Neonatal Near Miss and its associated factors at Injibara General Hospital, Awi Zone, Northwest Ethiopia, 2019

Background: Neonatal mortality is a significant problem in many low-resource countries, yet for every death there are many more new-born who suffer a life-threatening complication but survive. Neonatal near miss has been proposed as a tool for assessment of quality of care in neonates who suffered any life-threatening condition. However, there was limited evidence on magnitude of neonatal near miss and determinant factors in Ethiopia. The aim of this study was to assess proportion and associated factors of neonatal near miss among deliveries at Injibara General Hospital, Awi Zone, Northwest Ethiopia, 2019. Methods: Institutional based cross sectional study was conducted from February 1, 2019 to April 30, 2019 among 404 live births. Structured and pretested questioner used for mothers and structured checklist for neonates. Bivariate and multivariate logistic regressions model were fitted to identify factors associated with neonatal near miss. An adjusted odds ratio with 95 % confidence interval (CI) was computed to determine the level of significant. Result: Proportion of neonatal near miss was found to be 23.3 % with 95% CI: (19.1% -27.7%). Primiparous[Adjusted odds ratio(AOR):2.01, 95%CI:(1.03-3.95)], referral linkage [AOR:3.23, 95%CI:(1.89-5.513)], maternal perception of reduced fetal movement[AOR:5.95, 95%CI:2.47-14.33], premature rupture of membrane [AOR: 3.10, 95%CI: (1.27-5.59)], prolonged labor [AOR: 3.00, 95%CI: (1.28-7.06)], obstructed labor/cephalo-pelvic disproportion [AOR: 4.05; 95%CI: (1.55-10.57)] and non-reassuring fetal heart rate pattern [AOR: 3.75, 95%CI: (1.69-8.33)] were significantly associated with neonatal near miss. Conclusion: Proportion of neonatal near miss in the study area was found to be higher than studies in WHO neonatal near miss


Background
Neonatal near miss is defined as a newborn who presented a severe complication in the first 28 days of life almost died but survived during the neonatal period [1,2].The near miss concept and indicators provide useful information to evaluate the quality of care and set priorities for further assessments and improvement of health care [1,3].
Identification of neonatal near miss cases was based on two groups of criteria (pragmatic and management criteria). The pragmatic criteria; (Birthweight < 1750 g, Apgar score < 7 at 5 minutes and gestational age at birth < 33 complete weeks) and management criteria; ( parenteral antibiotic therapy up to 7 days and before 28 days of life, mechanical ventilation,nasal continuous positive airway pressure, intubation up to 7 days and before 28 days of life, phototherapy within 24 hours of life, cardiopulmonary resuscitation,use of vasoactive drugs,use of anticonvulsant drugs, use of surfactant, use of blood products,use of steroids for the treatment of refractory hypoglycemia, surgery, use of antenatal steroid,use of parenteral nutrition, identification of congenital malformation) [2,4].
Near miss concept is a potentially useful approach to assess quality of newborn care but due to enormous variability of socio -demographic and technological advances in newborn care and registration of health information makes no consensus on establishment of criteria of neonatal near miss [5,6].  [7].
Neonatal near miss rate in in different studies revealed that 72.5/1,000 live births in WHO multicounty survey, 220/1000 live births in Northeastern Brazil and 39.2 / 1000 live births in Birth in Brazil survey [8][9][10]. Data collection procedure and quality assurance A combination of data collection methods was used. The data from mothers was collected by using pre tested interviewer-administered structured questionnaire which were adapted from literature reviews and maternal charts also reviewed for clarity of diagnosis and intervention. Data from their neonates was collected by using structured checklist adapted from different literatures which were developed for similar purpose by different authors. The verbal autopsy was used to collect information from individuals who provided health care service. Maternal data collection tool (questionnaire) was prepared first in English and then translated to a local language (Amharic and Agew) and then retranslated back to English to verify the consistency and content of the questionnaire. Data was collected by 5 BSc midwives and supervised by two senior BSc midwives.
Training was given for data collectors and supervisors regarding to the objectives of the study, method of data collection and significance of the study to prevent any confusion and have a common understanding about the study. Pre-test was conducted for 10% of sample size on other district hospital that have similar characteristics with the study population. Throughout the course of the data collection, interviewers was supervised and regular meetings was held between the data collectors, supervisor and the principal investigator together in which problematic issues arising from interviews was discussed and addressed. The collected data was reviewed and checked for completeness before data entry.

Data analysis
All collected questionnaires were checked manually for completeness and then coded and entered in to Epi-data version 3.5 then exported in to SPSS (statistical packages for social science) version 20 for analysis.Discriptive statistics,binary and multivariable logistic regression analysis were used to identify associated factors. Variables having p-value < 0.20 in the bivariate analysis was selected for the multivariate logistic regression model for adjustment of confounding effect between explanatory variables. Adjusted odds ratio with 95 % confidence interval (CI) was computed and variables having P-value less than 0.05 in the multivariate logistic regression model was considered as statistically significant. Odds ratio was also used to determine the strength of association between independent variables and the outcome variable.

Socio-demographic characteristic of study subjects in Injibara General
Hospital, Awi Zone, Northeast Ethiopia, 2019 A total of 404 mothers with their live birth neonates were interviewed with a response rate of 100%. Mothers of newborn were in the age group of 20-34 years, 311(77%) with the mean age was (29 years ± 5.4 SD). 99% of mothers were married and 97% of mothers were orthodox religious follower. 289(71.5%) were Agew ethnicity and nearly two third were urban residence, 254(63%).Regarding to educational status, mothers were not attended formal education 150(37 %). Two hundred forty five (61%) of motheres were housewife.
Obstetrics and Gynecology characteristic of mothers of newborns All selected mothers of newborns had at list one ANC follow up visit.Women who had 1-3 ANC visit were 213(52.7%) and high proportion of neonatal near miss cases,57(60.6%) was found in this category of ANC follow up visit. Twenty eight percent of mothers were primiparous. High rate of neonatal near miss cases were observed in primiparous 36(38.3%). 148(36.6%) of mothers of newborns were referred from other health institution, among them more than half 56(60%) of neonatal near miss cases were found.

Neonatal near miss characteristic
A total of 94(23.3%) livebirth neonates were met the criteria of neonatal near miss.
Among neonatal near miss selection criteria; mechanical ventilation was the most commonly identified criteria, 50(53%) with proportion of 124/1000 live births and 35(37%) of neonatal near miss cases were preterm birth, less than 37completed weeks of gestation with proportion of 86.6/1000live births. Almost one third of neonatal near miss cases were low birth weight, 29(31%) and accounts almost 82/1000 live births. More than half of neonatal near miss cases, 53(58%) were faced more than one neonatal near miss criteria [ Table 2].

Factors associated with neonatal near miss
Multivariate logistic regressions revealed that primiparous, referral linkage, premature rupture of membrane (PROM), maternal perception of reduced fetal movement, obstructed labor/cephalo-pelvic disproportion; prolonged labor and non-reassuring fetal heart rate pattern were significantly associated with neonatal near miss.
Women who were primiparous increased 2 times the odds of neonatal near miss as  Table 3].

Discussion
In this study the proportion of neonatal near miss was 23.3 % with 95% CI: (19.1% -27.7%).This finding is consistent with the finding of study in Northeastern Brazil 22% [10].
This finding is high as compared to study done in WHO multicounty survey 7.25%, Birth in Brazil survey 3.92%, study in South of Brazil 3.3%, and in Southeast Brazil 1.7% [8,9,13,14]. Variation of neonatal near miss rate in WHO multicounty survey and Southeast Brazil was might be due to methodological difference and used only pragmatic criteria and also study in Birth in Brazil and study in South of Brazil was used only 4 selection items from management and pragmatic criteria.
In this study proportion of neonatal near miss is low as compared to study in Uganda 36.7%, this is might be due to methodological difference and inclusion criteria were newborns only from mothers with sever obstetric complication [15].
In this study high proportion of neonatal near miss criteria were observed for mechanical ventilation (53.2%), gestational age less than 37completed week (37.2 %), birth weight < 2.5kg (31%), 5 minute APGAR Score < 7 (22.3%) and use of parenteral antibiotics Detected non reassuring fetal heart rate pattern increased almost 4 times the odds of NNM [AOR:3.75, 95% CI: (1.69-8.33)] as compared to detected reassuring fetal heart rate pattern. Supporting study in Indonesia revealed that survival of newborn from mothers without sever complications was better than that of newborn from mothers with obstetric complications [20] and studies in Brazil also revealed that maternal near miss were strongly associated with prematurity, neonatal asphyxia and early respiratory discomfort This finding is supported, studies in Jimma university specialised hospital and Dessie referral hospital, shows that obstetric complication during current pregnancy and complication during labor and delivery were strongly associated with adverse birth outcomes(low birth weight,preterm birth, low APGAR score and still birth) [22][23][24].
Referral linkage was significantly associated with neonatal near miss. This result is in line with study in Jimma university specialised hospital, revealed that referral of mothers with complications from other facility for delivery service was high risk for adverse pregnancy outcomes than mothers who were not referred [22].This is might be due to the fact that referral cases were from mothers who faced obstetric complications and needs timely and better intervention to avoid maternal and neonatal morbidity and mortality.

Conclusion 12
The proportion of neonatal near miss in the study area was found to be high. Statistically associated variables with neonatal near miss were primiparous, referral linkage, premature rupture of membrane, maternal perception of reduced fetal movement, prolonged labor, obstructed labor/cephalo-pelvic disproportion, and non-reassuring fetal heart rate pattern. Ensuring the continuum of compressive maternal care from pregnancy through delivery to avoid preventable causes of neonatal morbidity and mortality and creating good referral linkage with health facilities within its catchment areas including feedback providing.

Consent for publication Not Applicable
Availability of data and materials When the ethics statement was obtained from Injibara General Hospital,we have agreed and signed not to publish the row data retrieved from the information of the mothers and their newborns. However, the datasets collected and analyzed for the current study is available from the corresponding author and can be obtained on a reasonable request.

Competing interest
We declare that there is no conflict of interest in this research

Funding
The author did not receive funding for this study Authors' contributions HG: raised the research idea, wrote the proposal, participated in designing the study, supervising data collection process, performed the statistical analyzes and writing the manuscript. MB: Participating in data analysis and revised drafts of the paper. SK and TH: reviewed and finalized them. All authors read and approved the final manuscript.

Acknowledgement
We would like to thank Bahir Dar University for the approval of the ethical clearance and technical support of this study. We are also very grateful for supervisors, data collectors and study participants.  N.B; this cannot be sum up to 100% because of multiple intervention were possible