Paediatrica Indonesiana

VOLUME 48 September ‡ NUMBER 5

Original Article

Early neonatal mortality rate and the risk factors

in Wangaya hospital
Made Indah Nastiti Utami Budha, Wayan Retayasa, Made Kardana

Abstract
Background The first week of life of a neonate is a critical period.
In Asia, early neonatal mortality rate remains high.
Objective To investigate early neonatal mortality rate and the risk
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Methods A cross sectional study was carried out retrospectively
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'HQSDVDU %DOL VLQFH -DQXDU\  7KH VWXG\ ZDV GRQH IURP
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exact test and multivariate logistic regression analysis model.
Results (DUO\QHRQDWDOPRUWDOLW\UDWHLQ:DQJD\D+RVSLWDOZDV
SHUOLYHELUWKV8QLYDULDWHDQDO\VHVVKRZHGWKDWWKHUHZHUH
five significant risk factors of early neonatal death, i.e., respiratory
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that those five variables were significant as risk factors of early
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ealth status of a nation or community,
among others, includes mortalities,
morbidities, and nutritional status. In
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neonatal mortality rate in the entire world were
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respectively. In developed countries, they were only 5
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neonatal mortality rate and early neonatal mortality rate
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respectively.3 Early neonatal mortality rate in Wangaya
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This study aimed to investigate early neonatal
PRUWDOLW\UDWHDQGLWVULVNIDFWRUVLQ:DQJD\D+RVSLWDOLQ
QHRQDWDOGHDWKLH25FRQILGHQFHLQWHUYDOIRUUHVSLUDWRU\ order to be able to conduct more intensive and optimal
GLVWUHVVWR@DVSK\[LDWR@ELUWK treatment to reduce early neonatal death rate.
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Conclusions (DUO\QHRQDWDOPRUWDOLW\UDWHLQ:DQJD\D+RVSLWDO
UHPDLQVKLJK5HVSLUDWRU\GLVWUHVVDVSK\[LDELUWKZHLJKW Methods
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factors of early neonatal death. [Paediatr Indones 2008;48:306- This retrospective study was conducted in Wangaya
11].
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Keywords: early neonate, mortality rate, risk

factors
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Request reprint to: Made Indah Nastiti Utami Budha, MD, Department
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306‡Paediatr Indones, Vol. 48, No. 5, September 2008

 Made Indah Nastiti Utami Budha et al: (DUO\QHRQDWDOGHDWKLQ:DQJD\D+RVSLWDO
subjects were obtained from the medical records of
WKH QHRQDWHV UHJLVWHUHG DW 3HULQDWRORJ\ 8QLW VLQFH
-DQXDU\  7KH LQFOXVLRQ FULWHULRQ ZDV DOO OLYH
ELUWKV UHJLVWHUHG DW 3HULQDWRORJ\ 8QLW LQ :DQJD\D
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who had incomplete data. This study was approved
by the Ethical Clearance from the Ethics Committee
of Medical School, Udayana University/Sanglah
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Samples size was calculated by using the sample
VL]H HVWLPDWLRQ HTXDWLRQ IRU VLQJOH SURSRUWLRQ5 one
thousand five hundred live births were included.
We collected data on medical record number,
gender, gestational age, birth weight, asphyxia,
congenital anomaly, respiratory distress, sepsis,
maternal age, parity, early neonatal deaths, and early
neonatal age at death.
Definitions
Early neonatal death was defined as neonatal death
in the first seven days of life.1 Early neonatal mortality
rate was the number of early neonatal death divided
E\ WKH QXPEHU RI OLIH ELUWKV PXOWLSOLHG E\ 
Live birth was defined as birth of infant regardless
are irregularity of body temperature (hyperthermia,
hypothermia), change of behavior/ consciousness
(lethargy, irritable), change of tone, change of normal
skin (poor of peripheral perfusion, cyanosis, mottling,
pale, petechie, rash, jaundice, sclerema), feeding
disorder (feeding intolerance), gastrointestinal
problems (vomiting, diarrhea, abdominal distension,
cardiopulmonary problems (tachypnea, tachycardia,
hypotension, respiratory distress), and metabolic
disorder (hypoglycemia, hyperglycamia, metabolic
acidosis).  Maternal age was calculated from
PRWKHU·V ELUWKGD\ FDWHJRUL]HG DV OHVV WKDQ  \HDUV
\HDUVDQGPRUHWKDQ\HDUV3DULW\ZDVGHILQHG
as a number of pregnancies until the present pregnancy,
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Data analysis
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Windows. Univariate analysis was performed using
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analysis, we performed multiple logistic regression
model, to determine risk factors that significantly
associated with early neonatal death. The strength
of the association was indicated by odds ratio
the length of intrauterine period, in which the baby
showed any signs of life as breathing, positive heartbeat
or umbilical cord pulse or any muscle movements.
Gestational age was defined as a period from the first
day of the last normal menstrual period until the day
of birth (calculated in weeks), grouped as gestational
DJHOHVVWKDQZHHNVDQG•ZHHNVBirth weight
was the body weight recorded at birth by baby scales at
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ORZ ELUWK ZHLJKW LI OHVV WKDQ  JUDP DQG QRW ORZ
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Results
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there were 58 infants died during the early neonatal
period, thus giving the early neonatal mortality
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condition where the baby had not adequate, spontaneous
and regular breathing at birth.Congenital anomaly was
anomaly that exist since birth.
Respiratory distress was defined as a syndrome
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distress: dyspnea with breathing frequency more than
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samples are described in Table 1. The results of early
neonatal death are shown in Table 2.
Multivariate analysis (logistic regression model)
showed that five variables were significant as risk
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(Table 3). Those five variables (figures indicate
subcostal, or suprasternal retraction, and cyanosis in 25ZLWKFRQILGHQFHLQHUYDOVZHUHUHVSLUDWRU\
room temperature.9 Sepsis was defined as a clinical GLVWUHVV   WR @ DVSK\[LD   WR
syndrome charcterized by systemic infections (minimal  ELUWK ZHLJKW  JUDP   WR 
3 organs involved) and / or followed by bacteremia VHSVLV   WR  DQG JHVWDWLRQDO DJH 
(positive blood culture). Clinical signs of sepsis ZHHNVWR

Paediatr Indones, Vol. 48, No. 5, September 2008‡307

 Made Indah Nastiti Utami Budha et al: (DUO\QHRQDWDOGHDWKLQ:DQJD\D+RVSLWDO
Discussion
Early neonatal death remains to be a health problem
and is the biggest component of neonatal mortality
rate. Early neonatal mortality rate in Wangaya
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higher than that observed in previous years (18.8 in
  LQ   LQ 4 and also higher
Table 1. $CUKEEJCTCEVGTKUVKEUQHUVWF[UWDLGEVU
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Characteristics
(n)
than that in Asia.3 Our data could not explain why
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increased gradually every years. We do not have data
whether it was caused by the decreased quality of
human resources or by limited resource instruments
LQ :DQJD\D +RVSLWDO RU E\ WKH LQFUHDVHG QXPEHU
of complicated pregnancy referred to Wangaya
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LQ PRUH QXPEHU RI LQIDQWV ERUQ ZLWK DVSK\[LD
related outcome. There was no data either about the
kind of complicated pregnancy or about the type of
delivery.
Percentage There were several studies which investigated
(%) early neonatal mortality. Data of previous study has
Gender (male) 819 54.6 SURYHGWKDWSUHPDWXULW\JHVWDWLRQDODJHZHHNV
Gestational age (< 37 weeks) 238 15.9
Birth weight (< 2500 gram) 307 20.5
was a risk factor of early neonatal death. The function
Asphyxia (yes) 370 24.7 of organs in premature newborns is not optimal,
Congenital anomaly (yes) 7 0.5 therefore, they more difficult to adapt and easier to
Respiratory distress (yes) 14 0.9
Sepsis (yes) 84 5.6
have complication and have high risk of death.13
Maternal age 192 12.8 Jimmy et al14 conducted an audit of neonatal care at

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1995 to 1999. The overall perinatal mortality rate

Table 2. Univariate analysis of risk factors of early neonatal death

END Non END
Risk factors in END
n (%) n (%) P OR 95% CI
Gender (male) 36 (4.4) 783 (95.6) 0.24 1.4Ȕ 0.8; 2.4
Gestational age (< 37 weeks) 43 (18.1) 195 (81.9) 0.00 18.3Ȕ 9.9; 33.6
Birth weight (< 2500 gram) 49 (16.0) 258 (84.0) 0.00 24.9Ȕ 12.1; 51.5
Asphyxia (yes) 48 (13.0) 322 (87.0) 0.00 16.7Ȕ 8.4; 33.4
Congenital anomaly (yes) 1 (14.3) 6 (85.7) 0.24 4.2Ԑ 0.5; 35.5
Respiratory distress (yes) 11 (78.6) 3 (21.4) 0.00 112.3Ԑ 30.3; 415.7
Sepsis (yes) 15 (17.9) 69 (82.1) 0.00 6.9Ȕ 3.7; 13.1
/CVGTPCNCIG
Ů[Q 9 (4.7) 183 (95.3) 0.53 1.3Ȕ 0.6; 2.6
2CTKV[
QTŮ 29 (3.9) 709 (96.1) 0.90 1.0Ȕ 0.6; 1.7

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END = Early Neonatal Death

Table 3./WNVKXCTKCVGCPCN[UKUQHTKUMHCEVQTUQHGCTN[PGQPCVCNFGCVJ

Risk factors of END E P OR 95% CI

Gestational age < 37 weeks 1.262 0.00 3.5 1.6; 7.8
Birth weight < 2500 gram 2.091 0.00 8.1 3.3; 19.9
Asphyxia 2.606 0.00 13.5 6.1; 29.9
Respiratory distress 2.819 0.00 16.8 3.7; 76.6
Sepsis 1.986 0.00 7.3 3.1; 17.1

END = Early Neonatal Death

308‡Paediatr Indones, Vol. 48, No. 5, September 2008

 Made Indah Nastiti Utami Budha et al: (DUO\QHRQDWDOGHDWKLQ:DQJD\D+RVSLWDO

ZDVSHUWRWDOELUWKVZLWKDQHDUO\QHRQDWDO of death in both term and preterm newborns. 

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major cause of death were prematurities, low birth anomaly was not a risk factor, possibly because of
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rate at gestational age of 34 weeks, 35 weeks, and
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the congenital anomaly was a mild anomaly or not
life threatening.
Bacterial sepsis and meningitis continue to be
major causes of morbidity and mortality in newborns,
particularly in low birth weight infants and also at risk
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respectively. In our study, it was found that gestational
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significant risk factors of early neonatal death.
Early neonatal death was found four times
in neonatal intensive care have decreased morbidity
and mortality from early onset sepsis in term infants.
Lawn et al in a systematic review of data from 44
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neonatal death globally were estimated to be infections
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ischemic encephalopathy due to perinatal asphyxia
is recognized as an important cause of neonatal
morbidity and mortality. The incidence of perinatal
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centers and is inversely related to gestational age and
birth weight.+HOOHUet al in their study on 513,315
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early neonatal mortality in term infants with Apgar
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showed that sepsis and or respiratory distress were risk
factors for early neonatal death.
There are several studies that show correlation
between maternal age and neonatal mortality. Chen
et al  in a cohort study conducted in US from
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associated with increased risks for preterm delivery,
low birth weight and neonatal mortality. Infants born
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cohort study carried out on 151,891 live birth infants
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neonatal death in preterm newborns with Apgar score
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higher risk for low Apgar scores at 5 minutes. Joseph
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and small for gestational age rate were also higher,
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newborns. Weinberg et al19 in a cohort study in three &,WRDPRQJZRPHQ\HDUVDQG
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concluded that low Apgar scores were associated
with increased neonatal morbidity and mortality in
preterm newborns. Antenatal maternal history and
pregnancy complications are not clearly associated
with low Apgar scores. Therefore, Apgar scores is a
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and the need for intensive care for preterm newborns.
In our study, asphyxia was a significant risk factor for
early neonatal death.
Indeed, severe congenital anomaly (neural
tube defect) is a risk factor of early neonatal death.
Birth defects were the single most common cause
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or older. Our study showed that maternal age was
not a risk factor of early neonatal death in Wangaya
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that of other studies, which maybe because of most
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parous is a risk factor for adverse outcome is
inconsistent. Wu et al in retrospective cohort study
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China , found that perinatal mortality rate increased
notably with parity and was higher in township
having lower income per capita. Aliyu et al analyzed
Paediatr Indones, Vol. 48, No. 5, September 2008‡309
 Made Indah Nastiti Utami Budha et al: (DUO\QHRQDWDOGHDWKLQ:DQJD\D+RVSLWDO

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the overall crude rates for low birth weight, very rakyat.com/cetak/0802/24
low birth weight, preterm birth, very preterm birth,  :+2 1HRQDWDO DQG SHULQDWDO PRUWDOLW\ &RXQWU\
and small and large for gestational age were 55, 11,
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The adjusted odds ratio for low birth weight, very
low birth weight, preterm and very preterm delivery
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Available from: URL: http://www.whqlibdoc.who.int/
publications/2006/9241563206_eng.
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GL UXDQJ SHULQDWRORJL 568' :DQJD\D SHULRGH 
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we did not find that parity was a risk factor for early
neonatal death.
The limitation of this study is that we did not
conduct adjustment for all risk factors of early neonatal
death, especially risk factors in maternal, such as social
economic status, maternal nutrient status, any maternal
illness or complicated pregnancy, previous pregnancies
or deliveries, delivery assistances, and type of delivery.
Finally, we do not know how many mothers were
referred caused by complicated pregnancy.
In conclusion early neonatal mortality rate in
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for early neonatal death were respiratory distress,
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on risk factors in early neonatal death which have not
been evaluated yet such as : maternal social economic
status, maternal nutritional status, maternal illness,
and previous pregnancies or deliveries in Wangaya
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Acknowledgments
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supervising the statistical analysis. Also for Director of Wangaya
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collecting.
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formasi kesehatan. 3XVDW GDWD GDQ LQIRUPDVL 'HSDUWHPDQ
Kesehatan RHSXEOLN,QGRQHVLDS
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Neonatologi praktis. Denpasar: Bag./SMF Ilmu Kesehatan
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9. Fanaroff AA, Fanaroff JM. Clinical examination. In: Donn
SM, Sinha SK, editors. Manual of neonatal respiratory care.
ndHG3KLODGHOSKLD0RVE\(OVHYLHUS
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11. Kardana M. Sepsis neonatorum. In: Suraatmadja S, editor.
Neonatologi praktis. Denpasar: Bag./SMF Ilmu Kesehatan
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