The prevalence of NNM was determined to be 79 per 1,000 live births in Koshi Hospital, Nepal, using a combination of pragmatic and management criteria. Factors significantly associated with NNM were maternal secondary and tertiary education, multiparity, severe maternal morbidity, and caesarean section. Secondary and tertiary education, multiparity, and caesarean section decreased the likelihood of NNM. SMM was found to increase the risk of NNM.
Consensus is lacking regarding a standardized period in which NNM is agreed to occur across countries, which makes it difficult to compare NNM between studies. Some studies have used a near-miss period of 0–6 days [7, 10, 11, 20, 21], while others have utilized 0–27 days [13, 15, 17, 18, 22, 23]. Kale et al. recommend extending extrauterine life from seven to 28 days to increase the sensitivity of near miss criteria. However, a decrease in sensitivity was found when it was applied for 0–364 days [24]. In the current study, a period of seven days was used because four-fifths of neonatal deaths still occur within the first week of life, with one quarter taking place in the first 24 hours [25]. Besides, the chance of information bias increases if NNM information is obtained from parents in the community, after hospital discharge.
The prevalence of NNM in this study, when compared, were within the range of previous studies, that used the same definition proposed by Pileggi-Castro et al. [11], i.e., 45.1 per 1,000 live births [7] to 72.5 per 1,000 live births [11]. A population-based study in Nepal reported NNM prevalence of 22 per 1,000 live births, which is lower than the prevalence of NNM in the current hospital-based study. Possible reasons may be due to differences in used NNM definition and criteria, as well as the study settings.
Using only pragmatic criteria [10], the prevalence of NNM was reported to be 87.6 per 1,000 live births in two studies from India [17, 18], which is higher than the 65 per 1,000 live births (pragmatic criteria only) in the present study. A possible explanation for the difference in findings is that a survival period of 28 days was used in India; hence, the sensitivity increased owing to the more extended survival period applied
Multiparity decreased the likelihood of NNM in the current study, similar to few other studies [15, 23]. Studies from southern and northern Ethiopia reported that multiparity was a risk factor for NNM [26, 27]. A recent prospective cohort study in Ethiopia reported that grand multiparity was a risk factor for perinatal mortality among women with MNM [28].
Both nulliparous and grand-multiparous mothers were at high risk of developing complications during birth [29, 30], which places neonates at risk of adverse outcomes [20, 31, 32]. Nulliparity among advanced aged mothers ( ≥ 35 years) was a risk factor for adverse perinatal outcomes [33, 34]. Neonates born to advanced aged nulliparous women had a higher likelihood of neonates admitting to NICU [34-36]. However, in this study, the proportion of women with more than four children and aged ≥ 35 years was small, which prevents the ability to draw further conclusions.
Literature reviews suggest that a significant proportion of nulliparous mothers are at increased risk of hypertension and lack experience in childbirth [37, 38]. This elucidates the likelihood of NNM affecting nulliparous women [20, 32]. Prior studies have shown that first-born infants are at higher risk of neonatal mortality than second- or third-born infants [37, 39]. However, in some studies, parity was not shown to be associated with neonatal mortality [40].
Elsewhere, a high chance of NNM affecting women undergoing caesarean section has been demonstrated [23, 26, 41-43]. In recent studies in India and Ethiopia, although NNM cases were higher in women who underwent caesarean birth, a direct association could not be established [7, 18]. Contrary to the findings in the literature, the present study showed that caesarean section was protective against NNM. In support of this finding, in the United States, the caesarean section was observed to reduce neonatal mortality in preterm births [44]. Another study in Gambia, found that among women with severe obstetric complications, risk of stillbirth among normal birth increased by four-fold compared to caesarean birth [45].
The WHO recommends caesarean sections only when medically necessary and recommends an upper limit of 15% [46]. In the current study, the overall percentage of births via caesarean birth was 17%, which is higher than 12% reported in public hospitals in Nepal [4]. Elective caesarean sections are not performed at Koshi Hospital. The proportion of caesarean sections performed in mothers with SMM was two times higher than that performed in mothers without SMM (31% versus 16%) in this study. Previous literature works show SMM to be significantly associated with higher current caesarean section [47-51], and higher number of preterm births were born to SMM mothers than mothers without SMM [47, 52]. An increase in fetal mortality and a higher number of babies admitted to NICU for seven days or longer was found together with an increase in the number of caesarean birth [50]. A systematic review and meta-analysis showed that maternal and perinatal outcomes were often linked [53]. Mothers at high risk of maternal complications that gave birth at the second stage via caesarean sections and the babies born to these women have a low Apgar score at 5 min. They were more likely to be admitted to NICU, than the mothers who gave birth at the first stage [53].
Caesarean birth is the urgent action the specialist takes to manage the severity of obstetric and fetal conditions to prevent disease progression [54, 55], but chances of intraoperative complications and haemorrhage following this procedure is high in the low- and middle- income countries [53]. Thus, the timely operational procedure can prevent an adverse impact on neonatal health among SMM mothers [40, 53], or at times exposed mothers to the risk of complications and infections [53, 56]. A caesarean section could be a confounder if an operational procedure is performed only among fetus with a greater likelihood of being born alive [57]. However, overall, there is a lack of consensus in the literature over a popular opinion that neonatal mortality and morbidity are higher in infants delivered by caesarean section [51, 53, 58-60].
In the current study, maternal secondary and tertiary education decreased the likelihood of NNM. Prior studies that assessed socio-demographic factors for NNM, have not established a significant association between NNM and maternal education [7, 15, 18, 26, 41]. However, a universal association between maternal education and neonatal mortality, especially in the low-income countries, has been demonstrated [39, 59, 61, 62], and supports current study’s findings. In addition, educated mothers are more likely to come from a higher socioeconomic status [59], have a better knowledge of healthy behaviours, have a more informed approach to self-care, make better health-related choices, and utilize the healthcare system appropriately [31, 63].
The current study found an association between severe maternal morbidity and NNM, consistent with the finding of a study in Ethiopia [7], but contradictory to a study in Brazil [64]. However, very few studies have explored the relationship between MNM and NNM. One study showed a strong association (OR: 17.15, 95% CI: 1.85–159.12) [64], whereas others have not demonstrated a significant association between MNM and NNM [15, 43]. Mixed association existed between hemorrhage and hypertensive disorder during pregnancy and NNM in southern Ethiopia [26] and Brazil [23]. In support of the current study, there existed an association between MNM and higher rates of adverse perinatal outcome born to these mothers [45, 57, 65, 66]. Tura et al. claim that adverse perinatal outcomes among MNM women is self-evident given the fact that MNM are identified using severe clinical criteria along with organ disfunction, which was also supported by their findings [28].
Among women with severe maternal morbidity condition, the odd of giving birth to adverse neonatal outcomes is higher [20, 67-69]. A considerable number of newborn infants with severe hypoxia [67], low birth weight [57], and neonatal asphyxia [57, 67] were born to women with MNM. There was two-fold increase in stillbirth risk among women with more than one complications in Gambia [45]. Similarly, maternal obstetric complications have been shown to play a role in the underlying causes of neonatal deaths [39, 70]. Therefore, early screening for poor obstetric conditions during the antenatal period and the appropriate management of intrapartum complications is crucial to ensure a reduction in the number of NNM cases.
The current study finding did not establish any association between ANC and NNM unlike a study in southern Ethiopia, adequate ANC visits was positively associated with NNM [26]. Mixed [15, 23] and converse [7] findings were found. Attending four or more ANC sessions was protective [30, 71], whereas an inadequate number of antenatal visits was associated with risk of neonatal mortality [70, 72], and adverse birth outcome [69].
Exploring possible explanations for non-association in this study were, firstly, only a quarter (24%) of women in Nepal receive all seven components of ANC [73]. The majority of Nepal public institutions lack basic ultrasonography and laboratory facilities (i.e., blood and urine testing) [73-75], and most pregnant women only receive health education, iron supplementation, blood pressure measurements, and anti-tetanus toxoid [73]. Secondly, there is poor compliance by pregnant mothers with ANC advice [76]. Hence, women with or without attending recommended four ANC sessions, owing to poor compliance, did not show a significant association with NNM in the current study.
Globally, advanced maternal age (≥ 35 years) may increase in pregnancy and obstetric complications [15]. With advancing age, the prevalence of pre-existing conditions appear to increase and also the risk of caesarean birth, contributing to the increased risk to the fetus [77]. Advanced maternal age [15] and under age (<18 years)[27] was significantly associated with NNM. Similarly, significant association has been reported between advanced maternal age [38, 39, 69] or younger age (< 20 years) [57, 58, 62], and adverse neonatal outcomes. Secondary analysis of the WHO multi-country survey on maternal and newborn health findings showed that advanced maternal age significantly increased the risk of stillbirths and perinatal mortalities [77]. However, no association was established between maternal age and NNM in this study.
The results of the current study are generalizable to births in the government institutions in Nepal. To the best of our knowledge, this is the only study to have explored factors that impact NNM in South Asia using both pragmatic and management criteria.
The study had several limitations. The cross-sectional nature of the research meant that casual association could not be proved. Seventeen of the 44 neonates with conditions requiring admission to the NICU were self-referred to private hospitals; therefore, these data were unavailable. The date of the last menstrual period was used to calculate gestational age; thus, incorrect estimations may have been introduced due to recall bias.
Recommendations
Nulliparity and severe maternal morbidity should be considered high-risk obstetric conditions. Therefore, screening should be performed during the antenatal period, and, if indicated, referral should be made to a tertiary hospital with adequate facilities. Future studies should explore contributory factors to NNM in illiterate women and those with communication barriers, as well as the impact of content and quality of ANC. An evaluation of the risk of NNM is recommended in specific maternal populations, such as advanced aged women, and those with multiple pregnancies. Near misses are lives saved due to timely intervention, so future studies should standardize this definition.