Article Information

Corresponding author: Hassan Mumtaz

Article Type : Research Article

Volume : 1

Issue : 3

Received Date : 10 Sep ,2020


Accepted Date : 26 Sep ,2020

Published Date : 01 Oct ,2020


DOI : https://doi.org/10.38207/jcmphr200234

Citation: Mumtaz H, Fatima T, Meer F, Tariq A, Shohab S, et al. (2020) Neonatal Mortality and Its Correlation with Low Birth Weight in Neonatal ICU of a Developing Country. J Comm Med Pub Health Rep 1(3): https://doi.org/10.38207/jcmphr200234

Copyright: © © 2020 Mumtaz H. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
  Neonatal Mortality and Its Correlation with Low Birth Weight in Neonatal ICU of a Developing Country

Hassan Mumtaz1, *, Tehreem Fatima2, Fatima Meer3, Ayesha Tariq4, Sara Shohab4, Ahsan Shafiq5, Tayyaba Naz6, Hajra Batool6, Zohaib Raza7 and Shamim Mumtaz8

1House Physician, Department of Paediatrics, Holy Family Hospital
2House Physician, Department of Medicine, Holy Family Hospital
3House Surgeon, Department of Surgery, Holy Family Hospital
4Post Graduate Trainee, Department of Paediatrics, Holy Family Hospital
5Post Graduate Trainee, Department of Medicine, Holy Family Hospital
6House Physician, Department of Paediatrics, Holy Family Hospital
7House Physician, Department of Paediatrics, Holy Family Hospital
8Post Graduate Trainee, Department of Paediatrics, Holy Family Hospital
9Professor of Microbiology, IMDC

*Corresponding author: Dr. Hassan Mumtaz, House Physician, Department of Paediatrics, Holy Family Hospital, Rawalpindi

Abstract
Introduction: Low birth weight (LBW) remains a significant public health problem in Pakistan and further understanding of factors associated with LBW is required.

Study Design: Cross sectional study.

Place and duration of study: Holy Family Hospital, from 1st Aug 2020 to 31st Aug 2020.

Methodology: 643 neonates admitted in Neonatal ICU were selected. The most important causes of admission and mortality were analyzed. Birth weight was categorized into strata, based on the WHO definitions with ELBW, VLBW, LBW, IBW, ABW or MACR. Statistical tools used were SPSS Version 21.

Results: Out of 643 neonates, 400 were male (62.2 %) and 243 (37.8 %) were female. 103 neonates (16 %) were under 1500 g, 251 (39 %) between 1501 - 2500 g, 231 neonates (35.9 %) between 2501 to 3500 g, whereas 58 (9 %) had weight 3501 - 4500 g. 36 % neonates were born premature, 20 % born with Birth Asphyxia, 13 % with RDS, 8 % neonates had EOS, 7 % were admitted with NNJ, 5 % neonates had HIE, 3 % neonates admitted with fits, 2 % neonates presented with delayed crying and 2 % neonates had MAS, 1 % neonates had Meningitis and Meconium Aspiration. 451 neonates (70.1 %) expired, 286 were male (63.5 %) and 165 were female (36.5 %), whereas 29.9 % neonates (192) were discharged.

Conclusion: Our research has demonstrated that the percentage mortality is 70 % in neonates with LBW. It confirms the association between LBW and mortality, which is a measure of mortality risk in resource-constrained settings, especially in developing countries like Pakistan. Improved care for those born with LBW is needed to ensure the well-being of such infants and hence decrease the mortality risk.Keywords: neonates, Low birth weight, adequate weight, macrosomic, neonate

Introduction
Neonatal mortality is an important indicator of public health for countries  around  the  world  [1].  With   an   estimated   298,000 neonatal deaths annually and a reported neonatal mortality rate of 49 per 1000 live  births, Pakistan accounts for  7 % of global  neonatal deaths. Infection (36 %), preterm birth (28 %) and birth asphyxia (23 %) account for 87 % of neonatal deaths worldwide [2]. This is a large number compared to many western countries i.e In the United States in 2017, the neonatal mortality rate was 3.8 per 1,000 live births [3]. Low birth weight (LBW) as defined by the World Health Organization is a birth weight of lower than 2.5 kg [4]. LBW births are more common in low-income countries. As per 2015 statistics, there were about 20.5 million LBW births worldwide, nearly three-quarters of them were in South-Asia and Sub-Saharan Africa. The two main reasons for LBW are preterm birth, intrauterine growth restriction (IUGR), or a combination of these two [5]. Low birth weight can be an appropriate measure of mortality risk in resource-constrained settings, especially in developing countries. A number of studies have linked NMR with LBW. Interestingly, the data varies with each country.

Hence, in this study, we aim to investigate any possible correlation between NMR and LBW. Accurate birth weight data and its association with mortality will not only help to improve child health care but also spread awareness about it. Furthermore, it would help to identify the most appropriate intervention in a given setting. Targeted measures to examine the reasons for LBW and then actions to improve care for those born with LBW are needed to ensure the well-being of such infants. And if an association is confirmed it might help us to achieve the Millennium Development Goal of lowering under-5 mortality.

Material and Methods
This cross-sectional study was carried out in the department of Pediatrics, Holy Family Hospital, affiliated with Rawalpindi Medical University, Pakistan. The data was collected during the month August 2020. A total sample size of 643 was achieved.

This institute is situated in the heart of Rawalpindi city. Rawalpindi is a city and capital of Rawalpindi Division located in the Punjab province of Pakistan. It is the fourth-largest city proper in Pakistan, while the larger Islamabad-Rawalpindi metropolitan area is also the country's  fourth-largest metropolitan area. Rawalpindi is adjacent to  Pakistan's capital  of Islamabad, and the two are jointly known as the "twin cities" on account of strong social and economic links between the cities [6]. It has a population of 2,098,231 having an area of 259 km [7]. The Rawalpindi district is divided into seven tehsils, these are Gujar Khan, Kahuta, Kallar Syedan, Kotli Sattian, Murree, Rawalpindi  and  Taxila  covering  a  total  area  of 5,286 km2 and having a population of 4,500,000.

Birth weight was categorized into strata, based on the WHO definitions with the following denominations: extremely low birth weight (ELBW), 500 - 999 g; very low birth weight (VLBW), 1000 - 1499 g; low birth weight (LBW), 1500 - 2499 g; insufficient birth weight (IBW), 2500 - 2999 g; adequate weight (ABW), 3000 - 3999 g; and macrosomic (MACR), 4000 g or more [8].

The database processing and analyses were performed by the Statistical Package for the Social Sciences (SPSS) - version 21. Ethics approval for the collection of data included in this study was granted by the Ethics Committees of the Department of Pediatrics, Holy Family Hospital, Rawalpindi.

Results

Table 1: Weight of neonates admitted in Neonatal ICU

Weight

Frequency

Percent

Valid Percent

Cumulative Percent

Under 1500 g

103

15.7

16

16

1501-2500 g

251

38.3

39

55.1

2501-3500 g

231

35.2

35.9

91

3501-4500 g

58

8.8

9

100

Total

643

98

99.9

262.1

Out of total 643 neonates, 103 neonates (16 %) were under 1500g, 251 neonates (39 %) were between 1501-2500 g, 231 infants(35.9 %) were between 2501 to 3500 g, and where as 58 neonates (9 %) had weight between 3501 - 4500 g (Table1).

Table 2: Gender based neonates admitted in Neonatal ICU

Gender

Frequency

Percent

Valid Percent

Cumulative Percent

Male Baby

400

61.0

62.2

62.2

Female Baby

243

37.0

37.8

100.0

Total

643

98.0

100.0

162.2

Male babies admitted in NICU were 400 (62.2 %) where as female babies were 243 which accounted for (37.8 %). (Table 2)

 

36 % neonates were born premature, 20 % were born with Birth Asphyxia, 13 % were born with RDS (Respiratory Distress Syndrome), 8 % neonates had EOS (Familial Gene for Eosinophilia), 7 % neonates were admitted with NNJ (Neonatal jaundice), 5 % neonates had HIE (Hypoxic Ischemic Encephalopathy), 3 % neonates were admitted with fits, 2 % neonates presented in with delayed crying and 2 % neonates had MAS (Macrophage Activation Syndrome). 1 % of the neonates had Meningitis and Meconium Aspiration. (Figure 1)

Table 3: Prognosis of the neonates admitted in NICU.

Gender

Frequency

Percent

Valid Percent

Cumulative Percent

Expired

451

70.1

70.1

70.1

Male Babies

286

63.5

63.5

63.5

Female Babies

165

36.5

36.5

36.5

Discharged

192

29.9

29.9

29.9

Total

643

100.0

100.0

100.0

451 neonates (70.1 %) expired out of which 286 male babies expired (63.5 %) and 165 were female babies (36.5 %) who expired, where as 29.9 % neonates (192) were discharged from NICU (Table 3).

Discussion
Regarding the risk of neonates mortality, all newborns with strata weighing less than 3000 g presented higher risk when compared with those of adequate birth weight (3000 - 3999 g). Our research has demonstrated that the percentage mortality is 70 % in infants with LBW, 63.5 % in male babies and 36.5 % in female babies. It confirms the association between LBW and mortality. A similar study has demonstrated that newborns with extremely low birth weight were 200 times  more  likely to die in the first year of life [9].

According to a study done in Ghana, 2016 showed that the Mortality declined with age but was consistently higher for low- birth-weight neonates than for normal-weight neonates. Age- specific illness rates increased over time. Upon adjustment for other factors, birth weight was not associated with infant illness overall although the association varied significantly with time  (P = 0.0013). Compared with normal weight infants,  infants born weighing 1.50 - 1.99 kg and less than 1.50 kg had higher illness rates in the neonatal period.Previous researches have documented that educated women are less likely to have a LBW baby and maternal education has a 33 % protective effect against LBW [10]. This has been observed in similar low-resource settings such as Nepal [11] and Bangladesh [12], and in another study from Pakistan [13]. We also found  that illiteracy was associated with LBW delivery, which is likely related to reduce service utilization and less knowledge of positive health behavior. Improving access to education for young girls will address this issue. Increasing health literacy among illiterate women is complex and requires additional resources directed toward individual counseling [14,15].

A study conducted in rural areas of Pakistan during 2017  showed that nulliparous mothers were more likely to deliver LBW babies compared to multiparous women. This finding was in agreement with previous meta-analyses [16,17] showing that nulliparous women are consistently more likely to have LBW babies compared to their multiparous and grand multiparous counterparts. Several hypotheses have been put forward to explain this association, including the biological immaturity of young mothers and maternal - fetal competition for nutrients in women still trying to achieve their own growth potential [18,19]. In a study conducted during 2001 in Totowa, New Jersey shows that developed countries, preterm birth generates high health care costs, particularly for neonatal intensive care, which is often required for many months for infants born extremely preterm (< 32 wk gestational age) [20,21]. Severely growth restricted infants are at increased risk of neonatal death and significant short-term morbidity from hypoglycemia, hypocalcemia and polycythemia [22].

A study conducted in Dhaka, Bangladesh 2001 showed the majority of LBW neonates in developing countries are small-for- dates rather than preterm [23], and the high prevalence of LBW can be explained mainly based on IUGR. For this reason, IUGR has become a focus for potential interventions, two assumptions being that: (i) intra- uterine growth may be more tractable to interventions than preterm labor (although the degree of tractability remains questionable and there are over- laps in etiology between the two areas); and (ii) its numerical dominance in the etiology of LBW means that interventions to reduce IUGR will pay dividends in terms of outcome [24]. This second assumption may be valid in the context of  later morbidity, since IUGR may have effects on childhood growth, cognitive development and subsequent diseases in adulthood [25-27].

The cohort study consisted entirely of LBW neonates, and the NMR was 133 deaths per thousand live births, roughly double the figures for unselected South Asian populations, which  ranged from 50 to 97 deaths per thousand live births [28-31]. The next most striking finding is that 84 % of cohort deaths occurred in the first week of extra uterine life, half within the first 48 hours. This is generally consistent with previous findings from Bangladesh indicating that 21 % of neonates die within the first three days [32], comparable results have been reported for Brazil [33]. By contrast, a study in the Gambia (NMR = 39 deaths per thousand live births) suggested that early and late neonatal deaths were roughly equal [34], although early deaths may have been underreported.

It also shows that VLBW is strongly associated with high mortality. VLBW neonates made up only 7 % of the LBW total, but accounted for a third of deaths and had a mortality rate of 780 per thousand live births. Like VLBW, lower gestational age at birth also carries a high mortality risk (769 per thousand live births at less than 32 weeks). More interesting, perhaps, is that  75 % of all deaths occurred in preterm neonates, even though they constituted only a third of all LBW babies [27].

A global network study conducted during 2015 showed Between October 2009 and March 2011, 153,728 babies were delivered and followed through day 28. Neonatal death rates ranged from 41 per 1000 births in Pakistan to 8 per 1000 in Argentina. 54 % of the neonatal deaths were > 37 weeks and 46 % weighed 2500 grams or more. Half the deaths occurred within 24 hours of delivery [35]. In our data set most of the patients with  LBW were premature (31 %), making it the most common reason for LBW. Out of total 643 neonates, (16 %) were under 1500 g, (39 %) were between 1501-2500 g, 231(35.9 %) between 2501 to 3500 g, whereas (9 %) had weight between 3501 - 4500 g.

Conclusion
Low birth weight is an appropriate measure of mortality risk in resource-constrained settings, especially in developing countries like Pakistan. Targeted measures to examine the reasons for LBW and then actions to improve care for those born with LBW are needed to ensure the well-being of such infants and hence decrease the mortality risk.

Acknowledgement: The authors are deeply indebted to Dr. Tariq Saeed, Associate Professor and Head of Paediatrics Department, Holy Family Hospital for his motivation to initiate and complete this project successfully.

Conflict of Interest: This study has no conflict of interest to be declared by any author.

Author’s contribution: HM, TM - Conception of study; FM, AT - Experimentation/study conduction; TN, HB - Statistical Analysis; AS, SS - Facilitation/ Material analysis; ZR- Critical review; SM - Manuscript writing

Funding Disclosure: None

Conflict of Interest: There is no conflict of interest to declare.

Reference

  1.  Mathews TJ, Driscoll AK (2017) Trends in Infant Mortality in the United States, 2005-2014. NCHS Data Brief 279: 1-8.
  2. WHO (2020) Neonatal mortality, risk factors and causes: a prospective population-based cohort study in urban Pakistan.
  3. March of Dimes (2020) Neonatal deaths: United States, 2007-2017.
  4. Moreira AIM, Sousa PRM, Sarno F (2018) Low birth weight and its associated factors. Einstein (Sao Paulo) 16(4): eAO4251.
  5. Katz J, Lee AC, Kozuki N, Lawn JE, Cousens S, et  al. (2013) Mortality risk in preterm and small-for-gestational- age infants in low-income and middle-income countries: a pooled country analysis. Lancet 382(9890): 417-425.
  6. Population Size and Growth of Major Cities.
  7. Wikipedia (2020) Rawalpindi.
  8. United Nations Organization (ONU) (1995) World Health Organization. World Declaration on the Survival, Protection and Development of Childrena.
  9. Vilanova CS, Hirakata VN, de Souza Buriol VC, Nunes M, Goldani MZ, et al. (2019) The relationship between thedifferent low birth weight strata of newborns with infant mortality and the influence of the main health determinants in the extreme south of Brazil. Population Health Metrics 17: 15.
  10. Silvestrin S, Silva CH, Hirakata VN, Goldani AA, Silveira PP, et al. (2013) Maternal education level and low birth weight: a meta-analysis. J Pediatr (Rio J) 89(4): 339-345.
  11. Bhaskar RK, Deo KK, Neupane U, Chaudhary Bhaskar S, Yadav BK, et al. (2015) A case control study on risk factors associated with low birth weight babies in Eastern Nepal. Int J Pediatr.
  12. Matin A, Azimul SK, Matiur AKM, Shamianaz S, Shabnam JH, et al. (2008) Maternal socioeconomic and nutritional determinants of low birth weight in urban area of Bangladesh. J Dhaka Med Coll 17(2): 83-87.
  13. Anjum F, Javed T, Faheem M, Ghazanfar Ali Sheikh A (2011) Maternal risk factors associated with low birth weight: a case control study in Lahore. Ann King Edward Med Univ 17(3): 1-6.
  14. Chanda SK, Howlader MH, Nahar N (2012) Educational status of the married women and their participation at household decision making in rural Bangladesh. Int J Adv Res Technol 1(6): 137-146.
  15. https://www.who.int/bulletin/volumes/95/8/16-180273/en/
  16. Habib MA, Greenow CR, Ariff S, Soofi S, Abid Hussain A (2017) Factors associated with low birthweight in term pregnancies: a matched case–control study from rural Pakistan.Eastern Mediterranean Health J 23(11).
  17. Kozuki N, Lee AC, Silveira MF, Sania A, Vogel JP, et al. (2013) The associations of parity and maternal age with small-for-gestational-age, preterm, and neonatal and infant mortality: a meta-analysis. BMC Public Health 13(Suppl 3): S2.
  18. Aliyu MH, Jolly PE, Ehiri JE, Salihu HM (2005) High parity and adverse birth outcomes: exploring the maze. Birth 32(1): 45-59.
  19. Bisai S, Sen A, Mahalanabis D, Datta N, Bose K (2006) The effect of maternal age and parity on birth weight among Bengalees of Kolkata, India. Hum Ecol 14: 139-43.
  20. Kramer MS, Victora CG (2001) Low Birth Weight and Perinatal Mortality. In: Semba R.D., Bloem M.W. (eds) Nutrition and Health in Developing Countries. Nutrition and Health. Humana Press, Totowa, NJ.
  21. Morrison JC (1991) Preterm birth: a puzzle worth solving. Obstet Gynecol 34(3): 289-289. 
  22. Barker DJP (1992) Fetal and Infant Origins of Adult Disease. BMJ Publishing Group, London, UK.
  23. Villar J, Belizan J (1982) The relative contribution of prematurity and fetal growth retardation to low birth weight in developing and developed countries. Am J Obstetrics Gynecol 143: 793-798.
  24. Villar J, Altobelli L, Kestler E, Beliźan J (1986) A health priority for developing countries: the prevention of chronic fetal malnutrition. Bulletin of the World Health Organization 64: 847-851.
  25. Barker DJP (1995) Fetal origins of coronary heart disease. British Med J 311: 171-174.
  26. Lucas A (1994) Role of nutritional programming in determining adult morbidity. Arch Dis Childhood 71: 288- 290.
  27. Yasmin S, Osrin D, Paul E, Costello A (2001) Neonatal mortality of low-birth-weight infants in Bangladesh Bulletin of the World Health Organization 79(7).
  28. Geospatial World (1996) Atlas of South Asian women and children. Kathmandu, United Nations Childrens Fund.
  29. Rahman S, Nessa F (1989) Neonatal mortality patterns in rural Bangladesh. J Trop Pediat 35: 199-202.
  30. Nessa S, Arco E, Kabir I (1992) Birth kits for safe motherhood in Bangladesh. World Health Forum 13: 66-69.
  31. Misra P, Thakur S, Kumar A, Tandon S (1993) Perinatal mortality in rural India with special reference to high risk pregnancies. J Trop Pediat 39: 41-44.
  32. Salway S, Nasim S (1994) Levels, trends and causes of mortality in children below 5 years of age in Bangladesh: findings from a national survey. J Diarrhoeal Disease  Res 12: 187-193.
  33. Victora C, Barros FC, Vaughan JP, Teixeira AMB (1987) Birthweight and infant mortality: a longitudinal study of 5914 Brazilian children. Int J Epidemiol 16(2): 239-245.
  34. Leach A, Mcardle TF, Banya WAS, Krubally O, Greenwood AM, et al. (1999) Neonatal mortality in a rural area of The Gambia. Annals Trop Paediatr 19(1): 33-43.
  35. Belizán JM, McClure EM, Goudar SS, Pasha O, Esamai F, et al. (2012) Neonatal death in low- to middle-income countries: a global network study. Am J Perinatol 29(8): 649-656.