Neonatal Morbidity and Mortality Pattern in Federal Medical Centre, Birnin kebbi, North- western Nigeria: A wakeup Call

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Corresponding Author Email: talktosani81@gmail.com Tel: +2347035632163

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DOI:

 Background: Neonatal mortality is still a significant contributor to under-5 mortality. In 2019 alone close to 50% of global under-5 mortality was due to neonatal death. To attain the SDG targets, there is a need for improvement in neonatal care including constant review of neonatal morbidity/ mortality. This study assessed the pattern of neonatal morbidity and mortality in Federal Medical Centre, Birnin- Kebbi, Kebbi State.

Subjects and methods: The records of newborns admitted into the Special Care Baby Unit (SCBU) over a 12 month period (May 2020 to April 2021) were reviewed. Information obtained included the sex, age at admission, gestational age, birth/admission weights, duration of hospitalization, diagnosis, and outcome of treatment.

Results: There were a total of 604 neonatal admissions but 600 had complete records. Of the 600, 62.2% were males and 37.8%, females; 56.0% were delivered by SVD while 51.2% were in-borns. Most (68.3%) babies were admitted within 24 hours of life and 57.1% were admitted for 1-  7  days.  Babies weighing 2.5- 3.99 kg constituted 56.5% of the subjects. Perinatal asphyxia was the commonest disease managed (29.0%) and death resulting from it  accounted  for 44.4% of all recorded mortalities. Analysis of the outcome revealed a mortality rate of 21% during the period under review.

Conclusion/ Recommendations

The mortality rate in the present study was high and mostly due to preventable causes. In order to stem the tide, there is a need to improve perinatal care, emergency obstetric care services, and neonatal resuscitation skills. Improved government spending on newborn care is also paramount.

Key words: Neonate, Morbidity, Mortality, Signed Against Medical Advice (SAMA), Birnin-Kebbi, North-Western Nigeria

 Newborn period is key to child health/survival and it is the most hazardous period during the child’s first year of life.^1,2 Neonatal death contributes significantly to under-5 mortality. For instance in 2019, close to 50% of all under-5 mortality globally occurred in the neonatal period with about one third of deaths occurring within 24 hours of life and close to three quarters dying within the first week of life.² This high neonatal mortality rate was not limited to the developing world. In Europe and Northern America, with the lowest under-five mortality rates (among Sustainable Development Goals (SDG) regions), 54 per cent of all under-five deaths also occur during the neonatal period.²

The neonatal morbidity pattern differs among countries and health facilities and also varies over time even at the same location. In the developed countries, the main cause of mortality and morbidity in the neonatal period are non-preventable causes like congenital abnormalities while in the low and middle income countries, preventable causes such as sepsis, perinatal asphyxia and neonatal jaundice are the commonest causes.³

The crucial need to end preventable child deaths was recognized by the global community. This was therefore made an integral   part   of   the   Global   Strategy for Women's, Children's, and Adolescent's Health (GSWCAH) as well as the Sustainable Development Goals (SDGs).^4,5 In order to achieve the set goals of both projects targeted by 2030, it is crucial for nations to appraise the current situation in the different domains of those goals including neonatal morbidity/mortality pattern.

Globally, advancement in perinatal and neonatal care have significantly reduced neonatal mortality rates.⁶ Even though globally, the neonatal mortality declined from 5.0 million in 1990 to 2.4 million in 2019, Nigeria still has the highest reported neonatal mortality rate in Africa and ranks second to India globally as the country with the highest number of neonatal deaths.^2,7 Hence there is a need to constantly review the newborn morbidity and mortality at different levels and locations in the country.

Studies on neonatal morbidity and mortality pattern were previously carried out in various hospitals in different parts of Nigeria and other West African countries.^{8 - 13} However, these may not be representative of the disease pattern in the current study location. To improve neonatal health, there is a need to evaluate the pattern of neonatal morbidity and mortality at various localities at the health facilities. Currently, there is paucity of data on neonatal diseases and outcomes in Kebbi State. Evaluating neonatal morbidity and mortality in the present study location would, in addition to providing a situational analysis, guide health care plan and interventions towards the attainment of the SDG and GSWCAH desired goals. This study therefore, sought to determine the pattern of neonatal morbidity and mortality at Federal Medical Centre, Birnin-Kebbi, Nigeria.

Study Setting/ Location:

This study was conducted in the Special Care Baby Unit (SCBU) of the Federal Medical Centre Birnin Kebbi (FMCBK), Kebbi State, North-West Nigeria. It is the only referral tertiary health centre in the state, established in the year 2000 to cater for a population of over 3 million. Its SCBU is the only neonatal unit in the entire state.

The SCBU FMCBK is a 15 bed nursery served by four consultants (on rotation), a senior resident, two medical officers and nurses working on shifts. The unit is equipped with functional incubators, radiant warmers, bag- mask devices, 2 bubble Continuous Positive Airway Pressure (CPAP) machines and suctioning machines.

Study Design: Descriptive and retrospective.

Study Population

 This was made up of neonates admitted into the SCBU of the hospital over a period of one year (May 2020 to April 2021).

Data Collection

 The case notes of all neonates admitted into the unit from May 2020 to April 2021 were reviewed. Using a study proforma adapted for the study, patients’ information such as sex, age at admission, gestational age, birth weight/admission weight, diagnosis, length of hospitalization and outcome of management were obtained from the medical record.

The various documented diagnoses were based on unit protocol using accepted standards. For instance, the diagnosis of prematurity and low birth weight (LBW) was mainly based on the World Health Organization definitions. Prematurity is described as live born neonates delivered before 37 completed weeks. LBW is described as the patient having a birth weight of<2.5kg: Very Low Birth Weight (VLBW) is a birth weight of 1.00-1.49kg and Extreme Low Birth Weight (ELBW) is birth weight <1kg.¹⁴

 The diagnosis of sepsis was documented based on clinical findings and confirmed by laboratory investigations. Birth asphyxia was defined as APGAR scores

< 5 at 5 minutes or history of delayed/ failure to cry at birth (for outborns with no APGAR scores) in addition to physical examination and relevant investigations (excluding arterial blood gas analysis). Diagnosis of neonatal jaundice was based on clinical examination and an estimation of serum bilirubin level.

Pneumonia, meconium aspiration syndrome and transient tachypnoea of the newborn were made on the clinical, hematological and radiological findings.

Ethical consideration

 Ethical approval for this study was obtained from the Ethics Review Committee of the hospital.

Data analysis

 Every case was allocated a unique number in this study which was used in the storage and management of all data relating to the patient. Data were captured and analyzed using Statistical Package for Social Sciences (SPSS) version 25. Cleaning of data was done using standardized queries to conduct range and logic check. Discrepant entries were rectified by reviewing the record form and other records as necessary. The program was used to compute frequencies, proportions and means of study variables to produce tabular and graphical representation of the data.

Comparisons of proportions (or categorical variables) were made using the Chi square test or where applicable, Fisher’s exact test. Statistical significance was set at a 5% probability level (that is, a p-value of less than 0.05).

 Demographic characteristics of study subjects.

There were a total of 604 neonatal admissions during the period under review. Out of these, 600 (99.3%) babies had complete records for analysis. While 411 (68%) of the subjects were admitted within 24 hours of life, 340 (56.5%) babies weighed between 2.5- 3.99kg. In- born deliveries constituted 307 (50.8%) of the subjects. Three hundred and seventy-six (62.3%) were males and 341(56.5%) subjects were delivered via SVD. The gestational age of 462(76.5%) study subjects was between 37 and 42 weeks and most subjects spent between 1-7days on admission. (Table 1)

Table I: Characteristics of the study subjects

 The most common morbidities managed were birth asphyxia (29.1%), prematurity (23.3%) and sepsis (22.8%) (Table II).

Table II: Disease pattern

MAS = meconium aspiration syndrome. CA= congenital anomaly

The outcome of the neonates managed is shown on figure 1. Of the patients managed,

126 (21%) died while 60 (10%) signed against medical advice (SAMA).

 Figure 1: Outcome of management

 Analysis of the outcome showed a mortality of 21%. Birth asphyxia (44.4%), prematurity (30.2%) and sepsis (14.3%) were the major contributors to mortality. Case fatality for neonatal tetanus was 33.3%. This is shown on Table III

Table III: Percentage mortality and case fatality

NNJ=neonatal jaundice. MA= meconium

aspiration. CA= congenital anomaly

Length of hospital stay, birth weight, place of delivery and gestational age were significantly associated with mortality (Tables IV and V).

Table IV:

Neonatal Mortality in relation to Newborn characteristics

TableV: Logistic Regression between Mortality and Newborn Variables

 The number of babies admitted within the one-year period under review was 604. This figure was higher than 519, 261 and 328 admissions recorded over similar period at Sagamu,⁸ Ogun State, Enugu⁹ and Azare,¹⁰ Bauchi State respectively. The higher figure in the present study could be because our facility is the only hospital with neonatal unit in the entire state. Hence, all neonates requiring medical attention presented to the facility. The 604 admissions reported in this study was, however, lower than 2963 and 853 reported from Kano¹¹ and Gusau¹² respectively in the same Northwestern Nigeria. This could partly be accounted for by the higher population of Kano. It could also be due to better health seeking behavior of Kano people which may be related to better economic empowerment and higher literacy level. Furthermore, the Gusau study was over a 3 year period as against 1 year of our study, hence the higher figure reported in their study.

In the present study, there were more males (62%) than females (38%); similar to what was reported in Kano,¹¹ Benin,¹⁵ Gwagwalada,¹⁶ Enugu⁹ and other tropical countries like Pakistan,¹ Ethiopia (North),¹⁷ and Ghana (central)¹³. This may be due to the fact that males are more susceptible biologically to some diseases than females. It may also be due to higher cultural value attached to males leading to higher tendency of being brought for medical attention whenever he is unwell.

The commonest morbidity leading to neonatal admission in the study was perinatal asphyxia. This was similar to findings in Enugu,⁹ Gusau¹² and Kano¹¹. This may be due to the common practice of unsupervised home deliveries. It may also reflect poor utilization of antenatal care services or inadequate essential newborn care. The prevalence of perinatal asphyxia in this study was close to the value reported about 5 years earlier in the same hospital.¹⁸ This means there has been no significant improvement over the years. This calls for more public enlightenment and research into the risk factors for birth asphyxia. The finding in the present study on the other hand contrasts the report of Omoigberale et al ¹⁵ in Benin City and Imodou et al ¹⁰ in Azare, Nigeria as well as Mushtaq et al ¹ in Wah, Pakistan in which neonatal sepsis was reported as the commonest morbidity. It may be that more deliveries were supervised by skilled birth attendants in those areas.

The neonatal mortality rate of 21% reported in this study was similar to 20.4% and 20.3% reported by Garba et al ¹² in Gusau and Omoigberale et al ¹⁵ in Benin respectively. It was also similar to 22.8% reported by Mekonnen et al ¹⁹ in South western Ethiopia and 21.5% by Baghel et al ²⁰ in Bastar, India. The finding in the current study also laid credence to the Multiple Indicator Cluster

Survey conducted by the Government of Nigeria in 2016/ 2017, which indicated that the rate of newborn deaths per 1000 births was 55 in Kebbi state; a value drastically higher than the national average of 37 deaths per 1000 births.²¹ These high mortality rates imply that we are still far from attainment of the SDG target of less than 12 deaths per 1,000 live birth planned to be achieved by 2030 (less than 10 years from now).⁵ The abysmally high neonatal mortality rate in the current study may be due to high rate of outborn deliveries, most of which may be home delivery, coupled with delay in presentation to the hospital sometimes only after complications have developed (particularly for perinatal asphyxia which was the commonest morbidity and also the commonest cause of mortality; as well as prematurity). Presence of only one neonatal unit in the whole state may also be a reason as some neonates may have to be transported for  up  to  3-  4  hours  before  reaching  the hospital.   It   could   also   be   due   to initial patronage of unqualified health provider/traditional healers before presenting to the hospital. Furthermore, a high poverty rate along with low literacy level may also be an important factor. In addition, poor governmental investment in neonatal equipment/facility possibly because of her failure to implement the recommended 15% budget allocation to health,²² and low doctor/patient ratio (particularly with recent exodus of Nigerian health care providers abroad),^23,24 could account for the observed rate. The current mortality rate was, however, higher than 13.3% to 17.5% in various studies from different parts of Nigeria, ^{8 - 12, 16} 13.4.0% in a Ghanaian study (Tamale),²⁵ 11.41% in an Indian study,²⁶ 14.3% in a University of Gonder, Ethiopia study ¹⁷, 17.2% from Pakistan.¹ This may perhaps be due to better health seeking behaviour and facilities in those areas.

In this study, most neonatal deaths occurred within the first 24 hours of life similar to findings in the Nigerian Demographic and Health Survey 2018,²⁷ as well as the Gusau,¹² Ibadan,²⁸ and Benin studies.¹⁵ This may be due to delay in presentation to the hospital for conditions such as perinatal asphyxia and prematurity. Birth/admission weights, gestational age, place of delivery were also found to be significantly associated with mortality.

The 10% SAMA rate documented in the current study was higher than 6%, 5.2%, 5.3%, 4.3% reported in Birnin- Kudu,²⁹ Azare,¹⁰ Gwagwalada¹⁶ and Port Harcourt³⁰ studies respectively. This may not be unconnected to unaffordable cost of treatment which is mainly out of pocket payment. It may also be due to inconvenience of staying in the hospital which may be far from patients’ homes. Ignorance and belief in alternative medical care could also be a contributing factor to this. Furthermore, the fear of contracting COVID-19 within the hospital could also be a factor as the period of study was within the pandemic. The SAMA rate in the present study, on the other hand, was lower than 16.4% reported in a study in Dhaka, Bangladesh.³ The reason for the high rate in the Dhaka study was however not stated.

 The neonatal mortality rate reported in this study was high with majority resulting from preventable causes and occurring within the first 24 hours of life. In order to stem the observed trend, there is a need for health education emphasizing importance of hospital delivery supervised by trained personnel. Furthermore, improvement in perinatal care is very crucial. There is also need for improvement of care for low birth weight and preterm neonates.

Traditional birth attendants in the community should also be trained on how to identify danger signs and refer early. There is also a need for improved government spending on neonatal health care delivery in addition to strengthening the health insurance scheme.

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