Articles

Incidence and Related Factors of Birth Asphyxia in Owerri Zone From 2019 – 2023

Okpe, Jane Ngozi, Amadike Egbuchulam J.N, Nwagwu Solomon Adanma and Emesowum Anthonia Chinwendu
Department of Nursing, Faculty of Health Science Imo State University Owerri.

Article Info

Received Date: 28 January 2025, Accepted Date: 01 February 2025, Published Date: 07 February 2025

*Corresponding author: Okpe, Jane Ngozi, Department of Nursing, Faculty of Health Science Imo State University Owerri.

Citation: Okpe, Jane Ngozi, Amadike Egbuchulam J.N,  N Solomon Adanma and E Anthonia Chinwendu. (2025). Incidence and Related Factors of Birth Asphyxia in Owerri Zone From 2019 – 2023. Biomedical and Clinical Research Journal, 1(1); DOI: http;/02.2025/BCRJ/004.

Copyright: © 2025 Okpe, Jane Ngozi. This is an open-access article distributed under the terms of the Creative Commons Attribution 4. 0 international License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

This study examined incidence and related factors of birth asphyxia in some selected hospitals in Owerri, Imo State, Nigeria from 2019 – 2023. This retrospective hospital-based study reviewed 344 postnatal records from three hospitals in Owerri between January 2019 and December 2023. Data were analysed using descriptive statistics and chi-square tests to assess relationships between maternal, antepartum, intrapartum, and neonatal factors with birth asphyxia, using APGAR scores as the outcome measure. The study found that 75.2% of newborns had an APGAR score below 7 at one minute, and 78.3% at five minutes, indicating a high incidence of birth asphyxia. Antepartum factors, including hypertension (52.4%) and infections (42.9%), were significantly associated with birth asphyxia at one minute (p = 0.001). Intrapartum complications, prolonged labour (>12 hours), and lack of foetal monitoring showed significant associations with low APGAR scores (p < 0.05). Neonatal factors such as gestational age were also significant (p = 0.002), while baby’s weight and antenatal visits were not. The findings underscore the need for enhanced antenatal and intrapartum care to address modifiable risk factors, including timely management of maternal complications and labour monitoring. Improving healthcare infrastructure and training is critical for reducing neonatal mortality. Birth asphyxia remains prevalent in Owerri, driven by maternal, intrapartum, and neonatal risk factors. Targeted interventions could mitigate its impact on neonatal outcomes.

Key words: incidence; related factors; birth asphyxia; owerri.

Introduction

Childbirth is a significant event, but ensuring a child's survival at birth remains a global challenge. While progress has been made in reducing deaths after the neonatal period, the decline in neonatal mortality has been slower over the past 15 years .  The percentage of deaths occurring in the neonatal period is 46% as reflected in the available statistics, and this percentage does not include the 2.6 million stillbirths, of which 1.2 million (45%) occur during labour 2.3 million newborns died in 2022. Of these deaths, 99% occur in low and middle-income countries (LMICs). Globally, about one-quarter of all new-born deaths are caused by birth asphyxia [1]

Birth asphyxia, otherwise known as perinatal asphyxia, is the inability to start and maintain spontaneous breathing at birth, which endangers the newborn's life and can cause permanent brain damage / Birth asphyxia remains the leading cause of newborn illness and mortality and is a significant factor in impaired developmental health among children under five. Almost all asphyxia related deaths (98%) occur during the first week of life. About 75% of such deaths occur on the first day, and less than 2% after 72 hour of birth .  Birth asphyxia results from an inadequate intake of oxygen by the baby during the birth process or just after birth. Indeed, decreased oxygen intake can result in chemical changes in the baby’s body that include hypoxemia, or low level of oxygen in the blood and acidosis, in which too much acid builds up the blood. This cascade of biochemical changes inside the body, whose event can lead to neuronal cell death and brain damage[2] . Birth asphyxia-related morbidities can be broadly divided into two categories: immediate and long-term. While cerebral palsy, epileptic disorder, motor disorders, developmental delays, speech delays, learning disabilities, mental retardation, hearing impairments, blindness, feeding impairment, and behavioural and emotional disorders are the long-term morbidities, the immediate effects include neonatal hypoxia, hypercarbia, acidosis, hypotension, and ischaemia [3].

Risk factors associated with birth asphyxia can be maternal, fetal, or related to the birth process. Maternal factors include advanced maternal age, young maternal age, low educational status, oligohydramnios, fewer antenatal care visits, antepartum haemorrhage, maternal hypotension or hypertensive diseases during pregnancy , diabetes, infections, general anaesthesia, and drug therapy. During childbirth, birth asphyxia may be linked to prolonged labour, home delivery, obstructed labour, oxytocin use, and malpresentation (Techane et al., 2022). Foetal factors include anaemia, intrauterine growth restriction (IUGR), meconium-stained amniotic fluid, congenital abnormalities, preterm or post-term birth, multiple births , low birth weight, tight nuchal cord, foetal distress . Additional factors involve issues with the placenta, cord, and membranes, such as placenta praevia, placental abruption, cord prolapse, polyhydramnios, oligohydramnios, and chorioamnionitis. These factors can interfere with normal blood flow to the foetus, potentially causing hypoxia before birth [4].

Birth asphyxia is a major contributor to neonatal mortality worldwide causing 24% of all neonatal deaths .Birth asphyxia accounts for an estimated 900,000 deaths each. Nigeria bears the heaviest burden of birth asphyxia in sub-Saharan Africa. In 2018, Nigeria was one of two countries responsible for a third of global under-five deaths, with approximately 267,000 newborn infant deaths, about 30% of which were due to asphyxia. Furthermore, asphyxia accounts for between 18% and 30% of new born admissions in the country. The in-hospital mortality rate for these infants varies significantly across local studies and, in some cases, exceeds 25% Consequently, Nigeria exemplifies a resource-constrained, high-burden setting for birth asphyxia [5].

Long-term consequences like problems with sensation, audition and language processing, cerebral palsy, autism and other cognitive impairments are associated with birth asphyxia. Birth Asphyxia is therefore not only a cause of neonatal deaths but also has an impact on the quality of life with early and permanent neurological insults [6]. However, there seem to be limited availability of data and possible underestimation of the real proportion of morbidities due to birth asphyxia in Nigeria, particularly Imo State, Nigeria. Hence, this study explores the incidence and contributing factors of birth asphyxia among neonates in Imo State.

Birth asphyxia is still a leading cause of newborn deaths and long-term neurological problems. Almost one quarter of the world’s 4 million annual neonatal deaths are caused by perinatal asphyxia and 99% of these deaths occur in low and mid-resource settings. Nigeria’s neonatal mortality rate (NMR) is very high at 37 deaths per 1,000 live births. The common causes of neonatal deaths in Nigeria are similar to the rest of Africa and it includes birth asphyxia, infections and complications of preterm birth[6].

Survivors of birth asphyxia often face lifelong health problems (80%), such as disabilities, developmental delays, palsy, intellectual disabilities, and behavioural problems. Furthermore, birth asphyxia places financial and emotional burdens on the families and communities involved. Despite improvements in maternal and newborn care, the rates of birth asphyxia remain high in certain areas, contributing to the ongoing challenges of newborn morbidity and mortality. In the Owerri zone of Imo State, there is no much knowledge about the incidence of birth asphyxia or the factors are contributing to it. This lack of information makes it hard to develop targeted healthcare strategies that could make a real difference [7].

Its important to identify and manage the risk factors for birth asphyxia early on, but to do that, we need solid data to guide clinical decisions and public health policies. This study aims to fill that gap by finding out the incidence of birth asphyxia and identifying the maternal, birth-related, and newborn factors that play a role in its occurrence in selected hospitals in Owerri, Imo State, Nigeria. Understanding these factors is key to developing effective strategies that can reduce the incidence of birth asphyxia, improve outcomes for newborns, and ultimately save lives.

Materials and methods

Research Design

This study adopted the hospital-based unmatched case control study design. The study reviewed post-natal record of mothers who accessed care in the selected hospitals which are Umuguma specialist hospital, Orlu teaching hospital (Ogbaku Annex) and Imo state university teaching hospital, from 2019 to 2023.

Area of Study

The study was conducted at three hospitals in Urban area of Imo State. Owerri Capital territory is the regional capital of Imo State. Owerri Capital territory was chosen as the capital of Imo State on the 15th of December, 1996. The Owerri Capital territory is located in the geographical center of Imo state, Nigeria with a land mass of 24.88 square kilometers. It has an estimated population of about 400,000 as reported from 2006 Census. Owerri Capital territory is the most developed local government area in Imo State and includes the districts of Owerri North, Owerri West and Owerri municipal. Hospitals are selected based on those who offer services based on critical care within Owerri Capital territory of Imo State.

Population of the Study

In this study which is a study of the entire population 344. The study involved all births both caesarean sections and spontaneous vaginal deliveries from mothers who accessed care from Umuguma specialist hospital, Orlu teaching hospital (Ogbaku Annex) and Imo state university teaching hospital and babies referred to these hospital’s Paediatric wards with birth asphyxia from January 2019 to December, 2023.

Sample Size and Sample Technique

This study is a study of the entire population. The entire mothers who had post-natal record of birth asphyxia were used in this study which means there were no sampling techniques.

 Inclusion criteria

All newborns diagnosed with birth asphyxia within the specified timeframe.

Exclusion criteria

Newborns with incomplete records, or records outside the timeframe or hospitals not selected for studying.

Instrument for Data Collection

A self-developed data collection schedule form (SDDCSF) was used for the study. The data collection schedule is designed in line with the objective of the study. The data collection schedule contains a guide for the collection of relevant information from the outpatient, admission and discharge registers as well as patient case notes and folders.

Validity of the Instrument

The self-developed data collection schedule form was validated by the supervisor.

Reliability of instrument

Collecting data from multiple departments involved in deliveries increased the reliability of the instrument used.

Method of Data Collection

To have access to the hospital records, an application letter of the researchers was presented to the chief medical director of the selected hospitals who refer the memo to the chief medical record officer. The chief record officer in turn assigned the recording officer who assisted the researcher in retrieving the required record using the already prepared data collection schedule sheet (DCSS). The recording officer checked and compile the record for the incidence of birth asphyxia from January 2019 to December, 2023 recorded. Data on cases diagnosed with birth asphyxia, including demographic, antepartum, intrapartum, and newborn-related factors were gathered.

Method of Data Analysis

Descriptive Statistics was used to analyze incidence rates and provide an overview of maternal and neonatal characteristics. Inferential Statistics in form of Chi-square tests was used to test hypotheses on associations between birth asphyxia and factors like maternal demographics, antepartum conditions, and neonatal factors.

Results

The analysis, presentation, and interpretation of the data that was acquired for the study are all presented in this chapter and presented.

1. Maternal Characteristics

Fig 4.1.1 Age of the Respondents.

Figure 4.1.3: shows that 91.0% of the respondents are married, 6.7% are single, 1.7% are divorced and 0.6% are widowed.

Fig 4.1.4: Employment status of the respondents.

Fig 4.1.4: shows that 65.7% are self-employed followed by 21.8% who are unemployed and at 12.5% have formal employment.

Fig 4.1.5: Mother’s Parity of the respondents

The dataset shows that 47.4% of the respondents have 2-3 children followed by 41.9% who indicated 1 child, 7.0% of the respondents indicated 4-5 children and 3.8% indicated 6 or more children.

Fig 4.1.6: How Many Ante-natal Visits Did the Respondents Have?

The dataset shows that 62.2% of the respondents had 7 or more antenatal care visits, followed by 27.9% of the respondents indicated4-6 visits at, and 9.9% had 1-3 visits.

Fig 4.1.7:  "What  Antepartum  Complications  Did  the  Respondents  Experience?

Fig 4.1.7: shows that 51.2% of the respondents indicated hypertension as an antepartum complication, followed by infections as indicated by 43.6% and diabetes by 5.2%.

 ​​​​1. Labour and delivery characteristics.

Fig 4.2.1: What was the Pregnancy Term of the Respondents?

Fig 4.2.1: shows that 64.8% of the respondents had full-term pregnancies which is 37–42 weeks, followed by 19.2% with post-term pregnancies which is greater than 42 weeks and 16.0% with preterm pregnancies which is less than 37 weeks.

Fig 4.2.2: What Was the Mode of Delivery for the Respondents?

Fig 4.2.2: shows that 52.3% of the respondents had a spontaneous vaginal delivery, followed by 22.1% of the respondents indicated emergency caesarean section, 13.1% indicated assisted delivery and 12.5% of the respondents indicated planned caesarean section.

Fig 4.2.3: What Were the Labour Durations of the Respondents?

Figure 4.2.3: shows that 49.7% of the respondents had labour durations of greater than12 hours, followed by 26.5% of the respondents with labour lasting more than less than 6 hours, and 23.8% with labour -12 hours 6 hours.

Fig 4.2.4: Did the Respondents Experience Labour Complications?

Figure 4.2.4: shows that 57% of the respondents experienced labour complications, while 43% did not.

Fig 4.2.5: Did the Respondents Use Labour Inducing Drugs?

Figure 4.2.5: shows that 47% of the respondents had labour induced, while 53% did not.

Fig 4.2.6: Did the Respondents Use Foetal Monitoring Devices?

Figure 4.2.6: shows that 96.9% of the respondents did use foetal monitoring devices, while 3.1% did not.

2. Neonatal characteristics

Fig 4.3.1: What Was the Baby's Weight at Birth?

Figure 4.3.1: shows that 72.2% of the respondents had babies weighing between <2.5kg, followed by 14.8% with babies 4kg or more and 14.0% with babies weighing between 2.5- 3.9kg.

Fig 4.3.2: What Was the Gestational Age of the Respondents' Babies?

Fig 4.3.2: shows that 44.5% of the respondents were indicated less than 28weeks gestational weeks range, followed by 24.1% of the respondents indicated less than greater than 42weeks, 23.3% indicated 28-36 weeks range, and 8.1% indicated 37-42 weeks

Fig 4.3.3: Did the Baby Cry After Birth?

Fig 4.3.3: shows that 90% of the respondents babies do not cry, while 10% indicated that the babies cried.

Fig 4.3.4: Did the Baby Require Resuscitation After Birth.?

Figure 4.3.4: shows that 90% of the respondents' babies required resuscitation, while 10% did not.

Fig 4.3.4: What Was the APGAR Score at 1 Minute

The dataset shows that 77.6% of the respondents babies had a low APGAR score at 1 minute less than 7 while 22.4% had a normal APGAR score 7–10.
Fig 4.3.5: What Was the APGAR Score at 5 Minutes

The dataset shows that 73.3% of the respondents' babies had a low APGAR score at 5 minutes (<7), while 26.5% had a normal APGAR score (7–10)

1.4. Postnatal and hospital care.

Fig 4.4.1: How Long Did the Respondents Stay in the Hospital After Delivery

Figure 4.4.1: shows that 53.2% of the respondents stayed in the hospital for 1–3 days after delivery, followed by 25.9% staying 4–7 days, 15.4% staying less than 24 hours, and 5.5% staying more than 7 days.

Fig 4.4.2: Did the Respondents Experience Delays in Receiving Medical Attention

Fig 4.4.2: shows that 58% of the respondents did not experience delays in receiving medical attention, while 42% did.

Fig 4.4.3: What Was the Mode of Transportation to the Hospital?

Figure 4.4.3: shows that 72.7% of the respondents used a private vehicle to get to the hospital, while 27.3% used public transport. No respondents used an ambulance.

Discussion

Birth asphyxia, which was as noted a condition that is typically presented to involve a newborn delivered in seemingly good condition but begins with shallow breaths that fail to achieve effective gas exchange, eventually leading to a pause in breathing called primary apnoea, lasting about 10 minutes. Here the findings from the study showed that the incidence of birth asphyxia which was determined using the APGAR scores at both 1 minute and 5 minutes after birth, revealed that at 1 minute, 77.6% of the newborns which comprises of about 267 out of 344 had an APGAR score of less than 7, which indicates that a majority of the newborns experienced birth asphyxia immediately after delivery. As seen in [8], who corroborates this finding, acute asphyxia is characterised by distinct behaviour in the foetus; where a foetus exposed to acute severe asphyxia will often present with a low heart rate and delayed onset of breathing at birth, resulting in a depressed Apgar score at one minute The typical presentation involves a newborn delivered in seemingly good condition who begins with shallow breaths that fail to achieve effective gas exchange, eventually leading to a pause in breathing called primary apnoea, lasting about 10 minutes. This also aligns with [9] who showed that within 1-2 minutes of primary apnoea, the baby starts gasping, initially increasing in frequency and strength, then gradually slowing down until the last gasp, lasting 5-10 minutes.

More so, the results from this study showed that by the 5th minute, the percentage of newborns with an APGAR score below 7 increased slightly to 73.5% which is about 253 out of 344. This shows that while some newborns may have improved over time, a significant proportion still experienced challenges with breathing and overall responsiveness within the first 5 minutes of life. It had initially reported to be true as this study showed that after birth, the heart rate initially drops, rises during primary apnoea and the early phase of gasping, and then slows down again [10]. Cardiac activity continues for about 10 minutes after the last gasp, known as terminal apnoea. This period is marked by severe biochemical changes, including a significant rise in hydrogen ions (pH below 6.5), pCO2 reaching 100 mmHg, unrecordable PaO2, and potassium levels above 15 mmol/l. The heart rate rapidly declines following premature separation of the placenta and uterine vessel constriction, which can occur in conditions like cocaine addiction [11].

The second objective of the study was to ascertain antepartum factors associated with birth asphyxia, here a Chi-Square test was conducted to examine the relationship between antepartum factors and birth asphyxia, using APGAR scores at 1 minute and 5 minutes. The Chi-Square value was 0.599 with a p-value > 0.05, indicating that antenatal care visits are not significantly associated with birth asphyxia at 1 minute. For APGAR at 5 minutes, the Chi- Square value was 0.541, showing that antenatal care visits are not significantly associated with birth asphyxia at 5 minutes. For Antepartum Complications, the Chi-Square test yielded a value of 0.002, showing a significant association between antepartum complications and birth asphyxia at 1 minute. At 5 minutes, the Chi-Square value was 0.001, indicating a significant association between antepartum complications and birth asphyxia at 5 minutes. For Maternal Age, the Chi-Square test value was 0.207, indicating no significant association between maternal age and birth asphyxia at 1 minute. For APGAR at 5 minutes, with APGAR <7, the distribution was similar. The Chi-Square test value was 0.204 showing no significant association between maternal age and birth asphyxia at 5 minutes.

In all, only antepartum complications were significantly associated with birth asphyxia at 1 and 5 minute, which is in tandem with the findings from [12], that showed some a few antepartum factors that include anemia during pregnancy found to be a significant determinant of birth asphyxia. Intra-partum hypoxia, resulting from disruptions in maternal and foetal oxygen transport, can contribute to asphyxia [13]. Anaemia may exacerbate this risk due to reduced oxygen-carrying capacity in the mother's blood. Newborns whose mothers had no ANC visits were 4.2 times more likely to experience birth asphyxia compared to those whose mothers had four or more visits. Lack of ANC can lead to inadequate counselling, reduced awareness of the benefits of antenatal care, and delayed pregnancy recognition. Cord prolapse was associated with a 4.5 times higher risk of birth asphyxia compared to cases without cord prolapse [14]. Caesarean delivery was also identified as a risk factor, with newborns delivered by caesarean section being 5.2 times more likely to develop birth asphyxia than those delivered vaginally. Additionally, the study showed that the lack of chest compression during caesarean delivery may hinder the

clearance of foetal lung secretions, contributing to the risk of asphyxia. Low birth weight was another determinant of birth asphyxia, with newborns weighing less than normal being 4.1 times more likely to experience this condition [15].

To ascertain intrapartum factors contributing to birth asphyxia was the third objective of this study, making use of a Chi-Square test with APGAR scores at 1 minute and 5 minutes. The variables analyzed were Pregnancy Term and Labour Complications. It was stated previously from the intrapartum category, assisted vaginal delivery, labor duration, and labor complications were highlighted, while fetal factors included gestational age and intrauterine growth restriction (IUGR) [16]. Birth asphyxia was ultimately associated with complications during labor, labor duration, maternal height, assisted vaginal delivery, and the mother's MUAC category. This finding corresponds with those of this study which showed that For Labour Complications and APGAR at 1 minute, the Chi-Square value was 0.001, indicating a significant association between labour complications and birth asphyxia at 1 minute. For APGAR at 5 minutes, the Chi-Square value was 0.000, showing a significant association between labour complications and birth asphyxia at 5 minutes. Also  it has been shown that mothers with a shorter stature (≤153 cm) were 6.43 times more likely to have a newborn with asphyxia compared to those with a normal height (>153 cm). Assisted vaginal deliveries (vacuum or forceps) increased the risk of neonatal asphyxia by 3.5 times compared to spontaneous vaginal deliveries [17]. Key factors identified from the maternal and antepartum category included the mother's height, occupation, MUAC category, parity, pregnancy duration, number of ANC visits, and illnesses during pregnancy, the findings from the respondents showed that pregnancy term were significantly associated with birth asphyxia at 1 minute and 5 minutes.

The final objective was to ascertain newborn related factors such as weight, age and gender in relation to birth asphyxia. The results from the Chi-Square test that was conducted to examine the relationship between newborn-related factors such as weight, age, and gender with birth asphyxia, using APGAR scores at 1 minute and 5 minutes, here, the variables analyzed were Baby’s Weight and Gestational Age. New born related factors can interfere with the normal blood flow to the foetus, potentially causing hypoxia [18,19]. The findings from the study revealed that for Baby’s Weight and APGAR at 1 minute, the Chi-Square value was 0.000 with a p-value < 0.05, indicating a significant association between baby’s weight and birth asphyxia at 1 minute. For APGAR at 5 minutes, the Chi-Square value was 0.001 indicating a significant association between baby’s weight and birth asphyxia at 5 minutes. This finding does correspond with [20] who had noted that low birth weight together with tight nuchal cord, foetal distress to be responsible for asphyxia. The respondents went on to show that for gestational age and APGAR at 1 minute, the Chi-Square test yielded a value of 0.002, showing a significant association between gestational age and birth asphyxia at 1 minute. For APGAR at 5 minutes, the Chi-Square test yielded a value of 0.001, indicating a significant association between gestational age and birth asphyxia at 5 minutes, which corresponds with [21], that foetal factors include anaemia, intrauterine growth restriction (IUGR), meconium-stained amniotic fluid, congenital abnormalities, preterm or post-term birth, multiple births[22]. This study also noted that additional factors involve issues with the placenta, cord, and membranes, such as placenta praevia, placental abruption, cord prolapse, polyhydramnios, oligohydramnios, and chorioamnionitis as other factors that could cause this at the gestational age.

Conclusions

This study highlights the persistent burden of birth asphyxia in Owerri, Imo State, Nigeria, with a significant proportion of neonates affected. Maternal complications such as hypertension and infections, as well as intrapartum factors like prolonged labour and inadequate monitoring, were identified as critical contributors to low APGAR scores and birth asphyxia. Additionally, neonatal factors such as gestational age significantly influenced outcomes. Addressing these issues requires targeted interventions, including strengthening antenatal care services, early identification and management of high-risk pregnancies, and ensuring skilled birth attendance during delivery. Enhancing access to intrapartum monitoring tools, such as foetal heart rate monitors, and improving emergency obstetric care are critical steps to mitigate the risk of birth asphyxia. Furthermore, community-level education on the importance of antenatal visits and institutional deliveries can contribute to better maternal and neonatal outcomes. This study provides a foundation for policy-making and health system improvements tailored to the local context. Future research should focus on long-term outcomes of neonates affected by birth asphyxia and the cost-effectiveness of interventions designed to reduce its prevalence. By addressing modifiable risk factors and investing in healthcare infrastructure, significant progress can be made toward reducing neonatal mortality and morbidity associated with birth asphyxia in low-resource settings like Owerri.