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. 2024 Mar 21;19(3):e0298519. doi: 10.1371/journal.pone.0298519

Neonatal birth trauma and associated factors in low and middle-income countries: A systematic review and meta-analysis

Beshada Zerfu Woldegeorgis 1,*, Amanuel Yosef Gebrekidan 2, Gizachew Ambaw Kassie 2, Gedion Asnake Azeze 3, Yordanos Sisay Asgedom 4, Henok Berhanu Alemu 1, Mohammed Suleiman Obsa 5
Editor: Mohammed Feyisso Shaka6
PMCID: PMC10957092  PMID: 38512995

Abstract

Neonatal birth trauma, although it has steadily decreased in industrialized nations, constitutes a significant health burden in low-resource settings. Keeping with this, we sought to determine the pooled cumulative incidence (incidence proportion) of birth trauma and identify potential contributing factors in low and middle-income countries. Besides, we aimed to describe the temporal trend, clinical pattern, and immediate adverse neonatal outcomes of birth trauma. We searched articles published in the English language in the Excerpta Medica database, PubMed, Web of Science, Google, African Journals Online, Google Scholar, Scopus, and in the reference list of retrieved articles. Literature search strategies were developed using medical subject headings and text words related to the outcomes of the study. The Joana Briggs Institute quality assessment tool was employed and articles with appraisal scores of seven or more were deemed suitable to be included in the meta-analysis. Data were analyzed using the random-effect Dersimonian-Laird model. The full search identified a total of 827 articles about neonatal birth trauma. Of these, 37 articles involving 365,547 participants met the inclusion criteria. The weighted pooled cumulative incidence of birth trauma was estimated at 34 per 1,000 live births (95% confidence interval (CI) 30.5 to 38.5) with the highest incidence observed in Africa at 52.9 per 1,000 live births (95% CI 46.5 to 59.4). Being born to a mother from rural areas (odds ratio (OR), 1.61; 95% CI1.18 to 2.21); prolonged labor (OR, 5.45; 95% CI 2.30, 9.91); fetal malpresentation at delivery (OR, 4.70; 95% CI1.75 to 12.26); shoulder dystocia (OR, 6.11; 95% CI3.84 to 9.74); operative vaginal delivery (assisted vacuum or forceps extraction) (OR, 3.19; 95% CI 1.92 to 5.31); and macrosomia (OR, 5.06; 95% CI 2.76 to 9.29) were factors associated with neonatal birth trauma. In conclusion, we found a considerably high incidence proportion of neonatal birth trauma in low and middle-income countries. Therefore, early identification of risk factors and prompt decisions on the mode of delivery can potentially contribute to the decreased magnitude and impacts of neonatal birth trauma and promote the newborn’s health.

Introduction

Birth trauma, which is defined as a structural or functional impairment of a newborn’s body due to mechanical forces sustained during labor, delivery, or neonatal resuscitation [1], has continued to be a significant source of jeopardy for the neonates and the family and also evokes concerns for healthcare providers [2].

According to the World Health Organization’s eleventh revision of the International Classification of Diseases, the diagnosis of birth trauma includes extracranial traumatic injuries such as caput succedaneum, subgaleal hemorrhage, cephalohematoma, and facial or ocular or nasal injuries; intracranial hemorrhages such as intraventricular hemorrhage, subdural hemorrhage, subarachnoid hemorrhage, and epidural hemorrhage; peripheral nerves injuries such as brachial plexus injury, phrenic nerve injury, and facial nerve injury; injury to skeletons such as clavicular fracture, humeral fracture, rib fracture, and femurs fracture; soft tissue injuries such as lacerations, contusions, bruisings, and fat necrosis; and organ injuries such as liver, spleen, kidney, adrenals, and trachea [3].

Birth trauma impacts on the prognosis of neonates are protean, ranging from clinically trivial extracranial superficial lesions to significant causes of morbidity and mortality, such as intracranial hemorrhage [4]. Chang et al. [5] described that resulting hypotension from traumatic subgaleal hemorrhage can lead to significant morbidities such as severe auditory dysfunction, cerebral palsy, and renal vein thrombosis, and estimated neonatal mortality proportion ranging from 12% to 18% [6]. Furthermore, the Global Burden of Disease Study 2019 found that newborn encephalopathy caused by birth trauma was a major contributor to neonatal mortalities ranging from 5.4% to 96.4% in low-resource settings [7]. Although research into the economic impacts of birth trauma focused in low and middle-income countries (LMICs) is lacking, a study conducted in the United States (US) revealed that neonatal brachial plexus palsy hospital length of stay was 48% higher (3.6 days vs. 2.5 days) and hospitalization costs were twice ($4891 vs. $2241) as high as in neonates without the condition [8].

The United Nations Sustainable Development Goals (SDG) 3.2 envisaged ending preventable deaths of newborns for each country aiming to reduce neonatal mortality to less than 12 per 1000 live births [9]. Nevertheless, at the midway point towards 2030, the special edition progress report against the global SDG indicator framework indicated that the neonatal mortality was just 18 per 1000 live births on a global scale [10] and continued to pose a considerable challenge in the south Asian and Sub Saharan African countries [7]. Birth trauma and asphyxia remain preventable causes of neonatal death, which accounts for an estimated half of all under-five mortality [11]. As a result, neonatal health has become an important public health concern worldwide [12].

Data exist on the incidence of birth trauma are divergent according to geographic areas and level of neonatal and obstetrics healthcare and so far a plethora of studies have documented the true estimate of neonatal birth trauma in resource-rich settings [2]. For instance, a nationwide registry study of 1,203,434 neonates in Finland suggests the overall incidence of birth trauma decreased from 34 per 1,000 live births in 1997 to 16.6 per 1,000 live births in 2017 [13]. Similarly, in the United States, hospital birth data obtained from the National Inpatient Sample of the Healthcare Cost and Utilisation Project demonstrated an incidence of birth trauma of 24.3 per 1,000 live births in 2003 [14], and 31.1 per 1,000 live births in 2021 [15]. A Chinese study comprising 4,682 newborns in Peking University International Hospital reported a birth trauma cumulative incidence of 42.9 per 1,000 live births [16]. In Canada, Muraca and colleagues determined that the incidence of birth trauma was 9.6 per 1,000 live births in a retrospective review of records of 1,326,191 live births from 2013 to 2019 [17].

In LMICs, estimates from individual studies suggest that the cumulative incidence of birth-related trauma ranges from an estimated 3 per 1,000 live births [18] to 869 per 1,000 live births [19] in Africa; 3 per 1,000 live births [20, 21] to 4.7 per 1,000 live births [22] in Asia and Pacific region; and 6.7 per 1,000 live births [23] to 87.3 per 1,000 live births [24] in the middle east. Operative vaginal deliveries such as vacuum extractions or forceps [25–34], fetal presentation other than vertex [25, 26, 30, 31, 35, 36], shoulder dystocia [28, 29, 31], gestational age [35], prolonged labor [27, 29, 31, 36], general anesthesia [35], and newborn birth weight greater than 4000 grams [26, 29, 30, 34, 36] have been found to increase the odds of sustaining birth trauma. Moreover, logistic regression analysis demonstrated that nulliparous women [25, 28], lack of or inadequate antenatal care follow-up [29, 30, 32, 36], gestational diabetes mellitus [36], residence in rural settings [25, 26, 30], maternal age [32, 35], and abnormal fetal heart rate patterns [25] have been correlated with a statistically significant increase in neonatal birth trauma.

To the best of our knowledge, there is no comprehensive, up-to-date, and accurate epidemiological data available regarding neonatal birth trauma in LMICs. Keeping with this, we aimed to seek answers to the following questions: (1) What is the pooled cumulative incidence of neonatal birth trauma in the LMICs? (2) What are the trends and clinical patterns of neonatal birth trauma in the LMICs? (3) What are epidemiologic risk factors correlated with neonatal birth trauma in the LMICs? and (4) What are the immediate/short-term adverse outcomes of neonatal birth trauma in the LMICs?

Methods

Protocol registration and reporting

We wrote the review protocol based on the Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 [37]. Details of the protocol for this systematic review were registered on PROSPERO with registration number CRD42023445028. Moreover, the review methods were amended four times (last modified on 14/08/2023) after registration and these records were made public along with the revision notes. The study was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement [38] (S1 Checklist).

Eligibility criteria

To define inclusion criteria, we consulted the methodological guidance for systematic reviews of observational epidemiological studies reporting prevalence and cumulative incidence data [39]. Accordingly, the CoCoPop mnemonic (Condition, Context, and Population) was adhered to. Population/Participants: were neonates (infants from birth to 28 days); condition/domain: studies that clearly stated and defined the factors of interest based on the incidence, associated factors, and trend or outcomes of birth trauma were included; and context/settings: all observational epidemiological studies (cross-sectional, case-control, and cohort studies) restricted to low and middle-income countries were considered. Moreover, articles reported in the English language from inception to July 31, 2023, and published in international or domestic peer-reviewed journals were included. Studies without full-text access; articles that contained insufficient information on the outcomes of interest; studies not available as free full-text; findings from personal opinions; articles reported outside the scope of the outcome of interest; qualitative study design; case reports; case series; letters to editors; and unpublished data were excluded.

Information sources and search strategy

To ensure complete coverage of the topic by accounting for variability between the indexing in each database, the search typically included the electronic bibliographic medical databases of Excerpta Medica database, PubMed, Web of Science, African Journals Online, Google Scholar, and Scopus. Furthermore, the reference lists of included studies were scanned to ensure literature saturation. For the advanced search, initially, we conducted a preliminary search in our title and identified relevant search terms from Google Scholar, Wikipedia, article, and Google for each concept, and then combined them in an advanced search using Boolean logic (“AND” and “OR”), double quotes and truncation. Moreover, filtrations were applied concerning language, research designs, and study settings. The search was double-blinded and conducted by two authors (BZW and AYG) from June 1, 2023, to July 31, 2023 (Table 1).

Table 1. PubMed’s history and search details.

Search Text Words (tw) MeSH Query Results
#1 incidence[tw], magnitude[tw], prevalence[tw], proportion[tw] "Incidence" [MeSH Terms] Incidence, Magnitude, Prevalence, Proportion (incidence[MeSH Terms] OR magnitude [tw] OR incidence [tw] OR prevalence [tw] OR proportion [tw]) 2,473,178
#2 "birth trauma"[tw], "birth injur*"[tw] "Birth injuries" [MeSH Terms] Birth trauma, Birth injury, Birth injuries ("birth injuries"[MeSH Terms] OR "birth trauma"[tw] OR "birth injur*"[tw]) 7,410
#3 newborns[tw], neonat*[tw], "live births"[tw] "Infant, Newborn" [MeSH Terms] Neonates, Newborns, Live births ("infant, newborn"[MeSH Terms] OR newborns [tw] OR neonat*[tw] OR "live births"[tw]) 848,237
#4 "risk factors"[tw], "predisposing factors"[tw], "associated factors"[tw], determinants[tw], predictors[tw] "Risk Factors" [MeSH Terms] Associated factors, Risk factors, Predisposing factors, Determinants, Predictors ("risk factors"[MeSH Terms] OR "risk Factors"[tw] OR "predisposing factors"[tw] OR "associated factors"[tw] OR determinants[tw] OR predictors[tw]) 1,689,149
#1 AND #2 AND #3 AND #4 265
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Abbreviations: MeSH, Medical subjects headings.

Study selection

The articles that were found through comprehensive searches were exported to EndNote X7, where duplicate studies were then eliminated. Two authors (MSO and BZW) independently screened the titles and abstracts against eligibility criteria. The screened articles were then subjected to a full article review by two independent authors (YSA and GAA). Pre-specified criteria for inclusion in the review were followed to determine which records were relevant and should be included. Where additional information was required to answer queries regarding eligibility, other authors were involved as needed. Disagreements about whether a study should be included were resolved by discussion. Furthermore, the reasons for excluding the articles were recorded at each step

Data extraction

Two authors (BZW and YSA) working independently excerpted the relevant data from studies by using a standardized Microsoft Excel spreadsheet. For data extraction, the Joana Briggs Institute (JBI) adopted data collection formats suitable for meta-analysis was used [40]. The data extraction format captured data on the following main components: information about data extraction from reports (name of data extractors, date of data extraction, and study identification number); study authors; year of publication of the article; study methods (study design, statistical analysis); participants and settings (regions and country from which study participants were recruited); information related to the pre-specified outcome domain in this systematic review (i.e birth trauma): measurement tool or instrument (including the definition of birth trauma); and information related to the results: for each study included in the quantitative analysis number of participants randomly assigned and included in the analysis, and the response rate. The reliability agreement among the data extractors was evaluated and verified using Cohan’s kappa coefficient after data was recovered from 30% of the primary studies [41]. As a consequence, the kappa coefficient’s strength of agreement was divided into five categories: low (0.20), fair (0.21–0.40), moderate (0.41–0.60), good (0.61–0.80), and virtually perfect agreement (0.81–1). A kappa statistic value of more than or equal to 0.5 was regarded as congruent and acceptable. In the case of disagreements between the two data extractors, a third author (MSO) was involved in adjudicating unresolved disagreements through discussion and re-checking of the original articles.

Effect measures

The outcome of this systematic review and meta-analysis was neonatal birth trauma. As a result, the OR was the appropriate effect measure for meta-analysis of dichotomous outcome data [42]. The ‘odds’ refers to the ratio of the probability that the neonatal birth trauma occurred to the probability that it did not.

Risk of bias (quality) assessment

The JBI critical appraisal checklist for studies reporting prevalence data [39], analytical cross-sectional and case-control study designs [43] were adhered to. Two authors (AYG and GAK) working independently carried out the quality assessment. Thus, studies conducted using a descriptive cross-sectional research design (n = 26) were evaluated against the following nine constructs: (Q1) Was the sample frame appropriate to address the target population? (Q2) Were study participants recruited appropriately? (Q3) Was the sample size adequate? (Q4) were the study subjects and setting described in detail? (Q5) Was data analysis conducted with sufficient coverage of the identified sample? (Q6) Were valid methods used for the identification of the condition? (Q7) Was the condition measured in a standard, reliable way for all participants? (Q8) Was there appropriate statistical analysis? and (Q9) Was the response rate adequate, and if not, was the low response rate managed appropriately? (S1A Table).

Articles that employed analytical cross-sectional study designs (n = 9) were critically appraised against the following eight questions: (Q1) Were the criteria for inclusion in the sample clearly defined? (Q2) Were the study subjects and the setting described in detail? (Q3) Was the exposure measured validly and reliably? (Q4) Were objective, standard criteria used for the measurement of the condition? (Q5) Were confounding factors identified? (Q6) Were strategies to deal with confounding factors stated? (Q7) Were the outcomes measured validly and reliably? (Q8) Was appropriate statistical analysis used? (S1B Table).

The remaining articles (n = 2), which employed the case-control study design, were evaluated against the following ten items: (Q1) Were the groups comparable other than the presence of disease in cases or the absence of disease in controls? (Q2) Were cases and controls matched appropriately? (Q3) Were the same criteria used for the identification of cases and controls? (Q4) Was exposure measured in a standard, valid, and reliable way? (Q5) Was exposure measured in the same way for cases and controls? (Q6) Were confounding factors identified? (Q7) Were strategies to deal with confounding factors stated? (Q8) Were outcomes assessed in a standard, valid, and reliable way for cases and controls? (Q9) Was the exposure period of interest long enough to be meaningful? (Q10) Was appropriate statistical analysis used? (S1C Table). For each question, the response option was, “yes”, “no” or “unclear”. The total score was determined by counting the “yes” responses to each question and adding them. In all scenarios, articles with appraisal scores of seven or more were deemed suitable to be included in the meta-analysis. When disagreements arose, they were settled by consulting with a third independent author (HBA)

Data synthesis methods

Extracted data were imported from Microsoft Excel 2010 into Stata 16 MP version for analysis. The presence and degree of variability (inconsistency/heterogeneity) among individual studies were evaluated graphically (present when the uncertainty interval for the results of individual studies generally depicted in forest plots using the horizontal lines have poor overlap) and more formally, using statistical methods (the X2 test, included in the forest plots, significant level:0.1; Higgins and Thompson’s I2 statistics: 0–25%: low heterogeneity; 25–50%: moderate heterogeneity; 50–75%: high heterogeneity; 75–100%: very high heterogeneity) [42]. We employed the random-effect meta-analysis model to estimate Der Simonian and Laird’s pooled effect as considerable statistical heterogeneity was observed (Higgins and Thompson’s I2 statistics was ≥ 50% and P.value was ≤ 0.1) in the fixed-effect meta-analysis model. Moreover, subgroup analyses (based on year of publication, and study region), meta-regression (based on year of publication, and sample size), and sensitivity analyses were performed.

To evaluate the presence of small study effects, publication bias was explored through statistical methods (Egger test: significant at P ≤ 0.05) and graphical approaches (funnel plots) [44]. The symmetrical distribution of the points about the summary effect size is an indication of the absence of a possible small-study effect or publication bias. However, any asymmetrical distribution of the points (the typical pattern in the presence of small-study effects is a prominent asymmetry at the bottom that progressively disappears as we move up to larger studies) may support the presence of a possible small-study effect or publication bias [44, 45]. Due to the presence of publication biases for the pooled cumulative incidence of neonatal birth trauma, we conducted the non-parametric trim-and-fill method of Duval and Tweedie. Regarding the determinant factors variables with P ≤ 0.05 were considered statistically significant and the strength of the association was presented by OR with a corresponding 95% confidence interval (CI). Tables, graphs and text narration were used to present results.

Results

Search results

The search identified 827 articles. Due to duplication, 540 articles were removed. The remaining 287 were screened based on their title and abstract, with 235 being removed as unrelated to our domain. Fifty-two full-text articles were evaluated against eligibility criteria and 26 of them were removed (due to different outcomes,n = 2; different settings, n = 18, and reported only single birth injury type, n = 6). In addition, citation searching identified 11 articles. Finally, 37 articles were included in the quantitative synthesis (Fig 1).

Fig 1. PRISMA flow diagram for identification and selection of articles.

Fig 1

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Study characteristics

There were 365,547 live births from Ethiopia [25, 26, 29, 30, 32, 36], Ghana [18, 46], Nigeria [19, 47–54], Cameroon [55], Niger [56], India [20–22, 57, 58], Israel [59], Iran [24, 28, 33, 60–64], Pakistan [65], Thailand [27], Iraq [31] and Saudi Arabia [23, 66]. Nineteen of 37 studies (51.4%) were conducted in African countries [18, 19, 25, 26, 29, 30, 32, 36, 46–56]. The remaining 18 studies (48.6%) were conducted in Asian countries [20–24, 27, 28, 31, 33, 57–66]. The authors employed cross-sectional [18–30, 32, 36, 46–66] and case-control [31, 33] observational epidemiological study designs. The study sizes ranged from 131 [33] to 118,280 [59] live births. A standardized data abstraction tool [18–30, 32, 33, 46–66] and interviewer-administered structured questionnaires with a data abstraction tool [29, 31, 36, 49–51] were employed for data collection. The year of publication ranges from 1985 [61] to 2023 [30, 33, 36]. A total of 6,429 newborns incurred at least one traumatic birth injury. A wide range of estimates with the lowest cumulative incidence in Ghana at 2.99 per 1,000 live births [18] and the highest in Ethiopia at 168.7 per 1,000 live births [30] were reported (Table 2).

Table 2. Summary of studies included in the systematic review and meta-analysis.

SN Authors /reference Year Continent Country Study design Data collection tool Study size Neonatal birth trauma Quality
Count Incidence per 1,000 live births
1 Tesfaye et al [25] 2016 Africa Ethiopia Analytical CS Extraction 272 42 154.4 8
2 Yemane et al [26] 2019 Africa Ethiopia Analytical CS Extraction 717 88 122.7 8
3 Biset et al [29] 2022 Africa Ethiopia Analytical CS Interview & Extraction 594 78 131.3 8
4 Tolosa et al [30] 2023 Africa Ethiopia Analytical CS Extraction 492 83 168.7 8
5 Belay et al [32] 2022 Africa Ethiopia Analytical CS Extraction 1,315 220 167.3 8
6 Mah et al [55] 2017 Africa Cameron Descriptive CS Extraction 14,284 263 18.4 8
7 Abdul-mumin et al [46] 2021 Africa Ghana Descriptive CS Extraction 5,590 205 36.7 8
8 Pius et al [49] 2018 Africa Nigeria Descriptive CS Interview & Extraction 1,071 61 57.0 8
9 West and Okari [50] 2021 Africa Nigeria Descriptive CS Interview & Extraction 5,692 39 6.9 8
10 Emeka et al [51] 2019 Africa Nigeria Descriptive CS Interview & Extraction 1,735 19 11.0 8
11 Warke et al [20] 2012 Asia India Descriptive CS Extraction 5,837 19 3.3 9
12 Linder et al [59] 2012 Asia Israel Analytical CS Extraction 118,280 2,876 24.3 8
13 Zama et al [22] 2020 Asia India Descriptive CS Extraction 850 100 117.7 8
14 Phuengphaeng et al [27] 2022 Asia Thailand Analytical CS Extraction 15,209 81 5.3 8
15 Borna et al [63] 2009 Asia Iran Analytical CS Extraction 3596 148 41.2 8
16 Mosavat and Zamani [64] 2008 Asia Iran Descriptive CS Extraction 3340 27 8.1 9
17 Abedzadeh-Kalahroudi et al [28] 2015 Asia Iran Analytical CS Extraction 7154 161 22.5 7
18 Shanthi et al [21] 2022 Asia India Descriptive CS Extraction 12,221 40 3.3 8
19 Awari et al [23] 2003 Asia Saudi Arabia Descriptive CS Extraction 31,028 208 6.7 8
20 Rezaie et al [24] 2009 Asia Iran Descriptive CS Extraction 2005 175 87.3 8
21 Enyindah et al [56] 2005 Africa Niger Descriptive CS Extraction 16631 50 3.0 8
22 Adegbehingbe et al [19] 2007 Africa Nigeria Descriptive CS Extraction 137 119 86.9 8
23 Osinaike et al [53] 2017 Africa Nigeria Descriptive CS Extraction 134 90 671.6 8
24 Fabamwo et al [48] 2006 Africa Nigeria Descriptive CS Extraction 7200 44 6.1 8
25 Njokanma and Kehinde [52] 2002 Africa Nigeria Descriptive CS Extraction 2941 50 17.0 8
26 Okoro and Oriji [54] 2018 Africa Nigeria Descriptive CS Extraction 14814 107 7.2 8
27 Danso and Shaka [18] 1999 Africa Ghana Descriptive CS Extraction 46113 138 3.0 8
28 Uchenna et al [47] 2021 Africa Nigeria Descriptive CS Extraction 1920 46 24.0 8
29 Gorashi et al [60] 2005 Asia Iran Descriptive CS Extraction 7660 102 14.1 8
30 Esmailpour et al [61] 1985 Asia Iran Descriptive CS Extraction 13117 141 10.8 8
31 Ray et al [58] 2006 Asia India Descriptive CS Extraction 4741 73 15.4 8
32 Prabhu et al [57] 2017 Asia India Descriptive CS Extraction 12735 283 22.2 8
33 Benjamin et al [66] 1993 Asia Saudi Arabia Descriptive CS Extraction 2222 57 25.7 8
34 Shabbir et al [65] 2014 Asia Pakistan Descriptive CS Extraction 3596 148 41.2 8
35 Hameed and Izzet [31] 2010 Asia Iraq Case control Extraction 200 NA NA 9
36 Basiri et al [33] 2023 Asia ` Iran Case control Extraction 131 NA NA 9
37 Tibebu et al [36] 2023 Africa Ethiopia Analytical CS Interview & Extraction 373 48 128.7 8
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Abbreviations: CS, cross-sectional; NA, not applicable

Incidence of neonatal birth trauma

In this epidemiological review of studies suited for meta-analysis, incidence data were abstracted from 35 articles [18–30, 32, 36, 46–61, 63–66] involving 365,547 live births. The weighted pooled cumulative incidence of neonatal birth trauma was estimated to be 34 per 1,000 live births (95% CI 30.5 to 38.5) (Fig 2).

Fig 2. Forest plot for the pooled cumulative incidence of neonatal birth trauma.

Fig 2

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Heterogeneity

Due to the observed very high statistical heterogeneity (i.e. Hiddigns and Thomsons I2 statistics = 99.3%, and P < 0.001), we conducted meta-regression and subgroup meta-analysis to explore the sources of statistical heterogeneity. As described in Table 3, the study size and publication year were not found to be the cause of the statistical heterogeneity.

Table 3. Meta-regression analysis of factors affecting between-study heterogeneity.
Covariates Regression coefficient Standard error t P>|t| 95% confidence interval
Study size -.0001549 .0001482 -1.05 0.304 -.0004568 .000147
Year of publication .1047447 .3460033 0.30 0.764 -.6000409 .8095304
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Subgroup meta-analysis based on the region demonstrated that the cumulative incidence of neonatal birth trauma in Africa, 52.9 per 1,000 live births (95% CI 46.5 to 59.4), was more than two-fold higher than in the Middle East, 24.9 per 1,000 live births (95% CI 17.6 to 32.3), and about three-fold higher than in Asia and the Pacific countries, 18 per 1,000 live births (95% CI 12 to 23.9) (Fig 3).

Fig 3. Forest plot for subgroup analyses by region.

Fig 3

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According to the year of publication, the cumulative incidence of neonatal birth trauma was found to be 45.5 per 1,000 live births (95% CI 39.1 to 51.8) in 2015 and beyond (Fig 4).

Fig 4. Forest plot for subgroup analyses by year of publication.

Fig 4

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Sensitivity meta-analysis

A leave-out-one sensitivity analysis was conducted to assess the impact of each study on the pooled incidence of neonatal birth trauma while gradually excluding each study. Results showed that the combined effects did not significantly change as a result of the excluded study (Table 4).

Table 4. Sensitivity analysis of pooled cumulative incidence with each study removed one by one.
SN Study omitted Year of publication Estimate per 1,000 live births 95% confidence interval
1 Tesfaye et al [25] 2016 33.6 29.6 37.6
2 Yemane et al [26] 2019 32.9 29.0 36.9
3 Biset et al [29] 2022 33.0 29.1 37.0
4 Tolosa et al [30] 2023 32.9 29.0 36.9
5 Belay et al [32] 2022 31.5 27.6 35.4
6 Mah et al [55] 2017 35.2 31.1 39.2
7 Abdul-mumin et al [46] 2021 34.2 30.2 38.2
8 Pius et al [49] 2018 33.9 29.8 37.9
9 West and Okari [50] 2012 35.8 31.7 39.9
10 Emeka et al [51] 2019 35.4 31.4 39.5
11 Warke et al [20] 2012 36.2 32.0 40.3
12 Linder et al [59] 2012 32.3 28.6 35.9
13 Zama et al [22] 2020 33.7 29.7 37.8
14 Phuengphaeng et al [27] 2022 36.4 32.2 40.6
15 Borna et al [63] 2009 34.1 30.1 38.1
16 Mosavat and Zamani [64] 2008 35.6 31.5 39.7
17 Abedzadeh-Kalahroudi [28] 2015 34.9 30.9 40.0
18 Shanthi et al [21] 2022 36.6 32.4 40.9
19 Awari et al [23] 2003 36.9 32.7 41.2
20 Rezaie et al [24] 2009 32.7 28.7 36.7
21 Enyindah et al [56] 2005 37.0 32.7 41.3
22 Adegbehingbe et al [19] 2007 29.3 25.7 33.0
23 Osinaike et al [53] 2017 32.5 28.6 36.4
24 Fabamwo et al [48] 2006 35.9 31.8 40.1
25 Njokanma and Kehinde [52] 2002 35.2 31.1 39.2
26 Okoro and Oriji [54] 2018 36.2 32.0 40.3
27 Danso and Shaka [18] 1999 38.1 33.6 42.6
28 Uchenna et al [47] 2021 34.9 30.8 38.9
29 Gorashi et al [60] 2005 35.9 31. 3 39.5
30 Esmailpour et al [61] 1985 35.8 31.6 39.9
31 Keshtkaran et al [62] 2007 34.4 30.4 38.4
32 Ray et al [58] 2006 35.3 31.2 39.3
33 Prabhu et al [57] 2017 34.9 30.8 38.9
34 Benjamin et al [66] 1993 34.8 30.7 38.8
35 Shabbir et al [65] 2014 34.1 30.1 38.1
36 Tibebu et al [36] 2023 33.5 29.5 37.5
Combined 34.5 30.5 38.5
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Publication bias

To explore whether there is a possibility of small-study effects, we examined the distribution of studies about the summary effect sizes using a graph. In this case, the funnel plot demonstrated a prominent asymmetrical distribution (Fig 5).

Fig 5. Funnel plot for publication bias.

Fig 5

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Moreover, the Egger linear regression test was statistically significant (t = 3.11; P = 0.004) further corroborating the presence of evidence of small study effects. The counter-enhanced funnel plot (Fig 6A) showed that small studies were found in non-statistical significance (white area). Thus, the asymmetry might have been caused by publication bias. The metric inverse counter-enhanced funnel plot (Fig 6B) also revealed the same.

Fig 6.

Fig 6

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(A) Counter-enhanced, and (B) the metric inverse counter-enhanced funnel plots of publication bias for the pooled cumulative incidence of neonatal birth trauma.

When evaluated against the Egger© regression test, the estimated bias coefficient was 10.53967 with a standard error of 1.953324, a P value of < 0.001, and 95% CI 6.6 to 14.5. The test thus provides strong evidence for the presence of a small study effect. In addition, as shown in Fig 7 while only two estimates just touched the regression line, the majority of the data points were below the regression line.

Fig 7. Regression graph of neonatal birth trauma.

Fig 7

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We also carried out the non-parametric trim-and-fill method of Duval and Tweedie, tests for funnel-plot asymmetry, which provides a way to assess the impact of missing studies because of publication bias on the meta-analysis. Thus, the meta-trim analysis demonstrated the presence of 15 unpublished studies (Fig 8).

Fig 8. Trim and fill analysis for the cumulative incidence of neonatal birth trauma.

Fig 8

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Trends and patterns of neonatal birth trauma

Fig 9 describes the trend of neonatal birth trauma. The highest cumulative incidence of neonatal birth trauma was documented in the year 2023 (168.7 cases per 1,000 live births).

Fig 9. The trend of neonatal birth trauma incidence in LMICs (1985 to 2023).

Fig 9

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Regarding the patterns, a wide gamut of birth trauma ranging from minor and self-limiting to severe trauma that had contributed to significant neonatal morbidity and mortality were noted. The most incident cases of birth trauma were cephalohematoma (an estimated 404 per 1,000 live births) followed by clavicular bone fracture (207 per 1,000 live births), and subgaleal hemorrhage (99 per 1,000 live births). Amongst the peripheral nerve injuries, brachial plexus injury (Erb’s Duchenne or Klumpke’s palsy) was estimated at 98.6 per 1,000 live births (Fig 10).

Fig 10. The patterns of neonatal birth trauma.

Fig 10

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* others include visceral injuries (spleen, and liver).

Adverse outcomes of neonatal birth trauma

In the studies that assessed immediate adverse outcomes [26, 46, 49–52, 59], a neonatal death incidence of 5.3% [51] to 28% [52] was reported. Profound neonatal hypovolemia secondary to the most clinically significant and potentially life-threatening injury,subgaleal hemorrhage [26, 46, 50, 52], and sepsis [51] were important complications of birth trauma that contributed to neonatal death. Another reported adverse outcome included anemia and hyperbilirubinemia that required blood transfusion, and phototherapy respectively [26, 49, 59] (Table 5).

Table 5. Short-term/immediate adverse outcomes of neonatal birth trauma.

Authors /reference Sample size Event Key outcomes
Yemane et al [26] 717 88 Ten (11%) of the neonates died from refractory hypovolemic shock ascribed to subgaleal hemorrhage. An estimated 40 (45.5%) newborns had medical problems, including anemia in ten (11.4%) and hyperbilirubinemia in 11 (12.5%). Transfusion was required for 16 (64%) neonates with anemia of acute blood loss.
Abdul-Mumin et al [46] 5590 205 Twenty-three (11.22%) neonates died in which extracranial birth injuries were the sole determinants. Furthermore, the hospital stay lasted up to a month.
Pius et al [49] 1071 61 Sepsis, hyperbilirubinemia, and anemia were adverse outcomes exhibited.
West and Okari [50] 5692 39 Three (7.7%) neonates died in the health facility.
Njokanma and Kehinde [52] 2941 50 In the hospital, death occurred in 14 (28%) of newborns.
Emeka et al [51] 1735 19 One (5.3%) neonate died of overwhelming sepsis secondary to infected cephalohematoma.
Linder et al [59] 118,280 2876 Prolonged hospitalization; neurologic features like myoclonic seizure, hypoxic-ischemic encephalopathy; and hyperbilirubinemia necessitating phototherapy.
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Factors associated with neonatal birth trauma

Eleven of the 37 studies (29.7%) evaluated the associations of various exposure variables with neonatal birth trauma. Accordingly, place of residence; labor, fetal presentation, shoulder dystocia, birth weight, and mode of delivery were significantly and positively associated with increased odds of birth trauma. To begin with, neonates born to mothers living in rural areas had 61% higher odds [OR,1.61; 95% CI, 1.18 to 2.21; Higgins and Thompson’s I2 statistics = 0.0%; Egger’s test for small-study effects = 0.110] of experiencing birth trauma compared to their counterparts. Prolonged labor was associated with 5.45-fold increased odds of neonatal birth trauma [OR, 5.45; 95% CI,2.30, 9.91; Higgins and Thompson’s I2 statistics = 71.8%; Egger’s test for small-study effects = 0.498].

Abnormal fetal presentation at the time of vaginal delivery [OR, 4.70; 95% CI, 1.75 to 12.26; Higgins and Thompson’s I2 statistics = 89.2%; Egger’s test for small-study effects = 0.885], and shoulder dystocia [OR, 6.11; 95% CI, 3.84 to 9.74; Higgins and Thompson’s I2 statistics = 0.0%; Egger’s test for small-study effects = 0.358] were associated with 4.70 and 6.11times higher odds of sustaining neonatal birth trauma. Compared to cesarean delivery, assisted vaginal delivery (vacuum extraction or forceps) was associated with 3.19 times [OR, 3.19; 95% CI, 1.92 to 5.31; Higgins and Thompson’s I2 statistics = 84.4%; Egger’s test for small-study effects = 0.790] higher odds of neonatal birth trauma. We also found out that macrosomic neonates (defined as a birthweight of 4000grams and beyond) [67] had 5.06 times [OR, 5.06; 95% CI, 2.76 to 9.29; Higgins and Thompson’s I2 statistics = 43.6%; Egger’s test for small-study effects = 0.061] higher odds of experiencing birth trauma (Table 6).

Table 6. Factors associated with neonatal birth trauma among neonates in low and middle-income countries.

Characteristics No. of studies Pooled odds ratio (95% confidence interval) P.value Statistical heterogeneity Egger’s test
I2 (%) P.value P > | t |
Mode of delivery
Operative vaginal vs. cesarean delivery [25–31, 33, 36] 9 3.19 (1.92,5.31) < 0.001* 84.4 <0.001 0.790
Antenatal care follow-up
No vs. yes [29, 30, 32] 3 0.62 (0.14, 2.71) 0.523 93.1 <0.001 0.645
Neonatal birth weight
Macrosomic vs. <4000 grams [26, 29, 30, 36] 4 5.06 (2.76, 9.29) < 0.001* 43.6 0.150 0.061
Labor
Prolonged vs normal [27, 29, 31, 36] 4 5.45 (2.30, 9.91) < 0.001* 71.8 0.014 0.498
Place of residence
Rural vs. urban [25, 26, 30] 3 1.61 (1.18, 2.21) 0.003* 0.0 0.723 0.110
Fetal presentation at delivery
Non-vertex vs vertex [25, 26, 30, 31, 36] 5 4.70 (1.75, 12.66) 0.002* 89.2 <0.001 0.885
Shoulder dystocia
Yes vs. no [28, 29, 31] 3 6.11 (3.84, 9.74) < 0.001* 0.0 0.494 0.358
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* Indicates statistically significant at P ≤ 0.05

Discussion

Globally, neonatal health has become an important public health concern. This systematic review and meta-analysis provides the most comprehensive and granular estimation, temporal trends, clinical spectrum, and immediate adverse outcomes of neonatal birth trauma in LMICs. Our analysis found that the pooled cumulative incidence of neonatal birth trauma was estimated at 34 per 1,000 live births. The combined estimates from African countries ranked in first place at 52.9 per 1,000 live births. The overall incidence proportion far outweighs the incidence of birth trauma in Canada (9.6 per 1,000 live births) [17], Finland (16.6 per 1,000 live births) [13], and the US (31.1 per 1,000 live births) [15].

Factors that explain a higher burden of neonatal birth trauma in LMICs include limited hospital capabilities with modern obstetrics and neonatal care; insufficient commitments towards ensuring the implementation of international and local policies related to child health promotion; geographic inaccessibility to prenatal care; inadequate skilled health personnel; frequent application of instrumental delivery; economic depression, political instability in some regions and variation in sample size. Nevertheless, the present analysis result was lower than a Chinese study (42.9 per 1,000 live births) [16]; and Indonesia (69.2 per 1,000 live births) [34]. This may be explained in part by the fact that forceps were applied in a larger proportion (18%) in the Chinese (18%) and the Indonesian (50%) studies. Another possible justification could be due to proper registration and good record-keeping practices, and the evaluation of newborns by neonatologists right away after birth contributed to the increased and true figure of neonatal birth trauma compared to the preceding research in China.

Understanding trends of neonatal birth trauma over time is warranted to accurately inform policies and set priorities for implementation. Taking into account the existence of individual countries’ variations, an overall upward trend of neonatal birth trauma was observed in the LMICs in contrast to most resource-rich countries [13–15]. This could be due to the majority (60%) of the studies were represented from Ethiopia where the estimate of the condition was highest according to country-based analyses. Moreover, inadequate access to gynecologic and prenatal care may partially explain the significant variation in the trend.

Regarding the clinical spectrum of the condition, studies on neonates from different settings show diverse birth trauma patterns [18–24, 26–28, 30, 36, 46–60, 63–66]. The most incident case of birth trauma was cephalohematoma. Such a pattern of neonatal birth trauma was generally consistent with other studies [15, 16]. According to Gupta et al., cephalohematomas might be markers of morbid brain injury [15]. Furthermore, our analysis shows that the trends of neonatal birth trauma were increasing over time. In contrast, the trends have been progressively decreasing over time in resource-rich settings [13–17, 34].

According to Presser et al. [68], major neonatal birth trauma is associated with increased risk of neonatal morbidity and mortality. In our study, neonatal death incidence of 5.3% [46] to 28% [47] had occurred due to birth-associated trauma, a proportion higher than reported in the US [15]. Other short-term adverse neonatal outcomes such as seizures, prolonged hospital stay, encephalopathy, anemia, and hyperbilirubinemia were also reported in studies in Canada [59], and China [16].

This systematic review and meta-analysis identified that place of residence, prolonged labor, shoulder dystocia, operative vaginal delivery, and macrosomia were associated with increased odds of neonatal birth trauma. To begin with, neonates born to mothers who were living in rural settings had 61% higher odds of sustaining birth trauma. This was congruent with a study in the Netherlands [69] that described a longer travel time from home in a rural area to a health facility associated with increased neonatal adverse outcomes. This may be due to access to maternity care is often limited in rural settings.

Prolonged labor was associated with a five-fold increased risk of sustaining birth trauma in neonates. Results supporting the current findings have been reported by Gupta et al. [15], and Pressler et al. [68]. This can be explained by the fact that there is an increased propensity to apply forceps or vacuum when labor is prolonged to expedite the delivery of the neonate, provided that the prerequisites are fulfilled and indications exist for operative vaginal delivery.

Another important factor associated with neonatal birth trauma was shoulder dystocia. According to the literature, shoulder dystocia has been reported to complicate 0.2–3% of all vaginal deliveries and neonatal morbidities such as brain damage, brachial plexus injury, and clavicular/humeral fracture) [70, 71]. This meta-analysis revealed that the odds of sustaining birth trauma were about 6 folds higher in labor with shoulder dystocia. Other studies also buttress the current results [72, 73]. Although most cases of shoulder dystocia are unpredictable, fetal macrosomia and maternal diabetes mellitus are the most frequently cited contributing factors which in turn results in mechanical injury to the newborn [74].

Furthermore, our study identified that macrosomic neonates had five times higher odds of experiencing birth trauma. The finding was congruent with a research report in another setting [34]. Evidence suggests that macrosomic infants are at increased risk of experiencing shoulder dystocia during vaginal delivery which in turn culminates in limb fracture and brachial plexus injury [75, 76]. Besides, an elevated need for an intensive care unit admission and clavicular fracture were among the adverse events following the delivery of macrosomic neonates [77]. Spontaneous vaginal delivery of macrosomic neonates is challenging because of cephalopelvic disproportion during which time the newborn infant sustains mechanical compression or is traumatized when instruments are applied to expedite the delivery.

Lastly, this study also found that operative vaginal delivery (forceps or vacuum-assisted vaginal delivery) had three times higher odds of neonatal birth trauma compared to cesarean delivery. Our finding was congruent with a systematic review and meta-analysis report by Woldegeorgis et al. [78] that described operative vaginal delivery as a significant contributor to trauma to both the mother and newborn. Moreover, comparative studies in California and Quebec [79], the Cochrane Database of systematic review [80], a study in China [16], Bulgaria [81], and a retrospective review of operative delivery, in Singapore [82] identified that forceps or vacuum-assisted vaginal delivery was associated with increased risk of neonatal birth trauma although the risks are generally instrument specific and also affected by correct application and delivery technique as well as complex procedures. According to Mazza et al., [83] the incidence of serious neonatal birth trauma decreased to zero for consecutive 15 months in all obstetrics facilities following a significant reduction in the use of vacuum and forceps delivery shedding a green light on the importance of the establishment of the interdisciplinary team that monitors best practices.

Strengths and limitations of the study

To the best of our knowledge, however, this is a novel study that provides comprehensive and accurate evidence of neonatal birth trauma in LMICs. Methodologically, the study was adequate and avoided duplication of similar work; intensive and comprehensive literature searches were conducted to minimize the risk of publication bias; and a double-blinded comprehensive search was conducted over a reputable period in more than six online databases to avoid missing published studies. The newly amended JBI critical appraisal tool was used for quality assessment. Further analyses were conducted to explore sources of dissemination or publication biases. Besides, a large number of neonates took part in the study, which enabled the determination of the true estimate and the investigation of the factors associated with birth trauma. This study has some limitations. To begin with, significant statistical heterogeneity was observed and therefore this requires a cautious interpretation of the result. Furthermore, only a few publications from resource-rich countries were found to compare with our results. Lastly, the combined estimates were compared with primary studies because of the lack of a previously published meta-analysis.

Conclusion and recommendations

The findings of our study demonstrated that the incidence of neonatal birth trauma in LMICs was considerably high. Being born to mothers living in rural areas, prolonged labor, macrosomia, operative vaginal delivery, fetal malpresentation, and shoulder dystocia were important factors contributing to neonatal birth trauma. Furthermore, there has been an increase in the temporal trends of birth trauma, related morbidities, and mortality. Anticipations and early identification of these risk factors, and prompt obstetrician’s decision on the most favorable mode of delivery would help significantly decrease neonatal birth trauma and associated morbidities and mortality.

Implications for researches and policies

Results obtained from this study have insightful implications for SDG 3.2, which aims to end preventable deaths of newborns. Besides, it helps guide health administrators and program managers at different levels, child health advocates, health care providers in health facilities, as well as the different partners and actors contributing to the implementation of policies and strategies toward the reduction of neonatal morbidities and mortalities in LMICs.

Supporting information

S1 Checklist. PRISMA 2020 checklist.

(DOCX)

pone.0298519.s001.docx (35.9KB, docx)
S1 Table

JBI’s critical appraisal tools: (A) Descriptive cross-sectional studies. (B) Analytical cross-sectional studies. (C) case-control studies.

(DOCX)

pone.0298519.s002.docx (32.5KB, docx)
S1 File. Data extraction sheet.

(XLSX)

pone.0298519.s003.xlsx (22.7KB, xlsx)
S2 File. Determinant factors for neonatal birth trauma.

(XLSX)

pone.0298519.s004.xlsx (17.4KB, xlsx)
S3 File. Pattern and trend of neonatal birth trauma.

(XLSX)

pone.0298519.s005.xlsx (27.6KB, xlsx)

Acknowledgments

We would like to express our gratitude to the authors of the original papers that were included in this systematic review and meta-analysis

Abbreviations

CI

Confidence interval

OR

odds ratio

JBI

the Joana Briggs Institute

LMICs

Low and middle-income countries

MeSH

Medical subject headings

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

PROSPERO

Prospective Register of Systematic Reviews

SDG

Sustainable Development Goals

US

United States

Data Availability

All relevant data are within the manuscript and its Supporting Information files

Funding Statement

The author(s) received no specific funding for this work

References

  • 1.Akangire G. and Carter B., Birth injuries in neonates. Pediatrics in review, 2016. 37(11): p. 451–462. doi: 10.1542/pir.2015-0125 [DOI] [PubMed] [Google Scholar]
  • 2.Chaturvedi A., et al., Mechanical birth-related trauma to the neonate: An imaging perspective. Insights Imaging, 2018. 9(1): p. 103–118. doi: 10.1007/s13244-017-0586-x [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Organization, W.H., ICD-11 for mortality and morbidity statistics (2018). 2018.
  • 4.Shah N.A. and Wusthoff C.J., Intracranial Hemorrhage in the Neonate. Neonatal Netw, 2016. 35(2): p. 67–71. doi: 10.1891/0730-0832.35.2.67 [DOI] [PubMed] [Google Scholar]
  • 5.Chang H.Y., et al., Neonatal subgaleal hemorrhage: clinical presentation, treatment, and predictors of poor prognosis. Pediatr Int, 2007. 49(6): p. 903–7. doi: 10.1111/j.1442-200X.2007.02482.x [DOI] [PubMed] [Google Scholar]
  • 6.Kilani R.A. and Wetmore J., Neonatal subgaleal hematoma: presentation and outcome—radiological findings and factors associated with mortality. Am J Perinatol, 2006. 23(1): p. 41–8. doi: 10.1055/s-2005-923438 [DOI] [PubMed] [Google Scholar]
  • 7.Paulson K.R., et al., Global, regional, and national progress towards Sustainable Development Goal 3.2 for neonatal and child health: all-cause and cause-specific mortality findings from the Global Burden of Disease Study 2019. The Lancet, 2021. 398(10303): p. 870–905. doi: 10.1016/S0140-6736(21)01207-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Chen H.Y., et al., Neonatal brachial plexus palsy: associated birth injury outcomes, hospital length of stay and costs. J Matern Fetal Neonatal Med, 2022. 35(25): p. 5736–5744. doi: 10.1080/14767058.2021.1892066 [DOI] [PubMed] [Google Scholar]
  • 9.The global indicator framework for the Sustainable Development Goals and targets of the 2030 Agenda for Sustainable Development.
  • 10.Progress towards the Sustainable Development Goals: Towards a rescue plan for people and planet report of the secretary general (special edition 2023) advance United Nations version. p. 3–43.
  • 11.Global progress and projections for neonatal mortality. Bill and Melinda Gates foundation Goal keepers neonatal mortality. 2022.
  • 12.Jamison D.T., et al., Global health 2035: a world converging within a generation. The lancet, 2013. 382(9908): p. 1898–1955. doi: 10.1016/S0140-6736(13)62105-4 [DOI] [PubMed] [Google Scholar]
  • 13.Kekki M., et al., The incidence of birth injuries decreased in Finland between 1997 and 2017: A nationwide register study. Acta paediatrica, 2020. 109(12): p. 2562–2569. doi: 10.1111/apa.15267 [DOI] [PubMed] [Google Scholar]
  • 14.Sauber‐Schatz E.K., et al., Descriptive epidemiology of birth trauma in the United States in 2003. Paediatric and perinatal epidemiology, 2010. 24(2): p. 116–124. doi: 10.1111/j.1365-3016.2009.01077.x [DOI] [PubMed] [Google Scholar]
  • 15.Gupta R. and Cabacungan E.T., Neonatal birth trauma: analysis of yearly trends, risk factors, and outcomes. The Journal of Pediatrics, 2021. 238: p. 174–180. e3. doi: 10.1016/j.jpeds.2021.06.080 [DOI] [PubMed] [Google Scholar]
  • 16.Wang H., Luo B., and Tong X.M., [A single-center study of the incidence of neonatal birth trauma and its risk factors]. Zhongguo Dang Dai Er Ke Za Zhi, 2019. 21(3): p. 249–252. doi: 10.7499/j.issn.1008-8830.2019.03.012 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Muraca G.M., et al., Maternal and neonatal trauma following operative vaginal delivery. Cmaj, 2022. 194(1): p. E1–e12. doi: 10.1503/cmaj.210841 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Danso K.A. and Shaka E.C., Birthinjuries among new borns: A review of 192 cases in Kumasi. Journal of Science and Technology (JUST) 1999. 19(1): p. 1–3. [Google Scholar]
  • 19.Adegbehingbe O.O., et al., Predictive Factors for Birth Trauma in Southwestern Nigeria. African Journal of Paediatric Surgery, 2007. 4(1): p. 20–25. [Google Scholar]
  • 20.Warke C., et al., Birth Injuries -A review of Incidence, perinatal risk factors and outcome. Bombay Hospital Journal, 2012. 54(2). [Google Scholar]
  • 21.Shanthi R. and Senthil Kumar K.M., Study of incidence, risk factors and types and outcome of birth injuries in a tertiary care hospital. International Journal of Academic Medicine and Pharmacy, 2022. 4(5): p. 570–573. [Google Scholar]
  • 22.Zama R.U., et al., A clinical study of neonatal birth injuries in a tertiary care hospital-NICU, Bijapur. Indian Joural of Child Health, 2020: p. 1–3. [Google Scholar]
  • 23.Awari B.H., et al., Birth associated trauma. 2003. [PubMed] [Google Scholar]
  • 24.Rezaie M., et al., Birth injuries and related risk factors in neonates born in Emam Sajjad hospital in Yasuj in 2005 to 2006. Armaghane danesh, 2009. 14(1): p. 122–129. [Google Scholar]
  • 25.Tesfaye W., Workneh N., and Girma E., Birth injury and associated factors in Jimma University Specialized Hospital, southwest, Ethiopia. Ethiop. J. Pediatr. Child Health 2016. XII(1). [Google Scholar]
  • 26.Yemane A. and Yeshidinber A., Birth trauma among neonates admitted to neonatal unit in a tertiary hospital in Addis ababa. Ethiop. J. Pediatr. Child Health 2019. XIV(1). [Google Scholar]
  • 27.Phuengphaeng A., Sirisomboon R., and Boriboonhirunsarn D., Incidence and risk factors of major neonatal birth injuries in a tertiary care hospital inThailand: A retrospective cohort study. Pacific Rim Int J Nurs Res, 2022. 26(2): p. 243–253. [Google Scholar]
  • 28.Abedzadeh-Kalahroudi M., et al., Incidence of Neonatal Birth Injuries and Related Factors in Kashan, Iran. Archives of Trauma Research, 2015. 4(1). doi: 10.5812/atr.22831 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.Biset G., et al., Magnitude of birth trauma and its associated factors in South Wollo public hospitals, northeast Ethiopia, August 2021: Institutional-Based Cross-Sectional Study. BMJ Open, 2022. 12(9): p. e057567. doi: 10.1136/bmjopen-2021-057567 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30.Tolosa G., et al., Neonatal Birth Trauma and Its Predisposing Factors Among Newborns Admitted to Public Hospitals in Eastern Ethiopia: A Cross-Sectional Study. Glob Pediatr Health, 2023. 10: p. 2333794x231183814. doi: 10.1177/2333794X231183814 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.Hameed N.N. and Izzet K.Q., Neonatal birth traumas: Risk factors and types. J Fac Med Baghdad, 2010. 52(3): p. 241–245. [Google Scholar]
  • 32.Belay A.S., et al., Prevalence and associated factors of birth injury among neonates admitted at neonatal intensive care unit (NICU) in governmental hospitals of Southwest Ethiopian people regional state, Ethiopia: A multicenteric cross-sectional study. Front Pediatr, 2022. 10: p. 1052396. doi: 10.3389/fped.2022.1052396 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.Basiri B., et al., Prevalence of Birth Injury and Its Determinants Factors in West Iran in 2020–2021. Medical-Surgical Nursing Journal, 2023. 11(3). [Google Scholar]
  • 34.Aminullah A., Budiwardhana N., and Firmansyah A., Neonatal birth trauma: incidence and predisposing factors. Paediatrica Indonesiana, 2003. 43(6): p. 220–5. [Google Scholar]
  • 35.García H., Rubio-Espíritu J., and Islas-Rodríguez M.T., [Risk factors for birth injuries]. Rev Invest Clin, 2006. 58(5): p. 416–23. [PubMed] [Google Scholar]
  • 36.Tibebu E.A., et al., Prevalence of birth injuries and associated factors among newborns delivered in public hospitals Addis Ababa, Ethiopia, 2021. Crossectional study. PLoS One, 2023. 18(1): p. e0281066. doi: 10.1371/journal.pone.0281066 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Shamseer L., et al., Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. Bmj, 2015. 349. doi: 10.1136/bmj.g7647 [DOI] [PubMed] [Google Scholar]
  • 38.Page M.J., et al., The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. International journal of surgery, 2021. 88: p. 105906. doi: 10.1016/j.ijsu.2021.105906 [DOI] [PubMed] [Google Scholar]
  • 39.Munn Z., et al., Methodological guidance for systematic reviews of observational epidemiological studies reporting prevalence and cumulative incidence data. JBI Evidence Implementation, 2015. 13(3): p. 147–153. doi: 10.1097/XEB.0000000000000054 [DOI] [PubMed] [Google Scholar]
  • 40.Aromataris E, M.Z., Chapter 1: JBI Systematic Reviews. In: Aromataris E, Munn Z (Editors). JBI Manual for Evidence Synthesis 2020.
  • 41.Sim J. and Wright C.C., The kappa statistic in reliability studies: use, interpretation, and sample size requirements. Physical therapy, 2005. 85(3): p. 257–268. [PubMed] [Google Scholar]
  • 42.Higgins J.P., et al., Cochrane handbook for systematic reviews of interventions. 2019: John Wiley & Sons. [Google Scholar]
  • 43.Moola S., et al., Chapter 7: Systematic reviews of etiology and risk. Joanna briggs institute reviewer’s manual. The Joanna Briggs Institute, 2017. 5: p. 217–269. [Google Scholar]
  • 44.Egger M., et al., Bias in meta-analysis detected by a simple, graphical test. Bmj, 1997. 315(7109): p. 629–634. doi: 10.1136/bmj.315.7109.629 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 45.Borenstein M., et al., Front matter (chapter 30–Publication bias). 2009, John Wiley and Sons, Hoboken, NJ. [Google Scholar]
  • 46.Abdul-Mumin A., et al., Factors associated with birth injuries in neonates admitted to the neonatal intensive care unit: a retrospective study in a Ghanaian tertiary care setting. HSI Journal, 2021. 2(1): p. 196–201. [Google Scholar]
  • 47.Uchenna, E., C. O.D., and A.I. Nwabueze Birth injuries in newborn: A prospective study of deliveries in South-East Nigeria. African Journal of Medical and Health Sciences 2021. 20(4): p. 41–46.
  • 48.Fabamwo A., et al., Birth trauma In A Tertiary Maternity Unit In South Western Nigeria. The Internet Journal of Pediatrics and Neonatology, 2006. 7(2): p. 1–5. [Google Scholar]
  • 49.Pius S., et al., Incidence and characteristics of neonatal birth injuries in Maiduguri North-Eastern Nigeria. Niger J Paediatr, 2018. 45(2): p. 99–105. [Google Scholar]
  • 50.West B.A. and Okari T., Incidence, Pattern and Outcome of Birth Injuries as Seen in a Tertiary Hospital in Southern Nigeria. International Journal of Research and Review, 2021. 8(6): p. 8–17. [Google Scholar]
  • 51.Emeka C.K., et al., Profile of Birth Injuries in a Tertiary Hospital in Enugu, Nigeria. American Journal of Biomedical and Life Sciences, 2019. 7(5): p. 99. [Google Scholar]
  • 52.Njokanma, O.F. and O. Kehinde, Mechanical birth trauma: An evaluation of predisposing factors at the Ogun state University teaching hospital,Sigamu. Nigerian journal of paediatrics 2002. 29(3): p. 61–65.
  • 53.Osinaike B., et al., Prevalence and predictive factors of birth traumas in neonates presenting to the children emergency center of a tertiary center in Southwest, Nigeria. Journal of Clinical Sciences, 2017. 14(4): p. 167. [Google Scholar]
  • 54.Okoro P.E. and Oriji V.K., Spectrum of birth trauma and predisposing factors. Experience in two nigerian tertiary health facilities. East African Medical Journal, 2018. 95(6): p. 1672–1679. [Google Scholar]
  • 55.Mah E.M., et al., Birth Injuries in Neonates at a University Teaching Hospital in Cameroon: Epidemiological, Clinical and Therapeutic Aspects. Open Journal of Pediatrics, 2017. 07(01): p. 51–58. [Google Scholar]
  • 56.Enyindah C.E. and Nte A.R., Mechanical birth injuries in the Niger Delta: a ten-year review (1989–1998). Tropical Journal of Obstetrics and Gynaecology, 2005. 22: p. 50–55. [Google Scholar]
  • 57.Prabhu R.S., Sajjid M., and Anandan Incidence H. and predisposing factors of birth trauma in a tertiary care hospital in Chennai,India: A prospective study. International Journal of Scientific Study, 2017. 4(10): p. 29–33. [Google Scholar]
  • 58.Ray M., Rakesh, et al., Prospective study of neonatal birth trauma: Indian perspective. Journal of Clinical Neonatology, 2016. 5(2): p. 91. [Google Scholar]
  • 59.Linder N., et al., Birth trauma–risk factors and short-term neonatal outcome. The Journal of Maternal-Fetal & Neonatal Medicine, 2013. 26(15): p. 1491–1495. doi: 10.3109/14767058.2013.789850 [DOI] [PubMed] [Google Scholar]
  • 60.Gorashi Z., Ahari H., and Okhchi R., Birth injuries of neonates in Alzahra hospital of Tabriz, Iran. 2005. [Google Scholar]
  • 61.Esmailpour N. and Asgharnia M., Early neonatal injuries in normal vaginal and cesarean study. Am J Dis Child, 1985. 139(2): p. 160–3.3883746 [Google Scholar]
  • 62.Keshtkaran A. and Keshtkaran V., Factors affecting neonatal death in Fars Province, Southern Iran, 2004. Midd East J Family Med, 2007. 5: p. 42–45. [Google Scholar]
  • 63.Borna H., et al., Incidence of and risk factors for birth trauma in Iran. Taiwan Journal of Obstetrics and Gynecology, 2010. 49(2): p. 170–173. doi: 10.1016/S1028-4559(10)60036-8 [DOI] [PubMed] [Google Scholar]
  • 64.Mosavat S.A. and Zamani M., The incidence of birth trauma among live born term neonates at a referral hospital in Rafsanjan, Iran. The Journal of Maternal-Fetal & Neonatal Medicine, 2008. 21(5): p. 337–339. [DOI] [PubMed] [Google Scholar]
  • 65.Shabbir S. and Younas M., Risk Factors and incidence of Birth Trauma in Tertiary Care Hospital of Karachi. P J M H S, 2014. 8(2): p. 481–492. [Google Scholar]
  • 66.Benjamin, B.a. and H. Kahan, Pattern of external birth trauma in Southwestern Saudi Arabia. The Journal of Trauma 1993. 35(5): p. 737–741. [DOI] [PubMed]
  • 67.Cunningham, F.G., et al., Williams obstetrics. Vol. 7. 2014: McGraw-Hill Medical New York.
  • 68.Pressler J.L., Classification of major newborn birth injuries. The Journal of Perinatal & Neonatal Nursing, 2008. 22(1): p. 60–67. doi: 10.1097/01.JPN.0000311876.38452.fd [DOI] [PubMed] [Google Scholar]
  • 69.Ravelli A.C., et al., Travel time from home to hospital and adverse perinatal outcomes in women at term in the Netherlands. Bjog, 2011. 118(4): p. 457–65. doi: 10.1111/j.1471-0528.2010.02816.x [DOI] [PubMed] [Google Scholar]
  • 70.Hoffman M.K., et al., A comparison of obstetric maneuvers for the acute management of shoulder dystocia. Obstet Gynecol, 2011. 117(6): p. 1272–1278. doi: 10.1097/AOG.0b013e31821a12c9 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 71.Menticoglou S., Shoulder dystocia: incidence, mechanisms, and management strategies. Int J Womens Health, 2018. 10: p. 723–732. doi: 10.2147/IJWH.S175088 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 72.Elmas B., et al., Risk factors for brachial plexus injury and permanent sequelae due to shoulder dystocia. Niger J Clin Pract, 2022. 25(12): p. 2016–2023. doi: 10.4103/njcp.njcp_464_22 [DOI] [PubMed] [Google Scholar]
  • 73.Dudenhausen J.W., [Shoulder dystocia—consequences and procedures]. Zentralbl Gynakol, 2001. 123(7): p. 369–74. [DOI] [PubMed] [Google Scholar]
  • 74.Ouzounian J.G., Shoulder Dystocia: Incidence and Risk Factors. Clin Obstet Gynecol, 2016. 59(4): p. 791–794. doi: 10.1097/GRF.0000000000000227 [DOI] [PubMed] [Google Scholar]
  • 75.Cordero L., et al., Neonatal outcomes of macrosomic infants of diabetic and non-diabetic mothers. J Neonatal Perinatal Med, 2015. 8(2): p. 105–12. doi: 10.3233/NPM-15814102 [DOI] [PubMed] [Google Scholar]
  • 76.Ezegwui H.U., Ikeako L.C., and Egbuji C., Fetal macrosomia: obstetric outcome of 311 cases in UNTH, Enugu, Nigeria. Niger J Clin Pract, 2011. 14(3): p. 322–6. doi: 10.4103/1119-3077.86777 [DOI] [PubMed] [Google Scholar]
  • 77.Gyurkovits Z., et al., Neonatal outcome of macrosomic infants: an analysis of a two-year period. Eur J Obstet Gynecol Reprod Biol, 2011. 159(2): p. 289–92. doi: 10.1016/j.ejogrb.2011.08.003 [DOI] [PubMed] [Google Scholar]
  • 78.Woldegeorgis B.Z., et al., Episiotomy Practice and Its Associated Factors in Africa: A Systematic Review and Meta-Analysis. Front Med (Lausanne), 2022. 9: p. 905174. doi: 10.3389/fmed.2022.905174 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 79.Werner E.F., et al., Mode of delivery in nulliparous women and neonatal intracranial injury. Obstet Gynecol, 2011. 118(6): p. 1239–1246. doi: 10.1097/AOG.0b013e31823835d3 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 80.Johanson R. and Menon B., Vacuum extraction vs forceps delivery. The Cochrane Library, 2000(4). [DOI] [PubMed] [Google Scholar]
  • 81.Krŭsteva M., et al., [Neonatal birth trauma in relation to the means of delivery]. Akush Ginekol (Sofiia), 1993. 32(2): p. 29–31. [PubMed] [Google Scholar]
  • 82.Zhang V.R., et al., Operative vaginal delivery: practice patterns and outcomes at a tertiary general hospital. Singapore Med J, 2023. 64(5): p. 313–318. doi: 10.11622/smedj.2022069 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 83.Mazza F., et al., The road to zero preventable birth injuries. Jt Comm J Qual Patient Saf, 2008. 34(4): p. 201–5. doi: 10.1016/s1553-7250(08)34025-2 [DOI] [PubMed] [Google Scholar]

Decision Letter 0

Mohammed Feyisso Shaka

2 Jan 2024

PONE-D-23-28607Neonatal birth trauma and associated factors in low and middle-income countries: A systematic review and meta-analysisPLOS ONE

Dear Dr. Woldegeorgis,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The manuscript is technically sound with details methods and appropriate use of statistical analysis. The authors clearly stated their justification for the study, objectives and research questions. The overall conclusion of the study was drawn from the results.

Reviewer #2: Peer Review Report

Title: Neonatal birth trauma and associated factors in low and middle-income countries: A systematic review and meta-analysis

General Comments:

The manuscript titled "Neonatal birth trauma and associated factors in low and middle-income countries: A systematic review and meta-analysis" provides valuable insights into neonatal birth trauma in low and middle-income countries. The language and organization of the manuscript are clear and concise, making it accessible to a wide audience. However, there are a few areas where additional information or clarification would enhance the manuscript's impact. With some major revisions and additions, this manuscript has the potential to make a valuable contribution to the field.

Specific Comments:

Abstract:

a. Could you provide more information on the methods used to search for articles and select studies for inclusion in the meta-analysis? This would help readers understand the rigor of the study selection process.

b. The abstract mentions the identification of potential contributing factors for birth trauma. Could you elaborate on the specific factors identified and their respective effect sizes? Providing this information would give readers a clearer understanding of the magnitude and significance of the identified factors.

Introduction and Background:

a. Can the authors provide a more comprehensive overview of the current state of neonatal birth trauma in low and middle-income countries? It would be helpful to include statistics or prevalence rates, if available. Additionally, are there any specific regions or populations within these countries that are more affected? Providing this information would give readers a better context for understanding the significance of the study.

b. It would be beneficial to include a discussion on the impact of birth trauma on neonatal morbidity and mortality in low and middle-income countries, as well as the economic burden associated with it. This discussion would help illustrate the broader implications of the research findings.

Methods:

a. Please provide more details on the search strategy used to identify relevant articles. Were any specific inclusion or exclusion criteria applied? Including this information would enhance the transparency and reproducibility of the study.

b. How was the quality of the included studies assessed? Were any measures taken to address potential bias or heterogeneity among the studies? Describing the quality assessment process and any steps taken to address bias or heterogeneity would strengthen the study's methodology.

c. Can the authors provide a rationale for selecting the Dersimonian-Laird model as the random-effects model for the meta-analysis? Justifying the choice of this model would help readers understand the statistical approach employed.

Results:

a. The authors report a high pooled cumulative incidence of birth trauma in low and middle-income countries. Can they discuss the potential reasons for this high incidence and how it compares to rates in high-income countries? Exploring the factors contributing to the high incidence and comparing it to rates in high-income countries would provide valuable insights into the unique challenges faced by low and middle-income countries.

b. It would be interesting to know if there are any temporal trends in the incidence of birth trauma in these countries. Did the authors find any studies reporting changes over time? Including information on temporal trends would enhance the understanding of the evolving situation and potential improvements over time.

c. The factors associated with neonatal birth trauma mentioned in the results are important. However, it would be beneficial to discuss the clinical implications of these factors and how they can inform preventive strategies in low and middle-income countries. Providing this discussion would help bridge the gap between research findings and practical applications.

Discussion:

a. The discussion could be strengthened by providing a more detailed analysis of the identified risk factors and their implications. Are there any modifiable factors that could be targeted to reduce the incidence of birth trauma? Including this analysis would provide actionable insights for healthcare providers and policymakers.

b. What are the potential limitations of the included studies that may affect the generalizability of the findings? Are there any gaps in the current literature that future research should address? Discussing the limitations and gaps in the literature would help readers understand the scope and applicability of the study's findings.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Fentahun Adane Nigat, Ph.D.

**********

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Attachment

Submitted filename: PLOS ONE REVIEWERS COMMENT.docx

pone.0298519.s006.docx (14.8KB, docx)
Attachment

Submitted filename: Peer Review Report.pdf

pone.0298519.s007.pdf (33.9KB, pdf)
PLoS One. 2024 Mar 21;19(3):e0298519. doi: 10.1371/journal.pone.0298519.r002

Author response to Decision Letter 0

5 Jan 2024

General note for the academic editor regarding the overall progress

First and foremost, I am thrilled to extend my heartfelt gratitude to Mohammed Feyisso Shaka, the academic editor at PLOS ONE, for allowing us sufficient time to revise and address all of the reviewer’s concerns, comments, suggestions, and journal requirements.

Dear Mohammed Feyisso Shaka, the reviewer's comments were critically evaluated, and necessary corrections and amendments were made. The manuscript was checked to meet PLOS ONE's style requirements, and the data availability statement was updated. We thoroughly addressed specific points made and uploaded a marked-up copy (revised manuscript with tracked changes) as a "Revised Article with Changes Highlighted” file and an unmarked version of the revised paper without tracked changes and uploaded it as a separate file labeled 'Manuscript'. Lastly, for comparison, we responded to the reviewer’s comment under each query. I hope you and the reviewers receive a significantly improved manuscript. Thank you incredibly much!

A. Point-by-point response letter to reviewer #1

Dear Revevier, thank you very much for taking the time to review our manuscript. We seriously considered your comments and suggestions and incorporated them into the revised manuscript. We gave due attention to the typographical errors, results, discussion sections, conclusions, and recommendations so that the manuscript has significantly improved.

Reviewer : TITLE – Appropriate.

Authors: Thank you!

Reviewer: Abstract- Well written with minor correction of typographical error (38 or 37 studied articles)

Authors: corrected , thank you

Introduction- Fairly written and justification for conducting the study was highlighted

Authors: Thank you!

Methodology- This is quite detail and the chosen method will achieve the set-out objectives of the study. Statistical analysis was reflected in the results.

Authors: Thank you!

Results- The results was well presented but the following observations were made:

1. Page 13, paragraph 2 line 2—Insert There were 365,547 live births instead of –About 365,547 live births.

Authors: We corrected it. Thank you

2. Page 15 line 2—data were abstracted from 35 articles ( Is it 35 or 37 articles?).

Authors: The total numbers of articles included in the SRMA were 37. However, incidence data were extracted from 35 articles as the two articles (Hameed and Izzet, and Basiri et al ) were case-control. Data from these two studies were used in the effect measure metaanalysis. Thank you for your critical observation.

3. Page 19 line1: from 1985-2023 but Title for the figure indicates from 2008-2023. This needs to be corrected.

Authors: Corrected ,thank you!

4. Page 20 line 1, 8, and 10: why the use of the word about in the case of an absolute number? It is more appropriate to use these words in the derived figures eg in percentages and so on.

Authors: The reviewer suggestion is appropriate. We took appropriate measure.

5. Page 21 line 14 insert—assisted vaginal delivery

Authors: The reviewer suggestion is appropriate. We correct it, thank you!

Reviewer: DISCUSSION: The authors did not DISCUSS the findings adequately. In most cases, it most often just restated the findings and did literature review.

Authors: reviewer suggestion was appropriate, thank you we elaborated the result driven discussion emphasasing to justification of the pooled estimate and risk factors, .

Reviewer: CONCLUSION/RECOMMENDATION- Guarded recommendations were made, but however, there was also no mention of the focus future studies.

Authors: The reviewer comment was appropriate. conclusion and recommendatios were revised as follows: “The findings of our study demonstrated that the incidence of neonatal birth trauma in LMICs was considerably high. Being born to mothers living in rural areas, prolonged labor, macrosomia, operative vaginal delivery, fetal malpresentation, and shoulder dystocia were important factors contributing to neonatal birth trauma. Furthermore, there has been an increase in the temporal trends of birth trauma, related morbidities, and mortality. Anticipations and early identification of these risk factors, and prompt obstetrician's decision on the most favorable mode of delivery would help significantly decrease neonatal birth trauma and associated morbidities and mortality.”Furthermore, Implications for research and policy were added to the the revised manuscript.

B. Point-by-point response letter to reviewer #2

Dear reviewer, thank you very much for taking the time to read our paper and for your helpful comments and suggestions. We made point-by-point responses for convenience as follows:

Reviewer: Could you provide more information on the methods used to search for articles and select studies for inclusion in the meta-analysis? This would help readers understand the rigor of the study selection process.

Authors: The reviewer’s suggestion was appropriate. The word count was a factor that limited our narration. Nevertheless, we incorporated the comment into the revised manuscript by highlighting the search strategy and study selection procedure as follows: “Literature search strategies were developed using medical subject headings and text words related to the outcomes of the study. Following the risk of bias assessment, articles with appraisal scores of seven or more were deemed suitable to be included in the meta-analysis.” Thank you!

Reviewer: The abstract mentions the identification of potential contributing factors for birth trauma. Could you elaborate on the specific factors identified and their respective effect sizes? Providing this information would give readers a clearer understanding of the magnitude and significance of the identified factors.

Authors: Dear reviewer, we have presented the specific risk factors (in summary form) with their respective ES (OR in our case) in the abstract. However, details were presented in the discussion section. We are very much thrilled to accept further suggestions in case we do not catch the point. Thank you!

Introduction and Background

Reviewer: Can the authors provide a more comprehensive overview of the current state of neonatal birth trauma in low and middle-income countries? It would be helpful to include statistics or prevalence rates, if available. Additionally, are there any specific regions or populations within these countries that are more affected? Providing this information would give readers a better context for understanding the significance of the study.

Authors: We revised the introduction and have added individual estimates regarding the prevalence of the condition in Africa, Asia and Pacific, and Middle East regions (lines 99 to 103). Thank you!

Reviewer: It would be beneficial to include a discussion on the impact of birth trauma on neonatal morbidity and mortality in low and middle-income countries, as well as the economic burden associated with it. This discussion would help illustrate the broader implications of the research findings.

Authors: We highlited the burden of the neonatal birth trauma based on individual estimates from High income contires and low and middle income countries. “ Although reseach in to the economic impacts of birth trauma is lacking in LMICs, a study conducted in the United States (US) revealed that neonatal brachial plexus palsy hospital length of stay was 48% higher (3.6 days vs. 2.5 days) and hospitalization costs were twice ($4891 vs. $2241) as high as in neonates without the condition [8]”.

Methods

Reviewer: Please provide more details on the search strategy used to identify relevant articles. Were any specific inclusion or exclusion criteria applied? Including this information would enhance the transparency and reproducibility of the study.

Authors: The reviewer note is appropriate.The search strategy involved databases and reference list. For the database search serch terms, MeSH,Boolean operators,trucncation,and astrics were employed where necessary (Table 1) .Furthermore, we scanned reference lists of included articles to ensure literature saturation. In addition, filterations were applied. Dear reviewer, to enhance the transparency and reproducibility of the study,as you said, we re-wrote the specific paragraph ,as there were fragmentation in expression.. Thank you !

Reviewer: How was the quality of the included studies assessed? Were any measures taken to address potential bias or heterogeneity among the studies? Describing the quality assessment process and any steps taken to address bias or heterogeneity would strengthen the study's methodology.

Authors: Dear reviewer, regarding the Quality/risk of bias assessment, articles were subjected to appraisal using the newly amended JBI tool (supplentary file S1 Table). We considered a score of ≥7 for inclusion in the quantitative synthesis and this has been narrated in our report. dear reviewer, we are thrilled to respond in the subsequent revision in case if we haven’t got your point.

Reviewer: Can the authors provide a rationale for selecting the Dersimonian-Laird model as the random-effects model for the meta-analysis? Justifying the choice of this model would help readers understand the statistical approach employed.

Authors: because a considerable statistical heterogeneity was observed (I2 = 99.3% and P < 0.001) in the fixed effect model, we choose the REM . In the REM ,the precesion was significantly improved although variation in the effect size attributable to heterogeneity was almost same. We incorporated the rationale in the revised manuscript. Thank you for your critical observation.

Results and discussion

Reviewer: The authors report a high pooled cumulative incidence of birth trauma in low and middle-income countries. Can they discuss the potential reasons for this high incidence and how it compares to rates in high-income countries? Exploring the factors contributing to the high incidence and comparing it to rates in high-income countries would provide valuable insights into the unique challenges faced by low and middle-income countries.

Authors: Yes! limited hospital capabilities with modern obstetrics and neonatal care; insufficient commitments towards ensuring the implementation of international and local policies related to child health promotion; geographic inaccessibility to prenatal care; inadequate skilled health personnel; and variation in sample size, economic depression,and political instability in some regions were possible justification for such a high magnitude of neonatal birth trauma in LMICs.

Reviewer: It would be interesting to know if there are any temporal trends in the incidence of birth trauma in these countries. Did the authors find any studies reporting changes over time? Including information on temporal trends would enhance the understanding of the evolving situation and potential improvements over time.

Authors: we thoroughly read each studies conducted in LMICs regarding birth traumas. We come across individual birth type with corresponding frequencies,but not their patterns. however, the US study and other high income countries report delineated the burden of the condition over time. Therefore, we tried to present temporal trends of cumulative incidence of birth trauma ,and we hope it will be a springboard for the future studies and also help formulate implementation strategies to reverse the steadily increasing burden of neonatal birth trauma in LMICs.

Reviewer: The factors associated with neonatal birth trauma mentioned in the results are important. However, it would be beneficial to discuss the clinical implications of these factors and how they can inform preventive strategies in low and middle-income countries. Providing this discussion would help bridge the gap between research findings and practical applications.

Authors: There are predictable and preventable/modifiable risk factors associated with increased odds of neonatal birth trauma through provision of antenatal care, training of skilled health personnel, establishment and expansion of health facilities with adequate obstetric and neonatal care, proper intrapartum surveillance and early intervention, reduction of instrumental deliveries/ or promote supervised use up on indication. The current findings help guide health administrators and program managers at different levels, child health advocates, health care providers in health facilities, as well as the different partners and actors contributing to the implementation of policies and strategies toward the reduction of neonatal morbidities and mortalities in LMICs

Reviewer: The discussion could be strengthened by providing a more detailed analysis of the identified risk factors and their implications. Are there any modifiable factors that could be targeted to reduce the incidence of birth trauma? Including this analysis would provide actionable insights for healthcare providers and policymakers.

Authors: Dear reviewer, we dealt in the above comment. Furthermore, we made broad discussion with respect to these six risk factors : place of residence; prolonged labor, fetal presentation, shoulder dystocia, birth weight, and mode of delivery. Thank you!

Reviewer: What are the potential limitations of the included studies that may affect the generalizability of the findings? Are there any gaps in the current literature that future research should address? Discussing the limitations and gaps in the literature would help readers understand the scope and applicability of the study's findings.

Authors:Yes! significant statistical heterogeneity was observed and therefore this requires a cautious interpretation of the results. Furthermore, only a few publications from resource-rich countries were found to compare with our results. Lastly, the combined estimates were compared with primary studies because of the lack of a previously published meta-analysis

Attachment

Submitted filename: Response To Reviewers.docx

pone.0298519.s008.docx (29.3KB, docx)

Decision Letter 1

Mohammed Feyisso Shaka

26 Jan 2024

Neonatal birth trauma and associated factors in low and middle-income countries: a systematic review and meta-analysis

PONE-D-23-28607R1

Dear Dr. Woldegeorgis,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Mohammed Feyisso Shaka, MPH

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: (No Response)

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: Yes: Fentahun Adane Nigat, PhD

**********

Acceptance letter

Mohammed Feyisso Shaka

2 Mar 2024

PONE-D-23-28607R1

PLOS ONE

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Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Checklist. PRISMA 2020 checklist.

    (DOCX)

    pone.0298519.s001.docx (35.9KB, docx)
    S1 Table

    JBI’s critical appraisal tools: (A) Descriptive cross-sectional studies. (B) Analytical cross-sectional studies. (C) case-control studies.

    (DOCX)

    pone.0298519.s002.docx (32.5KB, docx)
    S1 File. Data extraction sheet.

    (XLSX)

    pone.0298519.s003.xlsx (22.7KB, xlsx)
    S2 File. Determinant factors for neonatal birth trauma.

    (XLSX)

    pone.0298519.s004.xlsx (17.4KB, xlsx)
    S3 File. Pattern and trend of neonatal birth trauma.

    (XLSX)

    pone.0298519.s005.xlsx (27.6KB, xlsx)
    Attachment

    Submitted filename: PLOS ONE REVIEWERS COMMENT.docx

    pone.0298519.s006.docx (14.8KB, docx)
    Attachment

    Submitted filename: Peer Review Report.pdf

    pone.0298519.s007.pdf (33.9KB, pdf)
    Attachment

    Submitted filename: Response To Reviewers.docx

    pone.0298519.s008.docx (29.3KB, docx)

    Data Availability Statement

    All relevant data are within the manuscript and its Supporting Information files

    Articles from PLOS ONE are provided here courtesy of PLOS

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