Birth asphyxia in a resource-limited setting: Challenges and implications for neonatal care in Nepal

Abstract

Birth asphyxia is a common problem especially in low resource developing countries like Nepal during the delivery. Birth asphyxia remains a major cause of mortality and morbidity worldwide and specially in developing countries like Nepal. Despite the advancement in medical science birth asphyxia still remains a major problem in newborn and preventing the risk factors after evaluating remains the center of reducing the prevalence. Proper healthcare protocols, early intervention and appropriate management is important for preventing long term sequalae and mortality. This study aims to assess the prevalence and risk factors of birth asphyxia in our institution. This hospital- based cross sectional descriptive study aimed to study the corelation between perinatal asphyxia with obstetrics and neonatal risk factors and to identify the complications of perinatal asphyxia. A total of 56 neonates were enrolled, and the data were analyzed using Statistical Package for the Social Sciences (SPSS, Chicago) version 21. Prevalence of birth asphyxia in our setting is 2.1%. A significant relationship was found between meconium stained liqor and birth asphyxia. Mortality occurred in 7% of the neonates. As in our part of the world where the studies are very limited this study will be a great asset to evaluate the incidence and determine the preventable risk factors of birth asphyxia thus helping in reducing the grave sequalae associated with birth asphyxia.

1. Introduction

The neonatal period, encompassing the first 28 days of life, represents the most vulnerable time for a child’s survival. In 2017, the global neonatal mortality rate was 18 deaths per 1000 live births. That year alone, approximately 2.5 million neonates died within the first month of life – equating to nearly 7000 deaths each day. Of these, about one million died within the first 24 hours, and close to another million succumbed within the following 6 days.^[1]

Neonatal conditions place a significant burden on families, healthcare systems, and society at large. Because these conditions occur in the earliest weeks of life, they are substantial contributors to global disability-adjusted life years and years of life lost. According to the Nepal Demographic and Health Survey 2022, Nepal’s neonatal mortality rate stands at 21 deaths per 1000 live births.^[2]

Among various neonatal conditions, birth asphyxia is recognized as the third leading contributor to the global burden of disease, alongside preterm birth complications.^[3,4] Despite notable advances in perinatal care over the past decades, birth asphyxia remains a critical challenge, leading to substantial neonatal morbidity and mortality. Globally, it accounts for around 23% of neonatal deaths and contributes to 10% of all deaths in children under 5 years of age.^[5–7]

The term “asphyxia” is derived from the Greek word meaning “cessation of pulse.” Clinically, perinatal asphyxia refers to a condition occurring during the first and second stages of labor, in which impaired gas exchange results in fetal hypoxemia, hypercarbia, and metabolic acidosis.^[8] The World Health Organization defines birth asphyxia as the failure to initiate and sustain breathing at birth.^[9] The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists further define perinatal asphyxia based on specific clinical criteria, including profound metabolic acidemia (umbilical cord pH < 7.0), a 5-minute Apgar score of <3, neurological abnormalities such as seizures or encephalopathy, and evidence of multi-organ involvement.^[10]

As per the National Neonatal Perinatal Database, moderate birth asphyxia is defined by a 1-minute Apgar score of 4 to 6, while severe birth asphyxia is indicated by a score of 0 to 3.^[11] Each year, it is estimated that around one million neonates die due to intrapartum-related complications, commonly termed “birth asphyxia.” Additionally, about 2 million neonates develop Hypoxic-ischemic encephalopathy (HIE), and 1.2 million experience developmental delays.^[12,13] The majority of these deaths – approximately 98% – occur in the first week of life, with nearly 75% happening within the first 24 hours and another 2% within 72 hours.^[14,15]

In high-income countries, the incidence of birth asphyxia is low, contributing to fewer than 0.1% of neonatal deaths. However, in low- and middle-income countries, the incidence ranges from 4.6 to 7 per 1000 live births.^[9] Globally, of the approximately 140 million neonates born each year, 10 to 15 million do not cry or breathe at birth, reflecting a presentation consistent with birth asphyxia.^[16]

Perinatal asphyxia is a multi-organ disorder, primarily affecting vital organs such as the kidneys, brain, heart, and lungs. The kidneys are most commonly affected (up to 50%), followed by the central nervous system, cardiovascular system, and respiratory tract.^[17] HIE, a major consequence of perinatal asphyxia, remains a leading cause of neonatal mortality and long-term neurodevelopmental impairment. In developing countries, HIE affects approximately 26 neonates per 1000 live births, with mortality rates ranging from 20% to 30% during the neonatal period. Among survivors, 33% to 50% go on to develop permanent neurological sequelae, including cerebral palsy and cognitive deficits. The severity of HIE – categorized as mild, moderate, or severe – has variable prognostic outcomes. Neonates with mild HIE typically recover fully, while about 20% of those with moderate HIE experience some long-term deficits. In severe HIE cases, around half of the neonates die, and all survivors are likely to develop neurodevelopmental sequelae.^[18]

HIE is a central concern in the management of asphyxiated neonates due to its potential to cause irreversible neurologic damage. Management strategies should focus on anticipating complications and providing prompt supportive care to facilitate recovery. Common complications associated with perinatal asphyxia include metabolic disturbances such as hypoglycemia, hypocalcemia, hypomagnesemia, and metabolic acidosis, all of which are strongly linked to the occurrence of neonatal seizures. These seizures can further increase the risk of long-term neuromotor deficits.^[19–21]

No single marker is sufficient to diagnose perinatal asphyxia. Instead, a constellation of findings – including signs of fetal distress, meconium-stained amniotic fluid, low Apgar scores, umbilical cord pH measurements, and clinical features of HIE – is typically used. According to Cloherty et al, perinatal asphyxia is best defined as a state of fetal hypoxia and hypercarbia, evidenced by umbilical artery pH < 7.0. Clinically, mild encephalopathy may manifest as a hyperalert or jittery state, with abnormal responsiveness to stimuli. Moderate to severe encephalopathy is marked by diminished or absent responses to light, touch, or even painful stimuli.^[22]

In term neonates, asphyxia may occur antenatally, intrapartum, or during delivery due to compromised placental gas exchange. Various preconceptional factors such as maternal age over 35 years, infertility treatment, family history of neurological disease, and previous neonatal loss are linked to higher asphyxia risk. Antepartum factors include conditions such as preeclampsia, maternal thyroid disorders, multiple gestations, congenital anomalies, intrauterine growth restriction (IUGR), and antepartum hemorrhage. Intrapartum risks encompass events like abnormal fetal heart rate patterns, meconium-stained amniotic fluid, placental abruption, cord prolapse, uterine rupture, and maternal cardiac arrest.^[23]

Several studies have also highlighted multiple maternal, fetal, and intrapartum risk factors for perinatal asphyxia. These include antepartum complications such as preeclampsia and primigravida status, intrapartum conditions like breech presentation and maternal fever, and fetal factors including prematurity, fetal distress, and abnormal birth weight.^[24,25]

Birth asphyxia results from insufficient oxygen delivery to the brain and impaired cerebral blood flow around the time of birth. The resulting hypoxic insult may lead to irreversible central nervous system injury through necrosis and inflammation, manifesting later as cerebral palsy or deficits in cognitive, behavioral, or motor development.^[26,27] Prevention of the initial hypoxic insult is therefore critical in reducing both neonatal mortality and long-term neurodevelopmental impairment.^[28]

In low- and middle-income countries, limited access to quality antenatal and intrapartum care can compromise obstetric management, increasing the risk of birth-related complications.^[29] Multiple studies have investigated the role of intrapartum, obstetric, and fetal factors in the development of birth asphyxia.^[30–32] Timely and effective management of these complications – both during labor and after birth – can substantially reduce neonatal mortality and the risk of associated developmental delays.^[33–35]

2. Methodology

2.1. General objective

The general objective of this study was to assess the prevalence of perinatal asphyxia and to identify the associated risk factors contributing to its occurrence.

2.2. Specific objectives

The study specifically aimed to observe the relationship between perinatal asphyxia and obstetric and neonatal risk factors, identify the complications arising from perinatal asphyxia, and determine the preventable risk factors associated with its occurrence.

2.3. Research design

This study was a hospital-based, cross-sectional descriptive study designed to determine the prevalence of birth asphyxia and explore its associated risk factors. The research was conducted in the Neonatal Intensive Care Unit (NICU) of Nepal Medical College Teaching Hospital (NMCTH).

2.4. Hypothesis

The hypothesis for the study proposed that the prevalence of birth asphyxia is higher in neonates exposed to specific maternal and fetal risk factors.

2.5. Study setting and duration

The research was carried out at NMCTH over a period spanning from November 2022 to December 2023.

2.6. Study population

The study population included all neonates delivered at NMCTH during the study period who fulfilled the established inclusion criteria.

2.7. Sample size and sampling technique

The minimum required sample size was calculated using the single population proportion formula:

$${\displaystyle \begin{array}{l}{\displaystyle \mathrm{n}={\mathrm{Z}}^2\mathrm{P}\mathrm{Q}/{\mathrm{d}}^2,\mathrm{w}\mathrm{h}\mathrm{e}\mathrm{r}\mathrm{e}}\end{array}}$$

Z = 1.96 (standard normal deviate at 95% confidence level),

P = estimated prevalence of perinatal asphyxia (9%),

Q = 100 – P (91), and

d = acceptable margin of error (7.5%).

Substituting the values, the sample size was calculated as:

$${\displaystyle \begin{array}{l}{\displaystyle \mathrm{n}=(3.84\times 9\times 91)/56.25=55.9\approx 56\mathrm{n}\mathrm{e}\mathrm{o}\mathrm{n}\mathrm{a}\mathrm{t}\mathrm{e}\mathrm{s}.}\end{array}}$$

2.8. Inclusion criteria

The study included neonates with documented perinatal insults, defined as babies who did not cry or breathe immediately after birth and were admitted to the NICU. Additionally, neonates with an APGAR score of <7 at one minute or those who required bag and mask ventilation were also included.

2.9. Exclusion criteria

Neonates who were born outside NMCTH, those with major congenital malformations, and those whose guardians did not consent to participate were excluded from the study.

2.10. Method of data collection

Following ethical approval from the Institutional Review Committee of NMCTH, neonates who met the inclusion criteria were enrolled after obtaining written informed consent from parents or guardians. All data collected were kept strictly confidential. Each enrolled neonate underwent a detailed clinical examination, and a comprehensive maternal history was obtained to assess risk factors. APGAR scores were recorded at 1 and 5 minutes by the investigator or attending pediatric resident at delivery. Variables such as mode of delivery, gestational age, birthweight, and presence of meconium-stained liquor were documented. Neonates were followed up for early complications including HIE and mortality.

2.11. Variables used in the study

2.11.1. Outcome variables

Birth asphyxia was defined based on 1 or more of the following: failure to initiate or sustain breathing at birth, an APGAR score of <7 at 5 minutes, and the requirement for bag and mask ventilation. Predischarge mortality was defined as death of the neonate before hospital discharge.

2.11.2. Demographic characteristics

Sex of the neonate was recorded as male or female.

2.11.3. Neonatal characteristics

Birth weight was categorized as very low (<1500 g), low (1500–2499 g), and normal (2500–4000 g). Meconium aspiration was defined as the presence of meconium-stained liquor associated with respiratory distress. Gestational age was calculated based on the last menstrual period and categorized as preterm (<37 weeks) or term (≥37 weeks).

2.11.4. Obstetric characteristics

Mode of delivery was recorded as spontaneous vaginal delivery, instrumented delivery, or cesarean section. Suspected maternal infection was defined as the presence of fever and/or foul-smelling vaginal discharge requiring antibiotic treatment. Prolonged labor was considered as labor lasting 20 or more hours for primigravida or 14 or more hours for multigravida. Fetal malposition was noted when the presenting part of the fetus was not aligned with the maternal pelvis.

2.12. Definition of birth asphyxia

For the purpose of this study, birth asphyxia was defined as failure to initiate or sustain breathing immediately after birth, an APGAR score of <7 at 1 minute, or the need for bag and mask ventilation. APGAR scoring was used at both 1 and 5 minutes to assess the neonate’s condition using the standard parameters of appearance, pulse, grimace, activity, and respiration.

2.13. Data management

All data were collected by the principal investigator and compiled using Microsoft Excel. The compiled dataset was then transferred to the Statistical Package for the Social Sciences (SPSS, Chicago) version 29.0.2.0 for statistical analysis.

2.14. Statistical analysis

Descriptive statistics were used to summarize demographic characteristics and the prevalence of birth asphyxia. The association between risk factors and birth asphyxia was analyzed using ANOVA, and a P-value of <.05 was considered statistically significant.

2.15. Ethical considerations

Ethical clearance for this study was granted by the Nepal Medical College Institutional Review Committee (NMC-IRC). Written informed consent was obtained from the parents or legal guardians of all enrolled neonates. The confidentiality of all participants was strictly maintained throughout the study.

3. Results

This hospital-based, cross-sectional descriptive study was conducted to assess the prevalence of perinatal asphyxia and to identify the associated risk factors. The results were also analyzed in relation to the severity of asphyxia and early neonatal outcomes. A total of 56 neonates were enrolled in the study (Table 1). During the study period, there were 2643 total deliveries, of which 56 neonates were diagnosed with birth asphyxia. Hence, the prevalence of birth asphyxia at NMCTH during the study period was 2.1%.

Table 1.

Demographic factors of the study participants (N = 56).

Variables		Number (n = 56)	Percentage (%)
Sex	Male	32	57.1
	Female	24	42.9
Mode of delivery	Normal vaginal delivery	28	50
	Cesarean section	28	50
Gestational age	Preterm	16	28.5
	Term	40	71.5
Birth weight	<1500 g	5	8.9
	1500–2500 g	15	26.7
	2500–4000 g	34	60.7
	>4000 g	2	3.7

Among the 56 neonates, 32 (57.1%) were males and 24 (42.9%) were females. An equal number of neonates, 28 (50%) each, were delivered via normal vaginal delivery and lower segment cesarean section. Gestational age ranged from 29.2 to 40.2 weeks, with a mean gestational age of 36.68 weeks and a standard deviation of 2.648. Of the total cases, 16 (28.5%) were preterm, and 40 (71.5%) were term neonates.

Birth weights ranged from 1100 grams to 4300 grams, with a mean birth weight of 2685.23 grams and a standard deviation of 811.44 grams. Among the 56 neonates, 5 (8.9%) were classified as very low birth weight (VLBW), 15 (26.7%) as LBW, 34 (60.7%) had normal birth weight, and 2 (3.7%) were categorized as big babies.

The most commonly observed risk factor among the study population was meconium-stained liquor, seen in 33 cases (58.9%), followed by fetal malposition in 8 cases (14.3%) and maternal illness in 4 cases (7.1%). Additionally, 35.7% were LBW babies, 3.57% were big babies, and 28.5% were preterm (Tables 2 and 3).

Table 2.

Risk factors among the study participants (N = 56).

Risk factors	Number of Cases	Percentage of total cases (%)
Meconium stained liqor	33	58.9
Maternal illness (fever)	4	7.1
Malposition of fetus	8	14.3
Prolonged labor	0	0
Low birth weight (VLBW + LBW)	20	35.7
Big baby	2	3.57
Preterm	16	28.5

LBW = low birth weight, VLBW = very low birth weight.

Table 3.

Maternal parameters among the study participants (N = 56).

Maternal Parameters	Number (N)	Mean	Standard deviation
Prolonged labor	0	00	00
Maternal infection	4	0.07	0.260
Malposition of fetus	8	0.13	0.334
Meconium stained liqor	33	0.59	0.496

Based on the results of the ANOVA, the F-test was found to be statistically significant (P-value < 0.05). In our institution, meconium-stained liquor was significantly correlated with birth asphyxia, with a P-value of 0.002. However, other studied risk factors did not show statistically significant associations (Table 4).

Table 4.

Analysis of variances among the study participants (N = 56).

		Sum of Squares	Df	Mean Square	F	P-value
Prolonged labor	Between groups	.000	0	.000	–	–
	Within groups	.000	0	.000	–	–
	Total	.000	00	–	–	–
Maternal infection	Between groups	.079	4	.020	.276	.892
	Within groups	3.636	52	.071	–	–
	Total	3.714	56	–	–	–
Malposition of fetus	Between groups	.278	8	.070	.606	.660
	Within groups	5.847	48	.115	–	–
	Total	6.125	56	–	–	–
Meconium stained liqor	Between groups	3.721	33	.930	4.824	.002
	Within groups	9.833	23	.193	–	–
	Total	13.554	56	–	–	–

Among all cases, seizures were observed in 11 neonates (19.6%). There were 4 (7.1%) neonatal deaths, while 41 neonates (73.3%) were discharged without complications (Table 5).

Table 5.

Immediate outcomes among the study participants (N = 56).

Outcome	Number (n = 56)	Percentage (%)
Seizure	11	19.6
Mortality	4	7.1
Normal discharge with no complication	41	73.3

4. Discussion

In this study, the sample size was 56. The prevalence of birth asphyxia was assessed, and major associated risk factors were analyzed.

4.1. Prevalence of birth asphyxia

The prevalence of birth asphyxia was found to be 2.1% among neonates delivered at NMCTH. This rate is consistent with findings from other studies conducted in similar healthcare settings. Bhattacharya et al and Saha et al reported prevalence rates ranging from 1.5% to 3.0% in tertiary care hospitals in 2019 and 2021, respectively.^[36,37] Similarly, a study by Nair et al (2019) found a prevalence of 2.5% in a tertiary care hospital in India.^[38]

A prospective cross-sectional study conducted by Ghimire et al at Pokhara Academy of Health Sciences, involving 4120 live births and 914 NICU admissions between October 2021 and March 2022, reported that 60 babies were diagnosed with perinatal asphyxia. This accounted for 6.56% of total NICU admissions and 1.45% of total live births.^[39] These findings align with our results, suggesting that while birth asphyxia remains a clinical concern, the rates are comparable across similar hospital environments.

Variations in prevalence may be attributed to differences in healthcare practices, maternal health services, geographic conditions, and socioeconomic status.

4.2. Demographic characteristics

The demographic distribution in this study showed a higher proportion of male neonates (57.1%), which is consistent with global data indicating a slight male predominance at birth (54.6%), as observed in a study by Baker et al.^[40]

The equal distribution of delivery methods (50% vaginal delivery and 50% cesarean section) suggests that the mode of delivery was not significantly associated with birth asphyxia in this population. This highlights the importance of monitoring both delivery methods for potential risks. However, Khalil et al (2021) noted that emergency cesarean sections, often performed due to fetal distress, may contribute to higher rates of birth asphyxia.^[41] This discrepancy could be due to our smaller sample size or local healthcare practices.

4.3. Gestational age and birth weight

Most neonates in the study were term (71.5%) with a mean gestational age of 36.68 weeks. Normal birth weight was observed in 60.7% of cases, while 35.6% were LBW. Previous studies, such as that by Kumar et al (2018), consistently show that preterm and LBW infants are at increased risk for asphyxia.^[42] The significant number of term and normal birth weight infants in our study suggests that other risk factors may play a more pivotal role in this population.

In contrast, Ghimire et al reported that prematurity was the leading neonatal risk factor for perinatal asphyxia, accounting for 43.3% of affected infants.^[39] This discrepancy may stem from the smaller sample size in our study.

The mean birth weight in our study was 2685.23 grams, indicating that a substantial proportion of neonates were of normal weight. However, the presence of VLBW infants is also a recognized risk factor, as supported by Pattinson et al (2018).^[43]

4.4. Risk factors associated with birth asphyxia

Meconium-stained liquor was identified as the most significant risk factor in this study, present in 58.9% of cases. The association between meconium-stained amniotic fluid and birth asphyxia is well-documented; it can lead to airway obstruction and subsequent hypoxia, as noted by Yogev et al (2021).^[44] Sunny et al (2015) also found that neonates with meconium aspiration had a 24-fold increased risk of developing birth asphyxia (aOR: 23.7; 95% CI, 13.8–40.9).^[45]

Our ANOVA results support this association (P = .002), suggesting that timely identification and management of meconium-stained liquor during labor may reduce the incidence of asphyxia. Other risk factors observed included maternal illness (7.1%) and fetal malposition (14.3%), though these did not show statistically significant correlations. This aligns with findings from Nadeem et al, who reported that meconium was significantly associated with birth asphyxia, while other factors were not.^[46]

Similarly, a study by Palsdottir et al at Landspitali University Hospital in Iceland found meconium-stained amniotic fluid in 50% of asphyxia cases,^[47] consistent with our results.

In contrast, the absence of prolonged labor in our cohort differs from findings by Ritbano et al at Nigist Eleni Mohammed Memorial Teaching Hospital, Ethiopia. Their study reported that prolonged second-stage labor (AOR = 4.6; 95% CI = 1.6–13.3), preterm birth (AOR = 4.7; 95% CI = 1.5–14.1), and meconium-stained amniotic fluid (AOR = 7.5; 95% CI = 2.5–21.4) were significant risk factors for asphyxia.^[48] The variation may be due to sample size differences or the quality of antenatal care.

4.5. Early neonatal outcomes

Seizures occurred in 19.6% of neonates, and 7.1% of the study population did not survive, reflecting the severe implications of birth asphyxia. These outcomes are consistent with those reported by Liu et al (2021), who emphasized the long-term neurodevelopmental risks and increased neonatal morbidity associated with asphyxia.^[49]

In our study, 73.3% of neonates were discharged without complications, suggesting that timely intervention may reduce adverse outcomes. The incidence of HIE included 7.1% with severe HIE, 14.3% with moderate HIE, and 8.9% with mild HIE. These findings align with global data; McIntyre et al (2018) reported that severe HIE affects approximately 1 to 4 per 1000 live births.^[50] This spectrum of HIE outcomes underscores the importance of early recognition and neuroprotective management strategies to mitigate long-term effects.

This study has several limitations that must be acknowledged. The small sample size limits the generalizability of the findings and reduces the statistical power to detect significant associations. Additionally, the absence of a control group hinders the ability to establish causal relationships. The lack of adjustment for potential confounding variables may have introduced bias in the observed outcomes. Furthermore, being conducted in a single-center setting restricts the external validity of the results, as they may not be representative of broader populations or healthcare settings.

5. Conclusions

In conclusion, this hospital-based cross-sectional study found the prevalence of birth asphyxia to be 2.1% at NMCTH, with meconium-stained liquor identified as the most significant associated risk factor. While most affected neonates were term and of normal birth weight, a notable proportion experienced complications such as seizures and HIE, underscoring the critical impact of perinatal asphyxia on neonatal outcomes. Although other maternal and fetal risk factors were observed, their statistical significance was not established, likely due to the small sample size. These findings highlight the importance of vigilant intrapartum monitoring and timely neonatal intervention to reduce asphyxia-related morbidity and mortality.

Acknowledgments

We extend our gratitude to all the caretakers of study participants for their co-operation and support.

Author contributions

Conceptualization: Keshav Adhikari, Sajjad Ahmed Khan.

Data curation: Keshav Adhikari, Birendra Kumar Yadav, Chaitanya Darshan Bhattarai, Kumar Basnet, Arun Bajgain, Ananda Aryal, Jyoti Thapa.

Formal analysis: Birendra Kumar Yadav, Chaitanya Darshan Bhattarai, Arun Bajgain, Anu Budhathoki.

Investigation: Kumar Basnet.

Resources: Anu Budhathoki.

Writing – original draft: Sajjad Ahmed Khan.

Writing – review & editing: Sajjad Ahmed Khan.