Etiological and Sociodemographic characteristic of neonatal death

Supervised by : Dr. Ghada Mansour

Students

Marwa Mohammed

Sarah Qasim

Faten Younus

الرحيم الرحمن الله بسممن } اوتيتم وما ربي امر من الروح قل الروح عن ويسئلونك

قليال اال { العلم

العظيم الله صدق

االيه االسراء 85سوره

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Dedication:

We would like to express our appreciation our supervisor, (Dr. Ghada mansour)

who her cheerfully answered our queries, provided us with materials,

checked our examples, assisted us in a myriad ways with the writing and

helpfully commented on earlier drafts of this project. Also, we are also

Very grateful to our friends, family for support throughout the production of this project.

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Content :

-abbreviations…………………………………..page 5

-Abstract ………………………………………………page 6

Chapter one

-Introduction ………………………………………….page 7_9

Chapter two

- Subjects and method …………………………………Page 10

-Limitations …………………………………………….page 10

-Objective …………………………………………….page 11

Chapter three

-Result…………………………………………………page 12_17

Chapter four

-Discussion …………………………………………….page 18_20

-Conclusion …………………………………………….page 20

-Recommendation …………………………………………page 21

-Reference ………………………………………………page 22,23

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Abbreviations:

RDSHMDANCINCUNCUCPAPGBSE.ColiICUHIEKgWksSPSSH.influenzaeCSNVDWHOg

Respiratory distress syndromeHyaline membrane diseaseAntenatal care Intensive neonatal care unitNeonatal care unit Continuous positive airway pressureGroup B streptococcal infectionEscherichia coli Intensive care unitHypoxic ischemic encephalopathyKilogramWeeksStatistical Package for the Social Sciences Haemophilus influenzaeCaesarean sectionNormal vaginal delivery World Health Organizationgram

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Abstract :

This study was conducted to identify the causes of neonatal mortality in neonatal intensive care unit at Bint_Alhuda hospital in Dhi Qar.

The study sample was collected through a review of ICU records at Bint_Alhuda hospital during the period from 25 of September 2016 to the beginning of March 2017.

The study found that the main cause for neonatal death were respiratory distress syndrome which account for 40% of death ,followed by congenital malformation 20% and septicemia 14%.

91%of neonatal death occurred in the first 5 days of life .Also the study showed that 77% of neonatal death in mother aged (20_35 )years. This study was found majority of neonatal death occur in low birth weight (<2.5kg).The majority of mother live in urban area (54%) . 66% of neonatal death are found in mother with poor ANC.

The study recommended that significant effort should be made to assesses and determine the risk factor associated with neonatal death for proper management . In addition educate mother about the disease and to take folk acid 2 month prior to conception and with regular ANC during pregnancy .

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Chapter one

INTRODUCTION:

Neonatal period is the most hazardous period of life because of various problems / diseases which a neonate faces, There are a great overlap between the risks associated with morbidity and mortality in the perinatal and neonatal periods(1).

Approximately more than ten million die in the first month of life over all the world (with more than one hundred million born annually), also approximately 75 % of death in neonate occur in the first seven days of life and more than 25% of them occur in the first day of life (2) .The neonatal mortality rate includes all infants dying during the period from birth to the first 28 days of life and is expressed as the number of deaths per 1000 live births (3).

In Iraq, deaths in neonatal period account for more than half of under- five children deaths, highlighting urgent need to introduce health interventions to improve essential neonatal care and effective treatment for neonatal conditions(4).

Currently, a limited number of problems commonly account for neonatal death:

1- Extreme prematurity usually implies a neonate weighing less than 750g and/or less than 26 weeks gestation is associated with a high mortality risk, as they risk for RDS,apnea of prematurity,HIE,sepsis ,infection ,hypoglycemia, and others, although survival has increased considerably in recent years(5).

2- HMD (Respiratory Distress Syndrome) occurs primarily in premature infants, and its incidence is inversely proportional to gestational age and birth weight. It occurs in 60-80% of infants less than 28 wk. of gestational age, in 15-30% of those between 32 and 36 wks., in about 5% beyond 37 wks., and rarely at term. An increased frequency is associated with infants of diabetic mothers, delivery before 37 wks. gestation, multifetal pregnancies, cesarean section delivery, precipitous delivery, asphyxia, cold stress, and a history of previously

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affected infants. The incidence is highest in preterm male or white infants. The risk of HMD is reduced in pregnancies with chronic or pregnancy-associated hypertension, maternal opiate addiction, prolonged rupture of membranes, and antenatal corticosteroid use (6).

3- A neonatal sepsis is a significant cause of neonatal morbidity and mortality in the newborns particularly in preterm and low birth weight infants, The most common organisms causing the early onset infection are GBS, E.coli, other Streptococci, and H. influenza , While the organisms causing late onset infection are GBS, Listeria monocytogenes and Staphyloccocus(7,8,9).

4- A congenital anomaly defined as any abnormality of physical structure found at birth or during the first few weeks of life; or any irreversible condition exiting in a child before birth in which there is sufficient deviation in the usual number, size, shape, location of any part, organ, CELL to warrant its designation as abnormal(10).

5- Birth trauma: Injuries to the infant that result from mechanical forces such as (compression, traction)during the birth process are categorized as birth trauma, is used to denote avoidable and unavoidable mechanical and hypoxic- ischemic injury incurred by an infant during labour and delivery(11,12).

So Causes of neonatal death can be summarized into: Immaturity related including multiorgan immaturity, hyaline membrane disease or clinical respiratory distress in the absence of any other detectable cause, Birth asphyxia: when a normally formed term baby is unable to initiate and sustain respiration at birth or has low Apgar score, Congenital abnormalities: including fatal chromosomal & somatic malformations and Infections: sepsis, pneumonia or meningitis, Prematurity accounts for majority of high risk newborns as they face a large number of problem(13,14).

While, the maternal age at conception has long been demonstrated to have a significant correlation with pregnancy outcome and maternal health(15).

Classically, very young (<20 years old) and old (=or >35 years) women have been classified as high-risk categories for child bearing . Adverse pregnancy outcome

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like preterm delivery, low birth weight infant, respiratory distress syndrome, stillbirths and perinatal deaths have all been associated with adolescent mothers,teenage pregnancies have been reported to be associated with an adverse obstetric outcome (16).

Despite the abundance of existing literature on parity and maternal age as risk factors for adverse neonatal outcomes, methodological issues in many studies make it difficult to draw strong conclusions, several studies have utilized cross-sectional data, often Demographic and Health Surveys (17, 18).

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Chapter two

Subjects and method:

A descriptive study over 4 month period was done on the medical records of neonates admitted to NCU in Bint _Al_ huda hospital in Dhi_ Qar and died in the period from 25 of September 2016 to the first of march 2017.And we collect 100 cases from INCU.

The data regarding the neonatal factor (name , gender ,birth weight ,gestational age ,mode of delivery ,cause of death, age of death ) and maternal factor (age of the mother ,parity ,ANC ,mode and place of delivery ,residence ) all were gathered from neonates medical records and death certificates although the detailed data like occupation of mother , socio demographic state ,education of father and mother and consanguinity were not available due to inadequate information in medical record of the patient and the parents are not present at the time of taking data. Using the available statistical package of SPSS_24 .data was presented in simple measures of frequency,and P-Value was calculated.

Limitations:

We face too much limitations in our study .

As our time is limit and narrow ,so we don't cover all the cases which die during this period in our study, but the most difficult problem for us the case sheet was lack of adequate information which needed in our questionnaire.

Also family of neonate not present at hospital at time we collect data to help us answer our questionnaires directly and accurately.

And we collect all data from only Bint AL_Huda hospital so we lost so much cases from other hospitals in periphery and other hospital in our center.

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Objective:

1-To find maternal and neonatal risk factor that associated with neonatal death in Bint_Alhuda hospital

2-To see where further improvement may be possible and preventive method can be applied to decrease the mortality and morbidity .

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Chapter threeResult

Between 25 of September 2016 to the first of march 2017 collect 100 case die of newborns to identify maternal and newborn factor that associated with neonatal mortality in Bint _Al_ huda hospital in Dhi_ Qar and died in the.

Neonatal factor

Table1:

Gender Frequency Percent p-value

Male 49 49%

Female 51 51% 0,136

Total 100 100%

The table show : Male forming 49% and female 51% from neonatal death so there is no significant difference P-Value(0.136) between male and female gender associated with neonatal death.

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Table 2 :

Gestational age Frequency Percent p-value

LESS 34 35 35%

34-37 38 38%

37-42 24 24% 0,191

MORE THAN 42 3 3%

Total 100 100%

-This table showing that majority of neonatal death(73%)occur in premature neonate with gestational age (<37wks),and most of them at age 34-37(38%)

- 24%occur in term( 37-42)and less percentage occur in postterm(>42wks)which is (3%).

Table 3:

Birth weight Frequency Percent p-value

LESS THAN 1.5 KG32 32%

1.5-2.5 KG 38 38% 0,090

2.5-4 KG 30 30%

Total 100 100%

This table showing that most of neonatal death (38%) occur in low birth weight (1.5-2.5kg),followed by very low birth weight(<1.5kg)(32%) .The neonatal death

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in normal birth weight (2.5_4) kg was 30%. P value is (0,090), it is no significant difference between them .

Table4:

AGE of DEATH Frequency Percent p-value

0-5day 91 91%

6-28day 9 9% 0,507

Total 100 100%

This table show neonatal death most commonly occur during the first five days of life 91% and late neonatal death during (7_28) days was 9%.There is no significant difference in (P-Vlaue 0.507).

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Table 5:

CAUSES OF DEATH Frequency Percent

PREMATURITY 14 14%

RDS 26 26%

RESPITARY DISTRESS UNDIAGNOSED CAUSES

5 5%

SEPSIS 14 14%

HIE 8 8%

MECONIUM ASPIATION 3 3%

CONGENITAL ANOMALIES

20 20%

PMEUMONIA 7 7%

KERNICTERUS 1 1%

blood disorder 2 2%

Total 100 100%

This table showing that,the most common vause of neonatal death wasRDS(40%)followed by , congenital anomaly 20% ,sepsis 14% ,birth asphyxia

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8% ,pneumonia 7% ,respiratory distress undiagnosed cause 5%, meconium aspiration 3% ,blood disorder (vitamin k deficiency) 2%,kernicterus 1%.

Maternal factor

Table 6:

Age of MOTHER Frequency Percent p-value

LESS THAN 20 15 15.0

20_35 77 77.0

MORTH THAN 35

8 8.0 0,028

Total 100 100.0

This table showing that majority of women(77%)was age(20-35years)and (15%)was age(<20years)and (8%)was more than 35 years in age .P-value (0,028) , so there is statistically significant difference in age of mother

Table 7:

RESIDUENCE Frequency Percent p-value

URBAN 54 54%

RURAL 46 46% 0,002

Total 100 100%

These table shows 54% of neonatal deaths occur in women live in urban areas while 46% from women live in rural areas. P value (0,002) so there is highly significant difference between them.

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Table 8:

PARITY Frequency Percent p-value

PRIMI 30 30.0

MULTI 69 69.0

GRAND 1 1.0 0,555

Total 100 100.0

This table show neonate mortality rate high in multipara women which about 70% in compared to nullipara women which about 30% and grand multipara woman which 1%. P value (0,555) , it is no significant in parity.

Table 9:

ANC Frequency Percent P-value

good 34 34.0

poor 66 66.0 0,87

Total 100 100.0

This table show 34% of neonatal death occur in women with good ANC, while 66% of neonatal death occur in women with poor ANC. P value (0,87) , it is no significant between poor and good visit ANC.

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Chapter four

Discussion

The neonatal period carries the highest risk of death in human life. This research carried out in Bint-Al Huda hospital in Dhi-Qar to study the maternal and newborn risk factors associated with neonatal mortality.

In this study we found that majority of neonatal death (91% ) occurs during the first 5 days of life (0-5days), similar result was found in a study done in France (19).

This result may due to newborn during the first week of life more liable to infection and sepsis due to low immunity, in addition most cases of extreme prematurity and birth asphaxia die during the first week of life.

In this study also we found that low birth weight< 2.5 kg associated with higher mortality among neonates (70%). 38% of neonates weighed 1.5kg-2.5kg, and another 32% weighed<1.5kg. Similar result was found in a study in Namibia in Africa(20).

The mortality was high among low birth weight due to prematurity, RDS, low immunity, high risk of infection, and birth trauma like intracranial hemorrhage.

While another study done by Eveline Campos in Brazil(21), found that higher mortality rate occur among very low birth weight<1.5kg.

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This study also revealed that mortality was higher among preterm (73%) compared with term (24%) and post term neonates (3%) . Same result found in a study done in Rwanda(22). This high mortality related to complications associated with prematurity including RDS, infections, hypothermia and others.

There is no significant difference between male and female gender associated with neonatal death in compared to a study done by Eveline Capos in Brazil (21) that found male sex is more associated with neonatal death .The cause of death mostly found due to three magor proplem are Respiratory distress syndrome in 40%, congenital anomaly 20% ,sepsis 14% and there other cause like birth asphyxia 8% ,pneumonia 7% ,respiratory distress un diagnosed cause 5%, meconium aspiration 3% ,blood disorder (vitamin k deficiency) 2%,kernicterus 1% according to WHO found the magor cause of death are infection (sepsis and pnemonia) ,preterm (RDS) and birth asphyxia.

surprisingly this study show neonatal death occur 77% in women age between (20_30)years and 15% in less than 20 years and 8% more than 35 in contrast to

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study done in Rwanda which found that most of neonatal death occur in women <20 years and that maybe due to inadequate cases collected for this research.

The study found 54% of neonatal death from women live in urban areas and 46% from women live in rural areas, this result was the same as a study done in Baghdad (23) and this mostly due to most of the women who attend this hospital from the center of Dhi_Qar (urban area).

There is high mortality rate in multipara women about 70% in compared to nullipara women which about 30% most likely due to complication associated with multipara which include mal presentation, uterine atony, precipitate labour and postpartum hemorrhage (PPH) among others which could lead to poor pregnancy outcome ,this study was the same from Kenya Demographic and Health Survey

(KDHS) (24).

66% of neonatal death occur among women with poor ANC and 34% in women with good ANC .This study revealed that NVD associated with higher percent of neonatal death (58%) while 42% associated with CS .This result may related to complication during labor like obstructed labor ,birth asphyxia and birth trauma ,in contrast to a study done in Rwanda (22) founded that CS was associated with

higher mortality .

Conclusion: The Study findings pointed out some maternal and neonatal risk factor associated with neonatal death such as

1.Age of mother (20_35) years.

2.Multipara women (70%).

3.women live in urban area (54%) .

4.poor ANC (66)

5.The first 5 days of life (91%).

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6.prematurity and its complication like RDS (40%).

7.NVD (58%).

Recommendation

1 .We instruct every women to attend ANCand consult gynecologist or primary center for regular visit, and follow up by ultrasound to diagnose any cervical incompetence to prevent preterm labor. health

2 .Recommend every woman planning to get pregnant to take folic acid (0.4 miligram per day) for two month before conception and advise her for regular ANC .

3 .The mother should take care about her diet ,avoid heavy work and consult medical advice any time she note abnormality such abdominal pain ,fever and vaginal bleeding.

4 .Teenage mother should learn how to deal and take care about neonate.

5 .Parents should monitor any neonatal abnormality like jaundice, decrease feeding or fever and seek medical advice earlier because many of the neonates attend our hospital in progress state of disease like kernicterus and sepsis and should avoid dealing with common problems by using herbs and cattery .

6.We need training medical staff for neonatal resuscitation .All nurses and doctors involved in obstetrics and neonatal care should be trained in at least immediate care of the newborn.

7.Provision of equipment and drugs for immediate resuscitation .

8.The most common cause of death in neonate was RDS and prematurity ,so we need measure to decrease mortality and improve outcome of these prematures.

We need to provide surfactant ,ventilator and CPAP in INCU .

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Reference

1. Eman M. Mohamed, Asmaa M. A.Soliman, Osama M. El-Asheer.Predictors of mortality among neonates admitted to neonatal intensive care unit in pediatric Assiut University Hospital, Egypt. Journal of American Science. 2011; 7(6): 606-611.

2. World health report 2005: Make every mother and child count1. . Geneva: WHO;20053. Stoll B J, Kliegman R M.. Nelson Essentials of Pediatrics, 5th ed. WB Saunders& Elsevier, 2007;

11:275.4. Awqati NA, Ali MM, Alak M. Causes & differentials of childhood mortality in Iraq. BMC pediatrics

2009 June 22;9 (1): 40.5. Alistair G.S. Philip: Neonatal and Perinatal Mortality: A practical Guide of Neonatology, 4 thedition,

W.B. Saunders company, Philadelphia, 1996:257-2636. Ainsworth SB, Beresford MW, Milligan DWA, Nelson Textbook of Pediatrics 19th, 2011.7. Stoll BJ, Hansen N. infections In VLBW infants: Studies from the NICHD Neonatal Research

Network.Semin Perinatal, 2003; 27: 293-301.8. Mclntosh N, Stenson B. Neonatal infection. In: McIntosh N, Helms P, SmythR (eds). Forfar and

Arneil textbook of pediatrics. 7th ed. Philadelphia.Churchill Livingstone CO 2008: 274-2759. Stoll B J: Infections of the neonatal Infant. In:Behrman RE, Kliegman RM, Jenson HB ,Stanton

BF.Nelson Textbook of Pediatrics. 18th ed,Philadelphia. WB Saunders CO 2007: 794-81110. SinghA. Ravinder K . and Jammu S. Pattern of Congenital Anomalies in Newborn : AHospital Based

Prospective, Jammu(J&K)-India. 2009;11:34-36.11. Stoll B.J., Chapman I.A.: The Fetus and the Neonatal Infant: Nelson Textbook of pediatrics. Behrman

R.E., klieg man R.M., Jenson H.B. editors. 18th ed. Philadelphia, WB Saunders 2007; 99: 713-2112. Rusell R.C.G., Williams N., Bustrodemch C.J.K.:Craniocerebral trauma: Baily and Love’s short

practice of surgery, 24th ed. London, Arnold 2004; 43: 60413. Lawn JE, Cousens S. Four millions neonatal deaths: when?Where? Why?. Lancet 2005; 14. William W. Current pediatric diagnosis and treatment. Sixteen Edition. 2003;

1-63 2a)15. Hanif MH. Association between maternal age and pregnancy outcome: implications for the Pakistani

society, Journal of Pakistan Medical Association, March 2011;61(3): 313-1916. Shah N, Rohra DK, Shuja S, Liaqat NF et al,Comparision of obstetric outcome among teenage and

non-teenage mothers from three tertiary care hospitals of Sindh,Pakistan, Journal of Pakistan Medical Association, 2011 October; 61(10): 963-67

17. Taffa N: A comparison of pregnancy and child health outcomes between teenage and adult mothers in the slums of Nairobi, Kenya. International Journal of Adolescent Medicine and Health 2003, 15(4):321-329

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18. Titaley CR, Dibley MJ, Agho K, Roberts CL, Hall J: Determinants of neonatal mortality in Indonesia. BMC Public Health 2008, 8:232.

19. Koueta F, Ye D, Dao L. Neonatal morbidity and mortality in 2002-2006 at the Charles de gulle pediatric hospital (France). Child Care Health Dev 2004, 30(6):699-709.

20. . Indongo N. Risk factors and causes of neonatal deaths in Namibia. European scientific Journal August 2014.

21. Eveline Campos Monteiro de Castro . Perinatal factors associated with early neonatal deaths in very low birth weight preterm infants in Northeast Brazil .

22. Theoneste NDAYISENGA. Maternal and newborn risk factors associated with neonatal mortality in Gitwe District Hospital in Ruhango District,Rwanda. Int J Med. Public Health.2016;6(2):98-102.

23. Assistant professor, Maternal and child health department ,college of nursing .Effect of maternal age on the mother and neonatal health in BaghdadMaternity Hospitals.

24. Kenya National Bureau of Statistics (KNBS) and ICF Macro. Kenya Demographic and Health Survey 2008-09., Calverton, Maryland: KNBS and ICF Macro; 2010.

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Forma:

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:الخالصة

لحديثي المركزة العناية غرفه الى الداخلين الوالده حديثي االطفال وفيات اسباب لمعرفه الدراسة هذه تمتقار ذي في الهدى بنت مستشفى في .والدة

خالل الهدى بنت مستشفى في المركزة العناية وحده لسجالت مراجعه خالل من الدراسه عينة جمعت حيثمن تمتد عام ٢٥فتره من عام ٢٠١٦ايلول من اذار شهر بدايه ٢٠١٧الى

حديثي في وفاه حاالت اكثر الدراسه وجدت المركزه العنايه وحده في والده لحديثي وفاه حاله مئه تجميع تمالى تعود حيثشكلت والده التنفسيه الضيق بنسبه ٢٦متالزمه الخلقية تشوهات وتليها الوفاه حاالت من ٪

الدم ٢٠ وتسمم ٪١٤ %.

مابين ( وقعت والدة حديثي وفاه من بالمائة وتسعون حياتهم) ٥-٠واحد من ايام .

ان الدراسه اظهرت بعمر ٧٧وكذلك امهات عند والده حديثي وفيات من وفي . ٣٥-٢٠٪ نسبه وتزداد سنه . من بالمائه وستون ست ريف بمنطقه مقارنه الحضر منطقه في يعشن الالتي امهات عند والده اتحديثي

الحمل فتره خالل الصحيه مراكز اليزون الالتي امهات في توجد والده حديثي . وفيات

حديثي االطفال بوفيات مرتبطه الخطر عوامل وتحدد لتقيم كبيره جهود بذل ضروره الى الدراسه اوصتلحديثي المركز الغنايه وحده في المقدمه والتمريضيه الطبيبه الرعايه لتقيم كافي نحو على والده

لمعالجه . الشعبي الطب استخدام االمراضوتحنب باعراض امهات لتوعيه حمالت قسم الى باالضافه والدهمخاطر لتقيل الحمل فتره خالل االم لمتابعه صحيه مراكز زياره وضروره .امراض

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والمسببة الديمواغرافية االجتماعية العواملقار ذي محافظة في الوالدة حديثي عند للوفيات

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