International Journal of Pediatrics and Neonatal Health

Prevalence and associated factors of Neonatal near miss among Neonates Born in Hospitals at South Gondar Zone Amhara Region, North West Ethiopia, 2020

International Journal of Pediatrics and Neonatal Health

Research Article Volume 5 Issue 1, Prevalence and associated factors of Neonatal near miss among January 2021 Neonates Born in Hospitals at South Gondar Zone Amhara Region, North West Ethiopia, 2020 Copyright ©2021 Adnan Baddour et al. Enyew Dagnew*, Habtamu Geberehana, Minale Bezie, and Abenezer Melkie This is an open access article distributed under the terms of Debre Tabor University, College of Health Sciences, Debre Tabor, Ethiopia the Creative Commons Attri- bution License, which permits unrestricted use, distribution, Corresponding author: Enyew Dagnew and reproduction in any me- Debre Tabor University, College of Health Sciences, Debre Tabor, Ethiopia. Tel No: 0918321285, dium, provided the original E-mail: [email protected] author andsource are credited.

Article History: Received: February 07, 2020; Accepted: February 24, 2020; Published: January 18, 2021.

Citation Abstract Enyew Dagnew et al. (2021), Objective: The aim of this study was to determine prevalence and associated factors of neonatal near Features of Bone Mineraliza- miss in Hospitals at South Gondar Zone Amhara Region, Northwest Ethiopia, 2019. tion in Children with Chron- Institutional based cross sectional study was employed among 848 study participants. Data was ic Diseases. Int J Ped & Neo collected with pretested structured questionnaire. The data was entered by Epi-Info version 7 software Heal. 5:1, 10-18 and exported to SPSS version 23 for analysis. Statistical significance was declared at P value of < 0.05. Results: In this study, prevalence of neonatal near miss in the study area were 242 (28.54%) of neonates (95% CI 25.5%, 31.8%). Being Primiparous (AOR = 1.75, 95%CI (1.23, 2.49)),mothers` age <20 years ISSN 2572-4355 old (AOR = 2.99, 95%CI (1.69, 5.30)), mothers encountered premature rupture of membrane (AOR = 2.15, 95%CI (1.37, 3. 39)), pregnancy induced hypertension (AOR = 5.04, 95%CI (3.01, 8.46)), post term Published by pregnancy (AOR = 2.24, 95%CI (1.29, 3.89)) Cephalo pelvic disproportion (AOR = 3.92, 95%CI (2.67, Biocore Group | 5.75)), and diabetes mellitus (AOR = 2.17, 95%CI (1.08, 4.35)) were found to be significantly associated www.biocoreopen.org/ijpn/archive.php with neonatal morbidity near miss. Improving maternal and neonatal service provision and avoid early marriage shall be emphasized by the government of Ethiopia.

Keywords Neonatal near miss, Ethiopia, South Gondar zone Hospitals

Declaration of Conflicting Interest The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

10 International Journal of Pediatrics and Neonatal Health, Vol. 5, Issue. 1 January 2021 Prevalence and associated factors of Neonatal near miss among Neonates Born in Hospitals at South Gondar Zone Amhara Region, North West Ethiopia, 2020 Introduction Neonatal near miss(NNM) defined as a new-born who presented a severe complication in the first 28 days of life almost died but survived during the neonatal period(1). According to neonatal near-miss systemic review refers to situations where the new-borns nearly died between 0-28 days and they survived either by chance or because of the good quality of care they received (2). For the identification of neonatal near miss cases pragmatic and management criteria were used to help develop the neonatal near miss concept those are pragmatic criteria; (Birthweight< 1750 g , Apgar score < 7 at 5 minutes and Gestational age <33 complete weeks) and management criteria; ( Parenteral antibiotic therapy up to 7 days and before 28 days of life, Nasal continuous positive airway pressure, any intubation up to 7 days and before 28 days of life, Phototherapy within 24 hours of life, cardiopulmonary resuscitation,use of vasoactive drugs ,use of anticonvulsants, use of surfactant, use of blood products ,use of steroids for the treatment of refractory hypoglycaemia, surgery, use of antenatal steroid ,use of parenteral nutrition, identification of congenital malformation.(2-4). Neonatal near miss criteria are more difficult to define than maternal near-misses, and WHO has not yet produced a global definition and global criteria(1, 2).Near miss concept is a potentially useful approach to assess quality of new-born care but due to enormous variability of socio demographic and technological advances in new-borns care and registration of health information makes no consensus on establishment of criteria of neonatal near miss(1, 2, 5). As per global estimates for 2015, among 5.9 million children who ventions exist. In addition, there has not been significant reduction in neonatal mortality(7). Although remarkable progress has been in recent decades to reduce the number of child deaths worldwide, too many new-borns continue to die each year despite the availability of feasible, evidence-based solutions(8). According to EDHS 2016, Under-5 mortality declined from 166 deaths per 1,000 live births in 2000 to 67 deaths per 1,000 live births in 2016. This represents a 60% decrease in under-5 mortality over a period of 16 years. Infant mortality also declined from 97 deaths per 1,000 live births in 2000 to 48 deaths per 1,000 live births in 2016, which is about a 50% reduction in the last 16 years. Neonatal mortality declined from 49 deaths per 1,000 live births in 2000 to 29 deaths per 1,000 births in 2016, a reduction of 41% over the past 16 years.Although both, numbers and rates, have been lessening over the last 20 years, still neonatal mortality accounts for an increasingly proportion of under five deaths(9). Currently all public Hospitals are participating in the quality of improvement initiative. At present it is estimated that 50%-70% of these standards are being regularly implemented by Hospitals with the standards relating to outpatient service, inpatient service and pharmacy service. Even those Hospitals reform implementation was practiced; neonatal mortality and morbidity are high in Ethiopia yet(10). Neonatal mortality has three main causes in low and middle income country. Complication of preterm, asphyxia and neonatal infection together contribute to 85% of new-born death(11).In 2013, 35% of the global neonatal deaths were caused by complications of preterm birth, 24% by intrapartum related complications and 25% by infection. The rest of death is caused by congenital malformations(12). Neonates are more susceptible to death compared to other age groups. The target was to reduce by two thirds, between 1990 and 2015, the under-five mortality rate but the proportion of deaths occurring in the first 28 days of life has increased, from 37 percent in 1990 to 44 per cent in 2015 and two-thirds of infant deaths and half of under-five child deaths occur during the neonatal period. The neonatal period represents the most vulnerable time for a child’s survival. According to EDHS 2016 reports, neonatal mortality rate is 29 per 1000 LB ,this indicates that 1 in every 35 children dies within the first month .Studies on neonatal near miss cases is scarce in Ethiopia in general and in south Gondar Zone in particular. Therefore, it is necessary to determine factors associated with cases of neonatal near miss and try to identify neonatal life threatening conditions and also needed to design programs specific to neonatal morbidity and mortality. This review may use to provide evidence for policy makers and program managers. Methods and Materials Study area, design and population: Institutional based cross sectional study was conducted at Hospitals found in South Gondar Zone from Dec1, 2019–Feb30/2020. South Gondar Zone is found in Ethiopian Amhara Region. Based on the 2007 Census conducted by the Central Statistical Agency of Ethiopia, this zone had a total population of 2,051,738. South Gondar zone has 1 comprehensive specialized hospital, 7 primary hospitals, 97 health centers and 394 health posts which serve for the above population. In this study all live-born neonates delivered in Hospitals of south Gondar zone, Amhara Region, within the first 28 days of neonatal period, during data collection time. were included in the study area. Sample size determination: The sample size was determined using single population proportion formula by considering 50% proportion of live born neonates surviving life threating conditions during neonatal period among delivered in hospitals of South Gondar zone, Amhara Region (to obtain maximum sample size) with 95% confidence interval, 5% margin of error, and design effect of two. The final sample size after adding 10% non-response rate was 848.

11 International Journal of Pediatrics and Neonatal Health, Vol. 5, Issue. 1 January 2021 Prevalence and associated factors of Neonatal near miss among Neonates Born in Hospitals at South Gondar Zone Amhara Region, North West Ethiopia, 2020

Sampling procedure: As we got information from each hospitals of South Gondar zone, Amhara region there were a total of 22,280 live births in the last one year. Based on this data, a total of 848 sample size was allocated proportionally from each hospital. Study subjects were selected by using systematic random sampling method based on their order of registration on postnatal log book during discharge time. The first respondent with their live birth neonate was the first daily registered on postnatal log book for discharge then next respondents was selected at every three interval in each hospital up to desired sample was obtained. Data analysis: Data was entered by Epi-Info version 7 software and exported to SPSS version 23 for cleaning, editing and analysis. Bivariable and multivariable logistic regression analysis were performed to identify factors associated with neonatal near miss. Variables with P value of < 0.2 in the bivariable analysis were entered in the multivariable model to identify predictors of neonatal near miss. P value of < 0.05 with 95%CI was used to declare statistical significance. Ethical approval: Ethical clearance was obtained from research review committee of DebereTabor University College of health sciences. Written informed consent was obtained from each study participants. Confidentiality and anonymity of the information was also maintained. Operational definitions: Operational definition neonatal near miss /NNM rate was calculated as [(number of NNM cases/total number of live births) × 1,000]. NNM was considered when the newborn faced at least one of the following proposed criteria but survived those complications. Pragmatic criteria: Birth weight <2,500 g, gestational age <37 weeks; 5th-minute APGAR score <7. Management criteria: mechanical ventilation, cardiopulmonary resuscitation, intubation, nasal continuous positive airway pressure, parenteral antibiotics, parenteral nutrition, vasoactive drugs, phototherapy during the first 28 days(13). Result: Socio-demographic characteristics of study participants; A total of 848 mothers were interviewed and at the same time their neonates` cards were reviewed with a response rate of 100% .More than half 505 (59.5%) of mothers were between the age range of 20–34 years with the mean age of 29.5 years old at standard deviation 6.5 years (±6.5 SD). Almost all (95.7%) of the mothers were currently in marital union and 55.8% of them were urban in resident.

12 International Journal of Pediatrics and Neonatal Health, Vol. 5, Issue. 1 January 2021 Prevalence and associated factors of Neonatal near miss among Neonates Born in Hospitals at South Gondar Zone Amhara Region, North West Ethiopia, 2020

Variables(n=848) Frequency Percent Age <20 71 8.4 20-34 505 59.5 >=35 272 32.1 Marital status Currently in marital union 812 95.7 Currently not in marital union 36 4.3 Religion Orthodox 724 85.4 Muslim 87 10.3 Others* 37 4.4 Resident Urban 474 55.8 Rural 374 44.2 Ethnicity Amhara 764 90.1 Oromo 52 6.1 Tigre 32 3.8 Maternal education No formal education 306 36 Primary 263 31.1 Secondary 174 20.5 Diploma and above 105 12.4 Neonates farther education No formal education 258 30.5 Primary 274 32.2 Secondary 201 23.7 Diploma and above 115 13.6 Maternal Occupation House wife 487 57.4 Employed 128 15.1 Merchant 166 19.6 Daily worker 67 7.9 Neonates farther Occupation Farming 357 42 Employed 187 22.1 Merchant 229 27 Daily worker 75 8.9

Table1. Socio-demographic characteristics of mothers of new-borns in South Gondar Zone, Health institutions, Ethiopia, 2020.

13 International Journal of Pediatrics and Neonatal Health, Vol. 5, Issue. 1 January 2021 Prevalence and associated factors of Neonatal near miss among Neonates Born in Hospitals at South Gondar Zone Amhara Region, North West Ethiopia, 2020

Obstetric characteristics of mothers influencing neonatal near miss: About 731 (86.2%) of mothers were attend ante natal care follow up but more than 45% did not complete 4th ante natal care follow up which is crucial for them and their coming neonates.

Variables(n=848) Frequency Percent ANC Yes 731 86.2 No 117 13.8 Number of ANC No visits 117 13.8 1-3 343 40.5 >4 388 45.7 Parity Primiparous 268 31.6 Multiparous 580 68.4 History of abortion Yes 80 9.4 No 768 90.6 History of still birth Yes 63 7.4 No 785 92.6 History of PROM Yes 114 13.3 No 734 86.5 History of PIH Yes 78 9.2 No 770 90.8 History of haemorrhage Yes 63 7.4 No 785 92.6 History of post term pregnancy Yes 71 8.4 No 767 91.6 History of CPD Yes 170 20.1 No 678 79.9

Table 2. Obstetric characteristics to mothers of newborns in South Gondar Zone, health institutions, Ethiopia, 2020.

Criteria for neonatal near miss: 32.2% of neonates were borne before 33 completed weeks of gestational age and 33.9% of the birth weight of less than 1750gram s.

14 International Journal of Pediatrics and Neonatal Health, Vol. 5, Issue. 1 January 2021 Prevalence and associated factors of Neonatal near miss among Neonates Born in Hospitals at South Gondar Zone Amhara Region, North West Ethiopia, 2020

criteria of NNM Proportion of NNM in each category(n=242) frequency Percentage

Pragmatic marker of severity Gestational age < 33 completed weeks 78 32.2 Weight < 1750gram 82 33.9 5 minute APGAR Score < 7 120 49.6 Management markers of severity Resuscitated with bag and mask 128 52.9 Cardiopulmonary resuscitation (CPR) 94 38.8 Intubation 61 25.2 Nasal continuous positive airway pressure 53 22 Parenteral antibiotics 102 42.2 Use of parenteral nutrition 73 30.2 Vasoactive drugs 8.7 Phototherapy during the first 28 days 35 14.5 Anticonvulsants 18 7.4 Use of steroids for the treatment of refractory hypoglycaemia 31 12.8

Use antenatal steroid 37 15.3 Noted: The value cannot be summed up to 100% because of multiple intervention were possible. Table 3: Criteria for neonatal near miss among neonates in South Gondar Zone, Health institutions, Ethiopia, 2020. Factors associated with neonatal near miss In this study, prevalence of neonatal near miss in the study area were 242 (28.54%) of neonates (95% CI 25.5%, 31.8%). Mothers being Primiparous (AOR = 1.75, 95%CI (1.23, 2.49)),mothers` age <20 years old (AOR = 2.99, 95%CI (1.69, 5.30)), mothers who had faced premature rupture of membrane (AOR = 2.15, 95%CI (1.37, 3. 39)), pregnancy induced hypertension (AOR = 5.04, 95%CI (3.01, 8.46)), post term pregnancy (AOR = 2.24, 95%CI (1.29, 3.89)) Cephalo pelvic disproportion (AOR = 3.92, 95%CI (2.67, 5.75)), and diabetes mellitus (AOR = 2.17, 95%CI (1.08, 4.35)) were found to be significantly associated with neonatal morbidity near miss.

Table 4. Multiple logistic analysis on factors associated with neonatal near miss in South Gondar Zone, Health institutions, Ethiopia, 2020. 15 International Journal of Pediatrics and Neonatal Health, Vol. 5, Issue. 1 January 2021 Prevalence and associated factors of Neonatal near miss among Neonates Born in Hospitals at South Gondar Zone Amhara Region, North West Ethiopia, 2020 Discussion Our study revealed that 28.54%, (95% CI 25.5%, 31.8%) of neonates were faced neonatal near missed morbidity. This study finding is higher than study conducted in Injebara general hospital, Ethiopia (23.3%) but lower than study done in DebereTabor general hospital , Ethiopia (32.2%) , Dessie referral hospital; Ethiopia (32.5%)(14-16). The difference might be due to lower sample size in all studies comparing to our study and using secondary data for the study conducted previously at Debere Tabor General hospital and Dessie referral hospital. This finding is higher than a study done from North Eastern Brazil, which found 22%(17) .This finding is also higher compared to a study from the WHO using a multicounty survey (7.25%), of the birth in Brazil survey (3.92%), of a study in the South of Brazil (3.3%), and a study in South Eastern Brazil (1.7%)(18-21). The observed variation of neonatal near miss rates in a WHO multicounty survey and South East Brazil might be due to methodological difference and use of only pragmatic criteria. Also, both the study of birth in Brazil and the study in South of Brazil used only four items from the management and pragmatic se- lection criteria. In this study, the proportion of neonatal near miss is low compared to a study in Uganda, which was 36.7, Latin America which was 39.2 %(22, 23) ; this difference might be due to a methodological difference and inclusion criteria involved newborns only from mothers with severe obstetric complications and also study time differences. In our study maternal age less than 20 years old was statistically associated with neonatal near miss inversely studies done at six public maternal hospitals in South East Brazil and North East Brazil; Infants born to older mothers showed a nearly twofold risk of neonatal near miss, compared to mothers aged 20 to 34 and age older than 35 years old was statistically significant association with neonatal near miss respectively(13, 24). The possible explanation might be proportion of less than 20 years old women who gave birth in our study is more than proportion of mothers less than 20 years old studies conducted at t six public maternal hospitals in South East Brazil and North East Brazi. In our study Primiparous mothers were 1.75 times more likely encounter neonatal near miss as compared to multiparous mothers. This result is in line with the studies in North East Brazil and SouthEast Brazil(17, 21). This might be due to the fact that primiparous mothers were high-risk for malposition, mal- presentation, prolonged labor, increased induction of labor, and obstructed labor/Cephalo-pelvic disproportion. Premature rupture of membrane showed 2.2-times increased odds of neonatal near miss than their counterparts. Our study finding is supported by studies conducted at Debre Tabor General hospital, in selected hospitals of Gamo and Gofa zones,; Injebara general hospital,(14, 15, 25). This might be due to the fact that premature rupture of membrane usually leads to preterm labor, which is a risk factor for birth asphyxia, chorioamnionitis, neonatal sepsis, pulmonary hypoplasia, and cord prolapse all of which leads to neonatal near miss morbidities. Neonates born from mothers with pregnancy induced hypertension during recent pregnancy were 5 times more likely to face neonatal near miss as compared to their congruent. The result is in line with the study done at Debre Tabor general hospital(15, 26).This might be the fact high blood pressure during pregnancy can affect development of placenta, causing the nutrient and oxygen supply to the baby limit- ed. This can lead to an early delivery, low birth weight, and other complications for neonates. Women with cephalo-pelvic disproportion during labor delivery were 3.9 times increased odds of neonatal near miss, as compared to their counterparts. Our finding is in alignment with previous studies finding at Debere Tabor general hospital and Jimma university specialized hospital(15, 27). This might be obstructed labor causing fetal hypoxia, due to tonic uterine contraction that interferes uteroplacental cir- culation, intracranial hemorrhage due to super molding of the head, birth trauma, and prolonged labor in turn abnormal progress of labor leading to fetal distress, early neonatal and fetal infections. Mothers who were post term during the recent pregnancy were 3 times more likely to faced neonatal near miss as compared to those neonates delivered to women`s without encountered post term pregnancy. Our study finding is not concurrent to previous study finding at Debere Tabor general hospital(15). This might be due to former study at DebereTabor General hospital using secondary date and smaller sample size comparing to our studies. Neonates born from mothers who had diabetes nearly 2.2 fold risk of neonatal near miss, compared to those neonates born from mothers without diabetes mellitus(28). The result is in line with the study done by obstetrics and gynecology international. The reason might be due to burden of poor glycemic control of neonates. Conclusion Prevalence of neonatal near miss in our study was high .Maternal age, primiparous, premature rupture of membrane, pregnancy induced hypertension, post term pregnancy, cephalo pelvic disproportion, and diabetes mellitus were determinate factors of neonatal near miss morbidity. All cases of NNM better to be audited and improving continuum of care starting from preconception care to postpartum period. Limitation of the study Did not incorporate variables addressed in the community like wealth index, cultural aspects, and not triangulated with qualitative study.

16 International Journal of Pediatrics and Neonatal Health, Vol. 5, Issue. 1 January 2021 Prevalence and associated factors of Neonatal near miss among Neonates Born in Hospitals at South Gondar Zone Amhara Region, North West Ethiopia, 2020 Acronyms C/S: Caesarean Section, CPAP: Continuous Positive Airway Pressure, CPD: Cephalo-Pelvic Dispropor- tion, CPR: Cardiopulmonary Resuscitation, EDHS: Ethiopian Demographic and Health Survey LB: Live Birth, NNM: Neonatal Near Miss, PIH: Pregnancy Induced Hypertension: PROM: Premature Rupture of Membrane, SVD: Spontaneous Vertex Delivery. Acknowledgements The authors would like to acknowledge Debere Tabor University for financial support. The authors also extend their special thanks for both data collectors and supervisors. Last but not least we would like to acknowledge all study participants and South Gondar zone hospital administrative. Authors’ contributions ED, HG, MB, AM contributed in the study design, data collection, analysis, and write-up. All authors read and approved the final manuscript. Funding The data collection process has been funded by Debere Tabor University. The funding body has no role in the design, data collection, analysis and write-up. Funding was provided by Waiver and discount. Availability of data and materials The data set used in this study is available from the corresponding author and can be accessible through reasonable request. Ethics approval and consent to participate Ethical clearance was obtained from research review committee of DebereTabor University, college of health sciences. Written informed consent was obtained from each study participants. Confidentiality and anonymity of the information was also maintained. Consent for publication Not applicable. Author details College of Health Sciences, Debre Tabor University, Post Office Box: 272, Debre Tabor, Ethiopia. References [1] Pileggi C, Souza JP, Cecatti JG, Faúndes A. Neonatal near miss approach in the 2005 WHO Global Survey Brazil. Jornal de pediatria. 2010;86(1):21-6.

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