Pediatric Emergency Care and Medicine: Open Access

Keywords

Birth asphyxia; Risk factors; Apgar score; Millennium Development Goal 4 (MDG 4)

Introduction

Signi icance for public health

Asphyxia continues to be a major cause of morbidity and mortality in the neonatal period (WHO). Newborns are the backbone of every community and nation. Healthy newborns will lead to healthy nation. Over 8 million newborns die before their birthday each year and nearly all of the 5.1 million deaths in the neonatal period occur in developing countries. Although the causes of neonatal deaths are not always easy to assess, the world health organization estimates that 85% of deaths are caused by birth asphyxia, infections, birth injury and problems related to preterm birth. Birth asphyxia is a significant contributor to newborn morbidity and mortality as well as long term neurological deficits. It is a common problem in the developing world where there are lack of facilities and awareness. It has been recognized that of the 130 million newborns born each year globally, about 4 million die in the first 4 weeks of life, the neonatal period. It is estimated that about 23% of all newborn deaths are due to birth asphyxia. According to the Pakistan demographic and health survey 2006 the major causes of death among children under five are birth asphyxia (22%). In Khyber Pakhtoonkhwa the percentage of birth asphyxia is (18.3) [1].

Asphyxia is defined as lack of oxygen (hypoxia) due to failure of initiation of breathing. A condition during the perinatal period that severely reduces oxygen delivery and leads to acidosis. A lack of oxygen or an excess of carbon dioxide caused by the interruption in breathing, is the result of the failure of the gas exchange organ. According to the Pakistan demographic and health survey 2006 the major causes of death among children under five are birth asphyxia (22%), sepsis (14%), pneumonia (13%), diarrhea (11%) and prematurity (9%). Causes of death are highly correlated with age at death. Deaths during the neonatal period (first month of life) are almost entirely due to birth asphyxia, sepsis or prematurity. In all four provinces of Pakistan, birth asphyxia is the main cause of death (22.1%). In KPK the percentage of birth asphyxia is 18.3%, in Punjab the percentage is 24%, in Sindh the percentage is 21.5% and in Balochistan the percentage is 16% [2-5].

WHO estimates that approximately 3% of about 120 million newborns born each year in developing countries develop asphyxia and need resuscitation? Approximately 900,000 of these newborns die as the result of asphyxia. Asphyxia accounts for 23% of neonatal deaths globally and 8% of all deaths in children under five years of age. Reducing neonatal mortality is a critical component of achieving the fourth Millennium Development Goal 4 (MDG 4) target of two-third reduction in deaths among children under 5 years of age. The incidence of birth asphyxia is much higher in developing countries.

A retrospective study was conducted in neonatal unit of national institute of child health, Karachi (Pakistan) from 1^st January, 2001 to 31^st August, 2001. They analyzed variables included antenatal care, period of gestation, place of delivery, mode of delivery, birth weight and age at arrival in the hospital. The objective was to look for risk factors leading to birth asphyxia in newborns admitted in a tertiary care unit. The study recommended that trained personnel and neonatal resuscitation equipment should be made mandatory in all maternity homes/ hospitals.

The purpose of this study was to determine the frequency of moderate to severe birth asphyxia in newborns and its risk factors at two major hospitals of Kohat. This study helped us to recommend preventive measures for different risk factors of newborn birth asphyxia and to create awareness in community regarding proper antenatal care and to prevent morbidity and mortality among the newborns.

Types of birth asphyxia

Mild birth asphyxia: APGAR score >7 at 1 minute is labeled as mild birth asphyxia and it needed a short resuscitation course at neonatal intensive care unit.

Moderate birth asphyxia: Adequate breathing wasn’t established during the first minute after birth, but heart rate is 100 per minute and more; there is decreased muscle tone and poor reflex irritability. Apgar score is 4-6 at the first minute also called “blue asphyxia”.

Severe birth asphyxia: Heart rate is less than 100 per minute, breathing is absent or labored (gasping breathing) skin is pale, muscle atony. Apgar score is 0-3 at the first minute. “White asphyxia”. Babies with more serious asphyxia may need mechanical ventilation (a breathing machine), respiratory therapy, fluid and medicine to control blood pressure and prevent seizures.

Objectives

General: To determine the frequency of moderate to severe birth asphyxia of newborns and its risk factors at two major hospitals of Kohat [6-8].

Specific objectives:

• To determine the frequency of moderate to severe birth asphyxia in newborns.

• To determine the demographic characteristics of mothers whose babies are asphyxiated at birth.

• To determine the frequencies of different maternal risk factors leading to birth asphyxia.

• To determine the mortality rate of birth asphyxiated babies with follow-ups.

Materials and Methods

Study design was cross sectional (descriptive). The duration of study was 6 months. target population were all male and female newborns admitted at the nurseries at Liaqat memorial hospital and CMH Kohat (Pakistan). Study population included all newborns. Inclusion criteria was all alive newborns and exclusion criteria was newborns with lethal anomalies (e.g. cyanotic congenital heart defects), still births. Study area was Liaqat memorial hospital and C.M.H Kohat. Study Frame was newborns admitted at the nursery of Liaqat memorial hospital and CMH. Sample Size was 400 (za/2=2)/2 (prevalence of disease in KPK 18.3%). Sampling method was non-probability convenient sampling. Patients who were present at the nurseries at the time of sample collection were included. Data collection tools included well designed semi-structured questionnaire having both open ended and closed ended questions. Questions were asked from mothers of patients. Data was presented in form of tables and graphs. Data statistical analysis was done by computer so tware SPSS version. In order to check the feasibility and applicability of questionnaire and to make necessary changes where ever required the analysis was conducted on 10% of sample at first [9-12].

Variables

Dependable variable: Birth asphyxia

Independible variables: Demographic characteristics of mother (Age, area, education status), antenatal visits, abnormal presentation, low birth weight, gestational age of mother, cord prolapsed, placenta previa, abruptio placenta, hypertension in pregnancy, maternal anemia, meconium staining.

Results

The highest number of birth asphyxiated newborns were observed in age of mothers between 18 to 24 that was 12%, 10% mothers were between 25 to 30 and 6% were under 17, 6% mothers were between 31 to 35 and 5% mothers were above 35. Mothers from rural areas were 24% and 15%were from urban areas. 22% mothers were uneducated and 17% were educated. 17% mothers didn’t go for any antenatal visit and 22% attended. The gestational age of 10% mothers was less than 37 weeks, 22% mothers gestational age was between 37 to 42 and 7% mothers gestational age was above 42 weeks. Other maternal risk factors included hypertensive disorders were found in 12%mothers and in them 4% went to preeclampsia. 11.5%mothers were anemic. Abruptio placenta, placenta previa and cord prolapsed mothers were 5%, 4% and 6%respectively. 6% mothers had complications of abnormal presentation of baby. 5% newborns having birth asphyxia didn’t recover.

Out of the 400 (sample size) newborns during the three months of study period, 155 (39%) were birth asphyxiated and 245 (61%) newborns were non-diseased (Figures 1 and 2). Of those who had neonatal asphyxia 80 (20%) were males 75 (19%) and were females (Tables 1 and 2).

Table 1: Frequency of moderate to severe asphyxia in newborns.

Table 2: Gender distribution regarding birth asphyxia in newborns.

Newborns assessment and evaluation was done by the apgar score at 5 min was recorded. The distribution of newborns by their apgar score defined as moderate (4-6) and severe (0-3). In this study 155 newborns were asphyxia patients and in them 53 (13%) newborns were in severe condition having apgar score (0-3) at 5 min and 102(26%) newborns have apgar score (4-6) at 5 min that is moderate (Table 3 and Figure 3).

Table 3: Apgar score of asphyxiated newborns at 5 minute.

One of the important factors is the weight of the newborns; the low birth weight newborns are more likely to have birth asphysia as compared to normal birth weight. In this study among the 155 asphyxiated newborns 64 (16%) were low birth weight less than 2.5 kg and 47 (12 %) were between 2.5 kg to 3 kg and 44 (11%) were above 3 kg (Table 4 and Figure 4).

Table 4: Weight of asphyxiated newborns.

In this study the age was caterized in five parts <17, 18-24, 25-30, 31-35 and >35. According to this study 26 (6%) mothers were under 17, 50 (12%) mothers were 18-24, 38 (10%) mothers were 25-30, 22 (6%) were between 31-35 and 19 (5%) mothers were above 35 [13-15]. In this study the highest range of mothers were between 18 to 24. The mothers above 35 were very low in number (Table 5 and Figure 5).

Table 5: Age distribution of mothers of asphyxiated newborns.

The location was divided in two catagories urban and rural. In this study 58 (15%) mothers were from urban areas and 97 (24%) mothers were belonged to the rural areas (Table 6 and Figure 6).

Table 6: Area of residence of mothers.

Mother education has a significant effect on the health of the neonate. Upto primary level mother was considered uneducated and more than it, mother was considered educated. In this study mothers of 155 asphyxiated newborns, 67 17%) were educated and 88 (22%) were uneducated (Table 7 and Figure 7).

Table 7: Education status of mothers.

The role of antenatal care in reducing perinatal mortality and morbidity is well known. In this study the mothers of asphyxiated babies had a high attendance rate with 89 (22%) and 66 (17%) of the mothers did not have any antenatal visits (Table 8 and Figure 8).

Table 8: Antenatal visits.

The gestational age of 41(10%) mothers was less than or equal to 37 weeks, 88(22%) mothers gestational age was between 37 to 42 and 26(7%) mothers gestational age was above 42 weeks (Table 9 and Figure 9).

Table 9: Gestational age of mothers.

Vaginal delivery was the commonest mode at 119 (24%) followed by c/s 36 (15%) (Table 10 and Figure 10).

Table 10: Mode of delivery.

Some of the pregnancies were complicated by intrapartum maternal risk factors. These intrapartum accidents leads to the birth asphyxia in most cases like hypertensive disorders, maternal anaemia, abruptio placenta, placenta previa and cord prolapse. Hypertensive disorders of pregnancy were high among mothers of asphyxiated. In this study 49 (12%) mothers have hypertensive disorder and 17 (4%) mothers developed preeclampsia. 46 (11.5%) mothers of asphyxiated babies were anaemic.

Placenta previa was observed in 16 (4%) mothers, 21 (5%) have abruptio placenta, 24 (6%) mothers have cord prolapse. Meconium staining of liquor was recorded in 26 (6.5%) cases. 23 (6%) have abnormal presentation of fetus (Table 11 and Figure 11).

Table 11: Other maternal risk factors leading to birth asphyxia

Out of 155 newborns with low apgar score (0-6), 18 (5%) didn’t survive and 132 (34%) were alive or discharged (Table 12 and Figure 12).

Table 12: Outcome of birth asphyxiated newborns.

Discussion

Pakistan is a low income country with a population of 160 million and an infant mortality rate estimated to be 95/1000 live births in 1994. Birth asphyxia is a leading factor contributing in perinatal and neonatal mortality which reflects social, educational and economical standards of a community. Its incidence is very high in developing countries like Pakistan where health facilities are restricted to urban areas and only small population (21%) is getting benefits. In Khyber Pakhtoonkhwa the percentage of birth asphyxia is (18.3). It is very important to accurately diagnose perinatal asphyxia as early as possible and to predict the prognosis of the newborn. Given an early diagnosis, it may be possible to minimize unfavorable consequences through prompt application of appropriate treatment and rehabilitation exercises. Despite lot of improvement in the public health over the past many years, it is still a major contributing factor in neonatal mortality.

On the basis of the results we concluded that the frequency of the birth asphyxia was (39%). This was higher than previously reported findings of birth asphyxia (10.4%) reported by Kawo Urassa, Killeo and Massawe. The reason for this difference could be attributed to inadequate resuscitative facilities; lack of skilled personnel and increased numbers of admitted asphyxiated newborns.

In our study 20% were male and 19% neonate were female. A study in Finland also found that male babies have an increased risk for birth asphyxia (relative risk 1.49) than females.

Newborn assessment and evaluation was done by the apgar score at 5 min was recorded. The distribution of newborns by their apgar score defined as moderate (4-6) and severe (0-3). In this study 13% newborns were in severe condition having apgar score (0-3) and 26% babies have apgar score (4-6) that is moderate. Similarly a cross-sectional study was conducted in Nigeria in which antepartum and intrapartum factors associated with "very low" (0-3) or "intermediate"(4-6) five-minute Apgar scores were compared with correlates of low five-minute Apgar scores (0-6) based on multinomial and binary logistic regression analyses. The objective was to determine the potential impact of two classification methods of five-minute Apgar score as predictor for birth asphyxia.

In another retrospective study performed by analysis of medical charts (n=7,094) of all live newborns during the period of 2005 to 2009. In 7,094 births, there were 139 deaths, 58.3% during the first week and 3.6% of them with Apgar <4 in the 1st minute. A positive association was found between mortality and the apgar score.

Low birth weight newborns are more likely to have birth asphysia as compared to normal birth weight. In this study 16% were low birth weight less than 2.5 kg and 12% were between 2.5 kg to 3 kg and 11% were above 3 kg. This result is consistent with the earlier findings of Boonamnuaykij he also concluded that babies with weight below 2.5 kg were at risk of having birth asphyxia.

Demographic features of mothers included age of mother, education and the location of mother. Age is an imporatant facor according to other studies it was shown that below 17 years and over 35 years mothers were more likely to give birth to asphyxiated childs. In this study the age was caterized in five parts <17, 18-24, 25-30, 31-35, >35. According to this study 33 (6%) mothers were under 17, 87 (12%) mothers were 18-24, 97 (10%) mothers were 25-30 and 32 (6%) were between 31-35, 5% mothers were above 35. In this study the highest range of mothers were between 18 to 24. The mothers above 35 were very low in number. So we can that there is no significance association of age of mothers with the birth asphyxia.

Most of the mothers were from rural areas i.e. 24% and 15% mothers were from urban areas. Its mean that the rural areas mothers have more chances to give birth to asphyxiated babies as compared to urban. Same results were shown in national health family survey: 2005-2006, that in rural or slum areas proportion of pregnant woman receiving adequate antenatal care is low.

Education has a very important role. An educated mother is awared about the healthy practices that are important during pregnancy and how to avoid intrapartum accidents and how to adopt healthy life styles to avoid any type of complications. Women without formal education might find it difficult to benefit from reproductive health education. In this study 67 (17%) were educated and 88 (22%) were uneducated. Diallo, in Guinea also observed that a large proportion of asphyxiated newborns were born from uneducated mothers. Also in another study 80% respondent’s argued that education could play vital role in, health care, less education, lack of knowledge and awareness about maternal health protection and care during pregnancy could cause the neonatal death. It was revealed from the study who have better education is more responsible and go for care during pregnancy and less child mortality also observed on those groups.

The role of antenatal care in reducing perinatal mortality and morbidity is well known. In this study the mothers of asphyxiated babies had a high attendance rate with 22% and 17% of the mothers did not have any antenatal visits. This low figure is rather surprising because lack of antenatal care is considered to be associated with poor pregnancy outcome. Therefore a higher number would have been expected. Same results were shown in a study in Zimbabwe found that absence of antenatal care was not a significant risk for low apgar score.

A cross-sectional survey of mothers of newborns attending the Immunization clinic in a Nigerian teaching hospital was done between July and October 2010. The objective of this study was to assess the knowledge of mothers, who received health facility based antenatal care. Lower socioeconomic status, lack of counseling and nonattendance of teaching hospital antenatal clinic were associated with poor knowledge about risk factors and sequelae of birth asphyxia. According to gestational age of mothers the preterm babies were 10%, 22% were term babies and 7% mothers gestational age was above 42 weeks and babies were postdates.

The intrapartum risk factors leads to the birth asphyxia in most cases like abruptio placenta, placenta previa and cord prolapse. They carry a high risk for an unfavorable fetal outcome. They are unpredictable and can only be addressed if there is access to trained birth attendants, good referral system and availability of facilities to enable immediate surgical intervention. A rapid response to such an emergency may help to mitigate the consequences. In this study 5% mothers have abruptio placenta, 6% mothers have cord proplapse and 4% mothers have placenta previa and 6.5% have meconium staining. 6% have abnormal presentation of fetus.

Hypertensive disorders of pregnancy have been identified as obstetric risk factors for birth asphyxia 12% mothers have hypertensive disorder and 4% mothers developed preclampsia. The study shows that hypertension is an important risk factor of birth asphyxia. Similarly 11.5% mothers were anaemic. In this study hypertension and anaemia were the most common maternal risk factors associated with neonatal birth asphyxia. Palsdotir, et al. in 2007 have also concluded previously Pre eclampsia reported as a risk factor for severe birth asphyxia. These conditions could cause placental insufficiency, which reduces the oxygen supply to the foetus. In a multi-centre study on birth asphyxia in East and Central Africa, obstetric factors that contributed to asphyxia of newborns included prolonged labour, abnormal presentation intrapartum accidents and hypertensive disorders of pregnancy.

The overall survival rate was 34% and 5% did not survive and 61% were non-diseased. A prospective cohort study was conducted in Sindh Government Lyari General Hospital, Karachi from 2006 to 2008 showed that the commonest cause of death among neonatal death was identified as birth asphyxia that is 44.5%. A much higher case fatality rate of 74% was found in India. In 2007 Doba conducted a study in which he concluded from a total of 356 cases with asphyxia had 4.2% deaths.

Nelson, et al. in a prospective study in the USA found that apgar score of 0-3 at 5 min was ominous findings with 44% of the newborns were died and 5% of the survivors showed evidence of disability [25].

Conclusion

The study showed that the majority of early newborns complications were related to Birth Asphyxia (39%) with 13% severe Birth asphyxia and 26% moderate birth asphyxia. Most birth asphyxiated newborn mothers had low level of education with 22% illiteracy rate and17% were educated. 12% having age in range of 18 to 24 and 24% of mothers were from rural areas. The mothers with hypertensive disorder were high (12%) as compared to other maternal risk factors i.e. maternal anaemia, cord prolapsed etc. 5% newborns having birth asphyxia were died and 34% were recovered and discharged.

Ethical Consideration

Approval from research ethical committee of Gandhara university was taken. Written and verbal consent from mothers of patients was also taken.

Recommendation

Most risk factors associated with birth asphyxia can be prevented. Therefore, the timely and accurate diagnosis and proper management can reduce severe birth asphyxia. By launching awareness campaigns in communities providing maternal health education to prevent risk factors can reduce the birth asphyxia.

Delay in seeking care or receiving appropriate care on reaching the health facility may also contribute to increased risk of birth asphyxia. So therefore provision of safe motherhood services including antenatal care, clean and safe delivery and emergency obstetric and neonatal care services at the door step of women will help in reducing the birth asphyxia. The health care workers in all areas should be trained and well equipped to manage the birth asphyxia in newborns.

Governments should also be involved in launching free camps for antenatal checkups and awareness campaigns in different rural areas to reduce the frequency of birth asphyxia

Author’s Contribution

The author conceptualized, drafted a nd critically edited the manuscript.

Competing Interest

The author declares that they have no known competing interest.

Acknowledgement

The author want to thank those who shared their data and publication in the open data source like Wikipedia, WHO, PubMed, NCBI and Imedpub.

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