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PPt of NNM.pptx
1. Magnitude of neonatal near miss and associated
factors among neonates born in public
hospitals
in Harari region, eastern Ethiopia
Advisors: Abera Kenay (PhD, Assistant Professor)
: Agumasie Semahegn (PhD, Assistant
Professor)
MSc Thesis
Melese Adugna (BSc)
November 2021
Harar, Ethiopia
3. Introduction
Despite all the efforts, the decline in neonatal mortality rate
(NMR) is slow worldwide (WHO, 2019b; UN et al., 2019)
In 2018, 2.5 of 5.3 million under-five deaths were among the
neonates and with the highest-burden in sub-Saharan Africa
(28 per 1000 live births) (UN et al., 2019)
In Ethiopia, the neonatal mortality is still high; one neonate
in every 30 die with in neonatal period (EMDHS, 2019)
However, NMR shows only the superior tip iceberg of neonatal
ill health (Surve et al., 2017)
As such, the study of neonates who survived complications
(neonatal near miss) is becoming common in addition to NM
4. Introduction (Cont’d)
Neonatal near miss (NNM) is defined as neonate that nearly died
but survived complications in the 1st 28 days of life birth (Surve et al.,
2017).
NNM is an emerging concept analogous to maternal near miss
concept, which has been proposed for:
Detecting preventable and treatable factors
Assessing quality of care and
Surveillance and clinical audits for improving neonatal care
(Santos et al., 2015b; Santos et al., 2015a)
Despite its wider acceptance as a concept, there is no
commonly agreed identification criteria for NNM
But, the CLAP proposed standard definition of NNM (Santos
et al., 2015a)
More recently, a combined set of criteria (pragmatic and
management set) were recommended (Santos et al., 2015a;
Surve et al., 2017)
3
November
2021
5. Introduction (Cont’d)
Evidences from different studies show that :
Age, education, referral status, smoking status,
residence,
Parity, ANC, pre-gestational DM, APH, PROM, PIH,
abnormal progress of labor, abortion history, mode of
delivery, and
Patterns of heartbeat, presentation, birth weight,
gestational age, and Apgar score are contributing
factors for NNM
(Santos et al., 2015b; Surve et al., 2017; Wondimu et al., 2021;
4
6. Introduction (Cont’d)
Despite the emergence of NNM concept, NNM is less
researched and factors that interplay are less explored in
Ethiopia
This study, therefore, strives to fill in this research gap
The finding of this study will help:
Harari region health bureau
Public hospital administrator‘s
Future researcher’s
5
November
2021
7. Objectives
General objective
To assess magnitude of NNM and its associated
factors among neonates born in public hospitals in
Harari Region, Eastern Ethiopia from June 20 to
August 20, 2021
Specific objectives
To determine the magnitude of NNM
To identify factors associated with NNM
6
November
2021
8. Conceptual Framework
7
Sociode
mograph
ic
factors:
Age
Educatio
n
Occupati
on
Residenc
e
NNM
Referral status
Smoking status
Maternal
medical and
obstetric
factors:
Anemia
Diabetus
mellitus
Syphilis
History of
abortion
Parity, ANC
Mode of delivery
Obstetric
complications like:
APH, PIH, abnormal
labor progress,
PROM,
Neonatal factors:
NRFHRP, Fetal
presentation, Birth
weight,
Apgar score
Congenital malformation
Gestational age at birth
Outcome
Figure 1: Conceptual framework of factors associated with NNM among
neonates born in the public hospitals in Harari region, eastern Ethiopia,
Distal Intermediate Proximal
9. Methods and Materials
Study design,
Area, and Period
A facility based cross-sectional study was conducted in
HFCSH and JH from June 20 to August 20, 2021
Populations
Source population All neonates born in public hospitals in Harari Region
Study Population All live birth neonates with their mothers in two public
hospitals during the study period
Inclusion and Exclusion criteria
Inclusion Criteria All live birth neonates with their mothers during the data
collection period
Exclusion Criteria Multiple pregnancies, self-discharges or against medical
advice, and neonates referred out to other health
facilities
Sample Size Determination
1st Objective
𝒏 =
(𝒁∝ 𝟐)𝟐∗𝑷(𝟏−𝑷)
𝒅𝟐 =377; where, Z: 1.96, P: 33.4%, d= 0.05,
NRR=10%
2nd Objectives Assumptions: CI: 95%, Power: 80%, Ratio:1; Exposed:
10. Sampling Procedures
.
9
Both public hospitals in Harari Region (HFCSH and JH) were included
Estimated total deliveries in both hospitals over two
months = 1140
Proportional allocation for both hospitals
(ni = Ni*n/N)
405
Systematic Random Sampling
HFCSH= 700 JH=440
156
249
November 2021
11. Data Collection
Structured questionnaire were used to collect data from
neonates mothers
Validated checklist were used to collect data from
neonates using medical records (Surve et al., 2017;
Santos et al., 2015a; Pileggi‐Castro C et al., 2014)
Four BSC midwifes were recruited as a data collectors
and two MSc as a supervisors
A combination of data collection methods were used
On-site supervision was carried out daily
10
12. Variables of the study
Dependent Variable: Neonatal near miss
Independent Variables:
Socio-demographic factors
Maternal medical and obstetric factors
Neonatal factors
11 November 2021
13. Operational definition
Neonatal near miss: any neonate with any of the
following criteria but survived;
Pragmatic criteria: Birth weight <1750g, gestational age
<33 weeks, 5th minute Apgar score <7
Management criteria: Use of parenteral antibiotics, nasal
CPAP, parenteral nutrition, any intubation, phototherapy,
respiratory distress, vasoactive drugs, steroids for
treatments of refractory hypoglycemia, anticonvulsants,
feeding problems, use of blood products, and any surgery
(Pileggi‐Castro C et al., 2014; Santos et al., 2015b; Surve et
al., 2017)
12 November 2021
14. Data Quality Control
Standard WHOMCS questionnaire was used
Training was given for data collectors and
supervisors
The questionnaire was pre-tested
Data collection process was closely supervised on
daily basis
13
November
2021
15. Data Processing and Analysis
Data was entered using Epidata 3.1 and analyzed by
SPSS 25
Descriptive analysis was done to summarize data
Binary logistic regression was performed
After checking for multicollinearity, all variables with p-
value <0.25 were entered into the multivariable logistic
regression
14
16. Ethical Considerations
The proposal was approved by the IHRERC, HU, CHMS
Letter of support was submitted to respective hospitals
Informed, voluntary, written and signed consent was
obtained from mothers of each neonate
Confidentiality was maintained throughout the research
process
The standard safety measures for the prevention of COVID-
19 were strictly followed throughout the data collection
15
November
2021
17. Results
Socio-demographic Characteristics [ Table 2.docx ]
Of 405 women-neonate pairs approached, 401 were
included in the study
The mean age of the mothers was 26.73 (± 5.47 SD)
years
The majority of the mothers were in marital union 374
(93.3%) and housewives 316 (78.8%)
269 (67.1%) and 227 (56.6% of neonates mothers had no
formal education and were rural residents respectively
222 (55.4%) mothers were referred from other health
16
November
2021
18. Maternal and fetal conditions
A fifth of the mothers had pregnancy-induced
hypertension (20.2%), a history of abortion (22%), and
prolonged labor (19.2%)
Majority of mothers had visited ANC at least one (80%)
and spontaneous onset of labor (73.3%) [Table 3.docx]
Majority of neonates had vertex presentation (336;
83.8%), born at term (315; 78.6%), and had normal
birthwieght (341; 85%)
Near to a third of the neonates were admitted to NICU
(29.7%) [Table 4.docx ]
17 November 2021
19. Magnitude of Neonatal Near Miss
A total of 126 neonates had at least one NNM event;
making an overall magnitude of NNM (31.42%; 95% CI:
26.9-36.2%)
(76;19.2%) of neonates had at least one pragmatic
criteria of NNM
(125; 31%) of neonates had at least one
management criteria of NNM
[Table 5.docx ]
18 November 2021
22. Discussion
This study found that the overall magnitude of NNM was
31.42% (95%; CI: 26.9%–36.2%)
Inline with study in:
Lower than study in:
Uganda (36.7%)
(Nakimuli et al., 2015)
Ghana (70%)
(Bakari et al., 2019)
21
Hawassa (33.4%) (Tekola et al., 2021)
Debretabor (32.9%) (Tassew et al.,
2020)
Brazilian university hospitals (30.3%)
(Morais et al., 2019)
Possible explanation
Due to sociodemographic difference
Worked on neonates of mothers
with severe obstetric
complications
(Tura et al., 2019)
Difference, Setting
sociodemographic, inclusion
criteria
23. Discussion (Cont’d)
Finding
s
Comparison Possible explanation
NNM
[31.42
%
(95%;
CI:
26.9%
–
36.2%)]
Higher than study:
Ethiopia:
[ Jimma (26.7%)
(Wondimu et al.,
2021)
Injibara (23.3%)
(Gebrehana et al., 2020)
]
Abroad:
Nepal (7.9%)
(Rajbanshi et al., 2020)
Northeast Brazil
(8.7%) and 22.2%
[(de Araujo Brasilia et al.,
2019) and (de Lima et al.,
2018)]
22
ANC
Maternal education
Sampling method
ANC
Maternal education
Residence (rural)
Referred mothers from other HF
Inclusion criteria, Socio-
economic status,
Sample size
Ability of mothers to
recognize complications
early, and health-seeking
behavior
Criteria used to identify
NNM
24. Discussion (Cont’d)
Associated
factors
Comparison
Possible explanation
Referral
mothers
(AOR:2.24
(1.25- 4.03)
This is inline with:
Ethiopia
(Gebrehana et al., 2020;
Abebe et al., 2021)
Abroad
(Shroff and Ninama,
2019)
Delays of mothers:
In early recognizing
complications
Seeking care, and
reaching facilities
with complications
Problems with our
referral system-
delays
24
(Yeshialem et al., 2019; Carvalho et
al., 2020b)
25. Discussion (Cont’d)
A. factors Comparison Possible
explanation
Primiparity
(AOR:2.67
(1.49– 4.77)
This is consistent
with:
Ethiopia
(Gebrehana et al.,
2020; Tassew et al.,
2020)
Abroad
(de Lima et al., 2018;
Kale et al., 2017)
Pregnancy danger
signs, labor, and
delivery
Delay in health-
seeking
Risk for prolonged
labor, induction of
labor, and birth
asphyxia
This is contrast to:
Ethiopia
(Mersha et al., 2019;
Difference in
reference taking
categorizing parity
25
(Tasew et al., 2018;
Kassahun et al., 2020)
26. Discussion (Cont’d)
A.Factors Comparison Possible
explanation
No ANC
AOR:2.08
(1.10-3.93)
This is inline with:
Ethiopia (Mersha et al.,
2019; Tassew et al., 2020;
Yohannes et al., 2020),
Abroad (Carvalho et al.,
2020b)
Having ANC follow-up:
Pregnancy, regarding
danger signs, and where
to seek care when
needed
APH
(AOR:4.2
9 (2.16-
8.53)
This is consistent:
Ethiopia (Tassew et al.,
2020)
Abroad (Kale et al.,
2017)
Risk of compromised
fetal blood perfusion,
leads to uteroplacental
insufficiency, this might
result in preterm birth,
and birth asphyxia
(Shiferaw et al., 2021; Tolossa et al.,
2020)
(Tasew et al., 2018; Gebremedhin et al.,
2020;
Muchie et al., 2020, Zanardi et al., 2019)
26
27. Discussion (Cont’d)
A. factors Comparison
Possible explanation
PROM
(AOR:4.07
(2.05 – 8.07)
This is inline:
Ethiopia
(Gebrehana et al.,
2020; Tassew et
al., 2020; Mersha
et al., 2019)
PROM is associated with
preterm delivery, cord
prolapse, reduced amniotic
fluid volume,
chorioamnionitis, neonatal
sepsis, birth asphyxia, and
RDS
Obstructed
labor
(AOR: 2.61
(1.23-5.52)
This is consistent:
Ethiopia
(Wondimu et al.,
2021; Gebrehana
et al., 2020;
Tassew et al.,
A risk for abnormal fetal
heart rate tracing, fetal
hypoxia, birth trauma,
and infection/sepsis
27
(Alemu et al., 2020; Debelew et
al., 2014; Masanja et al., 2020)
(Yeshialem et al., 2019;
Harrison et al., 2015)
28. Discussion (Cont’D)
Additionally, neonates with the non-vertex
presentation at birth; were the odds of NNM (AOR:
3.03 (1.54-5.95)
This is inline with:
Studies in Ethiopia
(Wondimu et al., 2021; Mersha et al., 2019)
This might be due to:
Malpresentation being a risk and causes
complications like prolonged labor, birth asphyxia,
28 November
29. Strengths and Limitations
The study used interview and review of medical records for getting
comprehensive information about the neonates
Our observation was limited to hospitals discharge or 28 days and
hospital births and also limited not to assess the appropriateness
of mgt
Conclusion
Three out of ten neonates delivered in public hospitals in
Harari Region had developed NNM;
Referral mothers
Primiparous mothers
Mothers who had no ANC
Mother with APH, PROM, and Obstructed labor
Non-vertex fetal presentation
were more
likely to
develop
NNM cases
29
30. Recommendations
To Harari Region Health Bureau
To work more to improve referral linkages
To work on obstetrics complications
To participating hospitals
To prioritize referred women
To give attention to mothers who had APH, PROM,
and obstructed labor and consider mothers who had
no ANC, and primiparous to reduce NNM cases
To future researchers
To explore the appropriateness of management (i.e.,
care, timely management, and specific intervention)
given to the neonates
31 November
31. Acknowledgements
I would like to thank:
HU, CHMS, School of Nursing and Midwifery,
Mettu University,
My advisors:
Abera Kenay (PhD, Assistant Professor)
Agumasie Semahegn (PhD, Assistant Professor),
and
Mr. Getahun Tiruye (MSc.)
Data collectors, supervisors, study participants,
hospitals administrators, and all others who directly or
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