Predictors of mortality among newborns admitted

with perinatal asphyxia at public hospitals in

Ethiopia: A Prospective cohort study
Samuel Dessu (  [email protected] )
Researchers https://orcid.org/0000-0001-9800-1076
Zinabu Dawit
Arba Minch Health Science College
Abebe Timerga
Wolkite University
Muluken Bafa
Arba Minch Health Science College

Research

Keywords: Perinatal asphyxia, Prospective study, Predictor of mortality, Southern Ethiopia

DOI: https://doi.org/10.21203/rs.3.rs-184712/v1

License:   This work is licensed under a Creative Commons Attribution 4.0 International License.
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Abstract
Introduction:
Perinatal asphyxia is a fetus or the newborn's health problem caused; due to altered breathing or
inadequate inhalation and exhalation resulting in reduced oxygen perfusion to certain body tissues and
organs. Irrespective of the increased progress in health care towards newborns and implementations in
reductions in under- ve, infant, and neonatal mortality in the past ten years, perinatal asphyxia remains
as the most common severe newborn health challenge causing a high number of mortalities and
morbidity and is a major public issue.

Methods
A prospective cohort longitudinal study was implemented among the predetermined 573 samples of
newborns admitted with Perinatal asphyxia at public hospitals in Southern Ethiopia from 1st March 2018
to 28th February 2020. Data entry was conducted using Epi data version 3.02 statistical software and
exported to SPSS Version 25 statistical software for analysis. The perinatal survival time was determined
using Kaplan Meier survival curve together with a log-rank test. Variables that had a P-values less than
0.05 in the multivariable cox proportional hazard model were declared as statistically signi cant
predictors of mortality.

Results
The cumulative proportion of survival among the newborns admitted with perinatal asphyxia was 95.21%
(95%CI:91.00,97.48), 92.82% (95%CI:87.95,95.77), 92.02%(95%CI:86.84,95.22) and 90.78%
(95%CI:84.82,94.48) at the end of rst, second, third and fourth follow-up days respectively with the
overall mean survival time of 6.55(95%CI:6.33,6.77). Cord prolapse (AHR:6.5;95%CI:1.18,36.01), history of
PIH (AHR:25.4;95%CI:3.68,175.0), maternal iron de ciency anemia (AHR:5.9;95%CI:1.19,29.5) and having
convulsion of the newborn (AHR:10.23;95%CI:2.24,46.54) were statistically signi cant in multivariable
cox proportional hazard model.

Conclusion
The risk of death among newborns with perinatal asphyxia was high during the early follow-up periods
after admission to the hospital and the mortality risk decreased at the later follow up periods and cord
prolapse, history of PIH, maternal history of iron de ciency anemia and newborns history of convulsion
were the independent predictors of mortality.

Introduction
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Perinatal asphyxia is a complicated newborn health problem and applies a high contribution to the
increased proportion of newborn mortality (1). It is a leading cause of morbidity and mortality in newborn
babies globally, with higher case fatality rates and consequent complications in developing countries due
to poor health facilities (2, 3). Globally, around 2,500,000 child deaths were reported in the early 28 days
of age (neonatal age). These accounts for nearly 47% of under- ve mortality and 54% of all under- ve
deaths occur during this age in developing countries (4).

However, greater than 2/3rd of newborns can be saved through established maternal and newborn health
intervention programs. Though, most of the observed deaths have occurred at home delivered newborns
(5). Nearly 3.6 million (3%) of all infants suffer from a certain level of perinatal asphyxia. Among this
840,000 (23%) will die and approximately a similar proportion of newborns develop life-threatening health
problems in developing countries (6, 7).

Globally, around 25% of all newborn mortality is caused by perinatal asphyxia (8). In Ethiopia, in the year
2015, perinatal asphyxia contributed to 31.6% of newborn deaths, followed by prematurity and neonatal
sepsis, which accounted for 21.8% and 18.5% respectively (9).

Irrespective of the increased advancements in perinatal care and implementations in reductions of under-
ve, infant and neonatal mortality in the past decades (4, 10, 11), perinatal asphyxia remains a severe
newborn health problem. This leads to a high number of mortality and morbidity and is a major common
public health issue, commonly in developing countries like Ethiopia (12).

Even though Ethiopia reached its child mortality reduction goal 2 years earlier, the neonatal mortality rate
remained high. One of the major causes of newborn deaths was intrapartum-related complications of
which birth asphyxia accounts for 25% (13, 14).

Moreover, a very limited number of studies were conducted in Ethiopia to identify information for
intervention regarding the death due to perinatal asphyxia. Therefore; this study was planned to estimate
the time to death and its predictors among newborns with perinatal asphyxia at governmental hospitals
in Southern Ethiopia.

Methods
Study design, setting, period and populations

A prospective cohort longitudinal study was employed at Sawla General Hospital, Arba Minch General
Hospital and Chencha district Hospital from rst of March 2018 to 28th of February 2020. Among those
hospitals, over four thousand newborns were delivered per year and more than 612 newborns were
admitted to the neonatal intensive care unit (NICU) at each hospital15.

Follow up was started at diagnosis of perinatal asphyxia immediately after birth for those delivered at the
hospital and at admission to the hospital for those delivered from 1st March 2018 and the follow-up

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period was closed on 28th February 2020. Follow-up was initiated immediately at the diagnosis of PNA
and followed until seventh day of life. The follow-up was closed if the newborn was died, discharge with
recovery, lost to follow-up from treatment, transferred to another institution and follow-up time ended
without the event happening.

In this study, a newborn that withdrew treatment, discharged with recovery, transferred to another
institution, and who did not yet develop the event at the end of the follow-up period was operationally
de ned as Censored. Sample size was estimated by Open Epi 3.02 statistical software using double
population proportion formula in considering the assumptions; 95%CI, 80% power, exposed to unexposed
ratio: 1, percent of unexposed with outcome (Not having history of premature rupture of membrane
(PROM)): 50%, percent of exposed with outcome (Having history of PROM): 62%, AHR: 1.67 and
considering 10% for non-response, the sample size became 573. Sample size was allocated to each
hospital proportionally based on the number of the admitted cases and consecutive sampling method
was applied (Figure 1).

Study variables

The dependent variable was time to perinatal mortality and the independent variables were classi ed as
socio-demographic factors (sex of the newborn, maternal age, marital status, a religion of the mother,
maternal educational status, maternal occupational status, family size, place of residence, distance
between home and hospital and estimated monthly income), obstetrics related characteristics (number of
antenatal care (ANC) visits, gravidity, parity, number of pervaginal examinations, history of meconium-
stained amniotic uid, the onset of labor, history of antepartum hemorrhage, history of obstructed labor,
history of premature rupture of membrane, history of prolonged rupture of membrane, cord prolapse,
presentation of the fetus, mode of delivery and gestational age), newborn related factors (cry immediately
at birth, history of convulsion or spasm and birth weight) and maternal medical related characteristics
(history of PIH, maternal iron de ciency anemia, maternal diabetes mellitus, and maternal HIV status).

Operational de nitions

Perinatal Asphyxia: is a diagnosis when the newborn’s fth minute APGAR score less than 7 OR complete
absent respiratory effort immediately at birth.

Maternal Anemia: The hemoglobin level of a pregnant woman or early delivery mother less than 11gm/dl.

Premature rupture of the membrane: a rupture (breaking open) of the membranes (amniotic sac) before
labor begins.

Prolonged rupture of membrane: a rupture of membranes lasting longer than 18-24 hours (i.e., between
the time of rupture and time of delivery).

Convulsion: newborn who experience an episode of rigidity and uncontrolled jerky motions that generally
last a minute or two along with altered consciousness.
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Data collection procedure, quality control and analysis

Structured checklist was used to collect the data. Data extraction tool was carefully designed to improve
data quality. In addition; both data collectors and supervisors were trained. Pretest was conducted (5% of
the population). Sensitivity analysis was conducted. The maternal hemoglobin test results were obtained
from a laboratory report which was prepared for this research purpose. The hemoglobin level was
adjusted for altitude according to criteria set by WHO (World health organization).

Epi Data version 3.02 was used to enter the data, code the data, edit the data and clean the data. Finally,
the data entered in to Epi Data were exported to SPSS version 25 for statistical analysis. The Kaplan
Meier survival curve, together with a log-rank test, was used to estimate the survival time and the time
which had higher risk of death. Variables that had a p-value <0.05 in bivariate analysis were considered
as candidates for multivariable analysis and variables which had a p-value <0.05 in multivariable cox
proportional hazard model were considered as statistically signi cant.

Ethical consideration

Ethical clearance was obtained from Arba Minch University, college of medicine and health sciences
ethical review board. All participants provided an informed consent. Mothers were informed about the
objective and signi cance of the study prior to the data collection. Appropriate measures were applied to
ensure the con dentiality of the data.

Results
Socio-demographic characteristics
In this study a total of 573 newborns were involved, of which 351(61.3%) of them were males. In
considering maternal age maximum of the mothers (70.7%) were categorized as under 20–34 years of
age and the smallest amount (13.6%) were mothers having age less than 20 years old. Regarding the
marital status and religious status of the mothers, 51(8.9%) of the mothers were never married and the
maximum number of the mothers (43.5%) were orthodox in their religion followed by protestants (31.9%).

Equal numbers of mothers were both unable to read and write and college and above, each accounted for
11% of the whole mothers. Among the mothers of the newborns, 273(47.6%), 192(33.5%), and
108(18.8%) of the mothers had less than four, four to six, and greater than six family sizes. More than
three fourths (76.4%) of the mothers were urban residents and around 93(16.2%) of the mothers had
more than 50km distance between their home and the hospital. Among the dead newborns, 33.3% of
mothers were urban residents and 66.7% were rural residents.

In considering the maternal khat chewing and alcohol consumption habits, 18(7.9%) of the mothers had
a habit of khat chewing and similar proportions (7.9%) of the mothers had a habit of alcohol
consumption. In addition, one newborn was died among the khat chewer mothers, which accounts for

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6.7% of the dead newborns. Similarly, one newborn with perinatal asphyxia was died among the mothers
who had a history of alcohol intake, which accounts for 6.7% of the dead newborns with perinatal
asphyxia (Table 1).

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 Table 1
Socio-demographic characteristics of mothers of the newborn with perinatal asphyxia
Variables Category Status of the newborn

Died Survived

n(%) n(%)

Sex Male 18(60%) 324(61.4%)

Female 18(40%) 204(38.6%)

Maternal age < 20 9(20%) 69(13.1%)

20–34 15(33.3%) 390(73.9%)

> 35 21(46.7%) 69(13.1%)

Marital status Not married 30(66.7%) 21(4.0%)

Married 15(33.3%) 507(96.0%)

Religion Orthodox 21(46.7%) 228(43.2%)

Muslim 6(13.3%) 105(19.9%)

Protestant 18(40.0%) 165(31.3%)

Others 0(0.00%) 30(5.7%)

Educational status of the mother Unable to read and write 9(20.0%) 54(10.2%)

Able to read and write 12(26.7%) 105(19.9%)

Grade 1–8 9(20.0%) 207(39.2%)

Grade 9–12 9(20.0%) 105(19.9%)

College and above 6(13.3%) 57(10.8%)

Occupational status of the mother House wife 9(20.0%) 42(8.0%)

Self-employee 12(26.7%) 120(22.7%)

Farmers 9(20.0%) 198(37.5%)

Merchant 9(20.0%) 117(22.2%)

Civil servant 6(13.3%) 51(9.7%)

Family size <4 9(20.0%) 264(50.0%)

4–6 15(33.3%) 177(33.5%)

>6 21(46.7%) 87(16.5%)

Place of residence Urban 15(33.3%) 423(80.1%)

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 Rural 30(66.7%) 105(19.9%)

Distance b/n home and hospital < 10km 9(20.0%) 357(67.6%)

10-50km 12(26.7%) 102(19.3%)

> 50km 69(13.1%) 24(53.3%)

Estimated monthly income (ETB) < 1399 18(40.0%) 36(6.8%)

1400–1999 9(20.0%) 114(21.6%)

2000–2599 9(20.0%) 189(35.8%)

> 2600 9(20.0%) 189(35.8%)

Obstetric related characteristics

In this study, 81(14.1%) of the mothers had no antenatal visits. In addition; 207(36.1%), 87(15.2%),
78(13.6%), and 120(20.9%) of the mothers had one, two, three, and four antenatal visits, respectively. In
considering gravidity and parity, 177(30.9%) of the mothers were primigravids for this birth and nearly
one fourth (25.7%) of the mothers were primiparous.

Regarding the number of pervaginal examinations, 351(61.3%) of the mothers had one to three
pervagninal examinations. Nearly one fths (19.9%) of the newborns had a meconium-stained amniotic
uid. Among the respondents, 465(81.2%), 60(10.5%), 114(19.9%), 129(22.5%) and 120(2.9%) of the
newborn's mother faced the spontaneous onset of labor, obstructed labor, prolonged labor, PROM, and
prolonged rupture of membranes, respectively.

Nearly one fths (21.5%) of the newborns were delivered at the health center. Among those who were
delivered from the health center, 33(71.3%) were died. In considering complications during delivery,
102(17.8%) of the newborns with perinatal asphyxia had cord prolapse, and 129(22.5%) of the newborns
present with breech presentation. In addition, 408(71.2%), 117(20.4%), and 48(8.4) of the newborns were
delivered by SVD and assisted instrumental and cesarean sections, respectively (Table 2).

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 Table 2
Obstetric related characteristics of the newborns with perinatal asphyxia
Variables Category Status of the newborn

Died Survived

n(%) n(%)

Number of ANC visits No 18(60.0%) 54(10.2%)

One 9(20.0%) 198(37.5%)

Two 3(6.7%) 84(15.9%)

Three 3(6.7%) 75(14.2%)

Four and above 3(6.7%) 117(22.2%)

Gravidity Primigravida 6(13.3%) 171(32.4%)

Multigravida 39(86.7%) 357(67.6%)

Parity Primipara 3(6.7%) 144(27.3%)

2–4 birth 15(33.3%) 159(30.1%)

Five and above births 27(60.0%) 225(42.6%)

Number of pervaginal examinations 1–3 21(46.7%) 330(62.5%)

Four and above 24(53.3%) 198(37.5%)

History of Meconium stained amniotic Yes 36(80.0%) 78(14.8%)

uid
No 9(20.0%) 450(85.2%)

Onset of labor Spontaneous 36(80.0%) 429(81.3%)

Induced 9(20.0%) 99(18.8%)

Antepartum hemorrhage Yes 12(26.7%) 120(22.7%)

No 33(73.3%) 408(77.3%)

Obstructed labor Yes 18(60.0%) 33(6.3%)

No 18(40.0%) 495(93.8%)

Duration of labor (hrs) Less than 18 33(73.3%) 81(15.3%)

Greater than 18 12(26.7%) 447(84.7%)

Premature rupture of membrane Yes 30(66.7%) 99(18.8%)

No 15(33.3%) 429(81.3%)

Prolonged rupture of membrane Yes 33(73.3%) 87(16.5%)

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 No 12(26.7%) 441(83.5%)

Cord prolapse Yes 33(73.3%) 63(13.1%)

No 12(26.7%) 459(86.7%)

Presentation Cephalic 15(33.3%) 429(81.3%)

Breech 30(66.7%) 99(18.8%)

Mode of delivery Spontaneous vaginal 18(40.0%) 390(73.9%)

delivery

Assisted instrumental 21(46.7%) 96(18.2%)

Cesarean section 6(13.3%) 42(8.0%)

Gestational age(week) < 37 12(26.7%) 279(52.8%)

37–42 12(26.7%) 198(37.5%)

> 42 21(46.75) 51(9.7%)

Newborn related characteristics and Medical related

characteristics of the mother
Nearly half (50.8%) of the newborns were delivered at gestational age, less than 37 weeks and 72(12.6%)
of them were post terms (gestational age more than 42 weeks). In this study, a total of 573 newborns had
a rst minute APGAR score of three or less. All of the newborns were resuscitated at birth and 471(82.2%)
of the newborns did not cry during birth. Considering the birth weight, 186(32.5%) of the newborns had a
birth weight less than 2500 grams, of which 30 newborns died, which accounts for 66.7% of the dead
newborns. Twenty-one (3.7%) of the admitted newborns had at least one spot of convulsion or spasm.

Pregnancy induced hypertension (PIH), maternal iron de ciency anemia; maternal diabetes mellitus (DM)
and maternal HIV status were the identi ed health problems affecting the survival status of newborns
with perinatal asphyxia. In this study, 165(28.8%), 105(18.3%), 18(3.1%) and 30(5.2%) of the mothers had
a history of diagnosed PIH, iron de ciency anemia, DM and HIV respectively (Table 3).

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 Table 3
Newborn related and maternal medical disorders affecting the survival status
of the newborns with perinatal asphyxia
Variable Category Status of the newborn

Died Survived

n(%) n(%)

Cry immediately at birth Yes 3(6.7%) 99(18.8%%)

No 42(93.3%) 429(81.3%)

History of convulsion or spasm Yes 12(26.7%) 9(1.7%)

No 33(73.3%) 519(98.3%)

Birth weight (gram) < 2500 30(66.7%) 156(29.5%)

≥ 2500 15(33.3%) 372(70.5%)

Pregnancy induced hypertension Yes 36(80.0%) 129(24.4%)

No 9(20.0%) 399(75.6%)

Maternal Iron de ciency anemia Yes 24(53.3%) 81(15.3%)

No 21(46.7%) 447(84.7%)

Maternal Diabetes mellitus Yes 3(6.7%) 15(2.8%)

No 42(93.3%) 513(97.2%)

HIV status Positive 3(6.7%) 27(5.1%)

Negative 42(93.3%) 501(94.9%)

The survival status of newborns with perinatal asphyxia

The cumulative proportion of survival among the newborns admitted with perinatal asphyxia was 95.21%
(95%CI: 91.00, 97.48) at the end of the rst follow-up day. In addition, it was 92.82% (95%CI: 87.95,
95.77), 92.02% (95%CI: 86.84, 95.22) and 90.78% (95%CI: 84.82, 94.48) at the end of the second, third,
and fourth follow-up days respectively. As we have seen from Fig. 2, there was a rapid decline of survival
on the rst day and it became slow in the corresponding follow-up days. The overall mean survival time
was 6.55 (95%CI: 6.33, 6.77) (Fig. 2).

Among newborns admitted with perinatal asphyxia 27 (4.71%) died in the rst follow up day, which is
60% of the observed deaths within the study period. Similarly, the proportion of death at the second and
third follow-up days was 2.09% and 0.52% respectively. There was no observed death after the fourth
follow-up. In this study, 45(7.85%) of the newborns with perinatal asphyxia died and 531 (92.15%) were
recovered (Fig. 3).

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Log rank estimate of the covariates of variables
The Kaplan Meier survival curve together with the log-rank test estimates the chi square and p-value of
each variable. Distance between home and hospital, referral status of the newborn, meconium-stained
amniotic uid, obstructed labor, premature rupture of membrane, prolonged rupture of membrane, cord
prolapse, presentation, place of delivery, mode of delivery, history of convulsion or spasm, birth weight,
pregnancy-induced hypertension, and iron de ciency anemia were candidate variables for multivariable
analysis in cox proportional hazard model (Table 4).

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 Table 4
The log rank estimate of the variables determining the survival status
among newborns admitted with perinatal asphyxia
Variables Log rank estimate

Chi square (X2) P-value

Sex 0.003 0.959

Maternal age 1.365 0.81

Marital status 3.85 0.64

Religion 1.48 0.68

Educational status of the mother 2.97 0.56

Occupational status of the mother 3.73 0.44

Family size 2.21 0.310

Place of residence 1.79 0.32

Distance between home and hospital 20.05 0.0001

Referral status 26.02 0.0001

Estimated monthly income (ETB) 1.89 0.53

Maternal Khat chewing status 0.089 0.765

Alcohol intake 0.031 0.86

Number of ANC visits 3.09 0.74

Gravidity 2.31 0.129

Parity 3.27 0.194

Number of pervaginal examinations 1.43 0.23

Meconium stained amniotic uid 37.04 0.0001

Onset of labor 0.005 0.94

Antepartum hemorrhage 0.134 0.715

Obstructed labor 43.79 0.0001

Duration of labor 5.43 0.631

Premature rupture of membrane 17.9 0.0001

Prolonged rupture of membrane 28.35 0.0001

Cord prolapse 35.44 0.0001

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 Variables Log rank estimate

Presentation 18.40 0.0001

Place of delivery 26.02 0.0001

Mode of delivery 8.36 0.015

Gestational age 0.48 0.487

Cry immediately at birth 1.38 0.239

History of convulsion or spasm 26.32 0.0001

Birth weight(gram) 8.94 0.003

Pregnancy induced hypertension 21.12 0.0001

Maternal Iron de ciency anemia 13.15 0.0001

Maternal Diabetes mellitus 0.733 0.392

Maternal HIV status 0.07 0.79

The mean survival time among the covariates of predictors

of mortality
The mean survival time was different among the covariates of each predictor. The mean survival time
was higher among the newborns that had no cord prolapse as compared with those who had cord
prolapse during delivery. Similarly, the average survival time was higher among newborns born with a
mother who had no pregnancy-induced hypertension and no diagnosed iron de ciency anemia as
compared with those with pregnancy-induced hypertension and iron de ciency anemia respectively
(Table 5).

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 Table 5
The mean survival time estimate of the newborns with perinatal asphyxia
among the covariates of predictors
Variables Category Mean survival time (95%CI)

Cord prolapse Yes 5.19(4.31, 6.07)

No 6.85(6.70, 6.99)

Pregnancy induced hypertension Yes 5.76(5.14, 6.38)

No 6.87(6.73, 7.01)

Iron de ciency anemia Yes 5.72(4.94, 6.50)

No 6.74(6.56, 6.93)

Convulsion or spasm Yes 3.04(2.07, 4.02)

No 6.65(6.45, 6.85)

Predictors of mortality among newborns with perinatal

asphyxia
In this study, cord prolapse, pregnancy induced hypertension, iron de ciency anemia of the mother and
having a history of convulsion or spasm of the newborn were statistically signi cant in the multivariable
cox regression model.

Newborns having cord prolapse during delivery had six times higher risk of mortality as compared with
those who had no cord prolapse (AHR: 6.5; 95%CI: 1.18, 36.01). The risk of mortality among newborns
with perinatal asphyxia and delivered with mothers who had a history of pregnancy induced hypertension
was 25 times higher as compared with those who had no pregnancy induced hypertension (AHR: 25.4;
95%CI: 3.68, 175.0).

Newborns with perinatal asphyxia and delivered with mothers with iron de ciency anemia had ve times
higher risk mortality as compared with those mothers who had no iron de ciency anemia (AHR: 5.9;
95%CI: 1.19, 29.5). Newborns admitted with perinatal asphyxia and had history of convulsion or spasm
had 10 times higher risk of mortality as compared with those who had no history of convulsion of spasm
(AHR: 10.23; 95%CI: 2.24, 46.54)(Table 6).

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 Table 6
Predictors of mortality among newborns admitted with perinatal asphyxia.
Variables Category Status COR(95%CI) AOR(95%CI)

Died Survived

Distance b/n home and < 10km 3 119 1 1

hospital
10-50km 4 34 4.26(0.95, 0.24(0.01,
19.04) 5.36)

> 50km 23 8 11.53(3.04, 0.18(0.007,

43.65)* 5.01)

Referral status Yes 11 30 10.52(3.34, 0.65(0.02,

33.05)* 16.62)

No 4 146 1 1

Meconium stained Yes 12 26 16.95(4.78, 1.46(0.17,

amniotic uid 60.12)* 12.24)

No 3 150 1 1

Obstructed labor Yes 9 11 13.76(4.89, 0.48(0.02,

38.69)* 7.87)

No 6 165 1 1

Premature ROM Yes 10 33 7.08(2.42, 1.54(0.20,

20.72)* 11.90)

No 5 143 1 1

Prolonged ROM Yes 11 29 11.34(3.60, 0.50(0.02,

35.70)* 10.84)

No 4 147 1 1

Cord prolapse Yes 11 23 13.68(4.35, 6.5(1.18,

43.02)* 36.01)**

No 4 153 1 1

Presentation Cephalic 5 143 1 1

Breech 10 33 7.22(2.46, 4.1(0.91,

21.14)* 18.54)

Place of delivery Health center 11 30 10.52(3.34, 6.4(0.73,

33.05)* 6.82)

Hospital 4 146 1 1

Birth weight(gram) < 2500 10 52 2.09(1.22, 2.99(0.73,

3.58)* 12.13)

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 Variables Category Status COR(95%CI) AOR(95%CI)

Died Survived

> 2500 5 124 1 1

Pregnancy induced Yes 12 43 3.23(1.71, 25.4(3.68,

hypertension 6.09)* 175.0)**

No 3 133 1 1

Maternal Iron de ciency Yes 8 27 2.28(1.37, 5.9(1.19,

anemia 3.79)* 29.5)**

No 7 149 1 1

Mode of delivery SVD 6 130 1 1

Assisted 7 32 4.2(1.4, 0.87(0.15,

instrumental 12.65)* 5.12)

CS 2 14 2.96(0.59, 5.86(0.84,
14.70) 40.77)

Convulsion Yes 4 3 3.27(1.84, 10.23(2.24,

5.82)* 46.54)**

No 11 173 1 1

Key note: * indicates variables which have p-value < 0.25 and ** indicates variables which have p-
value < 0.05

Discussion
This study assesses the predictors of mortality among newborns admitted with perinatal asphyxia at
public hospitals in Southern Ethiopia and it showed there was a high proportion of mortality at the early
admission periods especially at the rst day and gradually declines as the follow-up period has been
increased.

Newborns having cord prolapse during delivery had six times higher risk of mortality as compared with
those who had no cord prolapse (AHR: 6.5; 95%CI: 1.18, 36.01). This study nding is similar with the
study conducted in Karachi, Pakistan (2). The principal causes of perinatal asphyxia in this context was
thought to be cord compression and umbilical arterial vasospasm which prevents venous and arterial
blood ow to and from the fetus. In addition; it can predispose other factors that lead the newborn to die
such as assisted ventilation requirement, low cord pH, meconium aspiration, hyaline membrane disease,
convulsion, neonatal encephalopathy, and cerebral palsy (16, 17).

Consistent with the study conducted at Dilla University referral hospital, Southern Ethiopia, Tigray
regional state, Ethiopia and tertiary care center in Ahmedabad, Gujarat, India and Ayder comprehensive
specialized hospital, Northern Ethiopia (18, 19, 20, 21), the risk of mortality among newborns with
Page 17/21
perinatal asphyxia and delivered with mothers who had a history of pregnancy induced hypertension was
25 times higher as compared with those who had no pregnancy-induced hypertension (AHR: 25.4; 95%CI:
3.68, 175.0). This might be related to the effect of diminished uteroplacental blood ow and placental
ischemia, which can be due to pregnancy-induced hypertension which reduces blood ow to the fetus (22,
23). In addition; pregnancy-induced hypertension (PIH) has an effect on the reduction of blood supply,
nutrients, and oxygen to the fetus at intrauterine life, nally which ends up in intrauterine growth
restriction. This condition can contribute to newborn mortality with perinatal asphyxia (24).

Newborns with perinatal asphyxia and delivered by mothers who have iron de ciency anemia had ve
times higher risk mortality as compared with the counterparts who had no iron de ciency anemia (AHR:
5.9; 95%CI: 1.19, 29.5). This study nding is concise with the study done at Dilla University referral
hospital, Southern Ethiopia, Southern Nations Nationalities and Peoples Regional State of Ethiopia and
Jimma Zone, Southwest Ethiopia (16, 25, 26).

Newborns admitted with perinatal asphyxia and had a history of convulsion of spasm had a 10 times
higher risk of mortality as compared with those who had no history of convulsion of spasm (AHR: 10.23;
95%CI: 2.24, 46.54). The possible reason might be convulsion that may cause the newborn to cease
breathing (apnea). If this interruption in breathing persists, it can result in a decline in oxygen saturation
in the blood to a life-threatening level.

Irrespective of the study conducted at Southern Nepal, Ayder comprehensive specialized hospital, Dilla
University referral hospital, primiparity, place of delivery, multi-parity, low birth weight, mode of delivery
and premature rupture of the membrane was not statistically signi cant predictors of mortality (18, 27,
28).

Limitation of the study

Since the study was conducted among the newborns delivered at public hospitals, it cannot be
generalized for the newborns delivered at home, health centers and health posts. In addition, this study
did not assess the complications secondary to perinatal asphyxia.

Conclusion
The survival status of newborns admitted with perinatal asphyxia was low at the early follow up periods
after admission to the hospital and the risk of mortality was decreased at the later follow up periods and
having cord prolapse of the newborn during delivery, maternal history of pregnancy-induced hypertension,
maternal history of iron de ciency anemia and newborn history of convulsion or spasm were the
independent predictors of mortality.

Abbreviations
ANC Antenatal Care

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APGAR Appearance, pulse, Grimmace, Activity and Respiratory effort

APH Antepartum hemorrhage

DM Diabetes mellitus

PIH Pregnancy induced hypertension

WHO World Health Organization

Declarations
Consent for publication
Not applicable

Availability of data and materials

The data sets generated and/or analyzed are available with a reasonable request through the
corresponding author.

Competing interest
I declare that the authors have no any con ict of interest.

Funding
Not applicable

Author’s contribution
All authors made a signi cant contribution to the work reported, whether that is in the conception, study
design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in
drafting, revising or critically reviewing the article; gave nal approval of the version to be published; have
agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects
of the work.

Acknowledgements

We would like to thank the mothers who are directly involved in the study and administrator of each
hospital for their effort and permission to conduct the study.

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