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Title: The public health importance of birth asphyxia in Kathmandu, Nepal
Author: Ellis, Matthew Edward
ISNI:       0000 0001 3446 1778
Awarding Body: University of London
Current Institution: University College London (University of London)
Date of Award: 1999
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Background: Birth asphyxia is considered to be an important cause of perinatal mortality and neurodevelopmental impairment but epidemiological data from low income countries is scarce. Objectives: To describe the prevalence, risk factors and outcome of birth asphyxia in the main maternity hospital in Kathmandu, Nepal where more than 50% of local mothers deliver. Methods: The prevalence of birth asphyxia: Design: Prospective descriptive cross-sectional survey Subjects: 14,771 births Outcomes: Fresh stillbirths (SB) of 2000 g or more Neonatal encephalopathy (NE) in term infants Perinatal death Risk factors for neonatal encephalopathy and fresh stillbirth in term infants Design: Retrospective case control study Subjects: 131 NE cases / 107 fresh stillbirths of 2000g or more / 635 controls Outcomes following neonatal encephalopathy Design: Prospective cohort study Subjects: 131 NE cases / 208 controls Outcomes: Death / Neurodevelopmental impairment at one year Results The prevalence of birth asphyxia The prevalence of fresh stillbirth and NE (as measures of birth asphyxia in term infants) were 8.5 per 1000 total births (95% CI 7.1-10.1) and 6.4 per 1000 live births (95% CI 5.2-7.8) respectively. Birth asphyxia in term infants accounts for 24% (95% CI 21-28%) of the total perinatal mortality of 44 per 1000 total births in the study population. Evidence of intrapartum compromise was more likely during the labours of fresh stillbirths (76%) and NE infants (68%) than of controls (12%). Risk factors for neonatal encephalopathy and fresh stillbirth Multivariate analysis found significant (p<0.05) independent risk factors to be a) for NE: low maternal educational status, low maternal height, previous neonatal death, lack of antenatal care, prolonged rupture of membranes and/or smelly liquor, non-cephalic presentation, exposure to syntocinon, large infant head size and low infant weight. b) for fresh SB: low maternal educational status, multiparity, previous stillbirth, prolonged rupture of membranes and/or smelly liquor, non-cephalic presentation, induction with syntocinon and low infant weight. Outcomes following neonatal encephalopathy 102 NE cases (78%) and 106 controls (51%) were followed up to one year of age. The relative risk of death (95% Confidence Interval) for mild, moderate and severe NE compared to controls was 4.5 (1.4-15), 7.7 (2.6-22) and 25.6 (9.8-67). The excess risk of death was limited to the neonatal period for all grades of NE. Of 27 survivors of moderate NE 16 (59%[95% CI 39-78]) developed major neurodevelopmental impairment by one year of age. The prevalence of disability at one year of age following birth asphyxia at term in this population is no more than 1 per 1000 birth cohort. Conclusions Birth asphyxia is an important cause of perinatal mortality in low income countries but accounts for less childhood disability than has previously been estimated. This study failed to identify a simple and affordable public health measure likely to have a major impact on the prevalence of birth asphyxia. The induction of delivery using syntocinon in the absence of continuous fetal and uterine monitoring may be dangerous to the fetus. Available resources are best aimed at the extension of obstetric services to reach more precisely targeted risk groups at the outset of labour. Closer attention to the management of intrapartum meconium both in the uterus prior to delivery and in the newborn airway immediately after delivery may help to improve outcome. Improvements in perinatal care in low income countries are unlikely to have a major impact on the prevalence of childhood disability.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available
Keywords: Neonatal encephalopathy; Stillbirth