Results Early neonatal mortality rate in Wangaya Hospital was 38.7 per 1000 livebirths. .... pale, petechie, rash, jaundice, sclerema), feeding disorder (feeding ...
Paediatrica Indonesiana September
VOLUME 48
NUMBER 5
Original Article
Early neonatal mortality rate and the risk factors in Wangaya hospital Made Indah Nastiti Utami Budha, Wayan Retayasa, Made Kardana
Abstract Background The first week of life of a neonate is a critical period. In Asia, early neonatal mortality rate remains high. Objective To investigate early neonatal mortality rate and the risk IDFWRUVLQ:DQJD\D+RVSLWDO Methods A cross sectional study was carried out retrospectively RQQHRQDWHVUHJLVWHUHGDW3HULQDWRORJ\8QLW:DQJD\D+RVSLWDO 'HQSDVDU %DOL VLQFH -DQXDU\ 7KH VWXG\ ZDV GRQH IURP 2FWREHU WR 1RYHPEHU 'DWD ZDV REWDLQHG IURP PHGLFDO UHFRUG DQDO\]HG DV XQLYDULDWH XVLQJ FKLVTXDUH WHVW RU )LVKHU·V exact test and multivariate logistic regression analysis model. Results (DUO\QHRQDWDOPRUWDOLW\UDWHLQ:DQJD\D+RVSLWDOZDV SHUOLYHELUWKV8QLYDULDWHDQDO\VHVVKRZHGWKDWWKHUHZHUH five significant risk factors of early neonatal death, i.e., respiratory GLVWUHVVDVSK\[LDELUWKZHLJKWOHVVWKDQJUDPVVHSVLVDQG JHVWDWLRQDODJHOHVVWKDQZHHNV0XOWLYDULDWHDQDO\VLVVKRZHG that those five variables were significant as risk factors of early QHRQDWDOGHDWKLH25 FRQILGHQFHLQWHUYDO IRUUHVSLUDWRU\ GLVWUHVV WR @DVSK\[LD WR @ELUWK ZHLJKW JUDPV WR @VHSVLV WR DQGJHVWDWLRQDODJH ZHHNV WR @ Conclusions (DUO\QHRQDWDOPRUWDOLW\UDWHLQ:DQJD\D+RVSLWDO UHPDLQVKLJK5HVSLUDWRU\GLVWUHVVDVSK\[LDELUWKZHLJKW JUDPVHSVLVDQGJHVWDWLRQDODJH ZHHNVZHUHLQGHSHQGHQWULVN factors of early neonatal death. [Paediatr Indones 2008;48:30611].
+
ealth status of a nation or community, among others, includes mortalities, morbidities, and nutritional status. In QHRQDWDO PRUWDOLW\ UDWH DQG HDUO\ neonatal mortality rate in the entire world were SHUOLYHELUWKVDQGSHUOLYHELUWKV respectively. In developed countries, they were only 5 SHUOLYHELUWKVDQGLQOLIHELUWKV,Q$VLD neonatal mortality rate and early neonatal mortality rate ZHUHSHUOLYHELUWKVDQGSHUOLYHELUWKV respectively.3 Early neonatal mortality rate in Wangaya +RVSLWDOLQZDVSHUOLYHELUWKV4 This study aimed to investigate early neonatal PRUWDOLW\UDWHDQGLWVULVNIDFWRUVLQ:DQJD\D+RVSLWDOLQ order to be able to conduct more intensive and optimal treatment to reduce early neonatal death rate.
Methods This retrospective study was conducted in Wangaya +RVSLWDOEHWZHHQ2FWREHU²1RYHPEHU'DWDRI
Keywords: early neonate, mortality rate, risk factors )URP WKH 'HSDUWPHQW RI &KLOG +HDOWK 0HGLFDO 6FKRRO 8GD\DQD 8QLYHUVLW\6DQJODK+RVSLWDO'HQSDVDU,QGRQHVLD Request reprint to: Made Indah Nastiti Utami Budha, MD, Department RI&KLOG+HDOWK0HGLFDO6FKRRO8GD\DQD8QLYHUVLW\6DQJODK+RVSLWDO -O31LDV'HQSDVDU%DOL,QGRQHVLD 7HOS)D[
306Paediatr Indones, Vol. 48, No. 5, September 2008
Made Indah Nastiti Utami Budha et al: (DUO\QHRQDWDOGHDWKLQ:DQJD\D+RVSLWDO
subjects were obtained from the medical records of WKH QHRQDWHV UHJLVWHUHG DW 3HULQDWRORJ\ 8QLW VLQFH -DQXDU\ 7KH LQFOXVLRQ FULWHULRQ ZDV DOO OLYH ELUWKV UHJLVWHUHG DW 3HULQDWRORJ\ 8QLW LQ :DQJD\D +RVSLWDOVLQFH-DQXDU\:HH[FOXGHGQHRQDWHV who had incomplete data. This study was approved by the Ethical Clearance from the Ethics Committee of Medical School, Udayana University/Sanglah +RVSLWDO'HQSDVDU Samples size was calculated by using the sample VL]H HVWLPDWLRQ HTXDWLRQ IRU VLQJOH SURSRUWLRQ 5 one thousand five hundred live births were included. We collected data on medical record number, gender, gestational age, birth weight, asphyxia, congenital anomaly, respiratory distress, sepsis, maternal age, parity, early neonatal deaths, and early neonatal age at death.
are irregularity of body temperature (hyperthermia, hypothermia), change of behavior/ consciousness (lethargy, irritable), change of tone, change of normal skin (poor of peripheral perfusion, cyanosis, mottling, pale, petechie, rash, jaundice, sclerema), feeding disorder (feeding intolerance), gastrointestinal problems (vomiting, diarrhea, abdominal distension, cardiopulmonary problems (tachypnea, tachycardia, hypotension, respiratory distress), and metabolic disorder (hypoglycemia, hyperglycamia, metabolic acidosis). Maternal age was calculated from PRWKHU·V ELUWKGD\ FDWHJRUL]HG DV OHVV WKDQ \HDUV \HDUVDQGPRUHWKDQ\HDUV3DULW\ZDVGHILQHG as a number of pregnancies until the present pregnancy, FDWHJRUL]HGDVSDULW\RUSDULW\DQGSDULW\
Definitions
'DWD ZHUH DQDO\]HG XVLQJ 6366 YHUVLRQ IRU Windows. Univariate analysis was performed using FKLVTXDUHWHVWRU)LVKHU·VH[DFWWHVW)RUPXOWLYDULDWH analysis, we performed multiple logistic regression model, to determine risk factors that significantly associated with early neonatal death. The strength of the association was indicated by odds ratio 25 FRQILGHQFH LQWHUYDOV ZHUH VXSSOLHG /HYHO RI VLJQLILFDQFHZDVVHWDW3
Early neonatal death was defined as neonatal death in the first seven days of life.1 Early neonatal mortality rate was the number of early neonatal death divided E\ WKH QXPEHU RI OLIH ELUWKV PXOWLSOLHG E\ Live birth was defined as birth of infant regardless the length of intrauterine period, in which the baby showed any signs of life as breathing, positive heartbeat or umbilical cord pulse or any muscle movements. Gestational age was defined as a period from the first day of the last normal menstrual period until the day of birth (calculated in weeks), grouped as gestational DJHOHVVWKDQZHHNVDQGZHHNVBirth weight was the body weight recorded at birth by baby scales at 3HULQDWRORJ\ 8QLW :DQJD\D +RVSLWDO FDWHJRUL]HG DV ORZ ELUWK ZHLJKW LI OHVV WKDQ JUDP DQG QRW ORZ ELUWKZHLJKWLIJUDP$VSK\[LDZDVGHILQHGDVD condition where the baby had not adequate, spontaneous and regular breathing at birth.Congenital anomaly was anomaly that exist since birth. Respiratory distress was defined as a syndrome FRQVLVWHGRIPLQLPDORIFDUGLQDOVLJQVRIUHVSLUDWRU\ distress: dyspnea with breathing frequency more than WLPHVSHUPLQXWHVQDVDOIODULQJJUXQWLQJLQWHUFRVWDO subcostal, or suprasternal retraction, and cyanosis in room temperature.9 Sepsis was defined as a clinical syndrome charcterized by systemic infections (minimal 3 organs involved) and / or followed by bacteremia (positive blood culture). Clinical signs of sepsis
Data analysis
Results )URPOLYHELUWKLQIDQWVHQUROOHGLQWKLVVWXG\ there were 58 infants died during the early neonatal period, thus giving the early neonatal mortality UDWH RI SHU OLYH ELUWKV $PRQJ WKH VXFFXPEHGLQIDQWV RFFXUUHGLQWKHILUVW KRXUV DIWHU ELUWK 7KH FKDUDFWHULVWLFV RI VWXG\ samples are described in Table 1. The results of early neonatal death are shown in Table 2. Multivariate analysis (logistic regression model) showed that five variables were significant as risk IDFWRUVRIHDUO\QHRQDWDOGHDWKLQ:DQJD\D+RVSLWDO (Table 3). Those five variables (figures indicate 25ZLWK FRQILGHQFHLQHUYDOV ZHUHUHVSLUDWRU\ GLVWUHVV WR @ DVSK\[LD WR ELUWK ZHLJKW JUDP WR VHSVLV WR DQG JHVWDWLRQDO DJH ZHHNV WR
Paediatr Indones, Vol. 48, No. 5, September 2008307
Made Indah Nastiti Utami Budha et al: (DUO\QHRQDWDOGHDWKLQ:DQJD\D+RVSLWDO
Discussion Early neonatal death remains to be a health problem and is the biggest component of neonatal mortality rate. Early neonatal mortality rate in Wangaya +RVSLWDOLQWKLVVWXG\ZDVSHUOLYHELUWKV higher than that observed in previous years (18.8 in LQ LQ 4 and also higher
Table 1. $CUKEEJCTCEVGTKUVKEUQHUVWF[UWDLGEVU Characteristics
0WODGT (n)
Percentage (%)
819 238 307 370 7 14 84 192 738
54.6 15.9 20.5 24.7 0.5 0.9 5.6 12.8 49.2
Gender (male) Gestational age (< 37 weeks) Birth weight (< 2500 gram) Asphyxia (yes) Congenital anomaly (yes) Respiratory distress (yes) Sepsis (yes) Maternal age
QTŮ[GCTUQNF 2CTKV[ QTŮ
than that in Asia.3 Our data could not explain why HDUO\ QHRQDWDO PRUWDOLW\ UDWH LQ :DQJD\D +RVSLWDO increased gradually every years. We do not have data whether it was caused by the decreased quality of human resources or by limited resource instruments LQ :DQJD\D +RVSLWDO RU E\ WKH LQFUHDVHG QXPEHU of complicated pregnancy referred to Wangaya +RVSLWDOE\SULYDWHSUDFWLWLRQHUSDUDPHGLFUHVXOWLQJ LQ PRUH QXPEHU RI LQIDQWV ERUQ ZLWK DVSK\[LD related outcome. There was no data either about the kind of complicated pregnancy or about the type of delivery. There were several studies which investigated early neonatal mortality. Data of previous study has SURYHGWKDWSUHPDWXULW\ JHVWDWLRQDODJH ZHHNV was a risk factor of early neonatal death. The function of organs in premature newborns is not optimal, therefore, they more difficult to adapt and easier to have complication and have high risk of death.13 Jimmy et al14 conducted an audit of neonatal care at 0DGLORQ+RVSLWDO0DGDQJ3DSXD1HZ*XDQHDVLQFH 1995 to 1999. The overall perinatal mortality rate
Table 2. Univariate analysis of risk factors of early neonatal death Risk factors in END Gender (male) Gestational age (< 37 weeks) Birth weight (< 2500 gram) Asphyxia (yes) Congenital anomaly (yes) Respiratory distress (yes) Sepsis (yes) /CVGTPCNCIG Ů[Q 2CTKV[ QTŮ
END n (%)
Non END n (%)
P
OR
95% CI
36 (4.4) 43 (18.1) 49 (16.0) 48 (13.0) 1 (14.3) 11 (78.6) 15 (17.9) 9 (4.7) 29 (3.9)
783 (95.6) 195 (81.9) 258 (84.0) 322 (87.0) 6 (85.7) 3 (21.4) 69 (82.1) 183 (95.3) 709 (96.1)
0.24 0.00 0.00 0.00 0.24 0.00 0.00 0.53 0.90
1.4Ȕ 18.3Ȕ 24.9Ȕ 16.7Ȕ 4.2Ԑ 112.3Ԑ 6.9Ȕ 1.3Ȕ 1.0Ȕ
0.8; 2.4 9.9; 33.6 12.1; 51.5 8.4; 33.4 0.5; 35.5 30.3; 415.7 3.7; 13.1 0.6; 2.6 0.6; 1.7
Ȕ7PKXCTKCVGCPCN[UKUYCURGTHQTOGFWUKPIEJKUSWCTGVGUV Ԑ7PKXCTKCVGCPCN[UKUYCURGTHQTOGFWUKPI(KUJGTŏUGZCEVVGUV
END = Early Neonatal Death
Table 3./WNVKXCTKCVGCPCN[UKUQHTKUMHCEVQTUQHGCTN[PGQPCVCNFGCVJ E
P
OR
95% CI
1.262 2.091 2.606 2.819 1.986
0.00 0.00 0.00 0.00 0.00
3.5 8.1 13.5 16.8 7.3
1.6; 7.8 3.3; 19.9 6.1; 29.9 3.7; 76.6 3.1; 17.1
Risk factors of END Gestational age < 37 weeks Birth weight < 2500 gram Asphyxia Respiratory distress Sepsis END = Early Neonatal Death
308Paediatr Indones, Vol. 48, No. 5, September 2008
Made Indah Nastiti Utami Budha et al: (DUO\QHRQDWDOGHDWKLQ:DQJD\D+RVSLWDO
ZDVSHUWRWDOELUWKVZLWKDQHDUO\QHRQDWDO PRUWDOLW\UDWHRIDQGDVWLOOELUWKUDWHRI7KH major cause of death were prematurities, low birth ZHLJKW VHSVLV DQGDVSK\[LD In D FRKRUW VWXG\ FRQGXFWHG E\ WKHVLV@'HQSDVDU 8QLYHUVLWDV8GD\DQD 0DGL\RQR % 3HUNLUDDQ EHVDU VDPSHO ,Q 6DVWURDVPRUR 6 ,VPDHO6HGLWRUV'DVDUGDVDUPHWRGRORJLSHQHOLWLDQNOLQLV ndHG-DNDUWD &96DJXQJ6HWR S 6XJLWR 3XUZDQWR $ ,VPDQGDUL ) *ORVDULXP GDWD GDQ LQ formasi kesehatan. 3XVDW GDWD GDQ LQIRUPDVL 'HSDUWHPDQ Kesehatan RHSXEOLN,QGRQHVLD S .DUGDQD0$VILNVLDQHRQDWRUXP,Q 6XUDDWPDMD6HGLWRU Neonatologi praktis. Denpasar: Bag./SMF Ilmu Kesehatan $QDN S +DPLG$$VILNVLDQHRQDWRUXP,Q 6XUDDWPDMD66RHWML QLQJVLKHGLWRUV3HGRPDQ'LDJQRVLVGDQ7HUDSL,OPX.HVH KDWDQ$QDN56836DQJODK'HQSDVDUDenpasar: Bag./SMF ,OPX.HVHKDWDQ$QDN S 9. Fanaroff AA, Fanaroff JM. Clinical examination. In: Donn SM, Sinha SK, editors. Manual of neonatal respiratory care. ndHG3KLODGHOSKLD 0RVE\(OVHYLHU S *RPHOOD7&&XQQLQJKDP'(\DO)*=HQN.(1HRQDWRO RJ\ 0DQDJHPHQW3URFHGXUHV2Q&DOO3UREOHPV'LVHDVH DQG'UXJV1HZ
