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Prevalence of perinatal asphyxia and its associated factors among live birth in Khartoum, Sudan: a hospital-based cross-sectional study

BMC Pediatrics volume 25, Article number: 150 (2025) Cite this article

Abstract

Background

Perinatal asphyxia is one of the leading causes of neonatal morbidity and mortality in the world. While there is much published data on the epidemiology of perinatal asphyxia in African countries, there is a lack of data on this topic in Sudan, which is the third-largest country in Africa. This study aimed to determine the prevalence of perinatal asphyxia and its associated factors among neonates delivered at Saad Abuelela Maternity Hospital, Sudan.

Methods

A cross-sectional study was conducted in Saad Abuelela Maternity Hospital, Sudan. Questionnaires were used to collect maternal sociodemographic, obstetric, and clinical data. The neonates’ clinical data (birth weight, sex of newborn, and Apgar score) were also collected and recorded. Multivariate binary analysis was performed.

Results

Six hundred and nineteen mother-neonate pairs were included in the study. The mothers’ median (IQR) age and parity was 27.0 (23.0–32.0) years and 3(1–5), respectively. Seventy (11.3%) neonates had perinatal asphyxia. In univariate analysis, the odds of perinatal asphyxia were increased in employed mothers, rural residents, cesarean delivery, preterm infants, and low birth weight neonates. There was no association between age, parity, mother education, mother anemia, sex of the neonates, and perinatal asphyxia. In multivariate analysis, the odds (adjusted) of perinatal asphyxia were increased in cesarean delivery (adjusted odds ratio [aOR] = 2.31, 95.0% CI [confidence interval] = 1.33‒4.02), preterm delivery (AOR = 6.37, 95.0% CI = 2.34‒7.95) and low birth weight (aOR = 2.29, 95.0% CI = 1.26‒4.18).

Conclusion

There was a high prevalence of perinatal asphyxia among newborns delivered at Saad Abuelela Maternity Hospital, Sudan. The factors associated with perinatal asphyxia among neonates were cesarean delivery, low birth weight, and preterm birth.

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Background

The World Health Organization (WHO) defines perinatal asphyxia as “the failure to initiate and sustain breathing at birth” [1]. Perinatal asphyxia is an injury that occurs during the perinatal time/period as a result of impairment in blood supply and gas exchange in the newborn brain or other vital organs during the perinatal period [2, 3]. Perinatal asphyxia is the inability to breathe and maintain breathing at birth [4, 5]. Perinatal asphyxia is a worldwide health problem that is encountered in six out of 10 newborns per 1000 live full-term births [6,7,8]. The WHO estimates that perinatal asphyxia accounts for around four million neonatal deaths annually [9]. The newborn with perinatal asphyxia who survived might have several neurological consequences, such as disabling cerebral palsy, inadequate mental development or low psychomotor scores, seizures, blindness, and severe hearing impairment [10]. In resource-limited countries, perinatal asphyxia is one of the leading health problems, and it can be utilized as an indicator of access to adequate medical care [11]. The WHO estimates that 3% of the 120 million infants born in low-income countries suffer from perinatal asphyxia [12]. Perinatal asphyxia accounts for 280,000 deaths of newborns on the first day of life in Africa [13].

Several previous studies showed high prevalence rates of perinatal asphyxia in African countries [14,15,16,17,18,19,20,21,22,23,24]. Maternal diseases such as hypertensive disorder of pregnancy and diabetes mellitus, as well as perinatal factors such as low birth weight and seizure, are the main risk factors for perinatal asphyxia [22, 25]. Several previous studies showed that labour problems [16, 22, 23, 25,26,27] and low birth weight [28,29,30] were the main factors associated with perinatal asphyxia in sub-Saharan Africa.

A recent study conducted in Sudan aimed at identifying neonatal mortality and associated factors in the neonatal intensive care unit of Gadarif Hospital revealed that 21.0% of the neonates died because of perinatal asphyxia [31]. Despite the high neonatal mortality rate from perinatal asphyxia in Africa [13] and particularly in Sudan, there is limited data on the prevalence and associated factors of perinatal asphyxia in Sudan. Determining the prevalence of perinatal asphyxia and its associated factors will help in developing appropriate interventions to reduce the incidence of perinatal asphyxia and ultimately reduce neonatal morbidity and mortality.

To improve the quality of care delivered within a country, one must first understand the problem and the issues that healthcare providers encounter. Improving maternal and neonatal care can lead to a significant decrease in the rate of perinatal asphyxia [32, 33] which is the global Sustainable Development Goal (SDG) target of reducing neonatal mortality to 12 per 1,000 live births by 2030 [34]. Thus, this study aimed to determine the prevalence of perinatal asphyxia and associated factors among neonates who were delivered at Saad Abuelela Maternity Hospital, Sudan.

Methods

Study design

A cross-sectional facility-based study was conducted from March to August 2022.

Study setting

Saad Abuelela Maternity Hospital is a tertiary hospital in Khartoum, Sudan. It is governed by the Faculty of Medicine, University of Khartoum, and it provides antenatal care, 24-hour delivery, an operating theatre, neonatal intensive care, and other medical and surgical services.

Participants

All neonates, with their mothers (mother neonate dyad), were delivered at the Saad Abuelela Maternity Hospital.

Inclusion and exclusion criteria

Sudanese women aged ≥ 18 years, signing informed consent, live births, single birth, gestational age ≥ 28 weeks. Women with ages < 18 years, multiple pregnancies, and congenital malformations were excluded.

Sample size determination and sampling procedure

The sample size of 619 newborns was computed using the OpenEpi Menu software [35] which was computed from the formula: (n) = Z(sq) × P(1-P)/d(sq). Z(sq) is standard normal variate (at 5% type 1 error (P < 0.05) = 1.96. P is the prevalence of the condition being studied and obtained from a previous study, while d is the level of precision. It was assumed that 15.0% of the newborns would have perinatal asphyxia, and this was based on the prevalence of perinatal asphyxia in the nearby country of Ethiopia [23]. Then, depending on the previous reports on cesarean delivery in Sudan [36]. It was assumed that 40.0% of newborns with perinatal asphyxia would have been delivered by cesarean section, while 25.0% of non-asphyxic newborns would have been delivered by cesarean section.

Sampling

The desired sample (619 women-neonates) was enrolled using the systematic random sampling technique. According to hospital records, 1977 women were delivered in the hospital over five months before the current study. Thus, a sampling interval of ≈ 3 was assumed by dividing the expected number (1977 women-neonates/calculated sample size (1977 /619 ≈ 3)) by 3. Thus, eligible women were interviewed every three intervals (one in three) until the required sample size (619) was reached.

Study variables

Dependent variables

Perinatal asphyxia (Yes/No).

Independent variables

Age, parity, educational level, occupation, residence, mode of delivery, sex of newborn, preterm birth, and low birth weight.

Data collection procedures and data quality management

The Strengthening of the Reporting of Observational Studies in Epidemiology (STROBE) was strictly followed (Additional file 1) [37]. It enrolled women (and their neonates) who gave birth at the hospital.

Data were obtained through direct interviews, and a questionnaire was filled out. Two female doctors were trained to collect and record the data appropriately for two days. The tool (questionnaire) was pretested with 3% of the sample size, and slight modifications were made. Maternal sociodemographic, obstetrics, and clinical data, including age, parity, residence, educational level, mode of delivery, gravidity, antenatal (ANC) utilization, and medical disease, were collected through a questionnaire. Apgar scores, birth weight, and sex of the newborn were the measures taken by the birth attendant (registrar on duty). Apgar scores (heart rate, respiratory effort, skin color, muscle tone, and reflex irritability) were recorded at five minutes. The newborns were weighed immediately using a digital floor scale (Seca, Hamburg, Germany) and recorded to the nearest two decimal points. The sex (male or female) of the newborn was also recorded.

Data analysis procedures

Statistical Package for the Social Sciences® (SPSS®) for Windows, version 22.0 (SPSS Inc., New York, United States) was used to analyze the data. Categorical data were expressed as frequencies (%) and compared between two groups using the Chi-square test. Shapiro–Wilk test was used to evaluate the normality of continuous variables, which were found to be not normally distributed and were expressed as median (interquartile range (IQR). Univariate analysis was conducted with perinatal asphyxia as the dependent variable. The independent variables were age, parity, educational level, occupation, residence, mode of delivery, sex of newborn, preterm birth, and low birth weight. We planned to shift variables with p < 0.05 to build up the binary multivariate analysis to rule out the confounders, and only one was detected, so the model was not built. Odds ratios (Crude, COR, and adjusted AORs) and 95% confidence intervals (CIs) were calculated as they were applied. A two-sided p-value of < 0.05 was considered statistically significant.

Operational definitions

Maternal anemia is defined as a hemoglobin concentration of < 11 g/dl [38].

Perinatal asphyxia: Based on the clinical diagnosis in this study, newborns with a 5 min Apgar score < 7 were considered to have perinatal asphyxia regardless of the gestational age [25].

Low birth weight: a birth weight of less than 2,500 g [39].

Results

General characteristics of the mothers and neonates

Of the 678, 59 (8.7%) mothers-neonates were excluded for different reasons (stillbirth, multiple pregnancies, and others). Six hundred and nineteen (91.3%) mothers-neonates were included in the study. The maternal median (IQR) age and parity was 27.0 (23.0–32.0) years and 3(1–5), respectively. Of 619 mothers, 422(68.2%) had their education ≥ secondary level, 562 (90.8%) were housewives, 325 (52.5%) were urban residents, and 565 (91.3%) had ≥ four antenatal care visits. Eighty-three (13.4%) mothers had medical diseases [diabetes mellitus (36 women), hypertension (24 women, thyroid disorders (9 women), and others (14 women)], and 316 (51.1%) were anemic. Of 619 neonates, 178 (28.2%) were delivered by cesarean section, and 336 (54.3%) were males. One hundred and two (16.5%) neonates were low birth weights, 80 (12.9%) were preterm, and 70 (11.3%) had perinatal asphyxia (Table 1).

Table 1 The socio-demographic characteristics of mother-newborn in Khartoum, Sudan, 2022
Full size table

Factors associated with perinatal asphyxia

In univariate analysis, the odds of perinatal asphyxia were increased in employed mothers when compared with housewives (OR = 2.31, 95.0% CI = 1.16‒4.63), rural residence compared with urban residence (OR = 2.02, 95.0% CI = 1.21‒3.83), cesarean section compared with vaginal delivery (OR = 2.17 95.0% CI = 1.30‒3.61), preterm birth compared with term delivery (OR = 6.3795.0 CI = 3.65‒11.12) and in low birth weight neonates compared with neonates with normal weight (OR = 6.3795.0% CI = 3.65‒11.12). There was no association between age, parity, mother education, mother anemia, sex of the neonates, and perinatal asphyxia (Table 2).

Table 2 Univariate analysis of the factors associated with perinatal asphyxia in Khartoum, Sudan, 2022
Full size table

When the factors that were associated with perinatal asphyxia in univariate were shifted to multivariate analysis, the odds (adjusted) of perinatal asphyxia increased in cesarean section compared with vaginal delivery (aOR = 2.31, 95.0% CI = 1.33‒4.02), preterm compared with term delivery (aOR = 6.37, 95.0% CI = 2.34‒7.95) and low birth weight neonates compared with neonates with normal weight (aOR = 2.29, 95.0% CI = 1.26‒4.18) (Table 3). Thus, employment and residency were associated with perinatal asphyxia in univariate analysis only (confounders).

Table 3 Multivariate analysis of the factors associated with perinatal asphyxia in Khartoum, Sudan, 2022
Full size table

Discussion

In this study, 11.3% of the newborns had perinatal asphyxia. This result is consistent with the prevalence of perinatal asphyxia, which was reported among neonates at the Aykel Primary Hospital in north-central Ethiopia (11.1%) [14], in Tanzania (11.5%) [21], Nigeria (12.8%) [20], and Central Africa (9.1%) [19]. The prevalence (11.3%) of perinatal asphyxia in our study was lower than the prevalence of perinatal asphyxia, which ranged from 18 to 41.2% reported in different regions of Ethiopia [16, 22,23,24]. Moreover, in a metanalysis that included 26 studies, the pooled prevalence of perinatal asphyxia in Ethiopia was 19.3% [40] and the pooled prevalence of perinatal asphyxia was 15.9% in a meta-analysis in East and Central Africa [19]. On the other hand, the prevalence (11.3%) of perinatal asphyxia in the current study was higher than the prevalence (2.5%) of perinatal asphyxia in Dire Dawa, in Eastern Ethiopia [41], Uganda (5.3%) [17], Ghana (2.4%), and Malawi (6.1%) [42]. The difference in the prevalence of perinatal asphyxia in our study and the other studies may be explained by the differences in socioeconomic development, the quality of care given throughout pregnancy and delivery, and the tool that was used to access the perinatal asphyxia itself.

The current study showed that neonates born by cesarean section were 2.31 times more likely than neonates born vaginally to have perinatal asphyxia. This is consistent with recent reports that cesarean delivery increased the odds of perinatal asphyxia in Ethiopia [15, 43]. It has been previously postulated that the decision to perform the cesarean section was due to complications of labor (including perinatal asphyxia) rather than the effect of the cesarean section of increasing the odds of perinatal asphyxia, i.e. the direction of cause-effect was not clear [44]. The reasons for neonates born via cesarean section having asphyxia may be related to the acuity of the mother or sentinel events that led to the cesarean section in the first place, late presentation, or/and time from decision to perform a cesarean section to actual cutting time may influence outcomes [45]. The use of drugs, e.g., narcotics and sedatives in cesarean delivery, can lead to a delay in the initiation of newborn breathing and perinatal asphyxia, perhaps by reducing the levels of relevant hormones, such as catecholamines, and glucocorticoids [46]. This finding indicates the cautious analysis and decision of interventions during intrapartum care to reduce unnecessary indications of cesarean section to minimize the magnitude of perinatal asphyxia.

In this study, newborns with low birth weights had a 2.2-fold higher risk of experiencing perinatal asphyxia than newborns with normal birth weights. Similar results were reported from studies in Ethiopia [15], Uganda [17], Nigeria [28], Zambia [29], and Tanzania [30]. Moreover, in a metanalysis that included 26 studies in Ethiopia, both low birth weight and preterm birth increased the odds of perinatal asphyxia [40]. The association between low birth weight babies and perinatal asphyxia could be explained by the fact that low birth weight babies are usually preterm, have insufficient surfactants, and hence have breathing difficulties, have insufficient brown fat tissue and are more prone to hypothermia [10].

While some of the investigated factors, such as maternal age, parity, residence, level of antennal care, maternal anemia, and sex of newborn, were not associated with perinatal asphyxia in the current study, several previous studies in Africa showed that maternal age [17], parity [40], antenatal care [14], residence [40], maternal anemia [40], male newborns [14, 17] were associated with perinatal asphyxia. The sociodemographic difference and the level and quality of care in the different settings could explain the difference between our results and those of the others.

Limitations of the study

It was a hospital-based study, which might not reflect the exact situation in the community, and it was conducted in one hospital; perhaps the problem in the other regions/hospitals in Sudan is different. While we have used a low APGAR score as a diagnostic tool for perinatal asphyxia, fetal or neonatal arterial blood gas is the best way to diagnose perinatal asphyxia. We did not access the details of the labor itself because this could be the first study, and we planned to use the first epidemiological tool (cross-sectional study) to have the basic data (magnitude of the problem). However, several previous studies have shown that labour complications were associated with perinatal asphyxia [16, 22, 25, 26].

Conclusion

There was a high prevalence of perinatal asphyxia among newborns delivered at Saad Abuelela Maternity Hospital, Sudan. The factors associated with perinatal asphyxia among neonates were cesarean delivery, low birth weight, and preterm birth. Therefore, clinicians should focus on the prevention and prompt management of neonates born by cesarean, low birth, and preterm.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

ANC:

Ante Natal Care

AOR:

Adjusted Odds Ratio

CI:

Confidence Interval. COR: Crude Odds Ratio

IQR:

Interquartile range, Statistical Package for the Social Sciences

SDG:

Sustainable Development Goal

WHO:

World Health Organization

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Acknowledgements

The authors would like to thank the women who participated in the study.

Funding

None receive.

Author information

Authors and Affiliations

  1. Department of Child Health, College of Medicine, University of Bisha, Bisha, Kingdom of Saudi Arabia

    Jaber Alfaifi

  2. Faculty of Medicine, University of Khartoum, BO Box 102, Khartoum, Sudan

    Mohamed A. Ahmed

  3. Department of Obstetrics and Gynecology, College of Medicine, Qassim University, Buraydah, Saudi Arabia

    Ghaday S. Almutairi, Norah H. Alhumaidi, Nadiah AlHabardi & Ishag Adam

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Contributions

JA and IA: conception, design, acquisition of data, analysis, interpretation of data, drafting the article. MAA and NA: conception, design, acquisition of data, analysis, interpretation of data, revising the manuscript critically for important intellectual content. GSA: design, acquisition of data, analysis, interpretation of data, revising the manuscript critically for important intellectual content. NHA: design, acquisition of data, analysis, interpretation of data, revising the manuscript critically for important intellectual content. All authors have approved the final version of this manuscript.

Corresponding author

Correspondence to Mohamed A. Ahmed.

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Ethics approval and consent to participate

Ethical approval was obtained from the Department of Obstetrics and Gynecology, Faculty of Medicine, University of Khartoum, Sudan (Ref. #2022, 07). Informed written consent was obtained from the mother of the neonates. Personal identifying information was not recorded on the questionnaire and the collected information was kept confidential, and all the methods were carried out in accordance with appropriate guidelines and regulations.

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The authors declare no competing interests.

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Alfaifi, J., Ahmed, M.A., Almutairi, G.S. et al. Prevalence of perinatal asphyxia and its associated factors among live birth in Khartoum, Sudan: a hospital-based cross-sectional study. BMC Pediatr 25, 150 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12887-025-05499-7

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12887-025-05499-7

Keywords

BMC Pediatrics

ISSN: 1471-2431

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