Over all process of the study
In this study 6986 study participants were interviewed in the baseline after excluding 131 twin deliveries from total live births in three selected public hospitals from two zones of Southern Ethiopia. During follow up for 28 days 153 study participants became loss to follow up and 64 were excluded from study because of inconsistent and incomplete information. At the end of follow up 6769 study participants stayed in the cohort and interviewed the end line which gave response rate of 96.9%. During follow up 6704 neonates were survived and 65 were died. Verbal autopsy had conducted among 52 dyed neonates and the rest were refused (Figure 1).
Socio-demographic and economic characteristics of the respondents
Of the neonates mother 3384 (50.0%) were age ranged 25-34 years old and with mean and standard deviation (SD) of 25.3±5.02. Majority (95.0%) were married and 3727 (55.0%) had from gamo ethnicity group. Regarding educational status of neonates mother 1439 (21.3) had no formal education and 2069 (30.6%), 1822 (26.9%) and 1439 (21.3%) had primary (grade 1-8), secondary (grade 9-12) and college and above respectively. Two thousand eighty (30.7%) of neonates father had educational status of college and above and 2497 (36.9%) had merchant. Out of neonates mother 2885 (42.6%) had orthodox religion follower and 420 (6.2%), 2966 (43.8%), 451 (6.7%) and 47 (0.7%) were catholic, protestant, muslim and traditional respectively. More than half (57.7%) of the neonates mother were house wife and 1057 (15.6%), 1403 (20.7%), 123 (1.8%) and 283 (4.2) were merchant, government employer, daily labour and student respectively and 4067 (60.1%) had urban residents (Table 2).
Table 2: Socio-demographic and economic characteristics of study participants in public hospitals of Gamo and Gofa Zones, Southern Ethiopia, 2018/9 (n=6769)
Characteristics
|
Survived
|
Died
|
Frequency (%)
|
Age
|
|
15-24
|
2979(99.2)
|
23(0.8)
|
3002(44.3)
|
25-34
|
3364(99.4)
|
20(0.6)
|
3384(50.0)
|
≥35
|
361(94.2)
|
22(5.7)
|
383(5.7)
|
Marital status
|
|
Married
|
6366(99.0)
|
64(1.0)
|
6430(95.0)
|
Other*
|
338(99.7)
|
1(0.3)
|
339(5.0)
|
Ethnicity
|
|
Gamo
|
3693(99.1)
|
32(0.9)
|
3725(55.0)
|
Gofa
|
1512(99.5)
|
7(0.5)
|
1519(22.4)
|
Other†
|
1499(98.3)
|
26(1.7)
|
1525(22.5)
|
Educational status of father
|
|
No formal education
|
1011(98.5)
|
15(1.5)
|
1026(15.2)
|
Primary (1-8)
|
1612(98.5)
|
24(1.5)
|
1636(24.2)
|
Secondary (9-12)
|
2023(99.8)
|
4(0.2)
|
2027(29.9)
|
College and above
|
2058(98.9)
|
22(1.1)
|
2080(30.7)
|
Occupation of the father
|
|
Farmer
|
1756(99.0)
|
17(1.0)
|
1773(26.2)
|
Merchant
|
2473(99.0)
|
24(1.0)
|
2497(36.9)
|
Government employer
|
1950(98.8)
|
24(1.2)
|
1974(29.2)
|
Wavier
|
275(100.0)
|
0(0.0)
|
275(4.1)
|
Daily labourer
|
250(100.0)
|
0(0.0)
|
250(3.7)
|
Average income per month
|
|
<70.8USD
|
1758(99.0)
|
17(1.0)
|
1775(26.2)
|
70.8-177USD
|
3147(98.5)
|
48(1.5)
|
3195(47.2)
|
>177USD
|
1799(100.0)
|
0(0.0)
|
1799(26.6)
|
*single, divorced and separated due to work
†zayise, amhara, oromo, gurage, woliata, konso, derashe, oyida and gidicho
Maternal and child health, and obstetric factors
Out of the neonates mother 3900 (57.6%) had multipara (birth order ≥2), only 350 (9.0%) had history of still birth and 434 (11.1%) encountered loss of conceptus. Two thousand eight hundred (71.8%) of the mothers of the neonates were birth inter of 24-48 month and 329 (8.4%) had history of neonatal death. Of the neonates mothers 6004 (88.7%) had antenatal care (ANC) and 6674 (98.6%) had immediate post natal care. Regarding mode of delivery 4943 (73.0%) gave birth by spontaneous vaginal delivery, 243 (3.6%) were instrumental and 1583 (23.4) were by caesarean section. One thousand two hundred sixty two (18.6%) encountered premature rupture of membrane and 524 (7.7%) developed hypertension (HTN) during pregnancy. Out of the neonates mothers 193 (2.9%) had anaemic and 682 (10.1%) faced dystocia. From those who faced labour dystocia 24 (3.5%) had due to uterine pre-rupture, 465 (68.2%) had due to prolonged labour and 193 (28.3%) had due to feto-pelvic disproportion. Two hundred thirty (3.4%) of the neonates mothers encountered infection and 130(1.9%) had developed other pathologies. Of the mothers who developed infection 33 (14.4%) had unspecified infection and 50 (21.7%), 100 (43.5%) and 47 (20.4%) had puerperal endometrities, pyelonephtitis and others (syphilis and malaria) respectively. From the mothers who developed other pathologies 33 (25.4%) had HIV/AIDS, 58 (44.6%) had heart diseases and 39 (0.3%) had others (DM, thyroid disorder, embolism and DIC). Regarding presentation of neonates 5818 (86.0%) delivered with vertex and 3606 (53.3%) were male neonates. Of the neonates 65 (1.0%) encountered birth trauma during delivery. From those 24 (36.9%) of the neonates had cephalhematoma, 9 (13.8%) developed caput succedaneum and 32 (49.3%) had others (fracture, bruising and subgleal haemorrhage) (Table 3).
Incidence of neonatal mortality
In this study inter and intra-hospital neonatal mortality incidence ratio was estimated with 95% level of confidence per 1000 live births. The highest proportion of neonatal mortality was reported from Chencha Primary Hospital that 1.0% (95%CI: 0.5, 2.20%) Over all, neonatal mortality incidence ratio in selected three public hospitals was 0.96% (95%CI: 0.75, 1.22%) (Table 4).
Causes of neonatal mortality
In this study 65 neonatal deaths were occurred during follow up period in selected three public hospitals of Gamo and Gofa Zones, Southern Ethiopia. Of the neonatal deaths only 52 respondents were agreed and interviewed for verbal autopsies but rest were refused for verbal autopsy. Almost half (51.9%) of the neonatal deaths were happened due to prematurity or gestational age less than 37 week, 13 (25%) due to neonatal infection, 7 (13.5%) were by birth asphyxia, 3(5.8%) congenital malformation due congenital malformation and the rest were with unspecified cause (Figure 2).
Table 3: Maternal and child health and obstetric factors of study participants in public hospitals of Gamo and Gofa Zones, Southern Ethiopia, 2018/9 (n=6769)
Variables
|
Survived
|
Died
|
Frequency (%)
|
Number of ANC visit
|
No visit
|
734(95.9)
|
31(4.1)
|
765(11.3)
|
1-3
|
1807(99.3)
|
13(0.7)
|
1820(26.9)
|
≥ 4
|
4163(99.5)
|
21(0.5)
|
4184(61.8)
|
Haemorrhage
|
Yes
|
305(96.8)
|
10(3.2)
|
315(4.7)
|
No
|
6399(99.1)
|
55(0.9)
|
6454(95.3)
|
Cause of haemorrhage
|
Placenta praevia
|
105(97.2)
|
3(2.8)
|
108(34.3)
|
PPH
|
151(98.7)
|
2(1.3)
|
153(48.6)
|
Other®
|
49(90.7)
|
5(9.3)
|
54(17.1)
|
Premature rupture of membrane
|
Yes
|
1236(97.9)
|
26(2.1)
|
1262(18.6)
|
No
|
5468(99.3)
|
39(0.7)
|
5507(81.4)
|
Hypertension during pregnancy
|
Yes
|
518(98.9)
|
6(1.1)
|
524(7.7)
|
No
|
6186(99.1)
|
59(0.9)
|
6245(92.3)
|
Classification of HTN
|
Pre-eclampsia
|
295(99.3)
|
2(0.7)
|
297(56.7)
|
Eclampsia
|
72(97.3)
|
2(2.7)
|
74(14.1)
|
Chronic hypertension
|
76(98.7)
|
1(1.3)
|
77(14.7)
|
Gestational hypertension
|
75(98.7)
|
1(1.3)
|
76(14.5)
|
Presentation
|
Vertex
|
5781(99.4)
|
37(0.6)
|
5818(86.0)
|
Non-vertex©
|
923(97.1)
|
28(2.9)
|
951(14.0)
|
Sex of the neonates
|
Male
|
3552(98.5)
|
54(1.5)
|
3606(53.3)
|
Female
|
3152(99.7)
|
11(0.3)
|
3163(46.7)
|
Gestational age
|
<37 week
|
777(96.2)
|
31(3.8)
|
808(11.9)
|
≥37 week
|
5927(99.4)
|
34(0.6)
|
5961(88.1)
|
Birth weight
|
<2500g
|
570(95.0)
|
30(5.0)
|
600(8.9)
|
≥2500g
|
6134(99.4)
|
35(0.6)
|
6169(91.1)
|
Baby referred to other health facilities
|
Yes
|
76(98.7)
|
1(1.3)
|
77(1.1)
|
No
|
6628(99.0)
|
64(1.0)
|
6692(98.9)
|
®accreta/increta/percreta, haemorrhage during delivery, uterine rupture and other obstetric haemorrhage and ©breech, transverse, face and brow
Table 4: Incidence of neonatal mortality among study participants in selected hospitals of Gamo and Gofa Zones, Southern Ethiopia, 2018/9 (n=6769)
Name Hospital
|
n(%) of NM
|
Total number of live births
|
NMIR®
|
with 95%CI per 1000 live births
|
AMGH
|
42(64.6)
|
4455(65.8)
|
9.4(6.9,12.7)
|
CPH
|
8(12.3)
|
794(11.7)
|
10.1(5.0,20.0)
|
SGH
|
15(23.1)
|
1520(22.5)
|
9.9(5.9,16.3)
|
Over all
|
65(100)
|
6769(100)
|
9.6(7.5,12.2)
|
®Neonatal mortality incidence ratio
Determinates of neonatal mortality
After adjusting in multivariable model age of the mother, number of ANC visit, haemorrhage, and presentation, gestational age at birth, birth weight and sex of the neonate were significantly associated with neonatal mortality. Advanced maternal age above 35 years old increased neonatal mortality significantly as compare to age group 15 to 24 years old (β =1.34; 95% CI:0.55,2.14). The number of antenatal visit from 1 to 3 significantly reduced neonatal mortality as compare to four or more visits (β =-0.80; 95% CI:-1.47,-0.13) and haemorrhage increased neonatal mortality significantly (β =0.95; 95% CI: 0.19, 1.71). Non-vertex presentation (β =1.19; 95% CI: 0.64, 1.74), gestational age of less than 37 week (β =1.17; 95% CI: 0.47, 1.88), birth weight of less than 2500g (β =0.73; 95% CI: 0.01, 1.45) and being male neonate (β =0.90; 95% CI: 0.19, 1.60) had significantly increased neonatal mortality (Table 5).
Table 5: Bivariate and multivariable analysis of determinates for neonatal mortality among study participants in selected hospitals of Gamo and Gofa Zones, Southern Ethiopia, 2018/9 (n=6769)
Variables
|
Crude estimate β
|
Adjusted estimate β
|
95%CI
|
Place of residence
|
Urban
|
-0.69(-1.19,-0.20)
|
-0.35(-0.93,0.23)
|
Age of the mother
|
25-34
|
-0.26(-0.86,0.34)
|
-0.65(-1.41,0.11)
|
≥35
|
2.07(1.47,2.66)
|
1.34(0.55,2.14)*
|
Birth interval
|
Not applicable (primi)
|
NA
|
NA
|
<24 month
|
-1.34(-2.74,0.06)
|
-0.89(-2.54,0.74)
|
24-48 month
|
-0.66(-1.86,0.53)
|
-0.43(-1.80,0.95)
|
Number of ANC visits
|
No visit
|
2.12(1.57,2.68)
|
-0.69(-1.41,0.03)
|
1-3 visit
|
0.35(-0.34,1.05)
|
-0.80(-1.47,-0.13)*
|
Party
|
Multipara
|
0.37(-0.15,0.88)
|
0.46(-1.08,1.99)
|
Haemorrhage
|
Yes
|
1.34(0.66,2.02)
|
0.95(0.19,1.71)*
|
Premature rupture of membrane
|
Yes
|
1.08(0.58,1.58)
|
0.23(-0.42,0.89)
|
Presentation
|
Non-vertex©
|
1.56(1.06,2.05)
|
1.19(0.64,1.74)*
|
Gestational age
|
<37 week
|
1.94(1.45,2.43)
|
1.17(0.47,1.88)*
|
Birth weight
|
<2500g
|
2.22(1.73,2.72)
|
0.73(0.01,1.45)*
|
Sex of the neonate
|
Male
|
1.47(0.82,2.12)
|
0.90(0.19,1.60)*
|
©breech, transverse, face and brow, NA: not applicable and *Significant at P<0.05