MIZAN TEPI UNIVERSITY

COLLEGE OF HEALTH SCIENCE

DEPARTMENT OF MIDWIFERY
PERVALANCE OF BIRTH ASPHYXIA AND ASSOCIATED FACTORS AMONG
NEWBORN BABYS WHO DELIVERED AT METTU KARL REFERAL HOSPITAL ILU
ABA BORA ZONE, OROMIA REGION, SOUTH WEST ETHIOPIA,2018 G.C

INVESTIGATORS:

1. Aregachew Enawgaw………………..HSR/095/08
2. Ziad Abdella………………………….HSR/642/08
3. Natnael Fikadu………………………..HSR/708/08
4. Nestanet Abeje………………………..HSR/479/08
5. Kango Kajela………………………….HSR/367/08

ADVISORS:
1) Mr. Ermiyas S.(BSC MSC)
2) Mr. Moges B.(BSC MSC)

A Research proposal submitted to Mizan Tepi University College of Health Science Department
of Midwifery in Partial Fulfillment of the requirements for the Degree of Bachelor of Science in
Midwifery.

DECEMBER, 2018 METTU, SOUTH WEST ETHIOPIA

1
 Acknowledgement

First of all, we would like to express our deepest gratitude and appreciation to our advisors Mr.
Ermiyas S (BSc, MSc) & Mr. Moges B (BSc), for their unreserved and constructive comments
for the proposal and research development. We would like to extend our appreciations to the data
collectors, study participants, and supervisors. We also want to thank Mizan Tepi University
College of health science department of Midwifery for giving permission letter to conduct this
research. We would like to extend our thanks to Mettu Karl Referral Hospital medical director
for permitting us to conduct the study.

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 Table of Contents
Acknoledgment..............................................................................................................................iii

List of Tables..................................................................................................................................vi

List of figures..................................................................................................................................vi

List of Acronyms and Abbreviations............................................................................................vii

SUMMARY.................................................................................................................................viii

1. INTRODUCTION.......................................................................................................................2

1.1 Background...........................................................................................................................2

1.2 Statement of problem.............................................................................................................4

1.3 Literature review....................................................................................................................6

1.3.1 Prevalence of birth asphyxia...........................................................................................6

1.3.2 Studies related to risk factors of birth asphyxia..............................................................7

Conceptual framework.....................................................................................................................9

1.4 Significance of the study......................................................................................................10

CHAPTER TWO...........................................................................................................................11

2 OBJECTIVES.............................................................................................................................11

2.1 General Objective................................................................................................................11

2.2 Specific objective.................................................................................................................11

CHAPTER THREE.......................................................................................................................12

3. METHODS AND MATERIALS..............................................................................................12

3.1 Study area.............................................................................................................................12

3.2 Study period.........................................................................................................................12

ii
 3.3 Study design.........................................................................................................................12

3.4 population................................................................................................................................12

3.4.1 Source population..........................................................................................................12

3.4.2 Study Population...........................................................................................................12

3.5 Eligibility criteria.................................................................................................................13

3.5.1 Inclusion criteria............................................................................................................13

3.5.2 Exclusion criteria...........................................................................................................13

3.6 Sample size determination and sampling procedure............................................................13

3.6.1 Sampling procedure.......................................................................................................13

3.7 Variables of study................................................................................................................14

3.7.1 Dependent variable........................................................................................................14

3.7.2 Independent Variables.............................................................................................14

3.8 Operational Definitions........................................................................................................14

3.9 Data collection tool and techniques.....................................................................................15

3.9.2 Data collection procedure.................................................................................................15

3.10 Data quality management...................................................................................................15

3.11 Data Processing and analysis.............................................................................................15

3.12 Ethical Consideration.........................................................................................................16

3.13 Dissemination of the result................................................................................................16

Chapter four: Work plan................................................................................................................17

CHAPTER FIVE:..........................................................................................................................18

BUDGET BREAK DOWN...........................................................................................................18

Reference.......................................................................................................................................20

Annexes.........................................................................................................................................23

Annex I. Participants Information Sheet....................................................................................23

iii
 ANNEX-II: CONSENT FORM.................................................................................................24

Annex III: English version of questionnaire.............................................................................25

iv
 LIST OF TABLES
Table 1; work plan of the study, January, 2018, Debre Tabor Ethiopia………………………16

Table 2: -Personal cost (Budget) for the proposal, February, 2018, Debre Tabor, Ethiopia….....16

Table 3:-Stationary cost (Budget) for the proposal, February, 2018, Debre Tabor, Ethiopia.......17

Table 4: - Total cost (Budget) for the proposal, February, 2018, Debre Tabor, Ethiopia……….18

List of figures
Fıgure1 conceptual framework for the study of birth asphyxia and its associated factors …………….8

v
List of Acronyms and Abbreviations

AAP American Academy of pediatrics

ANC Ante Natal Care

ADHD Attention Deficit Hyperactivity Disorder

APGAR Appearance, Pulse Rate, Grimace, Activity, Respiration Rate

BA Birth Asphyxia

CMR Child Mortality Rate

EDHS Ethiopian Demographic Health Survey

FMOH Federal Ministry of Health

GA Gestational Age

IMR Infant Mortality Rate

NICU Neonatal Intensive Care Unit

NMR Neonatal Mortality Rate

NR Neonatal resuscitation

MDG Millennium development goal

RDS Respiratory distress syndrome

TBA Traditional birth attendant

WHO World Health Origination

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 SUMMARY

Introduction: Birth asphyxia is failure to initiate and sustain breathing immediately after birth.
According to world health organization (WHO), it is the third major cause of neonatal death next
to infections and Preterm births in developing countries, accounts for an estimated 23% of the
annual 4 million neonatal deaths.
Objectives: The aim of this study is to assess the prevalence and associated factors of birth
asphyxia among babies born in Mettu Karl Referral Hospital.
Methods: Institutional based Cross sectional study will be conducted to assess the prevalence
and associated factors of birth asphyxia among babies born in Mettu Karl Referral Hospital from
December 12, 2018-Jannuary 12, 2019.
To determine sample size a single proportion formula will be used. According to this formula the
sample size of the study is 185. Systematic random sampling will be used to get the study unit.
The data will be entered, cleaned, checked and analyzed by using SPSS version20. Chi-square
with 95% confidence interval will be computed and p-value less than 0.05 will be considered as
a level of significance.

Budget: - Total budget required for this study 21954.00 Ethiopian birr.
Key Words: Birth asphyxia.

vii
1. INTRODUCTION

1.1 Background
Birth asphyxia is failure to initiate and sustain breathing immediately after birth (1, 2).
The exact definition of birth asphyxia is given, AAP` includes existence of 3 factors: Metabolic
or mixed acidemia (pH<7) which is determined by umbilical cord arterial blood samples; Apgar
score of <3 for longer than 5 min; neurological manifestations; and multisystem organ
dysfunction (3, 4). Lack of referrals and inadequate and inappropriate resuscitation measures and
lack of modern obstetric care, lack of intensive care technologists; lack of basic pediatric critical
care training for nurses to provide effective pediatric advanced life support; inadequate
resuscitation efforts; pediatric nurses’ inabilities to recognize critically ill neonates; lack of
modern or advanced equipment; and lack of transport services to facilitate movement of babies
from peripheral hospitals to neonatal units will contribute to increased risks of neonatal asphyxia
(5).

Worldwide Midwifes uses Apgar score for describing the wellbeing of new-born at birth.
Because it is a clinical indicator commonly used to describe the new-born’s physical condition at
birth. In many cases, the timing of asphyxia cannot be established with certainty that is why the
severity of asphyxia is widely assessed by the Apgar score, at 1 and 5 min. After birth
commonly the first 1 minute which is the “golden minute” the baby should be breathing well.
The low Apgar score beyond 5 minute is a suggestive criterion for an estimate of the severity of
asphyxia (6).

If new-born is unable to breathe spontaneously at birth it results birth asphyxia and causes a
damaging condition of impaired blood gas exchange and if it persists leading to progressive
hypoxemia hypercapnia with significant metabolic acidosis and tissue oxygen deficiency, which
can cause serious multi organ failure and poor prognosis and high mortality stillbirth or lifelong
disability in the surviving infant (7-9) commonly with a very high incidence of 25% irreversible
neurologic damage and 1.15 million develop clinical encephalopathy such as cerebral palsy,

1
mental retardation and epilepsy leading to detrimental long term consequences for both child and
family (10& 11-15) (16). Cognitive and behavioral difficulties which lead to memory and
attention deficit hyperactivity disorder (ADHD), autism and schizophrenia. In spite of
improvements in the obstetric and neonatal care, the incidence of birth asphyxia is similar in the
developing countries. In developing countries it is considerably higher because of negligible
antenatal care and poor prenatal services. According to world health organization (WHO), it is
the third major cause of neonatal death after infections and Preterm births. In developing
countries accounts for an estimated 23% of the annual 4 million neonatal deaths.

Birth asphyxia is a leading cause of mortality and morbidity in neonates in developing countries,
with an incidence of 100-250/1000 live births compared to 5-10/1000 live births in the developed
world(17). It remains a significant cause of loss of life and adverse developmental outcome (18).
The major causes of neonatal deaths globally were estimated to be infections (35%), preterm
births (28%) and birth asphyxia (23%) (3). As large number of deliveries in the developing world
takes place at home, there is According to 2011 DHS Ethiopia is experiencing high neonatal
mortality rate at 37 per 1000 live births comparable to the average rate of 35.9 per1000 live
births for the African region overall (19). Although birth asphyxia can be predicted for certain
conditions such as fetal distress and preterm child birth, most cases of birth asphyxia cannot be
predicted. Therefore all the attendants must be competent in newborn resuscitation and must
have the necessary equipment ready for the resuscitation of the newborn baby (16)

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1.2 Statement of problem

Globally, birth asphyxia has continued to pose a major clinical problem with approximately one
million babies affected annually. In developing countries, it is a major cause of death and
acquired brain damage with rates ranging from 4.6 per 1,000 in Cape Town to 26 per 1,000 in
Nigeria with case fatality rates of about 40% or higher [20].

Four million babies are born with asphyxia each year. According to statistics by WHO, in
developing countries 3% of infants (3.6 million babies) suffer from moderate to severe asphyxia,
of whom 23% (840,000) die which equates to nearly 1 million neonatal deaths per year and in a
countries with high neonatal mortality rates the death rate is 8 times that of countries with low
NMRs and almost the same number suffer from the associated consequences [1, 21& 12]. The
prevalence of birth asphyxia is increasing; in 1990s, the incidence of asphyxia was reported as
5.4/1000 live births while in the 2006, 25–73/1000 live births in developed countries an
incidence of 1-6/1,000 live births, and birth asphyxia (23%) represents the third most common
cause of neonatal death and 5-10/1000 live births in developing countries with 24–29% of
neonatal deaths up to 99% of these deaths [22, 23].

Africa accounts for 11% of the world’s population but more than 25% of the world’s new-born
deaths. Of every 4 children who die in Africa, one is a newborn. Due to this neonatal deaths have
remained stagnant globally [12, 24]. In sub-Saharan Africa born babies have a very high risk of
birth asphyxia because 280,000 deaths occur due to birth asphyxia during first day of life [12].

In Ethiopia birth asphyxia accounts 23% of 29/1000 live birth neonate’s mortality [21]. The
study in Dilchora Referral Hospital, in Dire Dawa,Prevalence of birth asphyxia by APGAR
score at 5th min were 204 (82.9%) 4-6 and 42 (17.1%) 0-3 scores. The prevalence of birth
asphyxia in Jimma Zone public hospital shows that 32.9% in the first minute and 12.5% in the
fifth minute. Usually hospital data shows a very high percentage of deaths due to asphyxia since
complicated births are more likely to come to hospital. Birth asphyxia is one among top three
causes of new-born deaths next to infections and complications of preterm birth which together
account for 88% of newborn deaths [25].

3
 A series of various maternal, obstetrical, and foetal factors cause hypoxia in the fetus and
asphyxia in the new-born. Therefore, the risk factors are associated with decreased blood flow
and oxygenation to the tissues. So birth asphyxia can be caused by events that have their roots in
50% of cases primarily ante-partum in origin, 40% cases intra-partum and remaining 10% of
cases are postpartum periods or combinations thereof [26, 5].

Birth asphyxia occurs when an inadequate amount of oxygen is delivered to the fetus, usually
leading to risk of lifelong disability in the surviving infant. Cognitive and behavioral difficulties
can also be expected because of the patterns of brain injury that have been associated with
neonatal encephalopathy. Other terms sometimes used for birth asphyxia include prenatal
asphyxia and fetal distress. Definitions of birth asphyxia designed for use in hospital-based
settings require evaluation of neo- natal umbilical cord pH, Apgar scores, neurological clinical
status, and markers of multi-system organ function, which are not feasible in community
settings. Therefore, it is difficult to recognize the causes of birth asphyxia in the community due
to lack of a consistent definition [27].
The greatest gap in new-born care is often during the critical first week of life when most
neonatal and maternal deaths often occur at home and without any contact with the formal health
sector. Some unacceptable practices such as unskilled attendants during delivery, unhygienic
delivery practices, taboos and superstitions associated with caring for the new-born greatly
affect new-born survival in Ethiopia
To improve today's neonatal care delivery, health-care providers need to better understand the
experiences of becoming a parent to a child with birth asphyxia. Knowledge and practice of high
quality management of birth asphyxia can reduce neonatal mortality.
Since midwives and neonatal ICU nurses have contacts with the asphyxiated babies at health
institutions, ignoring them may amount to inadequate or low level of care, poor out comes,
increased death rates and persistent high rates of infant mortality as we have it today in Ethiopia.
The management of birth asphyxia consists of supportive care to maintain temperature,
perfusion, ventilation and a normal metabolic state including glucose, calcium and acid-base
balance. Early detection by clinical and biochemical monitoring and prompt management of
complications must be done to prevent extension of cerebral injury [28].

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.1.3 Literature review

1.3.1: Prevalence of birth asphyxia

Globally birth asphyxia continues to present a major clinical problem and one of the common
and leading causes of prenatal and neonatal mortality and morbidity especially in developing
countries. The prevalence of birth asphyxia in Jimma Zone public hospital shows that 32.9% in
the first minute and 12.5% in the fifth minute in Dire Dawa 2.5 live births, in Gusau Nigeria
(21.1%). In Dares Salaam Tanzania (21.1%), Malawi (6.1%), In Cameroon (8.1%) and the study
in Iran showed that 35 (19.2%) patients had mild asphyxia, 107 (58.8%) had moderate asphyxia
and 40 (22%) were diagnosed as severe asphyxia[12, 17, 5, 29&30].

A cross sectional study conducted in university of Zambia, in USA shows that, among 182
infants to determine the base line incidence of birth asphyxia in neonatal intensive care unit.
Among these infants 42 (23%) had a clinical diagnosis of birth asphyxia. Of 42 infants with birth
asphyxia, 13 (31%) had an abnormal neurologic examination during the clinic visit: in contrast,
13 of 141 infants without birth asphyxia (9%) had an abnormal examination. The study
concludes that birth asphyxia survivors account for almost a quarter of NICU survivors in
developing countries [24].

According to a study in Pakistan, birth asphyxia contributed to 16.52% of hospital admissions

and is responsible for 21% of infant deaths [31].

The major difficulty in collecting accurate epidemiological data is lack of a common definition
of the diagnostic criteria of prenatal asphyxia. This is demonstrated by the difference in
occurrence according to different studies, where the incidence ranges from 5.4/1000 live births in
a Swedish study to 22/100 live hospital births in an Indian study [32]. Means of assessment
include umbilical pH, 1-hour post-delivery blood gas, Apgar scores, and neurological changes
ranging from twitching to hypotonia and seizures. When resources are lacking in developing
countries, prenatal asphyxia can be crudely assessed by use of the Apgar score.

In Africa birth asphyxia accounts 24% and 22% developed complication of asphyxia and it is
still the fifth largest cause of under-five mortality [33]. In 2013, lower-middle-income countries
(LMIC) share 98% of the total newborn mortality burden, whereas more than 4 in 10 of all
neonatal deaths worldwide occurred in just three countries: India, Nigeria, and Pakistan [34].

5
Birth asphyxia contributes to around 40% of the neonatal mortality burden in Pakistan and a
major fraction of these deaths occurs in rural areas (74%) [30]. A majority of these women give
birth at home and are either un assisted or assisted by an unskilled birth attendant, including
family and traditional birth attendants (TBA).

1.3.1 Studies related to risk factors of birth asphyxia

Risk factors of birth asphyxia in community and hospital based settings in developing countries
have been categorized into demographic, ante-partum, Intra-partum and neonatal risk factors

1.3.1.1 Socio-demographic characteristics

The study in Dire Dawa shows there was statistically significance association found between
birth asphyxia and age of mother. Maternal age group 15-20 years were four times and age
between 21-25 years old were two times to develop birth asphyxia when compared to age 26-
30years old (35). Maternal education was one of the factors associated with birth asphyxia. So
being illiterate was significantly associated with increased risk of birth asphyxia. The study in
Nepal indicates that, socioeconomic status, measured by a range of variables including parental
education and ethnicity, was significantly associated with increased risk of birth asphyxia
mortality. A study in Pakistan shows significant association of birth asphyxia with increasing
maternal age, poor dietary intake, and reproductive history including shorter birth intervals prior
stillbirths and child deaths and complications during pregnancy including self-reported high
blood pressure bleeding from the vagina, smelly or excessive vaginal discharge, and severe
abdominal pain, swelling on body (30&36).

1.3.1.2 Ante partum risk factors

The study in Addis Ababa shows that, ante-partum risk factors include, non-attendants for
antenatal care (64%), multiple births (4.8%), vaginal bleeding was strongly associated with
asphyxia in 34.44% 6 neonates. Lack of neonatal care, poor nutritional status, ante partum
hemorrhage, was associated with higher incidence of asphyxia [30]. The stud in Nepal shows
Ante-partum hemorrhage, maternal fever, pre-eclampsia, eclampsia, prolonged rupture of
membranes and obstructed labor have been associated with increased risk of birth asphyxia in
multiple hospital-based studies(36).

6
A study in Pakistan shows that, among antenatal risk factors, ante partum complications
(including smelly or excessive vaginal discharge and anemia or pallor) were the most important
factors related to increased risk of BA mortality. Furthermore, our study showed that small size
at birth has protective effect whereas larger babies are at an increased risk of asphyxia related
deaths (37).

1.3.1.3 Intra-partum Risk Factors

The study in Nigeria indicates that, prenatal asphyxia was observed most in infants with breech
presentation followed by infants with cephalic presentation, and face. Increased risk of prenatal
asphyxia in babies with non-cephalic presentation has been reported in other studies Birth
asphyxia was common in good sized babies with a mean birth weight of 3kg. This trend has also
been observed by other researchers and has been attributable to poor prenatal services in
maternity homes and hospitals. It is also pertinent to add that even where services are available,
they may not be utilized (37).
Study in Iran shows, birth asphyxia is associated with Risk factors like, emergent Caesarian
Section, preterm labor (<37w), low birth weight (<2500g).

The study in dire Dawa shows that mode of delivery is one of the factor that has significant
association with birth asphyxia. Neonate who were delivered by vacuum four times and
forceps delivery were five times develops birth asphyxia compared to caesarean section and
spontaneous vaginal delivery. This study also shows that there is significant statistical
association observed between mothers who spent less than 18 hr in labor were less likely to
develop birth asphyxia than those spent longer than 18 hr in labor (35).

A study in Pakistan, shows significant association among intra-partum risk factors, presence of
fever (indicative of infection), prolonged labor, breech delivery and cord around child’s neck
were found to be associated with high birth asphyxia mortality.

7
 Conceptual framework

Obstetric factors
Mode of delivery
obstetrics complications
during pregnancy

Socıo demographic factors

Mothers age
Ethınıcıty
Educational status Intra partum factors
Residence Fetal presentaıon
Socıo economic Birth Asphyxia Duration of labor
status Duration of rupture of membrane

Neonatal factors
Low birth weight
Preterm labor
prematurity

Fıgure1፡Conceptual framework on the assessment of birth asphyxia and its associated factors,
developed after reviewing different literature [35, 38].

8
1.4 Significance of the study
The birth asphyxia is a current and existing problem which needs attention and solution as it has
serious usually leading to risk of lifelong disability in the surviving infant. Thus, this study will
assess the rate of birth asphyxia and associated factors among newborns who will delivered in
Mettu Karl Referral Hospital, Oromia Region South West Ethiopia, 2011.The findings of the
study generally will help the health managers at a higher level and Health professionals in
particular to understand the extent of the bi

9
 CHAPTER TWO

2 OBJECTIVES
2.1 General Objective
 To assess the prevalence of birth asphyxia and its associated factors among babies born in
Mettu Karl referral Hospital Oromia Region South West Ethiopia, 2018.

2.2 Specific objective

 To assess the prevalence of birth asphyxia among babies born in Mettu Karl referral
Hospital Oromia Region South West Ethiopia, 2018.
 To identify the factors associated with birth asphyxia among babies born born in Mettu
Karl referral Hospital Oromia Region South West Ethiopia, 2018.

10
 CHAPTER THREE

3. METHODS AND MATERIALS

3.1 Study area
The study will be conducted in Mettu Karl referral Hospital, which is located in Mettu woreda,
Ilu Ababora zone, Oromia regional state, south west Ethiopia. Mettu is the capital city of Ilu
Ababora zone which is located 600kms from Addis Ababa the capital city of Ethiopia and 250
km from Jimma city. This town has a latitude and longitude of 8 o18N 35035`E/8.3000N 35.5830E
and an altitude of 1605 meters. The 2007 national census reported a total population for Mettu of
28,782, of whom 14,400 were men and 14,382 were women. The majority of the inhabitants
practiced Ethiopian Orthodox Christianity; with 47.55%, while 26% Muslim, and 26% were
protestant. This Hospital serves around 1.4 million people living in Ilu Ababora zone, Gambela
and others. Mettu Karl Referral Hospital currently staffed with 311 workers of different
professionals which includes; 16 General practitioners, 88 Nurses, 20 Midwifes, 2 General
surgeons 1 Internist, 2 Emergency surgeon ,2 Anastatist, 2 Health officers, 8 Laboratory
technicians, 5 Pharmacist, 1 Dentist, 1 Optometry nurse, 2 Gynecologist, and 161 other workers.
It has 5 yards and 180 beds to give a service for inpatient and outpatient.

The town has one general hospital, three health center and four private clinics. Debre Tabor
General Hospital was established in 1923E.c. It gives service for 1,000,000 peoples. It is only
hospital found in Debre Tabor town and has five wards. Those are NICU, pediatrics ward,
obstetrics and Gynecology ward, medical ward and two major OR. Currently the hospital has a
total of 384 staffs(137 nurses, 2 Health officers, 5 emergency surgeons, 23 midwives, 16 general
practitioners, 28 pharmacist, 5 X-ray, 6 psychiatrist,4 HIT, 15laboratory technicians, 6 medical
labratorists, 3 ophthalmologist, 1 environmental, 5 Anesthetist , 1 Dentist 11 specialist and 105
administrative staffs).

3.2 Study period

The study will be conducted from DECEMBER 12, 2018-JANUARY 30, 2019.

3.3 Study design

Institutional based cross sectional quantitative study design will be conducted.

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3.4 population
3.4.1 Source population
All babies who will be delivered at Mettu Karl Referral Hospital from December 12, 2018-
Febrwary 12, 2019.

3.4.2 Study Population

All babies who will be delivered at Mettu Karl Referral Hospital from December 12, 2018-
Febrwary 12, 2019.

3.5 Eligibility criteria

3.5.1 Inclusion criteria
The inclusion criteria will comprise of gestational age after viability and live birth.

3.5.2 Exclusion criteria

The exclusion criteria will consist of stillbirth and critical ill mothers.

3.6 Sample size determination and sampling procedure

Sample size will be determined using the formula for single population proportion based on the
following assumptions.
n = (Zα/ 2) 2p (1-p)
d2
Where: n= is desired sample size
Zα/2= is the standard normal value corresponding to the desired level of confidence
d=error of precision (marginal error).
P=is the estimated population proportion
1. The prevalence of birth asphyxia at fifth minuet was 12.5% in Jimma Zone public hospital
(25)
2. Degree of error d= 5 %( 0.05)
3. A confidence interval of 95% is assumed (Zα/2=1.96).
n= (1.96)2 0.125(1-0.125)
(0.05)2
n=168
Add 10% contingency for non response

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10% of 168=17

Then 168+17= 185 hence the final sample size will be 185.

Sampling procedure

To get the study unit systematic sampling technique will be used. The sampling interval of the
laboring mothers will be determined by dividing the total number of client flows within one
month by sample size. According to the hospital report, the average case flow for labor is 372
per month. So the K value will be 185/372 equal to1/2 i.e. the first participant will be selected by
simple random sampling by picking the numbers singed in one and two. Then every second
person starting from number picked will be asked.

3.7 Variables of study

3.7.1 Dependent variable
 Birth asphyxia

3.7.2 Independent Variables

 Socio demographic characteristics: Age, Income, ethnicity, religion, average monthly
income marital status, occupation (both the mother and her husband), Educational status
(both the mother and her husband).
 Maternal characteristics: ANC follow up, Parity, pregnancy complications like
preeclampsia
 Health Facility related factors: distance to the nearest health facility.
 Low birth weight, preterm delivery
 Labor abnormalities: obstructed labor, male presentation

3.8 Operational Definitions

Birth Asphyxia: a newborn who is breathing poorly less than 30 breaths per minute or not
breathing at all

Sever Asphyxia: Apgar score at first minuet is 0-3

Mild-Moderate asphyxia: Apgar score at first minuet is 4-7

13
Ante partum: event occurring before child birth

Intrapartum: events occurring during labor and delivery

Premature rupture of membrane: rupture of membrane of amniotic sac and chorine occur
more than one hour before the onset of labor.

Prolonged labor: it is considered when labor exceeds 12 hours in primi gravid or 8 hours in
multipara.

3.9 Data collection tool and techniques

3.9.1 Data collection tool
An interviewer administered questionnaire will be developed for the purpose of data collection
after reviewing relevant literature. It will be prepared originally in English and will be translated
to local language Oromifa and Amharic for the purpose of data collection and then it will be
translated back to English again for consistency. The questionnaire will have three parts; part one
socio demographic characteristics, part two and three questions related to ante-partum and Intra-
partum factors of birth asphyxia, which was adapted by revising various related researches

3.9.2 Data collection procedure

Face to face interview will be carried out by data collectors under the guidance of two Msc
midwifery supervisors for a period of one month. Data collectors will be the students in hospital,
Training will be given for one day on clarification of some terms and assessment tools, aim of
the study, concerning need for strict confidentiality of respondents information, time of data
collection and timely collection of data from respective hospitals and submission on due time.
Data will be collected for approximately one month.

3.10 Data quality management

To assure quality of data, all of data collectors will be given training regarding the Purpose of the
study and the way to gather the data. After data collection started closely monitoring by
supervisor will be done and also there will be day to day of supervision. Operational definitions
will be discussed. Finally data will be checked for completeness and accuracy every day before

14
entry. Prior to the data collection Pre-test will be made on 10 (5%) of the total sample size of the
respondent’s outside the study hospital.

3.11 Data Processing and analysis

The data gathered from study participants will be cleaned and checked for its completeness then coded
and entered in to computer software using statistical package for social science (SPSS) version 20.
Descriptive statistics such as, frequencies, proportions, chi-square with 95% confidence interval will be
computed and p-value less than 0.05 will considered as a level of significance. The results will be
represented in frequency, tables, charts and graphs.

3.12 Ethical Consideration

A formal letter of cooperation will be obtained from Mizan Tepi University, College of health
sciences Department of midwifery. Furthermore, letter of permission will be obtained from
Mettu Karl Referral Hospital to cascade the proposal. Verbal consent will be obtained from the
study subjects after they were informed about objectives and procedures of the study and their
right to refuse participation any time they want will be assured if they are not comfortable about
the questionnaire. Personal name will not be included so that the participant`s confidentiality will
be assured.

3.13 Dissemination of the result

The initial objective of this proposal is in a partial fulfillment of our requirement for the Degree
of Bachelors of Science in Midwifery; the final report will be submitted and presented to Mizan
Tepi University, College of Health Science Department of Midwifery. Beside, the copy of the
document will be given for Mettu Karl Referral Hospital as an input data for further finding and
formulating relevant program and also further effort will be applied to publish on journals.

15
Chapter four: Work plan

Table 3; work plan of the study, January, 2018, Debre Tabor Ethiopia

Task to be Responsible Dec27- Feb16 Jan1-30 March April

S.no performed body Feb15 -

Nov
Feb30
1 Topic Investigator
selection
2 Prepare PI
proposal &
first draft
of proposal
submission
to advisers
3 Feedback Advisor
from
advisors
4 Final PI
proposal
submission
5 Preparation PI
of study
tools
6 Data Data
collection collectors,
supervisors
and
investigator
7 Data PI
analysis
and report
writing
8 Submission PI
first draft
of report
9 Final PI
report
preparation
10 Report PI
submission
PI-Personal Investigator

16
 CHAPTER FIVE:

BUDGET BREAK DOWN

I-Personal cost

Table 4: -Personal cost (Budget) for the proposal, February, 2019, Mettu, South west Ethiopia

S.no Activities Number Working Cost/day Total

of Person days Price per cost
each

1 Data collectors 5 30 100 15000

2 Supervisors 2 30 150 9000

3 Secretary 1 5 80 4000

4 Investigator 5 30 100 9000

Sub total 37000.00

EB

II – Stationary
Table 3: -Stationary cost (Budget) for the proposal, February, 2019, Mettu, South west Ethiopia.

S.n Item Unit Quantity Unit/price Total

o cost

1 Paper RIM(pad) 4 90 360.0

0

2 Pen number 12 5 60.00

3 Pencil Number 3 2.00 6.00

4 Flash Disk (4GB) number 1 200 200.0

0

5 Eraser Number 3 5.00 15.00

6 Binder Number 3 15.00 60.00

17
 7 Duplication Pages 906 0.50 453.0
(Print)

8 Mobil card number 6 50 300.0

Sub Total 1454.

00

III – Total cost

Table 4: -Total cost (Budget) for the proposal, February, 2019,Mettu, south west Ethiopia.

S.no Total of resource Total

1 Human resource 37000.00

2 Stationery 1454.00

Total 38454.00EB

18
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intrapartum fetal asphyxia in term pregnancies. Am J Obstet Gynecol 184: 724-730.
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Opportunities for Africa’s Newborns Why? Lancet 365: 891-900.
13. Lee AC, Kozuki N, Blencowe H, Vos T, Bahalim A, et al. (2013) Intrapartum-related
neonatal encephalopathy incidence and impairment at regional and global levels for
2010 with trends from 1990. Pediatr Res 74: 50-72.

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 14. Save the Children (2001) The state of the world’s newborns: a report from saving
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Gynecol 2007; 50: 624-635.
19. Oestergaard MZ, Inoue M, Yoshida S, Mahanani WR, Gore FM, Cuosens S, LawnJE,
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practice in maternal and newborn care Maternal Death Surveillance and Response.
22. Antonucci R, Porcella A, Pilloni MD (2014) Perinatal asphyxia in the term newborn. J
Pediatr Neonat Individual Med 3: e030269.
23. Lawn JE, Manandar A, Haws RA, Darmstadt GL (2007) Reducing one million child
deaths from birth asphyxia-a policy and programme gaps and priorities based on an
international survey. Health Res Policy Syst 5:4.
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survivors in a developing country. Journal of investigate medicine. 2006;Vol-
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asphyxia among new born deliveries in Jimma public hospital, south weast Ethiopia
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 26. PannaChoudhury, Principles Of Pediatric Neonatal Emergencies, 2nd Edition, New
Delhi, Jaypee brothers publishers,2006, Page No.28-29.
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Attention Deficit-Hyperactivity Disorder? Pediatric Neurology, 21, 602-610.
http://dx.doi.org/10.1016/S0887-8994(99)00046-6
28. Birth asphyxia. Report of a meeting Cape Town 29th November to 2nd December 2002

29. WHO (2000) The World Health Report 2000 Health Systems: Improving performance.
Geneva: World Health Organization.
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Risk Factors for Perinatal Asphyxia as Seen at a Specialist Hospital in Gusau, Nigeria
Sub-Saharan Afr J Med.
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unit of Khyber teaching hospital Peshawar. Pak J Med Sci 2007, 23(2):249
32. Chandra s, Ramji s, Thirupuram S. Perinatal asphyxia. Multivariate analysis of risk
factors in hospital births. Indian pediatr 1997; 34: 206-212
33. Birth Asphyxia - Summary of the previous meeting and protocol overview. WHO
Geneva Milano, 11June, 2007 . Accessed 5th August 2015.
34. Berglund S, Grunewald C, Pettersson H, Cnattingius S (2010) Risk factors for asphyxia
associated with substandard care during labor. Acta Obstet Gynecol Scand 89: 39-48.
35. Ibrahim NA, Muhye A, Abdulie S (2017) Prevalence of Birth Asphyxia and Associated
Factors among Neonates Delivered in Dilchora Referral Hospital, in Dire Dawa,
Eastern Ethiopia. Clinics Mother Child Health 14: 279. doi:10.4172/2090-
7214.1000279
36. Kaye D. Antenatal and intrapartum risk factors for birth asphyxia among emergency
obstetric referrals in Mulago hospital, Kampala, Uganda. East Afr Med J 2003;80:140–
143. [PubMed: 12762429]
37. Dilenge ME, Majnemer A, Shevell MI (2001) Long-term developmental outcomes of
asphyxiated term neonates. J Child Neurol 16: 781-792.
38. Tabassum, F., Rizvi, A., Ariff, S., Soofi, S. and Bhutta, Z.A. (2014) Risk Factors
Associated with Birth Asphyxia in Rural District Matiari, Pakistan: A Case Control

21
 Study. International Journal of Clinical Medicine, 5, 1430-1441.
http://dx.doi.org/10.4236/ijcm.2014.521181.

Annexes
Annex I. Participants Information Sheet
The objective of this study is to assess prevalence of birth asphyxia and its associated factors
among babies born in Mettu Karl Referral Hospital from January 1-30, 2019.
Name of Principal Investigators:

Name ID Mobile No Email

1. Aregachew Enawgaw………………..HSR/095/08 0936607868

[email protected]
2. Ziad Abdella………………………….HSR/642/08
3. Natnael Fikadu………………………..HSR/708/08
4. Nestanet Abeje………………………..HSR/479/08
5. Kango Kajela………………………….HSR/367/08

ADVISORS:
1) Mr. Ermiyas S.(BSC MSC)
2) Mr. Moges B.(BSC MSC)

Department: Department of Midwifery, College of Health Sciences, Mizan Tepi University

Introduction
This information sheet and consent form is prepared with the aim of assessing prevalence and
associated factors of birth asphyxia. Assessing prevalence and associated factors of birth
asphyxia is an essential to have a good fetal outcome. The research group includes the principal

22
investigators, five trained data collectors, two supervisor, and two advisors from Mizan Tepi
University.

Purpose of the Research Project

The aim of this study is to assess prevalence of birth asphyxia and its associated factors among
babies born in Mettu Karl Referral Hospital.
Procedure and participation
The study involves mothers with newborn babies who are delivered in Mettu Karl Referral
Hospital. You are selected to be one of the study participants. If you are willing to take part in
this study, we kindly invite you to take part in our project. If you are willing to participate, we
are so happy and we need you to clearly understand the aim of this study and show your
agreement. Finally you are kindly requested to give your genuine response in the interview. I
have several questions which I would like to ask you, if you have the time and are willing. The
questionnaires include socio economic & demographic factors, obstetric factors.
Confidentiality
All information you provide will be kept confidential and stored in. we will not include any
identifiers, such as your name or exact address rather it will be reported by assigning a code
number. Only honest answers would contribute to improvement of health planning.
Benefits care and to design appropriate strategy to increase the health of newborn. But there is
no direct benefit you will gain participating this research project.
Risks
There is no any risk in participating in this research project.

Right to Refusal or Withdraw

You have the full right to refuse from participating in this research. You have also the full right
to withdraw from this study at any time you wish.

ANNEX-II: CONSENT FORM

MIZAN TEPI UNIVERSITY COLLAGE OF HEALTH SCIENCE DEPARTMENT OF
MIDWIFERY

23
Questionnaire for Assessment of Prevalence of Birth Asphyxia and its Associated
Factors among newborn babies who delivered at Mettu Karl Referral Hospital
South West IlluAbabora Zone Oromia Regional State of Ethiopia-2019.

Questionnaire Code ____

Introduction:-
Hello: Dear Participants this questionnaire is prepared by Geremew Bishaw, He is conducting
this research for a partial fulfillment of BSc degree which is fully supported and coordinated by
the Department of Midwifery, College of health science, to assess prevalence of birth asphyxia
and its associated factors among new born babies.

I hope you will help us by responding these questions. None of your answers will be available
to anyone at any time. All the information you give us will be kept private. The results of the
study would hopefully serve as an important input to intervention programs that aim at
improving child’s health in general. It will take you 30-40 minutes to complete the whole
questionnaire.

Would you be willing to participate in this study?

Are you voluntary to participate in the study: Yes /No
Signature ______________________
If Respondent agrees to be interviewed,

Date of data collection----------------------------------------

Name of data collector--------------------------------------- signature--------------------

Annex III: English version of questionnaire

General instruction

1. For multiple choice questions you can chose more than one.
2. If your answer is not listed among alternatives, please tell your answer for data collector.
3. If you have any question on the interview you can ask the data collector.
4. If there is any problem during the study call with 0935849781.

24
Part I: Socio -demographic characteristics
Sr.No Questions Possible answer for questions
1. Residence of mother A. Rural B. Urban
2.
What is your age In years.................
3. What is your marital status A. Married
B. Divorced
C. Widowed
D. Single E. Separated
4. What is your religion A. Orthodox
B. Muslim
C. Protestant
D. Others(specify) ____________
5. What is your ethnicity A. Amhara,
B. Oromo,
C. Tigray
D. Others, specify----------
6. What is your occupation A. House wife
B. Governmental Employee
C. Merchant
D. Daily Labourer
E. Student F. Other specify.......
7. What is your educational Status A. Unable to read and write
B. no formal education but can read and write
C. Primary education(1-8)
D. Secondary education(9-12)
E. College or University
What is your husband’s educational A. Unable to read and write
Status B. no formal education but can read and write
8.
C. Primary education(1-8)
D. Secondary education(9-12)

25
 E. College or University

9. Income per months ______________in birr

10. What is your husband’s occupation A. Farmer

B. Governmental employee
C. Merchant
D. Daily laborer
E Other, specify----------------

11. Distance to the nearest health ……..hours

facility

Part II: Questions related to general obstetric history of mother

Sr.No Questions Possible answer for questions

1. Number of pregnancies or ____________

Gravidity)
2. Number of alive children in number
3. Have you ever had abortion? A. Yes B. No

4. If yes how many times _________________.

5. Have you ever had neonatal death A. Yes B. No

6. Do you have history of preterm A. Yes B. No

delivery?

Part III the ante partum risk factors of birth asphyxia

26
 Sr.No Questions Possible answer for questions

1. Do you have ANC follow up A. Yes B. No

2. If yes number of ANC visits in _____________.
relation to index child
3. Place ANC attended A. Health post B. Public health center C.
Public hospital D. Others______

4. Did the mother suffer from any of A Maternal hypertension

these conditions during pregnancy? B Gestational diabetes
C Anemia
D Ante partum hemorrhage
E Pre-eclampsia

Part IV: Intra partum history of the mother of the index child
Sr.No Questions Possible answer for questions

1. Presentation of fetus A. Cephalic B. Breech C. shoulder D other__

2. Mode of delivery A. Spontaneous vaginal delivery
B. cesarean section
C. vacuum
D. forceps

3. Total duration of labor ___________ In hour.

4. Total duration of rupture of ___________ in hour

membrane
5. Who assisted delivery A, Family members
B, TBAC, HEWs
D, HCWs (Midwifes, nurses, IESO, GP)

27
 6. Did the following problems A. Obstructed labor
experienced during delivery? B. APH
C. Pre-eclampsia/eclampsia
D. cord prolapsed
E. mal-presentation
F. anemia G. Others ______.

7. Labor type A. Spontaneous without medication

B. Induced
C. Augmented

Identifications of Newborn and its associated risk factors of birth asphyxia

Sr.No Questions Possible answer for questions

1. Sex of the baby A. Male B. Female

2. Estimated gestational age at _______ In weeks.

delivery in week’s
3. APGAR score of baby at 1st and 5th ___________and ________.
minuets
4. Outcome of delivery A. Singleton B. Multiple
5. Weight of baby in grams ______

6. Was the child resuscitated Yes, No

7. If yes, then how was the newborn A. Suction

resuscitated B. Bag + mask IPPV
C. ET intubation IPPV

8. Did the neonate suffer any of the A. Failure to develop spontaneous breathing

28
 conditions given below B. Color of the baby turned blue
C. Difficult breathing after birth
D. others____________

29
30