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Unmatched Case Control Study Assela Referral
Teaching Hospital, Arsi Zone, Ethiopia
Magnitude and Determinants of Birth Asphyxia:
Unmatched Case Control Study Assela Referral
Teaching Hospital, Arsi Zone, Ethiopia
Negese Asefa Bedie1, Legesse Tadesse Wodajo2* and Solomon Tejineh Mengesha2
1 Asella Rehoboth Hospital and Medical College, Ethiopia
2 Department of Public Health, Arsi University, Ethiopia
Submission: October 01, 2019; Published: October 17, 2019
*Corresponding author: Legesse Tadesse Wodajo, Department of Public Health, College of Health Sciences, Arsi University, Ethiopia
How to cite this article: Negese Asefa Bedie, Legesse Tadesse Wodajo, Solomon Tejineh Mengesha. Magnitude and Determinants of Birth Asphyxia:
Unmatched Case Control Study Assela Referral Teaching Hospital, Arsi Zone, Ethiopia. Glob J Reprod Med. 2019; 7(1): 5556705. DOI: 10.19080/GJORM.2019.07.555705.
Backgrounds: Birth asphyxia is a common and serious neonatal cause morbidity and mortality globally. In developing countries majority of
the cases suffer from the consequences of birth asphyxia, while no information in the study area that the current study aimed to provide.
Methods: A cross sectional case control study design done on 346 neonates, 115 cases and 231 controls making 1:2 ratio. All neonates
delivered with Apgar score ≤7 at first minute taken as cases and two consecutive babies delivered with Apgar score >7 at first minute following
the case taken as control. Interviewer administered structured questionnaire for mother and check list to extract information from patient record
was used. The data entered using EPI info 7 statistical software and SPSS version 22 for checking consistency, accuracy and further analysis.
Result: The mean maternal age in the study group and control group was 27.0±5.5 years and 26±4.4 years, respectively. Independent risk
factors of birth asphyxia include preterm [AOR= 4.97; 95% CI(1.37,18.05)], instrumental delivery [AOR=4.68; 95% CI (2.12,9.95)], Wt < 2500gm
[AOR=3.64; 95% CI (1.50,8.87)], caesarean section [AOR = 3.23; 95% CI(1.70,6.12)],PROM [AOR=2.98; 95% CI (1.44,6.18)], rural residence
[AOR= 2.726;CI(2.51,4.38)],breech presentation [AOR=2.41; 95% CI (101,5.74)].
Conclusion and Recommendation: rural residence, breech presentation, instrumental deliveries, caesarean section delivery, PROM,
preterm delivery and low birth weight were risk factors of birth asphyxia. There is an immediate need to develop strategies for early identification
and management of birth asphyxia by involving beneficiaries, health professionals and policy makers. Health workers should be trained for
emergency obstetric care, basic newborn care and encourage early recognition and referral.
Keywords: Case control study; Birth asphyxia; Arsi
Abbreviations: ANC: Antenatal Care; APGAR: Appearance Pulse Grimace Activity Respiration; BPR: Business Process Re-engineering; BW: Birth
Weight; CI: Confidence Interval; CNS: Central Nervous System; CPD: Cephalo-Pelvic Disproportion; DHS: Demographic and Health Survey; DM:
Diabetes Mellitus; HC: Health Center; HIV/AIDS: Human Immune Virus/Acquired Immune Deficiency Syndrome; HP: Health Post; HSDP: Health
Sector Development Plan; IUGR: Intra Uterine Growth Retardation; IRB: Institutional Review Board; NICU: Neonatal Intensive Care Unit; OR: Odds
Ratio; PIH: Pregnancy Induced Hypertension; PROM: Premature Rupture of Membrane; WHO: World Health Organization
Ethiopia is the tenth largest country in the world and second
populous in Africa of whom 44.5% in the reproductive age .
There has been considerable health facility rehabilitation program
and furnishing during the Health Service Development Program
I (HSDP-I): HSDP-II and HSDP-III including improvements
in support facilities. As a result: the potential health service
coverage increased from 45% in 1996/97 to more than 95%% by
2008/09 . The term “asphyxia” is derived from the Greek and
means “stopping of the pulse”. Perinatal asphyxia is a condition
characterized by an impairment of exchange of the respiratory
gases (oxygen and carbon dioxide) resulting in hypoxemia and
hypercapnia: accompanied by metabolic acidosis . World
Health Organization (WHO) has defined birth asphyxia as
“failure to initiate and sustain breathing at birth” . Perinatal
asphyxia is a common and serious neonatal problem globally and
significantly contributes to both neonatal morbidity and mortality
. According to the (WHO) report: 130 million infants born
globally each year: approximately 4 million babies die before they
reach the age of 1-month. It has been shown that 99% of these
neonatal deaths take place in the developing countries where
perinatal asphyxia contributes to almost 23% of these deaths .
The incidence of asphyxia is 1 - 6 per 1000 births in developed
countries and 5 - 10 per 1000 births in developing countries .
Globally perinatal asphyxia is estimated to be the fifth largest cause of under-five child deaths (8.5%). Indeed: newborn deaths
constitute over 40% of all deaths in children aged under five .
The WHO’s classification of diseases according to ICD 10 (The
International Classification of Disease 10) defines birth asphyxia
when the Apgar score at 1 minute is less than or equal to 7 by
the two levels. Severe birth asphyxia is defined where the Apgar
score at 1 minute is 0-3 and mild or moderate birth asphyxia is
defined where the Apgar score at 1 minute is 4-6 . In Ethiopia:
despite the progress in child health over the past decades:
neonatal mortality rate is high and has remained stagnant .
Birth can occur as result of problems during labor and delivery
or after delivery due to neonatal factors. The ante-partum risk
factors are severe preeclampsia/eclampsia: multiple gestation:
breech presentation: trauma: increasing or decreasing maternal
age: lack of antenatal care: anemia and ante-partum hemorrhage.
Numerous intra-partum risk factors for asphyxia are including
prolonged rupture of membrane (PROM): abnormal fetal heart
rate during labor: chorioamnionitis: thick meconium: assisted
vaginal delivery: general anesthesia: emergency cesarean delivery:
induction/augmentation of labor with oxytocin: placental
abruption: umbilical cord prolapse and uterine rupture. Neonatal
risk factors including congenital malformation: twin pregnancy:
intrauterine growth restriction (IUGR): preterm delivery: fetal
distress and birth weight less than 2:500 grams. It should be noted
that: in many cases: the timing of asphyxia cannot be established
with certainty . Although the majority are transient: the longterm
consequences of asphyxia affect the central nervous system
(CNS): which can ultimately lead to cerebral palsy: epilepsy: and
learning disabilities [5,11]. Ethiopia is suffering from high rate
of neonatal morbidity and mortality. Neonatal asphyxia is one
of the major causes. Having gone through literature: there is no
sufficient documented report on magnitude and determinants
of perinatal asphyxia in our country. The result of this study is
intended to benefit health professionals: policy makers and NGOs
that are working on neonatology. It can also benefit neonates by
preventing them from losing their life and prevent them from
suffering by the complications of birth asphyxia. Finally, families
and society are also benefitted. Moreover: it is the most likely
practical intervention point to reduce the mortality and morbidity
associated with birth asphyxia. Therefore: this study was designed
to measure magnitude of birth asphyxia and its determinants in
the study area.
The study conducted at Assela Referral Teaching Hospital which
in Arsi Zone: South-Eastern part of Ethiopia. Assela is the capital
Town of Arsi Zone located at 175 km from Addis Ababa: Capital of
Ethiopia. According to the 2007 national census report projection:
Assela Town total population is estimated about 94:500 and Arsi
Zone has 3.5 million as of CSA projection . So: the hospital
assumed serves more than 3.6 million population together with
some of neighboring zones. The town has one public university:
one public referral hospital: two private general hospitals: two
health centers and ten private clinics. Assela Hospital is one of the
teaching hospitals in Ethiopia and it has different departments:
gynecology and obstetrics: surgery: internal medicine: pediatrics
and neonatal intensive care unit and ophthalmology. The hospital
is the largest health facility in Arsi Zone, and it serves as a referral
center from different facilities in the zone including six district
hospitals. More than 5:000 deliveries conducted in the hospital
annually. The current study conducted on newborn in Assela
referral hospital during the study period.
All live newborns with gestational age of 36 or more weeks
during the study period were screened for eligibility of the study.
Birth asphyxia (cases): Newborn babies with apgar score <7 at
first minute were defined as cases while newborns with apgar
score of >= 7 at first minute were considered as controls. Though
these cases were not found: the authors proposed to exclude
newborn with one or more malformations and incapability with
life: like cyanotic congenital heart defects and hydrops.
Newborns whose mothers refused informed consent:
Neonates with major congenital malformations such as cyanotic
congenital heart disease: severe meningomyelocele: and
anencephaly excluded from the study. Neonates who delivered
on the way to hospital. Patients with neurologic defects explained
by a condition other than perinatal asphyxia like electrolytic
alteration: inborn error of metabolism: patients with syndromes
(Down and hypotonic child). Neonates/mothers with incomplete
study records excluded.
Sample size of the study determined by using Epi-Info V. 7
based on the following parameters. The variable low birth weight
(birth weight <2500gms) used and based on this: the proportion
of controls with exposure =12.2% and odds ratio= 2.50 : level
of confidence = 95% and 80% power =80%. A ratio of 1:2 used
between cases and controls. Finally: 10% added for non-response
rate. The final sample size 115 cases and 231 controls while
overall was 346.
Subjects divided into cases and controls. All neonates who
were delivered with an APGAR score of <7 at first minute taken as a case until the required sample size fulfilled and risk set sampling
employed to select the controls. For each asphyxiated neonate
two non-asphyxiated neonates who born after the case taken as
a control i.e.: 115 neonates and 231 neonates required in the case
and control group: respectively.
It is an excellent tool for assessing the overall status of the
newborn soon after birth (one minute) and after a brief period of
observation (five minute). A normal apgar score is 7 and above at
one minute. It consists of five signs: heart rate: respiratory effort:
muscle tone: reflex irritability and color each evaluated out of two.
is defined as amniorrhexis prior to the onset of labor at any
stage of gestation. It has been suggested that the term “preterm
premature rupture of the membrane (PPRM)should be used to
define those patients who are preterm with ruptured membranes
whether or not they have contraction and is said prolonged if it
was lasting >18hrs without starting of labor.
Data collected using interviewer administered: structured
and pre-tested questionnaire for the mother and information
extracting check list for baby document that developed by
reviewing literatures in order to address the objective of the study.
It had three parts: sociodemographic of the mother: intrapartum
variable and neonatal variable. Data collection conducted by
data collectors. Data collectors were revised the patient chart:
examine the newborn and interview the mother to fill the
questionnaire and check list. A Medical doctor was a supervisor
from gynecology department and 5 mid-wives were participated
in the data collection process. Training given for data collectors
and the supervisor for one day before starting data collection by
the investigator. The questionnaire and check list pre-tested to
identify potential problem of the questionnaires: unanticipated
interpretation and cultural objections to any of the questions in
5% of the respondents having similar characteristics with the
study subjects. Based on the pre-test results the questioner then
adjusted contextually and terminologically: and distributed to
data collectors. Counter checking of daily filled questionnaire and
check list and regular supervision made by the supervisor.
The questionnaires and information extracting check list
whose internal consistencies checked by previous researchers
used after carefully adapted them into the current context and
without changing the original meaning. The adapted questionnaire
and check list pre-tested to identify potential problem:
unanticipated interpretations and cultural doubts to any question
in respondents having similar characteristics on five percent two
weeks back of the main study. Originally the questionnaires and
check list prepared in English and translated into Amharic and
back to English by language experts to keep the consistency of
the meanings. Questionnaire and check list checked thoroughly
for completeness before distributing. The collected data checked
daily by supervisor for its completeness. Finally: data checked for
consistency and completeness before entry to computer software
The collected data checked for its completeness: consistency
and accuracy using EPI info version 7 statistical software and
then exported to SPSS version 22 for further analysis. The data
presented by using descriptive and analytic statistics. All
independent variables processed individually with the dependent
variable using binary logistic regression model. Variables which
had significant association during binary analysis entered in to
multi variable logistic model and finally the variables which have
significance of association declared on the basis of adjusted odds
ratio at 95% confidence level and 0.05 % p-value.
During the study period: there were 115 newborns with
neonatal apgar score <7 at first minute from 687 total live births
during the study period and matched with 231 newborns with
apgar score ≥7 at first minute as controls. The incidence rate of birth
asphyxia obtained was 167/1000 live birth. Socio-demographic
features in neonates’ mothers among the study population:
Majority of mothers of the case and control groups were in the age
range of 19 to 35 years: 91(79.1%) and 209(90.5%) respectively.
Age group <19 years and >35years comprises 7(6.1%) and
17(14.8%) for cases and 4(1.7%) and 18(7.8%) for controls.
The mean maternal age in the case group and control group was
27.0±5.5 years and 26±4.4 years: respectively (Table 1).
Seven (6.1%) mothers of the case group and 3(1.3%) mothers
of the control group were short stature. Ninety-seven (84.3%)
mothers of the case group and 212(91.8%) mothers of the
control group had ANC follow up: at least one visit. Fifty-eight
(50.4%) mothers of the case group and 102(44.2%) mothers of
the control group were nulliparous while 57(49.6%) mothers
of the case group and 129(55.8%) mothers of the control group
were multiparous. In the case group 95(82.6%) were singleton
pregnancy and 20(17.4%) were multiple pregnancy while in
the control group 217(93.9%) were single and 14(6.1%) were
multiple pregnancy (Table 2).
Onset of labor was spontaneous in majority of case and
controls group 97(84.3%) and 188(81.4%) respectively. Majority
of mothers of the case group 99(86.1%) had moderate to thick
meconium stained amniotic fluid as compared to mothers of the
control group 3(1.3%) whereas majority of mothers of the control
group had clear amniotic fluid color as compared to mothers of
the study group: 193(83.5%) and 3(2.6%) respectively. Thirteen
(11.3%) mothers in case group and 35(15.2%) mothers in control
group had mild meconium stained amniotic fluid color (Table 3).
Gp- general practitioner
Sixty-two (53.9%) neonates in the case and 137(59.3%) in
control group were male and remaining were female. Majority of
neonates of both case and control groups were within gestational
age of 37 to 42 weeks: 94(81.7%) and 222(96.1%). The mean birth
weight of the case group was 2977.39±609.15grams (range 1700
-5500grams) whereas the mean birth weight of the control group
was 3216±455.68grams (range2100-5200 grams) (Table 4).
Perinatal asphyxia is a common and serious neonatal problem
globally and significantly contributes to both neonatal morbidity
and mortality  and incidence is very high in developing
countries. In this study: a total of 687 newborns were involved.
One hundred fifteen newborns (62 males and 53 females) with
birth asphyxia matched with 231 (137 males and 94 females)
newborns without the events as controls. From the current study:
the incidence rate of birth asphyxia obtained was 167/1000 live
births. Different studies revealed a rage of prevalence for birth
asphyxia in different areas. In Dilchora Hospital in Ethiopia
25/1000 live births : Nigeria 301/1000 live births : Nepal
26.9/1000 live births  and Zambia 230/1000 live births
. The current finding is more than that of Dilchora and Nepal
while by far less than the findings from Nigeria and Zambia. This
difference may occur due to differences in study measurements:
study settings and study populations evidenced a need for further
study to stabilize the cause. The current study report showed that
the risk of newborns developing birth asphyxia was 2.57 times
higher with confidence interval of (1.51:4.38) among neonates
of rural mothers as compared to those came from urban mothers
(Table 5). This could be explained: among others: by late arrival of
the mother to hospital where cesarean section and instrumental deliveries are conducted. Living in rural area in third world like
Ethiopia is obviously exposing to poor antennal care and referral
services that might define the current finding. This study identified
breech presentation as a significant risk of birth asphyxia (Table 5)
with adjusted odds ratio (AOR) of 2.40 and confidence interval of
(1.01: 5.74) when it is compared to neonates delivered by cephalic
presentation. This was a complimentary result with previous
studies in different study areas of Pakistan: Thai and India (13:
18: 19: 20). The assumption is that breech presentation has a high
rate of umbilical cord prolapse head entrapment: birth trauma:
prolonged labor and also increased perinatal mortality. Newborns
from mothers who were suffering from Premature Rupture of
Membrane (PROM) during the current delivery exhibit a 2.98
times higher risk of developing birth asphyxia with confidence
interval of: (1.44:6.18): compared to the contrary (Table 5). PROM
has also been severally reported previously as a significant risk
factor for birth asphyxia [18-22]. This could be that prolonged
rupture of membrane may be associated with intrauterine
infection resulting in birth asphyxia. Mode of delivery in our study
was found to be a risk factor for birth asphyxia as most of the
mothers of the asphyxiated neonates came with complications
requiring immediate intervention.
The occurrence of birth asphyxia was 3.23 times more likely
among cesarean delivery when compared to SVD. This finding
was in line with a similar study conducted in Turkey . This
could be explained by the fact that indications for the caesarean
sections were mostly due to prolonged obstructed labor and nonreassuring
fetal heartbeat. Instrumental delivery was major risk
factor in our study. Neonates who were delivered by vacuum/
forceps exhibit 4.68 times higher risk of developing birth asphyxia.
Other hospital-based studies on risk factors of birth asphyxia also
had reported similar finding . The current study revealed that
the risk of developing birth asphyxia was higher among preterm
newborns as compared to term neonates: with AOR of 4.97. This
was a complementary result with what was reported by other
literatures which were conducted in Pakistan: Thailand and
Nepal: [13,18,22]: respectively. Preterm babies have a variety of
morbidities: largely due to organ system immaturity: especially
lung maturation causing respiratory distress syndrome (RDS) in
infants after birth. In the case of preterm labor: it is important
to make a diagnosis and find the cause to provide appropriate
management to prevent preterm delivery. Nevers less: in our
study: no association has been detected between birth asphyxia
and IUGR. This was supported by a study conducted in Thailand
. This study found birth asphyxia was 3.64 times higher among
fetal birth weight less than 2:500 grams as compared to normal
fetal birth weight (2500-4000grs). This result was similar to other
studies which were conducted in Tigrai of Ethiopia  Thailand
and Pakistan [18-21]. It is beneficial here to note that low birth
weight (LBW) infants are often related to maternal complications
such as anemia: hypertension: and under nutrition that present
preconception or antepartum. To decrease the risk of LBW: in the
case of previously described maternal conditions: these pregnant
women should be advised to optimize their nutritional status and
get treatment for anemia and hypertension during ANC follow up.
a) Early identification of high-risk pregnancies is a top
b) Incapacitating professionals: establishing neonatal
centers and equipping the facilities will decrease the incidence:
morbidity and mortality associated with birth asphyxia of
rural residents: preterm babies and of C/s and instrumental
deliveries by providing optimum timely care.
c) Further investigation needed under this topic to develop
d) Strengths of the study:
e) The strength of our study lies in its design and extracted
primary data. In this study: Apgar score and clinical signs used
to diagnose birth asphyxia. Our Apgar score assigned correctly
by the maternity staff: general practitioners and obstetricians
present at deliveries.
f) Limitations of the study:
g) Biases might result because of case and control selection.
Another limitation of this study was that the study conducted
in one referral hospital of Assela where mostly patients belong
to the low and low middle-class economy and data couldn’t
predict the overall situation in the country. The third limitation
was Lack of national data and literatures on the topic area for
comparison. The fourth limitation was short sample size of
the study which may have limited our ability to detect small
The Ethical Review Committee of Arsi University: College
of Health Sciences approved the study protocol and the verbal
consent for participants. Project approved on 26th of January
2017: Project protocol number A/CHS/RC-1/17 and protocol
number of letter of recommendation to the institution A/U/H/
S/C/120/61-1/17 Informed verbal consent was obtained from
each participating woman after explaining to them all the purpose
of the study. The right of the participants to withdraw from the
interview at any step was assured. Any personal identifiers were
differed during coding: identifiers of the study subjects were
replaced with identification numbers.
BNA developed the study conception: design: proposal development: data collection: analysis and manuscript writing.
WLT and MST involved in designing: data analysis and manuscript
writing. All the authors read and approved the final manuscript
Authors would also like to thank all library staffs of Arsi
University and all labor ward staffs of Assela Hospital who provided
us the necessary information and materials in the development of
proposal and help us in the process of data collection. Lastly: but
not least: we shall forever be grateful to the mothers.
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