Incidence and risk factors for short-term poor outcomes among term infants admitted with birth asphyxia at Arua Regional Referral Hospital

Abstract

Background: Birth Asphyxia is defined by the World Health Organization (WHO) as ― "the failure to initiate and sustain breathing at birth". Millions of child deaths and stillbirths are attributable to it, yet limited information is available to high light the burden of the condition to guide policy and practice in developing countries like Uganda. The pattern of risk factors, nature of sequalae, options, and priority for interventions are different in both industrialized and developing countries. The severity of neurological sequalae after birth asphyxia depends upon the extent of the insult, metabolic imbalance during the reoxygenation period, and the developmental state of the affected region. This study determined the incidence, risk factors for short-term poor outcomes, and birth practice among mothers whose term infants had birth asphyxia and knowledge of health care workers at Arua Regional Referral Hospital (Arua RRH) on birth asphyxia. Objective: To determine the incidence and risk factors for short-term poor outcomes among term infants with birth asphyxia, describe the birth practices among mothers of term neonates with birth asphyxia, and assess the knowledge of health care workers on birth asphyxia at Arua RRH. Method: This was a cohort study using both quantitative and qualitative data at Arua RRH with a sample size of 326 for 6 months. Prospective quantitative data were obtained by taking the history of mothers whose term neonates had birth asphyxia. Admission charts for term neonates admitted with birth asphyxia and maternal charts were also reviewed. This provided data on the risk factors for short-term poor outcomes among term infants with birth asphyxia. Clinical follow-ups were done for the neonates on day 7 and at 6 weeks to determine poor perinatal outcomes. Descriptive statistics were summarized using means and standard deviation for normally distributed data, and median and interquartile range for skewed data. Categorical variables were summarized in the form of frequencies and percentages. The cumulative incidence of short-term poor outcomes was determined as the number of new born infants with sequalae from birth asphyxia divided by the total number of new born followed up to 6 weeks. For risk factors for short-term poor outcomes among term infants with birth asphyxia, incident rate ratios were estimated from the generalized linear model using the log link and presented in the form of tables. A p-value of <0.2 was significant in bivariate and <0.05 in multivariate analysis and the results are presented in tables. The data was analyzed using STATA 17.0. Qualitative data was obtained by conducting two focus group discussions with the mothers whose neonates were admitted with birth asphyxia each with 8 participants. In addition, 8 key informant interviews were conducted with the health care workers who were working in the maternity and Neonatal Intensive care Unit (NICU). Recorded focus group discussions and key informant responses were transcribed, and coded, and thematic analysis was used to describe the data which was presented in tables. Results: Out of a total of 290 neonates with perinatal asphyxia followed up to 6 weeks, 58.6% (170/290) were males and their mean gestational age was 38.2. 9 had died presenting a proportion of 3.1% with a 95% CI 1.6-5.9. Among the survivors, 4 out of 281 (1.4%) of the infants had clinical seizures at 6 weeks. Therefore, the cumulative incidence of short-term poor outcomes among term infants with birth asphyxia was 4.5% with a 95% CI of 2.6-7.6%. Need for Continuous positive airway pressure (CPAP) (RR; 0.94, 95%CI; 0.86-1.00, P=0.043), Thompson score >14(RR; 1.12, 95%CI; 1.00-1.25, P=0.041), maternal hypertension (RR; 0.85, 95%CI; 0.81-1.21, P=0.016) and premature rupture of membranes (PROM) (RR; 0.89, 95%CI; 0.79-1.11, P=0.041) were significantly (p<0.05) associated with poor perinatal outcomes among term neonates with birth asphyxia. Birth practices among mothers whose term neonates had birth asphyxia that was associated with short-term poor outcomes among term infants with birth asphyxia included prolonged laboring at home, birth before hospital arrival, missed opportunity for cesarean delivery, and delayed neonatal interventions. The health workers were generally knowledgeable about birth asphyxia. Conclusion: The incidence of short-term poor outcomes among term infants with birth asphyxia was 4.5% which was relatively low in our study and it is encouraging. The risk factors for short-term poor outcomes among infants with birth asphyxia were maternal hypertension, PROM, use of CPAP, and Thompson score >14. Birth practices among mothers whose term neonates had short-term poor outcomes from birth asphyxia were prolonged laboring at home, birth before arrival to the hospital, missed opportunities for cesarean delivery, and delayed interventions, implying that there is a need for sensitization of the communities on the importance of early seeking of delivery care services. The health care had generally good knowledge of birth asphyxia, its causes, and consequences. This could have contributed to the low incidence of poor perinatal outcomes in our study. Recommendations: To improve perinatal outcomes among neonates admitted with birth asphyxia, healthcare workers should screen all mothers for hypertension during pregnancy to optimize their blood pressure. In addition, the health care workers should also strengthen health education during antenatal care focusing on the dangers of prolonged laboring at home to avoid delays in seeking interventions, and another study that will follow up these babies with birth asphyxia beyond 6 weeks should be conducted to assess the long term outcomes.