The Morbidity Assessment Index for Newborns (MAIN) was developed as a global measure of morbidity in the first week of life for babies with no congenital anomalies delivered at a gestation age of more than 28 weeks. The MAIN score tool was based on items of routine clinical and laboratory examinations of newborns. The MAIN score tool had already been validated for use [14]. However, this tool was seldom used in resource-poor settings.
We adopted the MAIN score index from 47 items to 37 and later re-adapted it to 27 clinically relevant items, and a modified MAIN tool was developed. A checklist of all these 27 items was administered daily for seven days. A composite of neonatal morbidity was created, and neonates were assigned their appropriate severity status. This new modified MAIN tool was significantly shortened and cheaper in terms of resources Use of the modified MAIN tool solely as a measure of severe morbidity was avoided since the new modified tool’s performance had not been validated.
Our study revealed that the incidence of early neonatal morbidity at term among all admissions at the MNH Neonatal unit for four months was (538/2104) x1000 equals 255.7 per 1000 neonates. This finding is far higher than other published studies. In a study of severe neonatal morbidity of term neonates without congenital anomalies in the Netherlands, the incidence was 3–4 neonates per 1000 term neonates[11]. This could be due to differences in neonatal unit setups. Only neonates with life-threatening conditions were admitted to level three neonatal care units, hence low number. All sick neonates were mixed in the same neonatal unit in our setting. In another study comparing the morbidity of term and late pre-term neonates, the incidence of term neonates was found to be (0.3/1000) in Atlanta [15]. Developed countries are far better in quality of care than developing countries due to the availability of equipment and expertise; hence, less complication during antenatal, intrapartum, and immediate postpartum are expected. This could be another reason for the low incidences of severe morbidity in these two studies compared to the findings noted. The alarming incidence of neonatal morbidity of term neonates at MNH Neonatal Care Unit was possibly due to a scarcity of functioning neonatal care units at peripheral hospitals in the region and nearby regions, necessitating most cases being referred to this centre. The lack of expertise, drugs, and equipment for neonates is partly the reason for more referrals for neonatal care at MNH.
Earlier studies have defined severe morbidity in term neonates [16, 17]. We adapted these and defined our severe morbidity in term neonates as any admitted term neonate with at least one of the following conditions: death within the seven days of life, Multiple convulsions, Cardiopulmonary resuscitation any time before discharge, Apnea corrected by oxygen or by resuscitation, Need for intubation at birth, Hyperbilirubinemia bilirubin > 250µmol/L (needing phototherapy or exchange transfusion), Hypotonia, Severe thrombocytopenia with or without the bleeding disorder, Stupor, obtundation or Coma, Abnormal respiratory rate persisting for two days or longer, Need for blood transfusion and Abnormal heart rate.
We found that the proportion of neonatal severe morbidity at term was 47.5%. This finding was higher than other studies on severe morbidity available. A study done in Atlanta had a proportion of 2.5% (Shapiro-Mendoza et al., 2008). A study in the Netherlands found a proportion of 17.1% [11]. A recent study was done in Washington 5% -18% [12]. The proportions were lower compared to our study due to similar reasons as could be due to differences in study settings. They are high-level neonatal units with fewer referrals and fewer admissions than our setting. The low proportion of severe neonatal morbidity in developed countries may also be due to the availability of equipment and expertise. Only some studies on the severe morbidity of term neonates are available in developing countries to compare with ours. A study in Northern Tanzania [13] examined neonatal admission to ICU risk factors. The proportion of neonates admitted was 15%. However, the methodology was different; although diagnostic criteria were admission to the neonatal intensive care unit, it was a disease-specific study, and term neonates were not dealt with separately as in our study.
Urinary tract infection was independently associated with severe early neonatal morbidity of neonates admitted at the MNH neonatal care unit. These neonates were about 16 times at higher risk of severe early neonatal morbidity. This outcome was also like a study done in the UK by Murphy et al. [18] and another study by Osorno et al. [19], even though these related to poor outcomes among the neonates and not severe morbidity. This could be due to differences in the study setting and the methodology used. Another study done in Israel showed that Maternal UTI is independently associated with pre-term delivery, pre-eclampsia, intra-uterine growth restriction (IUGR), and cesarean deliveries (CD). Nevertheless, it was not associated with increased perinatal mortality rates compared with women without UTI [20].
Many other studies associated UTI with adverse pregnancy and neonatal outcomes, including low birth weight, premature rupture of membranes, intrauterine growth restriction, and even death [21–23]. The mechanism of UTI causing PROM was believed to be the release of metalloproteinases by macrophages via cytokines, which similarly degrade the membranes as collagenases and phospholipase issued from bacteria [21]. Maternal UTI was also associated with neonatal sepsis [24]. This study also observed that neonates born with a birth weight below 2500 grams were independently associated with severe early neonatal morbidity. These infants were classified as having low birth weight [25]. Another observation also strengthens this in a setting in Nigeria that showed birth weight was a significant predictor of neonatal mortality [26, 27]. Similar findings were in a setting in Canada where morbidity and mortality were found to increase among term neonates who were born with a birth weight below the 3rd percentile of their gestation age. The study further showed low birth weight related to a lower five-minute Apgar score, high incidence of seizures in the first 24 hours of life, increased risks of need for intubation at the delivery room, increased risk for neonatal sepsis, and mortality [21].