Perinatal asphyxia and associated factors among neonates admitted to a specialized public hospital in South Central Ethiopia: A retrospective cross-sectional study.

INTRODUCTION: Perinatal asphyxia continues to be a significant clinical concern around the world as the consequences can be devastating. World Health Organization data indicates perinatal asphyxia is encountered amongst 6-10 newborns per 1000 live full-term birth, and the figures are higher for low and middle-income countries. Nevertheless, studies on the prevalence of asphyxia and the extent of the problem in poorly resourced southern Ethiopian regions are limited. This study aimed to determine the magnitude of perinatal asphyxia and its associated factors.
METHODS: A retrospective cross-sectional study design was used from March to April 2020. Data was collected from charts of neonates who were admitted to NICU from January 2016 to December 31, 2019. RESULT: The review of 311 neonates' medical records revealed that 41.2% of the neonates experienced perinatal asphyxia. Preeclampsia during pregnancy (AOR = 6.2, 95%CI:3.1-12.3), antepartum hemorrhage (AOR = 4.5, 95%CI:2.3-8.6), gestational diabetes mellitus (AOR = 4.2, 95%CI:1.9-9.2), premature rupture of membrane (AOR = 2.5, 95%CI:1.33-4.7) fetal distress (AOR = 3,95%CI:1.3-7.0) and meconium-stained amniotic fluid (AOR = 7.7, 95%CI: 3.1-19.3) were the associated factors.
CONCLUSION: Substantial percentages of neonates encounter perinatal asphyxia, causing significant morbidity and mortality. Focus on early identification and timely treatment of perinatal asphyxia in hospitals should, therefore, be given priority.

Introduction

A decade remains to achieve the third Sustainable Development Goal (SDG) targets, including reducing preventable causes of neonatal mortalities [1, 2]. Though the number of neonatal deaths has declined significantly within the last thirty years, Africa alone accounted for about 41% of the total global neonatal mortality in the year 2017 [3].

Perinatal asphyxia, also called birth asphyxia, is one of the leading causes of neonatal deaths in the world following severe infections and prematurity [1, 4]. It results from the loss of the blood supply or impairment of gas exchange to or from the fetus before, during, or after the birth process [5]. Perinatal asphyxia may lead to severe metabolic acidosis, hypercarbia, progressive hypoxemia, neonatal encephalopathy, and multi-system organ failure, and even result in death [6-10].

An arterial blood sample, APGAR score (appearance, pulse, grimaces, activity, and respiration), immediate neurological complications, or evidence of multiple organ dysfunction are used to diagnose asphyxia. The APGAR score is assessed in the first and fifth minutes of life and ranges from zero to ten. According to the WHO classification, an APGAR score of four to seven in the first minute of life indicates moderate prenatal asphyxia, whereas zero to three suggests severe asphyxia [11, 12]. Factors related to antepartum, intrapartum or immediate postpartum period may contribute to perinatal asphyxia development [13]. These could be summarized into abnormal maternal oxygenation, congenital infections, insufficient placental perfusion, traumatic deliveries, or impaired umbilical circulation. Most studies identified that intrapartum factors as having the highest impact [7, 14, 15].

Worldwide, perinatal asphyxia is encountered amongst 6–10 newborns per 1000 live full-term birth [9, 16, 17]. Apparently, the numbers are higher for low and middle-income countries. In Africa, significant neonatal morbidity and mortality occur due to complications associated with perinatal asphyxia. Studies from different regions of the continent show variant figures on the magnitude. A study from two district hospitals in Ghana showed that birth asphyxia to be the second cause of admission (15.1%) and the third cause of mortality (20.7%). In contrast, another study conducted in Nigeria indicated severe perinatal asphyxia to be the most important cause of death in all birth weight categories except in extremely low birth weight babies [18, 19]. A systematic review conducted amongst east and central African countries has shown a pooled prevalence of perinatal asphyxia to be 15.9% [9].

Ethiopian studies are no different from the rest of Africa. Though the country has made efforts to minimize child and neonatal mortality rates by devising a National strategy for Newborn and Child Survival, current figures still show demand for committed action to target and tackle preventable causes like birth asphyxia [20, 21]. The Ethiopian Demographic and Health survey in 2019 revealed a reduction in early childhood mortality except for neonatal mortality, which had steady progress of decline since 2016. It was shown that birth asphyxia was and still is the primary cause of neonatal deaths [22]. Observational studies in different parts of the country also magnify this concern. A cross-sectional study conducted in the Tigray region of northern Ethiopia showed that 22.1% of the total neonates included in the study experienced perinatal asphyxia [23]. At the same time, another study from Dilla referral hospital revealed the prevalence of perinatal asphyxia to be 32.8% [24].

In order to improve the quality of care that is delivered within a country, one must first understand the problem and the issues that healthcare providers encounter. Improving the care of the maternal-infant dyad can lead to a significant decrease in the rates of perinatal asphyxia [22, 25]. In an effort to enhance care in Ethiopia, we sought to understand the burden of perinatal asphyxia and early assessment practices. To do this, we evaluated cases of perinatal asphyxia and identified associated factors among neonates admitted to the neonatal intensive care unit of Worabe Comprehensive Specialized Hospital (WCSH) in southern Ethiopia.

Methods

Study area and period

The study was conducted at Worabe Comprehensive Specialized Hospital (WCSH), Silte zone, south central Ethiopia, from March to April 2020 (by reviewing neonates’ charts from January/2016 to December 31/2019). WCSH was established in October 2014 and is located 170 km southwest of Addis Ababa. It is the only referral hospital in Silte zone and provides emergency, out-patient and in-patient services to the local and neighboring communities. The Neonatal Intensive Care Unit has 18 beds, 5 incubators, 15 radiant warmers and operates with 17 nurses, 2 midwives, 1 general practitioner, 2 pediatricians and 1 gynecologist. The NICU offers diagnostic and treatment services for approximately 1000–1500 newborns per year [26]. The level of newborn care is determined by the neonate’s gestational age, birth weight, sickness severity, and the facility’s general setup. The NICU service provision at WCSH is leveled into three. Accordingly, health practitioners at the level I offer basic newborn care to low-risk infants and triage unwell newborns. Specialty treatment (Level II NICU) is confined to newborn infants over 32 weeks gestational age weighing 1500 g or recovering from severe disease treated in a level III environment (subspecialty). All newborn infants with extreme preterm (28 weeks or less) or extremely low birth weight (1000g or less), or severe and/or complex disease are handled in level III NICU [26].

Study design

A facility-based retrospective cross-sectional study design was employed.

Population

Source population

All records’ of neonates who were admitted at NICU of Worabe comprehensive specialized hospital.

Study population

All the records’ of neonates who were admitted to the NICU of WCSH were added to the study. The records’ of neonates with incomplete documentation (no proper maternal or fetal measurement parameters), or with major congenital malformations or anomalies were excluded.

Sample size determination

The sample size was calculated using the single population proportion formula considering the p-value of 32.8% from a previous study conducted in Ethiopia [24].

Where, ni = initial sample size, p = proportion of prenatal asphyxia; 32.8% = 0.328, (zα/2)2 = confidence interval (95%), d = is the margin of sampling error tolerated (5%) = 0.05

Substituting the values for each of these variables in the above formula, the sample size was estimated to be 339.

Because the source population is less than ten thousand, we used a correction formula

Where nf = final sample size

ni = calculated sample size (initial sample size)

N = total number of neonates admitted to NICU of WCSH within the three years period (3796 neonates)

Sampling procedure

Systematic random sampling technique was used to select which charts to review. After the records of the neonates were put in their order of admission, the kth interval was determined by dividing the total population size by the total sample size.

Where, N is the total population at NICU of WCSH from January /2016 to December 31/2019,

nf = final sample size of the study.

Operational definitions

Perinatal asphyxia–is the inability of a newborn to initiate and sustain respiration by persistently scoring an APGAR score of less than 7 for more than 5 minutes after delivery [24, 27].

Prolonged labor–is the first stage of labor, exceeding 12 hours in primigravida or 8 hours in multipara mothers [25].

Premature rupture of membranes (PROM)–rupture of the amniotic sac and chorion membrane occurred before the onset of labor [24].

Study variables

Magnitude of perinatal asphyxia was the outcome variable. Maternal socio-demographic variable (age in year, educational status, religion, residency, and occupation), antepartum related variable (anemia during Pregnancy, ANC follow up, DM, pregnancy-induced hypertension, antepartum hemorrhage, chronic hypertension, gravidity, and parity), intrapartum related variable (PROM, prolonged labor, obstructed labor, place of delivery and mode of delivery), neonatal related variable (birth weight, fetal distress, the gender of the neonate and intrauterine meconium release) were independent variables.

Data collection tools and procedures

Data was collected from neonates’ registration and medical records using a structured checklist adapted and modified from different literature [13, 23, 24, 28]. The checklist contained four sections which assess socio-demographic, antepartum factors (parity/gravidity, gestational age, complications/illnesses during pregnancy), intrapartum factors (mode of delivery, duration of labor, fetal presentation, fetal distress, intrauterine meconium release occurrence of PROM, and obstructed labor) and neonatal factors (sex, birth weight, gestational age at birth and occurrence of perinatal asphyxia). To identify maternal-related factors, the maternal record chart of the same year was traced. Three nurses with bachelor’s degree were recruited as data collectors and were trained for two days on the checklist, data collection, and supervision. Furthermore, the sampling procedures were also elucidated to them. The checklist was pretested for its relevance and clarity to answer the research question.

Ethical considerations

Ethical clearance for the commencement of the study was obtained from the Addis Ababa University, School of Nursing and Midwifery Research Ethical Committee (Ref. no. 030/20/SNM). Permission was also sought and obtained from the ethical committee of Worabe comprehensive specialized hospital. Data was kept anonymous by keeping the identity of the neonate’s or mother’s credentials hidden before, during, and after the study.

Data analysis and management

The data were entered into statistical software Epi-data version 3.1. The entered data was subject to cleaning using simple frequency and tabulation to ensure the data’s validity. Then the analysis was made with IBM SPSS version 24.0 after exporting the prepared data. Descriptive statistics, such as frequency distribution, were computed to describe the significant variables of the study. Odds ratio and the p-value were computed. P≤0.05 was considered as statistically significant for association. Binary logistic regression was conducted to see the effect of each of the independent variables on the outcome variable, and variables that were statistically significant at P value less than 0.05 levels were put into the final model (multivariate analysis) to control for confounding.

Results

Socio-demographic characteristics of the mothers’ of neonates

Data were collected from a total of 311 neonatal medical records. Of the neonates’ mothers, 105(33.8%) were between the ages of 25–29 years, and 163(52.4%) of the mothers had no formal education. Almost all the mothers, 297 (95.5%), were Muslim by religion [

Obstetrics history of the mothers at WCSH

Regarding parity, 196(63%) mothers were multiparous, and 197(63.3%) of them were attending their antenatal follow up. Among the mothers, 129(41.5%) had anemia, while 86(27.7%) were diagnosed with preeclampsia. Only 61(19.6%) of mothers had gestational diabetes mellitus, and few mothers, 21(6.8%), had chronic hypertension. Of the 311 mothers, 92(29.6%) had an antepartum hemorrhage, and 222(71.4%) mothers of the neonates delivered by SVD. Concerning membrane status, 100(32.2%) mothers developed premature rupture of the membrane, and 115(37%) mothers had obstructed labor [.

Clinical characteristics of neonates at WCSH

From the total number of neonates, 192(61.7%) of them were males, and 119 (38.3%) were females, and most of the neonates, 240(77.2%), had birth weight between 2.5kg to 4kg. Only 84(27%) of babies passed their meconium during labor, and 119(38.3%) of them developed fetal distress [.

Magnitude of perinatal asphyxia

The overall prevalence of perinatal asphyxia among neonates who were delivered at WCHS was found to be 128(41.2%).

Factors associated with the occurrence of perinatal asphyxia

Different socio-demographic, neonatal, and maternal variables were tested for their association with the presence of perinatal asphyxia. For the multivariate logistic regression, all variables that were found to have an association with the outcome variable in bivariate logistic regression at P = 0.25 were included in the multivariate logistic regression models. During multivariate logistic regression, six variables (preeclampsia, antepartum hemorrhage, gestational diabetes mellitus, premature rupture of membrane, intrauterine meconium release, and fetal distress during labor) were found significantly associated with perinatal asphyxia (at p≤0.05).

Among maternal factors, preeclampsia was independently associated with significantly higher odds of the newborn developing perinatal asphyxia (AOR = 6.2, 95% CI, 3.1, 12.3). Neonates from mothers who had antepartum hemorrhage were 4.5 times more affected by asphyxia as compared to neonates who delivered from mothers who had no antepartum hemorrhage(AOR = 4.5, 95% CI, 2.3, 8.6). Furthermore, neonates from mothers with gestational diabetes mellitus were four times more likely to be asphyxiated than neonates from mothers without gestational diabetes mellitus (AOR = 4.2, 95% CI 1.9,9.2). Moreover, neonates of mothers who had a history of premature rupture of the membrane were 2.5 times more likely to be asphyxiated than those who had not encountered premature rupture (AOR = 2.5, 95%CI,1.33,4.7). Among the fetal factors, fetal distress during labor and meconium-stained amniotic fluid were significantly associated with asphyxia (AOR = 3, 95%CI, 1.3.7.0) and (AOR = 7.7, 95%CI, 3.1, 19.3) respectively [.

Discussion

The findings from this study revealed that the magnitude of perinatal asphyxia was 41.2%, which is quite higher compared to a study done in southern India (2.7%) [29], Sweden (5.4%) [30], Alberta Canada (2.28%) [31] and South-East Nigeria (12.8%) [32]. This discrepancy could be explained by the socioeconomic variation between the study area and the other countries. Better developed countries have the necessary infrastructure and skilled health care providers to significantly reduce the incidence of perinatal complications. Nonetheless, the finding is lower than a study done in Bangladesh (56.9%) [33] and Ghana 283(61.8%) [34]. The possible explanation for this variation stems from the latter two studies being conducted in more poorly resourced areas. Additionally, the higher magnitude in these studies may be due to the reported low number of healthcare professionals trained to conduct neonatal resuscitation. Comparably, this study’s result was higher than other studies conducted elsewhere in Ethiopia [12, 23, 28, 35, 36]. The difference could be attributed to the relative urban nature of the cities, which in turn affects the quality of setup amongst the facilities, the living standards of resident mothers and accessibility of health institutions. These are critical indicators that more emphasis is needed in studying perinatal asphyxia.

The Ethiopian ministry of health adopted the WHO recommendation of at least four ANC follow-up visits throughout a pregnancy. Despite this, ANC is utilized well in urbanized cities like Addis Ababa and Dire Dawa while semi urban and rural areas are far behind [22]. This is attributed to maternal illiteracy and low socio-economic status in the latter as these factors have direct relations to the delay in health seeking behavior [25]. The non-adherence to follow up could be catastrophic as it could endanger the maternal and fetal outcomes. This study revealed that 36.7% of mothers of neonates with asphyxia were not strictly attending their antenatal follow-up, paving the way for the ‘silent’ progress of pregnancy-induced complications (PICs) and associated perinatal outcomes.

The unpredictable nature of PICs, poor obstetric care and low service utilizations in Ethiopia, largely give rise to the maternal and perinatal sequelae. Even though the country adopted the “three delays” model, a set of strategies targeting delays in the decision to seek care, delays in seeking care, and delays in receiving adequate health care, successful implementation yet needs significant work [25]. This study has identified major PICs including preeclampsia, antepartum hemorrhage, gestational diabetes mellitus, premature rupture of the membrane that continue to be significant predictors of perinatal asphyxia.

Preeclampsia and eclampsia are known predictors of maternal and perinatal morbidities and mortalities [14]. These disorders, categorized under Pregnancy Induced Hypertensive Disorders (PIHD), are common concerns globally, even more in low-income countries like Ethiopia. Studies have shown that variations in the prevalence of PIHDs can be observed within a country. For instance, the SNNPR region where the study area is located is one of the poorly resourced areas of the country and has a higher percentage of PIHD than any other region in the country [14]. Despite the absence of novel approaches to exactly predict the occurrence of preeclampsia, complications like birth asphyxia could be lowered through frequent and consistent follow-up during pregnancy. This study reaffirmed that preeclampsia is significantly associated with perinatal asphyxia. Studies conducted in India [29], Bangkok Rajavithi hospital [37], Gusau Nigeria [38], and Tigray Ethiopia [23] are in line with this data.

Significant evidence reveals [15, 39, 40] that the occurrence of antepartum bleeding results in a decreased blood flow from the mother to the placenta with subsequent hypoxia to the fetus. Studies conducted in Ethiopia have also shown an increased incidence of perinatal asphyxia among mothers who encountered APH [15, 40]. This study also identified that antepartum hemorrhage was associated with perinatal asphyxia, consistent with the study conducted in Bangalore, Indonesia [41], and Accra Ghana [34].

Gestational diabetes mellitus was also a factor associated with perinatal asphyxia, and this result is in agreement with what was reported in Canada [31], Pakistan [13], and the study done in Sweden [30]. The possible explanations for these are the metabolic derangement responsible for the inadequate production of surfactants. In Ethiopia, health care providers screen and initiate counseling for lifestyle modification during the early stages of the diagnosis, followed by a prescribed insulin regimen. Nevertheless, effective implementation of these strategies once again is hindered [42, 43]. The current study found out that premature rupture of the membrane was significantly associated with perinatal asphyxia which is consistent with other findings from Pakistan [30, 44], Ghana [34], and Tanzania [45]. The similarity between the studies may be explained by the scientific evidence that links PROM to the incidence of oligohydramnios, resulting in possible infection and umbilical cord compression [46].

The present study identified fetal distress and meconium-stained amniotic fluid as significant factors impacting the occurrence of perinatal asphyxia. Comparable results were found from other parts of the world; Malawi [47], Thailand [37], Pakistan [44], and India [48]. Studies conducted in central, south, and northern parts of Ethiopia are also in line [24, 36, 49]. The rationale for the poor perinatal outcome in Ethiopia likely stems from sub-standard partograph utilization, poor intrapartum care, and ineffective neonatal resuscitation practices [50-54].

Limitations

Even though the study generated pertinent data that can be used as a baseline, the results can only describe the context in WCSH. Furthermore, the study also did not include other lower health care facilities where deliveries were conducted. The hospital where the study was conducted is an institution to which pregnant women with complications are referred. This may have inflated the magnitude of the problem. This study utilized only the APGAR score to diagnose perinatal asphyxia. Sarnat scores and additional investigations, such as the arterial blood gas analysis for pH, were not considered. The nature of cross-sectional study design also has an impact in defining cause and effect relationships.

Conclusion

The study revealed that a substantial percentage of neonates experienced perinatal asphyxia. Major PICs such as preeclampsia, APH, and gestational DM, PROM, and fetal factors like fetal distress and intrauterine meconium release were significantly associated with the occurrence of perinatal asphyxia. Focus on early identification and timely treatment of perinatal asphyxia in hospitals should, therefore, be given priority. Effective implementation of community engaging approaches such as mobilization and health information dissemination would improve the utilization of ANC services among mothers. Furthermore, revitalizing maternal waiting homes in the area may mitigate the delays in seeking care and associated complications. The Ministry of Health and the hospital administrators need to devise strategies that strengthen the health care system, meliorate the obstetric care setup and ensure the adherence of health care providers to intrapartum and immediate postpartum protocols such as partograph utilization and newborn resuscitation. Researchers should focus on conducting implementation research to assess the relative impact of strengthening and revitalizing best practices.

24 Jun 2021

PONE-D-21-06937

Perinatal asphyxia and associated factors among neonates admitted to a specialized public hospital in South Central Ethiopia: A retrospective cross sectional study

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Reviewer #1: The article “Perinatal asphyxia and associated factors among neonates admitted to a specialized public hospital in South Central Ethiopia: A retrospective cross-sectional study” by Mamo et al identifies the associated factors seen with perinatal asphyxia at one hospital in a low- and middle-income country. This is important information to have as LMICs are now beginning to initiate quality improvement programs. I applaud them for their efforts. I do think the manuscript can be improved. If the issues I note below are addressed, it will be a much stronger piece and deserves publication. Once rewritten, it needs a careful review of English syntax and grammar. I have made some corrections below, but some areas will need significant rewrites.

Abstract

Concise. Well-written and appropriate.

Line 29 – Edit to “Perinatal asphyxia continues to be a significant clinical concern around the world as the consequences can be devastating.”

Include that the charts were reviewed from a 3 year period

Introduction

Line 55 delete the word “only”

Rework 55-60. Try this:

56-60 Perinatal asphyxia, also called birth asphyxia, is one of the leading causes of neonatal deaths in the world following severe infections and prematurity (1, 4). It results from the loss of the blood supply or impairment of gas exchange to or from the fetus before, during, or after the birth process (5). Perinatal asphyxia may lead to severe metabolic acidosis, hypercarbia, progressive hypoxemia, neonatal encephalopathy, and multi-system organ failure, and even result in death (6-10).

Line 70 delete the word “staggering”

Line 71 Is this the name of a program? If so, it should all be capitalized. National Strategy for Newborn and Child Survival

Rework 77-82. Try this:

77-82 In order to improve the quality of care that is delivered within a country, one must first understand the problem and the issues that healthcare providers encounter. Improving care of the maternal-infant dyad can lead to a significant decrease in the rates of perinatal asphyxia (find a reference for this). In an effort to improve care in Ethiopia, we sought to understand the burden of perinatal asphyxia and early assessment practices. To do this, we evaluated cases of perinatal asphyxia and identified associated factors among neonates admitted to the neonatal intensive care unit of Worabe Comprehensive Specialized Hospital in southern Ethiopia

Methods

This whole section is a little unclear. Were all records reviewed? This is what it sounds like from the first few lines. Or, were only 311 records reviewed based on some sampling procedure? This is what it sounds like as you read on.

The section: “Sample size determination and sampling procedure” needs to be rewritten. I need more information about what is being seen at Worabe in order to know if this even makes sense. How many births occurred there during the three-year period? How many are admitted to the NICU over the three-year period? How did you randomly select which charts to review? It is all very vague.

The biggest thing that is lacking is how was perinatal asphyxia defined? I am worried there was no uniform definition and a Sarnat 1 baby is being included in with Sarnat 2 and 3 babies. While technically all three are encephalopathies (stages of it), outcomes are very different and your information would be strengthened if we knew the definition and the range of severity in your definition.

Results

Line 167 “developed respiratory distress during labor.” This seems to be referencing the baby. How does a baby develop respiratory distress during labor? Looking at Table 3, I believe you mean the baby developed perinatal asphyxia during labor.

Line 168 – where does it say this in the table?

Line 172,173 – the table says it is 119 and 38.3%

Discussion

Line 225 – “the definition of birth asphyxia.” This is key. What is the definition for this study? I didn’t see it defined.

Overall, I think the discussion could use significant work rather than just stating that you found what others did. I would expect that to happen as these are all well-documented factors associated with perinatal asphyxia.

What I would really like to see done in this section is how could this information be applied in Ethiopia to improve care? How could you use this information to design an educational intervention and then measure the impact? Don’t just draw conclusions from the data, but let it lead you somewhere.

I also need you to think about what the limitations of your study might be. One I see are the potential problems with your data. Was it good? What about how the clinicians defined perinatal asphyxia? I am worried that your numbers are so high because of a variation in diagnosis amongst the providers.

Conclusion

Based on the above feedback, the conclusion would also need to be reworked.

Reviewer #2: Perinatal asphyxia and associated factors among neonates admitted to a specialized public hospital in South Central Ethiopia: A retrospective cross-sectional study.

Thank you for the opportunity to review this manuscript.

Below are comments/suggestions for the authors' consideration.

The article is well written, highlights an actual problem ( perinatal asphyxia ), and uncovers factors associated with perinatal asphyxia.

The abstract is concise and accurately summarizes the essential information of the paper.

The introduction is appropriate for the content of the article although it would be better if the authors include a paragraph to detail the

(i) background introduction information of Ethiopia relevant to this topic.

(ii) associated risk factors to perinatal asphyxia

The methodology can be further enhanced:

-- The study was conducted at Worabe Comprehensive Specialized Hospital (WCSH), south-central Ethiopia, perhaps the reader would appreciate it if the authors could detail the study setting.

-- The authors have mentioned the systematic random sampling method. (page 5, line 106), this should be elaborated further on the systematic random sampling method used in Data Collection Procedure. ( Page 5, line 115-119)

--Description of the checklist.

--May need to include the IRB ethical approval number in the text.

--Number of records that meet the inclusion criteria. & the number and reasons of records excluded in this study.

Data analysis procedures are sufficiently described. Results are organized in a way that is easy to understand. The statistics are reported appropriately. Corrections need for :

The total number of occupational statuses is more than 311. (Table 1)

Please add notes explaining any acronyms or abbreviations in the table. (Table 2 & Table 4)

Revise no illness as it is misleading ( Table 2)

The author has reported the frequency of mothers of asphyxiated neonates is 128 ( Table 1). This is incongruent with Table 3 Clinical characteristics of neonates with perinatal asphyxia, the researcher has reported 119 in the yes category. Please recheck.

In reporting of factor associated with perinatal asphyxia, it would be more meaningful to report

e.g ...neonates from mothers who had antepartum hemorrhage were 4.5 times more affected by asphyxia as compared to neonates who delivered from mothers who had no antepartum hemorrhage(AOR= 4.5, 95%CI, 2.3,8.6) (Page 10 . line 188-189)

Table 4: Please add in notes * p<0.05

The discussion and conclusion are well articulated. However, it was rather scanty. Suggest to elaborate further on “ This major difference could be attributed to the methodological approaches employed amongst the studies, the definition of birth asphyxia, and the management protocol of the hospitals for perinatal asphyxia. (Page 13, line 225-226) & as appropriate. And the study limitations are not discussed.

However, the references/ citations are appropriate.

Thank you

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Reviewer #1: No

Reviewer #2: No

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Submitted filename: Plos One_ Perinatal Asphyxia_Cpl.docx

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31 Aug 2021

Responses for the Academic editor

Comment 1: Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

Response 1: We respectfully accepted the comment. The submitted version is corrected according to the PLOS ONE's style requirements.

Comment 2: Please ensure you have discussed any potential limitations of your study in the Discussion, including study design, sample size and/or potential confounders.

Response 2: We respectfully accepted the comment. The revised version added the limitations of this study after the discussion section.

Comment 3: Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified (1) whether consent was informed and (2) what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information.

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Response 3: We respectfully accepted the comment. The anonymity of the study participants was kept confidential throughout the entire process. We have also added a statement pertaining to the comments under the section ‘Ethical considerations’.

Responses for Reviewer 1

First of all, we are very grateful for your encouraging words. We are humbled by the constructive feedback and the details you went through to review our work.

Responses for Reviewer 1 (Abstract)

Comment 1: Line 29 – Edit to “Perinatal asphyxia continues to be a significant clinical concern around the world as the consequences can be devastating.”

Response 1: We respectfully accepted the comment. It was edited on the revised document.

Comment 2: Include that the charts were reviewed from a 3 year period.

Response 2: We respectfully accepted the comment. It was edited on the revised document.

Responses for Reviewer 1 (Introduction)

Comment 3: Line 55 delete the word “only”

Response 3: We respectfully accepted the comment. It was deleted on the revised document.

Comment 4: Rework 55-60. Try this: 56-60 Perinatal asphyxia, also called birth asphyxia, is one of the leading causes of neonatal deaths in the world following severe infections and prematurity (1, 4). It results from the loss of the blood supply or impairment of gas exchange to or from the fetus before, during, or after the birth process (5). Perinatal asphyxia may lead to severe metabolic acidosis, hypercarbia, progressive hypoxemia, neonatal encephalopathy, and multi-system organ failure, and even result in death (6-10).

Response 4: We respectfully accepted the comment. It was edited as such on the revised document.

Comment 5: Line 70 delete the word “staggering”

Response 5: We respectfully accepted the comment. It was deleted from the revised document.

Comment 6: Line 71 Is this the name of a program? If so, it should all be capitalized. National Strategy for Newborn and Child Survival

Response 6: We respectfully accepted the comment. Yes, it is a name of a program and a correction was made.

Comment 7: Rework 77-82. Try this: 77-82 In order to improve the quality of care that is delivered within a country, one must first understand the problem and the issues that healthcare providers encounter. Improving care of the maternal-infant dyad can lead to a significant decrease in the rates of perinatal asphyxia (find a reference for this). In an effort to improve care in Ethiopia, we sought to understand the burden of perinatal asphyxia and early assessment practices. To do this, we evaluated cases of perinatal asphyxia and identified associated factors among neonates admitted to the neonatal intensive care unit of Worabe Comprehensive Specialized Hospital in southern Ethiopia

Response 7: We respectfully accepted the comment. It was edited as such on the revised document.

Responses for Reviewer 1 on Methods

Comment 8: This whole section is a little unclear. Were all records reviewed? This is what it sounds like from the first few lines. Or, were only 311 records reviewed based on some sampling procedure? This is what it sounds like as you read on.

Response 8: We respectfully accepted the comment and question. The records that were reviewed were 311 out of the total neonatal records (3796) from the three years period. We used systematic random sampling technique to select the records. This was incorporated in the manuscript to make it clear.

Comment 9: The section: “Sample size determination and sampling procedure” needs to be rewritten.

Response 9: We respectfully accepted the comment. The sub-section is rewritten with more details.

Comment 10: I need more information about what is being seen at Worabe in order to know if this even makes sense. How many births occurred there during the three-year period? How many are admitted to the NICU over the three-year period? How did you randomly select which charts to review? It is all very vague.

Response 10: We respectfully accepted the comment and questions. The total birth at Worabe hospital during the three years period was 10,800 and 3796 newborns were admitted to the NICU within this time frame. Systematic random sampling technique was used to select which charts to review. After the card records of the neonates were put in their order of admission, the kth interval was determined by dividing the total population size by the total sample size.

Comment 11: The biggest thing that is lacking is how was perinatal asphyxia defined? I am worried there was no uniform definition and a Sarnat 1 baby is being included in with Sarnat 2 and 3 babies. While technically all three are encephalopathies (stages of it), outcomes are very different and your information would be strengthened if we knew the definition and the range of severity in your definition.

Response 11: We respectfully accepted the comment and questions. In our study, perinatal asphyxia was defined as the inability of a newborn to initiate and sustain respiration, by scoring an APGAR score less than 7 persistently for more than 5 min after delivery.

Responses for Reviewer 1 on Results

Comment 12: Line 167 “developed respiratory distress during labor.” This seems to be referencing the baby. How does a baby develop respiratory distress during labor? Looking at Table 3, I believe you mean the baby developed perinatal asphyxia during labor.

Response 12: We respectfully accepted the comment and questions. It was an error during the preparation of the manuscript. The phrase on line 167 “developed respiratory distress during labor” was to mean “fetal distress”. What was presented in Table 3 also is corrected as “fetal distress” instead of perinatal asphyxia.

Comment 13: Line 168 – where does it say this in the table?

Response 13: We respectfully accepted the comment. The percentage of neonates with and without perinatal asphyxia was incorporated into Table 3. The magnitude of perinatal asphyxia was indeed 41.2%. These errors are corrected on the revised manuscript.

Comment 14: Line 172,173 – the table says it is 119 and 38.3%

Response 14: We respectfully accepted the comment. It was an error and corrected as per the edition made to Table 3.

Responses for Reviewer 1 on Discussion

Comment 15: Line 225 – “the definition of birth asphyxia.” This is key. What is the definition for this study? I didn’t see it defined.

Response 15: We respectfully accepted the comment. The operational definitions for this study are added to the revised document.

Comment 16: Overall, I think the discussion could use significant work rather than just stating that you found what others did. I would expect that to happen as these are all well-documented factors associated with perinatal asphyxia.

Response 16: We respectfully accepted the comment. We added evidence-based supplements to the discussion section to modify it.

Comment 17: What I would really like to see done in this section is how could this information be applied in Ethiopia to improve care? How could you use this information to design an educational intervention and then measure the impact? Don’t just draw conclusions from the data, but let it lead you somewhere.

Response 17: We respectfully accepted the comment. The section was modified to address the concerns raised and it was contextualized based on the comments given.

Comment 18: I also need you to think about what the limitations of your study might be. One I see are the potential problems with your data. Was it good? What about how the clinicians defined perinatal asphyxia? I am worried that your numbers are so high because of a variation in diagnosis amongst the providers.

Response 18: We respectfully accepted the comment. The revised version incorporated the limitations of this study after the discussion section.

Responses for Reviewer 1 on Conclusion

Comment 19: Based on the above feedback, the conclusion would also need to be reworked.

Response 19: Thank you for the comment. The conclusion is rewritten in accordance with the discussion.

Thank you again!

Responses for Reviewer 2

First of all, we are very grateful for your encouraging words. We are humbled by the constructive feedback and the details you went through to review our work.

Responses for Reviewer 2 on Introduction

Comment 1: The introduction is appropriate for the content of the article although it would be better if the authors include a paragraph to detail the

(i) background introduction information of Ethiopia relevant to this topic.

(ii) associated risk factors to perinatal asphyxia

Response 1: We respectfully accepted the comment. These components are incorporated in the revised manuscript.

Responses for Reviewer 2 on Methods

Comment 2: The study was conducted at Worabe Comprehensive Specialized Hospital (WCSH), south-central Ethiopia, perhaps the reader would appreciate it if the authors could detail the study setting.

Response 2: We respectfully accepted the comment. We have included additional data pertaining to the study setting.

Comment 3: The authors have mentioned the systematic random sampling method. (page 5, line 106), this should be elaborated further on the systematic random sampling method used in Data Collection Procedure. ( Page 5, line 115-119)

Response 3: We respectfully accepted the comment. We have segregated the sub-section “Sample size determination and sampling procedure” into two. We explained the details on how we used the systematic random sampling under the “Sampling procedure” sub-section.

Comment 4: Description of the checklist.

Response 4: We respectfully accepted the comment. We have tried to describe the checklists used in this study under Data collection tools and procedures.

Comment 5: May need to include the IRB ethical approval number in the text.

Response 5: We respectfully accepted the comment. We have incorporated the ethics approval number granted by School of Nursing and Midwifery Research Ethical Committee into the revised document.

Comment 6: Number of records that meet the inclusion criteria. & the number and reasons of records excluded in this study.

Response 6: We respectfully accepted the comment. The calculated sample size was 311 and all randomly selected records fulfilled the inclusion criteria. We have not excluded a randomly selected record because we have robustly searched for other sources of data (to trace and find any missing information) including card room registration book, referral paper, ward admission and discharge registration book and documented nursing care plans.

Responses for Reviewer 2 on Results

Comment 7: The total number of occupational statuses is more than 311. (Table 1)

Response 7: We respectfully accepted the comment. A correction is made to the revised document.

Comment 8: Please add notes explaining any acronyms or abbreviations in the table. (Table 2 & Table 4)

Response 8: We respectfully accepted the comment. Notes explaining the acronyms or abbreviations are put under Tables 2 and 4.

Comment 9: Revise no illness as it is misleading (Table 2)

Response 9: We respectfully accepted the comment. It is corrected as chronic illness on the revised manuscript.

Comment 10: The author has reported the frequency of mothers of asphyxiated neonates is 128 ( Table 1). This is incongruent with Table 3 Clinical characteristics of neonates with perinatal asphyxia, the researcher has reported 119 in the yes category. Please recheck.

Response 10: We respectfully accepted the comment. The percentage of neonates with and without perinatal asphyxia was incorporated into Table 3. The magnitude of perinatal asphyxia was indeed 128 (41.2%). These errors are corrected in the revised manuscript.

Comment 10: In reporting of factor associated with perinatal asphyxia, it would be more meaningful to report e.g ...neonates from mothers who had antepartum hemorrhage were 4.5 times more affected by asphyxia as compared to neonates who delivered from mothers who had no antepartum hemorrhage(AOR= 4.5, 95%CI, 2.3,8.6) (Page 10 . line 188-189)

Response 10: We respectfully accepted the comment. It is corrected on the revised manuscript.

Comment 11: Table 4: Please add in notes * p<0.05

Response 11: We respectfully accepted the comment. The value of significance is added to the revised manuscript.

Comment 12: The discussion and conclusion are well articulated. However, it was rather scanty.

Response 12: We respectfully accepted the comment. Based on the suggestion, more content is added to enrich the discussion.

Comment 13: Suggest to elaborate further on “This major difference could be attributed to the methodological approaches employed amongst the studies, the definition of birth asphyxia, and the management protocol of the hospitals for perinatal asphyxia (Page 13, line 225-226) & as appropriate.

Response 13: We respectfully accepted the comment. These points are plausibly elaborated in the revised document.

Comment 14: And the study limitations are not discussed. However, the references/ citations are appropriate.

Response 14: We respectfully accepted the comment. The revised version incorporated the limitations of this study after the discussion section.

Thank you again!

Submitted filename: Response to Reviewers.docx

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15 Oct 2021

PONE-D-21-06937R1Perinatal asphyxia and associated factors among neonates admitted to a specialized public hospital in South Central Ethiopia: A retrospective cross sectional studyPLOS ONE

Dear Dr. Goshu,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.Thanks for resubmittion of an improved version of your paper.

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We look forward to receiving your revised manuscript.

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Barbara Wilson Engelhardt, MD

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

Dear Dr. Goshu,

Thanks for resubmittion of an improved version of your paper.

I am including reviewers comments plus some of my own:

1. For the reader an explanation of the 3 delays model would be helpful.

2. Please give more detailed information regarding possible different infections of the fetus and the neonate.

3. What umbilical cord compromises have occured in this patient sample?

4. What percent of reduction of neonatal mortality do you aim for, what is feasible?

5. Please explain the capabilities of the different nurseries, especially the NICU - levels of care 1-4.

6. Most importantly: Please review your paper, most of all the discussion, for unnecessary redundancies, length of text.

Sincerely

Barbara Engelhardt

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #1: Yes

Reviewer #2: (No Response)

**********

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Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Much improved manuscript.

Very minor grammar to address.

Line 26 - delete "in the world" as this is repetitive.

Line 334 - change to read "Utilization of the APGAR alone to diagnoses perinatal asphyxia may not..."

Reviewer #2: The paper has been significantly improved after revising.

It covers an important topic and is well written. In Abstract (page 2 lines 29-30), the authors stated that “ ...studies on the prevalence of asphyxia in these countries are limited.” The above statement is incorrect. This is not new information. Many other similar studies have been conducted in Ethiopia and published. It is unclear how this study specifically contributes to the literature. Suggest double-checking the similarity report too.

• https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0255488 Prevalence and risk factors associated with birth asphyxia among neonates delivered in Ethiopia: A systematic review and meta-analysis

• doi: 10.1016/j.heliyon.2020.e03793 Prevalence of perinatal asphyxia in East and Central Africa: systematic review and meta-analysis

• DOI: 10.1155/2020/4367248 Prevalence and Associated Factors of Perinatal Asphyxia in Neonates Admitted to Ayder Comprehensive Specialized Hospital, Northern Ethiopia: A Cross-Sectional Study

• doi: 10.1371/journal.pone.0226891 Birth asphyxia and its associated factors among newborns in public hospital, northeast Amhara, Ethiopia

• https://bmcpediatr.biomedcentral.com/articles/10.1186/s12887-021-02598-z Neonatal mortality among neonates admitted to NICU of Hiwot Fana specialized university hospital, eastern Ethiopia, 2020: a cross-sectional study design

• DOI: 10.1155/2018/5351010 Prevalence and Associated Factors of Perinatal Asphyxia among Neonates in General Hospitals of Tigray, Ethiopia, 2018

• doi: 10.2147/PHMT.S196265 Prevalence and associated factors of perinatal asphyxia among newborns in Dilla University referral hospital, Southern Ethiopia– 2017

Suggest consolidating the Introduction. The operational definition should be elaborated further in this section (not Methodology).

Methodology-A citation is needed for the study area and period (Page 4, line 97)

Please revise the inclusion criteria as it is similar to the source population. (page 5, line 105 & line 110). Please take note that “2016 to December 31, 2019” appeared three times in Methods.

Please remove this statement “The overall prevalence of perinatal asphyxia among neonates who were delivered at WCHS was found to be 128(41.2%) from Clinical Characteristics” (page11, lines 204-205). You have reported it under the magnitude of perinatal asphyxia (Page 12, lines 228-229).

The Discussion has improved. Suggest to re-write Limitation because it does not appear to be sound. The conclusion can be further enhanced by adding recommendations for future research.

Thank you

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

Reviewer #2: No

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Submitted filename: Plos One_ Perinatal Asphyxia_R1.docx

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5 Nov 2021

Responses for the Academic editor

Comment 1: For the reader an explanation of the 3 delays model would be helpful.

Response 1: We respectfully accepted the comment. It was briefly explained in the Discussion.

Comment 2: Please give more detailed information regarding possible different infections of the fetus and the neonate.

Response 2: We respectfully accepted the comment. We have noted that the statement put in the Discussion was ambigious. However the statemet was put as a rationale for the similarity between ours and other studies. We also have tried to correct it as such on the revised document.

Comment 3: What umbilical cord compromises have occured in this patient sample?

Response 3: We thank you for the question. We have noted that the statement put in the Discussion was ambigious. However the statemet was placed as a rationale for the similarity between ours and other studies. We also have tried to correct it as such on the revised document.

Comment 4: What percent of reduction of neonatal mortality do you aim for, what is feasible?

Response 4: We thank you for the question. In alignment with the sustainable development goals, we aim for a 35-40% reduction in the magnitude of perinatal asphyxia at WCHS by the end of the decade.

Comment 5: Please explain the capabilities of the different nurseries, especially the NICU - levels of care 1-4.

Response 5: We respectfully accepted the comment. It was briefly discussed in the Methods section, ‘Study area’ sub-section of the revised document.

Comment 6: Most importantly: Please review your paper, most of all the discussion, for unnecessary redundancies, length of text.

Response 6: We respectfully accepted the comment. We have tried to omit redundancies throughout the discussion section.

Thank you again!

Responses for Reviewer 1

Comment 1: Much improved manuscript.

Response 1: We are thankful once again for taking your time to refine our work.

Comment 2: Line 26 - delete "in the world" as this is repetitive.

Response 2: We respectfully accepted the comment. We have omitted the phrase.

Comment 3: Line 334 - change to read "Utilization of the APGAR alone to diagnoses perinatal asphyxia may not..."

Response 3: We respectfully accepted the comment. We have corrected it as per your recommendation.

Thank you again!

Responses for Reviewer 2

Comment 1: The paper has been significantly improved after revising. It covers an important topic and is well written.

Response 1: We thank you for the encouraging words and the time you have spent in refining the document.

Comment 2: In Abstract (page 2 lines 29-30), the authors stated that “ ...studies on the prevalence of asphyxia in these countries are limited.” The above statement is incorrect. This is not new information. Many other similar studies have been conducted in Ethiopia and published. It is unclear how this study specifically contributes to the literature. Suggest double-checking the similarity report too.

Response 2: We respectfully accepted the comment. As per your recommendation, a correction was made to the specific statement that indicated there is limited information on the topic. We also believe the study’s findings will add to the body of knowledge interms of illuminating the problem in the study area. Furthermore, the findings of this study will direct responsible federal and local stakeholders to design effective implementations to reduce the magnitude of perinatal asphyxia.

Comment 3: Suggest consolidating the Introduction. The operational definition should be elaborated further in this section (not Methodology).

Response 3: We respectfully accepted the comment. We added a paragraph on the diagnostic definitions of perinatal asphyxia in the Introduction. Further elaboration was added in the methods section, as there was a comment by other reviewer.

Comment 4: Methodology-A citation is needed for the study area and period (Page 4, line 97)

Response 4: We respectfully accepted the comment. A citation is added to the description of the study area.

Comment 5: Please revise the inclusion criteria as it is similar to the source population. (page 5, line 105 & line 110). Please take note that “2016 to December 31, 2019” appeared three times in Methods.

Response 5: We respectfully accepted the comment. We have tried to reduce the redundancies by compiling only the necessary information under the sub section ‘Study population’.

Comment 6: Please remove this statement “The overall prevalence of perinatal asphyxia among neonates who were delivered at WCHS was found to be 128(41.2%) from Clinical Characteristics” (page11, lines 204-205). You have reported it under the magnitude of perinatal asphyxia (Page 12, lines 228-229).

Response 6: We respectfully accepted the comment. As per your recommendation, the statement is removed in the revised editon.

Comment 7: The Discussion has improved. Suggest to re-write Limitation because it does not appear to be sound.

Response 7: We respectfully accepted the comment. We have tried to modify the Limitation in the revised edition.

Comment 8: The conclusion can be further enhanced by adding recommendations for future research.

Response 8: We respectfully accepted the comment. We added recommendations for future researchers in the revised document.

Thank you again!

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

31 Dec 2021

Perinatal asphyxia and associated factors among neonates admitted to a specialized public hospital in South Central Ethiopia: A retrospective cross-sectional study

PONE-D-21-06937R2

Dear Dr. Goshu,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Thank you for sending the revised copy. Except for some minor changes/suggestions, which I highlighted, the paper is now complete.

I have uploaded the last version of your paper with my suggestions for change, which should be very easily and quickly done.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Barbara Wilson Engelhardt, MD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

See upload from 12/29

.

.

.

Submitted filename: PONE-D-21-06937_R2 (3).pdf

Click here for additional data file.

Submitted filename: PONE-D-21-06937_R2 (4).pdf

Click here for additional data file.

Submitted filename: PONE-D-21-06937_.minor corrections.pdf

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Submitted filename: PONEgoshu1229.minor corrections.pdf

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5 Jan 2022

PONE-D-21-06937R2

Perinatal asphyxia and associated factors among neonates admitted to a specialized public hospital in South Central Ethiopia: A retrospective cross-sectional study

Dear Dr. Goshu:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Barbara Wilson Engelhardt

Academic Editor

PLOS ONE

Table 1

Socio-demographic characteristic of mothers of newborns at WCSH, South central Ethiopia (n = 311).

Variable	Category	Frequency/ Percentage of mothers’ of neonates (n = 311)	Frequency/Percentage of mothers’ of asphyxiated neonates (n = 128)
Age	≤19yr	12 (3.9%)	6 (4.68%)
	20-24yr	65 (20.9)	24 (18.75%)
	25-29yr	105 (33.8%)	44 (34.37%)
	30-34yr	84 (27%)	34 (26.56%)
	≥35	45 (14.5%)	20 (15.625%)
Educational status	No formal education	163 (52.4%)	78 (60.93%)
	Primary	64 (20.6%)	24 (18.75%)
	Secondary	45 (14.5%)	14 (10.93%)
	Higher education	39 (12.5%)	12 (9.37%)
Residence	Rural	207 (66.6%)	93 (72.65%)
	Urban	104 (33.4%)	35 (27.34%)
Religion	Muslim	297 (95.5%)	123 (96%)
	Orthodox	10 (3.2%)	3 (2.34%)
	Protestant	4 (1.3%)	2 (111.56%)
	Catholic	0 (0%)	0 (0%)
Occupation status	Housewife	120 (38.6%)	57 (44.53%)
	Private	2 (0.6%)	1 (0.78%)
	Government	63 (20.3%)	23 (17.96%)
	Merchant	112 (36%)	46 (35.93%)
	Student	14 (4.5%)	1 (0.78%)

Table 2

Obstetrics history of mothers at WCSH, South central Ethiopia (n = 311).

Variable	Category	Frequency(n = 311)	Percentage (%)
Parity	Primipara	115	37%
	Multipara	196	63%
Gestational age	<37weeks	43	13.8%
	>42weeks	18	5.8%
	37week-42week	250	80.4%
ANCa follow up	Yes	197	63.3%
	No	114	36.7%
Anemia	Yes	129	41.5%
	No	182	58.5%
Preeclampsia/eclampsia	Yes	86	27.7%
	No	225	72.3%
Chronic hypertension	Yes	21	6.8%
	No	290	93.2%
APHb	Yes	92	29.6%
	No	219	70.4%
DM	Yes	24	7.7%
	No	287	92.3%
Gestational DMc	Yes	61	19.6%
	No	250	80.4%
Chronic illness	Yes	247	79.4%
	No	64	20.6%
Mode of delivery	SVDd	222	71.4%
	C/Se	72	23.2%
	Instrumental	17	5.5%
Duration of labor	>12hr(prolong)	95	30.5%
	<12hr	216	69.5%
PROMf	Yes	100	32.2%
	No	211	67.8%
Obstructed labor	Yes	115	37%
	No	196	63%

aAntenatal Care

bAntepartum Hemorrhage

cDiabetes mellitus

dSpontaneous Vaginal Delivery

eCesearian Section

fPrematue Rupture of Membrane.

Table 3

Clinical characteristics of neonates at WCSH, South central Ethiopia (n = 311).

Characteristics	Category	Frequency(n = 311)	Percentage (%)
Presentation	Vertex	251	80.7%
	Non vertex	60	19.3%
Place of delivery	Home	10	3.2%
	Health center	157	50.5%
	Private clinic	3	1%
	Hospital	141	45.5%
Gender	Male	192	61.7%
	Female	119	38.3%
Birth weight	<2.5kg	59	19%
	2.5kg-4kg	240	77.2%
	>4kg	12	3.9%
Intrauterine meconium release	Yes	84	27%
	No	227	73%
Fetal distress	Yes	119	38.3%
	No	192	61.7%
Perinatal asphyxia	Yes	128	41.2%
	No	183	58.8%

Table 4

Factors associated with perinatal asphyxia among neonates admitted at WCSH, South central Ethiopia (n = 311).

Variables	Asphyxiated		COR 95%CI	AOR 95%CI	p-value
	No	Yes
Educational status
No formal education	85	78	2.07(.98, 4.4)	1.6(.5, 5.1)	0.420
Primary	40	24	1.4(.6, 3.2)	1.2(.4, 3.7)	0.624
Secondary	31	14	1.0(.4, 2.6)	1.2(.4, 3.5)	0.607
Higher education	27	12	1	1
Residence
Rural	114	93	1.6(.985,2.63)	1.0(0.4,2.3)	0.911
Urban	69	35	1	1
Preeclampsia/Eclampisa
Yes	25	61	5.75(3.33, 9.93)	6.2(3.1,12.3)	0.000 *
No	158	67	1	1
Antepartum hemorrhage
Yes	31	61	4.464 (2.656, 7.5)	4.5(2.3,8.6)	0.000 *
No	152	67	1	1
Gestational diabetes mellitus
Yes	17	44	5.115(2.757,9.5)	4.2(1.9,9.2)	0.000 *
No	166	84	1	1
Mode of delivery
SVDa	139	83	1	1
CSb	39	33	1.417(.828,2.425)	1.0(0.5,2)	0.912
Instrumental	5	12	4.019(1.368,11.81)	2.3(0.5,9.5)	0.258
Duration of labor
>12hr	49	46	1.534(.942,2.5)	1.1(0.6,2.2)	0.703
<12hr	134	82	1	1
Presentation of the fetus
Vertex	153	98	1	1
Non vertex	30	30	1.561(.886,2.75)	1.5(0.7,3.5)	0.311
Premature rupture of membrane
Yes	42	58	2.782(1.705,4.54)	2.5(1.33,4.7)	0.004 *
No	141	70	1	1
Obstructed labor
Yes	52	63	2.442(1.522,3.92)	1.9(1.0,3.8)	0.053
No	131	65	1	1
Fetal distress during labor
Yes	59	60	1.854(1.164,2.95)	3.0(1.3, 7.0)	0.010 *
No	124	68	1	1
Intrauterine meconium release
Yes	23	61	6.33(3.62,11)	7.7(3.1,19.3)	0.000 *
No	160	67	1	1
Birth weight
< 2.5kg	40	19	1	1
2.5kg-4kg	137	103	2.105 (0.6, 7.39)	2.67(0.6, 12.6)	0.207
>4kg	6	6	1.33(.417, 4.24)	2.904(0.7,12.2)	0.146

aSpontaneous Vaginal Delivery

bCesearian Section

*AOR = statistically significant at p<0.05.