ADDIS ABABA UNIVERSITY

COLLEGE OF HEALTH SCIENCES

SCHOOL OF NURSING & MIDWIFERY

DEPARTMENT OF NURSING POSTGRADUATE PROGRAM

PREVALENCE OF BIRTH INJURIES AND ASSOCIATED

FACTORS AMONG NEWBORNS DELIVERED IN PUBLIC
HOSPITALS ADDIS ABABA, ETHIOPIA, 2021.

BY: ESUBALEW AMSALU (BSc)

A THESIS TO BE SUBMITTED TO THE DEPARTMENT OF

NURSING, SCHOOL OF NURSING AND MIDWIFERY,
COLLEGE OF HEALTH SCIENCE, ADDIS ABABA
UNIVERSITY, FOR PARTIAL FULFILLMENT OF THE
REQUIREMENTS OF MASTERS OF SCIENCE IN NEONATAL
NURSING.

JUNE, 2021

ADDIS ABABA, ETHIOPIA

 ADDIS ABABA UNIVERSITY

COLLEGE OF HEALTH SCIENCES

SCHOOL OF NURSING & MIDWIFERY

DEPARTMENT OF NURSING POSTGRADUATE PROGRAM

PREVALANCE OF BIRTH INJURIES AND ASSOCIATED FACTORS

AMONG NEWBORNS DELIVERED IN PUBLIC HOSPITALS ADDIS
ABABA, ETHIOPIA, 2021.

BY: ESUBALEW AMSALU (BSc)

ADVISORS:

1. Ms. KALKIDAN WONDWOSSEN (MSc, ASS. PROF)

2. Mrs. FEVEN MULUGETA (BSc, MSc)

A THESIS TO BE SUBMITTED TO THE DEPARTMENT OF NURSING,

SCHOOL OF NURSING AND MIDWIFERY, COLLEGE OF HEALTH
SCIENCE, ADDIS ABABA UNIVERSITY, FOR PARTIAL
FULFILLMENT OF THE REQUIREMENTS OF MASTERS OF
SCIENCE IN NEONATAL NURSING.

JUNE, 2021

ADDIS ABABA, ETHIOPIA

i
 APPROVAL SHEET

I, the undersigned MSc student, declare that I have submitted my original work on prevalence
of birth injury and associated factors among newborns delivered in public hospitals Addis
Ababa, Ethiopia for the examination.

Submitted by:

Name: Esubalew Amsalu (BSc) Signature: _______________ Date: _______________

This thesis work has been submitted for examination with my approval as an advisor.

Examiner:

1. Name of examiner: _______________ _______________

Signature Date
Advisors:

1. Ms. Kalkidan Wondwossen _______________ _______________

Name of Major Advisor Signature Date

2. Mrs. Feven Mulugeta _______________ _______________

Name of Co-Advisor Signature Date

ii
 STATEMENT OF DECLARATION

I, the undersigned, declare and affirm that this thesis is my own work. I have followed all
ethical principles of scholarship in the preparation, data collection, data analysis and
completion of this thesis. All scholarly matter that is included in the thesis has been given
recognition through citation. I affirm that I have cited and referenced all source used in this
document. Every effort has been made to avoid plagiarism in the preparation of this thesis.

This thesis is submitted in partial fulfillment of the requirement for graduate degree from
Addis Ababa University at College of Health Science, School of Nursing and Midwifery. The
thesis is deposited in the Addis Ababa University Digital Library and is made available to
local and international scientific community. I solemnly declare that this thesis has not been
submitted to any other institution anywhere for the award of any academic degree, diploma or
certificate.

Brief quotations from this thesis may be used without special permission provided that
accurate and complete acknowledgement of the source is made. Requests for permission for
extended quotations from, or reproduction of, this thesis in whole or in part may be granted by
the head of the department or all advisers of the theses when in his or her judgment the
proposed used of the material is in the interest of scholarship and publication. In all other
instances, however, permission must be obtained from the author of the thesis.

STUDENT:

Name: Esubalew Amsalu Signature: _______________ Date: _______________

RESEARCH ADVISORS:

_______________ _______________ _______________ _______________

NAME RANK SIGNATURE DATE

_______________ _______________ _______________ _______________

NAME RANK SIGNATURE DATE

iii
 APPROVAL BY THE BOARD OF EXAMINATION

This thesis by Esubalew Amsalu is accepted in its present form by the board of examiners as
satisfying thesis requirement for the degree of Masters of Science in Neonatal Nursing.

EXAMINER:

_______________ _______________ _______________ _______________

NAME RANK SIGNATURE DATE

RESEARCH ADVISORS:

_______________ _______________ _______________ _______________

NAME RANK SIGNATURE DATE

_______________ _______________ _______________ _______________

NAME RANK SIGNATURE DATE

DEPARTMENT HEAD

_______________ _______________ _______________ _______________

NAME RANK SIGNATURE DATE

iv
 ACKNOWLEDGMENT
First and for most I would like to thank the almighty God to reach in this success. Secondly, I
would like to acknowledge department of Nursing, School of Nursing and Midwifery, Addis
Ababa University and St.Peter Specialized Hospital for giving me sponsorship to learn these
masters of neonatal nursing program at Addis Ababa University. I would like to thank my
advisors Ms. Kalkidan Wondwossen and Mrs. Feven Mulugeta for their fruitful comments,
guidance and support throughout this work.

My deepest appreciation and thanks also extend to Mr. Bereket G/Michael for his unreserved
guidance and constructive comments since starting of the proposals up to final development of
the thesis.

I also would like to thank Dr. Asrat Demtse for her encouragement and support throughout
this work. I would like to thank Addis Ababa University, College of Health Science Ethical
Review Board (IRB), Addis Ababa city administration health bureau IRB, Yekatit-12 Hospital
Medical College IRB and St. Paul Hospital Millennium Medical College IRB for giving me
ethical clearance and allowing me to collect data.

My gratitude will also extend to data collectors, study participants and supervisors for their
supports and commitments to gather data.

v
 ABBREVIATIONS/ ACRONYMS

AAU Addis Ababa University

ANC Antenatal Care
APGAR Appearance, Pulse rate, Grimace, Activity and Respiration
BMI Body Mass Index
CI Confident Interval
CNS Central Nervous System
CPD Cephalopelvic disproportion
C/S Caesarian Section
DM Diabetes Mellitus
EDHS Ethiopian Demographic Health Survey
GA Gestational Age
GDM Gestational Diabetes Mellitus
GMH Gandhi Memorial Hospital
ICD International classification of disease
IRB Institutional Review Board
LMICs Low and Middle Income Countries
MRN Medical Record Number
NGO Non- Governmental Organization
OR Odds Ratio
PI Principal Investigator
PTSD Post-Traumatic Stress Disorder
SPHMMC St. Paul Hospital Millennium Medical College
TASH Tikur Anbessa Specialized Hospital
WHO World Health Organization
Y-12HMC Yekatit 12 Hospital Medical College

vi
 TABLE OF CONTENTS

APPROVAL SHEET ii

STATEMENT OF DECLARATION iii

APPROVAL BY THE BOARD OF EXAMINATION iv

ACKNOWLEDGMENT ii

ABBREVIATIONS/ ACRONYMS vi

TABLE OF CONTENTS vii

LIST OF TABLES xi

LIST OF FIGURES xii

ABSTRACT xiii

1. INTRODUCTION 1

1.1. Background 1

1.2. Statement of the problem 3

1.3 Significance of the study 5

2. LITERATURE REVIEW 6

2.1 Overview of Birth Injuries 6

2.2 Prevalence of Birth Injuries 6

2.3 Associated factors of birth asphyxia and birth trauma 7

2.3.1 Socio demographic factors 7
2.3.2 Medical and obstetric factors 8
2.3.3 Intra-partum factors 10
2.3.4. Neonatal factors 12

2.4. Conceptual framework 13

vii
3. OBJECTIVE 14

3.1. General objective 14

3.2. Specific objectives 14

4. MATERIALS AND METHODS 15

4.1 Study area 15

4.2 Study period 15

4.3 Study design 15

4.4 Population 15
4.4.1 Source population 15
4.4.2 Study population 15

4.5 Inclusions and Exclusions criteria 16

4.5.1 Inclusions criteria 16
4.5.2 Exclusion criteria 16

4.6 Sample size determination 16

4.7 Sampling procedure 17

4.8. Study variables 19

4.8.1 Dependent variable 19
4.8.2 Independent variables 19

4.9 Operational definitions/ Definition of terms 20

4.10 Data collection tools and procedures 21

4.11 Data quality assurance 21

4.12 Data processing and analysis 22

4.13 Ethical consideration 22

4.14 Dissemination of results 23

5. RESULTS 24

viii
 5.1 Socio demographic characteristics of the mothers 24

5.2 Medical and obstetric characteristics of the mothers 25

5.3 Intrapartum related factors 26

5.4 Early neonatal related factors 28

5.5. Prevalence of birth injuries 29

5.6. The associated factors of birth injuries 31

5.6.1. The associated factors of birth asphyxia 31
5.6.2. The associated factors of birth trauma 33

6. DISCUSSION 35

6.1. Prevalence of birth injury 35

6.2. The associated factors of birth asphyxia 36

6.3. The associated factors of birth trauma 38

7. LIMITATION OF THE STUDY 40

7.1 Strength of the study 40

7.2 Limitation of the study 40

8. CONCLUSION 41

9. RECOMMENDATIONS 42

7. REFERENCES 43

8. ANNEXES 49

Annex I: Participant information sheet (to be translated in to Amharic) 49

Annex II: Statement of informed consent from the mothers (English version) 50

Annex III: English Version Questionnaires 51

Annex IV Data Extraction Checklist 53

ix
Annex V፡ የተሳታፊዎች የመረጃ ቅፅ በአማርኛ 57

Annex VI: የስምምነት መግለጫ ፎርም - በአማርኛ 58

Annex VII: መጠይቅ - አማርኛ ቅጽ 59

x
 LIST OF TABLES
Table 1:Socio-demographic characteristics of mother for the study of prevalence of birth
injuries and associated factors among newborns delivered in public hospitals, Addis Ababa,
Ethiopia, 2021 (n=373). 24
Table 2:Medical and obstetrics characteristics of mother for the study of prevalence of birth
injuries and associated factors among newborns delivered in public hospitals, Addis Ababa,
Ethiopia, 2021 (n=373). 25
Table 3:Intra-partum factors of mother for the study of prevalence of birth injuries and
associated factors among newborns delivered in public hospitals, Addis Ababa, Ethiopia, 2021
(n=373). 27
Table 4:Early neonatal related factors of newborns delivered in public hospitals, Addis Ababa,
Ethiopia, 2021 (n=373). 29
Table 5: Common types of birth trauma among newborns delivered in public hospitals, Addis
Ababa, Ethiopia, 2021. 30
Table 6: Bivariate and multivariable logistic regression analysis for the associated factors of
birth asphyxia among newborns delivered in public hospitals, Addis Ababa, Ethiopia, 2021
(n=373). 32
Table 7: Bivariate and multivariable logistic regression analysis for the associated factors of
birth trauma among newborns delivered in public hospitals, Addis Ababa, Ethiopia, 2021. 34

xi
 LIST OF FIGURES

Figure 1: Conceptual framework on prevalence of birth injuries and associated factors among
Newborns delivered in public hospitals Addis Ababa, Ethiopia, 2021. 13
Figure 2: Diagrammatic presentation of sampling procedure for the newborns in selected four
public hospitals in Addis Ababa, Ethiopia, 2021. 18
Figure 3: Prevalence of birth injury among newborns delivered in public hospitals Addis
Ababa, Ethiopia, 2021. 30

xii
 ABSTRACT
Background: Birth injury is harm/damage that a baby suffers during the entire birth process.
It includes both birth asphyxia and physical trauma (birth trauma). In Ethiopia, intra-partum
related complications’ including birth injury has become the leading cause of neonatal
morbidity and mortality, accounting around 28%-31.6 % of neonatal mortality. This study was
done to assess the prevalence and factors associated with birth injuries among newborns
delivered in public hospitals Addis Ababa, Ethiopia, 2021.
Methods: Institution based cross-sectional study was conducted on total of 373 samples from
February 15th to April 20th, 2021 in selected public hospitals of Addis Ababa, Ethiopia.
Random sampling (lottery method) and systematic random sampling were used to select study
area and study participants respectively. Interview and chart review were used to collect data.
Data was entered by using Epi data version 4.0.2 and exported in to SPSS Software version 25
for analysis. Both bivariate and multivariable logistic regressions analysis were used to
analyze the data. Finally P-value 0.05 was used to claim statistically significant.

Result: In this study, the prevalence of birth injury was 24.7 %. Each birth asphyxia and birth
trauma accounted 13.9 % and 12.9 % respectively. In the final model, birth asphyxia was
significantly associated with the short height of the mothers (AOR=10.7, 95% CI: 3.59-32.4),
intrapartal fetal distress (AOR=4.74, 95% CI: 1.81-12.4), cord prolapse (AOR=7.7. 95% CI:
1.45-34.0), tight nuchal cord (AOR=9.2. 95% CI: 4.9-35.3), birth attended by residents
(AOR=0.19, 95% CI: 0.05-0.68), male sex of the newborns (AOR=3.84, 95% CI: 1.30-11.3)
and low birth weight of the newborns (AOR= 5.28, 95% CI: 1.58-17.6). Whereas, birth trauma
was significantly associated with gestational diabetic mellitus (AOR=5.01, 95% CI: 1.38-
18.1), prolonged duration of labor (AOR= 3.74, 95% CI: 1.52-9.20), instrumental delivery
(AOR=10.6, 95% CI: 3.45-32.7) and night time birth (AOR=4.82, 95% CI: 1.84-12.6).

Conclusion and recommendation: The prevalence of birth injury among newborns has
continued to increases and become life-threatening issue in the delivery and neonatal intensive
care unit in our study area. Therefore, considering the prevailing associated factors, robust
effort has to be made to optimize the quality of ANC care, obstetric care and follow up and
emergency obstetrics team has to be strengthened to reduce the prevalence of birth injury.

Key words: - Births injury, Birth Asphyxia, Birth trauma, Newborns, Prevalence

xiii
 1. INTRODUCTION

1.1. Background
The process of birth, whether spontaneous or assisted, is naturally traumatic for the newborns.
Birth injury is diminishing of body function due to adverse event that occur at birth. It is also
defined as the structural destruction or functional deterioration of the neonate’s body due to a
traumatic event at birth(1). They can be avoidable or unavoidable. Birth related injuries
encompass both those due to lack of oxygen (birth asphyxia) and physical trauma during the
birth process (birth trauma). Both can occur separately or in combination(2–5).
Injuries to the newborns that result from mechanical forces (i.e. compression, traction) during
the birth process are classified as mechanical birth trauma. Birth trauma was suggested to be
mostly due to difficult vaginal delivery especially with abnormal fetal presentation and use of
instruments during delivery like forceps and vacuum (6).

Another classification of birth injuries that occurs on the newborns were birth asphyxia.
According to the World Health Organization (WHO), birth asphyxia defined as a “failure to
initiate and sustain breathing at birth”(7). It’s usually considered by low APGAR score:
(Appearance, Pulse rate, Grimace, Activity and Respiration) <7 at 5th minutes, arterial cord
pH < 7 and base deficit >12, neonate did not cry at birth or needed resuscitation, acidosis,
seizure and hypotonia (8). Study suggested that, birth asphyxia occur due to maternal
antepartum, intra-partal and post partal factors (9). Intra-partum related factors accounts the
highest proportion of risk factors for birth asphyxia 70%. Whereas, antepartum and post partal
factors accounts 20% and 10% respectively (10).

Many babies suffer from minor injuries during the entire delivery process. Minor injuries do
not need to be treated and often heal by themselves; the major ones are often fatal and require
prompt recognition and intervention (11). According to international classification of disease
10th revision (ICD-10) and different literature , the common types of birth injuries includes
birth asphyxia and birth trauma (soft tissue injuries (bruises, petechial, subcutaneous fat
necrosis, ulceration and perforation), extra cranial hemorrhages (cephalhaematoma, caput
succedaneum, subgalial hemorrhage), intra-cranial hemorrhages, neurological injury (spinal

1
cord injury, facial nerve palsy, brachial plexus injury such as Erb’s palsy and Klumpke’s
palsy), musculoskeletal injury (long bone and clavicular fracture)(12–15).

Identification of high risk deliveries by fetal and perinatal ultrasound prior to labor, the use of
less harmful obstetrical instruments and techniques and timely caesarean section (C/S),
becoming more and more accepted ways of preventing birth injuries(6,16). Birth injuries are
commonly diagnosed by series of taste to examine which part of the body are affected .These
are physical examination, APGAR score, brain imaging ,umbilical cord blood gas analysis and
radiology like x-ray in case of fracture (17,18).

2
1.2. Statement of the problem
Birth injuries are the most preventable cause of neonatal mortality and morbidity
worldwide(19). According to 2016 WHO reports, it is estimated that 662, 000 neonatal deaths
and 1.3 million stillbirths occur annually due to intra-partum related complications, or
complications during labor and delivery. Birth injuries are among the three leading cause of
most neonatal death worldwide which accounts for 10% of deaths in children under 5 years of
age(20).

The incidence of birth injuries varies from place to place and it is mostly determined by the
standard of available obstetrical management. In developed countries like the United States,
the incidence of birth trauma ranges from 20 to 37/1000 live birth (21). Whereas in India
ranged from 3.2- 15.4/1000 live birth(22). In Africa, reports on birth injuries are limited,
however studies done in some African countries like Mali and Morocco showed frequencies of
0.68% and 0.26% respectively, while report from Egypt showed prevalence of 17 % (14,23).
In Ethiopia, there was insufficiency of literature done on birth injury; A study done in Jimma
University Specialized Hospital, South Western Ethiopia reported that the magnitude of birth
injury was 15.4 % (24). Whereas, the prevalence of birth asphyxia was estimated to be
between 3.1-32.9 % in different study area (25).

In 2014 and 2015 intra-partum related complications (Birth asphyxia and birth trauma) were
accounted 28% and 31.6 % of neonatal death respectively(10,26). Mechanical birth trauma
may affect several organ systems of the newborns such as neurologic, musculoskeletal and
visceral injuries. Injuries may be mild, transient or disabling and even it can be fatal (4). Birth
asphyxia is a leading cause of brain damage and also survivors often experience lifelong
health problems like disabilities, developmental delays, palsy, intellectual disabilities and
behavioral problems (27,28).

Due to the birth injuries and its complication most mothers may develop negative traumatic
birth experience. This can affect the next life of the mother and neonates by affecting lower
self-esteem and poor mental health, Post-Traumatic Stress Disorder (PTSD), poor maternal-
neonatal attachment, avoidance of breastfeeding and sexual malfunction(29,30). They are also
more prone to develop acute stress reactions and postpartum depression(31,32).

3
In different literature, various factors were identified to be associated with birth injury such as
maternal-related factors (Primigravida, short maternal stature, maternal pelvic anomalies,
maternal infection, maternal diabetes, obesity, placental abruption and maternal age (very
young and old). Labor-related factors (prolonged or extremely rapid labor, induced labor,
abnormal presentation, use of forceps or vacuum extraction, version, and extraction). Infant-
related factors (very low birth weight or extreme prematurity, fetal macrosomia, twin
(particularly the second one) (33–36). However, it was not well studied whether these
associated factors are similar to in our setup or not.

In developed countries, the occurrences of birth injury are decreased due to the improvements
in obstetric practice and care. However, it has been estimated that only 25% of deliveries are
supervised by skilled birth attendants in the developing countries which leads to increased
incidence of birth injuries. Most of them are possibly avoidable with recognition and proactive
management of the risk(37). In Ethiopia, according to 2019 mini EDHS (Ethiopia
Demographic and Health Survey) reported, the percentages of delivery by skilled providers
increased from 28% in 2016 to 50% in 2019. Despite of this, the number of neonatal death
increased from 29 per 1000 live births to 30 per 1000 live births in Ethiopia (38).

The Federal Ministry Health of Ethiopia developed and implemented high impact
interventions, including focused antenatal care, skilled birth service, post natal care and
comprehensive National Child Survival Strategy (2015–2020) in 2015, aiming to decrease
under-five mortality by two thirds (39,40). Despites of this efforts high number of newborn
death reported due to birth injuries and related complication in our country Ethiopia. So,
investigation of birth injuries is very important because it may show the possible associated
factors and prevention of its occurrence.

Reports about the prevalence of birth injures among live birth newborns are limited in
Ethiopia. As far as literature review revealed that, there is a limited research done on
prevalence of birth injuries among live birth delivery especially in the study area. However,
intra-partum related complications among newborns during the time of delivery are still the
leading cause of neonatal morbidity and mortality in Addis Ababa public hospitals. Due to
these reason, this study was carried out to assess the prevalence of birth injuries and associated
factors among newborns delivered in public hospitals Addis Ababa, Ethiopia, 2021.

4
1.3 Significance of the study
The result of this study was contributed to determine the prevalence of birth injuries among
newborns and identify unaddressed associated factors which may fill the gap to decrease the
occurrence of birth injuries and will be important for hospital manager to use data on neonatal
birth injuries as an indicator to assess the quality and safety of delivery units in the study area.

It also helps different stake holder of federal and regional health officer to see important way
to improve the prevention of birth injuries and appropriate methods of obstetric cares. The
findings will be important for policy makers and program designers that work on prevention of
birth injuries. It also increases the nursing body of knowledge, nursing education and
promotes nursing research. Additionally it provides valuable information that will be used as a
base line for future researchers.

5
 2. LITERATURE REVIEW
2.1 Overview of Birth Injuries
Birth injuries are a damage suffered by the neonates during labor and delivery. Despite exact
prenatal care, birth injuries usually occur. Injury to a fetus or neonate during labor and
delivery can be due to different factors. The predisposing factors for birth injuries can be
classified into socio-demographic, medical & obstetrics, intra-partum and early neonatal
factors. Neonatal birth injuries are among the major cause of neonatal mortality in most
developing countries(15).

2.2 Prevalence of Birth Injuries

The neonatal birth injuries occur occasionally with an incidence of a proximately 6-8 /1000
live births worldwide (33). A retrospective cross sectional study conducted in United States of
America reported that, the incidence of birth trauma was 2.9 %. In this study the three most
common birth traumas were injuries to the scalp 2%, injuries to the skeleton 0.37% and
fracture of the clavicle 0.243 % (21).

Different studies conducted in India (south India, Kolkata and Bombay hospital) revealed that,
the incidence of birth injuries were 11.76 %, 1.54% and 0.326 % respectively. The most
prevalent types of birth injuries were birth asphyxia (5.29 %) and cephalhaematoma (3.76 %)
in south India, whereas soft tissue injury (0.59%) and skull injury (0.51%) in Kolkata and
clavicular fracture (9.6%) and extra cranial bleeding (51.16%) in Bombay hospital (15,22,33).

Different studies performed in Iran (Kashan and Ahvaz), reported that the incidence of birth
injuries were 2.2 % and 1.96 % respectively. In their findings, the most common injuries were
birth trauma (cephalhaematoma) (57.2%) and birth asphyxia (16.8%) in Kashan and clavicular
15(0.14%) and humeral 6(0.056%) fracture in Ahvaz (12,35). According to prospective cohort
study conducted in Pakistan, the incidence of birth trauma was 41.16 per 1000 live birth.
Among this, cephalhaematoma and clavicular fracture were the two most common birth
trauma which accounts 2.14% and 1.56% respectively(37).

Prospective cross-sectional studies conducted in different part of Nigeria (Maiduguri and

Lagos) reported that, the incidence of birth injuries were 5.7 % and 67.2 % respectively. The
most prevalent cases were soft tissue injury (60.7%), sub-conjunctival hemorrhages (41.0%)

6
and severe birth asphyxia (39.3%) in Maiduguri. Similarly, caput succedaneum (22.2%) and
sub-conjunctival hemorrhage (22.2%) were the most common cases in Lagos (14,41). Based
on a retrospective descriptive study (2003-2014) conducted at the University Teaching
Hospital Cameron, the incidence of birth injuries was 1.84%. In their study, the most common
birth injuries were obstetric brachial plexus palsy (70.6%), fracture of the clavicle (22.5%) and
fracture of the humerus (4.80%) (42).

A cross-sectional study done in South west Ethiopia at Jimma University Specialized Hospital,
as they reported the magnitude of birth injury was 15.4%. Birth asphyxia and mechanical birth
trauma were the two dominant injuries and each accounts 22 (8.1%). Two newborns
developed both birth asphyxia and birth trauma and the most common mechanical birth
trauma was scalp injury which contributed to 63.6% (24). Studies made in different part of
Ethiopia (Dire Dawa, Hossana, north east Amhara ,Debre Tabor and Jimma) showed that, the
prevalence of birth asphyxia were 2.5 %, 15.1%, 22.6% ,28.35% and 32.9 % respectively
(9,43–46).

2.3 Associated factors of birth asphyxia and birth trauma

Different studies discussed that, the associated factors that affect birth asphyxia and birth
trauma were socio demographic factors, medical and obstetrics factors, intra-partum factors
and early neonatal factors.

2.3.1 Socio demographic factors

According to different studies maternal age, maternal weight, maternal height, body mass
index (pre-pregnancy BMI), maternal educational status, marital status and place of residence
were significantly associated with birth asphyxia and birth trauma (11,18,19,26,36,41–
43,47,48,49-52).

Different studies performed in Iran, Cameroon and Nigeria showed that maternal age between
20-30 years old was significant factors contributing to birth trauma(12,41,42). Other studies
also conducted in different part of Ethiopia (Dire Dawa, Hossana and Tigray) reported that,
maternal age between 21-25 years old (37%), maternal age >35 years old (Adjusted OR=6.4)
and maternal age between 25-35 years old (56.9%) were the factors significantly associated
with birth asphyxia (9,43,49). A Case- control study done in Colombia revealed that, mothers

7
without a partner were 2.56 times more likely risky for the development of birth asphyxia as
compared to mothers with partner (OR=2.56)(50)

A population-based retrospective cohort study done in the California and Sweden showed that,
pre-pregnancy BMI was significantly associated with the occurrence of birth trauma. Women
with class III obesity (pre-pregnancy BMI= >40 kg/m²) had more likely in giving birth
macrosomic baby than women with a normal pre-pregnancy BMI in California and incidence
of birth trauma like intracranial hemorrhages and shoulder dystocia were increased with
increasing maternal pre-pregnancy BMI in Sweden (36,51). A Systematic Review and Meta-
Analysis performed in Canada showed that, maternal obesity is associated with fetal
overgrowth (>4000g) (OR=2.17) ,birth weight ≥4500 g (OR= 2.77) and birth weight ≥90% lie
for gestational age (OR 2.42)(52) .

Studies done on Demographic and Health Survey (DHS) for the 34 Sub-Saharan African
countries and Uganda revealed that, Short maternal stature was associated with low APGAR
score and birth traumas such as clavicle fracture and brachial plexus in 34 Sub-Saharan
African Countries, whereas maternal height (AOR= 0.97) and maternal pelvis height
(AOR=0.73) were significantly associated with adverse pregnancy outcomes in Uganda
(47,48).

Different studies conducted in Ethiopia (Gondar and Tigray) showed that maternal educational
status was significantly associated with birth asphyxia. Illiterate women’s were 2.76 and 1.82
times more likely to develop birth asphyxia when compared with mother who were literate in
Gondar and Tigray respectively (19,49). Another study done in Jimma, South West Ethiopia
reported that, maternal place of residence was a factor significantly associated with birth
asphyxia, but maternal educational status was not significantly associated with birth asphyxia
and birth trauma(24).

2.3.2 Medical and obstetric factors

Different studies reported that various medical and obstetrics factors were associated with
birth asphyxia and birth trauma. Antenatal care (ANC), pregnancy type, parity, maternal
diabetes, gestational diabetes, pregnancy induced hypertension, chronic hypertension and
abruption placenta were factors associated with birth asphyxia (24,34,41,50,53–59). Factors

8
associated with birth trauma were antenatal care (ANC), parity, maternal diabetes and
gestational diabetes(34,41,55,57,58).

A retrospective study conducted in Thailand reported that, women’s with severe pre-eclampsia
were giving birth with high risk of required neonatal resuscitation (19.0%), first minutes
APGAR score <7 (15.5%) and fifth minutes APGAR score < 7 (5%) compared to
normotensive women (54). Different studies conducted in India revealed that, primiparous
womens carrying singleton pregnancies were at higher risk of developing both birth asphyxia
and birth trauma (34,55). The findings from other studies conducted in India and Ethiopia
revealed that, mothers with incomplete ANC follow up (<4) was significantly associated with
birth asphyxia (55,56).

A study carried out in Nigeria reported that, mother who have ANC follow up at primary
health care center gave birth around 44.4% babies with birth trauma compared to other health
facility(41). On the other hand, a study conducted in Ethiopia showed that, ANC visit was not
associated with birth asphyxia & birth trauma(24).

Crossectional study conducted in Nigeria showed that, mothers with diabetes mellitus were
delivering newborns with birth trauma (6.7%)(41). A retrospective case- control study carried
out in Ghana reported that, strong influence of baby's weight by gestational diabetes mellitus
(OR=14.2;p<0.0001) indicating that women who developed GDM are 14.2 times more likely
to deliver macrosomic babies compared to those did not develop GDM, that resulted in the
occurrence of birth asphyxia and trauma (shoulder dystocia) (57).

According to the world journal of diabetes, one of the neonatal complication in mothers of
gestational/chronic diabetes is macrosomia, which is risk factors for birth asphyxia and birth
trauma (58). A prospective cohort study conducted in Tigray region, Ethiopia showed that
women with pregnancy induced hypertension delivered babies with birth asphyxia (46.5%)
higher than normotensive pregnant women (11.3%) (59).

According to the study conducted in China , among mothers who developed abruption
placenta 19.4% of them delivered newborns with birth asphyxia, similarly a report from
Colombia also showed that, mothers with history of abruption placenta were 41 times (AOR=
41.09 ) higher risk to develop birth asphyxia than mothers with no abruption palcenta (50,53).

9
2.3.3 Intra-partum factors
Several studies revealed that different intra-partum factors were associated independently with
birth asphyxia and birth trauma. Factors associated with birth asphyxia includes fetal
presentation, duration of labor, cephalopelvic disproportion (CPD), premature rupture of
membrane, prolonged rupture of membrane, meconium stained amniotic fluids, cord prolapse,
tight nuchal cord, mode of delivery, intra-partal fetal distress, induction of labor, time of birth
and qualification of birth attendant. Whereas, factors associated with birth trauma are fetal
presentation, duration of labor, cephalopelvic disproportion (CPD), mode of delivery, time of
birth and qualification of birth attendant.

A retrospective study conducted in New work city reported that, forceps and vacuum assisted
birth were the most common contributing factors of birth trauma. The odds of brachial plexus
trauma and facial nerve palsy were 50.98 and 27.95 times more likely to occur during forceps-
assisted vaginal delivery compared with cesarean delivery respectively. On the other hand,
brachial plexus trauma and fracture were 49.92 and 6.55 times higher to occurs during
vacuum-assisted vaginal delivery compared with cesarean delivery(60).

Studies conducted at Turkey (Ankara) and Nigeria (Maiduguri) reported that, newborns
delivered by instrumental vaginal deliveries (vacuum and forceps) were the most common
predisposing factors for birth trauma. In Ankara, 0.5 %, 0.06 % and 0.16 % of the newborns
developed clavicular fracture, brachial plexus injury and shoulder dystocia respectively and in
Maiduguri 18% of newborns developed birth trauma (14,61). In addition to this, different
studies conducted in Indonesia, Indian and Ethiopia showed that, instrumental assisted
delivery was significant contributing factors of birth asphyxia(25,43,45,55,62).

A systematic review and meta-analysis done in USA reported that, umbilical cord prolapse
had significant impact on newborns by developing low APGAR score (<7 at 1st and 5th
minutes) immediately after birth (63). Different studies conducted in Indonesia, India and
Ethiopia revealed that prolonged rupture of membrane was significantly associated with birth
asphyxia. Neonates born with prolonged rupture of membranes more than 18 hours were
10.61, 2.19 and 2.98 times higher likely experienced birth asphyxia than neonates born with
normal duration of rupture of membranes respectively (49,55,62).

10
Different studies conducted in Nepal and Ethiopia revealed that, non-cephalic presentations
had significantly associated with birth asphyxia and birth trauma(24,64).

A study conducted in India (Bijapur) showed that, out of 100 newborns who developed birth
trauma, 87% and 9% of them were babies with vertex and breech presentation
respectively(15). Another prospective crossectional study conducted in India revealed that
prolonged labor and delivery time during (8:00 PM -2:00 AM) were factors significantly
associated with birth trauma with AOR= 207.6 and AOR= 91.4 respectively(22).

Studies from Thailand and India reported that, newborns delivered with meconium stained
amniotic fluids were 5.51 and 4.92 times more likely to encounter birth asphyxia than
newborns delivered with clear amniotic fluids respectively(55,65). Another similar study
conducted in Ethiopia revealed that, babies born with meconium stained amniotic fluids and
tight nuchal cord were 7.5 times and 3 times have a greater chance of developing birth
asphyxia respectively(9). A hospital-based cross sectional study conducted in Tanzania
showed that night shift deliveries with (OR =1.62) was significantly associated with adverse
birth outcome such as birth asphyxia, still birth and early neonatal death compared to morning
shift and evening shift deliveries with (OR =0.58) (66).

Studies conducted in Iran and Nigeria reported that, delivery by residents (6%) were having
high risk for developing birth trauma compared to deliveries done by specialists (2.1%),
midwifes (2.5%) and the students (2.5%) in Iran. Whereas, in Nigeria those births attended by
Midwives/Nurses were at higher risk of developing birth trauma (57.4%) compared to
obstetrics resident (4.9%) and consultants (16.4%) (12,14). In our country, Ethiopia a study
reported that among labors attended by Midwifes 56.2% were developed birth asphyxia and it
was higher compared to labors attended by medical interns alone (22.2%) and
Obstetrician(21.7%)(45).

Different studies conducted in Nigeria reported that, duration of labor, mode of delivery and
delivery attended by obstetricians were significantly associated with birth trauma(41) and
cephalopelvic disproportion (CPD) was a significant contributing factor for birth
asphyxia(67). A crossectional study conducted in Jimma and Gondar revealed that, intrapartal
fetal distress were significantly associated with birth asphyxia (19,24). Institutional based

11
crossectional study conducted in North East Amhara and Debre Tabor showed that, babies
born from mothers with premature rupture of membrane were 3.8 times and 6.3 times having
higher risks of developing birth asphyxia respectively (44,45).

2.3.4. Neonatal factors

As different literatures reported that early neonatal factors were significantly associated with
birth asphyxia and birth trauma. These include sex, birth weight, head circumference, APGAR
score, need of resuscitations and gestational age.

Reports from literatures in Iran and India showed that, neonatal sex was significantly
associated with birth trauma. Male neonates were 1.8 times (AOR=1.8) more likely to develop
birth trauma than female neonates in Iran (12). But study done in Indian shows that, male
neonates were 85.9% (AOR=0.141) less likely to encounter birth trauma than female
neonates(22). On the other hand, a study done in Nigeria reported that, neonatal sex was not
associated with the occurrence of birth trauma(41) and birth asphyxia(67).

In different studies high birth weight (>4000 gram)/fetal macrosomia was associated with
higher risks of developing birth trauma(37,68,69). A study conducted in Ethiopia showed
that, low birth weight newborns were 7.72 times at higher risks of developing birth asphyxia
than normal birth weight newborns(19). Other studies revealed that, neonatal head
circumference was a significant predictor of birth trauma in Pakistan with p-value =0.001(37)
and in Iran p-value <0.0001(12).

In a study from Nigeria showed that, gestational age at delivery (p-value= 0.89) have no any
association with birth trauma(41). In different studies done in Iran and Gonder showed that,
low first minutes and fifth minutes APGAR score were significantly associated with birth
trauma and birth asphyxia respectively (12,70). In Ethiopia as studies indicated, gestational
age less than 37 weeks was a significant determinant of birth asphyxia. Preterm delivery was
approximately four times (AOR =3.98) (56) and five times (AOR=4.7) (9) more likely to
develop birth asphyxia compared to term infant.

12
 2.4. Conceptual framework
Below are the conceptual frame work of the study developed after reviewing different related
literature (9,12,37,41–43,45). This conceptual framework shows the interaction between
different independent variables with two dependent variables (birth asphyxia and birth trauma)
(Fig.1).
Socio demographic factors
 Maternal age in years
 Educational status
 Marital status
 Prepregnancy BMI
 Maternal weight
 Maternal height
 Place of residence Intra-partum factors
Medical and Obstetric
factors  Fetal Presentation
 Duration of labor
 ANC follow up Birth asphyxia  Cephalopelvic
 Pregnancy type disproportion
 Parity  Intra-partal fetal
 Maternal diabetes distress
 Gestational  Premature rupture of
Birth trauma
diabetes membrane
 Chronic  Prolonged rupture of
hypertension membrane
 Pregnancy induced  Meconium stained
hypertension Early neonatal factors amniotic fluids
 Abruptio placenta  Mode of delivery
 Sex
 Induction
 Birth weight
 Cord prolapse
 Head circumferences
 Tight nuchal cord
 Need of resuscitation
 Time of birth
 APGAR score
 Qualification of
 Gestational age birth attendant

, weight
Figure 1: Conceptual framework on prevalence of birth injuries and associated factors among
Newborns delivered in public hospitals Addis Ababa, Ethiopia, 2021.
, andionality

 atern
13
 3. OBJECTIVE
3.1. General objective
 To assess the prevalence and factors associated with birth injuries among newborns
delivered in public hospitals Addis Ababa, Ethiopia, 2021.

3.2. Specific objectives

 To determine the prevalence of birth asphyxia among newborns delivered in public
hospitals Addis Ababa, Ethiopia, 2021.
 To determine the prevalence of birth trauma among newborns delivered in public
hospitals Addis Ababa, Ethiopia, 2021.
 To identify the associated factors for birth asphyxia among newborns delivered in
public hospitals Addis Ababa, Ethiopia, 2021.
 To identify the associated factors for birth trauma among newborns delivered in public
hospitals Addis Ababa, Ethiopia, 2021.

14
 4. MATERIALS AND METHODS
4.1 Study area
This study was conducted in Addis Ababa, the capital city of Ethiopia that is located in the
central part of the country. The city resides in a total area of 527 km2 with a total population
of 3,384,569 with an annual growth rate of 2.7%(71).The population in the near future
expected to raise to exceed 6.5 million population. This region has an estimated density 5165
people per square kilometer. Its average elevation is 2,500 meters above sea level and has a
fairly favorable climate and weather conditions(72).

The city has eleven sub city and 116 woredas. There are 12 public hospitals in the city, of
which 6 are owned by Addis Ababa City Administration Health Bureau, 5 by Federal Ministry
of Health, 1 by Addis Ababa University. Among these, one hospital was excluded (Amanuel
Psychiatric Hospital) due to unavailability of delivery service. From the rest eleven (11)
hospitals, four hospitals (TASH (Tikur Anbessa Specialized Hospital), Yekatit 12 Hospital
Medical College (Y-12HMC), GMH (Gandhi Memorial Hospital) and SPHMMC (St. Paul
Hospital Millennium Medical College) were selected by using simple random sampling
(lottery method).

4.2 Study period

This study was carried out from February 15th to April 20th, 2021.

4.3 Study design

Institutional based cross- sectional study was conducted.

4.4 Population

4.4.1 Source population

All newborns delivered in public hospitals of Addis Ababa with in the study period.

4.4.2 Study population

All randomly selected newborns delivered in selected public hospitals in Addis Ababa, during
the study period and fulfill the inclusion criteria’s.

15
4.5 Inclusions and Exclusions criteria

4.5.1 Inclusions criteria

 All live birth newborns delivered in selected public hospitals with gestational age of ≥
28 weeks.

4.5.2 Exclusion criteria

 Neonates with major congenital anomalies were excluded.
 Newborns whose birth weight of <1000 g were excluded.
 Those who have incomplete documentation (has no appropriate data that measure both
maternal and early neonatal parameter).
 Mothers who are seriously ill and unable to respond to the question.

4.6 Sample size determination

A single population proportion formula was used to determine the sample size based on the
following assumption:

Where; n=Sample size

Z= 95 % confidence level (Z α/2 = 1.96)

α = Level of significance 5% (α= 0.05) and

d= Margin of error 5% (d = 0.05).

The following formula was applied to determine the sample size for each dependent variable.

n=( p (1-p)

The prevalence of birth trauma was (P) = 8.1% taken from the previous study done in Jimma
University Specialized Hospital, South Western Ethiopia(24).

𝑛=( x 0.081(1-0.081) = 114

After considering 10% non-response rate, the total sample size was 125

16
The prevalence of birth asphyxia was (P) = 32.9 % taken from the previous study conducted in
Jimma zone public Hospitals, South West Ethiopia (46) after comparing with other studies
done in Ethiopia (9,43–45).

𝑛= x 0.329(1-0.329) = 339

After considering 10% non-response rate, the total sample size was 373

Finally, from the calculated sample size for the first and second dependent variables, the
largest sample size was 373

4.7 Sampling procedure

Simple random sampling technique (lottery method) was used to select four hospitals to be
included in the study from 11 public hospitals. The number of study unit to be sampled from
each selected hospital were determined by proportional to size allocation formula, based on
three months report of delivery in each selected hospital. The study subject were selected from
list of delivery registration book by using systematic random sampling technique every “K”
value=20, which was obtained through dividing the total number of delivery in three month
report from selected hospital to the required sample size. The first study participant was
selected by randomly from 1 to 20, then the rest of the study subject were included every “20”
value. Mothers that delivered more than one baby like twin, one of these babies was selected
by using simple random sampling technique.

K= Total number of delivery in three month report = 7500 ≈ 20

Required sample size 373

Proportional to size allocation formula was used to select study unit in each selected hospital.

𝑛 𝑛

𝑛 = the final sample size

17
 𝑛 = the number of three months delivery in each hospital

N= the total number of deliveries in the selected hospitals.

TASH= 373 1500 = 74.6≈ 75

7500

GMH = 373 3300 = 164.12 ≈ 164

7500

SPHMMC = 373 1500 = 74.6 ≈ 75

7500

Y-12HMC=373 1200 =59

7500
Public hospitals in Addis
Ababa having delivery
service

Simple random sampling

TASH GMH SPHMMC Y-12HMC

N= 1500 N=3300 N=1500 N=1200

n=75 n=164 n= 75 n= 59
By using proportional to size allocation formula

Systematic random sampling

Total sample size= 373

Figure 2: Diagrammatic presentation of sampling procedure for the newborns in selected four
public hospitals in Addis Ababa, Ethiopia, 2021.

18
4.8. Study variables
4.8.1 Dependent variable
 Birth injuries categorized as
 Birth asphyxia and
 Birth trauma
4.8.2 Independent variables
Socio demographic variables
Maternal age in year’s Maternal weight
Maternal height Pre-pregnancy BMI
Level of education Place of residence
Marital status

Medical and obstetrics variables

ANC follow up Pregnancy type
Parity Chronic DM
GDM Chronic hypertension
Abruptio placenta Pregnancy induced hypertension.

Intra-partum variables
Fetal presentation Duration of labor
Cephalopelvic disproportion Intra-partal fetal distress
Mode of delivery Time of birth
Cord prolapse Qualification of birth attendant
Nuchal cord Induction of labor
Meconium stained amniotic fluids Premature rupture of membrane
Prolonged rupture of membrane

Early neonatal variables

Sex Birth weight
Head circumferences APGAR score
Need of resuscitation Gestational age

19
4.9 Operational definitions/ Definition of terms
Birth injury: Injury to newborns that occur during labor and delivery who has diagnosis of
birth trauma, birth asphyxia or both.

Birth trauma: Any physical injury to newborns during the entire birth process that can be
recognized by clinical physical examination.

Birth Asphyxia: Failure to initiate, sustain breathing and not crying at birth and diagnosed
based on Apgar score <7 at 5th minutes.

Fetal distress: When the fetal heart rate is either <100 or >180 beat/minutes or if there is
non-reassurance fetal heart rate pattern.

Major congenital anomalies: Are structural or functional abnormalities which are

significance effect to reduce life expectancy of newborns such as hydrops, congenital heart
disease and neural tube defects.

ANC follow up: A programmed clinical visits of a mother at least one during her pregnancy
in this study.

Prolonged labor: Defined as when the combined duration of the first and the second stage of
labor are more than 12 hours in primipara or 8 hours in multipara mothers.

Premature rupture of membrane: Rupture of membrane of the amniotic sac and chorion
occurred one hour before onset of labor.

Prolonged rupture of membrane: Duration of rupture of membrane of the amniotic sac and
chorion >18 hours till delivery.

Birth weight: This was categorized as low, normal and large if birth weight was <2500 g,
2500-3999 g and ≥4000 g respectively.

Gestation at delivery: This was classified as ‘preterm’ if delivery was before 37 completed
weeks of gestation, ‘term delivery’ if baby was born 37 up to 42 completed weeks of
gestation and ‘post term’ if baby was born after 42 completed weeks of gestation.

Time of birth: This was categorized as ‘day time birth’ if the delivery was occurs during
6:00 AM- 5:59 PM and ‘night time birth’ if the delivery was occurs during 6:00 PM -5:59
AM.

20
4.10 Data collection tools and procedures
Data collection tools were developed by reviewing different related literatures
(9,12,24,41,43,45). Data was collected by Nurses and Midwives at delivery and post-natal
ward by using structured interviewer administered questionnaire and checklist. Both interview
and chart reviews were done in this study. The questionnaire was consists of a total of 21
questions that used to assess maternal socio-demographic variables 5 question (such as,
maternal age, maternal pre-pregnancy weight, residency, level of education and marital
status). Medical and obstetrics variables includes 16 questions (such as, ANC care, parity,
maternal diabetes, gestational diabetes, chronic hypertension, pregnancy induced
hypertension) were taken by interviewing the mother.

The checklist was consists of a total of 22 questions that used to assess data on intra-partum
variables 14 questions (such as, fetal presentation, duration of labor, prolonged rupture of
membrane, premature rupture of membrane, cephalopelvic disproportion, intra-partal fetal
distress, meconium stained amniotic fluids, mode of delivery, instrument use during delivery,
cord prolapse, nuchal cord, time of birth and qualification of birth attendant). Data on early
neonatal variables includes 8 questions (such as, sex, birth weight, gestational age, APGAR
score, need of resuscitation, head circumference) were taken from chart review of pregnant
women who delivered during data collection period by using structured checklist.

On maternal socio-demographic variables (maternal height) and neonatal variable (birth

weight and head circumference) there are 3 questions and data was collected by either chart
review if documented or by measurement. The remaining one variable pre-pregnancy BMI
was obtained by either asking maternal pre-pregnancy weight if she remembers or it was taken
from chart review during first trimester weight if she didn’t remember her weight, then
calculating by dividing her weight to height (Kg/m²). Birth injuries diagnosis obtained from
mothers medical record which was diagnosed by gynecologist/obstetricians and residents.

4.11 Data quality assurance

To assure the quality of data, the checklist was assessed for its completeness by external
experts including gynecologists and midwifery professionals and the questioner were pretested
on 5% (n=19 participants) of the total sample size similar newborns in another public hospital
( St Peter Specialized Hospital) which is out of the study site in Addis Ababa, Ethiopia. Then,

21
the tool was modified based on the comments of expert in the field and pretest result. Four
BSc midwife and nurses who are not staff members of the hospitals were assigned to collect
the data. One supervisor was assigned to control the process of data collection. For data
collectors, training was provided by the principal investigator about the aim of the study and
the components of the questionnaires.

4.12 Data processing and analysis

After completing data collection, data were categorized, coded, cleaned and recorded. The
data was entered by using Epi data version 4.0.2 and exported in to SPSS software version 25
for analysis. Descriptive statistical analysis such as frequencies, percentages, crosses
tabulation and mean were done. To assess the factors independently associated with birth
injury, two regression models (considering the dependent variables to be (i) birth asphyxia and
(ii) birth trauma) were used.
Bivariate logistic regression analysis was used to check the association between each
independent variable with dependent variable. Then those variables with p-value ≤ 0.25 were
entered a multivariable logistic regression model analysis in order to control the confounding
factors. In order to check the correlation between independent variables, multi-colinearity
(colinearity diagnostic taste) was done by using the value of variance inflation factors and
tolerance. Hosmer and Lemeshow goodness of fit test and omnibus tests of model coefficients
were done to test the fitness of the logistic regression in the final model, then it was found
good (statistically insignificant value, P value >0.05). The strength of association between
dependent and independent variables was expressed by using adjusted odds ratio with 95%
confidence interval. P-value 0.05 was considered as statistically significance. Eventually, the
findings were presented by using text, tables and graph.

4.13 Ethical consideration

This study was conducted after it is ethically reviewed and approved by School of Nursing and
Midwifery, Addis Ababa University, College of Health Science, Institutional Review Board
(IRB). Permission was also sought from each hospital. Study participants were asked for their
willingness to participate in the study after explaining the purpose of the study. Then written
informed consent was obtained from each participant. The privacy and confidentiality of
information was strictly maintained by not writing the name of study participants on data
collection tool.

22
4.14 Dissemination of results
The result of this research was presented to the Department of Nursing, College of Health
Sciences, Addis Ababa University. The result will also submit to each selected hospital. The
findings will also be disseminated to concerned governmental and non-governmental
organizations and soft copy of report will be available at College of Health Science library.
Finally, the finding will be submitted to peer reviewed journals for publication.

23
 5. RESULTS
5.1 Socio demographic characteristics of the mothers
In this study, all of the 373 mothers were give an informed consent to participate with a
response rate of 100%. The mean maternal age was 27.28 ± 5.16 SD years of whom 141
(37.8%) of mothers belonged to age groups of 25-29 years. Besides, around 133 (35.7%) of
mothers attended primary education. Almost all 358 (96%) of the participants were living in
urban area. In addition, around 339 (90.9%) of the respondents were married. The mean of
BMI and height of the mothers were 22.65 ± 3.34SD kg/m² and 156.8 ± 8.5 SD cm
respectively. Majority of the mothers i.e. 264 (70.8%) were categorize in the range of normal
body mass index (18.5-24.9). Regarding to the height of the mothers, about 322 (86.3%) of
mothers had body height of ≥145 cm (Table 1).

Table 1:Socio-demographic characteristics of mother for the study of prevalence of birth

injuries and associated factors among newborns delivered in public hospitals, Addis
Ababa, Ethiopia, 2021 (n=373).

Variables Category Frequency (n) Percentage (%)

Age group of the 15-19 22 5.9
mothers 20-24 88 23.6
25-29 141 37.8
30-34 73 19.6
≥35 49 13.1
Educational status No formal education 51 13.7
Primary education 133 35.7

Secondary education 108 29.0

More than secondary 81 21.6
Residency Urban 358 96
Rural 15 4
Marital status Married 339 90.9
Divorced 18 4.8
Single 16 4.3
Height of the <145 51 13.7
mother (in cm) ≥145 322 86.3

24
BMI of the <18.5 (underweight) 30 8
mothers (Kg/m²) 18.5-24.9 (Normal) 264 70.8
25-29.9 (overweight) 68 18.2
≥30 (obese) 11 2.9

5.2 Medical and obstetric characteristics of the mothers

Among 373 study subjects, 367 (98.4%) of mothers attended ANC follow up during their
pregnancy period. Majority of the participants, 312 (83.6%) had four and above ANC follow
up. Besides, nearly three quarter 266 (71.3%) of the respondents had ANC follow up at health
center. Half 186 (49.9%) of the mothers were primipara. Regarding the chronic medical illness
of the mothers, majority of the participants 364 (97.6%) and 369 (98.9%) did not have chronic
DM and hypertension respectively. Pregnancy induced hypertension 52 (14%) and gestational
diabetes mellitus 40 (10.7%) were the most common obstetrics complication during
pregnancy. Around one-tenth 39 (10.5%) of the participants who had pregnancy induced
hypertension developed pre-eclampsia. Majority of the mothers 341 (91.4%) had single type
of pregnancy and only 32 (8.6%) of the mothers had twin types of pregnancy (Table 2).

Table 2: Medical and obstetrics characteristics of mother for the study of prevalence of birth
injuries and associated factors among newborns delivered in public hospitals, Addis Ababa,
Ethiopia, 2021 (n=373).

Variables Category Frequency (n) Percentage (%)

ANC follow up Yes 367 98.4
No 6 1.6
Number of ANC 1-3 55 14.7
follow up ≥4 312 83.6
Facilities of ANC Health centers 262 70.2
follow up Government hospitals 78 20.9
Private hospitals 19 5.1
Private clinic 6 1.6
NGO clinic 2 0.5
Parity Primipara 186 49.9
Multipara 187 50.1
Gravidity Primigravida 160 42.9

25
 Multigravida 213 57.1
Types of pregnancy Single 341 91.4
Twins 32 8.6
Medical illness of the mothers
Chronic DM Yes 9 2.4
No 364 97.6
Chronic hypertension Yes 4 1.1
No 369 98.9
HIV test done Yes 373 100
No 0 0
HIV Status Positive 8 2.1
Negative 365 97.9
Others* 12 3.21
Obstetric complication of the mothers
Gestational DM Yes 40 10.7
No 333 89.3
Pregnancy induced Yes 52 14
hypertension No 321 86
Types of pregnancy Pre-eclampsia 39 10.5
induced hypertension Eclampsia 13 3.5
Abruptio placenta Yes 8 2.1
No 365 97.9
Others** 26 7
Key:*= Anemia, congestive heart failure, thrombocytopenia, asthma and hydronephrosis

**= Oligohydramnious and chorioamnionitis

5.3 Intrapartum related factors

According to the result of this study, majority 342 (91.7%) of the newborns were at vertex
presentation. Around 88 (23.6%) of the newborns had intrapartum fetal distress. Among the
total participated mothers, above two third 254 (68.1%) and 60 (16.1%) had spontaneous and
induced onset of labor respectively. In addition to this, about 59 (15.8%) of the mothers did
not experience any onset of labor during delivery i.e. delivered by elective cesarean section.

26
Nearly one third 119 (31.9%) of the mothers had prolonged duration of labor. Furthermore,
one quarters 90 (24.1%), 54 (14.5%) and 81(21.7%) of the mothers faced premature rupture of
membranes, prolonged rupture of membranes (≥18 hours) and meconium stained amniotic
fluid respectively. More than half 217 (58.2%) and 37(9.9%) of the newborns delivered by
cesarean section and instrumental delivery respectively. Regarding to cord problem, only 8
(2.1%) and 13 (3.5%) of the newborns developed cord prolapse and tight nuchal cord during
delivery respectively. Majority of the delivery 184 (49.3 %) and 135 (36.2%) attended by
residents and midwifes respectively (Table 3).

Table 3: Intra-partum factors of mother for the study of prevalence of birth injuries and
associated factors among newborns delivered in public hospitals, Addis Ababa, Ethiopia, 2021
(n=373).

Variables Category Frequency Percentages

(%)
Fetal presentation Vertex presentation 342 91.7
Breech presentation 23 6.2
Face presentation 5 1.3
Brow presentation 3 0.8
Intrapartal fetal distress Yes 88 23.6
No 285 76.4
CPD Yes 9 2.4
No 364 97.6
Condition of labor Spontaneous 254 68.1
Induced 60 16.1
No labor (elective c/s) 59 15.8
Duration of labor Normal 195 52.3
Prolonged 119 31.9
No labor 59 15.8
Premature rupture of Yes 90 24.1
membrane No 283 75.9
Duration of rupture of <18 hours 317 85
membrane ≥ 18 hours 56 15
Color of amniotic fluid Clear 292 78.3
Meconium stained 81 21.7
Mode of delivery SVD 119 31.9
Instrumental delivery 37 9.9

27
 C/S 217 58.2
Cord prolapse Yes 8 2.1
No 365 97.9
Tight nuchal cord Yes 13 3.5
No 360 96.5
Qualifications of birth Gynecologists/obstetri 54 14.5
attendant cians
Residents 184 49.3
Midwifes 135 36.2
Time of birth Day time birth 230 61.7
Night time birth 143 38.3

5.4 Early neonatal related factors

Of the total newborn babies, 225 (60.3%) of them were males. More than three quarters 288
(77.2%) of the newborn babies’ gestational age was in the range of 37-42 weeks at birth. The
mean gestational age at the time of birth was 39.45 ± 2.52 SD weeks. Besides, majority 285
(76.4%) of the participants had normal birth weight (2500-3999) gram and the average birth
weight of the newborn babies was 3119.09 ± 649.25 SD grams. 336 (90.1%) of the
participants had normal head circumference (33-38 cm) respectively. Moreover, around 52
(13.9%) of the newborns were unable to cry immediately after birth. About 321 (86.1%) of the
newborn babies had normal Apgar score at fifth minutes after birth (7-10). Additionally,
43(11.5%) and 9 (2.4%) of the participants had moderate (4-6) and low (0-3) APGAR score
respectively. Out of the study population, 52 (13.9 %) of the newborns needed resuscitation
after birth (Table 4).

28
Table 4: Early neonatal related factors of newborns delivered in public hospitals, Addis
Ababa, Ethiopia, 2021 (n=373).

Variables Category Frequency Percentages

(%)
Sex Male 225 60.3
Female 148 39.7
Gestational age <37 weeks (preterm) 44 11.8
37-42 weeks (term) 288 77.2
>42 weeks (post term) 41 11
Birth weight <2500 gram 54 14.5
2500-3999 gram 285 76.4
≥4000 gram 34 9.1

Head circumference <33 cm 21 5.6

33-38 cm 336 90.1
>38 cm 16 4.3
Cry after birth Yes 321 86.1
No 52 13.9
APGAR score (1st 0-3 (low) 17 4.6
minutes) 4-6 (moderate) 62 16.6
7-10 (normal) 294 78.8
APGAR score (5th 0-3 9 2.4
minutes) 4-6 43 11.5
7-10 321 86.1
Resuscitation after Yes 52 13.9
birth No 321 86.1

5.5. Prevalence of birth injuries

The overall prevalence of birth injury was found to be 92 (24.7%) of the total study
participants in this study. Birth asphyxia and birth trauma were identified in 52 (13.9%) and
48 (12.9%) of these babies, respectively. A total of eight newborns (2.1%) suffered from both
birth asphyxia and birth trauma (Fig.3).

29
Figure 3: Prevalence of birth injury among newborns delivered in public hospitals Addis
Ababa, Ethiopia, 2021.
Among those newborns who diagnosed with birth trauma, the most common types were extra
cranial trauma 39 (81.2%), neurological trauma 13 (27 %) and soft tissue trauma 10 (21%).
From extra cranial trauma, more than half, 20 (51.2%) and 10 (25.6%) of the newborn babies
developed subgalial hemorrhage and cephalhaematoma respectively. Among neurological
trauma and soft tissue trauma, the largest proportions contributed by facial palsy 8 (61.5%)
and facial &skin bruises 5(50%) respectively. Furthermore, 14 (29.2%) newborns developed
two types of birth trauma (Table 5).

Table 5: Common types of birth trauma among newborns delivered in public hospitals, Addis
Ababa, Ethiopia, 2021.

Types of birth trauma Frequency Percentages (%) Percentages (%)

(n) from newborn with from study
birth trauma population
(n=48) (n=373)
Extra cranial trauma
Caput succedaneum 9 18.8 2.41
Cephalhaematoma 10 20.8 2.68
Subgalial hemorrhage 20 41.7 5.36
Neurologic trauma

Erb’s palsy 5 10.4 1.3

Facial palsy 8 16.7 2.1
Soft tissue trauma
Facial and skin bruises 5 10.4 1.3
Skin laceration 3 6.3 0.8
Sub-conjuctival hemorrhage 2 4.2 0.5

30
5.6. The associated factors of birth injuries

5.6.1. The associated factors of birth asphyxia

According to the results of bivariate logistic regression analysis, there were 20 factors
associated with cruds odds ratio for birth asphyxia. Namely, age of the mothers, educational
status of the mothers, BMI of the mothers, height of the mothers, parity, GDM, types of
pregnancy, abruption placenta, intrapartal fetal distress, CPD, condition of labor, duration of
labor, duration of rupture of membrane, color of amniotic fluid, cord prolapse, tight nuchal
cord, qualifications of birth attendant, time of birth, sex and birth weight of the newborns. In
multivariable logistic regression analysis, short height of the mothers, intrapartal fetal distress,
cord prolapse, tight nuchal cord, birth attended by residents, male sex and low birth weight of
the newborns were the most contributing factors of birth asphyxia (Table 6).

The occurrence of birth asphyxia was 10.7 times (AOR=10.7, 95% CI: 3.59-32.4) higher to
occur among neonates born from mothers with short height (<145 cm) in relative to neonates
born from mothers with height >145 cm. Similarly, the odds of birth asphyxia among mothers
who had intrapartal fetal distress were nearly five times (AOR=4.74, 95% CI: 1.81-12.4)
higher than their counterpart. Furthermore, newborns who had cord prolapse and nuchal cord
during delivery were 7.7 times (AOR=7.7, 95% CI: 1.45-34.0) and 9.2 times (AOR=9.2, 95%
CI: (4.9-35.3) more likely experienced birth asphyxia compared to those neonates born
without cord prolapse and nuchal cord respectively.

Labor attended by residents were 81% less likely (AOR=0.19, 95% CI: 0.05-0.68) to
encounter birth asphyxia among newborns compared to those labor attended by
gynecologist/obstetricians. Besides, the odds of experiencing birth asphyxia was nearly four
times higher (AOR=3.84, 95% CI: 1.30-11.3) among male newborns comparing to female
newborns. In addition to this, low birth weight newborns were 5.28 more likely (AOR= 5.28,
95% CI: 1.58-17.6) to develop birth asphyxia relative to normal birth weight newborns (Table
6).

31
Table 6: Bivariate and multivariable logistic regression analysis for the associated factors of
birth asphyxia among newborns delivered in public hospitals, Addis Ababa, Ethiopia, 2021
(n=373).

Variables Category Birth asphyxia COR(95% AOR (95% CI)

Yes(n=52) No(n=321) CI)
Age groups of 15-19 4(7.7%) 18(5.6%) 1 1
mothers 20-24 14(26.9%) 74(23.1%) 0.85(0.25-0.28) 0.71(0.11-4.46)
25-29 19(36.5) 122(38%) 0.70(0.21-2.29) 0.67(0.10-4.30)
30-34 4(7.7%) 69(21.5%) 0.26(0.05-1.14)* 0.59(0.06-5.48)
≥35 11(21.2%) 38(11.8%) 1.30(0.36-4.65) 3.85(0.44-33.0)
Educational No formal 9(17.3%) 42(13.1%) 3.25(1.02-10.3)* 1.09(0.22-5.41)
status of education
mothers Primary 21(40.4%) 112(34.9%) 2.85(1.03-7.88)* 1.38(0.37-5.03)
Secondary 17(32.7%) 91(28.3%) 2.84(1.00-8.05)* 1.33(0.32-5.51)
Above 5(9.6%) 76(23.7%) 1 1
secondary
BMI <18.5 4(7.7%) 26(8.1) 1 1
(Kg/m²) 18.5-24.9 26(50%) 238(74.1%) 0.71(0.23-2.19) 1.06(0.18-6.06)
25-29.9 19(36.5%) 49(15.3%) 2.52(0.77-8.18)* 2.08(0.31-13.5)
≥30 3(5.8%) 8(2.5%) 2.43(0.44-13.2) 3.06(0.29-32.4)
Height of the <145 cm 22(42.3%) 29(9%) 7.38(3.78-14.4)* 10.7(3.59-32.4)**
mothers ≥145 cm 30(57.7%) 292(91%) 1 1
Parity Primipara 31(59.6%) 155(48.3%) 1.58(0.87-2.86)* 2.04(0.72-5.77)
Multipara 21(40.4%) 166(51.7%) 1 1
GDM Yes 10(19.2%) 30(9.3%) 2.31(1.05-5.06)* 2.24(0.52-9.67)
No 42(80.8%) 291(90.7%) 1 1
Types of Single 50(96.2%) 291(90.7%) 2.57(0.59-11.1)* 4.48(0.49-40.7)
pregnancy Twine 2(3.8%) 30(9.3%) 1 1
Abruptio Yes 4(7.7%) 4(1.2%) 6.6(1.59-27.2)* 5.30(0.52-54.0)
placenta No 48(92.3%) 317(98.8%) 1 1
Intrapartal Yes 26(50%) 62(19.3%) 4.17(2.26-7.68)* 4.74(1.81-12.4)**
fetal distress No 26(50%) 259(80.7%) 1 1
CPD Yes 4(7.7%) 5(1.6%) 5.26(1.36-20.3)* 5.08(0.85-30.3)
No 48(92.3%) 316(98.4%) 1 1
Condition of Spontaneous 42(80.8%) 212(66%) 3.78(1.13-12.6)* 6.73(0.88-51.2)
labor Induced 7(13.5%) 53(16.5%) 2.5(0.61-10.2)* 2.88(0.30-27.4)
No labor 3(5.8%) 56(17.4%) 1 1
Duration of Normal 24(49%) 171(64.5%) 1 1
labor Prolonged 25(51%) 94(35.5%) 1.89(1.02-3.5)* 1.80(0.70-4.62)
No labor 3(5.8%) 56(17.4%) 0.38(0.11-1.31)* 0.54(0.35-2.42)
Duration of <18 hours 41(78.8%) 276(86%) 1 1
rupture of ≥18 hours 11(21.2%) 45(14%) 1.64(0.78-3.43)* 1.05(0.33-3.32)
membranes
Color of Clear 33(63.5%) 259(80.7%) 1 1
amniotic fluids Meconium 19(36.5) 62(19.3%) 2.4(1.28-4.51)* 1.95(0.72-5.27)
stained
Cord prolapse Yes 4(7.7%) 4(1.2%) 6.6(1.59-27.2)* 7.7 (1.45-34.0)**
No 48(92.3%) 317(98.8) 1 1
Tight nuchal Yes 7(13.5%) 6(1.9%) 8.16(2.62-25.3)* 9.2 (4.9-35.3)**
cord No 45(86.5%) 315(98.1%) 1 1

32
 Continued
Qualification Gynecologist 14(26.9%) 40(12.5%) 1 1
of birth Residents 25(48.1%) 159(49.5%) 0.44(0.21-0.94)* 0.19(0.05-0.68)**
attendant Midwifes 13(25%) 122(38%) 0.3(0.13-0.7)* 0.62(0.15-2.56)
Time of birth Day time 20(38.5%) 210(65.4%) 1 1
Night time 32(61.5%) 111(34.6%) 3.02(1.65-5.53)* 1.81(0.73-4.51)
Sex Male 39(75%) 186(57.9%) 2.17(1.11-4.23)* 3.84(1.30-11.3)**
Female 13(25%) 135(42.1%) 1 1
Birth weight <2500 g 12(23.1%) 42(13.1%) 2.10(1.01-4.39)* 5.28(1.58-17.6)**
2500-3999 g 34(65.4%) 251(78.2%) 1 1
≥4000g 6(11.5%) 28(8.7%) 1.58(0.61-4.09) 0.29(0.04-1.75)

Hosmer and Lemeshow test, P-value=0.758. *statistically significant by COR at P-value ≤0.25.
** Statistically significant by AOR at P-value<0.05.
COR= Crude odds ratio. AOR= Adjusted odds ratio

5.6.2. The associated factors of birth trauma

The results of bivariate logistic regression analysis showed that, there were 11 factors
associated by crudes odds ratio with birth trauma. These includes BMI of the mothers, height
of the mothers, number of ANC follow up, GDM, fetal presentations, duration of labor, mode
of delivery, time of birth, sex, birth weight and head circumference of the newborns. To
control the effect of confounding, multivariate analysis were done and factors independently
associated with birth trauma were GDM, prolonged duration of labor, instrumental delivery
and night time birth (Table 7).

The odds of birth trauma were 5 times (AOR=5.01, 95% CI: 1.38-18.31) higher among
neonates born from mothers with gestational diabetic mellitus compared to those born from
mothers who did not experience gestational diabetic mellitus. Regarding duration of labor,
neonates born from mothers who had prolonged labor were 3.74 times (AOR= 3.74, 95% CI:
1.52-9.20) more likely to develop birth trauma when compared to those born from mother with
normal duration of labor. Those neonates born via instrumental assisted were nearly 10.6
times (AOR=10.6, 95% CI: 3.45-32.7) more susceptible to experience birth trauma than
neonates delivered via caesarian section. Moreover, neonates delivered during the night time
were nearly five times (AOR=4.82, 95% CI: 1.84-12.6) more likelihood of acquiring birth
trauma than neonates born during the day time (Table 7).

33
Table 7: Bivariate and multivariable logistic regression analysis for the associated factors of
birth trauma among newborns delivered in public hospitals, Addis Ababa, Ethiopia, 2021.

Variables Category Birth trauma COR (95% CI) AOR (95% CI)
Yes No
(n=48) (n=325)
BMI (Kg/m²) <18.5 3(6.3%) 27(8.3%) 1 1
18.5-24.9 24(50%) 240(73.8%) 0.90(0.25-3.18) 1.55(0.21-11.2)
25-29.9 18(37.5%) 50(15.4%) 3.24(0.87-11.9)* 1.59(0.17-14.5)
≥30 3(6.3%) 8(2.5%) 3.37(0.56-20.0)* 3.09(0.23-41.5)
Height of the <145 cm 13(27.1%) 38(11.7%) 2.8(1.36-5.76)* 1.73(0.54-5.55)
mothers ≥145 cm 35(72.9%) 287(88.3%) 1 1
Number of 1-3 10(20.8%) 45(13.8%) 1 1
ANC follow ≥4 36(75%) 276(84.9%) 0.58(0.27-1.26)* 0.37(0.13-1.10)
up
GDM Yes 16(33.3%) 24(7.4%) 6.27(3.02-13.0)* 5.01(1.38-18.1)**
No 32(66.7%) 301(92.6%) 1 1

Fetal Vertex 41(85.4%) 301(92.6%) 0.06(0.006-0.76)* 0.04(0.002-1.08)

presentation Breech 1(2.1%) 22(6.8%) 0.02(0.001-0.51)* 0.11(0.002-5.55)
Face 4(8.3%) 1(0.3%) 2.00(0.07-51.5) 3.36(0.05-21.7)
Brow 2(4.2%) 1(0.3%) 1 1
Duration of Normal 19(36.6%) 176(54.2%) 1 1
labor Prolonged 29(60.4%) 90(27.7%) 2.98(1.58-5.61)* 3.74(1.52-9.20)**
No labor 0(0%) 59(18.2%)

Mode of SVD 13(27.1%) 106(32.6%) 1.44(0.65-3.08) 1.15(0.39-3.32)

delivery Instrument 18(37.5%) 19(5.8%) 11.1(4.94-25.1)* 10.6(3.45-32.7)**
al
C/S 17(35.4%) 200(61.5%) 1 1
Time of Day time 13(27.1%) 217(66.8%) 1 1
birth
Night time 35(72.9%) 108(33.2%) 5.41(2.74-10.6)* 4.82(1.84-12.6)**
Sex Male 34(70.8%) 191(58.8%) 1.7(0.88-3.29)* 0.99(0.39-2.51)
Female 14(29.2%) 134(41.2%) 1 1
Birth weight <2500 g 4(8.5%) 50(15.4%) 0.70(0.23-2.09) 0.36(0.06-2.21)
2500-3999 29(60.4%) 256(78.8%) 1 1
g
≥4000 g 15(31.3%) 19(5.8%) 6.96(3.20-15.1)* 1.70(0.41-7.00)
Head <33 cm 3(6.3%) 18(5.5%) 1 1
circumferenc 33-38 cm 36(75%) 300(92.3%) 0.72(0.20-2.56) 0.12(0.01-1.09)
e >38 cm 9(18.8%) 7(2.2%) 7.71(1.60-37.1)* 1.25(0.09-17.1)

Hosmer and Lemeshow test, P-value =0.85. *= Statistically significant by COR at P-value ≤0.25.

**=Statistically significant by AOR at P-value<0.05. COR= Crude odds ratio, AOR= Adjusted
odds ratio

34
 6. DISCUSSION
Birth injury is the primary cause of morbidity and mortality among newborns. The prevalence
of birth injury differs widely from place to place. The medical service provided to the mothers
and newborns during delivery is important to reduce the overall prevalence of birth injury and
its burden. In this study, it was tried to identify and report the prevalence and associated
factors of birth injury among newborns delivered in public hospitals, Addis Ababa, Ethiopia.

6.1. Prevalence of birth injury

It was found that, the overall prevalence of birth injury among live birth newborns was 24.7%
with 95% CI (20.1-29.0). The prevalence in this study was higher than studies conducted in
Indian, Iran, Nigeria and Jimma (11.76%, 2.2 %, 5.7%, 15.4% respectively) (12,14,15,24).
This variation might be due to difference in sample size and study area (this study conducted
in referral hospitals where more complicated cases and referred from different setting that
could increase the prevalence of birth injury in the study area).

In this study the prevalence of birth asphyxia was 13.9% with 95% CI (10.5-17.7). This
finding was higher compared to studies conducted in Jimma university hospital 8.1% (24),
Dire Dawa 2.5 % (43) and South Indian 5.29% (15). However, it was lower than the studies
conducted in Jimma zone public hospitals 32.9% (46), Debre Tabor 28.35% (45), North East
Amhara 22.6% (44) and Hossana 15.1% (9). Similarly, this finding also lower as compared to
the studies conducted in Iran 16.8%(12) and Nigeria 39.3%(14). The possible reason might be
difference in sample size, using different definition of birth asphyxia (some studies used 1st
minutes APGAR score, but this study used 5th minutes APGAR score to define birth
asphyxia), variation of the study area and variation in distribution of skilled birth attendant in
different setting.

The current study showed that the prevalence of birth trauma was 12.9% with 95% CI (9.7-
16.4). This finding was higher as compared to the studies done in USA 2.9% (21), Pakistan
4.11% (37), India 1.54% (22) and Jimma 8.1% (24), However, this result was lower than
studies conducted in Nigeria 67.2% (41). This might be due to difference in study design,
sample size, study population and variation in diagnosis of birth trauma, i.e. this study used
birth trauma that was diagnosed only by physical examination but other studies included birth
trauma diagnosed by both physical examination and radiological.

35
The most common birth trauma seen in the current study was extra cranial trauma 39 (81.2%),
neurological trauma 13 (27%) and soft tissue trauma10 (21%). Subgalial hemorrhage 41.7 %
and cephalhaematoma 20.8 % were the most common birth trauma. This finding was higher
than studies done in Jimma and Nigeria, they were found that the most prevailing birth trauma
was subgalial hemorrhage which accounts 20% and 13.1 % respectively. The possible reason
might be in the current study, instrumental delivery is significantly associated with birth
trauma but not in study conducted in Jimma (24). In addition to this, there was low rate of
instrumental assisted delivery due to fear of cultural belief, so most women prefer to deliver
by spontaneous vaginal delivery in study conducted in Nigeria (14).

Cephalhaematoma was the second most common types of birth trauma diagnosed in around
20.8% of the newborns, it was lower when compared to studies done in Iran (12) and India
(33), they were found that the most common type of birth trauma was cephalhaematoma
accounts 57.2% and 38.7% respectively. However this finding was higher than study done in
Nigeria 16.4% (14) and Pakistan 2.14% (37). This might be due to differs in the skill of birth
attendant and frequency of instrumental delivery.

In this study, facial palsy was the most prevailing among neurological trauma. This finding
was supported by studies carried out in Iran (12), Indian (22), Bombay Hospital (33) and
Nigeria (Maiduguri) (14). The possible reason may be the fact that facial palsy occur during
difficult delivery when forceps are applied and leads to paralysis of seventh cranial nerve.

6.2. The associated factors of birth asphyxia

Factors independently associated with birth asphyxia were short height of the mothers,
intrapartal fetal distress, cord prolapse, tight nuchal cord, birth attended by residents, male sex
of the newborns and low birth weight of the newborns.

The occurrence of birth asphyxia was 10.7 times (AOR=10.7, 95% CI: 3.59-32.4) higher
among neonates born from mothers with short height (<145 cm) in relative to neonates born
from mothers with height >145 cm. This finding was supported by studies conducted in
Swedish (73) and Uganda (48). This could be due to the fact that those mothers who had short
height may have short stature that impair the progress of descent of the fetal head and leads to
prolong the duration of labor. This predisposes the newborn for birth asphyxia.

36
This study also identified that intrapartal fetal distress was significantly associated with birth
asphyxia. The odds of birth asphyxia among mothers who had intrapartal fetal distress were
nearly five times (AOR=4.74, 95% CI: 1.81-12.4) higher as compared to those mothers
without history of intrapartal fetal distress. This finding was almost similar to the previous
studies conducted in Gonder (19) and Addis Ababa(25). The likely reason is either fetal
tachycardia or fetal bradycardia is the main cause for fetal-placental oxygen deprivation that
exposes the newborn for birth asphyxia. Usually it’s an indication for emergency cesarean
section. But this finding is lower than study conducted in Jimma, Ethiopia neonates with
intrapartal fetal distress had 6.4 times more likely to develop birth asphyxia when compare to
neonates without intrapartal fetal distress (24). This difference may be due to variation in
study setting and quality of the obstetric care.

The occurrence of birth asphyxia was also independently associated with cord prolapse and
tight nuchal cord. Newborns who had cord prolapse during delivery were 7.7 times (AOR=7.7,
95% CI: 1.45-34.0) and tight nuchal cord during delivery were 9.2 times (AOR=9.2, 95% CI:
4.9-35.3) more likely experienced birth asphyxia compared to their counterpart. This finding
was supported with the previous studies conducted in USA (63), Hossana (9) and Jimma (46).
This could be due to the fact that compression of the cord may impair blood flow to the fetus
and compromise the fetal oxygenation; as a result the chance of occurrence of birth asphyxia
will be more likely.

Labor attended by residents were 81% less likely (AOR=0.19, 95% CI: 0.05-0.68) to
encounter birth asphyxia among newborns compared to those labor attended by
gynecologist/obstetricians. This might be due to since the study was conducted in teaching
hospitals; most labor was attended by residents, but labor attended by
gynecologists/obstetricians was critical cases/ consulted case that was unable to handle by
residents. This finding was inconsistent with study conducted in Debre Tabor, Ethiopia
neonates delivered by Midwives 56.2% developed birth asphyxia (45). The difference may be
due to variation in study setting and distribution of skilled birth attendant i.e. in Debre Tabor
most of the birth was attended by Midwives.

The odds of experiencing birth asphyxia was nearly four times higher (AOR=3.84, 95% CI:
1.30-11.3) among male newborns comparing to female newborns. This finding was supported

37
by study conducted in Washington, American (74) and Ayder Hospital, Ethiopia (75). This
might be due to biological difference makes male more at risk for birth asphyxia and it needs
further investigation. In addition to this, low birth weight newborns were 5.28 more likely
(AOR= 5.28, 95% CI: 1.58-17.6) to develop birth asphyxia relative to those who had normal
birth weight. This finding was in agreement with study conducted in Addis Ababa (25),
Gonder (19) and Jimma (46). This might be clarified by the fact that most low birth weight
neonates delivered during preterm gestation that might have immature lung and unable to pass
the transition period without difficulty of breathing.

In this study, age of the mothers, educational status of the mothers, BMI of the mothers,
parity, GDM, types of pregnancy, abruption placenta, condition of labor, duration of labor,
duration of rupture of membrane, color of amniotic fluid and time of birth were factors not
significantly associated with birth asphyxia in multivariable logistic regression analysis.
However, different studies revealed that these factors were associated with birth asphyxia
(9,49,50,53,55,62,65–67). This variation might be due to difference in study setting, health
care coverage, socio demography and methodology (study design i.e. case-control study was
carried out in (50) but this study was crossectional study).

6.3. The associated factors of birth trauma

The other dependent variable is birth trauma and the associated factors were found to be
GDM, prolonged duration of labor, instrumental delivery and night time birth. The odds of
birth trauma were 5 times (AOR=5.01, 95% CI: 1.38-18.1) higher among neonates born from
mothers with gestational diabetic mellitus compared to those born from mothers who did not
experience gestational diabetic mellitus. This finding was consistent with the studies
conducted in Nigeria (41) and Turkey (61). This might be due to the truth that, one of the
complications of infant of diabetic mothers is macrosomia, and this will predispose the
newborn for mechanical birth trauma that is why it’s the main reason for emergency C/s.

Neonates born from mothers who had prolonged labor were 3.74 times (AOR= 3.74, 95% CI:
1.52-9.20) more likely to develop birth trauma when compared to those born from mother with
normal duration of labor. This finding was supported by studies done in Nigeria (41), Indian
(22) and Bombay hospital (33). This is due to the fact that when there is prolonged labor, the
women may experience tiredness and unable to progress the labor. Therefore, to prevent fetal

38
distress, the birth attendant may apply forceps or vacuum to assist the labor. All these
difficulty may leads to birth trauma.

Another contributing factor significantly associated with birth trauma was instrumental
delivery. Those neonates born via instrumental assisted were 10.6 times (AOR=10.6, 95% CI:
3.45-32.7) more susceptible to experience birth trauma than neonates delivered via cesarean
section. This finding was in agreement with studies conducted in Bombay Hospital (33),
Indian(15) and Nigeria(14). The likely reason was due to the fact that, application of forceps
and vacuum on the fetal head may expose to extra cranial hemorrhage, intra cranial
hemorrhage and soft tissue abrasion/laceration. All these complication may leads to birth
trauma. But, this finding was higher than study done in Pakistan(37), neonates delivered by
instrument assisted were 2.14 times (AOR=2.14) more likely to develop birth trauma than
neonates delivered via cesarean section. This difference might be due to variation in study
setting and skill of birth attendant.

Night time delivery was also another contributing factor for birth trauma. Neonates delivered
during the night time were nearly five times (AOR= 4.82, 95% CI: 1.84-12.6) more likelihood
of acquiring birth trauma than neonates born during the day time. This finding was supported
by study conducted Indian (22). This is possibly justified by the number of birth attendant
assigned during duty hours were few that makes them unable to accomplish the overburden
during night time, expert in the field/gynecologist may not arrived on time for consulted cases
and it might be large proportion of referred cases during night time.

In this study, BMI of the mothers, height of the mothers, numbers of ANC follow up, fetal
presentation, sex of the newborns, birth weight and head circumference of the newborns were
factors not associated with birth trauma in multivariable logistic regression analysis. However,
the finding of different studies show that these factors were associated with birth trauma
(12,22,37,47,48,68,69). This difference might be due to variation study setting, socio
demographic of the mothers and methodology (study design i.e. retrospective cohort study was
conducted in (68), but this study was crossectional study).

39
 7. LIMITATION OF THE STUDY

7.1 Strength of the study

 Data was obtained prospectively among live birth delivery by interviewing the
mothers, chart review and measurement.
 The previous conducted research did not consider qualification of birth attendant and
time of birth, but this study investigated this factors.

7.2 Limitation of the study

 In this study, the diagnosis of birth asphyxia was made by using 5th minutes APGAR
score <7 only due to unavailability of arterial blood gas analysis and umbilical cord PH
in the laboratory facility. But according to American academy of pediatrics birth
asphyxia diagnosed based on arterial blood gas analysis, cord blood PH, fifth minutes
APGAR score <7 and altered CNS status.
 This study conducted in referral public hospitals, where most of the mothers admitted
to labor ward were referral cases from different community; this may probably
overestimate the prevalence of birth injury.
 This study was also share the disadvantage of crossectional study i.e. does not show
cause and effect relationship between dependent variable with its own contributing
factor.

40
 8. CONCLUSION
The overall prevalence of birth injury in this study was 24.7%, which is still higher than the
previous studies conducted in developing countries. Each birth asphyxia and birth trauma
constitutes 13.9% and 12.9% respectively. Birth asphyxia was independently associated with
short height of the mothers, intrapartal fetal distress, cord prolapse, tight nuchal cord, birth
attended by residents, male sex of the newborns and low birth weight of the newborns. In
addition to this, birth trauma was independently associated with GDM, prolonged duration of
labor, instrumental delivery and night time birth. However, the finding of this study could only
be generalized to this cohort womens – newborns in the study setting. Therefore, most of the
above contributing factors are preventable strong effort must be done to improve prenatal care
and the delivery service which are vital to reduce the occurrence of birth injury and its
complications.

41
 9. RECOMMENDATIONS
The increasing prevalence of birth injury can be reduced by active participation of the
following concerned bodies in order to improve the quality of newborns health.

 For maternal and newborn health care professionals:

- In the ANC follow up, give attention for early detection of obstetric complication
and strict follow up. Besides, counseling the mothers about good glycemic control
during pregnancy and its impact on the fetus during delivery if she had GDM.
- Strong effort has to be made to improve the intrapartal obstetric care and in case of
abnormalities occurs early decision of the obstetric team is mandatory.
- Following the mothers strictly during labor to avoid the complications of prolonged
labor.
- In case of high risk delivery, birth asphyxia should be anticipated and neonatal
health care professionals trained with neonatal resuscitation have to be there to
prevent birth asphyxia.
- Careful use of instrument (forceps and vacuum) during delivery and avoid
traumatizing the newborns is recommended.
 For hospitals:
- The hospitals administration should assign enough number of staff during the night
time and also assign night time supervision to solve the problem and improve delivery
service.
 For the researchers:
- The researchers should conduct longitudinal study in order to assess the long term
consequence of the newborns with birth injury. Furthermore, Qualitative studies should
be done to know the quality of delivery service and assess challenges faced by health
professional at delivery ward during their stays to improve newborns birth outcomes.

42
 7. REFERENCES
1. Akangire G, Carter B. Birth Injuries in Neonates. Pediatr Rev. 2016;37(11).
2. Rosenberg AA. Traumatic Birth Injury. Neoreviews. 2020;4(10).
3. OF Njokanma OK. mechanical birth trauma-An evaluation of predisposing factors at
ogun state univerity teaching hospital,sagamu. Niger J Paediatr. 2012;29(3):61–5.
4. Chaturvedi A, Chaturvedi A, Stanescu AL. Mechanical birth-related trauma to the
neonate : An imaging perspective. Insights Imaging. 2018;9:103–18.
5. Tekes A, Pinto PS. Birth-Related Injury to the Head and Cervical Spine in Neonates.
Magn Reson Imaging Clin N Am. 2011;19:777–790.
6. Fette A. Birth and Neonatal Care Injuries : A Special Aspect of Newborn Surgery.
Pediat Ther. 2012;2(5).
7. WHO. Basic newborn resuscitation_ A practical guide,Maternal and
Newbornhealth/safe motherhood unit division of reproductive health. WHO, Geneva;
2020.
8. The American College of Obstetricians and Gynecologists & American Academy of
Pediatrics. The Apgar Score. Committee opinion. Am Acad Pediatr Am Coll Obstet
Gynecol. 2017;126(644):e52–5.
9. Abdo RA, Halil HM, Kebede BA, Anshebo AA. Prevalence and contributing factors of
birth asphyxia among the neonates delivered at Nigist Eleni Mohammed memorial
teaching hospital , Southern Ethiopia : a cross- sectional study. BMC Pregnancy
Childbirth. 2019;6:1–7.
10. Ethiopian Federal Ministery of Health. Neonatal Intensive Care Unit ( NICU ) Training
Participants ’ Manual. 2014;
11. Uhing MR. Management of birth injuries. Clin Perinatol. 2015;32(1):19–38.
12. Abedzadeh-kalahroudi M, Talebian A, Jahangiri M. Incidence of Neonatal Birth
Injuries and Related Factors in Kashan , Iran. Arch Trauma Res. 2015;4(1):e22831.
13. WHO. ICD-10 Version_2016.
14. Ba I, Ag F, Simon P. Incidence and characteristics of neonatal birth injuries in
Maiduguri North-Eastern Nigeria. Niger J Paediatr. 2018;45(2):99–105.
15. u-zama R, Jeergal NA, Thobbi AN, Vijay Katti S. a Clinical Study of Neonatal Birth
Injuries in a Tertiary Care Hospital-Nicu, Bijapur. Indian J Child Health.
2020;7(7):288–90.
16. Nyström ME, Westerlund A, Höög E, Millde-luthander C, Högberg U, Grunewald C.
Healthcare system intervention for prevention of birth injuries – process evaluation of
self-assessment , peer review , feedback and agreement for change. BMC Health Serv
43
 Res. 2012;12:1–14.
17. Diagnostic Tests for HIE, Cerebral Palsy and Birth Injuries. Reiter & Walsh, PC; 2010.
18. Zhang XH, Zhang BL, Guo SM, Wang P, Yang JW. Clinical significance of dynamic
measurements of seric TNF-α, HMGBl, and NSE levels and aEEG monitoring in
neonatal asphyxia. Eur Rev Med Pharmacol Sci. 2017;21(19):4333–9.
19. Wosenu L, Worku AG, Teshome DF, Gelagay AA. Determinants of birth asphyxia
among live birth newborns in University of Gondar referral hospital, northwest
Ethiopia: A case-control study. PLoS One. 2018;13(9):1–12.
20. Liu L, Mathers C, Oza S, Chu Y, Black B, Cousens S, et al. MCEE-WHO methods and
data sources for child causes of death 2000-2015. World Heal Organ. 2016;1:20.
21. Sauber-Schatz EK, Markovic N, Weiss HB, Bodnar LM, Wilson JW, Pearlman MD.
Descriptive epidemiology of birth trauma in the United States in 2003. Paediatr Perinat
Epidemiol. 2010;24(2):116–24.
22. Ray S, Mondal R, Samanta M, Hazra A, Sabui T, Debnath A, et al. Prospective study of
neonatal birth trauma: Indian perspective. J Clin Neonatol. 2016;5(2):91.
23. Darmstadt GL, Hussein MH, Winch PJ, Haws RA, Gipson R, Santosham M. Practices
of rural Egyptian birth attendants during the antenatal, intrapartum and early neonatal
periods. J Heal Popul Nutr. 2018;26(1):36–45.
24. Tesfaye W, Netsanet Workneh EG. BIRTH INJURY AND ASSOCIATED FACTORS
IN JIMMA UNIVERSITY SPECIALIZED HOSPITAL, SOUTHWEST ETHIOPIA.
Ethiop J Pediatr Child Heal. 2016;XII(1).
25. Health P. Risk Factors of Perinatal Asphyxia Among Newborns Delivered at Public
Hospitals in Addis Ababa , Ethiopia : Case – Control Study. Pediatr Heal Med Ther.
2020;(297–306).
26. Unicef for every child.Maternal and Newborn Health Disparities Ethiopia.2015.
Ethiopia.
27. Eunson P. The long-term health, social, and financial burden of hypoxic-ischaemic
encephalopathy. Dev Med Child Neurol. 2015;57(S3):48–50.
28. Id CCE, Andoh HD, Frimpong-barfi A. Parental costs for in-patient neonatal services
for perinatal asphyxia and low birth weight in Ghana Christabel C Enweronu-Laryea,
Hilary D Andoh, Audrey Frimpong-Barfi, Francis M Asenso-Boadi. PLoS One.
2018;13(10):1–14.
29. Garthus-Niegel S, Knoph C, von Soest T, Nielsen CS, Eberhard-Gran M. The Role of
Labor Pain and Overall Birth Experience in the Development of Posttraumatic Stress
Symptoms: A Longitudinal Cohort Study. Birth. 2014;41(1):108–15.
30. Brown A, Jordan S. Impact of birth complications on breastfeeding duration: An

44
 internet survey. J Adv Nurs. 2013;69(4):828–39.
31. Gürber S, Bielinski-Blattmann D, Lemola S, Jaussi C, Von Wyl A, Surbek D, et al.
Maternal mental health in the first 3-week postpartum: The impact of caregiver support
and the subjective experience of childbirth - A longitudinal path model. J Psychosom
Obstet Gynecol. 2012;33(4):176–84.
32. Christl B, Reilly N, Smith M, Sims D, Chavasse F, Austin MP. The mental health of
mothers of unsettled infants: Is there value in routine psychosocial assessment in this
context? Arch Womens Ment Health. 2013;16(5):391–9.
33. Warke C, Malik S. Birth Injuries -A Review of Incidence, Perinatal Risk Factors and
Outcome. Bombay Hosp J. 2012;54(2).
34. Rosario DP, David LS, Kulkarni N, Beck MM. Risk factors associated with major
neonatal birth injuries during caesarean section in a tertiary care hospital in southern
India. J Clin Diagnostic Res. 2018;12(9):QC14–7.
35. Nasab SAM, Vaziri S, Arti HR, Najafi R. Incidence and associated risk factors of birth
fractures in the newborns. Pakistan J Med Sci. 2011;27(1):142–4.
36. Ekéus C, Högberg U, Norman M. Vacuum assisted birth and risk for cerebral
complications in term newborn infants: A population-based cohort study. BMC
Pregnancy Childbirth. 2014;14(1).
37. Shabbir S, Zahid M. Risk factors and incidence of birth trauma in tertiary care hospital
of Karachi. Pakistan J Med Heal Sci. 2015;31(1):66–9.
38. CSA. Ethiopia Mini Demographic and Health Survey. 2019.
39. Federal ministry of health FHD. National Strategy for Child Survival in Ethiopia.
Magzine Artic. 2015;
40. Summary E, Ababa A. Improving Antenatal Care Services Utilization in Ethiopia Full
Report. 2016;
41. Osinaike BO, Akinseye LOO, Akiyode OR, Anyaebunam C, Kushimo O. Prevalence
and predictive factors of birth traumas in neonates presenting to the children emergency
center of a tertiary center in Southwest , Nigeria. 2017;167–72.
42. Mah EM, Foumane P, Ngwanou DH, Nguefack S, Chiabi A, Dobit JS, et al. Birth
Injuries in Neonates at a University Teaching Hospital in Cameroon: Epidemiological,
Clinical and Therapeutic Aspects. Open J Pediatr. 2017;07(01):51–8.
43. Abdurashid N. Prevalence of Birth Asphyxia and Associated Factors among Neonates
Delivered in Dilchora Referral Hospital , in Dire Dawa , Eastern Ethiopia Clinics in
Mother and Child Health. Clin Mother Child Heal. 2017;14(4).
44. Woday A, Muluneh A, Denis CS. Birth asphyxia and its associated factors among
newborns in public hospital , northeast,Amhara, Ethiopia. PLoS One. 2019;14(12):113.

45
45. Bayih WA, Yitbarek GY, Aynalem YA, Abate BB. Prevalence and associated factors of
birth asphyxia among live births at Debre Tabor General Hospital , North Central
Ethiopia. 2020;2:1–12.
46. Wayessa ZJ, Belachew T, Joseph J. Birth asphyxia and associated factors among
newborns delivered in Jimma zone public hospitals , Southwest Ethiopia : A cross-
sectional study. J Midwifery Reprod Heal. 2018;6(5):2189-1295.
47. Arendt E, Singh NS, Campbell OMR. Effect of maternal height on caesarean section
and neonatal mortality rates in sub- Saharan Africa : An analysis of 34 national datasets.
PLoS One. 2018;1–15.
48. Munabi IG, Luboga SA, Mirembe F. A cross sectional study evaluating screening using
maternal anthropometric measurements for outcomes of childbirth in Ugandan mothers
at term. BMC Res Notes. 2015;8(1):1–8.
49. Hospitals G, Gebreheat G, Tsegay T, Kiros D, Teame H, Etsay N, et al. Prevalence and
Associated Factors of Perinatal Asphyxia among Neonates in General Hospitals of
Tigray , Ethiopia , 2018. Biomed Res Int. 2018;(November 2018).
50. Linea AEN. Risk factors associated with the development of perinatal asphyxia in
neonates at Hospital Universitario del Valle, Cali, Colombia. Biomédica. 2017;37:1–6.
51. Id AWGR, Lee HC, Lakshminrusimha S, Parry SS, Arief VN, Delacy IH, et al. Trends
in maternal prepregnancy body mass index ( BMI ) and its association with birth and
maternal outcomes in California , 2007 – 2016 : A retrospective cohort study. PLoS
One. 2019;1–2.
52. Gaudet L, Ferraro ZM, Wen SW, Walker M. Maternal Obesity and Occurrence of Fetal
Macrosomia : A Systematic Review and Meta-Analysis. 2014;2014.
53. Li Y, Tian Y, Liu N, Chen Y, Wu F. Analysis of 62 placental abruption cases : Risk
factors and clinical outcomes. Taiwan J Obstet Gynecol. 2019;58(2):223–6.
54. Kampruan R. Pregnancy Outcomes amongst Normotensive and Severe Preeclampsia
with or without Underlying Chronic Hypertension Pregnancy. Thai J Obstet Gynaecol.
2016;24(3):202–8.
55. Gane B, B VB, Rao R, Nandakumar S, Adhisivam B, Joy R. Antenatal and intrapartum
risk factors for perinatal asphyxia : A case control study Antenatal and intrapartum risk
factors for perinatal asphyxia. Curr Peditr Res. 2013;17(2).
56. Desalew A, Semahgn A, Tesfaye G. Determinants of birth asphyxia among newborns in
Ethiopia : A systematic review and meta-analysis. Int J Health Sci (Qassim).
2020;14(1).
57. Bawah AT, Ngala RA, Alidu H, Seini MM, Dokurugu J, Wumbee K, et al. Gestational
diabetes mellitus and obstetric outcomes in a Ghanaian community. Pan Afr Med J.
2019;32:1–7.

46
58. Mitanchez D, Yzydorczyk C, Simeoni U. What neonatal complications should the
pediatrician be aware of in case of maternal gestational diabetes ? World J Diabetes.
2015;6(5):734–43.
59. Berhe AK, Ilesanmi AO, Aimakhu CO, Mulugeta A. Effect of pregnancy induced
hypertension on adverse perinatal outcomes in Tigray regional state , Ethiopia : a
prospective cohort study. BMC Pregnancy Childbirth. 2020;6:1–11.
60. Savitz DA, Lipkind HS. Mode of Delivery in Nulliparous Women and Neonatal
Intracranial Injury. Obs Gynecol. 2013;118(6):1239–46.
61. Iskender C, Kaymak O, Erkenekli K, Ustunyurt E, Uygur D. Neonatal Injury at
Cephalic Vaginal Delivery : A Retrospective Analysis of Extent of Association with
Shoulder Dystocia. PLoS One. 2014;9(8):1–6.
62. Article O, Kardana IM. Risk factors of perinatal asphyxia in the term newborn at
sanglah general hospital , bali-indonesia. Bali Med J (Bali Med J). 2016;5(1):175–8.
63. Id DJLH, Warland J, Parast MM, Bendon RW, Hasegawa J, Banks J, et al. Umbilical
cord characteristics and their association with adverse pregnancy outcomes : A
systematic review and meta- analysis.2020.36(1–36).
64. Kozuki N, Katz J, Khatry SK, Tielsch JM, Leclerq SC, Mullany LC. Risk and burden of
adverse intrapartum-related outcomes associated with non-cephalic and multiple birth
in rural Nepal. BMJ Open. 2017;1–9.
65. Pitsawong C. Risk Factors Associated with Bir th Asphyxia in Phramongkutklao
Hospital. Thai J Obstet Gynaecol. 2011;19(4):165–71.
66. Mgaya A, Hinju J, Kidanto H. Is time of birth a predictor of adverse perinatal
outcome ? A hospital-based cross- sectional study in a low-resource setting , Tanzania.
BMC Pregnancy Childbirth. 2017;17:1–9.
67. Ba W. Perinatal asphyxia in a specialist hospital in Port Harcourt , Nigeria. Niger J
Paed. 2013;40(3):206–10.
68. Turkmen S, Johansson S, Dahmoun M. Foetal Macrosomia and Foetal-Maternal
Outcomes at Birth. J Pregnancy. 2018;2018.
69. Choukem S, Njim T, Atashili J, Hamilton-shield JP, Mbu R. High birth weight in a
suburban hospital in Cameroon : an analysis of the clinical cut-off , prevalence ,
predictors and adverse outcomes. BMJ Open. 2016;
70. Gudayu TW. Proportion and factors associated with low fifth minute Apgar score
among singleton newborn babies in Gondar University referral hospital ; North West
Ethiopia . Afr Health Sci. 2017;6–11.
71. Authority CS. 2007 POPULATION and HOUSING CENSUS OF ETHIOPIA
ADMINISTRATIVE REPORT Addis Ababa. 2012;(April).

47
72. WUP. Addis Ababa Population 2020 (Demographics, Maps, Graphs) [Internet]. Report.
2020. Available from: https://worldpopulationreview.com/world-cities/addis-ababa-
population.
73. Liljeström LB asphyxia. F scalp blood sampling and risk factors for hypoxic ischemic
encephalopathy. DCS of UD from the F of M 1435. 81 pp. UAUUI 201. Birth asphyxia.
2018.
74. Mohamed MA, Aly H. Impact of race on male predisposition to birth asphyxia. J
Perinatol. 2014;(September 2013):449–52.
75. Gebregziabher GT, Hadgu FB, Abebe HT. Prevalence and Associated Factors of
Perinatal Asphyxia in Neonates Admitted to Ayder Comprehensive Specialized
Hospital, Northern Ethiopia: A Cross-Sectional Study. Int J Pediatr. 2020;2020:1–8.

48
 8. ANNEXES
Annex I: Participant information sheet (to be translated in to Amharic)
Good morning/ after noon

My name is……………………………….. I am coming here in order to collect data for the

study of prevalence of birth injury and associated factors among newborns delivered in Addis
Ababa public hospitals, 2021. This study is conducted by Esubalew Amsalu, who is masters of
neonatal nursing students in AAU. Now I am kindly asking you to explain about this study and
if you are willing, you will be a participant for this study

1. Title of the research project: Prevalence of birth injuries and associated factors
among newborns delivered in public Hospitals Addis Ababa, Ethiopia, 2021.
2. Aim of the study: The purpose of this study is to assess the prevalence of birth injuries
and associated factors among newborns at selected public Hospitals in Addis Ababa,
Ethiopia, 2020/21.
3. Benefits for participations: Study participants will not have any financial incentives
from participating on this study. The result of the study will be beneficial for policy
makers and program designers that work on prevention of birth injuries. It will benefit
the hospitals to identify gaps at delivery ward and used as reference for their quality
improvement project.

4. Risks and Complication: There are no anticipated risks to your participation except
taking little minutes from your time.

5. Confidentiality:- Any information about you will kept as confidential. The

information collected about you will be coded using code numbers. At any time you
have the right to stop or withdraw from the study.

So, are you willing to be part of this study?

If yes, please continue to the next page

If no, thank you very much.

49
Annex II: Statement of informed consent from the mothers (English version)
Code No___________

I have read the information above. I have been given the opportunity to ask questions and my
questions have been answered. I voluntarily consent that I would participate in this study.
With full understanding of the situation I agree to give the entire necessary information. I
understand that I have the right to withdraw from the study at any time.

Name of the researcher ____________________ Signature ______Date :______(

dd/mm/yy)

Date of interview: ____________________ Time started ______ Time finished______

Interviewer Name ___________________ Signature ______ Date ______

Supervisor Name : ____________________ Signature ______

We thank you for consenting to take part in the study

50
Annex III: English Version Questionnaires
Addis Ababa University, College of Health Sciences, School of Nursing and Midwifery.

This questionnaire was used to assess socio-demographic and medical and obstetrics factors of
the mothers associated with birth injuries among newborns delivered in public hospital, Addis
Ababa, Ethiopia, 2021.

Identification related information

Data collector Name-------------------------------- Date: ------------------

Supervisor’s Name: Signature -------------

Questionnaire Code No: MRN: -------------------

Hospital name: -----------------------------------

Part I. Socio demographic characteristics of mothers

S. No Question Response Skip
101 Age of the mother in completed year? 1. --------years
102 What is your level of education? 1. No formal
education
2. Primary
3. Secondary
4. More than
secondary
103 Where is your residence? 1. Urban
2. Rural
104 What is your marital status? 1. Married
2. Divorced
3. Single
4. Widowed
105 What is your pre-pregnancy weight? 1. ……….. Kg

Part II Medical and obstetric characteristics of mothers

S. No Question Response Skip
201 Did you have ANC follow up during this 1. Yes If no, skip to Q no
pregnancy? 204
2. No
202 If yes, how many times you visited health 1. …….(put in No)

51
 services for ANC?

203 Facilities where you received ANC? 1. Health center

2. Governmental
hospital
3. Private hospital
4. Private clinic
5. NGO clinic
6. Others……
204 How many times you gave birth including 1. ………(put in No)
this pregnancy (Parity)?

205 How many times you become pregnant, 1……..(put in No)

including this one (Gravida)?
Did you have any medically confirmed cases during this pregnancy?

206 Chronic diabetes mellitus 1. Yes If no, skip to Q

no,207
2. No
207 Gestational diabetes? 1. Yes If no, skip to Q
no,208
2. No
208 Chronic hypertension? 1. Yes If no, skip to Q
no,209
2. No
209 Pregnancy induced hypertension? 1. Yes If no, skip to Q no
210
2. No
210 If yes to question No 210, what was the 1. Pre-eclampsia
diagnosis?
2. Eclampsia
211 HIV test done? 1. Yes If no, skip to Q no
2. No 213

212 HIV status? 1. Positive

2. Negative
213 If others, specify? ……………………..
214 What is the type of pregnancy? 1. Single
2. Twine
3. Triplet
4. Others.
215 Did you get vaginal bleeding during this 1. Yes
pregnancy?
2. No

52
Annex IV Data Extraction Checklist
Title of research project: Prevalence of birth injuries and associated factors among
newborns delivered in public hospitals, Addis Ababa, Ethiopia 2020/21.
Name of investigator: Esubalew Amsalu (BSc)

Name of organization: Addis Ababa University, College of Health Science, School of

Nursing and Midwifery.

Name of sponsor: Addis Ababa University.

Introduction: This checklist is prepared for the collection of intra-partum and early neonatal
factors that will be important for the assessment of associated factors of birth injuries among
newborns delivered in public hospitals in Addis Ababa. This is prepared for head
nurse/midwifes of the delivery and post natal unit in order to create awareness about the study
and to get consent to perform the study.

Purpose of the research project: To assess the prevalence of birth injuries and associated
factors among newborns delivered in public Hospitals Addis Ababa, Ethiopia, 2020/21.

Procedure: The information which is important for this study will be retrieved from maternal
chart review.

Risk: Since this information will be conducted by taking necessary information from maternal
chart review, it will not harm to the patient and the information obtained from mothers will
kept confidential

Benefit: This research have no benefit to the study participant

Confidentiality: For confidentiality the data in the chart will be collected without recording
the name of study participant and the information will kept in key and locked system with
computer password.

Person to contact: If you have any question you want to ask, you can contact any of the
following individuals (Investigators or Advisors)

PI: Esubalew Amsalu Email: [email protected] , Tel: +251916507583

Advisors: Ms. Kalkidan Wondwossen (MSc, Assistant professor)

Tel: +251913634088

Mrs. Feven Mulugeta (MSc), Tel: +251910712396

53
Part III Intra-partum factors

S. No Question Response Skip

301 Fetal presentation? 1. Vertex presentation

2. Breech presentation
3. Face presentation
4. Brow presentation
5. Shoulder
presentation
302 Intra-partal fetal distress? 1. Yes If no, skip to Q no
303?
2. No
303 Cephalopelvic disproportion? 1. Yes If no, skip to Q no
304
2. No
304 Is labor started? 1. Yes If no, skip to Q no
2. No 307
305 Conditions of labor? 1. Spontaneous
2. Induced
306 Duration of labor in hours? 1. ………………
307 Duration of rupture of membrane in 1. ……………….
hours till delivery?
308 Premature rupture of memberane? 1. Yes
2. No
309 What is the color of the amniotic 1. Clear
fluids? 2. Meconium stained

310 Mode of delivery? 1. Normal Vaginal

2. Instrumental
delivery
3. Cesarean section
Did the neonate suffer from cord problem during delivery?

311 Cord prolapse? 1. Yes

2. No
312 Nuchal cord? 1. Yes
2. No
313 Qualification of birth attendant? 1. Gynecologist-
obstetricians

54
 2. Residents
3. General practitioner
4. Interns
5. Midwifery
6. Other
(specify)………
314 Time of birth? 1. Hours
Part IV Neonatal factor
S. No Question Response Skip
401 Baby sex? 1. Male
2. Female
402 GA (wks.) 1. ………weeks
403 Did the baby cry immediately after 1. Yes
birth? 2. No
404 Apgar score (1st and 1. …… (Put in number?)
5thminute)respectively
405 Resuscitated at birth (Bag mask) 1. Yes
2. No
406 Are there birth injuries after 1. Yes If no,
delivery? 2. No skip to
Part IV
407 If yes to question No 405, What are 1. Birth asphyxia
the types of birth injuries present? 2. Birth trauma
3. Both birth asphyxia and birth
trauma

55
  Extra cranial injury
408 If there is birth trauma, what are the 1. Caput succedaneum
types? 2. Cephalhaematoma
3. Sub galial hemorrhage
 Fractures
4. Skull fracture
5. Clavicular fracture
6. Humeral fracture
7. Rib fracture
8. Femoral fracture
 Neurologic trauma
9. Facial palsy
10. Erb’s palsy
11. Spinal cord injury
 Soft tissue injuries
12. Facial and skin bruises
13. Ecchymosis /bluish of skin
14. Skin laceration
15. Sub conjuctival hemorrhage
Other birth injuries (specify)……..

Part V. Question to be filled by medical record or measurement

1. What is the height of the mother (measure or see card?)…………………(In cm)

2. Pre-pregnancy BMI (calculate?)……………………………..( kg/m2 )
3. What is the weight of the newborn at birth (measure or see card?)…………(Ingram)
4. What is the head circumference of the newborn at birth (measure or see card?)… (In
cm)

56
Annex V፡ የተሳታፊዎች የመረጃ ቅፅ በአማርኛ
ሥሜ __________________ እባላለው ፤ በአዲስ አበባ ዩኒቨርሲቲ፣ ጤና ሳይንስ ኮሌጅ፣ ነርሲንግና

ሚድዋይፍሪ ትምህርት ክፍል የ2ኛ ዓመት የማስትሬት ድግሪ ተመራቂ ተማሪ ነኝ፡፡ በአሁኑ ሰዓት

በአዲስ አበባ ውስጥ በሚገኙ የመንግስት ሆስፒታሎቸ ውስት በወሊድ ወቅት ስለሚከሰት የጨቅላ

ህጻናት አደጋ እና አጋላጭ ሁኔታዎችን ለመለየት በማጥናት ላይ ነኝ፡፡

የጥናቱ ርዕስ፡ - በአዲስ አበባ ውስጥ በሚገኙ የመንግስት ሆስፒታሎች ውስጥ በወሊድ ወቅት

ስለሚከሰት የጨቅላ ህጻናት አደጋ እና አጋላጭ ሁኔታዎችን መለየት ፣ኢትዮጵያ፣ 2013 ዓ.ም፡፡

የጥናቱ አላማ፡- በወሊድ ወቅት የሚከሰት የጨቅላ ህጻናት አደጋ እና የሚያጋልጡ ሁኔታዎችን

ለመለየት፡፡

ተሳታፊዎች፡ - በአዲስ አበባ በሚገኙ የመንግስት ሆስፒታሎቸ ውስጥ አዲስ የተወለዱ ጨቅላ ህፃናት

የጎንዮሽ ጉዳት፡ - በዚህ ጥናት መሳተፍ ምንም አይነት ጉዳት የለውም፡፡

ጥቅማጥቅም፡ - በጥናቱ ለሚሳተፉ ፍቃደኛ ተሳታፊዎች ምንም አይነት የገንዘብ ክፍያ የለም፣ነገር ግን

የጥናቱ ውጤት በወሊድ ወቅት ስለሚከሰት የጨቅላ ህጻናት አደጋ ለመከላከል ስለሚጠቅም በተዘዋዋሪ

መንገድ ሌላ ህመምተኛ እንዲሁም ህብረተሰቡን የመጥቀም እድል ያገኛሉ፡፡ስለዚህ የተወሰኑ

ጥያቄዎችን ልጠይቅዎት እወዳለሁ፡፡ የእርስዎ በእውነት ላይ የተመሰረተ መልስ ለዚህ ጥናት መሳካት

አስተዋፅኦ ያደርጋል፡፡ እርስዎ የሚሰጡት መረጃ ከአጥኚውና ቃለመጠይቅ አድራጊው በስተቀር

በማንኛውም መልኩ ለሌላ 3ኛ ወገን ተላልፎ አይሰጥም፡፡ በሙሉ ፈቃደኝት እንዲሳተፉ እየጠየቅሁ

ያለመሳተፍ ወይም በማንኛውም ጊዜ ራስዎን ከጥናቱ የማግለል ሙሉ መብት አለዎት፡፡ ማንኛውም

ጥያቄ ካለዎት በሚከተለው አድራሻዬ ማግኘት ይችላሉ፡፡

የጥናቱ ባለቢት ሰም ፡ እሱባለው አምሳሉ

ስልክ፡ 0916507583

ኢሜል፡ [email protected]

57
Annex VI: የስምምነት መግለጫ ፎርም - በአማርኛ
አዲስ አበባ ዩኒቨርሲቲ፤ጤና ሳይንስ ኮሌጅ፤ነርሲንግ ትምህርት ክፍል፤ድህረ ምረቃ ፕሮግራም

እኔ ለዚህ ጥናት የስምምነት ፊርማዬን ስሰጥ፤የዚህ ጥናት ዓላማ በደንብ የተብራራልኝ ሲሆን

የጥናቱንም ዓላማ ተረድቻለሁ፡፡ በዚሁ ጥናት ላይ መሳተፍ በሙሉ ፈቃደኝነት ላይ የተመሰረተ መሆኑን

በሚገባ የተረዳሁ ሲሆን በማንኛውም ጊዜ ከጥናቱ ራሴን የማግለል መብት እንዳለኝ አውቄአለሁ፡፡

ስለሆነም የምሰጠው መረጃ እስከተጠበቀ ድረስ በዚህ ጥናት ለመሳተፍ ተስማምቻለሁ፡፡ በጥናቱ

ስሳተፍ በህጻኑ/ኗ ወይም በኔ ላይ ምንም አይነት ጉዳት እንደሌለው በግልጽ ተረድቻለሁ፡፡በዚህ ጥናት

ለመሳተፍ ስምምነቴን ስገልፅ ለምጠቀው ጥያቄ በእውነት ላይ የመሰረተ መልስ ለመስጠት

የተስማማሁ መሆኔን አረጋግጣለሁ፡፡በመብቴ ዙሪያም ሆነ ስለ ጥናቱ መንኛውንም ያልገባኝን ጥያቄ

መጠየቅ እንደምችል ተገልጾልኛል፡፡

የመረጃ ሰጪ ፊርማ ____________________ ቀን _______________

የተጀመረበት ሰዓት ____________________ ያለቀበት ሰዓት______________

የጠያቂው ስም ___________________ ፊርማ_____________ ቀን______________

የተቆጣጣሪ ስም__________________ ፊርማ________________ ቀን_____________

58
Annex VII: መጠይቅ - አማርኛ ቅጽ
አዲስ አበባ ዩኒቨርሲቲ፤ ጤና ሳይንስ ኮሌጅ ፤ነርሲንግ ዲፓርትመንት፤ ድህረ ምረቃ ፕሮግራም

ይህ መጠይቅ የተዘጋጀው በአዲስ አበባ በሚገኙ የህዝብ ሆስፒታሎች ውስጥ በወሊድ ወቅት

ለሚከሰት ለጨቅላ ህጻናት አደጋ እና የሚያጋልጡ ሁኔታዎችን ለመለየት ነው፡፡

የጠያቂው ስም ____________________ ቀን______________

የተቆጣጣሪ ስም__________________ ቀን_____________

የመጠይቁ መለያ ቁጥር__________ የተቋሙ ስም__________

ክፍል አንድ፡- የወላጅ የጨቅላ ህጻኑ እናቱ አጠቃላይ ሁኔታ.

ተ. ጥያቄ መልስ ይዝለሉ

ቁ
101 እድሜዎ ስንት ነው ( በአመት) ? 1. ......
102 የትመህርት ደረጃዎ ስንት 1. ያልተማረች
ነው? 2. የመጀመሪያ ደረጃ
3. ሁለተኛ ደረጃ
የተማረች
4. ሁለተኛ ደረጃ
በላይ
103 የመኖሪያ ቦታዎ የት ነው? 1. ከተማ
2. ገጠር
104 የጋብቻ ሁኒታ? 1. ያገባች
2. የፈታች
3. ያላገባች
4. ባሉዋ የሞተባት
105 ከእርግዝና በፊት የነበረዉን ክብደትዎን ስንት 1. …………..
ነው ?
ክፍል ሁለት፤ ከዉሰጥ ደውና ከቅድመ ወሊድ ጋር የተያያዙ አጋላጭ ሁኔታዎች
የቅድመ ወሊድ ክትትል አግኝተዋል? 1. አዎ አላገኘሁም ካሉ
201 2. አላገኘሁም ወደ ጥያቄ 204
ይሂዱ
202 አዎ ከሆነ መልስዎ ስንት ጊዜ የቅድመ 1. ………
ወሊድ ክትትል አድርገዋል ? (በቁጥር)
203 የት ነበር የቅድመ ወሊድ ክትትል ያደረጉት? 1. ጤና ጣቢያ
2. የመንግስት ሆስፒታል
3. የግል ጤና ተቓም

59
 4. የግል ክልኒክ
5. NGO ክልኒክ

204 በእድሜዎ ስንት ጊዜ ወልደው ያውቃሉ? (በቁጠር ይገለጽ)

(የአሁኑን ጨምሮ) …………...
205 በእድሜዎ ስንት ጊዜ ወልደው ያውቃሉ? (በቁጠር ይገለጽ)
(ሞተው የተወለደዉንም ጨምሮ) …………....

206 ከእርግዝና በፊት የነበረ የታወቀ የስካር 1. አዎ አልነበረም ካሉ፣

ህመም አለብዎት? 2. አልነበረም ወደ ጥያቄ 207
ይሂዱ
207 በእርግዝና ወቅት የተከሰተ የስኩዋር በሽታ 1. አዎ አልነበረም ካሉ፣
አለብዎት ተብለዋል? ? 2. አልነበረም ወደ ጥያቄ 208
ይሂዱ
208 ከእርግዝና በፊት የነበረ የደም ግፊት ህመም 1. አዎ አልነበረም ካሉ፣
አለብዎት ተብለዋል? 2. አልነበረም ወደ ጥያቄ 209
ይሂዱ
209 በኣሁኑ እርግዝና ወቅት ከእርግዝናው ጋር 1. አዎ አልነበረም ካሉ፣
በተያያዘ የደም ግፊት አለብዎት 2. አልነበረም ወደ ጥያቄ 211
ተብለዋል? ይሂዱ
210 አዎ ከሆነ ደረጃው ምን ነበር? 1.በእርግዝና ጊዜ
የተባባሰ የደም ግፊት
2.በደምግፊት የሚመጣ
መንቀጥቀጥ
3. አላውቅም
211 HIV ምርመራ አድርገው ነበር 1. አዎ አላደረኩም ካሉ፣ ወደ
2. አላደረኩም ጥያቄ 213 ይሂዱ
212 የምርመራዉ ዉጤት 1. HIV አለ
2. HIV የለም
213 የእርግዝናሽ አየነት? 1. አንድ
2. መንታ
3. ሶስት
4. ከዛበላይ
214 በዚህ እርግዝናዎ ወቅት የደም መፍሰስ 1. አዎ
(በወር አበባ ከተለመደው በላይ) 2. አልነበረም
አጋጥሞዎት ነበር?

60