Published online May 1, 2008
PEDIATRICS Vol. 121 No. 5 May 2008, pp. e1381-e1390 (doi:10.1542/peds.2007-1966)
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ARTICLE

Risk Factors for Neonatal Mortality Due to Birth Asphyxia in Southern Nepal: A Prospective, Community-Based Cohort Study

Anne CC. Lee, MD, MPHa, Luke C. Mullany, PhDa, James M. Tielsch, PhDa, Joanne Katz, ScDa, Subarna K. Khatry, MBBSb, Steven C. LeClerq, MPHa,b, Ramesh K. Adhikari, MDc, Shardaram R. Shrestha, MPHb and Gary L. Darmstadt, MD, MSa

a Department of International Health, International Center for Advancing Neonatal Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
b Nepal Nutrition Intervention Project-Sarlahi, Kathmandu, Nepal
c Institute of Medicine, Tribhuvan University, Kathmandu, Nepal

OBJECTIVE. Our goal was to identify antepartum, intrapartum, and infant risk factors for birth asphyxia mortality in a rural, low-resource, population-based cohort in southern Nepal.

PATIENTS AND METHODS. Data were collected prospectively during a cluster-randomized, community-based trial evaluating the impact of newborn skin and umbilical cord cleansing on neonatal mortality and morbidity in Sarlahi, Nepal. A total of 23662 newborn infants were enrolled between September 2002 and January 2006. Multivariable regression modeling was performed to determine adjusted relative risk estimates of birth asphyxia mortality for antepartum, intrapartum, and infant risk factors.

RESULTS. Birth asphyxia deaths (9.7/1000.0 live births) accounted for 30% of neonatal mortality. Antepartum risk factors for birth asphyxia mortality included low paternal education, Madeshi ethnicity, and primiparity. Facility delivery; maternal fever; maternal swelling of the face, hands, or feet; and multiple births were significant intrapartum risk factors for birth asphyxia mortality. Premature infants (<37 weeks) were at higher risk, and the combination of maternal fever and prematurity resulted in a 7-fold elevation in risk for birth asphyxia mortality compared to term infants of afebrile mothers.

CONCLUSIONS. Maternal infections, prematurity, and multiple births are important risk factors for birth asphyxia mortality in the low-resource, community-based setting. Low socioeconomic status is highly associated with birth asphyxia, and the mechanisms leading to mortality need to be elucidated. The interaction between maternal infections and prematurity may be an important target for future community-based interventions to reduce the global impact of birth asphyxia on neonatal mortality.

Key Words: asphyxia neonatorum • risk factors • mortality • neonatal • Nepal

Abbreviations: RR—relative risk • CI—confidence interval • OR—odds ratio • IL—interleukin

Accepted Aug 31, 2007.