Authors: Mulugeta Dile Worke, Benyam Seifu, Belete Belgu, Kasiye Shiferaw
Categories: Research, Prevalence, Predictors, Birth asphyxia, Systematic review and meta-analysis, Ethiopia
Source: BMC Pregnancy and Childbirth
Authors: Mulugeta Dile Worke, Benyam Seifu, Belete Belgu, Kasiye Shiferaw
Birth asphyxia is one of the leading causes of most neonatal deaths. Hence, strengthening and investing in care is crucial, particularly around birth and the first week of life. As a result, several studies, including an umbrella review, were conducted even though significant variations were observed among those investigations. Thus, this is an updated systematic review and meta-analysis aimed to determine predictors of birth asphyxia in Ethiopia.
Online databases such as CINAHL, PubMed, Embase, Web of Science, and Cochrane Library were searched. Online searches turned up pertinent grey literature, and repositories of several universities were also searched. Observational studies carried out in Ethiopia were included. The authors conducted an independent search, quality check, and data extraction. The Newcastle Ottawa Scale checklist was used to evaluate the quality of articles. STATA version 17 was used for both data entry and statistical analysis. Since there were variations among studies, a random-effect model was employed for analysis. Egger’s regression test and funnel plot were utilized to assess publication bias, and the I-squared test was performed to verify the studies’ heterogeneity.
This analysis comprised 38 studies with 13,593 sample sizes. The pooled prevalence of birth asphyxia was 23.07% (95% CI: 19.96, 26.18). An intrapartum (i.e., prolonged labor, blood- or meconium-stained amniotic fluid, tight nuchal cord, cord prolapse, intrapartum fetal distress, malposition/malpresentation, and premature rupture of membrane) and obstetric procedure (i.e., labor induction, emergency cesarean sections, instrumental deliveries, and night time deliveries) factors were significantly associated with birth asphyxia. Moreover; neonatal (i.e., low birth weight, premature birth, and the male sex of the neonate), and maternal (i.e., place of residence, primigravida, mother’s age, chronic hypertension, pregnancy-induced hypertension, anemia throughout pregnancy, antepartum hemorrhage, absence of antenatal care follow-up) were also significantly associated with birth asphyxia.
This meta-analysis indicates nearly one in four newborns suffered from birth asphyxia in Ethiopia. It implicates tailored interventions for an intrapartum, maternal, neonatal, and an obstetrics procedure-related associated factors are needed to reduce birth asphyxia, thereby enhancing achievement of the sustainable development goal that aimed to reduce neonatal mortality to less than 12 per 1000 live births. Therefore, advocacy for public health initiatives aimed at increasing awareness of birth asphyxia and promoting early detection and intervention strategies, multidisciplinary approaches, and interventional studies are crucial.
The online version contains supplementary material available at 10.1186/s12884-025-08346-w.
The World Health Organization (WHO) estimates that in 2022, the first month of life claimed the lives of 2.3 million newborns [1, 2]. Sub-Saharan Africa (SSA) accounts for 43% of global newborn deaths (27 deaths per 1000 live births), followed by central and southern Asia, which account for 36% of global newborn deaths (21 deaths per 1000 live births) [1]. A study indicated that the pooled prevalence of neonatal mortality was 6.78% in Ethiopia [3], and mini Ethiopian Demographic Health Survey 2019 showed that the neonatal mortality rate was above the SSA average [4]. A million newborn deaths occur in the first 24 h of delivery [1]. Significant causes of newborn deaths are preterm delivery, birth asphyxia [5], infection, and congenital disabilities [1, 2]. Birth asphyxia is a significant cause of neonatal mortality and morbidity in Ethiopia [6]. Inadequate access to high-quality healthcare services, poor nutrition, and environmental variables, including air pollution, are also other factors that lead to newborn deaths [2].
Birth asphyxia refers to a condition where a newborn baby does not receive enough oxygen before, during, or immediately after birth [7]. Understanding the determinants of birth asphyxia is crucial for developing effective interventions and reducing its occurrence [6, 8]. Antepartum determinants of birth asphyxia in Ethiopia refer to factors that occur before labor and delivery and contribute to the risk of oxygen deprivation during childbirth by compromising fetal oxygen supply or increasing the likelihood of difficult labor [9–14]. On the other hand, intrapartum determinants of birth asphyxia refer to factors that occur during labor and delivery [15–22].
Meta-analysis in Ethiopia identified illiterate mothers [9], antepartum hemorrhage (APH) [9], cesarean section [9], pregnancy-induced hypertension [9], induction of labor [9], parity [9], preterm [9], non-cephalic presentation [9, 23], gestational age < 37 weeks [23], prolonged labor [9, 24, 25], low birth weight [9, 24], meconium-stained amniotic fluid [9, 24–26], cord prolapse [25], Premature Rupture of Membrane [25] and instrumental delivery [9, 24, 25] were the determinant factors of birth asphyxia.
Despite several studies, meta-analysis that conducted using few studies in Ethiopia (i.e., less than 15 articles) have remarkable variations [9, 24–26]; hence comprehensive search including recent publications are very crucial to have the complete picture of the factors, design appropriate interventions and influence strategies. Further, study indicated pooled estimates may not actually represent the national figure of birth asphyxia due to several limitations [27]. A comprehensive understanding of the burden and contributing factors was necessary because the prevalence of prior meta-analyses varied, each evaluation included a small number of papers (i.e., between 9 and 15), and all of the meta-analyses were carried out four years ago.
It is important to note that an antepartum and intrapartum determinant often interact with each other and contribute collectively to the occurrence of birth asphyxia. Hence, addressing these determinants requires a comprehensive approach that includes improving maternal healthcare services, promoting early detection and management of maternal health conditions, enhancing antenatal care (ANC) coverage, ensuring skilled attendance at births with proper monitoring techniques, availing emergency obstetric care facilities equipped with necessary resources for managing complications [28, 29].
Strengthening healthcare systems at all levels by improving infrastructure and training healthcare providers on evidence-based practices, community education programs aimed at raising awareness about ANC utilization, and recognizing danger signs during pregnancy could help reduce the burden of birth asphyxia [30–32]. Strengthening and investing in care, particularly around birth, and improving maternal and newborn care quality during the perinatal period, including strengthening midwifery, are some of the World Health Organization’s responses [1].
Thus, understanding the determinants of birth asphyxia is crucial for developing effective preventive strategies, improving neonatal outcomes, and achieving sustainable development goal target 3.2, which is aimed at reducing neonatal mortality and stillbirth to at least as low as 12 per 1000 live births and births, respectively by 2030 [33, 34]. Therefore, this study aimed to conduct a systematic review with meta-analysis to identify the determinants of birth asphyxia in Ethiopia. The findings will provide valuable insights into the specific intrapartum, maternal, neonatal, and obstetric procedure-related factors contributing to birth asphyxia. This knowledge can guide healthcare professionals and policymakers in implementing targeted interventions to reduce the burden of birth asphyxia and improve neonatal outcomes.
The systematic review and meta-analysis protocol was not registered for this systematic review and meta-analysis. The new version of the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guideline for reporting protocol was used [35] (Fig. 1) and the PRISMA 2020 Checklist was used to write this article. Fig. 1PRISMA 2020 flow diagram of updated systematic review with meta-analysis articles considered in predictors of birth asphyxia in Ethiopia
First-hand studies published in peer-reviewed journals were systematically searched using electronic databases (PubMed, Embase, Scopus, Web of Sciences, and the Cochrane Library databases) using relevant keywords related to maternal factors, antepartum factors, intrapartum factors, neonatal factors, obstetric procedure-related factors and birth asphyxia, and Ethiopia. Repositories in Ethiopian universities were also visited for unpublished studies. Additional publications were identified based on references cited within the eligible studies. The internet (using the Google search engine) was also searched to maximize search effectiveness. Medical Subject Heading (MeSH) terms and free text words were used to identify relevant studies from the databases. The population, exposure, and outcome (PEO) terms were combined using the Boolean operator to search in the databases (Additional file 1).
Combining essential ideas to find birth asphyxia and related variables in the PubMed database, Boolean operators like “AND” and “OR” were utilized to optimize the sensitivity and specificity of our search approach. The search terms were improved by running a trial among randomly chosen articles and searching for more pertinent terms within each topic from recovered papers. Following several iterations of trial and error, we arrive at the following final search word for PubMed: (((“infant, newborn“[MeSH Terms] OR (“infant“[All Fields] AND “newborn“[All Fields]) OR “newborn infant“[All Fields] OR “infant newborn“[All Fields] OR (“infant, newborn“[MeSH Terms] OR (“infant“[All Fields] AND “newborn“[All Fields]) OR “newborn infant“[All Fields] OR “neonatal“[All Fields] OR “neonate“[All Fields] OR “neonates“[All Fields] OR “neonatality“[All Fields] OR “neonatals“[All Fields] OR “neonate s“[All Fields]) OR (“infant, newborn“[MeSH Terms] OR (“infant“[All Fields] AND “newborn“[All Fields]) OR “newborn infant“[All Fields] OR “newborn“[All Fields] OR “newborns“[All Fields] OR “newborn s“[All Fields])) AND (“Fetal distress“[All Fields] OR “Nonreassuring Fetal Status“[All Fields] OR “hypoxic-ischaemic encephalopathy“[All Fields] OR “postasphyxial encephalopathy“[All Fields] OR “intrauterine asphyxia“[All Fields] OR “intra-partum asphyxia“[All Fields] OR “perinatal asphyxia“[All Fields] OR ((“perinatal“[All Fields] OR “perinatally“[All Fields] OR “perinatals“[All Fields]) AND (“asphyxia“[MeSH Terms] OR “asphyxia“[All Fields] OR “suffocate“[All Fields] OR “suffocating“[All Fields] OR “suffocation“[All Fields] OR “suffocations“[All Fields] OR “suffocated“[All Fields])) OR “neonatal asphyxia“[All Fields] OR “birth asphyxia“[All Fields] OR “postnatal asphyxia“[All Fields] OR “asphyxia neonatorum“[All Fields] OR “suffocation*“[All Fields])) OR (“asphyxia“[MeSH Terms] OR “asphyxia“[All Fields] OR “asphyxias“[All Fields] OR (“asphyxia“[MeSH Terms] OR “asphyxia“[All Fields] OR “suffocate“[All Fields] OR “suffocating“[All Fields] OR “suffocation“[All Fields] OR “suffocations“[All Fields] OR “suffocated“[All Fields]))) AND (“parturition“[MeSH Terms] OR “parturition“[All Fields] OR “delivery, obstetric“[MeSH Terms] OR (“delivery“[All Fields] AND “obstetric“[All Fields]) OR “obstetric delivery“[All Fields] OR “parturitions“[All Fields] OR “parturitional“[All Fields] OR (“birth s“[All Fields] OR “birthed“[All Fields] OR “birthing“[All Fields] OR “parturition“[MeSH Terms] OR “parturition“[All Fields] OR “birth“[All Fields] OR “births“[All Fields]) OR (“parturition“[MeSH Terms] OR “parturition“[All Fields] OR “childbirth“[All Fields] OR “childbirths“[All Fields])) AND (“Ethiopia“[MeSH Terms] OR “Ethiopia“[All Fields] OR “Ethiopias“[All Fields] OR “Federal Democratic Republic of Ethiopia“[All Fields]).
Later, it was updated based on the requirements of each database to obtain the most relevant results. We changed the original search keywords for each database to get useful results. MD and KS, the two reviewers, conducted the searches and determined eligibility independently. In the event of a disagreement, the third (BS) arbitrated the final selection of research based on consensus. After conducting numerous database searches, a compilation of items published through October 31, 2023, was created. After duplicates were removed, all the articles retrieved from the databases were combined into a single endnote library.
All cross-sectional, case-control, and cohort observational studies that showed a connection between birth asphyxia and the characteristics investigated in Ethiopia were eligible for inclusion in this systematic review and meta-analysis. Mostly, to avoid translation problems, articles published in the English language up until October 31, 2023, were included. All published articles and gray literature conducted among Newborns and their mothers were included. Several factors contributed to the exclusion of the (a) papers with no reported 95% confidence intervals or odds ratios; (b) reviews; (c) studies conducted among different populations (twins, cesarean section (C/S) deliveries, preterm births); (d) articles not reporting birth asphyxia and its determinants or associated factors; and (e) animal or case studies. Articles without abstract and full-text, duplicated studies, anonymous reports, editorials, and qualitative studies were excluded from the analysis. In addition, studies that did not include events in both the risk and non-risk groups were excluded after at least two email contacts of the primary author. The exclusion of these studies was because of the inability to extract the data of studies.
Three writers used the relevant instruments to independently evaluate the quality of the listed studies (e.g., the Newcastle-Ottawa Scale (NOS) for observational studies) [36]. This scale is divided into three maximum 5-star ratings for sample selection, maximum 2-star ratings for subject comparability across various outcomes, and maximum 3-star ratings for result measurement. The Newcastle—Ottawa quality assessment technique for case-control and cohort studies was used to evaluate the possibility of bias for case-control studies [37].
Authors (MD and KS) assigned stars to each item in the NOS tool. The total score was calculated by adding the scores of each item; one star equals a one, while no star equals a zero. Each study’s rating was derived from ten scores, and the results were presented as individual supporting data in Excel format for each criterion (Additional file 2). The quality of each study was rated using the following scoring “good” if ≥ 7 points score, “fair” if 2 to 6 points score and “poor” if ≤ 1 point score; other authors also used similar cut-offs points [38, 39]. Accordingly, to improve the validity of this systematic review result, we only included primary studies with fair to good quality [40].
A Cochrane Public Health Group data extraction form was used to extract all the required data [41]. The review questions were customized to fit the data extraction form. The initial draft of the data extraction form was created by one author (MD). Using a standardized format, data on study characteristics, participant characteristics, exposure variables (maternal, fetal, and obstetric factors), outcome (birth asphyxia), and effect estimates were extracted by two independent authors (MD & KS). Furthermore, every study had its study setting, exposure comparators, case ascertainment, confounder adjustment, and quality evaluation scores extracted. The review questions served as the basis for determining which variables were extracted. Each reviewer cross-checked the extracted data items, and if there was a disagreement, a third reviewer arbitrated the issue or reached a consensus.
World Health Organization defined ‘birth asphyxia’ as failure to initiate and sustain breathing at birth [7]; it has a dichotomous outcome of ‘Yes’ if initiate and sustain breathing at birth or ‘No’ otherwise.
Using STATA version 17 software, all pertinent extracted data were examined. A random-effects meta-analysis model was employed to generate the pooled estimate since heterogeneity between studies in design, geography, exposure to different biomass fuels, different outcome measuring methods, different confounding factors, and methodological variations were expected. Using I^2^ statistics and the p-value, as well as Cochran’s Q test, the heterogeneity among the included studies was evaluated. Plotting the study standard errors allowed for detecting any asymmetry in the study distribution.
The present systematic review included 38 studies, encompassing 13,593 combined sample sizes. These institution-based studies were conducted from 2015 to 2022. Seventeen and 21 studies were conducted in multi-center and single institutions, respectively. The method data ascertainment was combined (i.e., mothers recall, record review, and observations), mother recall, and record review for 25, 5, and 8 studies, respectively. Of 38 studies, 17, 4, and 6 were from Amhara regional state [14, 19, 28, 30, 42–54], Oromia National regional state [55–58], and Tigray provincial state [59–64], respectively. Similarly, 6, 2, and 1 were from South Nation, Nationalities and People Region (SNNPR) [8, 65–69], Addis Ababa [70, 71], and Harari [72], respectively. There was also one study from Benishangul-Gumiz regional state [73] and one study that was conducted in Harari regional state and Dire Dawa city administration [74]. Majority of studies were cross-sectional (22) [30, 42, 44, 46–49, 52–54, 57–59, 61, 62, 65–70, 72, 74] and unmatched case-control (15) [8, 14, 19, 28, 43, 45, 50, 51, 55, 56, 60, 63, 64, 71, 73] study design whereas only one study was cohort study design [53] (Additional file 3).
Of thirty-eight included studies, nine and twenty-nine primary studies included in the review had fair and good quality, respectively (Additional file 2).
The pooled prevalence of birth asphyxia in Ethiopia was 23.07% (95% CI: 19.96, 26.18) among 23 studies that reported the proportion of birth asphyxia (Fig. 2).Fig. 2Forest plot of studies for the pooled prevalence of birth asphyxia in Ethiopia, 2023
There was a significant heterogeneity (I ^2^ = 92.31%, p-value < 0.05) among studies. The funnel plots showed an asymmetric shape, which indicates the presence of significant publication bias. Similarly, Egger’s regression test showed the presence of publication bias across studies (p-value < 0.001). To rectify the publication bias, this analysis was applied to fill three studies on the 23 observed studies in the funnel plot. Following the imputation of these three studies on the observed 23 articles, the pooled prevalence of birth asphyxia was 19.76 (95% CI: 18.95, 20.58) (Fig. 3).Fig. 3Figure indicating publication bias, trim and fill analysis for the prevalence of birth asphyxia studies in Ethiopia, 2023
According to the random-effects model analysis for sensitivity, there was no single study that had a significant impact on the total estimate of the prevalence of birth asphyxia in Ethiopia (Fig. 4).Fig. 4Forest plot of sensitivity analysis of studies for the prevalence of birth asphyxia in Ethiopia, 2023
The present meta-analysis indicated intrapartum (i.e., prolonged labor, amniotic fluid stained with blood or meconium, tight nuchal cord, cord prolapse, delivery problems, intrapartum fetal distress, malposition/malpresentation, and premature rupture of membrane; PROM), maternal (i.e., place of residence, Primigravidity, mother’s age, mother’s health status (chronic hypertension, pregnancy-induced hypertension, anemia throughout pregnancy, APH), and absence of ANC follow-up), neonatal (i.e., low birth weight, premature birth, and the male sex of neonate) and obstetric procedure (i.e., labor induction, emergency cesarean sections, instrumental deliveries, and deliveries during night time) factors were significantly associated with birth asphyxia.
It was evidenced that infants born after prolonged labor were more likely to develop birth asphyxia than infants born less than 12 h [24, 25, 27, 75]. In this analysis, 12 eligible studies reported the association of prolonged labor with birth asphyxia [14, 19, 28, 43, 48, 50, 51, 56, 57, 59, 61–63, 65, 67, 68, 70]. Therefore, the pooled estimate revealed that infants of women who had greater than 12 h labor duration were more than three times more likely exposed for increased odds of birth asphyxia than infants of women who had less than 12 h labor duration (OR = 3.15, 95%CI: 2.55, 3.90). The pooled estimate indicated that infants of women who had blood-stained amniotic fluid had more than 20 times increased odds of birth asphyxia than infants of women who had clear amniotic fluid (OR = 20.99, 95%CI: 1.09, 405.91) (Fig. 5 A, B).Fig. 5A, B Forest plot of studies for prolonged labor and having blood-stained meconium fluid as the predictors of birth asphyxia in Ethiopia, 2023.
Evidence revealed that infants born to women who had meconium-stained amniotic fluid [9, 24, 25, 27, 75] were more likely to develop birth asphyxia than infants born to women who had clear amniotic fluid. Further, infants born to women who had blood-stained amniotic fluid were found to be associated with birth asphyxia compared to infants born to women who had no blood-stained amniotic fluid [54, 68]. The pooled estimate of 21 studies [8, 14, 19, 42, 43, 46–49, 58–67, 69, 71] revealed that infants born to women who had meconium-stained amniotic fluid experienced nearly six times increased odds of birth asphyxia than infants born to women who had clear amniotic fluid (OR = 5.60: 95%CI: 4.37, 7.17) (Fig. 6).Fig. 6Forest plot of studies for meconium-stained amniotic fluid as the predictor of birth asphyxia in Ethiopia, 2023
Evidence revealed that cord prolapse [8, 68, 73] and tight nuchal cord [58, 60, 65] had an association with birth asphyxia. The pooled estimate revealed that infants who were born after the tight nuchal cord had four times increased odds of birth asphyxia (OR = 4.44, 95% CI: 2.18, 9.05). Infants who were born after cord prolapse had six times increased odds of birth asphyxia (OR = 5.71, 95%CI: 2.23, 14.64) compared to their respective counterparts. Similarly, the pooled estimate of studies [30, 48, 50, 54, 58] revealed that infants who were born to women who experienced birth complications had more than three times increased odds of birth asphyxia than infants whose mothers had uncomplicated labor (OR = 3.66, 95%CI: 2.62, 5.10) (Fig. 7A-C).Fig. 7A-C Forest plot of studies for tight nuchal cord, cord prolapse, and birth complications as the predictors of birth asphyxia in Ethiopia, 2023.
Infants delivered with intrapartum fetal distress had nearly six times increased odds of birth asphyxia than infants born without intrapartum fetal distress [8, 19, 69, 71] (OR = 5.63, 95% CI: 3.39, 9.37). The pooled estimate of studies [8, 14, 28, 43, 46, 47, 55, 56, 58, 60] revealed that infants that had malposition/malpresentation were nearly five times increased odds of birth asphyxia than infants who had normal position/presentation (OR = 4.75, 95%CI: 3.73, 6.05). Similarly, the pooled estimate of ten studies [42, 45, 46, 48, 54, 55, 67–69, 74] revealed that infants who were delivered to women who had PROM were three times increased odds of birth asphyxia than infants who were delivered to women who had matured term rupture of membrane (OR = 3.00, 95%CI: 2.34, 3.84) (Fig. 8A-C).Fig. 8A-C Forest plot of studies for intrapartum fetal distress, malposition and premature rupture of membrane as the predictors of birth asphyxia in Ethiopia, 2023
The pooled estimate of studies [42, 55] showed that infants who were born to mothers who resided in rural areas had nearly three times increased odds of birth asphyxia than infants born to mothers who resided in urban areas (OR = 2.69, 95%CI: 2.07, 3.50). Studies [42, 44, 54, 57, 59, 60, 64, 65] indicated infants born to primigravida women had increased odds of birth asphyxia compared to infants born to multigravida women (OR = 3.36, 95%CI: 2.40, 4.69). According to the pooled estimate of studies [45, 65], infants of advanced-age women had nearly seven times increased odds of birth asphyxia than infants of mothers who aged less than 35 years (OR = 6.90, 95%CI: 2.77, 17.22) (Fig. 9A-C).Fig. 9A-C Forest plot of studies for residence, gravidity, and mothers age as the predictors of birth asphyxia in Ethiopia, 2023.
The present systematic review and meta-analysis revealed that maternal health conditions such as chronic hypertension (OR = 4.89, 95%CI: 1.76, 13.55), anemia during pregnancy (OR = 3.65, 95%CI: 2.29, 5.79), and pregnancy-induced hypertension (OR = 4.80, 95% CI: 3.34, 6.89) had a very strong association with birth asphyxia (Fig. 10A-C).Fig. 10A-C Forest plot of studies for chronic hypertension, anemia during pregnancy, and pregnancy-induced hypertension as the predictors of birth asphyxia in Ethiopia, 2023.
The pooled estimate of eight studies [14, 45, 49, 63, 64, 69–71] revealed that infants born to women who experienced APH had nearly five times increased odds of birth asphyxia (OR = 4.88, 95%CI: 3.43, 6.94). Similarly, the pooled estimate of three studies [30, 58, 73] revealed that lack of ANC follow-up had nearly five times increased odds of birth asphyxia (OR = 4.72, 95%CI:2.36, 9.43). Furthermore, the pooled estimate of five studies revealed that infants of mothers who are unable to read and write had more than seven times more likely increased odds of birth asphyxia than infants of mothers who had an educational level of college and above (OR = 7.16, 95%CI: 4.55, 11.26) (Fig. 11A-C).Fig. 11A-C Forest plot of studies for antepartum hemorrhage, lack of ANC attendance, and being unable to read and write as factors associated with birth asphyxia in Ethiopia, 2023
The present meta-analysis indicated neonatal characteristics such as preterm birth, low birth weight, and male sex of the neonate were factors significantly associated with birth asphyxia. The pooled estimate of ten studies [14, 43–45, 47, 55, 56, 64, 65, 71] revealed that infants after preterm birth were more than three times increased odds of birth asphyxia than infants after term birth (OR = 3.44, 95%CI: 2.65, 4.47). Furthermore, two studies revealed that infants with the male sex were more than three times more likely exposed to birth asphyxia than female infants (OR = 3.11, 95%CI: 1.55, 6.25) (Fig. 12 A, B). In addition, seventeen studies revealed infants of low birth weight had more than four times increased odds of birth asphyxia than infants of normal birth weight (OR = 4.12, 95%CI: 3.50, 4.85) (Fig. 13).Fig. 12A, B Forest plot of studies for preterm birth and sex of neonate as the predictors of birth asphyxia in Ethiopia, 2023Fig. 13Forest plot of studies low birth weight as the predictor of birth asphyxia in Ethiopia, 2023
This meta-analysis revealed an obstetric procedure-related variables such as labor induction (OR = 2.94, 95% CI: 1.87, 4.61), emergency cesarean sections (OR = 2.87, 95% CI: 2.15, 3.83), deliveries during night time (OR = 3.26, 95% CI: 1.06, 10.01) (Fig. 14A-C), and instrumental deliveries (OR = 3.52, 95% CI: 2.74, 4.52) (Fig. 15) were significantly associated with birth asphyxia in Ethiopia.Fig. 14A-C Forest plot of studies for labor induction, emergency CS, and night time delivery as the predictors of birth asphyxia in Ethiopia, 2023Fig. 15Forestplot of studies forinstrumental delivery as the predictor of birth asphyxia in Ethiopia, 2023
The purpose of this meta-analysis was to emphasize the crucial factors that associated with birth asphyxia in Ethiopia. Thus, an intrapartum (i.e., prolonged labor, blood- or meconium-stained amniotic fluid, tight nuchal cord, cord prolapse, intrapartum fetal distress, malposition/malpresentation, and PROM) and an obstetric procedure (i.e., induction of labor, emergency cesarean sections, instrumental deliveries, and night time deliveries) factors were significantly associated with birth asphyxia in Ethiopia. Further, maternal (i.e., place of residence, primigravidity, mother’s age, mother’s health status, including chronic hypertension, pregnancy-induced hypertension, anemia throughout pregnancy, APH, and lack of ANC follow-up) and neonatal (i.e., low birth weight, premature birth, and the male sex of neonate) factors were significantly associated with birth asphyxia.
Nearly one fourth newborns in Ethiopia encounter birth asphyxia which is consistent with previous meta-analysis and an umbrella review findings in Ethiopia (19.3%) [75], (22.5%) [25], (21.1%) [26], (22.8%) [9], (24.06%) [24], and (22.52%) [27]. However, it is higher and lower than the pooled prevalence of birth asphyxia in East and Central Africa (15.9%) [76], and West Africa (30%) [77], respectively. This diversity may be due to variations in the demographic, study design, study setting, and ways to raise community awareness of Ethiopia’s maternal health issue and how the general public is informed about the risks associated with unfavorable delivery outcomes. The disparities in how services are provided to new moms and their infants could be another factor.
Although West African nations had more advanced medical facilities than East and Central African nations (15.9%), unfortunately unpublished 2017 data from 16 neonatal referral clinics in Ghana, Nigeria, and the Republic of Benin revealed that 30% of admitted term newborns suffered from perinatal hypoxia. All of the participants in the study in West Africa were admitted neonates, while all of the participants in the study in East Africa were newborns. Furthermore, Nigeria bears a large share of the worldwide burden of unattended childbirth. The burden of birth asphyxia is lower in Central Africa (9.1%) than in East Africa (18%), and it could contribute to overall low burden. However, more research is required to determine the primary cause of the regional difference.
The high prevalence of birth asphyxia in Ethiopia can have far-reaching implications for healthcare, the economy, and the well-being of the population. For instance, in terms of healthcare, high rates of birth asphyxia can strain the resources of hospitals and healthcare providers, leading to increased healthcare costs and decreased quality of care for other patients. This can also result in a higher burden on the healthcare system as more resources are needed to care for infants with birth asphyxia. Economically, high rates of birth asphyxia can lead to increased healthcare expenditures, lost productivity due to disability, and decreased quality of life for affected individuals and their families. This can also impact the country’s economy, as families may struggle to provide care and support for their affected children.
Furthermore, high birth asphyxia rates can have long-term implications for the population’s well-being, as it can lead to an increased prevalence of disabilities and chronic health conditions. This can affect the overall health and productivity of the population and place a significant emotional and financial burden on affected individuals and their families.
Birth asphyxia is significantly associated with prolonged labor, meconium-stained amniotic fluid, tight nuchal cord, cord prolapse, fetal distress, malposition, and premature rupture of membrane. These findings corroborated the findings of previous research [9, 24–27, 75]. In resource-limited settings like Ethiopia, the association between birth asphyxia and intrapartum variables might have noteworthy consequences for both the mother and the newborn. These factors may increase the likelihood of birth asphyxia and its associated complications, such as hypoxic-ischemic encephalopathy, cerebral palsy, developmental delays, and other consequences of neonatal hypoxia. Birth asphyxia risk factors may be more common in Ethiopia due to restricted access to comprehensive prenatal care and obstetric procedures. Healthcare facilities and providers may have to handle more cases of birth asphyxia and its long-term effects as a result, which could put an additional strain on them. The consequences of birth asphyxia might also be made worse by the absence of neonatal care facilities and qualified medical personnel in these areas. Due to intrapartum circumstances, infants who suffer from birth asphyxia may not receive timely and appropriate neonatal care, which can result in worse outcomes and increased rates of morbidity and mortality.
Moreover, in resource-constrained environments, a lack of knowledge and instruction regarding birth asphyxia among medical professionals and families may be associated with delays. This meta-analysis thus emphasizes the necessity of focused efforts to enhance public health campaigns, obstetric procedures, neonatal care, and prenatal care. Ethiopia can endeavor to lessen the effects of birth asphyxia and improve the general health and well-being of its people, especially in environments with limited resources, by addressing these issues.
Maternal factors such as place of residence, primigravidity, mother’s age, mother’s health status (i.e., chronic hypertension, pregnancy-induced hypertension, anemia, APH, and absence of ANC follow-up) were associated with birth asphyxia in line with previous findings [9, 24–27, 75–77]. Women living in rural or remote areas may have limited access to comprehensive ANC and obstetric practices, leading to delayed recognition and management of potential risk factors and exacerbates the risk of birth asphyxia, as regular prenatal visits are crucial for monitoring maternal and fetal health and identifying potential complications. Maternal age, chronic hypertension, pregnancy-induced hypertension, anemia throughout pregnancy, and APH can directly impact fetal well-being and increase the likelihood of birth asphyxia. These highlight the need for targeted interventions in Ethiopia to improve ANC access and quality, address maternal health conditions, and promote ANC follow-up, ultimately improving the overall health and well-being of mothers and infants in the country.
The present meta-analysis also revealed that neonatal factors such as low birth weight, premature birth, and the male sex of neonate were significantly associated with birth asphyxia in, consistent with previous findings conducted in Ethiopia [9, 24–27, 75], West Africa [77], and East and Central Africa [76]. Low birth weight and premature birth are known risk factors for birth asphyxia, as these conditions can lead to underdeveloped organs and physiological systems, making the newborn more susceptible to oxygen deprivation during the birthing process. The male sex of the neonate has also been associated with a higher risk of birth asphyxia, potentially due to biological differences in fetal development and response to stress during childbirth [78].
Similarly, several studies have indicated increased vulnerabilities of males to birth asphyxia which is also supported by previous animal and human studies that showed males have more cardiac defects, lower cardiac function and poorer lung maturity than females. It has been demonstrated that female fetuses create surfactant earlier, swallow more actively, grow larger airways that are more resilient to injury, and have more mature lungs during fetal development. The higher operative deliveries or birth weight for male neonates may contribute to high birth asphyxia. Since the mechanisms underlying these variations in the prenatal period are still unclear, more rigorous experimental and clinical study is required [79–81]. These associations highlight the need for targeted interventions to address the specific vulnerabilities of low birth weight, premature, and male neonates in Ethiopia. These may include supplementation of micronutrients and quality ANC; however, must be complemented by the overall health system to be effective.
Furthermore, the implications of these associations underscore the importance of comprehensive neonatal care and support for at-risk newborns in Ethiopia. This includes access to specialized neonatal care facilities, skilled healthcare providers, and appropriate medical interventions to mitigate the impact of birth asphyxia and improve neonatal outcomes. Addressing these implications requires a multifaceted approach that focuses on improving prenatal care, promoting maternal health, and strengthening neonatal healthcare services in Ethiopia. Thus, actions across the spectrum of care from adolescence, preconception, pregnancy, the safe management of labor and delivery and effective immediate postnatal care are needed. By addressing these neonatal factors and their association with birth asphyxia, Ethiopia can work towards reducing the burden of neonatal morbidity and mortality, ultimately improving the long-term health and well-being of its newborn population.
Obstetric procedures, such as labor induction, emergency cesarean sections, instrumental deliveries, and night-time deliveries, were significantly linked with birth asphyxia. Studies in Ethiopia [9, 24–27, 75], West Africa [77], and East and Central Africa [76] supported this finding. These associations are potentially due to the complications and stress related to these procedures. These highlight the need for careful consideration and monitoring during obstetric procedures (i.e., ensuring that healthcare providers are well-trained and equipped to handle potential complications during labor and delivery, as well as providing adequate support and interventions) to minimize the risk of birth asphyxia. These associations also underscore the importance of access to timely and appropriate obstetric care, such as ensuring that pregnant women have access to skilled healthcare providers, safe delivery facilities, and necessary interventions.
This study highlights that improved ANC, obstetric practices, and neonatal care are crucial for addressing birth asphyxia. Ensuring comprehensive ANC to manage risk factors, implementing evidence-based obstetric practices for safe childbirth, investing in neonatal care facilities and resuscitation training, and increasing awareness among healthcare providers and families are key interventions. Public health initiatives, research into causes, and support services for affected individuals are also vital. In order to reduce neonatal morbidity and mortality a comprehensive approach to improving obstetric care and promoting safe delivery practices is needed. An implementation of neonatal resuscitation programs and helping babies breathe initiatives are mandatory. Low demand and coverage variability due to health financing, inaccessibility, socio-cultural norms, and low literacy are challenges in preventing birth asphyxia in SSA. Obstetric supply challenges system from insufficient manpower, inequitable distribution of resources, and quality gaps. Secondary prevention is hampered by a lack of basic skills and equipment for neonatal resuscitation. Tertiary prevention is challenged by the absence of functional multidisciplinary rehabilitative care teams. Locally adapted solutions, safer pregnancy outcomes, accessible quality neonatal resuscitation, and human capacity development are key. Ethiopia’s efforts to expand ANC services and HBB training should be strengthened. Limited resources, low coverage, equity, and quality in obstetric care, along with environmental factors and poor working conditions during pregnancy, contribute to birth asphyxia.
The study contributes to a global effort to reduce neonatal mortality. A PRISMA guideline, Newcastle-Ottawa Scale (NOS) to assess study quality, random-effects model to address heterogeneity and Egger’s test and funnel plots to assess publication bias were used. A transparent and well-structured method, which reduces bias and guarantees all pertinent papers are incorporated into the analysis. Combining data from several research studies can find tiny but significant effects with a larger sample size and statistical power. Further, compared to individual investigations, these meta-analyses produced more broadly applicable results. Lastly, it might help determine the causes of variation among research, such as variations in study populations or techniques.
This study has limitations despite the merits mentioned above. First, the results of this meta-analysis could also be biased because the individual studies had biases. Second, there is often heterogeneity in the outcomes from observational studies due to differences in study design, demographic characteristics, and outcome measures. Because observational studies can only demonstrate associations, the results of this meta-analysis might not be able to prove a cause-and-effect link. Additionally, although authors searched comprehensively for both published and unpolished studies, there’s a chance that papers with statistically significant findings may be published more frequently and substantial important evidence may be missed, which could skew the results of this meta-analysis, leads to distortion of the true findings and over inflate significance and make getting full picture of meta-analysis difficult. Hence, policy makers and clinicians should interpret the results of the meta-analysis with caution.
Additionally, although twin neonates, neonates delivered with C/S, and preterm birth neonates are susceptible to birth asphyxia, their inclusion in the study with term newborns increased the burden of birth asphyxia, so they were excluded. As a result, we advise future research to pool the burden of birth asphyxia among these populations. Lastly, the protocol of this review was not registered.
The present meta-analysis indicates nearly one in four newborns suffered from birth asphyxia in Ethiopia. Prolonged labor, blood or meconium-stained amniotic fluid, tight nuchal or prolapsed cord, PROM, malposition, and fetal distress are intrapartum factors that are associated with birth asphyxia. Place of residence, primigravidity, mother’s age, maternal health statuses, such as chronic and pregnancy-induced hypertension, anemia during pregnancy, APH, and lack of ANC follow-up, are maternal predictors of birth asphyxia. An induced labor, deliveries during night time, and mode of deliveries are an obstetric related factors that significantly associated with birth asphyxia. Similarly, low birth weight, premature birth, and the male sex of neonate are neonatal factors that significantly associated with birth asphyxia. While this study found significant associations, it crucial that readers acknowledge limitations of high heterogeneity (I^2^ > 90%), potential to publication bias, exclusion of some populations which may affect external validity and designs limitation of observational studies (i.e., inability to establish causal and effect relationships). It also highlights tailored interventions for intrapartum, maternal, neonatal, and obstetrics procedure-related associated factors are needed to reduce birth asphyxia.
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Supplementary Material 3.