Authored by Tchagbele Ouro-Bagna*
Abstract
Introduction: The reduction of neonatal mortality requires the identification of its risk factors. The objective of this study was to assess the causes of death in term newborns at the Sylvanus Olympio University Hospital Center (CHU SO).
Material and method: This was a retrospective descriptive and analytical study of term newborns who died in hospital. The main parameters studied were clinical and therapeutic data and causes of death.
Results: The hospital frequency of mortality of term newborns was 10.3%, of which 84.4% in the early neonatal period. Neonatal factors associated with early neonatal death were perinatal asphyxia, neonatal infection and congenital malformations, resuscitation in the delivery room. Inborn transfer and triple antibiotic therapy in the newborn were protective factors.
Conclusion:b> Neonatal mortality remains a major public health problem in Togo. Huge efforts remain to be made in the surveillance and followup of the mother, fetus and newborn.
Keywords: Neonatal death; Term newborn; Neonatal risk factors; Togo
Introduction
Neonatal deaths remain a major public health problem in countries with limited resources [1]. These countries are characterized by the absence of care structures adapted to newborns or by an inadequate neonatal transfer system from one center to another, explaining a high rate of neonatal hospital mortality [2]. In Togo, the infant and child mortality rate was 89‰ and that of neonatal mortality 27‰ according to the Demographic Health Survey in Togo, 3rd Edition (EDST III) of 2013 [3].
The achievement of Sustainable Development Goals (SDGs) in infant and child health requires a significant reduction of neonatal mortality in countries with limited resources [1]. Thus, several government actions whose objectives were to improve the survival of the newborn were undertaken. These included free cesarean sections, nationwide training for care providers in charge of newborns in maternity hospitals and peripheral care units on essential newborn’s care and on neonatal resuscitation based on the HBB (Helping Babies Breathe) approach [4].
It is three decades since the work on the mortality of term newborns was carried out in Togo. However, several studies have often focused on premature and low birth weight newborns in the country [5,6]. Even if overall, the causes of death of term newborns are well known in Togo, each hospital center, depending on its level in the pyramid of care and the realities of the population served, has specificities that must be identified. Thus, the absence of specific hospital studies in each care unit does not allow us to pinpoint the different causes of death of term newborns and therefore to identify the appropriate actions to be taken to reduce neonatal mortality. It therefore seemed appropriate to us to carry out this work on the mortality of term newborns at the Sylvanus Olympio Teaching Hospital (CHU SO) in Lomé, in order to determine the different neonatal factors related to this neonatal mortality.
Material and Method
Study framework
The intensive care unit for term newborns in the pediatric department of the Sylvanus Olympio Teaching Hospital served as a study ward.
Type and period of study
This was a descriptive and analytical retrospective study covering a period of 05 years from January 1st, 2013 to December 31st, 2017.
Study material
Were included in our study, all records of term newborns aged between 0 and 28 days who died in the ward during the study period. Our study did not include records of newborns who died at admission to the ward, premature, and low birth weight newborns. Were excluded, non-or incorrectly completed records of deceased infants where information on the course of the pregnancy and perinatal history was missing.
The data collection tools consisted of the department’s hospitalization register and records of hospitalized newborns who died during the study period.
The studied parameters were age, sex, perinatal manifestations, clinical data, treatment received at birth and in hospital, and causes of death. Data processing was carried out with Excel 2016 and Epi Info software version 7.2.3.0. The values of p≤0.05 were considered significant. The 95% confidence interval (CI95) was significant when it did not contain the value 1. When the odds ratio (OR) is greater than 1, CI95 is significant and p≤0.05 we are in the presence of ‘a risk factor. When the odds ratio is less than 1, IC95 is significant and p≤0.05 we are faced with a protection factor.
Results
Epidemiological data
From January 1st, 2013 to December 31st, 2017, 7,241 newborns were hospitalized in the pediatric neonatology unit of the CHU SO. Of these 7,241 newborns, 746 had died, of which 692 were included in this study according to our criteria and 6,549 were released alive. The average in-hospital neonatal mortality rate was 10.3%. The deceased newborns in our sample (N=692) were male in 426 cases (61.6%) and female in 263 cases (38.4%), for a sex ratio of 1.6. Three cases of sexual ambiguity were found (0.4%).
The mean age at admission was 2.26 days with extremes of 0 and 28 days. Three hundred and eighty-one (381) newborns out of the 692 (55.1%) had been admitted to pediatric hospitalization on the first day of life, 244 between the second and the seventh day, and 67 between the eighth and the twenty-eighth day.
As for the age at death, 217(31.4%) newborns had died within the first 24 hours of life. Death in the first week of life amounted to 584 cases, an early neonatal mortality of 84.4%; and 15.6% for late neonatal mortality.
Factors of neonatal death linked to newborns
Newborns who died were from a single pregnancy in 98.8% and multiple pregnancy in 1.2% of cases. The mean gestational age of these newborns was 38 weeks of amenorrhea (WA) + 6 days (range 37 WA and 41 WA + 5 days).
The mean duration of hospitalization for deceased newborns was 2 days ± 2.9 with extremes of 0 and 25 days.
The main causes of death were neonatal infection (74.4%), perinatal asphyxia (51.4%), birth defects (10.7%), and hemorrhagic disease of the newborn (2.9%).
We describe the deaths according to the different neonatal factors of early mortality in Table 1.
Neonatal factors significantly associated with early neonatal death were an Apgar score of less than 7 at the fifth minute (p=0.0000002), perinatal asphyxia (p=0), neonatal infection (p=0.01), a congenital malformation (p=0.000003), resuscitation in the delivery room (p=0.00000005).
Inborn transfer was a protective factor against early neonatal mortality (p=0.001), as was triple antibiotic therapy (p=0.01).
Pregnancy type (single or multiple), excess birth weight greater than 4000 g, and neonatal hemorrhagic disease were not significantly associated with neonatal mortality. Neither were the absence of treatment or therapies such as the use of anticonvulsants, corticosteroids, mono or biotherapy antibiotics which did not influence early neonatal death.
Discussion
Neonatal risk factors
An Apgar score of less than 7 at the fifth minute was associated with early neonatal mortality. Our results are similar to those found in Cameroon [7]. The Apgar score measures the well-being of the newborn. An Apgar score of less than 7 is associated with perinatal asphyxia, the management of which is complex in our work context where neonatal care units are poorly equipped or sometimes even non-existent with providers who do not often master resuscitation procedures [8,9].
Internal transfer (inborn) was a protective factor against early neonatal mortality. It is the same in the work of Chiabi et al. [7]. Assisted deliveries should be encouraged and referral delays avoided.
Treatment received at hospital
The transition from fetal to ectopic life involves dramatic changes in the cardiovascular and respiratory systems of newborns. Most of them adjust without help; but in 3% of cases resuscitation does not turn out necessary [10]. In our study, newborns who received resuscitation in the delivery room or in the hospital room had a significant risk of dying during the first week of life. This finding differs from that of Manley et al. who argue that effective resuscitation has the potential to improve disability-free survival of newborns [10]. This observation was made from studies in high income countries; hence the difficulty of extrapolating to modest clinical settings in low- and middle-income countries.
The combination of three antibiotic molecules, namely two beta-lactams and an aminoglycoside, was a protective factor in early neonatal death in term newborns. Tripathi et al. also found that clinicians used combinations of empiric antibiotics at the first sign of neonatal infection [11]. However, this approach has its limitations, as the clinical response may be different in newborns due to maturation differences in immunity or the innate toxicity of antibiotics [12].
Duration of hospitalization
The mean duration of hospitalization for deceased newborns was 2 days ± 2.9 with extremes of 0 and 25 days. This short hospital stay reflects the seriousness of the situations in which these newborns arrive in the unit. Parental control of danger signs and consultation as soon as the first signs of disease appear in newborns would improve the vital prognosis of these newborns. These figures are similar to those obtained by Susana de Paula et al. in Brazil [13]. What differs from the results of Simiyu et al. in Kenya [14] and Kambarami et al. in Zimbabwe [15] who found an average hospital stay of 4 and 8 days for dead newborns.
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