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Neonatal mortality in the case of Felege Hiwot referral hospital, Bahir Dar, Amhara Regional State, North West Ethiopia 2016: a one year retrospective chart review

  • Tilahun Tewabe1Email author,
  • Yenatfanta Mehariw1,
  • Eyerusalem Negatie1 and
  • Bertukan Yibeltal1
Italian Journal of Pediatrics201844:57

https://doi.org/10.1186/s13052-018-0498-5

Received: 12 February 2018

Accepted: 9 May 2018

Published: 21 May 2018

Abstract

Background

Ethiopia is among the countries with the highest neonatal mortality with the rate of 37 deaths per 1000 live births. In spite of many efforts by the government and other partners, non significant decline has been achieved over the last 15 years. Thus, identifying the prevalence and associated factors of neonatal mortality is very crucial for policy and program improvement. This study was designed to assess neonatal mortality rate in Felege Hiwot referral hospital, North West Ethiopia.

Methods

A hospital based chart review was done in Felege Hiwot referral hospital based on patient charts from July 2015 to June 2016. The data were collected using structured checklists. The collected data was coded, filtered and entered in to Microsoft Excel 2007 and transferred to STATA version 12.0 for analysis. Binary logistic regression analysis was used to identify factors associated with neonatal mortality. A p - value of < 0.05 was considered as significant.

Results

The prevalence of neonatal mortality in Felege Hiwot referral hospital was 13.29% (95% CI: 10.09–17.07). Early age of the newborn (< 7 days) [AOR = 0.39 (0.16–0.97)], gestational age at delivery [AOR = 2.14 (1.0–4.52)], late initiation of breastfeeding [AOR = 2.89 (0.99–8.38)], non exclusive breastfeeding [AOR = 6.77 (3.04–15.07)], inadequate ante natal visit [AOR = 5.02 (1.02–24.70)] were the determinant factors for neonatal death.

Conclusions

This study revealed that neonatal mortality is still high in the study area. Early age of the newborn, late initiation of breastfeeding, exclusive breastfeeding and ante natal vist were the determinant factors for neonatal mortality in the study area. Therefore, giving attention for newborns who are small for age, timely initiation of breastfeeding, exclusive breastfeeding and increasing ante natal visit were recommended to reduce neonatal mortality.

Keywords

Neonatal mortalityFelege Hiwot referral hospitalBahir DarEthiopia

Background

Globally, 6.6 million kids died before celebrating their fifth birthday per year. About 5 million deaths occurred within the first 28 days of life. This showed nearly 44% of under five mortalities and 60% of infant mortalities are covered by neonatal deaths. Above 98% of neonatal mortalities occurred in developing countries. Sub Saharan Africa takes the highest rate of newborn death, these are regions having least improvement in decreasing neonatal death rates [1].

In Ethiopia there is a high prevalence neonatal mortality. The trends of neonatal mortality in the country has slight decrease over past 20 years. Which were 46 in 1991–1995, 42 in 1996–200, 39 in 2001–2005 and 37 in 2006–2011 per 1000 live births. In spite of this, around 63% of infant mortalities in the country happened within the first 28 days of newborns life [2].

Most cases of neonatal deaths i.e., 99% occurred in low and middle income countries. Around half of the cases occurred among home deliveries, making the global rate of neonatal mortality 30 per 1000 live births [3].

Reducing this huge number of neonatal death is a major challenge in Ethiopia since the targeted health interventions proposed to cover most fatal causes of neonate are usually vary from those required to tackle under five mortality [2].

Neonatal mortality rate has shown slow decline i.e. by 0.9% per year from 1995 to 2010. This high prevalence of early neonatal death comprises 74% of neonatal deaths [2, 4]. And a study done in Jimma showed that neonatal mortality rate was 35.5 per thousand live births [5] and 14.4% in Addis Ababa [6].

This number is higher than former countries with high prevalence of neonatal deaths such as India and Indonesia. This obviously showed the condition of neonatal deaths is still towering and non progressing telling targeted interventions with all partners at various levels [7, 8].

Therefore, the study was intended to assess neonatal mortality in Felege Hiwot Referral Hospital from July 2015 to July 2016.

Methods

Study design and setting

Institution based retrospective chart review was conducted in Felege Hiwot referral hospital based on patient charts from July 2015 to June 2016.

The study was conducted in Felege Hiwot Referral Hospital, Bahir Dar, North West Ethiopia. It is located 563 Kms far from Addis Ababa. Felege Hiwot referral hospital officially commenced its function in 1963 and currently it delivers health care services with medical, surgical, gynecological, orthopedic, intensive care units, paediatrics and ophthalmological wards with a total of 375 beds and 561 staffs. Annually, nearly 6300 neonates were seen with different health problems. The neonatal unit has 60 beds, 5 pediatricians and 20 nurses.

The sample size was calculated with single population proportion formula and by taking into consideration: prevalence (P) of neonatal mortality 43.8% [9], confidence level (CL) 95%, margin of error (d) 5, 10% non response rate and by using simple random sampling technique a total of 410 neonatal charts were selected for study.

Measurement

Data collection was done by using checklists which were prepared by using similar studies done on related topics [4, 5, 9]. Which consists: socio demographic information, risk factors of neonatal deaths and health service utilization characteristics. Eight data collectors and two supervisors were participated in the data collection. Before the actual data collection started, training was given for data collectors and supervisors for 1 day about proper data collection and recording.

Data analysis

The collected data from patient charts were coded, filtered and entered in to Microsoft excel 2007 and transferred to STATA Version 12.0 for analysis. To identify factors associated with neonatal mortality, first bivariate analysis was done to each independent variable with the dependent variable. Those variables which were associated with neonatal mortality in the bivariate logistic regression analysis with p-value < 0.05 were included in the multivariate logistic regression analysis. The strength of association was determined using odds ratio and 95% confidence level. Statistical significance was stated at P value of < 0.05.

Results

Socio demographic data and risk factors of neonatal mortality

Out of 410 selected patient charts 391 neonatal charts were studied. The rest were discarded due to incompleteness. From all 275 (70.3%) were neonates less than 7 days and 209 (53.5%) were males. Regarding to the birth weight, 297 (76%) were between 2001 and 4000 kg. Most (76.5%) of the neonates were delivered between 37 and 42 weeks of gestation. Among all neonates, 241 (61.6%) were initiated breast milk within 1 hour of birth. From total 251 (64.9%) neonates were on exclusive breastfeeding. About three-fourths of the mothers 384 (72.6) had four or more ante natal care during their pregnancy. Majority of (96.5%) the mothers delivered in the health institution and 253 (64.7%) delivered normally through the vagina. Sepsis (23.8%), preterm (12.5%), pneumonia (10%) were the main recorded problems of the neonate during admission and from all 13.29% of admitted neonates were died (Table 1).
Table 1

Risk factors affecting neonatal mortality in Felege Hiwot referral Hospital, Bahir Dar, Amhara Regional State, North West Ethiopia 2016

Variables

Response

Frequency

Percent

Age

< 7 days

275

70.3

8–28 days

116

29.7

Sex

Male

209

53.5

female

182

46.5

Weight at birth

< 1500 kg

15

3.8

1501–2000 kg

69

17.6

2001–3999 kg

297

76.0

> 4000 kg

10

2.6

Origin

Rural

151

38.6

urban

240

61.4

Week of delivery

37–42 weeks

299

76.5

< 37 weeks

63

16.1

>  42 weeks

29

7.4

Breast feeding initiation time

Within 30 min

90

23.0

With in 1 h

151

38.6

After one hour

150

38.4

Exclusive breast feeding

Yes

254

64.9

No

137

35.1

Immunization status

Yes

380

97.2

No

11

2.8

Number of ANC

One

2

0.5

Two

17

4.3

Three

87

22.2

Four

238

60.8

Above four

46

11.8

Place of delivery

Health center

377

96.4

home

14

4.6

Mode of delivery

Medical tool

118

30.3

Operation

20

17.9

Spontaneous

253

64.7

Congenital abnormality

Yes

3

0.8

No

388

99.2

Chronic disease

Yes

15

3.8

No

376

96.2

Problem after delivery

Pneumonia

39

10

Sepsis

93

23.8

CHF

9

3

Jaundice

18

3

Preterm/low birth wt

49

17

Other (eg.DM, etc)

183

18

CHD

9

2.3

Jaundice

18

4.6

Preterm/LBW

49

12.5

Others

183

46.8

Chronic disease of mother

Yes

23

5.9

No

368

94.1

Factors associated with neonatal mortality

The associations of the independent and dependent variables were first tested by using bivariate analysis. Variables which were associated (p < 0.05) in the bivariate analysis were tested in the final multivariate analysis to see their significant association with neonatal mortality. The identified independent predictor of neonatal mortality were: early age of the newborn, gestational age < 37 weeks or preterm, late initiation of breastfeeding, non exclusive breastfeeding and inadequate ante natal visit.

Early age of the newborn (neonates in the first week) was significantly associated with neonatal mortality in the study area. Neonatal mortality was significantly higher at early age (first week) of the neonates than at later age [AOR = 0.39 (0.16–0.97)].

On the other hand gestational age at delivery was also significantly associated with the of neonatal mortality. The newborns who were preterm were two times higher to die than who were delivered term [AOR = 2.14 (1.0–4.52)].

Late initiation of breastfeeding was also associated with the occurrence of neonatal mortality. Mothers who initiate breastfeeding within 1 hour of birth of infant were almost three times higher to save their newborn than those who delayed breastfeeding initiation [AOR = 2.89 (0.99–8.38)].

Exclusive breastfeeding practice is known to save the life of a newborn. An infant who was not on exclusive breastfeeding was almost seven times higher to die than a neonate who was on exclusive breastfeeding [AOR = 6.77 (3.04–15.07)].

The number of ante natal vist was also associated with the prevalence of neonatal mortality. A neonate born from a mother with inadequate ante natal visit less than four times were almost five times higher to die than an infant born from a mother having adequate ante natal follow up [AOR = 5.02 (1.02–24.70)] (Table 2).
Table 2

Factors affecting neonatal mortality in Felege Hiwot referral Hospital, Bahir Dar, Amhara Regional State, North West Ethiopia 2016

Variables

Response

Number of neonate

Number of deaths

Prevalence % (95% CI)

Odds ratio (95% CI)

P-value

Age

Early

275

43

15.63(11.32–19.95)

0.39(0.16–0.97)

0.04

Late

116

9

7.76(2.85–12.66)

1

 

Week of delivery

37- 38 weeks

299

31

10.37(6.89–13.84)

1

< 37 weeks

63

21

33.33(21.56–45.10)

2.14(1.0–4.52)

0.04

> 42 weeks

29

0

Breast feeding initiation time

Early

90

5

5.56(0.78–10.33)

1

Timely

151

14

9.27(4.62–13.93)

1.23(0.39–3.90)

0.73

Lately

150

33

22.0(15.33–28.67)

2.89(0.99–8.38)

0.04

Exclusive breastfeeding

Yes

254

18

7.08(3.92–10.26)

6.77(3.04–15.07)

0.00

No

137

34

24.82(17.53–32.09)

1

 

Number of ANC visit

One

2

0

1

Two

17

4

23.53(2.68–44.38)

6.48(0,89–46.69)

0.06

Three

87

14

15.91(8.19–23.62)

2.35(0.45–12.26)

0.31

Four

238

32

13.44(9.09–17.80)

5.02(1.02–24.70)

0.04

More than four

46

2

4.35(−1.6–10.32)

 

1 = references, p < .0.05 indicates significant variables

Discussion

The prevalence of neonatal mortality in Felege Hiwot referral hospital was 13.29%. This finding was higher than the prevalence reported in north Gonder [9] and Jimma zone Ethiopia [5]. The variations may be due to methodological differences among studies and dissimilarity in socio cultural, health service utilization and economical variations among study participants of the study areas.

Risk factors like chronic disease of the mother, problems after delivery, weight of the newborn and type of aid during delivery were the risk factors considered by other researchers [4, 9, 10]. However, in the current study: age of neonate less than 7 days, week of delivery, initiation of breast feeding, non exclusive breastfeeding and inadequate number of ANC visit were significantly associated with neonatal mortality.

Early age (< 7 days) of the newborn and being preterm were significantly associated with neonatal mortality. The occurrence of neonatal death was higher in preterm’s than those born to term. Which consistent with studies [8, 1016]. This is due to the fact that being preterm exposes the new born for different conditions. Since they have many physiologic challenges to adapt extra uterine life. Due to this they are exposed to different fatal conditions like: hypothermia, respiratory center depression, different cardiovascular and hematological conditions like anemia, hyperbilirubinemia, immature immune defences which exposes them to infections, nutritional and gastrointestinal problems like poor feeding and entrocollitis, metabolic problems like hypoglycemia, fluid and electrolyte imbalance, low glomerular filtration rate and inability to handle water and solute loss are the major problems associated with preterm that increases the incidence of neonatal mortality.

Late initiation of breast feeding and non exclusive breastfeeding were the determinant factor for neonatal mortality. Neonatal mortality was higher in neonates who started breastfeeding after one hour and in those who were not on exclusive breastfeeding. Which is in line with studies done [5, 9]. This due to breast milk is the ideal nutrient for the newborn, easily digestible absorbable and metabolized, promote bonding, improved behavioural and neurodevelopment, protects against various infectious diseases and promotes long term health which ultimately decreases neonatal mortality if it is practiced optimally.

Neonatal mortality was significantly associated with inadequate number of ante natal care visits. The danger of neonatal mortality was significantly reduced in those mothers who performed ANC visit four times and above than those who had less than four ANC visits. This is similar with the previous studies [9, 17, 18]. This may be due to proper ante natal vist increases early detection and management of the problems related with the pregnancy which ultimately improves the neonatal outcome.

Among the common diseases identified as a causes of neonatal mortality: pneumonia (5.13%), sepsis (9.68), congestive heart failure (33.33), jaundice (16.67), premature delivery (34.69) and other unidentified causes (9.84%). Which is consistent with studies [9, 11, 1416] where the most common conditions for neonatal mortalities were preterm, asphyxia, neonatal infections; diarrhoea, sepsis, pneumonia, tetanus, and congenital malformations.

Conclusions

This study stated that the level of neonatal mortality is high in the study area. The great majority of neonatal deaths occurred in the first week of life, in neonates born preterm, not started breastfeeding on time, not on exclusive breastfeeding and in those mothers did not have adequate ante natal care visit. Recommendations to decrease neonatal mortality were: ensuring ante natal care during pregnancy, proper delivery care, and immediate postnatal care, increasing ante natal visits, delivering in health facility, providing comprehensive neonatal care, prevention and interventions of neonatal infection were recommended to reduce neonatal mortality.

Limitations

The study was identified based on the documented data and could not display all factors that are not documented in the patient’s files, representativeness, completeness and quality of the recorded information.

Abbreviations

ANC: 

Anti natal care

DHS: 

Demographic and health survey

FHRH: 

Felege Hiwot Referral Hospital

ICU: 

Intensive care unit

MDG: 

Millennium development goal

NMR: 

Neonatal mortality rate

PROM: 

Premature rupture of membrane

SPSS: 

Statistical package soft ware

WHO: 

World Health Organization

Declarations

Acknowledgments

We would like to thank Bahir Dar University, college of Medicine and Health Science School of nursing for the opportunity given to us to conduct this title. We would like to thank school of nursing for their support by writing letter of cooperation for Felege Hiwot Referral Hospital to get the data. We would like to thank the staff member of Felege Hiwot Referral Hospital for their cooperation to give available information about how to get neonatal mortality records.

Availability of data and materials

Anonymous of data has been included within the manuscript, however the raw data is kept confidential to protect patient identity.

Authors’ contributions

All authors; TT, YM, EN, BY contributed for this study. Authors designed study, analyzed and interpreted data. TT drafted the manuscript for considerable intellectual content. Authors reviewed the revised draft and approved the last version for submission.

Ethics approval and consent to participate

Ethical clearance was obtained from the college of medicine and health sciences institutional review board. Collected data were used for study purpose only; care and caution were exercised when data handled. A head of consulting secondary data sources, the neonatal department of Felege Hiwot Referral Hospital were requested for cooperation and offered permission for the study. The department were communicated about the purpose of the study.

Competing interests

The authors declare that they have no competing interests.

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Authors’ Affiliations

(1)
College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia

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