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The magnitude of birth injuries and its associated factors among neonates admitted to neonatal intensive care units of hospitals of Southern Ethiopia: multicenter facility-based cross-sectional study

The magnitude of birth injuries and its associated factors among neonates admitted to neonatal intensive care units of hospitals of Southern Ethiopia: multicenter facility-based cross-sectional study

Mandefro Teme Mandefro1, Amene Abebe Kerbo1,&, Daniel Baza Gargamo2


1Department of Public Health, Wolaita Sodo University, Wolaita Sodo, Ethiopia, 2Department of Pediatrics and Neonatal Nursing, Wolaita Sodo University, Wolaita Sodo, Ethiopia



&Corresponding author
Amene Abebe Kerbo, Department of Public Health, Wolaita Sodo University, Wolaita Sodo, Ethiopia




Introduction: approximately half of the birth injuries are avoidable if appropriate and timely evidence based measures are taken. However, there is a shortage of studies in Ethiopia. Therefore, this study aimed to assess the magnitude of birth injuries and associated factors among neonates in Southern Ethiopia.


Methods: multicenter facility-based cross-sectional study was conducted from March to April 2021. The systematic sampling method was used to select 344 mother-neonate pairs admitted to neonatal intensive care units in the included hospitals. Data were collected by face-to-face interview and review of medical records. Epi-info version 4.1 was used to enter data and SPSS version-25 for analysis. Descriptive statistics, binary and multivariable logistic regressions analyses with 95% CI were done. A P-value < 0.05 was used to declare the association of variables.


Results: the magnitude of birth injuries in the present study was found to be 24.7% (95% CI=24.7% - 24.8%). The majority 71.6% of the neonates had soft tissue injuries while 16.6% of them had birth asphyxia. Both birth asphyxia and physical trauma were encountered in 2.9% of the neonates. Antenatal care (ANC) follow-up by the health professionals less than four (AOR=0.31, 95% CI, 1.003-11.044), short maternal height (AOR=0.206 95% CI, 0.05 - 0.79), macrosomic baby (AOR= 0.46, 95% CI= 0.013 -0.16) and fetal mal-presentations (AOR=29.69, 95% CI =10.61 - 43.09) are significantly associated with birth injuries in the current study.


Conclusion: the magnitude of birth injuries was higher than other similar studies in Ethiopia. Antenatal care follow-up less than four, short maternal height, macrosomic baby, and fetal mal-presentations are significantly associated with birth injuries. Thus, promotion of full antenatal care follow-up, adequate maternal nutrition, close monitoring of mothers during intrapartum period and timely clinical decision of labor and childbirth process are recommended.



Introduction    Down

Birth injuries are defined as damage to the newborn's body structure or function due to adverse outcomes of the birth processes [1]. Birth injuries can be due to oxygen insufficiency for tissues (birth asphyxia) or physical trauma (birth trauma) during labor or delivery [2]. Despite how much adequate prenatal care is provided, birth injuries could occur due to unavoidable risks such as long and/or difficult labor or fetal mal-presentations [3].

The incidence of birth injuries varies based on the type of delivery, fetal presentations, and type of injury [2]. The spectrum of birth injuries ranges from superficial injury to the skin which is the most common type of injury to the more severe damages of the central nervous system and other soft tissues [4]. Birth injuries can significantly be reduced with the use of appropriate methods of obstetric care to monitor the prognosis of the labor, the fetal status, and by making the timely decision for Cesarean Section (C/S) delivery [4-6].

Skull injury (subgaleal hemorrhage, caput succedaneum, cephalohematoma), soft tissue injuries (bruises, petechial and subcutaneous fat necrosis), intra-abdominal (hepatic and splenic injuries), and central nervous system (intracranial hemorrhage, facial nerve palsy injuries), bone (humeral fracture, femoral fracture, and clavicular fracture injuries) and systemic injuries including perinatal asphyxia are the commonest types of birth injuries occurring during the birth process [7,8].

An estimated 7-9% per 1000 live births injuries happen each year worldwide, while from the total neonatal deaths, about 99% of them take place in developing countries [4]. Perinatal asphyxia alone contributes to 42 million disability-adjusted neonatal life years lost and 23% of the deaths [9,10]. Approximately 3% of the 130 million newborns delivered each year globally develop severe consequences of birth injuries such as epilepsy, cerebral palsy, and developmental delay [11].

Evidence shows larger than the average birth weight of the fetus, small pelvis, small maternal stature, maternal obesity, and presence of maternal pelvic anomalies are the common maternal-related risk factors for birth injuries. Fetal macrosomia, pre-term or post-term delivery, and fetal mal-presentation are neonatal-related risk factors for birth injuries. Induction of labor, shoulder dystocia, and operative childbirth are the intrapartum-related risk factors of birth injuries [10,12].

Ethiopia achieved the millennium development goals for under-five death two years earlier than planned but it is less successful in reducing neonatal deaths. Limited studies in Ethiopia show, childbirth-related complications and/or birth injuries are among the major and direct causes of neonatal deaths [8,13]. However, there is a dearth of studies in this aspect. Therefore, this study aimed to assess the magnitude of neonatal birth injuries and their associated factors in public hospitals of Silte Zone, Southern Ethiopia. The specific objectives included the magnitude birth injuries among neonates admitted to neonatal intensive care units of hospitals of Silte Zone, Southern, Ethiopia. We have also identified factors associated with birth injuries among neonates admitted to neonatal intensive care units of hospitals of Silte Zone, Southern, Ethiopia.



Methods Up    Down

Study design, period, and study area

The multicenter facility-based cross-sectional study design was conducted from March to April 2021. The study was conducted in Silte Zone which is located in the Southern part of Ethiopia. The zone has 10 Districts and 3 administrative towns. Based on the information obtained from the Silte Zone Health Department, the population of the Silte Zone is estimated to be 1,033,954 in 2019.

Population and eligibility criteria

All women regardless of the mode of delivery and their neonates in Silte Zone were the source population and all women and neonates delivered at the included hospitals were taken as the study population. Neonates with major congenital malformations and referred from other health facilities to the included hospitals during the data collection period were excluded.

Sample size determination of the study

By using the single population proportion formula and considering the following sample size calculation assumptions: confidence level of Zα/2 of 95%, marginal of error 4%, a reasonable estimate for the proportion of birth injury from the study result of Jima, Southwest Ethiopia (P=0.154) [14] the sample size was calculated as follows:

After adding 10% non-response, the final sample size was 344 mother-neonate pairs were included in the study.

The sampling procedure

All four public hospitals in the Silte Zone: Worabe Comprehensive Specialized Hospital (WCSH), Kibet Primary Hospital (KPH), Tora Primary Hospital (TPH), and Alem Gebeya Primary Hospital (AGPH) were included in the study. Then proportionally allocation of the required calculated total sample size for each hospital was done considering the average number of labor and delivery service visits of one month before data collection: WCSH=203 per month, KPH=175 per month, TPH=181 per month, and AGPH=162 per month with a total of 721 per month in the four hospitals included. After proportionally allocating the required sample size to each hospital: WCSH=344x203/721=97, AGPH= 344x162/721=77, TPH=344x181/721 =86, and KPH = 344x175/721=84 and a systematic sampling technique with the sampling interval of two (721/344=2) was applied to select mother-neonate pairs (Figure 1).

Variables of the study

Dependent variable: birth injury on the neonates during childbirth, (Yes/No).

Independent variables

Maternal socio-demographic characteristics: age, educational status, residence, occupation, marital status.

Maternal obstetrics and reproductive characteristics: gravidity, parity, the onset of labor, mode of delivery, premature rupture of membrane, pregnancy-induced hypertension, preeclampsia, Ante Partum Hemorrhage (APH), ANC follow-up.

Medical disorders and infection on the mother: hemoglobin level, malaria, urinary tract infections, HIV/AIDS, chronic medical conditions like hypertension, Diabetes Mellitus (DM), cardiac disease.

Maternal physical and lifestyle characteristics: Mid Upper Arm circumference (MUAC), substance use, physical activity; Neonatal factors: sex of the neonate, neonatal weight, fetal presentation, Apgar score, neonatal trauma/injuries.

Operational definitions

Birth injury: a neonate who has been diagnosed with oxygen insufficiency for tissue (perinatal asphyxia/birth asphyxia), mechanical birth trauma, or both encountered during childbirth.

Mechanical birth trauma: the presence of mechanical (physical) trauma of the soft tissue or organs of the newly borne neonate during labor and/or childbirth.

Perinatal asphyxia (birth asphyxia): a diagnosis made according to NICU management protocol of Ethiopia based on the criteria failure to initiate and sustain breathing at birth, impairment of placental or pulmonary gas exchange leading to hypoxemia and hypercarbia (persistence of an APGAR score of less than 3 at 10th minute and evidence of multi-organ (the brain, heart, lung, kidney, liver) dysfunction immediately following childbirth [8].

Data collection tool and procedures

Data were collected by face-to-face interviewer-administered and structured questionnaires, anthropometric measurements, and by reviewing the mother-neonate pair medical records to identify the type of birth injury encountered using checklists. The questionnaire consisting of information on socio-demographic and reproductive characteristics, morbidity status, different chronic maternal medical disorders, gynecologic and obstetric factors, and neonatal-related factors, and others were extracted from the literature review and used. The questionnaire was constructed in English and translated to the Amharic language and back to English to keep its consistency and equivalency. Six midwifery professionals and 6 neonatal nurse professionals collected the required data.

Data quality management

The tool was evaluated and validated by senior researchers and subjects experts. Two days of training were given for data collectors. The pre-test was employed on 5% of the sample size in Halaba Kulito general hospital. Based on the pre-test result modification of the sequence of questions was done and vague terminologies were replaced with simple common words. Daily evaluation of the data collection process was monitored by the researchers. Data completeness and problems encountered during data collection were followed each day and the necessary correction was done accordingly.

Data processing and analysis

The completeness of the questionnaire was rechecked preceding data entry. Following this, data coding, entry, cleaning, recording, and analysis were accomplished by using SPSS version 25. Descriptive statistics were computed. Bivariable logistic regression analysis was done after dichotomizing the dependent variables with coding 1 for Yes and 0 for No. CORs and AOR were computed to assess the presence and degree of association between the dependent and independent variables. In the bivariable logistic regression analysis, the variables with P-value <0.25 were entered into a multivariable logistic regression analysis model to control confounding variables and to check the independent and significant association. A P-value of <0.05 with a 95% CI was used to express the strength and statistical association of the variables. The results were presented using text descriptions, tables, and graphs.

Ethical consideration

This study was conducted following the declaration of Helsinki for studies involving human participants. Ethics approval was obtained from the Institutional Review Board (IRB) of Wolaita Sodo University. Permission was secured from Silte Zone Health Department, District Health Offices, and the leaders of respective Hospitals sequentially. The purpose and procedure of the study were explained to respective health officials. After getting permission from the medical director, obstetrics and gynecologic and pediatric departments of the hospitals, they have been requested to confirm the applicability of this study and to write a letter of cooperation to the delivery case team and NICU, and medical record office of the respective hospital. Finally, the researchers obtained informed written consent from all mothers/guardians after an agreement has been reached to participate in the study.



Results Up    Down

Socio-demographic and economic characteristics of the study participant

A total of 344 (100%) response rate study respondents participated in the study. The mean age of respondents was 28 years, ranging from 17 to 43 years. More than 81% of the mothers were 20-35 years of age while 14.2% of them were aged greater than or equal to 35 years. The median family size of the respondents was 5. More than half of the respondents, 208 (60.5%) were rural residents and (48%) had no formal education. By religion, the majority, 319 (92.7%) were Muslims followed by Orthodox, 19 (5.5%). Regarding marital status, all of the study participants 344 (100%), were married. As to the occupation of respondents, the majority 164 (47.7%) were housewives while 8 (22.7%) were merchants (Table 1).

Maternal obstetrics and reproductive characteristics

The majority of mothers 265 (77%) were multiparous and the rest 79 (23%) were primiparous. More than half (54.9%) of the participants had less than 4 ANC follow-up care visits by healthcare professionals. Approximately 21.2% of mothers were diagnosed with mal-presentation of the fetus. About 23% of the study participants had complications during their previous childbirth which includes pregnancy-induced hypertension, APH, chronic medical conditions like hypertension, DM, asthma, and cardiac disease.

Mode of delivery of the study participants

The majority of mothers 70.6% childbirth was Spontaneous Vaginal Delivery (SVD), 14.5% of them by Cesarean Section (C/S), and the reaming 14.8 % gave childbirth was assisted SVD (Figure 2).

The neonatal characteristics

The majority 61% of the neonates were males. Low birth weight was observed in 9% of the neonates and 1.2% were macrocosmic. The proportion of preterm babies was 13.1% and post-term accounted 2.9%. Nearly twenty-three (22.7%) of neonates had low (0-3), 18.9% had moderate (4-6) and the remaining 58.4% had mild APGAR score (Table 2).

The magnitude of birth injuries

The magnitude of birth injuries in the current study was found to be 24.7% (95% CI=24.7%-24.8%). Approximately 2.9 % of neonates had birth asphyxia and physical trauma while 16.6 % of the neonates had birth asphyxia (perinatal asphyxia). The majority 71.6 % and 6 % of the neonates had been affected with soft tissues and scalp injuries respectively while 3.6 % of them had fractures (Figure 3).

Factors associated with birth injury in selected public hospitals of Silte Zone, Southern Ethiopia

Bivariable logistic regression analysis was conducted to identify the possible associated factors with birth injury. In the current study, residence (COR=2.64, 95% CI= 1.51-4.61), (source of referral (COR=0.72 , 95% CI= 0.44-1.20), history of pre-term (COR=13.82, 95% CI=3.72-51.2), gestational age (COR=0.603, 95% CI = 0.30-1.20), ANC follow-up (COR=0.514, 95% CI=0.30-0.88), mode of delivery (COR=0.51, 95% CI =0.88-2.87), history of obstetric complications (COR=0.2.16 ,95% CI =1.25-3.74), maternal height (COR=0.18, 95% CI =0.08-0.41), birth weight (COR=0.06 ,95% CI=0.03-0.13) , fetal presentation (COR=17.86, 95% CI=9.57-33.33) were associated with birth injury in the binary logistic regression analysis. ANC follow-up by health professionals less than four (AOR=0.31, 95% CI =1.003-11.044) , short maternal height (AOR=0.206, 95% CI= 0.05 - 0.79 ), macrosomic baby (AOR= 0.46, 95% CI=0.013 -0.16 ) and fetal mal-presentations (AOR=29.69, 95% CI =10.61 - 43.09) were significantly and independently associated with birth injury in multivariable logistic regression analysis (Table 3).



Discussion Up    Down

The magnitude of birth injury in the current study is 24.7% (95% CI=24.7%-24.8%) in this study is higher than the study reports of some developing countries [13,15,16] including the study done in Jimma University specialized hospital and tertiary hospitals of Addis Ababa, Ethiopia where 15.4% and 12.3% of the neonates encountered birth injuries respectively [14,17]. The possible reason for this variation might be due to the differences in the infrastructures of the healthcare facilities, sample size, study design, and the time-lapse between the studies.

Perinatal asphyxia or birth asphyxia alone in the current study contributed to 16.6% of birth injuries. This finding is higher than the study report of Jima University specialize hospital where 8.1% of the neonates sustained birth asphyxia from the total birth injuries of 15.4% [14]. This result is also higher than the study reports of New Delhi 3.6% 9 and, Uganda referral hospital 12.8% [6,18]. The dissimilarities of the findings might be due to the differences in the socio-demographic and socio-economic factors, quality of the service delivered during prenatal, labor, and childbirth, and the availability, accessibility, and affordability of maternal service.

The previous finding of the recent study is lower than the study finding of Zambia where perinatal asphyxia magnitude of 23% [19]. The discrepancies might be due to the differences in the characteristics of the study population, sample size, the time lapse between the two studies, and the study settings.

The present study confirmed that neonates who were born from mothers of ANC follow-up less than four (AOR=0.313, 95% CI=0.12 - 0.83) had a higher risk of encountering a birth injury than their counterparts. This finding was congruent to the study report done in Hungary [20], but it is not similar with the study finding of Jimma University specialized hospital, and tertiary hospitals of Addis Ababa, Ethiopia where ANC follow up less than four times were not reported having association with birth injury [14,17,21,22].

Neonates borne by assisted vaginal childbirth had a 3.3 (AOR=3.3, 95% CI=1.003-11.044) times the high risk of getting injury than those delivered spontaneously. This finding is similar to the study done in Dessie town, Ethiopia [23]. Neonates borne from mothers who had a history of obstetric complications had 1.5 times (AOR=1.5, 95% CI=0.528-4.139) more chance of sustaining birth injuries than those mothers without obstetric complications. This finding is congruent to the study finding of Chennai, India [15].

According to this study, a short maternal height of <153 cm (AOR=0.206, 95% CI, 0.05 - 0.79) was more risk for birth injury of the neonates than their counterparts. A similar report was found in the study done in Dessie town, Ethiopia, and the study in tertiary care hospitals of Chennai, India, and Nigeria [3,15,23].

Macrosomic babies (>4000 gm) had more chance of sustaining birth injury than their counterparts (AOR=0.308, 95% CI=0.058-1.623). This finding was supported by the study done at the University of Gondar, Ethiopia, and another descriptive study report in Chinnai, India [15,24]. Fetal mal-presentions (AOR=29.69, 95% CI=10.61-83.09) impose a very high chance of sustaining a birth injury when compared with those delivered head-first presentations. This finding is also reported similarly in the studies done in Jimma university specialized hospital, Ethiopia, and Chennai, China [14,15].

The risk of birth injury was also significantly high among neonates of assisted childbirth (AOR=5.51, 95% CI=1.01 -3.01), fetal mal-presentation (AOR =5.78, 95% CI=1.99 -16.78), and short maternal height (AOR =0.046, 95% CI=0.013 -0.16). These results are reported similarly in the studies conducted in Jimma university specialized hospital, Ethiopia and a prospective study done in Chennai, India [14,15]. Unlike many other studies from low and middle-income countries, in this study, length of labor, primiparity, sex of the neonates, maternal weight, and MUAC had no association with a birth injury [2,21,23,25,26].


The limitations of the present study include the result of the current study might not be generalized to the whole population since this study was conducted at the health care facilities level. Additionally, this was done using only the quantitative approach, it would have been more informative if it included a qualitative approach. Finally, as the study was conducted in primary and referral hospitals most of the childbirth might be referral cases and this might be the reason for the slightly increased magnitude of birth injury relative to other studies in Ethiopia.



Conclusion Up    Down

The magnitude of birth injury in this study was higher than other similar studies done in developing countries. Birth injuries were significantly high among neonates of mothers who attended less than four ANC follow-up visits, assisted birth /instrumental deliveries, neonates of mothers with short maternal height, macrosomic babies, and neonates with fetal mal-presentations. Therefore, efforts should be made to improve the quality of prenatal and intrapartum care services to prevent birth injuries. Improving the referral system and strengthening the capacity of health professionals, improving maternal nutrition, and equipping health facilities with essential supplies are recommended.

What is known about this topic

  • Birth injuries are known risk factors of neonatal morbidity and mortality;
  • Maternal, neonatal, and/or intrapartum-related factors are involving in birth injuries;
  • In Ethiopia, the magnitude and factors associated with birth injuries studied in different settings and time.

What this study adds

  • No study have been conducted regarding magnitude and factors associated with birth injuries so far in the current study setting;
  • In Ethiopia, neonatal mortality remains unacceptably high but no locally sensitive evidences been identified.



Competing interests Up    Down

The authors declare no competing interests.



Authors' contributions Up    Down

Mandefero Teme Mandefero: involved from the conception and design, acquisition of data, analysis and interpretation; Amene Abebe Kerbo: involved from the conception of the study to design, acquisition of data, analysis and interpretation and manuscript preparation; Daniel Baza Gargamo: involved from the inception to design, acquisition of data, analysis, interpretation and drafting the manuscript. All authors read and approved the final manuscript.



Acknowledgments Up    Down

Our heartfelt thanks go to Wolaita Soddo University, College of Health Science and Medicine, the study respondents, focal persons, and other staff working at NICU, and data collectors for their exceptional contribution to the successful completion of this work.



Tables and figures Up    Down

Table 1: socio-demographic and economic characteristics of study participants in silte zone public hospitals, southern Ethiopia, June 2021

Table 2: characteristics of neonates who participated in the study, June 2021

Table 3: bivariate and multivariate analysis of birth injury with maternal, pregnancy, and labor related factors in Silte Zone public hospitals, June 2021

Figure 1: schematic presentation of sampling procedure of the study, Silte Zone, Southern Ethiopia, June 2021

Figure 2: mode of delivery among mothers who gave birth in the included public hospitals of Silte Zone, Southern Ethiopia, June 2021

Figure 3: magnitude of birth injuries among the neonates in the public hospitals of Silte Zone, Southern Ethiopia, June 2021



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