Risk Factors of Birth Asphyxia among Newborns at Debre Markos Comprehensive Specialized Referral Hospital, Northwest Ethiopia: Unmatched Case-Control Study

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Study Justification:
– Neonatal mortality remains high in developing countries, and birth asphyxia is a significant contributor to neonatal deaths.
– Limited data on the risk factors of birth asphyxia in Ethiopia, particularly in the study area.
– Identifying the risk factors can help inform interventions and reduce neonatal mortality associated with birth asphyxia.
Study Highlights:
– The study used an unmatched case-control design to identify risk factors of birth asphyxia among newborns at Debre Markos Comprehensive Specialized Referral Hospital in Northwest Ethiopia.
– Data were collected through interviews with mothers and chart reviews.
– Significant risk factors of birth asphyxia were identified, including prolonged labor, meconium-stained amniotic fluid, assisted vaginal delivery, gestational age less than 37 weeks, noncephalic presentation, comorbidity, and low birth weight.
Study Recommendations:
– Attention should be given to holistic pregnancy, labor, and delivery care, as well as post-natal care, to reduce neonatal mortality associated with birth asphyxia.
– Interventions should target the identified risk factors, such as providing appropriate management for prolonged labor, monitoring and managing meconium-stained amniotic fluid, and ensuring skilled assistance during delivery.
– Collaboration between obstetricians, pediatricians, nurses, and midwives is essential to implement these interventions effectively.
Key Role Players:
– Obstetricians: Provide appropriate management for prolonged labor, meconium-stained amniotic fluid, and other obstetric complications.
– Pediatricians: Provide specialized care for newborns with birth asphyxia and support interventions to reduce neonatal mortality.
– Nurses and Midwives: Assist during labor and delivery, provide post-natal care, and implement interventions to prevent and manage birth asphyxia.
Cost Items for Planning Recommendations:
– Training and capacity building for healthcare professionals on managing prolonged labor, meconium-stained amniotic fluid, and birth asphyxia.
– Equipment and supplies for neonatal intensive care units (NICU) to support the care of newborns with birth asphyxia.
– Monitoring and evaluation systems to assess the effectiveness of interventions and track neonatal mortality rates.
– Awareness campaigns and community education programs to promote prenatal care and early recognition of risk factors for birth asphyxia.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, but there are a few areas for improvement. The study design is clearly stated as an unmatched case-control study, which provides valuable information on risk factors. The sample size calculation and sampling techniques are also described. The data collection tool and procedure are well-explained, including the use of a pre-tested questionnaire and the determination of birth asphyxia using APGAR scores. The data analysis section is thorough, with the use of descriptive statistics and multivariable logistic regression. However, there are a few areas that could be improved. First, the abstract does not mention the response rate, which is important for assessing the representativeness of the sample. Second, the abstract could provide more information on the limitations of the study, such as potential biases or confounding factors. Finally, the abstract could include more details on the implications of the findings and how they can be translated into actionable steps to reduce neonatal mortality associated with birth asphyxia.

Background: Despite a global decline in under-five deaths, the neonatal mortality rate remains slow in developing countries and birth asphyxia remains the third cause of neonatal deaths. Globally, neonatal deaths accounts for 45% of under-five deaths, birth asphyxia causes 23-40% of neonatal deaths in Ethiopia. There is limited data on risk factors of asphyxia in Ethiopia, particularly in the study area. Therefore, this study aimed to identify the risk factors of birth asphyxia among newborns. Methods: This research followed a hospital-based unmatched case-control study design at Debre Markos comprehensive specialized referral hospital, Northwest Ethiopia, among 372 newborns (124 cases and 248 controls). Data were collected by interviewing index mothers and chart review using a pre-tested questionnaire. Then it was entered in Epi-data version 3.1 and transferred to STATA version 14.0 for analysis. Bivariate and multiple variable logistic regression were carried out to the possible risk factors. Finally, statistical significance was declared using adjusted odds ratio with 95% CI and p-value 12, meconium-stained amniotic fluid, assisted vaginal delivery, gestational age < 37 weeks, noncephalic presentation, comorbidity, birthweight12 hours, meconium-stained amniotic fluid, assisted vaginal delivery, gestational age < 37 weeks, non-cephalic presentation comorbidity, fetal distress, birthweight<2500grams were found to be risk factors of birth asphyxia were risk factors of birth asphyxia. Therefore, to reduce neonatal mortality associated with birth asphyxia, attention should be given to holistic pregnancy, labor and delivery care, and post-natal care. Moreover, interventions aimed at reducing birth asphyxia should target the identified factors.

Study design, period and setting: Institutional-based unmatched case-control study design was conducted considering neonates with asphyxia as cases and those without asphyxia as controls among newborns from August 1/2019 to October 2019 at Debre Markos referral hospital which is located in Debre Markos town, East Gojjam Zone, Amhara regional state. The town is found 299 km north west from Addis Ababa, capital city of Ethiopia. According to information obtained from the administrative offices of Debre Markos comprehensive specialized referral hospital, they provide different services in the outpatient department, inpatient department and operation room theatre department. The hospital serves for more than 3.5 million populations in the catchment area and it has more than 30 beds in NICU with annual admission of more than 2800 neonates of which, more than 770 neonates are by birth asphyxia. There are five pediatricians and 21 nurses in NICU. In obstetrics and gynecology ward there 7 gynecologists and 45 midwifery professionals with the annual delivery 6734 neonates. Study participants: The study population was both neonates with asphyxia and those without asphyxia admitted to neonatal intensive care units (NICU) in Debre Markos referral hospital. All live newborns who were born after 28 weeks of gestation were screened for eligibility. The study classified participants into cases and controls. Newborn babies with 12 hours) were obtained from a previously conducted study (17) and the total sample size was obtained by adding 10% nonresponse rate, which was 372 (124 cases and 248 controls). Cases and controls were recruited on a continuous basis between August 1, 2019 and October 30, 2019 until the appropriate sample size was reached for both groups. Data collection tool and procedure: Data were collected using a pre-tested and adapted standardized questionnaire (18) it was administered by interviewers, observational and chart review was used to gather data on sociodemographic maternal variables, variables related to obstetric history (mother’s age, education, pregnancy number, parity, history of pregnancy outcome, gestational age; antepartum factors (prime parity, maternal fever, pregnancy-induced hypertension, anemia, peripartum hemorrhage, history of previous neonatal deaths); intrapartum factors (mal-presentation, prolonged labor, meconium-stained liquor, pre-eclampsia, eclampsia, augmentation of labor, complicated labor, mode of delivery); fetal factors (sex, birth weight, the maturity of the newborn). The tools were prepared in English and translated to Amharic; eventually, it was translated back to English to check the consistency. Birth asphyxia was determined using APGAR score which consisted of five components such as appearance (color), pulse (heart rate), grimace (reflexes), activity (muscle tone) and respiration, each with a score of 0, 1, or 2. A score of (≥7) showed no asphyxiation of a newborn while a low score (< 7) revealed an asphyxiated newborn (17). Data quality control: The quality of the data was ensured by using properly designed data collection tools. Training was given for data collectors and supervisors for two-days on data collection procedures, techniques and methods. Prior to data collection, the questionnaire was tested in five percent (7 cases and 14 controls) at Lumame hospital to verify the questioner's accuracy. Clarification of question and time to complete the questionnaire was assessed. The supervisors and the principal investigator reviewed and updated the computed questionnaires every day, and the data collectors provided the necessary input for the next morning before the actual procedures began. Study variables: Birth asphyxia was the dependent variable. While the independent variables include maternal characteristics and variables related to obstetric history (mother's age, education, pregnancy number, parity, history of pregnancy outcome (singleton or multiple ), gestational age; antepartum factors (prime parity, maternal fever, pregnancy-induced hypertension, anemia, peripartum hemorrhage, history of previous neonatal deaths); intrapartum factors (mal-presentation, prolonged labor, meconium-stained liquor, pre-eclampsia, eclampsia, augmentation of labor, complicated labor (cord prolapse), mode or type of delivery); fetal factors (sex, birth weight, the gestational age of the newborn). Data analysis: Data was entered in Epi-data version 3.1 and transferred to STATA version 14.0 for analysis. Using descriptive statistics, socio-demographic factors, antepartum, intrapartum, and neonatal- related factors are presented using frequency tables, figures, and percentages. In the second stage, bivariate logistic regression was used to identify possible factors of candidate variables with a p-value <0.2 for the final model. The model fitness test was carried out using the Hosmer – Lemeshow test, which is a statistical test for fitness for logistic regression models. Finally, the multivariable logistic regression model was fitted to identify significant risk factors of birth asphyxia through a backward stepwise method, risk factors of birth asphyxia among newborns were determined using their adjusted odds ratio with 95% CI and p-value < 0.05. The following operational definitions are used Birth asphyxia: Neonate failure to start and sustain sufficient respiration within 5 minutes of birth with an Apgar score below 7 (19). Cases (asphyxiated newborns): all neonates diagnosed with asphyxia by the attending health professionals using an Apgar score of less than 7 at 5 minutes after birth were considered as cases. Controls (non-asphyxiated newborns) – all neonates diagnosed as non-asphyxiated by the attending health professionals using an APGAR score of more than 7 at 5 minutes were considered as controls. Ethics Approval and Consent to Participate: The ethical clearance letter has been received from the research and review committee from college of health sciences, Debre Marks University. Additionally, prior to beginning data collection permission was obtained from the hospital authority. Finally, informed written consent was received from each participant mothers after explaining the research objectives. The participants were briefed on the study's purpose, procedures, potential risks, and benefits. In addition, the participants were told that failure to agree or to withdraw from the study would not change or endanger their access to treatment.

Based on the provided information, here are some potential innovations that can be used to improve access to maternal health:

1. Telemedicine: Implementing telemedicine services can improve access to maternal health by allowing pregnant women to consult with healthcare professionals remotely. This can be particularly beneficial for women in rural or remote areas who may have limited access to healthcare facilities.

2. Mobile health (mHealth) applications: Developing mobile applications that provide information and resources related to maternal health can help women access important healthcare information, track their pregnancy progress, and receive reminders for prenatal care appointments.

3. Community health workers: Training and deploying community health workers who can provide basic maternal health services, education, and support to pregnant women in their communities can improve access to care, especially in underserved areas.

4. Transportation services: Establishing transportation services specifically for pregnant women can help overcome barriers related to distance and transportation, ensuring that women can access prenatal care and emergency obstetric services when needed.

5. Maternal health clinics: Setting up dedicated maternal health clinics in areas with high maternal mortality rates can provide comprehensive care and support to pregnant women, including prenatal care, skilled birth attendance, and postnatal care.

6. Public awareness campaigns: Conducting public awareness campaigns to educate communities about the importance of maternal health and the available services can help reduce stigma, increase demand for care, and encourage women to seek timely and appropriate healthcare during pregnancy.

7. Strengthening referral systems: Improving the referral systems between primary healthcare facilities and higher-level facilities can ensure that pregnant women with complications are promptly referred to appropriate facilities for specialized care.

8. Maternity waiting homes: Establishing maternity waiting homes near healthcare facilities can provide a safe and comfortable place for pregnant women to stay during the final weeks of pregnancy, ensuring they are close to the facility when labor begins.

9. Task-shifting and training: Training and empowering midwives and other healthcare providers to perform certain tasks traditionally done by doctors can help alleviate the shortage of skilled birth attendants and improve access to maternal health services.

10. Financial incentives: Implementing financial incentives, such as conditional cash transfers or maternity vouchers, can help reduce financial barriers and encourage pregnant women to seek and utilize maternal health services.

It is important to note that the specific implementation of these innovations should be tailored to the local context and healthcare system in order to effectively improve access to maternal health.
AI Innovations Description
Based on the information provided, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Holistic Pregnancy, Labor, and Delivery Care: Implement comprehensive and integrated care programs that focus on providing quality prenatal, intrapartum, and postnatal care to pregnant women. This includes regular check-ups, health education, nutrition support, and monitoring of risk factors for birth asphyxia.

2. Strengthening Health Facilities: Improve the capacity and resources of healthcare facilities, particularly neonatal intensive care units (NICUs), to handle cases of birth asphyxia. This includes increasing the number of beds, ensuring the availability of necessary equipment and supplies, and training healthcare providers on neonatal resuscitation techniques.

3. Training and Education: Conduct training programs for healthcare providers, including midwives, nurses, and doctors, on the identification, prevention, and management of birth asphyxia. This should include training on the use of APGAR scores, resuscitation techniques, and early detection of risk factors.

4. Community Awareness and Education: Raise awareness among the community about the importance of maternal health and the prevention of birth asphyxia. This can be done through health education campaigns, community workshops, and the involvement of community leaders and influencers.

5. Collaboration and Partnerships: Foster collaboration between healthcare facilities, government agencies, non-governmental organizations, and other stakeholders to improve access to maternal health services. This includes sharing resources, knowledge, and best practices, as well as advocating for policy changes and increased funding for maternal health programs.

6. Monitoring and Evaluation: Establish a system for monitoring and evaluating the implementation of interventions aimed at reducing birth asphyxia. This includes collecting and analyzing data on maternal and neonatal outcomes, identifying gaps and challenges, and making necessary adjustments to improve the effectiveness of interventions.

By implementing these recommendations, it is expected that access to maternal health services will be improved, leading to a reduction in the incidence of birth asphyxia and neonatal mortality rates.
AI Innovations Methodology
Based on the provided study, here are some potential recommendations to improve access to maternal health:

1. Strengthen antenatal care services: Increase the availability and accessibility of antenatal care services to ensure early detection and management of risk factors associated with birth asphyxia. This can include regular check-ups, health education, and screening for high-risk pregnancies.

2. Improve obstetric care during labor and delivery: Enhance the quality of obstetric care during labor and delivery by ensuring skilled birth attendants are available, promoting evidence-based practices such as timely intervention in cases of prolonged labor, and providing adequate monitoring and management of fetal distress.

3. Enhance postnatal care: Strengthen postnatal care services to ensure proper monitoring and management of newborns, including early detection and intervention for birth asphyxia. This can involve providing support for breastfeeding, promoting kangaroo care, and educating mothers on newborn care and danger signs.

4. Increase awareness and education: Conduct community-based awareness campaigns to educate pregnant women and their families about the importance of seeking timely and appropriate maternal healthcare services. This can include raising awareness about the signs and symptoms of birth asphyxia and the available interventions.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could involve the following steps:

1. Define the indicators: Identify specific indicators that can measure the impact of the recommendations, such as the percentage increase in antenatal care coverage, the reduction in cases of prolonged labor, or the improvement in postnatal care utilization.

2. Collect baseline data: Gather data on the current status of access to maternal health services, including the utilization rates of antenatal care, skilled birth attendance, and postnatal care, as well as the prevalence of birth asphyxia.

3. Develop a simulation model: Create a simulation model that incorporates the identified recommendations and their potential impact on the selected indicators. This model can be based on existing data, expert opinions, and evidence from similar interventions.

4. Input data and run simulations: Input the baseline data into the simulation model and run multiple simulations to estimate the potential impact of the recommendations. This can involve varying the parameters, such as the coverage of antenatal care or the quality of obstetric care, to assess different scenarios.

5. Analyze results: Analyze the results of the simulations to determine the potential impact of the recommendations on improving access to maternal health. This can include quantifying the expected changes in the selected indicators and assessing the feasibility and cost-effectiveness of the interventions.

6. Refine and validate the model: Refine the simulation model based on the analysis of the results and validate it using additional data or expert input. This can help ensure the accuracy and reliability of the model in predicting the impact of the recommendations.

7. Communicate findings and make recommendations: Present the findings of the simulation study to relevant stakeholders, such as policymakers, healthcare providers, and community leaders. Use the results to make evidence-based recommendations for improving access to maternal health and advocate for the implementation of the identified interventions.

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