Risk factors of birth asphyxia among newborns in public hospitals of Central Zone, Tigray, Ethiopia 2018
Tasew?et?al. BMC Res Notes
Risk factors of?birth asphyxia among?newborns in?public hospitals of?Central Zone, Tigray, Ethiopia 2018
Hagos Tasew 0
Micheal Zemicheal 1
Girmay Teklay 0
Teklewoini Mariye 0
Ebud Ayele 0
0 School of Nursing, College of Health Science and Comprehensive Specialized Hospital, Aksum University , Tigray , Ethiopia
1 School of Medicine, College of Health Science and Comprehensive Specialized Hospital, Aksum University , Tigray , Ethiopia
Objective: The aim of study was to identify risk factors of birth asphyxia among newborns in public hospitals of Central Zone Tigray, Ethiopia 2018. Results: A total of 88 cases and 176 controls were included in the study. Thirty (34.1%) cases and 28 (15.9%) of controls were not able to read and write. Twenty-one (23.9%) cases and 9 (5.1%) controls were had meconium stained on pelvic examination. Multivariable logistic regression analysis showed that maternal illiteracy [AOR = 6; 95% CI (1.51, 23.80)], low birth weight [AOR = 6.9; 95% CI (3.01, 15.81)], preterm [AOR = 2.2; 95% CI (1.022, 4.76)], prim parous [AOR = 3.1; 95% CI (1.51, 6.38)], antepartum hemorrhage [AOR = 12; 95% CI (2.29, 63.11)] and meconium stained amniotic fluid [AOR = 7.88; 95% CI (2.92, 21.29)] were independent risk factors of birth asphyxia.
Birth asphyxia; Risk factors; Neonates; Central Zone; Tigray; Ethiopia
Birth asphyxia is defined as a failure to initiate, establish
and sustain breathing at birth. It can also be defined as
placental or pulmonary gas exchange impairment
leading to hypoxemia and hypercarbia [
]. Birth asphyxia
is oxygen deficit at delivery which can lead to severe
hypoxic organ damage (heart, lungs, liver, gut, kidneys),
but brain damage is of most concern and perhaps the
least likely to quickly or completely heal. In more
pronounced cases, an infant will survive, but with damage to
the brain manifested as either mental, such as
developmental delay or intellectual disability, or physical, such as
A diagnosis of birth asphyxia may be made when a
baby has a < 7 Apgar score. Another way of identifying
birth asphyxia is checking the acidity of the blood in the
umbilical cord. If it is too acidic, it can be a sign that the
baby has had a period of oxygen deprivation [
]. A baby
diagnosed with birth asphyxia may be breathing weakly
or not breathing at all; it may have bluish or very pale
skin, a low heart rate, poor muscle tone or be
experiencing seizures a few hours after birth [
Over 130 million infants born every year globally
and about four million neonatal deaths occurred each
]. Neonatal deaths (deaths in the first 28? days of
life) account for almost 40% of under-five deaths and
29/1000 neonatal death occur in Ethiopia [
]. For over
three quarters of these deaths was due to serious
infections, including tetanus (36%), complications of preterm
birth (27%) and birth asphyxia (23%) in developed
]. About 1? million babies were died due to
birth asphyxia related complications in the 1st month
of life, and millions have a lifetime of impairment. Birth
asphyxia was one of the contributors of early neonatal
death with 34% and followed by 25% prematurity and
18% sepsis and other infectious conditions [
There are tested risk factors of birth asphyxia in
different studies however there are factors which are not
tested particularly in our setting [
]. Hence, to reduce
the impact of birth asphyxia on neonatal morbidity and
mortality it needs further different study in diverse
setting. Therefore, this study aims to identify the risk factors
of birth asphyxia which produce broader implication on
prevention of birth asphyxia.
Study area and?period
The study was carried out in public hospitals of Central
Zone Tigray, Ethiopia. Data collection for this study was
undertaken from January up to February 2018.
A facility based unmatched retrospective case?control
study design was employed.
The source population was all mothers were born their
child in central zone, Tigray, Ethiopia.
Mothers with their newborns who diagnosis as birth
Mothers with their newborns who diagnosis without
Sample size calculation
Sample size of the study was calculated using EPI
Info software version 7.1.1 with the following
parameters for unmatched case control study: confidence
level = 95%; power = 80%; odds ratio = 2.53; case to
control ratio = 1:2; proportion of controls with exposure
]; proportion of cases with exposure = 35.2%.
Assuming a non-response rate of 10% the sample size for
cases = 88; sample size for controls = 176 the overall
sample size was = 264.
Systematic random sampling technique was used to
select the study subjects from four public hospitals with
every two study subjects for both cases and controls.
Data collection tool and?procedure
Data was collected using interviewer administered
structured questionnaire adapted [
], observational and
chart analysis. The questionnaire was initially prepared in
English and then translated into Tigrigna. The questioner
reliability was checked using Cronbach?s alpha.
Data quality control
Quality of the data was assured with properly designed
data collection instruments. The enumerators and the
supervisors were given training for 5?days on procedures,
techniques and ways of collecting the data. Five percent
pretest was done at Shul hospital to check consistency
of the questioner. The collected data was reviewed and
checked for completeness by principal investigator and
Plan for?data processing and?analysis
Data was entered and cleaned using Epi info version
7.1.1. Data was analyzed using SPSS version 22.0
statistical software. Cross tabulation was done among
dependent variable and independent variables. Binary logistic
regression model was used to determine significant
association between birth asphyxia and possible risk factors.
Variables which were show statistical significance during
bivariate analysis at p-value ? 0.25 were entered to
multivariable logistic regression. Multivariable logistic
regression was done with considering a selected variables of
bivariate logistic regression analysis. Data was finally
presented and interpreted at p-value < 0.05 being considered
as statistically significant.
Socio?demographic characteristics of?study participants
In this study, a total of 88 neonates who had birth
asphyxia (cases) with their index mothers and 176
newborns who had no birth asphyxia (controls) with their
index mothers were included making a response rate of
100%. Forty-nine (55.7%) of cases and 64 (36.4%) controls
were living in rural areas. Regarding to marital status, 75
(85.2%) cases and 166 (94.3%) of controls were married.
Forty-seven (53.4%) of cases and 89 (50.6%) of controls
were house wives and 30 (34.1%) cases and 28 (15.9%) of
controls were not able to read and write (Table?1).
Antepartum factors of?study participants
Seventy-six (86.4%) cases and 159 (90.3%) controls
their mothers were had antenatal care follow up and 11
(12.5%) cases and 6 (3.4%) controls their mothers were
had preeclampsia. Two (2.3%) cases and 5 (2.8%) controls
their mothers were with the complication of
polyhydramnios and 6 (6.8%) cases and 3 (1.7) controls their
mothers were had oligohydramnios as a complication. Three
(3.4%) cases and 5 (2.8%) controls their mothers were
anemic patients and 8 (9.1%) cases and 11 (6.3%) controls
their mothers were had maternal infection. Three (3.4%)
cases their mothers had experience of having history of
smoking and 10 (11.4%) cases and 34 (19.3%) controls
had history abortion. Forty-three (48.9%) cases and 64
(36.4%) controls were prim parous parity.
Distributions of?intrapartum and?fetal factors among?participants
Twenty-three (26.1%) cases and 36 (20.5%) controls their
mothers were had experience of prolonged labor and
7 (8.0%) cases and 8 (4.5%) controls their mothers were
had prolapsed cord as a complication of labor. Sixty-three
(71.6%) cases and 135 (76.7%) controls their mothers
were delivered spontaneously and 78 (88.6%) cases and
158 (89.8%) controls their mothers were had vertex
presentation. Twenty-one (23.9%) cases and 9 (5.1%) controls
their mothers were had meconium stained on pelvic
examination. Forty-three (48.9%) cases and 19 (10.5%)
controls were low birth weight and 49 (55.7%) cases and
40 (22.7%) and controls were preterm (Table?2).
Risk factors of?birth asphyxia
As showed from the result of bivariate analysis, 13
variables did show a significant association with birth asphyxia
at 25% level of significance. Multivariable logistic
regression was done by taking 13 variables into account
simultaneously. The backward elimination method of
regression was used to assess the confounding.
Educational status of mothers were showed significant
association with birth asphyxia. The odds of unable to read
and write were 6 times higher compared to those who were
educated above diploma [AOR = 6; 95% CI (1.51, 23.80)].
Parity was significantly associated with birth asphyxia.
This study showed that those who were primiparous 3
times higher risk than those who were multiparous to
effect birth asphyxia [AOR = 3.10; 95% CI (1.51, 6.38)].
Antepartum hemorrhage was significantly associated
with birth asphyxia. Mothers who had antepartum
hemorrhage had 12 times higher risk than those who were
not had antepartum hemorrhage to the outcome of birth
asphyxia [AOR = 12; 95% CI (2.29, 63.11)].
Status of meconium stained had significant
association with the outcome variable of birth asphyxia.
Those who had meconium stained were 7.9 times
higher risk than were not had meconium stained to
birth asphyxia [AOR = 7.88; 95% CI (2.92, 21.29)].
Preterm babies were 2.2 times higher risk than term
developing birth asphyxia [AOR = 2.20; 95% CI (1.02,
4.76)]. Similarly, the weight of the neonate had also
a significant association with birth asphyxia. Low
birth weight neonates were 6.9 times higher at risk
than normal weight as determinant of birth asphyxia
[AOR = 6.9; 95% CI (3.01, 15.81)] (Table?3).
This study was aimed to assess risk factors of birth
asphyxia in order to tackle the burden of the disease
and its associated problems. It has attempted to look the
determinants of birth asphyxia by incorporating as many
risk factors as possible.
This study showed that illiterate mothers were
significant with birth asphyxia. Unable to read and write were
6 times higher compared to those who were educated
above diploma. This result is consistent with a study
conducted in Nepal and Indonesia [
] which showed
that illiteracy was culprits of birth asphyxia. This may
be due to maternal illiteracy is a very broad indicator of
poor socio-economic conditions associated with
consequent malnutrition, frequent pregnancies and also
influence care seeking during antepartum period.
Birth weight was significant association to birth
asphyxia. Low birth weight was 6.9 times more likely
to be asphyxiated than normal weight (? 2500? g). This
The symbol (*) indicated that these factors had significant association with birth asphyxia
finding is similar with studies conducted in Pakistan and
] presented that low birth weight was
a risk factors of birth asphyxia. This may be due to the
fact that low birth weight was developed due to
maternal complication like hypertension, diabetes mellitus that
present pre-conception or antepartum.
Preterm babies were 2.2 times more likely to be
asphyxiated than term babies. This study is in line with a study
conducted in Jordan discovered that preterm babies had
risk of development birth asphyxia [
]. This may be
due to premature infants are more susceptible to ischemia
due to incomplete blood brain barrier formation.
Moreover, it may be due to the fact that preterm babies face
multiple morbidities including organ system, immaturity
specially lung immaturities causing respiratory failure.
Meconium stained mothers had a significant
association with birth asphyxia. Those who had meconium
stained were 7.9 times higher risk than were not had
meconium stained to birth asphyxia. This study is in line
with other previous study [
]. In healthy, well
oxygenated fetuses, this diluted meconium is readily cleared
from the lungs by normal physiological mechanism,
however in few cases meconium aspiration syndrome occurs.
Parity had significant association with birth asphyxia.
Those who were prim parous 3 times higher risk than
those who were multiparous to effect birth asphyxia. This
study is consistent with other studies [
]. This may be
due to the fact that prim parous are often ignorant of the
demands of pregnancy and often neglect regular
attendance to antenatal care. This may result in complications
that lead to perinatal asphyxia. However, socioeconomic
and cultural factors may also contribute for the same.
Antepartum hemorrhage had significant
association with birth asphyxia. Mothers who had antepartum
hemorrhage had 12 times higher risk than those who
were not had antepartum hemorrhage to the outcome of
birth asphyxia. This study is in line with studies reported
]. This could be due to the fact in the
antepartum bleeding, there is decreased blood flow from
mother to placenta so the hypoxemia can occur in the
fetus. This condition can lead to perinatal asphyxia if the
transfusion to the mother or delivery is postpone.
Birth asphyxia is one of the worldwide problem of
neonates. It arises different complications, if the cases left
untreated and leads to death. There are different variables
which culprits of birth asphyxia. In this study, maternal
illiteracy, prim parous, low birth weight, preterm
delivery and meconium stained amniotic fluid were the risk
factors of birth asphyxia. Most of these variables are
preventable by holistic care of pregnancy, labor and delivery
and post-natal care.
? This study is quantitative; it was better if qualitative
approach was also employed to investigate in detail
on extra determinant factors of birth asphyxia.
? The study was done in single one region of Ethiopia.
It is difficult to generalize for the whole country with
? This study also subjected to recalling bias of mothers
when they remembered their previous history.
AOR: adjusted odd ratio; COR: crudes odd ratio; SPSS: Statistics Package for
Social Science; WHO: World Health Organization; TRHB: Tigray Regional Health
HT: conceived and designed the study, analyzed the data and wrote the
manuscript. MZ, GT, TM and EA involved in data analysis, drafting of the
manuscript and advising the whole research paper and also were involved in
the interpretation of the data and contributed to manuscript preparation. All
authors read and approved the final manuscript.
We would like to thank all study participants and data collectors for their
contribution in the success of our work.
This manuscript maintains no competing financial interest declaration from
any person or organization, or non-financial competing interests such as
political, personal, religious, ideological, academic, intellectual, commercial or
Availability of data and materials
The data sets used and analyzed during the current study available from the
corresponding author on reasonable request.
Consent to publish
Ethics approval and consent to participate
Ethical clearance was obtained from Aksum University, college of health
science, institutional review board (AKU-CHS, IRB) of the research committee.
Respondents were informed about the purpose of the study, then information
were collected after obtaining written consent from each participant. Written
consent was wanted from all the informed respondents before a start of each
interview. Respondents were allowed to refuse or discontinue or participation
at any time they want. Information was recorded anonymously and
confidentiality and beneficence were assured throughout the study.
Aksum University was the source of funding.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
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