Factors associated with neonatal near miss: Case of the University Hospital Center IbnSina of Rabat Morocco 2021

Abstract

OBJECTIVES:

Analogous to the Near Miss Maternal approach, the concept of Near Miss Neonatal (NNM) is an approach recently developed to identify newborns who survive near-fatal complications during the first 28 days of ectopic life. The objective of this study is to shed light on the cases of Neonatal Near Miss and identify its factors associated with live births.

METHODS:

A prospective cross-sectional study was conducted to identify factors associated with Neonatal Near Miss in newborns admitted to the National Reference Center in Neonatology in Rabat, Morocco from January 1 to December 31, 2021. A pre-tested, structured questionnaire was used to collect the data. These data were entered using Epi Data software and exported to SPPS23 for analysis. To identify the determinants of the outcome variable, binary multivariable logistic regression was used.

RESULTS:

Among the 2676 selected live births, 2367 (88.5%; 95% CI: 88.3–90.7)) were cases of NNM. Factors in women which were significant predictors of NNM included being referred from other health care facilities [AOR: 1.86; 95% CI: 1.39–2.50], residing in a rural area [AOR: 2.37; 95% CI: 1.82–3.10], having less than four prenatal visits [AOR: 3.17; 95% CI: 2.06–4.86], and having gestational hypertension [AOR: 2.02; 95% CI: 1.24–3.30].

CONCLUSIONS:

This study revealed a high proportion of NNM cases in the study area. The factors associated with NNM which were found to increase these cases demonstrates the primary health care program must be further improved to avoid preventable causes of neonatal mortality.

Keywords

Apgar score associated factors low birth weight neonatal near miss events newborn health

1 Introduction

The neonatal period is the most vulnerable period for a newborn. Each year, 2.4 million newborns die before the age of one month, representing approximately 7000 deaths per day [1]. However, for every child who dies, there are many who survive serious complications. Some investigators have defined the NNM as a morbid event that nearly resulted in the death of a neonate during the neonatal period where he or she survived either by chance or with quality care [2, 3]. These events may include diseases, interventions, and organ dysfunction. The NNM could be useful in detecting risk factors for death, studying the quality of care provided to this population, strengthening the health care system, and reducing the infant mortality rate [2].

The recommended pragmatic criteria include: birth weight less than 1750 g, gestational age < 33 weeks, or Apgar score < 7 at five minutes in neonates surviving 28 days after birth. Other investigators added management markers that included use of intravenous therapeutic antibiotics, continuous nasal positive airway pressure, intubation, phototherapy within the first 24 hours, cardiopulmonary resuscitation, vasoactive drugs, anticonvulsants, surfactant administration, blood products, and steroids to treat refractory hypoglycemia for diagnostic accuracy [4,5, 4,5].

However, the incidence of NNM varies considerably between studies due to the difference in the criteria used. For those that used pragmatic criteria only, the incidence of NNM ranged from 21.4 to 86.7 per 1000 live births in Brazil and India respectively [4,5, 4,5]. In studies that used pragmatic and management criteria, the incidence of NNM varied between 39.2 and 367 per 1000 live births [6–7].

The association of maternal complications and the occurrence of Neonatal Near Miss has been highlighted in several studies [8 –11]. Factors found to be significantly associated with an increased risk of NMN and Neonatal Mortality include the rate of monitoring and management during pregnancy (less than 6 prenatal consultation visits), eclampsia, uterine rupture, multiparity, Premature Membrane Rupture (PROM), cesarean delivery, and referrals from other health care facilities [9 –11]. Morocco is among the countries that have integrated the newborn in its strategy to combat maternal and neonatal morbidity and mortality. A decrease in infant mortality has been observed; 18 per 1000 live births were cases of infant mortality with 75% of mortality occurring during the neonatal period (13.65 per 1000) [12]. Despite this decrease, the rate remains high. Subsequently, several authors have discussed neonatal mortality. However, few studies have addressed the prevalence of NMN and analyzed the main factors associated with NMN in Morocco. Knowing its determinants in different contexts may reorient public health actions towards preventive interventions. Thus, the present study is the first to use a combination of pragmatic and managerial criteria in Morocco to determine the prevalence of NNM and identify associated factors at the University Hospital Center of Rabat, Morocco.

2 Materials and methods

2.1 Study design and subjects

A prospective cross-sectional study was conducted to identify factors associated with Neonatal Near Miss in newborns admitted to the National Reference Center in Neonatology and Nutrition Department of Medicine and Neonatal Resuscitation of the Children’s Hospital of Rabat, Morocco from January 1st to December 31st 2021.

2.2 Data collection

Of the 2676 newborns admitted to the National Reference Center in Neonatology and Nutrition Department of Medicine and Neonatal Resuscitation of the Children’s Hospital of Rabat, Morocco, a total of 2367 newborns and their mothers were selected and examined.

Data were extracted using a pre-tested structured questionnaire. Training was provided to data collectors and supervisors and a pretest was conducted. Data on the clinical diagnosis of newborns and the management were extracted from patient records.

Throughout the data collection process, data collectors were supervised and regular meetings were held to address any issues. Prior to analysis, double-check data entry was conducted to increase the validity and accuracy of data entry.

2.3 Inclusion criteria

All newborns born at the University Hospital of Rabat Morocco and the National Reference Center in Neonatology and Nutrition Department of Medicine and Neonatal Resuscitation of the Children’s Hospital of Rabat, Morocco from January 1 to December 31, 2021 were included in the study.

The main inclusion criteria was the presence of at least one pragmatic and/or management criteria of the Near Miss Neonatal definition as well as admission of the neonates to the Neonatal Medicine and Resuscitation Department of the Rabat Children’s Hospital. All were followed up to 28 days to determine the chances of survival.

We used both pragmatic and management criteria for defining NNM [13]. Therefore, NNM was considered when the newborn met at least one of the following criteria:

Pragmatic criteria: birth weight less than 1750 g, gestational age < 33 weeks, or Apgar score < 7 at five minutes in newborns surviving 28 days after birth.

Management criteria: use of intravenous therapeutic antibiotics, continuous nasal positive airway pressure, intubation, phototherapy within the first 24 hours, cardiopulmonary resuscitation, vasoactive drugs, anticonvulsants, surfactant administration, blood products, steroids to treat refractory hypoglycemia, and any surgical procedure [13].

Explanatory variables include maternal age, place of residence, marital status, socioeconomic level (education level, occupation, health coverage, residence), mode of admission, parity, previous abortion, pregnancy follow-up frequency of prenatal visits (ANC), premature rupture of the membrane (PROM), mode of delivery, pathologies during pregnancy (hypertension, diabetes, anemia), mode of delivery, and presentation.

2.4 Data analysis

The data was coded, entered and exported to SPSS Version 23 for analysis. Independent variables with marginal associations (p value < 0.5) in the bivariate analysis were eligible for multivariable logistic regression analysis to detect association with outcome variables. Adjusted odds ratios (AOR) with 95% CIs were used to estimate the strength of associations and statistical significance was reported at a p value < 0.05.

2.5 Ethical approval

The study protocol was approved by the Ethics Committee of the Faculty of Medicine and Pharmacy at Mohammed University of Rabat, Morocco (Ethics approval number: C64/20). Participants were also informed of the objectives and methods of the study and oral and written consent was obtained. Confidentiality of their participation and anonymity of their data were assured.

3 Results

Of a total of 2676 newborns admitted to the National Reference Center of Neonatology and Nutrition Department of Medicine and Neonatal Resuscitation of the Children’s Hospital of Rabat, Morocco, 2367 (88.5) (95% CI: 88.3–90.7) were classified as NNM cases and 309(11.5) (95% CI: 10.4–12.7) were classified as non NNM.

3.1 Sociodemographic and obstetrical characteristics

Variables which show significantly higher amounts of Near Miss Neonatal cases and cases classified as not Near Miss Neonatal (Table 1) and (Table2) include rural residence, secondary education or less, low socioeconomic level, newborns of referred mothers, pregnancy follow-ups, less than four prenatal visits, arterial hypertension, diabetes during pregnancy, and premature rupture of membranes.

Table 1
Socio-demographic characteristic among mothers’ population

Variables categories Neonatal Near Miss No Neonatal Near Miss P-Value

N = 2367 N = 309

Age in years # 0.2^γ

Less than 20 113(4.8) 21(6.8)

[20–34] 1636(69.1) 214(69.3)

≥35 618(26.1) 74(23.9)

Residence# <0.001 ^β

Urban 1603(67.7) 131(42.4)

Rural 700(29.6) 174(56.3)

Suburban 64(2.7) 4(1,3)

Maternal education level # <0.001 ^γ

Illiterate 630(26.6) 131(42,4)

Primary 838(35.4) 60(19,4)

Secondary 724(30.6) 56(18,1)

Higher 175(7.4) 62(20,1)

Socioeconomic level # 0.003 ^β

Low 1799(76.0) 207(67,0)

Medium 562(23.7) 101(32,7)

High 6(0.3) 1(0,3)

Mode admission # <0.001 ^γ

Self-referred 1005(42.5) 169(54.7)

Referred by facility 1362(57.5) 140(45.3)

Marital Status #

Married 2349(99.2) 309(100) 0.1^β

Single 18(0.8) 0(0)

Medical cover # 0.1^γ

No 902(38.1) 127(41,1)

Yes 1465(61,9) 182(58,9)

Variables categories	Neonatal Near Miss	No Neonatal Near Miss	P-Value
Age in years #			0.2^γ
Less than 20	113(4.8)	21(6.8)
[20–34]	1636(69.1)	214(69.3)
≥35	618(26.1)	74(23.9)
Residence#			<0.001 ^β
Urban	1603(67.7)	131(42.4)
Rural	700(29.6)	174(56.3)
Suburban	64(2.7)	4(1,3)
Maternal education level #			<0.001 ^γ
Illiterate	630(26.6)	131(42,4)
Primary	838(35.4)	60(19,4)
Secondary	724(30.6)	56(18,1)
Higher	175(7.4)	62(20,1)
Socioeconomic level #			0.003 ^β
Low	1799(76.0)	207(67,0)
Medium	562(23.7)	101(32,7)
High	6(0.3)	1(0,3)
Mode admission #			<0.001 ^γ
Self-referred	1005(42.5)	169(54.7)
Referred by facility	1362(57.5)	140(45.3)
Marital Status #
Married	2349(99.2)	309(100)	0.1^β
Single	18(0.8)	0(0)
Medical cover #			0.1^γ
No	902(38.1)	127(41,1)
Yes	1465(61,9)	182(58,9)

Note: Values are expressed as counts and percentages. Note: # Values are expressed as a number (percentage). ^βFisher’s test. ^γPearson chi-square test. p < 0.05 is considered to be significant.

3.2 Risk factors for neonatal near miss cases

In the hierarchical bivariate analysis, the sociodemographic and obstetric variables that showed statistically significant associations with MNN were women referred from other health facilities [AOR: 1.63; 95% CI: 1.28–2. 07], women who lived in a rural residence [AOR: 3.04; 95% CI: 2.38–3.88], women who had less than four antenatal [AOR: 3.17; 95% CI: 2.06–4.86], and women with gestational hypertension [AOR: 2.02; 95% CI: 1.24–3.30].

All variables assessed in the bivariate analysis were included in a multivariate analysis using a hierarchical logistic regression model. Factors that remained associated with a higher risk of NDD were women referred from other health care facilities [OR: 1.86; 95% CI: 1.39–2.50], women who resided in a rural residence [OR: 2.37; 95% CI: 1.82–3.10], women with less than four prenatal visits [OR: 3.17; 95% CI: 2.06–4.86], women with pregnancy hypertension [OR: 2.02; 95% CI: 1.24–3.30], and women with low educational levels [OR = 0.43; 95% CI: 0.30–0.62].

4 Discussion

This study evaluated the proportion of cases and associated factors of NNM in newborns born at the University Hospital of Rabat, Morocco and admitted at the National Reference Center of Neonatology and Nutrition Service of Medicine and Neonatal Resuscitation of the Children’s Hospital of Rabat, Morocco, from January 1st to December 31st 2021.

The study found that the proportion of NNM cases was high likely due to factors such as mothers of newborns being referred from other care facilities, residing in a rural residence, having less than four prenatal visits, and having gestational hypertension.

The results of the study revealed the proportion of NNM cases to be 88.5%, which is consistent with the results of studies conducted in India, with 87.6% of cases being NNM as well as Ghana with 86.5% of cases [6 –14]. The agreement between these studies could be due to the fact that these studies are conducted in neonatal intensive care units or referral hospitals that manage high-risk women.

The proportion of NNM found in the present study is higher than reported in other studies (22% in northeast Brazil and 17.2 per 1000 live births in Australia) [15, 16]. This discrepancy could be attributed to the difference in study settings.

Most of the aforementioned studies were conducted in study settings with high-quality maternal and newborn health care, unlike our setting. Also, this difference may also be due to the criteria used to identify NNM. In addition, these discrepancies could also be due to differences in the demographic, socioeconomic, and obstetric characteristics of the study population. The results of the study showed that the risk of suffering from NNM was 2.37 times higher in newborns born to rural resident mothers than their counterparts. This finding is consistent with the study conducted in northern Ethiopia, which found that infants born to rural mothers had a fourfold higher risk of developing NMN (AOR = 4 : 41; 95% CI: 2.57, 7.55) [16]. This could be explained by the disparity in access to health care services and health information between residences.

Newborns born to mothers referred from other health facilities were 1.86 times more likely to develop NNM than self-referred mothers [OR: 1.86; 95% CI: 1.39–2.50]. This may be due to delayed access to emergency care services. This is consistent with a survey conducted in Uganda, Ethiopia [7]. This can also be explained by the particularity of our working site since the study was conducted in a national referral center. The access and availability of health services will help to reduce the episode of NNM.

Table 2
Obstetric characteristics among mothers

Variables categories Neonatal Near Miss No Neonatal Near Miss P-Value

N = 2367 N = 309

Parity # 0.2 ^γ

Primiparous 949(40.1) 134(43.4)

Multiparous 1419(59.9) 175(56.6)

Antenatal care follow up# 0.003 ^γ

Yes 2144(90.6) 263(85)

No 223(9.4) 46(14.9)

Frequency of Antenatal care follow up # <0.001 ^γ

<4 1859(78.5) 283(91.6)

≥4 508(21.5) 26(8.4)

History of abortion# 0.45 ^γ

Yes 442(18.7) 52(16.8)

No 1925(81.3) 257(83.2)

Pathologies during pregnancy# (n = 618)

Hypertension 302(49) 20(6.5) 0.04 ^γ

Diabetes 293(47.5) 26(8.4) 0.002 ^γ

Premature rupture of membrane# 0.002 ^γ

No 1527(64.5) 171(55.3)

Yes 840(35.5) 138(44.7)

Presentation # 0.7 ^γ

Vertex 2283(96.6) 297(96.1)

Non-vertex 84(3.4) 12(3.9)

Mode of delivery # 0.1 ^γ

Vaginal deliveries 1411(59.6) 956(40.4)

Cesarean section 169(54.7) 140(45.3)

Variables categories	Neonatal Near Miss	No Neonatal Near Miss	P-Value
Parity #			0.2 ^γ
Primiparous	949(40.1)	134(43.4)
Multiparous	1419(59.9)	175(56.6)
Antenatal care follow up#			0.003 ^γ
Yes	2144(90.6)	263(85)
No	223(9.4)	46(14.9)
Frequency of Antenatal care follow up #			<0.001 ^γ
<4	1859(78.5)	283(91.6)
≥4	508(21.5)	26(8.4)
History of abortion#			0.45 ^γ
Yes	442(18.7)	52(16.8)
No	1925(81.3)	257(83.2)
Pathologies during pregnancy# (n = 618)
Hypertension	302(49)	20(6.5)	0.04 ^γ
Diabetes	293(47.5)	26(8.4)	0.002 ^γ
Premature rupture of membrane#			0.002 ^γ
No	1527(64.5)	171(55.3)
Yes	840(35.5)	138(44.7)
Presentation #			0.7 ^γ
Vertex	2283(96.6)	297(96.1)
Non-vertex	84(3.4)	12(3.9)
Mode of delivery #			0.1 ^γ
Vaginal deliveries	1411(59.6)	956(40.4)
Cesarean section	169(54.7)	140(45.3)

Note: Values are expressed as counts and percentages. ^γPearson chi-square test. p < 0.05 is considered to be significant.

Table 3

Multiple logistic analysis on factors associated with neonatal near miss in national reference center of neonatology, Morocco, 2021

Independent variables	NNM(n = 2367)		Univariate analysis			Multivariate analysis
(N = 2676)	Yes	No	OR	95% CI	p	OR	95% CI	p–value
Referred by facility	1362(57.5)	140(45.3)	1.63	1.28–2.07	<0,001	1.86	1.39–2.50	<0.001
Rural Residence	1603(67.7)	131(42.4)	3.04	2.38–3.88	<0,001	2.37	1.82–3.10	<0,001
Low education level	630(26.6)	131(42.4)	0.43	0.30–0.62	<0,001	0.33	0.21–0.52	<0.001
Antenatal care follow up	2143(90.6)	263(85.1)	1.68	1.19–2.36	0.003	0.86	0.59–1.25	0.4
Frequency of Antenatal care follow up < 4	1859(78.5)	283(91.6)	2.97	1.96–4.49	<0,001	3.17	2.06–4.86	<0,001
Premature rupture of membrane	840(35.5)	138(F44.7)	1.46	1.15–1.86	0.002	0.87	0.59–1.25	0.3
Diabetes	293(12.4)	26(8.4)	1.53	1.01–2.34	0.04	1.53	0.99–2.38	0.56
Pregnancy induced hypertension	302(12.8)	20(6.5)	2.11	1.32–3.37	0.002	2.02	1.24–3.30	0.004

NNM: Neonatal Near Miss. OR: odds ratio, CI: confidence interval, p < 0.05 is considered to be significant.

Regular prenatal care is important. In theory, more prenatal visits could increase the chances of receiving care, especially in high-risk pregnancies. In Morocco, antenatal care coverage and the number of visits has increased in recent years [12]. Our results show that attendance at less than 4 prenatal visits was statistically significantly associated with NNM, increasing the risk by 3.7-fold. This result is consistent with previous studies reported in Ethiopia and southeast Brazil [5 –17]. Most neonatal deaths are maternal obstetric problems that were not resolved before birth [18].

Therefore, there is a need to expand prenatal care coverage and improve the quality of services provided, especially for women with high-risk pregnancies.

The pregnancy-induced hypertension is documented as a risk factor that can lead to fetal complications during intrauterine life, such as intrauterine growth retardation, and preterm delivery, which is more likely to be low weight and also causes birth asphyxia. In this sense, a systematic review and meta-analysis have shown that maternal and perinatal outcomes are often related [19].

According to the present study, newborns born to women who had high blood pressure during pregnancy were 2.02 times more likely to suffer from NNM. This is consistent with the findings of the previous study inEthiopia [16].

5 Conclusion

Given the paucity of evidence for NNM in the Moroccan context, the result of the present study could be used as a basic conclusion for researchers, policy makers, and/or anyone concerned with neonatal health problems. The associated factors found to threaten the increase in these cases show that the primary health care program needs to be further improved to avoid preventable causes of neonatal morbidity and mortality.

Footnotes

Acknowledgments

The authors express their appreciation and gratitude to all people who were involved in this review.

Declaration of competing interest

There is no conflict of interest

Funding

This research did not receive any specific grant from funding.

References

WHO. Newborns: Improving their survival and well-being. Key facts. Report 2022. https://www.who.int/fr/newsroom/factsheets/detail/newbornsreducing-mortality

Pileggi

, Souza

, Cecatti

, Faúndes

Neonatal near miss approach in the WHOGlobal Survey Brazil, J Pediatr (Rio J) 2010;86(1):21–6.

Kale

, Jorge

MHPM

, Laurenti

, Fonseca

, Silva

KSD

Pragmatic criteria of the definition of neonatal near miss: a comparative study, Rev Saude Publica 2017;51:111.

Pileggi-Castro

, Camelo

JS Jr

, Perdoná

, Mussi-Pinhata

, Cecatti

, Mori

, et al. WHO Multicountry Survey on Maternal and Newborn Health Research Network, Development of criteria for identifying neonatal near-miss cases: analysis of two WHO multicountry cross-sectional studies. BJOG 2014;121(Suppl 1):110–8.

Santos

, Cecatti

, Serruya

, Almeida

, Duran

, Mucio

, et al. Neonatal near miss: The need for a standard definition and appropriate criteria and the rationale for a prospective surveillance system, Clinics 2015;70(12):820–6.

Ninama

, Shroff

Will outlining neonatal near miss events make a change? A hospital based case control study, Int J Community Med Public Health 2019;6:4570–4.

Nakimuli

, Mbalinda

, Nabirye

, Kakaire

, Nakubulwa

, Osinde

, et al. Stillbirths, neonatal deaths, and neonatal near-misses due to severe obstetric complications: a prospective cohort study in two referral hospitals in Uganda, BMC Pediatr 2015;15:44.

Tekola

, Baye

, Amaje

, Tekola

Neonatal near misses and associated factors among mother’s who give a liveneonate at Hawassa City governmental hospitals, a facility based crosssectional study design, BMC Pregnancy Childbirth 2021;21:125.

Yohannes

, Assefa

, Dessie

Determinants of neonatal near miss among neonates admitted to Ambo University Referral Hospital and Ambo General Hospital, Ethiopia, Clin J ObstetGynecol

2020;3:046–53.

10.

Assurage

, Limenih

, Wassie

, Ambie

Neonatal near miss and its associated factors at Injibara General Hospital, Awi Zone, Northwest Ethiopia, Explor Res Hypothesis Med

2020;5:62–9.

11.

Abebe

, Wasie

, Yeshaneh

, Shitu

, Mose

, Adane

, et al. Determinant factors of neonatal near miss among neonates in Gurage Zone Hospitals, Ethiopia: A Case-Control Study, Pediatric Health Med Ther 2021;12:129–39.

12.

National Population and Family Health Survey Morocco. 2018. Summary of key indicators:5.

13.

Santos

, Pileggi-Castro

, Camelo

Jr , Silva

, Duran

, Serruya

, et al. Neonatal near miss: A systematic review, BMC Pregnancy Childbirth 2015;15:320.

14.

Bakari

, Bell

, Oppong

, Bockarie

, Wobil

, Plange-Rhule

, et al. Neonatal near-misses in Ghana: A prospective, observational, multi-center study, BMC Pediatr 2019;19(1):509.

15.

De Lima

THB

, Katz

, Kassar

, Amorim

Neonatal near miss determinants at a maternity hospital for high-risk pregnancy in Northeastern Brazil: A prospective study, BMC Pregnancy Childbirth 2018;18(1):401.

16.

Hassen

, Chojenta

, Egan

, Loxton

Determinants of neonatal near miss in Australia: A multilevel analysis, Early Hum Dev 2021;156:105343.

17.

Mersha

, Bante

, Shibiru

Factors associated with neonatal near-misses in selected hospitals of Gamo and Gofa zones, southern Ethiopia: nested case control study, BMC Pregnancy and Childbirth 2019;19:516.

18.

Pedrosa

LDCO

, Sarinho

, Ordonha

Important information on neonatal causes of neonatal offenses, no problem on mortality information: Information on basic causes of neonatal death recorded in the mortality information system: A study conducted in Maceióa, Alagoas State, Brazil, –] Cad Saude Publica

2007;23(10):2385–95.

19.

Sobhy

, Arroyo-Manzano

, Murugesu

, Karthikeyan

, Kumar

, Kaur

, et al. Maternal and perinatal mortality and complications associated with caesarean section in low-income and middle-income countries: a systematic review and meta-analysis, Lancet 2019;393(10184):1973–82.