Neonatal mortality and associated factors at a provincial hospital, Western Province of Rwanda: A facility based cross-sectional study, 2019-2021

Christophe Nkundabaza^1,&, Gilbert Rukundo², Jean d’Amour Sinayobye³, Joseph Ntaganira¹, Judith Mukamurigo¹

 

¹University of Rwanda, School of Public Health, Department of Epidemiology and Biostatistics College of Medicine and Health Sciences, K,igali, Rwanda, ²Rwanda Biomedical Centre, Kigali, Rwanda, ³AFENET-Rwanda, Kigali, Rwanda

 

 

^&Corresponding author
Christophe Nkundabaza, University of Rwanda, School of Public Health, Department of Epidemiology and Biostatistics, College of Medicine and Health Sciences, Kigali, Rwanda.

 

 

 

 

The neonatal period is the most vulnerable period for neonates and children under age 5 in general where children face the highest risk of dying [1]. Globally, it was estimated at 17 deaths per 1,000 live births in 2019 with 6,700 daily deaths approximately [2]. During this year of 2019, it contributed to 60% of infant deaths [1,2].

 

Neonatal mortality is a public health problem worldwide primarily in low and middle-income countries [3], where the majority of neonatal deaths occur without a clear cause of death [4], just because many factors could be linked to the exact underlying cause of neonatal mortality, such as parity, prematurity, asphyxia, jaundice, congenital anomaly, and were categorized among those related to maternal or fetal conditions according to different literature [3].

 

WHO in its recent report affirmed that 2.4 million children died in the first month of life globally in 2019, and 47% of all children deaths were of under the age of 5 years [5]. The majority of all neonatal deaths (75%) occur during the first week of life, and about 1 million new-borns die within the first 24 hours. Preterm birth, intrapartum-related complications (birth asphyxia or lack of breathing at birth), infections, and birth defects were among the most causes of neonatal deaths. Almost all (99%) new-born deaths occur in low- and middle-income countries, especially in Africa and South Asia, while the least progress in reducing neonatal deaths has been made. WHO affirms that two-thirds of new-born deaths can be prevented with low cost if effective health measures are provided at birth and during the first week of life [5].

 

Accurate information concerning the cause of neonatal deaths is essential, especially in low-income countries, for public health and medical officials to choose appropriate interventions likely to reduce these deaths [6].

 

Recent studies conducted in Rwanda both showed neonatal mortality as challenging problem and emphasized on intensifying efforts to strengthen the quality of immediate new-born care by adhering to the current WHO protocol [7, 8].

 

The target of Rwanda in its fourth health sector strategic plan 2018-2024 is to reduce neonatal mortality by up to 15.2 deaths per 1000 live births by 2024 in response to SDGs adopted by the United Nations which call every country to end by 2030 preventable new-borns deaths and reduce neonatal mortality rate to at least as low as 12 per 1,000 live births [9].

 

According to the 2019-2020 Rwanda District Health Survey (RDHS) report, about 1/22 children die before the 5th birthday and recent data indicated a neonatal mortality rate of 19 deaths per 1,000 live births countrywide [10, 11]. The rural areas had a higher mortality rate (20 deaths per 1000 live births) compared to the Urban areas (15 deaths per 1000 live births). Demographic characteristics of both mother and children have been found to play an important role in the survival of children [10].

 

Despite notable progress completed in recent years, neonatal mortality remains a health challenge and Rwanda is still struggling to reach the SDGs target by 2030 and a big number of new-borns are still being admitted with different causes in all hospitals across the country. A better understanding of neonatal mortality-associated factors is important to strengthen the quality of immediate new-borns care provided at birth and during the first week of life for preventing avoidable deaths. Due to limited data on hospital-specific mortality and associated factors of neonates in Rwanda, this study aimed to assess the prevalence and factors associated with neonatal mortality at Bushenge provincial hospital.

 

 

Study Design and setting

 

A health facility based retrospective cross-sectional study was conducted at Bushenge provincial hospital, using neonatal records (registers, files and death audits) from 2019 to 2021.

 

The hospital is located in Nyamasheke District, Western Province of Rwanda. It serves three surrounding district hospitals, and 17 public health facilities in its catchment area which include 7 health centers and 10 health posts. The hospital is nearing Nyungwe forest and lake Kivu. Its climate is tropical savanna, with the highest average temperature of 25°C in February and the lowest of 22°C in May according to Rwanda Meteorology.

 

Its Neonatology unit has three rooms: one room for neonatology high dependent Unit, one for kangaroo mother care, and another for neonatal infections. The unit has 17 neonatal beds and 6 kangaroo mother care (KMC) beds. It has also 6 incubators, 4 radiant warmers, 3 Continuous Positive Airway Pressure (CPAP) as well as phototherapy, oxygen concentration machines and neonatal resuscitation equipment. Advanced procedures such as blood transfusion and lumber puncture are performed.

 

The unit is staffed with 2 paediatricians,1 stable general practioner and 8 neonatal Nurses. The unit is located near maternity service to receive high-risk new-borns. Furthermore, the unit also receives neonates referred from other health facilities and home. Maternal services are offered by two gynaecologists and 12 midwives. According to the report of last year (2021) 4,362 delivery cases in the catchment area were recorded, from which 1,922(44%) mothers give birth at hospital.

 

Study population and sample size

 

All available medical records of neonates admitted to the neonatology unit of Bushenge provincial hospital from January 2019 to December 2021 were included in the study.

 

Inclusion and exclusion criteria: All neonates admitted during the study period, properly filled in the register were included in the study. Neonates´ records with a missing diagnosis of admission, missing clinical outcomes, or duplicated during recording were excluded from the study. With these criteria, two of 1485 medical records reviewed were excluded from the study due to duplication.

 

Data collection and management

 

Data were extracted from neonate´s medical records (registers, files and death audits) using a data collection form created in Epi info 7.0 by taking into account all the relevant variables available. Two Nurses were recruited and trained on data collection, with daily supervision. Crosschecking with the data source was done for any incompleteness, error, and/ ambiguities in the recording. Collected information was reviewed and possible errors were corrected directly. For security purpose, data were stored in a computer with restricted access.

 

Study variables and definitions

 

These variables were selected based on the study objectives, literature review, and their availability in the neonates´ medical records.

 

Dependent variable

 

Neonatal outcome (Survived, Died). Any neonate admitted or born to Bushenge provincial hospital neonatology unit who died within the unit during the neonatal period, (within the first 28 days after live birth) was categorized as ‘neonatal death/died’. Neonates admitted to the mentioned unit who survived the first 28 days after live birth was categorized as improved.

 

Independent variables

 

Factors included are: Parity refers to the number of times a woman has given birth to a live neonate (any gestation), regardless of whether the child was viable or non-viable; Gestation age categorized as pre-term (< 37 weeks) or term(≤37 weeks), Number of ante-natal care visits graded from 1 to 4; Mode of delivery categorized as whether the child was born by Caesarean Section or normal delivery; The age of the mother in years and Gender of babies categorized as male or female as well as socio-economic status which are graded from 1, 2, 3 and 4 where 4 consisting of households with the highest income, while 1 consists of those who are the most vulnerable [12].

 

Marital status was categorized as single, married or widow; Birthplace categorized as home, street, health center or hospital; Apgar score categorized as severe depressed or excellent condition; Birth weight in grams, measured at birth if the child was born in health institutions or estimated if the child was born at home or street; Weight at admission in grams measured directly during child registration; Temperature at admission taken at admission, and causes of admission.

 

Data analysis

 

Available neonatal mortality recorded data entered in Epi Info 7.0 were extracted in form of excel. The obtained MS excel was then imported in Stata SE 16 version for cleaning and analysis.

 

In the analysis, the principal outcome was considered to be neonatal mortality ‘Death/Alive’ during a period of 28 days post-partum.

 

Different independent variables were used for analysis, those include socio-demographic, and obstetric characteristics of the mothers together with clinical characteristics of neonates´ variable for analysis. The exploratory data analysis (EDA) was done to present participants characteristic, where frequencies and proportion tables were highlighted to describe characteristics among neonates with different outcome values. Non-parametric chi-square test (test of independence) was used to measure the association between independent variables and the outcome. Bivariate logistic regression model was used to assess the association of each independent variable with the outcome of interest. Thereafter, significant variables in bivariate analysis were considered for multivariable logistic regression to adjust for possible confounding. Through the analysis, Odds ratio, a confidence interval of 95%, and a p -value less than 0.05 were used to assess the statistical significance.

 

Ethical considerations

 

The study was approved by the Institutional Review Board (IRB), College of Medicine and Health Sciences (CMHS) for ethical clearance and authorized by Bushenge provincial hospital through its ethical committee. No informed consent was used because secondary data were used but a confidentiality agreement was signed between researcher and the hospital management. To ensure the confidentiality of the research data, only codes were used instead of patient´s identification. Results from the study were submitted to Bushenge provincial hospital, and school of public health.

 

 

Description of socio-demographic and clinical characteristics of infants and their mothers

 

A number of 1483 records of Newborns met the criteria of inclusion in the study for the three years period. One hundred thirty-two (8.9%) of 1483 neonates included in the study died, within neonatal period (28 days of live birth) .93(71%) of dead infants were born at hospital, 32(24%) referred from health centers and 7(5%) born at home (Figure 1). The results of socio-demographic and clinical characteristics of infants admitted in Bushenge provincial hospital neonatology unit are shown in table1. Of all neonates admitted, 822(55.4%) were male and 1,026(69.2%) were born at hospital. High rate of admission was recorded in 2021, and was 546(36.8%).

 

The clinical characteristics showed that, only 966(65.1%) born with normal Apgar score compared to 86(5.8%) who were depressed, 744(50.2%) were in hypothermia condition, 189(12.7%) had neonatal infection, 494(33.3%) were premature and 202(13.6%) had Asphyxia. 44(3.0 %) of them were born with extreme low birth weight,120(8.1%) with very low birth weight, and 360(24.2%) with low birth weight. 59(4.0%) had neonatal jaundice, 42(2.8%) were born with malformation and other conditions represented 197(13.3%) (Table 1).

 

Table 2 shows the characteristics of mothers whose infants died or survived within 28 days following delivery. The mean age of all women was 30.51(15-50) of whom,1,008(68.0%) were aged between 20-35 years, 1,186(80.0%) were married compared to 297(20.0%) who were single. Only 764(51.5%) have given birth more than three times, 494(33.3%) gave birth of pre-term babies, only 189(12.7%) attended four antenatal care (ANC)standard visits, 543(36.6%) gave birth through Caesarean section and 684(46.12%) of them were in socio-economic status category1.

 

Bivariate analysis

 

The association between maternal and neonates´ characteristics of infants and their mothers is shown in table 3 and table 4. While testing the association of causes of neonatal and maternal conditions with the neonatal mortality using binary logistic regressions, several variables were significantly associated with neonatal mortality:

 

Being single (OR 1.92,95%CI:1.3-2.85), Pre-term babies(OR 6.39,95%CI:4.23-9.67) , Cesarean section(OR 1.6,95%CI:1.11-2.29), Infant age ≤ 7 days (OR 2.31,95%CI:1.22-4.36), Extreme Low birth weight (OR 65.97,95%CI:30.74-141.57),Very low birth weight(OR 6.75,95%CI:4.08-11.17),APGAR ≤6 (OR 8.97,95%CI:5.12-15.71), hypothermia(OR 2.98,95%CI:1.92-4.63),hospital stay of one week (OR 6.36,95%CI:3.67-11.0), Prematurity(OR 6.12,95% CI: 4.11- 9.11), Asphyxia(OR 2.55, 95%CI:1.68 - 3.88),neonatal infection(OR 1.78,95%CI:1.12-2.82), Respiratory distress syndrome(OR 5.21,95%CI:1.28-21.09),Trisomy 21(OR: 7.83,95%CI:1.73-35.37),and Cyanotic Heart Disease(OR: 5.8,95%CI:2.10-15.94).

 

Mother´s age, parity, ANC visits, socio-economic status, Birthplace and infant´s gender were not associated with neonatal mortality (Table 3 and Table 4).

 

Multivariate analysis

 

Factors that showed significant association (P<0.05) in bivariate logistic regression with the outcome were selected for multivariate analysis. In multivariate analysis, eleven (11) independent variables were found to be the significant predictors of the neonatal mortality (Table 5).

 

For birth weight; neonates born with extreme low birth weight had 14.4 times higher risk of dying (AOR 14.4,95%CI: 6.61-31.75) and those with Very low birth weight had 5.6 times higher risk of dying (AOR 5.6,95%CI:2.59-12.34) compared to those with normal birth weight. Neonates admitted because of infection had 3.8 times increased risk of mortality (AOR 3.8, 95%CI:1.9-7.57), Premature infants were 6.1 times more likely to die compared to term infants (AOR 6.1,95% CI:3.39 -11.09), those with Apgar score =6 had 8.1 times increased risk of dying (AOR 8.1,95%CI:3.57 - 18.44), and infants with Asphyxia had 5.3 times increased risk of mortality (AOR 5.3,95%CI:2.62-10.97).

 

The odds of deaths among newborns who had history of Trisomy 21 was 20.7 times higher than those who didn´t have that condition (AOR 20.7,95%CI:2.44-154.17), and those who experienced Cyanotic Heart Disease had 5.6 times increased risk of death compared to infants who did not (AOR:5.6,95%CI:1.34-20.18). Furthermore, infants born through cesarean section had 1.6 times increased risk of mortality (AOR 1.6,95%CI:1.02-2.75). The neonatal mortality was high among infants aged below or equal to 7 days (AOR 3.5,95%CI:1.56-7.95) and most of neonates died within 7 days of hospitalization (AOR 12.7, 95% CI:6.65-24.48).

 

 

The aim of the current study was to identify the prevalence and factors associated with neonatal mortality at Bushenge provincial neonatology unit. In this study, the prevalence of neonatal mortality was 8.9 %(n=132/1483) of which 117(88.6%) of deaths occurred during the first day of life. The result of this study is higher than the prevalence of neonatal mortality reported in Ethiopia (4.4%) [13] and in Zambia (3.4%)[14].

 

The prevalence of neonatal mortality in this study is lower than a study conducted in Rwanda (13.3%) [7], a study conducted in Mauritania (34.6%) [15] and another conducted in Tanzania (11.3%) [16]. The above variation in neonatal mortality rate might be due to difference in sample size, study setting, geographic locations, and timing of the study, skilled human resources, quality of care delivered, and equipment availability, socio-economic status, as well as causes of deaths which vary between different countries.

 

Factors found to be statistically significant associated with neonatal mortality in multiple logistic regression were: Prematurity, Extreme low birth weight, very low birth weight, Neonatal infection, Asphyxia, malformation, caesarean-section, Infants age, Low Apgar score and, hospital stay.

 

The study findings revealed prematurity (72.0%), Low Apgar score <6 (27.3%), extreme low birth weight (25.8%), Very low birth weight (23.5%), asphyxia (26.5%) and neonatal infection (19.7%) as the major causes of neonatal mortality. This finding is consistent to many studies: A study conducted by Sheka Shemsi Seid et.al, 2019[17] and another by Fikaden B et.al,2020 [18], both revealed low birth weight, prematurity and birth asphyxia as the leading causes of neonatal death. The highest risk was observed in those neonates delivered before 28 weeks of gestation. The same was true for the birth weight; the risk of mortality decreased as the birth weight increased. The odd of neonatal death in preterm birth was higher compared to term births.

 

Another study with similar findings was conducted in 25 hospitals of Rwanda [8] and found severe prematurity (OR=4.64, 3.05-7.06), low APGAR scores (OR=7.39, 3.97-13.77), low birth weight (OR=1.69, 1.29-2.23), and birth Asphyxia (OR:1.81,95% C.I .44-2.28) as the major leading causes of neonatal mortality. This could be explained by the majority of neonatal deaths in developing countries that are related to conditions of labor, intrapartum and the immediate newborn care practices.

 

In this study, Trisomy 21(2.27%), and Cyanotic Heart Diseases (4.55%) were congenital abnormalities statistically significant associated with neonates' mortality. Our finding is supported by the findings of studies; one conducted in Rwanda [19], another by J.A. Sainz et.al, 2014 [20] and another by Benhaourech et.al,2016 [21],both emphasized on down syndrome (Trisomy 21) and other congenital heart disease to be the main cause of death in this population during the first two years of life and the probability of a child being born with some type of congenital defect ranges from 2% to 4%.

 

This study revealed that most neonates died within 7 days of hospitalization. The odds of deaths among neonates stayed for one week at neonatology unit was 12.7 times higher compared to those who stayed more than one week but this finding differs from a study conducted at public hospitals, pastoral region, Ethiopia [22], which revealed that neonates stayed for five or more days were 77% less likely to die compared to neonates who stayed for less than five days. Our finding can be explained because most neonatal deaths happen in the early neonatal periods (0-6 days of life) than in the late neonatal period (7-28 days) [23], and most of dead neonates were premature. Thus, due attention should be given for neonates in the early neonatal period to reduce neonatal mortality in the health facilities.

 

This study indicated that neonates delivered by caesarean section had 1.6 times higher odds of neonatal death than neonates born by vaginal. This finding is similar with a study conducted by Abay Woday et.al, 2021 [22], where giving birth through caesarean section was 3.59 times associated with neonates´ mortality. This might be related to neonates born via C-section without clear indications such as prolonged labor, fetal distress, obstructed labor and other medical problems during pregnancy.

 

These neonates delivered through C-section are at greater risk of birth asphyxia than neonates born with birth canal. Therefore, neonates born through C-section had a high probability of death than neonates delivered through normal delivery. However, our result is contrary with a study conducted by Ruth Guinsburg et.al, 2021 [24], where caesarean delivery, compared to vaginal, was protective against neonatal mortality.

 

This can be explained by timely decision making rather than simply waiting for vaginal delivery, which may save the life of the neonate and the mother. Thus, delivering through C-section with clear indications can reduce the risk of death by early identification and intervention of birth related complications such as prolonged labor.

 

This study also revealed that neonates who were admitted because of birth asphyxia had 5.3 times a greater odd of neonatal death compared to those who were not asphyxia and this finding is consistent with many studies [16,17,24] both emphasized that neonates born with asphyxia had increased risks of death compared to those who did not. This may be due to the fact that neonates with respiratory problems like birth asphyxia had a greater risk for a poor prognosis and death compared to neonates admitted with other medical problems. Therefore, neonates with a respiratory distress have higher chance of death when compared to those who do not experience any respiratory distress.

 

In this study, most of dead infants had 7 days of life. The odd of death among neonates aged below 7 days was 3.5 times higher compared to those aged above 7 days and this finding is similar with a study conducted in Ethiopia [18] where 98.3% of deaths reported occurred during the first 7 days of age. This high mortality in the first seven days of age could be due to the high number of prematurity-related deaths. As the first few hours of age after birth are very critical to adapt the environment, simple and inexpensive measures can decrease neonatal mortality in the first days of life.

 

Our findings indicate neonates born on women attended less antenatal care visits (0-3) to be protected from death than those who attended standards antenatal care visits but this is different from findings of the study conducted in Ethiopia [22] and a study conducted in Eritrea [25]. This can be explained by the fact that women not having antenatal care follow up during pregnancy are more at risk for pregnancy and intrapartum related problems, which in turn, can put the newborn at risk of death. Therefore, women with adequate antenatal care visits have a better chance of early detection and management of the birth related problems.

 

In this study hypothermia was not statistically significant associated with neonatal mortality but this was not the same with the findings of studies conducted by Zacharie [8], and a study conducted in Mauritania [15].

 

This can be justified by measures taken by Bushenge PH to protect infants from hypothermia by restructuring the neonatology building. Normally, neonates who are in a hypothermic state may be more prone to different infections. As result, they are more likely to become septic and die when compared to neonates with normal body temperatures [26].

 

Limitations

 

This study used only medical records of neonates and their mothers found at hospital, which may not illustrate all factors affecting neonatal mortality. Thus, the results may not be fully representative of the community. Additionally, our review was limited to documented case only at hospital, and it didn´t include deaths of neonates born outside the hospital. So, this may underrepresent the total number of deaths in the catchment area.

 

 

This study revealed that Bushenge Provincial hospital had lower prevalence of neonatal mortality than other rural hospitals in Rwanda. Neonatal infection, low Apgar score, Cesarean section, the length of hospital stay, low birth weight, prematurity, perinatal asphyxia, and congenital malformations were factors associated with neonatal mortality, most of which could be avoidable. Thus, preventive measures such as enhancing the utilization of antenatal care services and, early identification and referral of high-risk pregnancy and neonates could reduce the neonatal deaths.

 

 

The authors declare no competing interests.

 

 

NKUNDBAZA Christophe led all aspects of the study from study design, data collection and analysis, interpretation of results, and manuscript writing. Dr Judith Mukamuringo supervised the study and supported the study design, and results interpretation, and provided constructive feedback on the manuscript. Dr Jean d'Amour Sinayobye and Prof Joseph Ntaganira supported study design, data analysis, and results interpretation and critically reviewed the manuscripts, and Mr. Gilbert Rukundo: supported study design, and assisted on data analysis and results interpretation.

 

 

Authors thank University of Rwanda, College of Medical and Health Sciences for its ethical review Process. Authors also thank MOH/Rwanda Biomedical Centre and AFENET-Rwanda for their help. Authors then thank supervisors, Mentors, data collectors and Bushenge provincial hospital leadership for their contributions throughout this work.

 

 

Table 1: Demographic and clinical characteristics of infants admitted or born at Bushenge PH neonatology unit, 2019-2021

Table 2: Socio-demographic characteristics of mothers whose infants admitted or born at Bushenge PH neonatology unit, 2019-2021

Table 3: Bivariate analysis of association between maternal characteristics and neonates mortality

Table 4: Bivariate analysis of the association between neonates characteristics and neonates mortality

Table 5: Multivariate analysis of the factors associated with neonatal mortality

Figure 1: Proportion of neonates mortality by birth place, Bushenge PH, 2019 - 2021

 

 

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