ORIGINAL

ARTICLES
Neonatal Birth Trauma: Analysis of Yearly Trends, Risk Factors, and
Outcomes
Ruby Gupta, MBBS, MS, and Erwin T. Cabacungan, MD, MPH

Objective To evaluate the trends, proportions, risk factors, resource utilization, and outcomes of neonatal birth
trauma in the US.
Study design This cross-sectional study of in-hospital births used the Nationwide Inpatient Sample for 2006-
2014. We divided the cases by type of birth trauma: scalp injuries and major birth trauma. Linear regression for
yearly trends and logistic regression were used for risk factors and outcomes. A generalized linear model was
used, with a Poisson distribution for the length of stay and a gamma distribution for total spending charges.
Results A total of 982 033 weighted records with neonatal birth trauma were found. The prevalence rate increased
by 23% from (from 25.3 to 31.1 per 1000 hospital births). Scalp injuries composed 80% of all birth traumas and
increased yearly from 19.87 to 26.46 per 1000 hospital births. Major birth trauma decreased from 5.44 to 4.67
per 1000 hospital births due to decreased clavicular fractures, brachial plexus injuries, and intracranial hemorrhage.
There were significant differences in demographics and risk factors between the 2 groups. Compared with scalp
injuries, major birth trauma was associated with higher odds of hypoxic-ischemic encephalopathy, seizures,
need for mechanical ventilation, meconium aspiration, and sepsis. Length of stay was increased by 56%, and total
charges were almost doubled for major birth trauma.
Conclusions Neonatal birth trauma increased over the study period secondary to scalp injuries. Major birth
trauma constitutes a significant health burden. Scalp injuries are also associated with increased morbidity and
might be markers of brain injury in some cases. (J Pediatr 2021;-:1-7).

B
irth trauma is defined as structural damage or functional deterioration secondary to mechanical forces during labor,
delivery, or both.1-4 Birth trauma is often used interchangeably with the term “birth injury.”5 Ranging from minor skin
lacerations to life-threatening events, such as subgaleal hemorrhage, it is a significant cause of morbidity and mortal-
ity.6 Well-known risk factors for birth trauma are a large for gestational age (LGA) neonate,7,8 vacuum/forceps delivery,9,10 and
malpresentation at delivery. The epidemiology of these risk factors is changing as instrumental deliveries are decreasing11 and
maternal obesity and gestational diabetes leading to LGA are increasing.12 From 2005 to 2014, the use of forceps declined by
39% (from 0.93% to 0.57% of all births) and the use of vacuum extraction declined by 32% (from 3.87% to 2.64%).13 During
the same period, the incidence of LGA with birth weight >4000 g increased from 7.8 to 8 per 1000 births, and the rate of cesarean
delivery increased from 31.1 to 32.2 per 100 births.13 The rate of elective cesarean delivery continues to increase for suspected
macrosomia and/or breech presentation, and the practice has been found to be protective for birth trauma.14-19 In 1993, birth
trauma was ranked 11th among major causes of neonatal death; however, from 2007 onward, it has not made the list of top 15
causes of neonatal death.20
The most frequently reported birth traumas are scalp and skeletal injuries.15,21,22 Scalp injuries are considered minor birth
trauma, because most heal without intervention. We categorized other birth trauma types as major because they might require
intervention, admission to a neonatal intensive care unit and/or a prolonged hospital length of stay (LOS), or cause significant
long-term morbidity.10 Population-based studies in 2003 and 2010 found estimated incidences of birth trauma of 24.3 per 1000
births and 29 per 1000 births, respectively.4,10

HCUP Healthcare Cost and Utilization Project

ICD-9-CM International Classification of Diseases, Ninth Revision, Clinical Modification
IDM Infant of mother with diabetes
IRR Incidence rate ratio
IUGR Intrauterine growth retardation
LGA Large for gestational age
LOS Length of stay
NIS National Inpatient Sample From the Division of Neonatology, Department of
Pediatrics, Medical College of Wisconsin, Milwaukee, WI
RDS Respiratory distress syndrome
The authors declare no conflicts of interest.
SGA Small for gestational age
TCH Total hospital charges 0022-3476/$ - see front matter. ª 2021 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jpeds.2021.06.080

1
THE JOURNAL OF PEDIATRICS  www.jpeds.com
The present study aimed to identify annual trends, risk fac-
tors, short-term outcomes, LOS, and total charges associated
with birth trauma, stratified by scalp injuries and major birth
trauma. We hypothesized that risk factors for birth trauma
have changed over time and lead to differences in prevalence
and in the yearly trends of major birth trauma and scalp in-
juries.
Methods
This study is a retrospective, cross-sectional analysis of
neonatal discharge records describing neonatal birth trauma.
Data Source
We used administrative discharge data for 2006-2014 from
the National Inpatient Sample (NIS) of the Healthcare Cost
and Utilization Project (HCUP), sponsored by the Agency
for Healthcare Research and Quality. The NIS was created
by the Agency for Healthcare Research and Quality from
the state inpatient databases provided by public and private
statewide data organizations from participating states as
part of a federal–state–private collaboration. The NIS is the
largest all-payer inpatient care database in the US, with an
annual average of 7 million hospitalizations from approxi-
mately 1000 hospitals. The NIS approximates a 20% stratified
random sample of all short-term US community hospitals.
The American Hospital Association defines “community
hospitals” as all nonfederal general and specialty hospitals
(including public hospitals and academic medical centers)
with an average LOS of <30 days and whose facilities are
open to the public. The NIS includes patient-level data,
such as demographic and hospital characteristics, admission
type, and source. It contains up to 25 International Classifica-
tion of Diseases, Ninth Revision, Clinical Modification (ICD-9-
CM) diagnostic and procedural codes, along with total hos-
pital charges (TCH), LOS, and discharge disposition data.
Measures
Definitions. Birth trauma was defined as any injury to the
neonate during labor and delivery due to mechanical forces.
We divided birth trauma into scalp injuries and major birth
trauma, comprising all nonscalp injuries labeled as major in-
juries. The ICD-9-CM codes for birth trauma are 767.0-
767.9. The specific types of birth traumas included in the
study were subdural and cerebral hemorrhage (ICD-9-CM
code 767.0), injuries to the scalp (767.1), fracture of the clav-
icle (767.2), other injuries to the skeleton (767.3), injury to
the spine and spinal cord (767.4), facial nerve injury and
facial palsy (767.5), injury to the brachial plexus (767.6),
other cranial and peripheral nerve injuries (767.7), other
specified birth trauma (767.8), and unspecified birth trauma
(767.9).
Demographics
We included sex, race (using categories), insurance (public vs
private), and median household income for the patient’s ZIP
code (using quartiles). Moreover, variables such as small for
2 Gupta and Cabacungan
Volume -  - 2021
gestational age (SGA), intrauterine growth retardation
(IUGR), low birth weight (<2500 g), LGA, birth weight
³4500 g, infant of mother with diabetes (IDM), multiple
gestation, and death.
Selected Birth Trauma Risk Factors
The following labor and delivery risk factors for birth trauma
were examined: breech delivery and extraction (763.0); other
malpresentation, malposition, and disproportion during la-
bor and delivery (763.1); forceps delivery (763.2); delivery
by vacuum extractor (763.3); cesarean delivery (V30.01,
V31.01, V33.01, V34.01, V37.01, V39.01, and 763.4);
maternal anesthesia and analgesia (763.5); precipitous deliv-
ery (736.6); abnormal uterine contractions (763.7); other
specified complications of labor and delivery affecting a fetus
or newborn (763.8x); and unspecified complication of labor
and delivery affecting a fetus or newborn (763.9).
Adverse Neonatal Outcomes
The selected outcomes examined were intrauterine asphyxia
(768.0-768.6), hypoxic-ischemic encephalopathy (768.70-
768.73), hyperbilirubinemia (774.0-774.7), respiratory
distress syndrome (769), transient tachypnea of the newborn
(770.6), meconium aspiration (770.11-770.12), seizures
(779.0), sepsis of the newborn (771.8x), need for continuous
positive-pressure ventilation (939.0), and mechanical venti-
lation (967.0-967.2).
Statistical Analyses
The discharge records of interest with neonatal hospitaliza-
tion using the HCUP codebook variable NEOMAT, and in-
hospital births were identified using HOSPBRTH. We used
weighted analysis to produce nationally representative esti-
mates. Prevalence was described as annual frequency per
1000 in-hospital births. A nonparametric test for trend
(nptrend) including linear regression (Cochran–Armitage
test) was used for yearly trends, logistic regression was used
for risk factors and outcomes, and a generalized linear model
was used with a Poisson distribution for LOS and a gamma
distribution for TCH. Hospital charges were adjusted for
inflation to 2020 US dollars. The logistic regression results
were expressed as OR, Poisson regression, incidence rate ra-
tio (IRR), and generalized linear model regression as coeffi-
cients. Regressions were adjusted to the patient and
hospital characteristics and to labor and delivery complica-
tions. Analyses were performed using the “survey command”
options in Stata 15.0/IC (StataCorp).
Ethical Considerations
The HCUP NIS data are exempt from a review of the Medical
College of Wisconsin’s Institutional Review Board.
Results
Out of a total of 35 317 076 discharge records, we found 982
033 weighted records with birth trauma. From 2006 to 2014,
- 2021
annual birth trauma rates increased by 23% (from 25.3 to
31.1 per 1000 hospital births), with a 33% increase in scalp
injuries and a 16% decrease in other types of birth trauma
(Figure). The most common type of trauma was scalp
injury, followed by clavicular fracture, brachial plexus
injuries, and subdural and cerebral hemorrhage (Table I;
available at www.jpeds.com). Over time, the prevalence of
major birth trauma has decreased by 20% for brachial
plexus injuries and by 11% for clavicular fractures. There
were no changes in the prevalence of facial injuries and
other injuries to the skeleton.
Females had lower odds of having scalp injuries compared
with males. Asian or Pacific islanders had higher odds of scalp
injuries. Compared with scalp injuries alone, LGA (2.4-fold),
birth weight ³4500 g (4.5-fold), IDM (1.8-fold), and multiple
gestations (2-fold) are associated with higher odds of major
birth trauma. SGA/IUGR and low birth weight infants have
lower odds of any type of birth trauma. Infants who died
had higher odds of major birth trauma but lower odds of
scalp injuries (Table II).
Table III (available at www.jpeds.com) shows the
prevalence of various patient and hospital characteristics by
group: no birth trauma, major birth trauma, and scalp
injuries.
The annual prevalences of the following labor and delivery
complications are increasing: breech delivery, by 140%; other
malpresentations, by 56%; delivery by vacuum extraction, by
71%; and cesarean delivery, by 4.4% (Table IV). The yearly
trends for SGA/IUGR, LGA, IDM, and multiple gestations
Figure. Yearly trends in birth trauma, 2006-2014.
Neonatal Birth Trauma: Analysis of Yearly Trends, Risk Factors, and Outcomes
ORIGINAL ARTICLES
are increasing; however, the yearly trends for infants with
low birth weight and birth weight ³4500 g are decreasing.
Compared with no birth trauma, major birth trauma is
associated with higher odds of intrauterine asphyxia,
hypoxic-ischemic encephalopathy, seizures, and death. It
also has higher odds of hyperbilirubinemia, respiratory
distress syndrome (RDS) of the newborn, transient tachyp-
nea of the newborn, meconium aspiration, sepsis, and the
need for continuous positive airway pressure and mechanical
ventilation. We found that scalp injuries also increase the
odds of intrauterine asphyxia, hypoxic-ischemic encephalop-
athy, seizures, hyperbilirubinemia, transient tachypnea of the
newborn, meconium aspiration, sepsis, and the need for
continuous positive airway pressure. However, compared
with no birth trauma, scalp injuries had lower odds of death,
RDS, and the need for mechanical ventilation (Table V).
There is a trend toward increasing LOS from 2006 to 2014
(Table VI; available at www.jpeds.com), from 4.2 to 6.5 days
(56% increase in mean) for major birth trauma and from 2.7
to 2.9 days (7% increase in mean) for scalp injuries. However,
there was no change in the yearly trends of median LOS.
Compared with no birth trauma, there was increase in LOS
for major birth trauma (IRR, 1.15; 95% CI, 1.11-1.18;
P < .001) and a decrease for scalp injuries (IRR, 0.91; 95%
CI, 0.89-0.93; P < .001).
The mean TCH adjusted to 2020 dollars increased from
2006 to 2014 (Table VI), from $15 299 to $47 397 (210%
increase in mean) for major birth trauma, from $6085 to
$10 903 (79% increase in mean) for scalp injuries, and by
3
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the 2 types of birth trauma. Scalp injuries once thought to

Table II. Adjusted logistic regression of major birth be benign are now also associated with an increase in
trauma and scalp injuries morbidity; however, major birth trauma is associated with
Major birth much higher odds of morbidity and mortality, longer LOS,
Characteristics trauma Scalp injuries and greater TCH.
Patient characteristics A study using the 2003 HCUP Kid’s Inpatient Database
Female sex 1.05 (1.02-1.07)* 0.77 (0.76-0.78)†
Race
shows birth trauma rates similar to what we found in our
Caucasian Reference Reference study.4 By 2014, we found 6 more cases of birth trauma per
Black 0.90 (0.84-0.96)* 0.91 (0.81-1.02) 1000 in-hospital births compared with the 2006, owing an in-
Hispanic 1.04 (0.96-1.13) 0.91 (0.84-1.00)
Asian/Pacific Islander 1.00 (0.90-1.10) 1.30 (1.18-1.43)†
crease in scalp injuries. It is important to note that the inci-
Native American 0.96 (0.72-1.29) 0.85 (0.70-1.05) dence of major birth trauma is decreasing, as was also noted
Other 1.02 (0.93-1.12) 1.13 (0.95-1.33) in a population-based study from 2004 to 2013.22 On further
Public insurance 1.15 (1.09-1.21)† 1.10 (1.03-1.17)*
Median income for patient
analysis of major birth trauma, the most frequent causes—
ZIP code fracture of the clavicle, injury to the brachial plexus, and
First quartile Reference Reference other specified birth trauma—have decreased. As in other
Second quartile 1.00 (0.95-1.05) 1.02 (0.94-1.10)
Third quartile 0.94 (0.89-1.00) 1.11 (1.00-1.24)‡
studies, we found that Asians and Pacific Islanders are
Fourth quartile 0.90 (0.83-0.98)‡ 1.15 (0.99-1.34) more likely to experience an increase in scalp injuries, which
Died 2.41 (2.05 -2.85)† 0.34 (0.26-0.45)† is speculated to be due to a small maternal pelvis and large
SGA/IUGR 0.60 (0.54-0.68)† 0.79 (0.74-0.85)†
Low birth weight (<2500 g) 0.52 (0.48-0.56)† 0.32 (0.29-0.36)†
heads.23 This study also found that the same population
LGA 3.47 (3.32-3.63)† 1.47 (1.38-1.55)† has lower odds of major birth trauma. Our findings show
Birth weight ³ 4500 g 6.24 (5.41-7.21)† 1.38 (1.22-1.56)† that the rates of IDM and LGA are increasing over the years.
IDM 2.06 (1.89-2.26)† 1.14 (1.05-1.23)†
Multiple gestations 3.49 (3.30-3.69)† 1.70 (1.55-1.86)†
Gestational diabetes is a risk factor for macrosomia, defined
Hospital characteristics as birth weight ³4000 g,24 and mothers with pregnancy
Hospital region complicated by gestational diabetes are at increased risk for
Northeast Reference Reference
Midwest 0.93 (0.83-1.03) 0.95 (0.77-1.17)
planned or emergency cesarean delivery.25 These macroso-
West 1.10 (0.95-1.27) 1.07 (0.85-1.34) mic infants are at increased risk for shoulder dystocia, clavic-
South 0.89 (0.79-1.01) 1.40 (1.11-1.78)* ular fractures, brachial plexus injuries, and neonatal intensive
Hospital control
Government or private Reference Reference
care unit admission.26,27 Shoulder dystocia is an unpredict-
(collapsed category) able obstetric emergency that can result in significant neuro-
Government, nonfederal 0.80 (0.70-0.95)‡ 0.91 (0.60-1.38) logic injury and even death.7,28 Compared with females,
(public)
Private, not for profit 0.77 (0.66-0.91)* 0.71 (0.55-0.91)*
males are usually larger and grow more rapidly later in preg-
(voluntary) nancy,29 and thus are at greater risk of malposition and the
Private, investor-owned 0.62 (0.52-0.74)† 0.77 (0.57-1.05) need for cesarean delivery. In our study, males were at higher
(proprietary)
Private (collapsed category) 0.93 (0.76-1.14) 0.76 (0.54-1.08)
risk of scalp injuries.
Hospital location/teaching status Prolonged labor due to malposition leads to other
Rural Reference Reference neonatal complications, such as fetal distress and asphyxia.
Urban nonteaching 0.93 (0.82-1.03) 1.03 (0.79-1.29)
Urban teaching 0.83 (0.72-0.96) 0.95 (0.72-1.26)
The incidence of cesarean delivery is increasing slowly after
Hospital bed size peaking in 2009.13 During the study period, there was a
Small Reference Reference 4.4% increase in cesarean deliveries, and the prevalence of
Medium 0.94 (0.83-1.05) 1.19 (0.99-1.43)
Large 0.93 (0.83-1.04) 1.22 (1.03-1.44)‡
LGA infants also increased. It is possible that many of the ce-
sarean deliveries were performed electively for a malposi-
Logistic regression was performed and adjusted to patient and hospital characteristics. tioned or large infant. Recent American College of
*P < .01.
†P < .001. Obstetricians and Gynecologists guidelines note that predict-
‡P < .05. ing macrosomia is imprecise. Scheduled cesarean delivery
may be beneficial to prevent adverse infant outcomes for fetal
62% for cases of no birth trauma. Compared with no birth weight >4500 g in pregnant women with diabetes and
trauma, there was increase in TCH for major birth trauma >5000 g in pregnant women without diabetes.30 Therefore,
(coefficient, 0.34; 95% CI, 0.30-0.38; P < .001) and no we speculate that the decrease in major birth trauma is
difference for scalp injuries (coefficient, 0.28; 95% CI, related to increased cesarean deliveries in the presence of
0.02 to 0.07; P not significant). risk factors including malposition, breech presentation, and
macrosomia.
Discussion Instrumental deliveries, such as forceps and vacuum ex-
tractions, are important risk factors for birth trauma. Com-
This study establishes that the annual rate of neonatal birth mon indications for use of these procedures include
trauma is increasing owing to an increase in scalp injuries. maternal exhaustion, fetal distress, and arrest of the second
Patient characteristics, risk factors, and outcomes differ in stage of labor. The probability of successful extraction is

4 Gupta and Cabacungan

- 2021 ORIGINAL ARTICLES

Table IV. Yearly trends in factors associated with birth trauma, 2006-2014*
Factors 2006 2007 2008 2009 2010 2011 2012 2013 2014 P value†
Labor and delivery complications
Breech delivery and extraction 0.92 1.00 1.26 1.57 1.49 1.38 1.59 1.76 2.21 <.001
Other malpresentation and malposition 2.06 1.92 2.13 2.39 2.57 2.51 2.56 2.83 3.21 <.001
Forceps delivery 0.50 0.37 0.65 0.59 0.40 0.46 0.56 0.55 0.53 .304
Delivery by vacuum extraction 1.92 2.10 2.75 2.19 2.75 2.92 2.85 2.95 3.28 <.001
Precipitous delivery 0.40 0.39 0.47 0.41 0.54 0.49 0.57 0.60 0.69 <.001
Maternal anesthesia and analgesia 0.25 0.23 0.17 0.18 0.22 0.19 0.19 0.21 0.23 .106
Abnormal uterine contractions 0.18 0.13 0.18 0.25 0.18 0.24 0.26 0.28 0.30 <.001
Other specified complications 7.08 8.75 10.90 7.65 9.15 11.27 11.02 12.16 15.02 <.001
Unspecified complications 0.02 0.04 0.05 0.03 0.05 0.04 0.04 0.06 0.06 <.001
Complications without cesarean delivery 12.85 14.46 17.76 14.71 16.69 18.77 18.93 20.63 24.53 <.001
Cesarean delivery 319.25 332.2 332.69 341.27 335.48 337.45 338.22 336.78 333.2 <.001
Demographic factors
SGA/IUGR 16.14 17.08 18.47 20.24 22.21 22.51 24.74 28.22 30.90 <.001
Low birth weight (<2500 g) 52.75 52.70 50.70 51.72 53.65 49.98 51.16 50.76 50.16 <.001
LGA 52.15 53.19 50.50 51.58 52.69 52.38 55.17 54.68 55.63 <.001
Birth weight ³4500 g 3.35 2.96 2.75 3.10 2.55 2.35 2.28 2.27 2.40 <.001
IDM 9.68 10.12 10.49 11.59 13.26 13.24 14.68 16.08 18.76 <.001
Multiple gestations 58.82 62.21 61.09 67.62 72.36 69.32 71.24 73.11 77.50 <.001

P values < .05 are significant.

*Per 1000 discharge records.
†Tests of trend (nptrend) were performed.

high when vacuum delivery is performed at full cervical dila-
tion, with the fetal head at station 1 or lower, and with a non-
macrosomic fetus. The increased use of instrumental
deliveries has resulted in an increased incidence of birth
trauma.31,32 Deliveries by vacuum extraction can cause
such neonatal complications as scalp edema, scalp bruising,
cephalhematoma, and, less commonly, subgaleal and intra-
cranial hemorrhage.33 Compared with successful extraction,
failed vacuum extraction is associated with higher odds of
neonatal complications.34
In our study, the rate of forceps deliveries remained con-
stant, but there was an almost 70% increase in vacuum
extraction. The increase in scalp injuries could be attributed
to the increase in vacuum deliveries; however, during life-
threatening hypoxia/asphyxia, the benefits of using instru-
mentation outweigh the risk of scalp injuries.
Pregnancies with multiple gestation are a known risk for
birth trauma. In the US, the rates of multiple gestation
increased from 34.5 per 1000 births in 2010 to 35.1 per
1000 births in 2014.35 We found a 37.1% increase in multiple
gestations over the study period. Both types of birth trauma
were increased, and the odds of major birth trauma were
twice as high as the odds of scalp injuries. Studies show
that multiple gestations are at high risk of growth restriction,
deformation, and malposition.36 The interval for delivery of
the second twin might be prolonged, leading to cesarean de-
livery and other adverse outcomes.
Compared with no birth trauma, such outcomes as
hypoxic-ischemic encephalopathy, seizures, death, RDS,
and sepsis are associated with higher odds of major birth
trauma and scalp injuries, related to prolonged LOS and
increased resource utilization leading to higher TCH.

Table V. Multivariable analysis of birth trauma outcomes

Major birth trauma Scalp injuries
Outcomes No birth trauma Unadjusted Adjusted Adjusted Adjusted
Intrauterine asphyxia Reference 2.80 (2.37-3.31)* 2.22 (1.74-2.84)* 2.06 (1.71-2.50)* 2.06 (1.71-2.50)*
Hypoxic-ischemic encephalopathy Reference 19.18 (15.97-23.04)* 5.44 (3.52-8.42)* 1.96 (1.22-3.14)* 1.96 (1.22-3.14)*
Hyperbilirubinemia Reference 1.67 (1.62-1.72)* 1.43 (1.36 -1.50)* 2.06 (1.97-2.16)* 2.06 (1.97-2.16)*
RDS Reference 1.92 (1.80-2.06)* 1.46 (1.30-1.64)* 0.64 (0.58-0.71)* 0.64 (0.58-0.71)*
Transient tachypnea of the newborn Reference 2.11 (2.01-2.21)* 1.54 (1.42-1.66)* 1.26 (1.19-1.34)* 1.26 (1.19-1.34)*
Meconium aspiration Reference 3.15 (2.85-3.48)* 1.75 (1.49-2.06)* 1.62 (1.46-1.80)* 1.62 (1.46-1.80)*
Seizures Reference 16.82 (15.21-18.59)* 9.62 (8.20-11.29)* 2.14 (1.80-2.55)* 2.14 (1.80-2.55)*
Sepsis of the newborn Reference 2.78 (2.64-2.93)* 1.72 (1.58-1.87)* 1.20 (1.10-1.31)* 1.20 (1.10-1.31)*
Died Reference 2.63 (2.33-2.96)* 2.63 (2.21-3.12)* 0.29 (0.21-0.39)* 0.29 (0.21-0.39)*
Procedures
Continuous positive airway pressure Reference 2.68 (2.50-2.87)* 1.83 (1.63-2.04)* 1.22 (1.09-1.36)† 1.22 (1.09-1.36)†
Mechanical ventilation Ref. 3.28 (3.09-3.49)* 2.37 (2.13-2.63)* 0.75 (0.67-0.83)* 0.75 (0.67-0.83)*

Logistic regressions were performed and adjusted to patient and hospital characteristics and labor and delivery complications.
P values of < .05 are significant.
*P < .001.
†P < .01.

Neonatal Birth Trauma: Analysis of Yearly Trends, Risk Factors, and Outcomes 5
THE JOURNAL OF PEDIATRICS  www.jpeds.com
Therefore, obstetricians play an essential role in preventing
birth trauma by earlier delivery decisions in cases of fetal
distress and consideration of delivery methods in the pres-
ence of risk factors. Birth trauma is one of the perinatal
care quality indicators37; therefore, a decrease in major birth
trauma might indicate improved obstetric care. However,
even with the best obstetric care, some birth trauma is un-
avoidable, so good communication with families and good
documentation can prevent future litigation. This study
demonstrates that scalp injuries are also associated with
increased morbidity. Scalp injuries could be a marker of
head injury leading to hypoxic-ischemic encephalography,
seizures, and other newborn illnesses, such as sepsis and hy-
perbilirubinemia.
This study has some limitations. The NIS is an administra-
tive database in which some cases are missed because of no
neonatal or maternal diagnosis. Moreover, in some instances,
birth trauma might not be visible at birth and may be diag-
nosed only after discharge. In one study, 13.8% of clavicular
fractures were diagnosed after discharge.38 Another limitation
is the possible variation among hospital coding practices.
Moreover, variables can change over time, suggesting
improved coding practices and an increased number of diag-
noses reported to the HCUP. However, the finding that the
prevalence of scalp injuries increased while the other types of
birth trauma decreased with no significant change in the inci-
dence trend line indicates that this change did not affect our
results. Despite these limitations, this large cross-sectional
study identified birth trauma rate trends over the years as an
effect of change in epidemiology and obstetric management.
Most previous studies of birth trauma included only specific
types of birth trauma, such as clavicular fracture or brachial
plexus palsy.38-40 The strength of this study is its inclusion all
birth traumas and differentiated scalp injury from major birth
trauma. Our large sample size allowed us to report rates for
specific types of birth trauma, risk factors, and outcomes.
We speculate that the decrease in major birth trauma
might be due to an increase in cesarean delivery in the pres-
ence of risk factors and delivery by vacuum extraction when
done for fetal distress and the probability of successful extrac-
tion is high. However, this increase in vacuum extraction has
led to an increase in scalp injuries. Scalp injuries are also asso-
ciated with an increase in morbidity. This information may
allow health professionals to identify ways to reduce birth
trauma and associated infant morbidity and predict the out-
comes according to the types of birth trauma. There should
be an individualized delivery plan for each birth considering
maternal and neonatal risk factors for birth trauma. n
We thank Dr Michael R. Uhing for his critical review of the manu-
script; he declares no conflicts of interest.
Submitted for publication Apr 8, 2021; last revision received Jun 27, 2021;
accepted Jun 30, 2021.
Reprint requests: Ruby Gupta, MBBS MS, Children’s Corporate Center, 999
North 92nd Street, Suite C410, PO Box 1997, Wauwatosa, WI 53226. E-mail:
rgupta@mcw.edu
6 Gupta and Cabacungan
Volume -
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1. Akangire G, Carter B. Birth injuries in neonates. Pediatr Rev 2016;37:
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2. Parker LA. Part 1: Early recognition and treatment of birth trauma: in-
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Table I. Yearly trends in birth trauma subtypes, 2006-2014*

Birth trauma injuries 2006 2007 2008 2009 2010 2011 2012 2013 2014 P value†
Scalp injuries 19.87 21.13 20.93 25.02 24.64 23.30 23.29 24.32 26.46 .000
Subdural and cerebral hemorrhage 0.37 0.33 0.35 0.33 0.28 0.28 0.29 0.35 0.35 .020
Fracture of the clavicle 2.18 2.14 2.16 1.98 2.07 2.08 1.98 1.99 1.93 .000
Other injuries to the skeleton 0.28 0.25 0.28 0.26 0.24 0.30 0.28 0.32 0.28 .161
Spine and spinal cord injuries 0.00 0.00 0.00 0.00 0.01 0.00 0.00 0.00 0.00 .000
Facial nerve injury and palsy 0.22 0.19 0.22 0.18 0.18 0.23 0.21 0.22 0.22 .107
Brachial plexus injury 1.09 0.95 0.89 0.93 0.97 0.93 0.90 0.83 0.87 .000
Other cranial and peripheral nerve injuries 0.03 0.02 0.04 0.02 0.04 0.04 0.03 0.02 0.03 .000
Other specified birth trauma 1.35 1.43 1.47 1.44 1.28 1.39 1.19 1.16 1.05 .000
Unspecified birth trauma 0.09 0.10 0.11 0.10 0.09 0.07 0.10 0.08 0.10 .016

P values < .05 are significant.

*Per 1000 discharge records.
†Tests of trend (nptrend) were performed.

7.e1 Gupta and Cabacungan

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Table III. Patient and hospital characteristics by no birth trauma, major birth trauma, and scalp injuries
No birth trauma Major birth trauma Scalp injuries
Characteristics (n = 34 335 044), % (n = 179 088), % (n = 802 945), % P value*
Patient characteristics <.001
Sex
Male 50.94 52.01 58.02
Female 48.90 47.88 41.81
Missing 0.16 0.11 0.17
Race <.001
Caucasian 43.02 43.02 42.75
Black 11.40 10.95 10.41
Hispanic 18.51 19.51 18.52
Asian/Pacific Islander 4.20 3.65 6.17
Native American 0.71 0.62 0.63
Other 5.09 5.14 5.84
Missing 17.07 17.10 15.69
Insurance .003
Private 47.92 44.41 47.77
Public 49.22 52.68 49.41
Missing 2.86 2.91 2.82
Median income for patient ZIP code <.001
First quartile 26.72 28.31 24.89
Second quartile 24.89 25.76 23.62
Third quartile 24.18 23.60 25.01
Fourth quartile 22.37 20.18 24.30
Missing 1.83 2.15 2.18
Died 0.31 0.82 0.06 <.001
SGA/IUGR 2.22 1.67 1.74 <.001
Low birth weight (<2500 g) 5.22 5.74 2.38 <.001
LGA 5.20 16.00 7.66 <.001
Birth weight ³4500 g 0.26 1.58 0.36 <.001
IDM 1.28 4.23 1.60 <.001
Multiple gestations 6.70 17.26 8.04 <.001
Hospital characteristics
Hospital region <.001
Northeast 14.45 15.80 14.87
Midwest 19.22 19.27 16.93
West 33.67 35.72 30.45
South 21.96 19.31 25.47
Missing 10.70 9.90 12.28
Hospital control .379
Government or private (collapsed category) 39.57 43.80 39.48
Government, nonfederal (public) 4.38 4.50 4.76
Private, not for profit (voluntary) 14.11 12.66 12.46
Private, investor-owned (proprietary) 6.67 5.15 6.18
Private (collapsed category) 2.65 3.07 2.30
Missing 32.62 30.82 34.82
Hospital location/teaching status <.001
Rural 9.79 10.51 8.58
Urban nonteaching 36.63 32.98 35.18
Urban teaching 42.26 45.88 43.35
Missing 11.32 10.63 12.89
Hospital bed size .016
Small 9.75 10.07 8.72
Medium 23.67 24.07 23.68
Large 55.27 55.23 54.71
Missing 11.32 10.63 12.89

P values < .05 are significant.

*Pearson c2 test.

Neonatal Birth Trauma: Analysis of Yearly Trends, Risk Factors, and Outcomes 7.e2
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THE JOURNAL OF PEDIATRICS

Table VI. Yearly trends in LOS and TCH for no birth trauma, major birth trauma, and scalp injuries, 2006-2014
Variables 2006 2007 2008 2009 2010 2011 2012 2013 2014 P value†
LOS, d*
No birth trauma .602
Mean  SE 3.25  0.05 3.25  0.05 3.23  0.06 3.37  0.05 3.51  0.06 3.37  0.06 3.43  0.03 3.42  0.03 3.44  0.03
Median (IQR) 2 (2-3) 2 (2-3) 2 (2-3) 2 (2-3) 2 (2-3) 2 (2-3) 2 (2-3) 2 (2-3) 2 (2-3)
Major birth trauma .100
Mean  SE 4.15  0.18 4.44  0.19 4.41  0.23 4.91  0.29 4.99  0.24 5.24  0.24 5.07  0.21 5.96  0.30 6.47  0.39
Median (IQR 2 (2-3) 2 (2-3) 2 (2-3) 2 (2-3) 2 (2-3) 2 (2-3) 2 (2-3) 2 (2-3) 2 (2-3)
Scalp injuries .697
Mean  SE 2.67  0.04 2.74  0.05 2.67  0.04 2.80  0.05 2.84  0.05 2.94  0.07 2.91  0.04 2.90  0.04 2.90  0.04
Median (IQR) 2 (2-3) 2 (2-3) 2 (2-3) 2 (2-3) 2 (2-3) 2 (2-3) 2 (2-3) 2 (2-3) 2 (2-3)
TCH, $‡,§


No birth trauma .000

www.jpeds.com
Mean  SE 9333  387 10 712  508 10 444  508 11 283  495 12 713  550 13 014  791 13 737  363 14 417  376 15 126  382
Median (IQR) 2636 (1817-4187) 2778 (1925-4439) 2911 (2003-4658) 3053 (2087-4947) 3303 (2222-5347) 3365 (2261-5504) 3498 (2336-5789) 3707 (2460-6203) 3910 (2599-6585)
Major birth trauma .000
Mean  SE 15 299  1236 18 470  1577 21 237  2635 22 705  2213 23 389  1937 27 869  2199 31 503  2254 40 634  3705 47 397  4621
Median (IQR) 3262 (2146-6562) 3326 (2146- 6562) 3550 (2376-7077) 3774 (2442-8041) 4079 (2626-9069) 4404 (2733-9697) 4504 (2916-10 232) 4879 (2994-12 536) 5178 (3198-13 099)
Scalp injuries .000
Mean  SE 6085  332 6760  385 7397  499 7664  557 8511  453 10 119  912 9797  444 10 523  537 10 902  498
Median (IQR) 2811 (1870-4644) 2852 (1947-4763) 3175 (2182-5238) 3227 (2159-5287) 3550 (2326-6169) 3819 (2403-6875) 3856 (2519-6499) 4150 (2714-7009) 4337 (2800-7565)
*Poisson distribution, adjusted to patient and hospital characteristics.
†P values < .05 are significant.
‡Generalized linear model with g-distribution and adjusted to patient and hospital characteristics.
§Adjusted to January 2020 $.
Gupta and Cabacungan

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