Background: During the past two decades there has been a sustained decline in child mortality; however, neonatal mortality has remained stagnant. Each year approximately 4 million babies are born asphyxiated resulting in 2 million neonatal deaths and intrapartum stillbirths. Almost all neonatal deaths occur in developing countries, where the majority is delivered at homes with negligible antenatal care and poor perinatal services. Objectives: To identify socio-demographic and clinical risk factors associated with birth asphyxia in Matiari District of Sindh Province, Pakistan. Method: A matched case control study was conducted in Matiari District with 246 cases and 492 controls. Newborn deaths with birth asphyxia diagnosed through verbal autopsy accreditation during 2005 and 2006 were taken as cases. Controls were the live births during the same period, matched on area of residence, gender and age. Result: The factors found to be associated with birth asphyxia mortality in Matiari District of Sindh Province, Pakistan are maternal education, history of stillbirths, pregnancy complications (including smelly or excessive vaginal discharge and anemia), intrapartum complications (including fever, prolong or difficult labour, breech delivery, cord around child’s neck, premature delivery, large baby size) and failure to establish spontaneous respiration after birth. Conclusion and Recommendation: There is an immediate need to develop strategies for early identification and management of factors associated with birth asphyxia by involving women, families, communities, community health workers, health professionals and policy makers. Community health workers should be trained for emergency obstetric care, basic newborn care including preliminary resuscitation measures to provide skilled birth attendance and encourage early recognition and referral.
Most developing countries have witnessed substantial declines in under 5 mortality [
Birth asphyxia is defined by the World Health Organization as “the failure to initiate and sustain breathing at birth” [
In 2013, lower-middle-income countries (LMIC) share 98% of the total newborn mortality burden [
To the best of our knowledge this is the first study to identify risk factors of BA mortality among neonates
Community based study | Hospital based studies | ||
---|---|---|---|
Demographic risk factors | Antepartum risk factors | Intrapartum risk factor | Infant/postnatal |
Parental education and occupation [ | Primiparity [ | Malpresentation [ | Prematurity [ |
Cast and ethnicity [ | Maternal fever [ | Prolonged labor [ | Low birth weight [ |
Pregnancy induced hypertension [ | Meconium stained amniotic fluid [ | Intrauterine growth restriction [ | |
Anemia [ | Pre-eclampsia [ | ||
Antepartum hemorrhage [ | Premature rupture of membranes [ | ||
History of prior neonatal death [ | Oxytocin augmentation of labor [ | ||
Umbilical cord prolapsed [ |
conducted in rural resources limited settings in Pakistan.
It was a matched case control study conducted from September 2009 to January 2010 in Matiari District of Sindh Province, Pakistan. The estimated population of the area is about 5 million. The Matiari District is administratively divided into taluk as which further comprised of 19 union councils. The study area was selected on the availability of verbal autopsies data on under 5 mortality captured during the survey conducted by department of Paediatrics & Child Health in year 2005-2006. Neonatal death (0 - 28 days) rate was 50/1000 live births as per the available data. Verbal autopsies of all neonatal deaths captured during the survey were reviewed by trained Pediatricians to assign a reference standard primary cause of death. The verbal autopsy concluded that around 30% of all neonatal deaths were caused by birth asphyxia. We took these deaths as cases while controls were the live births of same area during the same period, matched on gender and age to reduce confounding by these variables.
Sample size was calculated using the proportion of birth asphyxia among controls (22.1%) from the Pakistan Demographic and Health Survey PDHS2006-07. Expecting to obtain an odds ratio of 1.5, required sample size was 246 cases over 492 controls, at 5% level of significance and 80% power.
The study teams comprised of research assistant from the local community and were trained on data collection instruments and study methodology. A structured data collection tool was designed and administered after informed verbal consent from mother of case or control child. Data was collected on a wide range of factors including household demographics, reproductive history, antenatal care seeking, maternal complication during pregnancy, labor, delivery and neonatal complications at birth. To ensure quality of data collection, project supervisor checked 5% of the total forms. The fieldwork was very closely monitored by the team leader and prior to data entry, all forms were checked for completeness and consistency as well as coding of open ended responses and area code, etc. In case of inconsistency or missing responses, the field supervisor flagged the errors and consulted the interviewers for possible explanations. All data was entered twice for the purpose of sufficient accuracy. Data quality was assured by performing dual and error checks simultaneously with data entry. A sub sample of data was checked manually for validation.
To evaluate potential predictors for birth asphyxia mortality risk factors were grouped into four major domains: socio-demographics, antepartum, intrapartum, and postnatal or infant characteristics. Univariate distributions were explored using frequencies/proportions, and means/medians and histograms, as appropriate. Multivariate analysis was conducted via conditional logistic regression to ensure adequate statistical power and efficiency. Results are reported as the odds ratios (OR) with respective 95% CI. All potential covariates were examined independently in univariate analysis. Variables significant at a liberal p < 0.25 were considered for adjustment in the multivariate model. Covariates that were found insignificant at multivariate level were dropped consecutively from model after careful assessment of confounding. The final model was selected on the basis of theoretical and statistical significance of predictors. Type 1 error rate was held at 0.05 and statistical analyses were performed using STATA (version 12).
The study protocol was examined and approved by the Aga Khan University ethics review committee.
We studied 246 cases and 492 controls. Among various socio-demographic indicators birth asphyxia was found to be significantly associated with mother and father education levels. Maternal literacy decreased the risk of mortality with birth asphyxia (OR 0.5, 95% CI: 0.3 - 0.7) while father’s higher education levels possessed protective effect on mortality (OR 0.5, 95% CI: 0.3 - 0.9). Significant association was not established with major socio-demographic determinants such as socio-economic position (SES quintiles), improved water and sanitation facilities with birth asphyxia (
Exposure | Control (n = 492) | Cases (n = 246) | OR | p-value |
---|---|---|---|---|
HH characteristics | ||||
Source of drinking water | ||||
Tap in house | 73.0 | 69.9 | 1 | |
Public tap | 9.1 | 11.8 | 1.4 (0.8 - 2.5) | 0.26 |
Other | 17.9 | 18.3 | 0.9 (0.5 - 1.8) | 0.92 |
Kind of toilet facilities | ||||
Latrine with flush system | 37.4 | 35.8 | 1 | |
Latrine without flush system | 18.9 | 16.7 | 0.9 (0.4 - 1.9) | 0.85 |
No facilities/use the fields | 43.7 | 47.6 | 1.4 (0.8 - 2.4) | 0.30 |
Wealth quintiles | ||||
Poorest | 21.1 | 17.1 | 0.6 (0.3 - 1.2) | 0.17 |
Poorer | 20.3 | 19.9 | 0.8 (0.5 - 1.6) | 0.70 |
Middle | 18.1 | 23.6 | 1.2 (0.7 - 2.2) | 0.42 |
Richer | 20.7 | 19.1 | 0.8 (0.5 - 1.5) | 0.65 |
Richest | 19.7 | 20.3 | 1 | |
Respondent characteristics | ||||
Maternal education | ||||
No formal schooling | 76.8 | 85.8 | 1 | |
Literate (primary or above) | 23.2 | 14.2 | 0.5 (0.3 - 0.7) | 0.001 |
Maternal occupation | ||||
Unemployed | 89.2 | 88.6 | 1 | |
Employed | 10.8 | 11.4 | 1.1 (0.6 - 1.9) | 0.77 |
Father age | ||||
<40 years | 78.7 | 77.6 | 1 | |
≥40 years | 21.3 | 22.4 | 1.0 (0.7 - 1.5) | 0.86 |
Father education | ||||
No formal schooling | 46.4 | 54.1 | 1 | |
Primary/middle | 22.6 | 23.6 | 1 (0.6 - 1.5) | 0.87 |
Metric or above | 31.1 | 22.4 | 0.5 (0.3 - 0.9) | 0.01 |
*Wealth quintiles constructed through PCA using construction of HH, no of rooms, cooking fuel, electrification, source of drinking water and sanitation facilities.
Our data shows significant association of birth asphyxia with increasing maternal age (OR: 1.4, 95% CI: 1.1 - 2.0), poor dietary intake (OR: 2.2, 95% CI 1.4 - 3.3), reproductive history including shorter birth intervals (OR: 1.8, 95% CI: 1.2 - 2.6), prior stillbirths (OR: 2.9, 95% CI: 1.9 - 4.5) and child deaths (OR: 94, 95% CI: 30 - 295) and complications during pregnancy including self-reported high blood pressure (OR: 2, 95% CI: 1.3 - 2.9), bleeding from the vagina (OR: 3.3, 95% CI: 1.6 - 6.8), smelly or excessive vaginal discharge (OR: 3.1, 95% CI: 1.8 - 5.2), severe abdominal pain (OR: 1.7, 95% CI: 1.2 - 2.5), swelling on body (OR: 1.5, 95% CI: 1.1 - 2.2). However, maternal malnutrition and working routine did not appear to contribute to BA mortality (
Exposure | Control (n = 492) | Cases (n = 246) | OR | p-value |
---|---|---|---|---|
Maternal age | ||||
<30 years | 42.3 | 34.6 | 1 | |
30+ years | 57.7 | 65.4 | 1.4 (1.1 - 2.0) | 0.03 |
Maternal malnutrition | ||||
Low BMI (<18.5) | 28.7 | 26.5 | 0.9 (0.6 - 1.3) | 0.54 |
Short stature (ht < 145 cm) | 11.8 | 12.2 | 1.0 (0.6 - 1.7) | 0.86 |
Food habits during pregnancy | ||||
More or usual diet | 85.3 | 75.2 | 1 | |
Less than usual diet | 14.6 | 24.8 | 2.2 (1.4 - 3.3) | 0.0003 |
Working habits during pregnancy | ||||
Less than usual work | 13.8 | 9.7 | 1 | |
More or usual work | 86.2 | 90.2 | 1.5 (0.9 - 2.5) | 0.1 |
Birth history | ||||
Miscarriages | 20.7 | 25.2 | 1.3 (0.9 - 1.8) | 0.15 |
Still birth | 12.0 | 26.4 | 2.9 (1.9 - 4.5) | <0.001 |
Child death | 31.9 | 97.6 | 94.2 (30.1 - 295.3) | <0.001 |
Birth interval < 2 years | 66.3 | 77.4 | 1.8 (1.2 - 2.6) | 0.001 |
Complications during pregnancy | ||||
Bleeding from the vagina | 3.05 | 8.94 | 3.3 (1.6 - 6.8) | 0.001 |
Smelly or excessive vaginal discharge | 7.11 | 17.48 | 3.1 (1.8 - 5.2) | <0.001 |
Severe or persistent abdominal or back pain that was not labour pain | 29.07 | 37.80 | 1.7 (1.2 - 2.5) | 0.006 |
Swelling on body parts (hand, face, leg) | 26.42 | 33.74 | 1.5 (1.1 - 2.2) | 0.02 |
Blurring of vision | 47.15 | 54.07 | 0.4 (1 - 1.9) | 0.06 |
Severe headache | 58.54 | 65.85 | 1.4 (1.0 - 2.0) | 0.05 |
High blood pressure | 30.49 | 41.46 | 2 (1.3 - 2.9) | 0.001 |
Anaemia/pallor | 21.54 | 29.67 | 1.6 (1.1 - 2.4) | 0.01 |
Almost half of the deliveries took place at medical facilities, proportion of hospital births being higher in cases than in controls (OR 1.6, 95% CI: 1.1 - 2.4). Complications during labor and delivery including high blood pressure (OR 2.4, 95% CI: 1.6 - 3.6), convulsions (OR 2.8, 95% CI: 1.5 - 5.2), excessive bleeding (OR 2.8, 95% CI: 1.6 - 5.1), water bag broke before labor (OR 2.8, 95% CI: 1.2 - 6.5), breech delivery (OR 6.2, 95% CI: 2.8 - 13.8), prolong labor (OR 5.2, 95% CI: 3.3 - 8.3) and baby movement stopped (OR 4.9, 95% CI: 1.7 - 13.9) were significantly associated with increased risk of birth asphyxia mortality. Exact gestational age was not available therefore mother’s reported duration of pregnancy was taken as proxy and the data suggests that early ended pregnancies carried higher risk of birth asphyxia mortality (OR 5.4, 95% CI: 2.9 - 10). Delivery augmented with medicine significantly predict increased chances of birth asphyxia mortality (OR 2.2, 95% CI: 1.4 - 3.4) (
Data on birth weight was not available therefore size at birth taken as proxy. Small size at birth was associated
Exposure | Control (n = 492) | Cases (n = 246) | OR | p-value |
---|---|---|---|---|
Complications occurred during labour | ||||
High blood pressure | 29.30 | 42.30 | 2.4 (1.6 - 3.6) | <0.001 |
Convulsions | 4.50 | 11.00 | 2.8 (1.5 - 5.2) | 0.001 |
Fever | 16.10 | 28.50 | 2.4 (1.6 - 3.6) | <0.001 |
Excessive bleeding | 5.50 | 12.60 | 2.8 (1.6 - 5.1) | 0.001 |
Prolonged/difficult labour | 13.8 | 37.0 | 5.2 (3.3 - 8.3) | <0.001 |
Breech delivery | 1.6 | 10.2 | 6.2 (2.8 - 13.8) | <0.001 |
Cord around child’s neck | 2.2 | 4.1 | 2 (0.8 - 5) | 0.13 |
Place of delivery | ||||
Home | 42.1 | 33.3 | 1 | |
Hospital | 57.9 | 66.7 | 1.6 (1.1 - 2.4) | 0.009 |
Last movement in the womb | ||||
During labour or delivery | 98.4 | 93.5 | 1 | |
At least one or two day prior to delivery | 1.2 | 5.3 | 4.9 (1.7 - 13.9) | 0.003 |
Pregnancy ends up | ||||
Early | 3.7 | 17.9 | 5.4 (2.9 - 10) | <0.001 |
In time | 88.0 | 72.8 | 1 | |
Late | 7.9 | 8.9 | 1.5 (0.8 - 2.7) | 0.21 |
Labour type | ||||
Spontaneous without medication | 62.0 | 51.6 | 1 | |
Induced with medicine | 9.1 | 12.2 | 1.3 (0.7 - 2.4) | 0.42 |
Augmented with medicine | 28.9 | 36.2 | 2.2 (1.4 - 3.4) | 0.001 |
Timing of breakage of water bag | ||||
Before labour | 4.3 | 8.1 | 2.8 (1.2 - 6.5) | 0.014 |
During labour | 95.6 | 91.8 | 1 | |
Length of delivery and labor | ||||
Less than 12 hours | 93.1 | 80.9 | 1 | |
Twelve hours or more | 6.7 | 19.1 | 4.3 (2.4 - 7.5) | <0.001 |
Outcome of delivery | ||||
Singleton | 98.8 | 95.9 | 1 | |
Multiple | 1.2 | 4.1 | 1 (0.9 - 1.1) | 0.63 |
with increased risk of birth asphyxia mortality (OR 2.5, 95% CI: 1.5 - 4.1) whereas being large at birth had twice more risk of mortality due to birth asphyxia (OR 4.1, 95% CI: 2.0 - 8.3). Other significantly associated neonatal risk factors were difficult breathing (OR 79, 95% CI: 29 - 214), baby not breathing immediately after birth (OR 38.4, 95% CI: 18.9 - 78.1), cyanosis (OR 301, 95% CI: 42 - 2147) and chest in drawing after birth (OR 2.3, 95% CI: 1.5 - 3.8) (
Multivariate analysis yielded interesting results as some of the associations between outcome and predictors
Exposure | Control (n = 492) | Cases (n = 246) | OR | p-value |
---|---|---|---|---|
Size of baby at birth | ||||
Smaller than average | 12.2 | 20.3 | 2.5 (1.5 - 4.1) | <0.001 |
Average | 84.1 | 67.9 | 1 | |
Larger than average | 3.5 | 11.8 | 4.1 (2.0 - 8.3) | <0.001 |
Failure to develop spontaneous breathing | 6.9 | 70.6 | 38.4 (18.9 - 78.1) | <0.001 |
Color of the baby turned blue after 5 minutes of birth | 2.3 | 67.2 | 301 (42 - 2147) | <0.001 |
Difficult breathing after birth | 9.8 | 81.6 | 79 (29 - 214) | <0.001 |
Chest in drawing after birth | 9.1 | 17.9 | 2.3 (1.5 - 3.8) | <0.001 |
Nostrils flare with breathing | 38.2 | 27.4 | 0.4 (0.3 - 0.7) | <0.001 |
were not found significant after controlling the effect of other variables although these predictors have shown conspicuous relationship during bi-variate analysis. The significant mortality contributory factors were maternal education (OR: 3.2, 95% CI: 1.2 - 8.5), history of stillbirths (OR: 4.4, 95% CI: 1.8 - 10.8), smelly or excessive vaginal discharge (OR: 3.1, 95% CI: 1.1 - 8.4) or anemia (OR: 2.2, 95% CI: 1.0 - 4.9) during pregnancy, intrapartum complications such as fever (OR: 2.4, 95% CI: 1.0 - 5.6), prolong labour (OR: 3.8, 95% CI: 1.5 - 9.6), breech delivery (OR: 6.1, 95% CI: 1.2 - 31.8) and cord around child’s neck (OR: 8.8, 95% CI: 1.4 - 54.5), duration of pregnancy (proxy for gestational age) (OR: 5.3, 95% CI: 1.7 - 16.8), large size of baby at birth (proxy for birth weight) (OR: 5.3, 95% CI: 1.6 - 16.9) and child didn’t cry immediately after birth (OR: 53.8, 95% CI: 20.7 - 139.6) (
Our study demonstrates that maternal education, history of stillbirths, prenatal complications (including smelly or excessive vaginal discharge and anemia) and intrapartum complications (including fever, prolong or difficult labour, breech delivery, cord around child’s neck, premature delivery, large baby size and failure to establish spontaneous respiration after birth) were significantly associated with higher risk of neonatal mortality related to birth asphyxia in Matiari District of Pakistan. To our knowledge, this is the first study to identify risk factors of birth asphyxia mortality among newborns, conducted in rural resource limited settings in Pakistan, where quality of care is inadequate to respond to emergency situations. We evaluated broad range of risk factors including socio-demographic, antenatal, intrapartum and neonatal complications.
Among the sociodemographic risk factors, our study identified maternal education as one of the factors associated with BA mortality. Similar patterns were reported by other studies conducted in rural areas of Southern Nepal and Mexico City [
It is well known that diseases and complications during pregnancy are the most important risk factors of perinatal mortality [
Indicators | Adjusted OR | 95% CI | p-value |
---|---|---|---|
Maternal education | |||
No formal schooling | 3.2 | 1.2 - 8.5 | 0.02 |
Literate (primary or above) | 1 | ||
Reproductive history of stillbirth | 4.4 | 1.8 - 10.8 | <0.001 |
Prenatal complications | |||
Smelly or excessive vaginal discharge | 3.1 | 1.1 - 8.4 | 0.03 |
Anemia/pallor | 2.2 | 1.0 - 4.9 | 0.05 |
Intrapartum complications | |||
Fever | 2.4 | 1.0 - 5.6 | 0.04 |
Prolong/difficult labor | 3.8 | 1.5 - 9.6 | 0.01 |
Breech delivery | 6.1 | 1.2 - 31.8 | 0.03 |
Cord around child’s neck | 8.8 | 1.4 - 54.4 | 0.02 |
When this pregnancy end? | |||
Early | 5.3 | 1.7 - 16.8 | <0.001 |
In time | 1 | ||
Late | 1.2 | 0.3 - 4.1 | 0.82 |
Size of baby at birth? | |||
Smaller than average | 0.4 | 0.1 - 1.0 | 0.04 |
Average | 1 | ||
Larger than average | 5.3 | 1.6 - 16.9 | 0.01 |
Failure to develop spontaneous breathing | 53.8 | 20.7 - 139.6 | <0.001 |
significantly associated with neonatal deaths due to BA. This is in accordance with several previously published studies in similar settings [
Our findings reflect unsatisfactory perinatal and delivery services in the in resource-limited rural settings of Matiari, Pakistan. Such inadequacies and low quality care delivery has also been previously highlighted by other studies conducted in [
One of the limitations of our study is that our study was conducted on limited and specified geographic settings that involved less resourced rural setup. Larger studies are required to demonstrate the true associations in the population. Other limitations include potential reporting bias of maternal, infant symptoms and recall bias in verbal autopsy interviews.
Concrete and coordinated efforts are required to decrease the burden of neonatal deaths related to BA specifically in low-resource settings. Neonatal and late fetal deaths are closely linked to maternal deaths, requiring common solutions. There is an immediate need to develop strategies for identification and management of birth asphyxia by involving all pathways to survival, including women, families, communities, community health workers, health professionals and policy makers. There is a need to maintain high coverage of skilled birth attendants, promotion of birth preparedness, essential new born care including hygiene and thermal care for new born, trained community workforce for early recognition, referrals at primary health care with well equipped and trained health personnel, training of obstetricians and paramedics staff for emergency obstetric care, and basic newborn care including preliminary resuscitation measures in low resource settings where access to health services are difficult.
This study was made possible because of the research assistants working in Matiari Yar Mohammad, Bushra Memom and data coordinators Imran Ali. Statistical assistance was provided by Dr. Salim Iqbal epidemiologist. We also thank full to assistant professor Dr. Asiha Yousfzai and senior instructor Rehana Salam for their technical support.
All authors declare that they have no conflicts of interest.
This study was funded by PAIMAN (Pakistan Initiative for Mothers and Newborns) and John Snow Inc., via a grant from by the US Agency for International Development (USAID).
ZAB conceptualized the study and as principal investigator involved in all aspects of this study. SS participated in study design, data analysis and interpretation of data and reviewed final manuscript. SA critically reviewed the final manuscript. FT was project supervisor developed study protocol, data collection material and oversaw study implementation and writing of the manuscript. AR was statistician for this study and conducted data analysis. All authors reviewed and approved the final manuscript.