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Proportion of Neonatal Hypothermia and Associated Factors among New-borns at Gondar University Teaching and Refferal Hospital, Northwest Ethiopia: A Hospital Based Cross Sectional Study

Tewodros Seyum1* and Erekia Ebrahim2
1Department of Midwifery, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
2Department of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
Corresponding Author : Tewodros Seyum
Department of Midwifery
College of Medicine and Health Sciences
University of Gondar, Gondar, Ethiopia
Tel: + 251 581141232
E-mail: [email protected]
Received: June 12, 2015 Accepted:July 10, 2015 Published: July 15, 2015
Citation:Seyum T, Ebrahim E (2015) Proportion of Neonatal Hypothermia and Associated Factors among New-borns at Gondar University Teaching and Refferal Hospital, Northwest Ethiopia: A Hospital Based Cross Sectional Study. Gen Med (Los Angel) 3: 1000198. doi: 10.4172/2327-5146.1000198
Copyright: ©2015 Seyum T et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Abstract

Introduction: Hypothermia is highly prevalent and a major contributor of neonatal morbidity and mortality, even in warmer tropical countries. Neonatal hypothermia is increasingly recognized as a risk factor for new-born survival in Ethiopia. It is crucial and effective to reduce perinatal and neonatal morbidity and mortality. The aim of the study was to assess the proportion of neonatal hypothermia and associated factors among new-borns at Gondar University Teaching and Referral Hospital, Northwest Ethiopia, 2014.

Methods: Across sectional study was carried out from September to October 2014 at Gondar University teaching and referral Hospital. A total of 421 new-borns delivered in the hospital were included using systematic random sampling technique. Data were entered into Epi data version 3.1 and analyzed by Statistical package for social science version 20. P-value <0.05 was taken as statistically significant association.

Result: The proportion of hypothermia in the study area was found to be 69.8%. Low birth weight (AOR=3.75, 95%CI: 1.29, 10.88), no skin to skin contact (AOR=2.81, 95%CI: 1.40, 5.66), night time delivery (AOR=6.61, 95%CI: 3.75, 11.66), delayed initiation of breast feeding (AOR=7.58, 95%CI: 3.61, 15.91) and problems of the neonates (AOR=3.10, 95%CI: 1.06, 9.46) were significantly associated with hypothermia.

Conclusion: In this study the proportion of hypothermia among new-borns was found to be high. Low birth weight, no skin to skin contact, night time delivery, delayed initiation of breast feeding and problem of neonate were significantly associated with hypothermia. Therefore, attention is needed Improve basic routine practice such as warm environment, early breast feed and skin to skin contact by health care providers.

Abstract

Introduction: Hypothermia is highly prevalent and a major contributor of neonatal morbidity and mortality, even in warmer tropical countries. Neonatal hypothermia is increasingly recognized as a risk factor for new-born survival in Ethiopia. It is crucial and effective to reduce perinatal and neonatal morbidity and mortality. The aim of the study was to assess the proportion of neonatal hypothermia and associated factors among new-borns at Gondar University Teaching and Referral Hospital, Northwest Ethiopia, 2014.

Methods: Across sectional study was carried out from September to October 2014 at Gondar University teaching and referral Hospital. A total of 421 new-borns delivered in the hospital were included using systematic random sampling technique. Data were entered into Epi data version 3.1 and analyzed by Statistical package for social science version 20. P-value <0.05 was taken as statistically significant association.

Result: The proportion of hypothermia in the study area was found to be 69.8%. Low birth weight (AOR=3.75, 95%CI: 1.29, 10.88), no skin to skin contact (AOR=2.81, 95%CI: 1.40, 5.66), night time delivery (AOR=6.61, 95%CI: 3.75, 11.66), delayed initiation of breast feeding (AOR=7.58, 95%CI: 3.61, 15.91) and problems of the neonates (AOR=3.10, 95%CI: 1.06, 9.46) were significantly associated with hypothermia.

Conclusion: In this study the proportion of hypothermia among new-borns was found to be high. Low birth weight, no skin to skin contact, night time delivery, delayed initiation of breast feeding and problem of neonate were significantly associated with hypothermia. Therefore, attention is needed Improve basic routine practice such as warm environment, early breast feed and skin to skin contact by health care providers.
 
Keywords

Proportion; Hypothermia; Associated factors; New-borns
 
Abbreviations and Acronyms

AOR: Adjusted Odds Ratio; APGAR: Appearance, Pulse, Gremmies, Activity, Respiration; CI: Confidence Interval; COR: Crud Odds Ratio; CPR: Cardio Pulmonary Resuscitation; C/S: Caesarean Section; GA: Gestational Age; LBW: Low Birth Weight; NBW: Normal Birth Weight; NICU: Neonatal Intensive Care; SVD: Spontaneous Vertex Delivery; WHO: World Health Organization
 
Background

Neonatal hypothermia is progressive reduction in body temperature and the newborn’s body temperature drops below 36.5°C that leads to adverse clinical effects ranging from mild metabolic stress to death [1]. Immediately after delivery if no action is taken, the core and skin temperatures of term neonate can decrease at a rate of approximately 0.1°C and 0.3°C per minute respectively. Neonates can lose heat through conduction, convection, evaporation and radiation immediately following birth [1,2].

World Health Organization (WHO) categorized hypothermia in to three stages based on core temperature of a new-born below 36.5 comeasured as skin temperature in the axial: mild hypothermia (36.0 co–36.4 co), moderate Hypothermia (32.0 co–35.9 co) and severe hypothermia (<32.0 co) [3]. Hypothermia is a common cause of neonatal morbidity and mortality, even in warmer tropical countries [4]. Neonatal hypothermia is increasingly recognized as a risk factor for new-born survival [5]. For these studies hypothermia was defined as <36.5 co based on WHO definition.

The incidence of primary hypothermia which is an independent morbidity as a result of cold stress is high immediately following birth in hospital setting especially in the first 24 hours [6,7]. In developed countries neonatal hypothermia accounts for 28% of the global burden. a study in California 56.2% infant NICU were hypothermia [8], it was revealed that in USA 45% and Australia, showed that 17% of infants born during transport were hypothermic [9].

In developing countries, however, this problem is more prevalent even in healthy, full term and normal-birth-weight (NBW) infants [10]. In Nepal, a study on 500 new born revealed that 85% of neonates were hypothermic within 2 hours after delivery [11].More than 98% of the 4 million annual neonatal deaths occur in developing countries, where specific data on hypothermia are scarce and largely limited to hospital-based data.

A number of hospital based studies in such settings have demonstrated that thermal stress is common, and more than one-half of new-borns experience hypothermic episodes. Some hospital based studies have also showed higher mortality risk among admitted babies with hypothermia broadly defined as any temperature measurement lower than 36.0°Cor 36.5°C [7].The incidence in Ugandan hospital was 79% and 85% in Zimbabwe [10].

A study from Tanzania found a 22% prevalence of hypothermia among new-borns admitted to a neonatal intensive care unit (NICU), and hypothermic children had three fold increased mortality in the hospital as compared to new-born with a normal body temperature [12,13]. In developed countries, however, awareness of the problem has resulted in improved care, and the incidence of neonatal hypothermia was mostly confined to out born, premature and LBW infants [11]. In many parts of the world, health professionals are not aware of the importance of

Keeping babies warm by simple methods such as drying and wrapping immediately after birth, avoiding harmful traditional practices, encouraging early breastfeeding and keeping new-borns in close contact with their mother [3].

In a study conducted in Ethiopia, Bihar Dar, on admission, 67% and high-risk infants admitted to a special care unit were hypothermic [14]. In Ethiopia, previous reports about the prevalence and associated factors of neonatal hypothermia are not that much easily available, and those found are with small sample sizes or are local surveys. Regarding this variable information, the researcher of this study believes that neonatal hypothermia is a serious health problem in our country, even among those born at Hospitals. Therefore, obtaining more accurate information about the prevalence and associated factors of hypothermia at Gondar University teaching and referral hospitals important to have better trained staffs and students as expected.
 
Methods

Institution based cross sectional study was conducted in in Gondar University teaching referral hospital from September to October, 2014. Gondar town which is found in Northwest Ethiopia, located 732 km from Addis Ababa. It is home to a population of 258,178. The study was conducted in Gondar University teaching referral hospital. It is one of the biggest tertiary level referral and teaching center hospital in the region. It provides a service of an estimated 5 million population. The hospital owns a total 750 staff including 3 gynecology/ obstetrics specialists, 35 residents and about 40 midwives working in three units.

The services rendered in the hospital include delivery of outpatient, in patient obstetric and gynecologic, each day about 20-30 newborns are delivered in the hospital. The hospital also serves as a referral hospital receiving obstetrics and gynecology cases referred from all health centers in the town and the surrounding districts as well as zones.

The study participants were All neonates delivered alive from immediate delivery to the first six hours after delivery in Gondar University teaching and referral hospital were included.

The required sample size was calculated by considering the assumptions for single population proportion formula: Prevalence of Hypothermia (P)=53% from the previous study conducted study conducted, 5% of absolute Precision, Z=standard normal distribution value at 95% confidence level of Zα/2=1.96 and adding a 10 % non-response rate, the final sample sizes were 421. By using systematic random sampling technique, every other live new-born were included.

Data were collected by pretested and structured interviewer administered questionnaire containing the socio-demographic characteristics of the mother and new-born and other factors such as obstetric and environmental characteristics and as well APGAR score, birth weight and GA were taken from the mothers chart. Axillary temperature of the baby was measured within the first 6 hours of delivery by digital classical thermometer which measures between 32°C-42.9°C by the data collectors. In addition the room temperature was measured from the beginning of data collection to the end by room temperature measurement. Hypothermia of the new-born was considered if a new-born whose axillary temperature is below 36.5°C (WHO). Five BSc(Bachelor of Science) female (one in each hospital) midwives graduating class students were employed as data collectors and trained for one day about the way of data collection, timely collection and reorganization of the collected data from the respondents.

Data were checked, coded and entered to EPI Info version 3.5.3 then it was exported to Statistical Package for Social Sciences (SPSS) version 20 for analysis. Both descriptive and analytical statistical procedures were utilized. Descriptive statistics like percentage mean and standard deviation were used for the presentation of demographic data and utilization of obstetric analgesia. The collected questionnaires were checked manually for completeness, coded and entered into EpiInfo version 3.5. After the entry was completed the data were exported to SPSS version 20.0 for analysis. Descriptive and summary statistics were done. Bivariate logistic regression analysis was used to check existence of association with each independent variable with the outcome variable. Finally Variables significant in bi-variate analysis (P<0.2) were entered into a multivariate logistic regression model to adjust the effects of possible cofounders on the outcome variable. Odds ratio (OR) with 95% confidence interval (CI) was used to see strength of the association between independent variables and a dependent variable. Ethical approval was obtained from University of Gondar then permission letter was obtained from the Gondar university referral Hospital clinical director before conducting the study. Verbal consent was obtained from the mother after explaining the aim, risk, benefit and voluntary participation of the study. The hypothermic new-borns were helped and the results were communicated with duty physicians and the mothers and hypothermic babies were consulted for paediatrician for better management and health education was given on kangaroo mother care and the benefit of early initiation of breast feeding for the mothers.
 
Result

Socio-demographic characteristics

A total of 421 mothers with neonates after delivery were included with 100% response rate. Majority of age group were between 20-29 (63.4%) years of age. The mean age of the respondents was 26.5 years (SD) 5.19. Two hundred sixty five (62.9%) were urban residents. Regarding their marital status most of them (86.9%) were married. Two hundred fifty (59.4%) were house wives. Around one hundred nine participants (25.9%) were unable to read and write. Two hundred sixty five (62.9%) respondents had monthly income less than 1200 ETB (Table 1).
 
Proportion of hypothermia

The proportion of hypothermia among new-born infants at Gondar University teaching and referral hospital was found to be 294(69.8%).
 
Infant, obstetric and environmental factors

Majority of the infants were females in sex 225(53.4%) and with gestational age (GA) >37 wk 365 (86.2%). Most of them, 322(76.5%) had an APGAR score of >7.

Besides birth weight of ≥2500 gram was recorded by 356(84.6%). Sixteen (3.8%) did receive CPR. Most of the pregnancies 391(92.9%) were singleton. More than half 280(66.5%) were delivered by SVD.

The room temperature was <25°C when 404 (94%) were born. Three fourth of the babies 295 (70.5%) had no skin to skin contact immediately after birth, More than half of neonates had late initiation of breast feeding 238 (56.5%).

Most of them 337 (80%) had no any obstetric complication. Fifty three (12.6%) had problem of neonate. Sixty six (15.7%) were referred to NICU and most of them, 253 (60.1%).were delivered at night (Table 2).
 
Factors associated with hypothermia

In Bivariable logistic regression analysis factors which were found to be significantly associated with the occurrence of hypothermia low birth weight, delivery at night, delayed early initiation of breast feeding within one hour, no skin to skin contact to their mother immediately after delivery, problem of neonate, preterm delivery and undergoing CPR .

In multiple logistic regression analysis factors which were found to be significantly associated with occurrence of hypothermia low birth weight, delivery at night, delayed early initiation of breast feeding within one hour, no skin to skin contact to their mother immediately after delivery, problem of neonate. Neonates with low birth weight to were almost 4 times more likely to have hypothermia compared to normal birth weight ones (AOR=3.75, 95%CI: 1.29, 10.88). Those babies who had problem were 3 times more likely to have hypothermia when compared with those without other problems (AOR=3.10, 95%CI: 1.06, 9.46). Those new-borns who were delivered during night time were about 6.6 times more likely to develop hypothermia compared to those who were delivered during the day (AOR=6.61, 95%CI: 3.75, 11.66). In the same way, new-borns who did not put to their mothers abdomen within one hour after delivery were almost 3 times more likely to be hypothermic when compared to those who have skin to skin contact within one hour (AOR=2.81, 95%CI: 1.40, 5.66). Moreover, those new-borns for whom breast feeding was not initiated within one hour were about 7.5 times more likely to develop hypothermia compared with those who have started within one hour (AOR=7.58, 95%CI: 3.61, 15.91) (Table 3).
 
Discussion

The proportion of hypothermia in new-borns in this study was 69.8%. This finding was consistent with a multi country study, (Nigeria (80%)less than six hours, Zambia (69%), and Uganda (73%) [6], in Bahirdar, Ethiopia (67%) [14], but higher than study done in Iran (53%) [11]. The possible explanation might be due to the study design, data collection tool, study setting and cultural difference between the study areas. In addition, it indicates that high proportions of new-borns are suffering from hypothermia; practices contributing to heat loss in the new born are still deeply rooted in many cultures and are difficult to change; and technologies adapted to resource poor environments are still at a developmental stage [6,15-21]. Findings from this study have showed that low birth weight neonates were 4 times more likely to develop hypothermia than neonates with normal birth weight. This finding is in line with study done in Nigeria [20] and Iran [11]. The reason could be low birth weight babies are usually preterm those had poor subcutaneous tissue so they had immature thermoregulation, and surface area to body ratio of low birth weight babies is high [15].

Babies who born during night time were about 6.6 times more likely to develop hypothermia compared to day born neonates. This might be due to the fact that room temperature is low during night time when compared to day time. It could also be due to the work overload during night time as the number of staffs working in labour room during night time is not equal to day time staffs. Moreover, new-borns that were not put to their mothers’ abdomen within one hour after delivery were almost 3 times more likely to be hypothermic when compared to those who have skin to skin contact within one hour. This is in line with the study conducted in Zambia [6] and Nigeria [20]. The possible reason could be new-borns who were delivered immediately to their mothers’ abdomen might gain heat through conduction heat gain during the critical few hours. Neonates that had not initiated to breast feeding within one hour were more than 7 times more likely to develop hypothermia as compared with those who had already started it. This is in line with a study conducted in Nigeria [20]. This might be due to the fact that neonates who didn’t breast feed within one hour could be susceptible to hypoglycemia which results in hypothermia.

The more they breast feed they would have adequate glucose to cope up with their energy expenditure. Those babies who have problem were 3 times more likely to have hypothermia when compared with those without problem. This is in parallel with study done in Nigeria [20].This could be explained due to neonates with poor oxygenation leads to have inadequate ATP production, which is a backbone for heat production in new-borns. The more neonates become deprived of oxygen the more it depresses their respiratory center which interferes with glycogenolisis in the cell of the host.
 
Author’s Contributions

TS wrote the proposal, participated in data collection, analyzed the data and drafted the paper. EE approved the proposal with some revisions, participated in data analysis and revised subsequent drafts of the paper. Finally all authors read and approved the final manuscript.
 
Acknowledgement

We are very grateful to the University of Gondar for the approval of the ethical clearance and for financial support. We would like to thank University of Gondar referra hospital management for permission to conduct the study; all study participants in this study for their commitment in responding to our interviews. Our gratitude also goes to supervisors, the data collectors and the staff at the hospitals.
 
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