10.1258/td.2012.110206.
Gebrehiwot Teklehaimanot Gebregziabher et al. Prevalence and Associated Factors of Perinatal Asphyxia in Neonates Admitted to Ayder Comprehensive Specialized Hospital, Northern Ethiopia: A Cross-Sectional Study. Int J Pediatr. 2020; 2020: 4367248
Shireen N, Nahar N and Mollah AH. Risk factors and short-term outcome of birth asphyxiated babies in Dhaka Medical College Hospital. Bangladesh J Child Health. 2009; 33(3): 83–89.
Memon S, Shaikh S and Bibi S. To compare the outcome (early) of neonates with birth asphyxia inrelation to place of delivery and age at time of admission. JPMA. 2012; 62: 1277.
Aslam HM, Saleem S, Afzal R, Iqbal U, Saleem SM, Shaikh MWA and Shahid N. Risk factors of birth asphyxia. Italian Journal of Pediatrics. 2014. Doi 10.1186/s13052-014-0094-2.
Kibret Y., Hailu G., Angaw K. Determinants of birth-asphyxia among newborns in Dessie Town Hospitals, North Central Ethiopia. International journal of Sexual Health and Reproductive Health. 2018;1(1):1–12.
Ibrahim N. A., Muhye A., Abdulie S. Prevalence of birth asphyxia and associated factors among neonates delivered in Dilchora Referral Hospital, in Dire Dawa, Eastern Ethiopia. Clinics Mother Child Health. 2017;14(4):p. 279. doi: 10.4172/2090-7214.1000279.
BakiBillah, A. H. (2022). The Reality Check of Community Clinic in Bangladesh: A Case Study of Two Selected Villages of Naogaon District.
BakiBillah, A. H., & Chowdhury, A. A. (2022). Factors Influencing Sexual and Reproductive Health-related Misuse of Digital Media in Bangladesh.
Muhammad, F., Oruche, C. A., & Billah, A. K. B. (2021). Self-Medication Overview: An African Perspective. OIRT Journal of Scientific Research, 1(1), 1–2.
Parvez, M. A., Islam, M., Billah, A. H. M. K. B., & Islam, M. T. (2019). Reproductive Health Risks of Divorced Poor Women and its Consequences.

The authors declare no competing interests.

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Prevalence and Predictors of Birth Asphyxia Among Neonates in Bangladesh: A Cross-Sectional Study

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Abstract

Figures

Introduction

Materials And Methods

Results

A: Health status by using APGAR score

C: Association Of The Neonate’s Health/asphyxia Status By Using Apgar Scores With Characteristics Of Neonates

D: Association Of The Neonate’s Health/asphyxia Status By Using Apgar Scores With Obstetric History

Discussion

Conclusion

References

Additional Declarations

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