Magnitude of Preterm Birth Admission, Immediate Outcomes and Their Predictors in Debre Markos Referral Hospital, North West, Ethiopia.

Background: Each year 15 million preterm babies are born. Pre-term birth complications account for 35% of the estimated 3.1 million global neonatal deaths and are the second leading cause of death in children less than 5 years aged. Objective: we assessed the magnitude of preterm birth admissions, immediate outcomes and their predictors in Debre Markos Referral Hospital, North West, Ethiopia, 2019. Methodology: An institutional based retrospective cross- sectional study design was conducted among 212 neonates registered from January 1, 2014, to January 1, 2019. Data was entered using Epidata version 3.1 and exported to SPSS version 20 for analysis. Bivariable and multivariable logistic regressional analysis were done. Variables with p value <0.05 in multivariate analysis were declared as statistically signicant at a 95% condence interval. Results: Out of 212 neonates involved in the study, 27.8% were preterm birth admissions. From this 36.3% of neonates was died before discharge. In the nal multivariate analysis hypertension during pregnancy was signicantly associated for preterm admissions (P= 0.013, AOR= 4.464, 95% CI: (1.375, 14.498)) and being extreme low and very low birth weight (P= 0.005, AOR= 2.107, 95% CI: (0.023, 0.508)) and those with low APGAR score (P= 0.016, AOR= 3.113, 95% CI: (0.019, 0.669)) was signicantly associated with death before discharge. Conclusion: Preterm admissions accounted for a signicant percentage of with signicant rupture membrane weight and very low weight for regular screening of pregnant mothers for medical and obstetric complications.


Introduction
Now a day's preterm birth is increasing across the globe. Globally, an anticipated 15 million infants are born too early each year. Recent estimates of preterm birth rates (all live births before 37 completed weeks) for 184 countries in 2010 and a time series for 65 countries suggest that 14.9 million (range from: 12.3-18.1 million) babies were born preterm in 2010 (1). More than 60% of all premature babies are born in South Asia and sub-Saharan Africa, with just over half now being born in facilities (2,3). In Ethiopia, 320,000 premature babies are born annually (4) Complications of preterm birth are the single largest direct cause of neonatal deaths, responsible for 35% of the world's 3.1 million deaths per year, and the second most common cause of under-5 deaths. Almost annually due to direct preterm complications (4). In addition to its signi cant contribution to mortality, the effect of preterm complications among survivors may continue throughout life (5).
Different strategies have been implemented to reduce the neonatal mortality rate across the globe. According to the recent UN estimate, the neonatal mortality reduced by 48% from the 1990 estimate to 28 per 1000 live births in 2013 while the reduction rate of under-ve mortality rate was by about 67%. From this neonatal death preterm birth accounts 37%(6). Regardless of signi cant success in infant and under-5 deaths in Ethiopia, the reduction in neonatal mortality is relatively low. Based on EDHS 2011 report, the Neonatal Mortality Rate was 37/1000 live births, which has not shown signi cant declines from the 2005 EDHS report of 39/1000 live births (7,8). A study conducted in Southwest Ethiopia, Jimma zone indicates neonatal mortality rate in 2013 was 35.5 per 1000 live-births.
69.1% of them died within the rst week of life making weighted early neonatal mortality rate to be 23.7 and risk of neonatal death was found to be increased in prematurity as compared to term births (9). Different reasons contribute for the morbidity and deaths of preterm neonate (10,11). In developing countries particularly in Ethiopia most preterm births occur after 32 weeks of gestation (84%) and deaths in these babies can almost all be prevented by essential new-born care (2,3). In low earning areas, 1/2 of the infants born under 32 weeks die because of a loss of feasible and cost-powerful care including warmth, breastfeeding aid, simple take care of infections and helping baby to breathe (1).
Studies indicate that, prematurity, low birth weight for gestational age; male sex, maternal hypertension during pregnancy, Home delivery, cry immediately at birth, hypoglycaemia at admission, presence of jaundice, hyaline membrane disease was signi cantly associated with neonatal mortality.

Study setting
The study was carried out at the Neonatal Intensive Care Unit (NICU) of the Debre Markos compressive specialized referral Hospital. Debremarkos is a capital city of East Gojjam Zone Amhara Regional State 299 Km from Addis Ababa. Debre Markos compressive specialized hospital is the only referral hospital found in the zone and serves for more than ve million people.

Study Design
A ve years institutional based retrospective cross-sectional study design was conducted.

Study Population
All neonates admitted in NICU from January 1, 2014, to January 1, 2019 with complete medical record were included in the study.

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The total sample size 228 was determined using the assumption of a single population proportion formula by taking P-value from the previous study 16%, 95% con dence interval (CI), 80% power, 5% margin of error (d = 0.05) and 10% incomplete data. The required sample size was selected by rst, assessing the total neonates admitted in the NICU in the database on the registered chart/form from the discharge catalog of admitted patient's in neonatal intensive care unit from January 1, 2014, to January 1, 2019. Then the medical registration numbers of all admitted neonatal patients were sorted. After this, a systematic random technique was applied to select the required sample size.

Data Processing and Analysis
The collected data was entered using Epidata version 3.1 and exported to SPSS version 25.0 for analysis.
Descriptive and analytic statics were done. Descriptive statics was presented by texts, graphs and tables.
Binary and multiple logistic regressions were applied to determine associated factors of preterm admission and immediate outcomes of preterm birth. Covariates and logistic regression assumptions were checked using goodness of t by VIF test. Associations were described using odds ratio at 95% CI and statistical test was considered signi cant at a P value of less than or equal to 0.05.

Result
Among 228 neonatal medical charts reviewed, 212 neonatal medical charts with complete maternal and neonatal record were included in the study giving a response rate of 92.98%.

Analysis of maternal factors
The mean age of the mothers of admitted neonate was 26.57 years old (± 6.517 SD) within range of 18 to 44 years and 26 was the median age. More than half of the mothers (54.2%) were below the mean age (< 26).
One third 71 (33.5%) of participants were from urban. Nearly half 108(50.9%) of mothers of admitted neonate were gravida 1 and most 199 (93.9%) of mothers of admitted neonate were married (Table 1).  In multivariate analysis low APGAR score and extremely low and very low birth weight were signi cantly associated with neonatal death. Neonates who have low APGAR score at the 1st and 5th minute were 3.113 times more likely to die than those neonates who have high APGAR score (AOR = 3.113, 95% CI: (0.019, 0.669)). Similarly, extremely low and very low birth weight neonates were 2.107 times more likely to die than normal birth weight neonates (AOR = 2.107, 95% CI: (0.023, 0.508) ( Table 3).

Discussion
In this study, we examined the relation between some maternal factors such as age, pregnancy induced hypertension and PROM with preterm admissions. This study showed the prevalence of preterm birth admissions was 27.8%. This nding was similar to a study conducted by Kuppusamy et al in India (12) in which the prevalence of preterm admissions was 28.25%. However, the nding of our study was higher than studies conducted by Kunle-Olowu, et al in southern Nigeria, Niger Tertiary Hospital which was 24% (13)and studies conducted by Abebe T in Addis Ababa which was16.15% (14).This discrepancy might be due to differences in the incidence of preterm births in the various parts of the country as well as methodological and socio-economic differences across the studies.
In the present study there were more preterm males than females which is similar to the study by Kunle-Olowu, et al. in Nigeria and Abebe T in Addis Ababa who reported more preterm males. According to born too soon, preterm birth is more common in boys, with around 55% of all preterm births occurring in males worldwide (5).
In this study, 86 (40.6%) of the mothers had been diagnosed at least with one medical problem during the current pregnancy which is similar with studies by Abebe T which was 40.6% (14).  (11). This difference may probably due to difference in early identi cation and intervention of prenatal maternal problems across the country.
From those preterm neonates admitted to NICU 77 (36.3 %) were died before discharge which is lesser when compared with the study done in Addis Ababa 45.3% (14) and mean weight of the preterm in this study was 1679.95 grams (± 396.174 SD) which is nearly comparable with the mean weight 1669.4gms (± 508.688 SD) (14).
In this study respiratory distress and hyaline membrane disease has signi cant association with death outcome of preterm birth which is almost similar to Singh Uma, et al, India, Septicaemia, respiratory distress syndrome (RDS) and birth asphyxia were the important causes of neonatal morbidity (15). According to Kunle-Olowu, et al, the commonest medical conditions were respiratory problems in 95 (68.8%) followed by jaundice in 94 (68.1%) and sepsis in 54 (39.1%) of the patients almost similar with this study (13).
In this study neonates with low APGAR score was signi cantly associated with death outcome. Similar ndings are found in studies conducted by Kunle-Olowu, et al and Abebe T in Addis Ababa (13,14). Also, in this study being extreme low and very low birth weight were signi cantly associated with death outcomes.
This nding is supported with studies in Addis Ababa, Ethiopia and Legos Nigeria (13,14). This might be due to extreme low and very low birth weight neonates are easily vulnerable to infections and physiological disturbances. Referral hospital. Informed consent was not required, due to data was taken from chart review only but extracted data from medical record were kept con dentially Authors' contributions BA and AA performed the analysis and interpretations. BA wrote the rst draft, TY and AA contributed to the design of the study and substantive revision of the nal draft. All authors read and approved the nal manuscript.

Funding
The author(s) received no nancial support for the research, authorship, and/or publication of this article.

Availability of data and materials
All materials and data are available from the corresponding author without any restriction.

Consent for publication
Not applicable.

Competing interests
The authors declare that they have no competing interests.  Common medical problems of admitted neonates in Debre Markos hospital, Ethiopia, 2019.