This article has Open Peer Review reports available.
The study of etiological and demographic characteristics of neonatal mortality and morbidity - a consecutive case series study from Pakistan
© Manzar et al.; licensee BioMed Central Ltd. 2012
Received: 6 April 2012
Accepted: 21 August 2012
Published: 27 August 2012
To determine the etiology, management, bacteriological spectrum and outcome of neonatal patients admitted in Civil Hospital Karachi (CHK) and to examine the factors associated with it.
This hospital based descriptive study of 1463 patients from both sexes who were admitted to Paediatric department, CHK from 1st January 2008 till 31st December 2010 with an established cause according to modified Wigglesworth classification and fulfilling other inclusion criteria were included in the study. Data regarding their demographic profile and potential risk factors was collected on a well structured proforma. Cases were followed until discharge or expiry. Data was analyzed using descriptive statistics.
The male to female ratio in our study was 1.12:1. Seven hundred and thirty-four patients were delivered at home (50.2%) and 1010 were less than 7 days old (69%). Out of the total cohort of expired subjects, 89 participants (74.8%) were < 7 days of life. Mortality was more in neonates born at home in rural areas to illiterate mother; 74 patients (62.2%). Most of the deaths; 57 were in neonates suffering from specific infections (47.9%) followed by 38 deaths in immaturity group (31.9%) and 19 related to asphyxial conditions (15.9%). The most common isolates were Staphylococcus aureus (28.7%) followed by Klebsiella (24.8%) and Pseudomonas aeruginosa (16.6 ). One hundred and nineteen (8.13%) of the neonates died in our study group.
These results suggest that neonates with illiterate mothers with high parity and below average socioeconomic level were more susceptible to mortality in the early neonatal period. Most of the cases of mortality were due to specific infections.
Every year 4 million neonates die during the first four weeks of life . Out of these mortalities, 99% take place in the developing countries of the world, where there are a lack of proper health care facilities . Pakistan accounts for 7% of the global neonatal mortality with an estimated 298000 neonatal deaths annually and a reported mortality rate of 56 per 1000 live births . Infection, immaturity and asphyxia account for 87% of neonatal deaths worldwide . Bacterial sepsis is considered to be an important cause of neonatal morbidity and mortality. The organisms isolated in the developed part of the world in cases of sepsis differ greatly from those seen in developing countries and sometimes within the same countries the organism isolated are very different. With the ever changing knowledge of bacteriological spectrum, simple and inexpensive interventions are the need of the time during prenatal, natal and postnatal period to counter these organisms. These interventions include proper nutrition, immunization and supplementation of the pregnant mother followed by skilled delivery, early breast feeding of the neonate and in case of morbidity, appropriate management of the neonate to prevent mortality [5–8]. One of the United Nation’s Millennium Development Goal aspires to reduce the under 5 childhood mortality to 30 per 1000 live births by 2015 and since 41% of all deaths in children under 5 years of age is shared by neonatal deaths, our focus should be on reducing neonatal mortality . In order to achieve this goal we need to address all the factors associated with neonatal morbidity and mortality. New evidence suggests that demographic factors like maternal education, socioeconomic and parity status also plays an important role in neonatal mortality and morbidity . A lot of studies on neonatal morbidity and mortality are available from the developed countries, however, there is a paucity of data from developing countries like Pakistan because there is neither a national database nor any relevant authority to collect and standardize the data but individual studies have been carried out in local cities in the past. These studies have many limitations and have mainly focused on neonatal sepsis while ignoring other important factors contributing to high neonatal mortality and morbidity rate. The magnitude of the problem coupled with the parents anguish as well as cost of admission and the treatment expenditure incurred to the state compelled us to carry out our research. Factors such as patient’s age, gender, weight, presenting symptoms, treatment and their outcome in terms of mortality and morbidity as well as demographic factors were taken into consideration. The main objective of our study was to determine the etiology, management, bacteriological spectrum and outcome of neonatal patients admitted in Civil Hospital, Karachi (CHK) and to examine the factors associated with it.
Demographic and risk factors in the household of the subjects
Maternal age (years)
Baseline characteristics of patients
No. of patients
(n = 1463)
(n = 119)
Mean ± std. dev
5.12 ± 1.3 days
Place of birth
Mean ± std. dev
2.42 ± 1.5 kg
Timing of neonatal death
Early (0–7 days)
Late (8–28 days)
Neonatal morbidity and mortality based on modified Wigglesworth’s hierarchical classification
No. of patients
Culture positive bacterial isolates from patients
No. of Patients
N = 205
Gram Positive Bacteria
Gram Negative Bacteria
The neonatal period carries the highest risk of death in human life . The risk of children dying under the age of five has fallen, but the number of deaths in neonatal period has actually increased . In the present study, neonates with illiterate mothers with high parity and below average socioeconomic level were more susceptible to mortality in the early neonatal period. This is due to the fact that in low income countries there is a major focus on maternal death and under 5 children deaths but less attention has been paid to neonatal morbidity and mortality . Neonatal deaths represent an increasing proportion of under 5 deaths . Male to female ratio in our study was similar to other such studies carried all over the world [17, 18]. The majority of neonates admitted were less than 7 days of life which is comparable to a study done in France in which the mean age of neonates was 7 ± 1 day . A study carried out by Afsheen et al. documented a morbidity rate of 82.1% in neonates less than 7 days old and early neonatal mortality was also high as has been seen in this study . The mortality rate in our study was 8.13% which is comparatively low when compared to 13% , 15% , 16.4% , and 9.6% , from studies carried out in Nigeria, France, India and Pakistan respectively. However, this figure must be taken with caution since some of the patients were referred or left against medical advice and hence the actual mortality rate may be higher than seen in the study. In our study, majority of the patients that died were those that were home delivered (62.2%) in rural areas potentially because of the delay in reaching the center as well as the unhygienic cord practices and lack of proper antenatal care . A study carried out in squatter settlements of Karachi showed a 43.9% rate of birth at homes . However, in our study the rate of delivery at home is more. This may be due to the fact that study center also serves a large part of rural Sindh. These traditional birth practices are still very common in rural parts of Sindh, where local midwives are not properly trained to handle birth care leading to delayed presentation and high mortality. In our study, highest mortality was seen in neonates with specific conditions (infections). Similar findings have been observed in Africa where 38.3% of morbidity and 43.7% of mortality was attributed to neonatal infection and sepsis . Eighteen percent, 16.8% and 91% of deaths in Nigeria, France and Northern parts of India have been attributed to specific infections respectively [19, 20, 22]. Furthermore, our finding that infections including sepsis, pneumonia and meningitis, are important contributors to neonatal deaths is consistent with recent studies from developing countries and emphasizes the importance of monitoring delivery and hospital acquired infections . Immature neonates contributed the second most common cause of neonatal death which was consistent with other studies in which prematurity and LBW were the major factors [20, 24]. In a study carried out in rural India, preterm deliveries contributed to 30% and infection based deaths contributed to 25% of deaths taking place in the early neonatal period. However the proportion of deaths due to infection based causes tend to increase in the late neonatal period . In another study carried out in Lahore most of the deaths were attributed to prematurity (11.4%) followed by asphyxia (7%) and infection (4.2%) . Majority of the deaths due to preterm delivery can be prevented by proper antenatal care and by promoting maternal health . Antenatal care four times during pregnancy by a skilled medical provider is recommended by WHO since 1944 . and is shown to be associated with improved neonatal morbidity and mortality [28, 29]. Policy and programme attention is shifting towards a maternal, newborn, and child health (MNCH) continuum of care, instead of competing calls for mother or child, the focus is on universal coverage of effective interventions, integrating care throughout the lifecycle and building a comprehensive and responsive health system.
Gram negative infections (62.9%) were more common than gram positive organisms (37.1). The most common gram positive isolate was Staphylococcus aureus (28.7%) while Klebsiella was the most common isolate (22.9%) in the gram negative group. A study carried out on neonatal sepsis in Pakistan documented S. aureus to be the most common organism in the gram positive group however E. coli was the commonest agent seen in the gram negative group . Similarly, in another study conducted by Rabia et al. Enterobacter was the commonest gram negative isolate while S. aureus was seen as the commonest gram positive isolate . This shows the variable spectrum of bacteriological isolates seen in various studies and even in studies in different cities of the same country. Evidence has shown that certain demographic and social factors are implicated in neonatal mortality and morbidity. In this study, neonates with illiterate multiparous mothers of below average socioeconomic status were prone to mortality and morbidity. This conclusion has also been drawn in other studies carried out in South Asia [10, 18].
Finally this study fulfills the objective set by the study protocol for this project of assessing the socio-demographic factors and causative agents of neonatal morbidity and mortality as well as the bacteriological spectrum and outcome of subjects brought to CHK. This study holds important implications for public health and highlights the high prevalence of morbidity and mortality in the Pakistani neonate population. However there remain certain limitations due to the hospital based nature of the study as well as the mortality rate was potentially less conclusive due to the exclusion of patients lost to follow-up, brought dead, referred or left against medical advice. In addition CHK receives patients from other cities and rural areas, so this may not represent the true statistics of the area of our study as well as cannot be generalized for the whole population. A large scale prospective multi-center study with appropriate power is recommended for further evaluating the ethnicity, geographic differences and other risk factors for neonatal mortality and morbidity in underdeveloped countries like Pakistan.
On the basis of our study we conclude that the most common cause of neonatal mortality was due to specific infections. Gram negative bacteria were the most common organisms isolated. Early neonatal period was the time when neonates were most susceptible to a high mortality rate. Literacy rate of mothers correlated significantly with neonatal morbidity with the highest 78.8% of cases in neonates with illiterate mothers. In most of the cases neonates belonged to rural mothers with high parity and below average socioeconomic level.
None to declare.
- Zupan J: Perinatal mortality in developing countries. N Engl J Med. 2005, 352: 2047-2048. 10.1056/NEJMp058032.View ArticlePubMedGoogle Scholar
- Ngoc NT, Merialdi M, Abdel-Aleem H, Carroli G, Purwar M, Zavaleta N, et al: Causes of stillbirths and early neonatal deaths: Data from 7933 pregnancies in six developing countries. Bull World Health Organ. 2006, 84: 699-705. 10.2471/BLT.05.027300.View ArticlePubMedPubMed CentralGoogle Scholar
- Lander T: Neonatal and perinatal mortality: country, regional and global estimates. 2006, Geneva: WHOGoogle Scholar
- Lawn JE, Cousens S, Zupan J: 4 million neonatal deaths: when? Where? Why?. Lancet. 2005, 365: 891-900. 10.1016/S0140-6736(05)71048-5.View ArticlePubMedGoogle Scholar
- Darmstadt GL, Walker N, Lawn JE, Bhutta ZA, Haws RA, et al: Saving newborn lives in Asia and Africa: cost and impact of phased scale-up of interventions within the continuum of care. Health Policy Plan. 2008, 23: 101-117.View ArticlePubMedGoogle Scholar
- Bhutta ZA, Darmstadt GL, Hasan BS, Haws RA: Community-based interventions for improving perinatal and neonatal health outcomes in developing countries: a review of the evidence. Pediatrics. 2005, 115: 519-617.PubMedGoogle Scholar
- Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, et al: Evidence-based, costeffective interventions: how many newborn babies can we save?. Lancet. 2005, 365: 977-988. 10.1016/S0140-6736(05)71088-6.View ArticlePubMedGoogle Scholar
- Abhimanyu N, Sanjay PZ, Suresh U, Shrikant IB: Neonatal Morbidity and Mortality in Tribal and Rural Communities in Central India. Indian J Community Med. 2011, 36 (2): 150-158. 10.4103/0970-0218.84137.View ArticleGoogle Scholar
- Oestergaard MZ, Inoue M, Yoshida S, Mahanani WR, Gore FM, et al: Neonatal Mortality Levels for 193 Countries in 2009 with Trends since 1990: A Systematic Analysis of Progress, Projections, and Priorities. PLoS Med. 2011, 8 (8): e1001080-10.1371/journal.pmed.1001080.View ArticlePubMedPubMed CentralGoogle Scholar
- Baqui AH, Darmstadt GL, Williams EK, Kumar V, Kiran TU, et al: Rates, timings and causes of neonatal deaths in rural India: implications for neonatal health programmes. Bull World Health Organ. 2006, 84: 706-713. 10.2471/BLT.05.026443.View ArticlePubMedPubMed CentralGoogle Scholar
- Mirzrah EM: Neonatal seizures and neonatal epileptic syndrome. Neural Clin. 2001, 19: 427-463. 10.1016/S0733-8619(05)70025-6.View ArticleGoogle Scholar
- Jamal H: Estimation of multidimensional poverty in Pakistan. Social policy and development centre. 2009, 79: 1-14.Google Scholar
- Wigglesworth JS: Classification of perinatal deaths. Soz Praventivmed. 1994, 39: 11-14. 10.1007/BF01369938.View ArticlePubMedGoogle Scholar
- Winbo IG, Serenius FH, Dahlquist GG, Kallen BANICE: A new cause of death classification for still births and neonatal deaths. Neonatal and Intrauterine death classification according to etiology. Int J Epidemiol. 1998, 27: 499-504. 10.1093/ije/27.3.499.View ArticlePubMedGoogle Scholar
- Chang JY, Lee KS, Hahn WH, Chung SH, Choi YS, Shim KS, et al: Decreasing trends of neonatal and infant mortality in Korea: compared with Japan, USA and OECD nations. J Korean Med Sci. 2011, 26 (9): 1115-1123. 10.3346/jkms.2011.26.9.1115.View ArticlePubMedPubMed CentralGoogle Scholar
- Black RE, Cousens S, Johnson HL, Lawn JE, Rudan I, Bassani DG, et al: Global, regional and national causes of child mortality in 2008: a systematic analysis. Lancet. 2010, 375 (9730): 1969-1987. 10.1016/S0140-6736(10)60549-1.View ArticlePubMedGoogle Scholar
- Shams R, Khan N, Hussain S: Bacteriology & Anti-Microbial Susceptibility of Neonetal Septicemia in NICU, PIMS, Islamabad-A Tertiary Care Hospital of Pakistan. Ann Pak Inst Med Sci. 2010, 6 (4): 191-195.Google Scholar
- Ayaz A, Saleem S: Neonatal Mortality and Prevalence of Practices for Newborn Care in a Squatter Settlement of Karachi, Pakistan: A Cross-Sectional Study. PLoS One. 2010, 5 (11): e13783-10.1371/journal.pone.0013783.View ArticlePubMedPubMed CentralGoogle Scholar
- Kouéta F, Yé D, Dao L, Néboua D, Sawadogo A: Neonatal morbidity and mortality in 2002–2006 at the Charles de gulle pediatric hospital (France). Child Care Health Dev. 2004, 30 (6): 699-709. 10.1111/j.1365-2214.2004.00485.x.View ArticleGoogle Scholar
- Owa JA, Osinaike AI: Neonatal morbidity and mortality in Nigeria. Indian J Pediatr. 1998, 65 (3): 441-449. 10.1007/BF02761140.View ArticlePubMedGoogle Scholar
- Emmanuel D: Study on maternal mortality and neonatal morbidity in Africa. J rural integrated relief service-Ghana. 2007Google Scholar
- Kumar M, Paul VK, Kapoor SK, Anand K, Deoraria AK: Neonatal outcomes at a subdistrict hospital in north India. J Trop Pediatr. 2002, 48 (1): 43-46. 10.1093/tropej/48.1.43.View ArticlePubMedGoogle Scholar
- Zaidi AK, Huskins WC, Thaver D, Bhutta ZA, Abbas Z, Goldman DA: Hospital-acquired neonatal infections in developing countries. Lancet. 2005, 365: 1175-88. 10.1016/S0140-6736(05)71881-X.View ArticlePubMedGoogle Scholar
- Modi N, Kirubakaran C: Reasons for admission,causes of death and costs of admission to a tertiary neonatal referral unit in India. J Trop Pediatr. 1995, 4 (2): 99-102.View ArticleGoogle Scholar
- Seyal T, Husnain F, Anwar A: Audit of Neonatal Morbidity and Mortality at Neonatal Unit of Sir Gangaram Hospital Lahore. Ann King Edward Med Uni. 2011, 17 (1): 9-13.Google Scholar
- Rashid AKM, Rasul CHH, Hafiz SM: Neonatal mortality: a scenario in a tertiary level hospital of developing country. Pediatr Rep. 2010, 2 (1): e9-View ArticleGoogle Scholar
- Berg CJ: Prenatal care in developing countries: The World Health Organization technical working group on antenatal care. J Am Med Womens Assoc. 1995, 50: 182-186.PubMedGoogle Scholar
- Carroli G, Villar J, Piaggio G, Khan-Neelofur D, Gulmezoglu M, et al: WHO systematic review of randomised controlled trials of routine antenatal care. Lancet. 2001, 357: 1565-1570. 10.1016/S0140-6736(00)04723-1.View ArticlePubMedGoogle Scholar
- Ba'aqeel H, Piaggio G, Lumbiganon P, Miguel Belizan J, et al: WHO antenatal care randomised trial for the evaluation of a new model of routine antenatal care. Lancet. 2001, 357: 1551-1564. 10.1016/S0140-6736(00)04722-X.View ArticlePubMedGoogle Scholar
- Muhammad Z, Ahmed A, Hayat U, Wazir MS, Rafiyatullah , Waqas H: Neonatal sepsis: causative bacteria and their resistance to antibiotics. J Ayub Med Coll Abbottabad. 2010, 22 (4): 33-36.PubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2431/12/131/prepub
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.