Early Adverse Outcomes of Neonatal Hypoxic-Ischemic Encephalopathy in a Resource- Constrained Setting

Early Adverse Outcomes of Neonatal Hypoxic-Ischemic Encephalopathy in a Resource- Constrained Setting | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Early Adverse Outcomes of Neonatal Hypoxic-Ischemic Encephalopathy in a Resource- Constrained Setting Chigozie Kingsley Onyeje, Blessing Tochukwu Onyeje, Chimezie Udennaka, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8663752/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 14 You are reading this latest preprint version Abstract Background Hypoxic-ischemic encephalopathy (HIE) remains a leading cause of neonatal mortality and long-term neurological disability, particularly in resource-limited settings. Understanding factors associated with early adverse outcomes is crucial for optimizing management strategies. Objective To identify maternal and neonatal factors associated with early adverse outcomes in newborns with HIE in a Nigerian tertiary health institution. Methods A prospective hospital-based study was conducted at Nnamdi Azikiwe University Teaching Hospital, Nnewi, from September 2023 to May 2024. Seventy term newborns with HIE admitted within 72 hours of delivery were enrolled. HIE diagnosis was based on abnormal neurological examination using the Thompson score. Data on demographic characteristics, maternal factors, and biochemical parameters were collected and analyzed using SPSS version 25. Fisher's exact test and Chi-square analysis was used to determine associations between variables, with p < 0.05 considered significant. Results Among 70 newborns, 45.7% (32/70) experienced short-term adverse outcomes. The case fatality rate was 17.1% (12/70), while 28.6% (20/70) developed complications including seizures (80%), absent nutritive suckling (65%), poor Moro reflex (25%), respiratory distress (20%), and altered consciousness (15%). Place of delivery was significantly associated with adverse outcomes (p = 0.005), with outborn neonates exhibiting a higher risk compared with inborn neonates. Both HIE severity and a 5-minute Apgar score < 7 were significantly associated with adverse outcomes (p < 0.001 for both). Maternal factors significantly associated with adverse outcomes included mode of delivery (p = 0.032) and maternal occupation (p = 0.020). Random blood glucose levels showed significant association with outcomes (p < 0.001), while serum magnesium levels did not (p = 0.980). Conclusion HIE severity, a low 5-minute Apgar score, outborn delivery status, and abnormal blood glucose levels were significantly associated with early adverse outcomes in neonatal HIE. These findings emphasize the importance of skilled birth attendance, early recognition, and prompt glucose monitoring in improving outcomes for affected newborns in resource-limited settings. Hypoxic-ischemic encephalopathy neonatal outcomes predictors resource-limited setting Nigeria Figures Figure 1 Introduction Perinatal asphyxia remains a major cause of neonatal death globally, disproportionately affecting developing regions like Sub-Saharan Africa where survivors often face long-term health challenges,( 1 ) including cerebral palsy, seizures, mental disorders, vision and hearing impairment, and cognitive and learning disabilities.( 2 – 4 ) Hypoxic-ischemic encephalopathy (HIE) is a syndrome of neurologic dysfunction which complicates perinatal asphyxia;( 5 ) it is the commonest cause of neonatal encephalopathy.( 6 ) Survival rates in babies with HIE depend not just on severity, but also on factors like place of birth, quality of prenatal care, underlying cause, gestational age, maternal health and age, economic status, and access to timely specialized care.( 6 – 9 ) Factors predisposing to HIE can be antenatal,( 10 – 12 ), perinatal,( 13 – 17 ) or a combination of both.( 18 ) During hypoxic–ischaemic injury, excessive glutamate release over-stimulates neuronal glutamate receptors, triggering excitotoxic enzyme cascades that damage cell membranes and intracellular structures, leading to the clinical manifestations of HIE.( 19 ) Using the modified Sarnat and Sarnat staging system, HIE is categorized into three levels of increasing severity.( 20 , 21 ) Management outcomes in neonatal HIE depends on several factors including; need for advanced resuscitation and abnormal neurological examination;( 22 ) presence of seizures- clinical or electrophysiological, low APGAR scores and poor electroencephalogram background activity;( 23 ) severity of HIE and the clinical status of the neonate at birth.( 24 ) A hospital-based retrospective study done in Nigeria found that place of delivery, booking status of mother, gestational age at birth, age of infant at presentation and severity of HIE significantly predict in-hospital mortality in babies with HIE.( 6 ) Approximately 20–30% of infants with HIE die in the neonatal period, with about 33–50% of survivors left with permanent neuro-developmental abnormalities.( 20 ) HIE accounts for 6% to 9% of all neonatal deaths and 21% to 23% of deaths in term infants. While HIE affects 1.5–2.5 per 1000 births in developed countries,( 25 ) rates increase dramatically to over 26 per 1000 births in resource-limited settings,( 26 ) with one hospital-based study in Sagamu, Ogun State Nigeria reporting an even higher prevalence of 35.9%.( 5 ) It is still a scientific puzzle why some asphyxiated newborns develop HIE while others do not. However, some researchers have suggested variation in newborns’ compensatory thresholds and intrinsic resistance of the brain to severe asphyxia;( 27 ) complex relationship between the neonatal brain and the immune system during the perinatal period;( 28 ) developmental maturity of the brain( 29 , 30 ) and possibly intrinsic genetic factors of the neonates,( 31 ) as plausible explanations. Identifying neonates with HIE at higher risk of severe neurological impairment or death is a major focus of research, as this will set the tune for determining management modalities including neuro-protective therapies, prognostication and anticipatory counseling of caregivers.( 24 , 32 ) We studied the interplay between some identified risk factors and clinical findings at presentation in influencing early adverse outcomes in newborns with HIE in a tertiary health institution in Nigeria. Understanding these factors will not only guide clinicians in predicting management outcomes but also in deciding which interventions are most urgent for affected newborns. The objectives of the study therefore include: to determine case fatality rate and prevalence of major short-term adverse outcomes among newborns with HIE; to evaluate neonatal (age, gender, place of delivery, sentinel events in labour, 5th minute Apgar score, HIE severity) and maternal (age, parity, mother’s educational level and occupation and mode of delivery) factors associated with adverse outcomes in neonatal HIE; to assess the relationship between serum biochemical parameters (including magnesium and random blood glucose levels) and short-term adverse outcomes in neonates with HIE; To propose actionable interventions based on study findings to improve early management outcomes among newborns with HIE in resource-limited settings Materials and methods Study area This was a hospital-based prospective study conducted at the Special Care Baby unit (SCBU) of the Nnamdi Azikiwe University Teaching Hospital (NAUTH), Nnewi, Anambra State. NAUTH is a Federal tertiary health institution located in the commercial city of Nnewi, Anambra State. The facility offers specialized healthcare while serving as a referral center for primary and secondary health facilities in the state and neighboring regions. The SCBU is equipped with 15 incubators, four resuscitaire, two handheld pulse oximeters, four phototherapy units, four apnea monitors, three bubble CPAP machines and different oxygen delivery systems with piped oxygen supply. The SCBU Protocol for management of HIE involves respiratory support with free flow intranasal oxygen or continuous positive airway pressure; anti-seizure drugs; prophylactic antibiotics; dextrose-containing intravenous fluid for caloric support and nasogastric tube feeding when appropriate. Newborn participation and enrolment The study population comprised of seventy term newborns with HIE (both in-born and out-born) admitted into the SCBU within 72hours of delivery, who met the inclusion criteria. The study duration spanned nine months from September, 2023 to May, 2024. In the present study, a diagnosis of HIE was based on abnormal neurologic examination during the first 72hours of life as judged by application of the Thompson score (Table 1 ) and any one of the following: Weak/poor cry at birth. Need for assisted ventilation initiated at birth and continued for at least 5minutes Eligible newborns with HIE received comprehensive evaluation including medical history and clinical examination, then were classified using the Thompson score (mild HIE: 1–10; moderate HIE: 11–14; severe HIE: ≥15). Exclusion Criteria All newborns with evidence of septicemia (e.g. temperature instability, abdominal swelling, abnormal bleeding, petechiae rash), intrauterine infection, congenital anomalies, necrotizing enterocolitis Newborns who were clinically anaemic Newborns of diabetic mothers Newborn babies of mothers who received opioids, other depressant medications or general anesthesia. After obtaining written informed consent from each participating mother in her preferred language and voluntariness assured, eligible newborns were enrolled consecutively into the study and monitored daily until discharge or death. Research variable The following information was obtained on admission or at subsequent reviews using a structured researcher administered questionnaire. These include the outcome and predictor variables. Outcome variables – this is the final outcome of newborns admitted for HIE in the special care baby unit during the study period. This includes death; survived without complications; or survived with complications such as respiratory distress, absence of a nutritive suckling reflex, altered level of consciousness, seizures and poor Moro reflex. These were recorded on the 7th day of admission. Predictor variables – these are independent variables that are related to newborn management outcomes. They include birth and demographic variables, clinical parameters, laboratory parameters, and HIE scores. Laboratory parameters include random blood glucose using capillary blood obtained by heel prick and read using a glucometer (Fine test auto-coding premium, OSANG Healthcare Co., Ltd., Korea), normal range 73-109mg/dl. Serum magnesium- estimated using the xylidyl blue spectrophotometric method, normal range 1.50-2.30mg/dl. Treatment protocol for asphyxiated neonates with HIE Perinatal asphyxia is a neonatal emergency condition. Upon admission, affected newborns are resuscitated as required including giving intermittent positive pressure ventilation using a bag-valve-mask device. Once regular breathing is achieved, other components of care mainly supportive are given. Affected newborn were followed up by a daily clinical examination (mainly with the Thompson score parameters recorded at presentation, 24 hours and 48 hour later) and short-term outcomes recorded on day 7 of admission. Data Analysis The collected data were initially entered into Microsoft Excel, cleaned and subsequently exported and analyzed using statistical package for social science (SPSS) version 25 (IBM Corp., Armonk, New York, USA). Descriptive statistics of frequency count, percentages, mean and standard deviation was used to summarize demographic characteristics. The Fisher’s exact test and Chi-square (χ2) analysis were used to determine association between variables. P values < 0.05 was considered as statistically significant. Ethical Consideration Approval for this study was obtained from the NAUTH Ethics Committee with reference number NAUTH/CS/66/VOL.15/VER.3/100/2022/057. Informed consent was obtained from every mother-newborn dyad following adequate explanation of the research objectives, potential benefits of participation, and assurance that the study posed minimal risk to their newborns. Participation in the study was entirely voluntary and no form of financial inducement was involved. Voluntary withdrawal at any stage of interaction was guaranteed for all subjects without any adverse consequence for the newborns. All information was handled with strict confidentiality. Results Among the 603 neonates admitted into the SCBU during the study period, 200 were diagnosed with perinatal asphyxia; however, 100 of them were excluded based on the eligibility criteria (Figure 1). A further 30 babies were excluded as they did not meet the criteria for diagnosis of HIE; thus, a final analysis included 70 newborns. Thirty-two out of 70 (45.7%) had short-term adverse outcome; among these 37.5% (n =12) died within seven days of admission given a case fatality rate of 17.1%, while 62.5% (n =20) developed at least one adverse complication. The prevalence of major short-term adverse outcomes include: seizure- 80% (16/20), absent nutritive suckling – 65% (13/20), poor Moro reflex- 25% (5/20), respiratory distress- 20% (4/20) and altered consciousness- 15% (3/20). Table 1: The HIE Score (Thompson score) Sign/Score 0 1 2 3 Tone Normal Hypertonia Hypotonia Flaccid LOC Normal Hyper alert Lethargic Comatose Seizures None Infrequent2 per day Posture Normal Fisting/cycling Strong distal flexion Decerebrate Moro Normal Partial Absent Grasp Normal Poor Absent Sucking reflex Normal Poor Absent ± bites Respiration Normal Hyperventilation Brief apnoea IPPV (apnoea) Fontanel Normal Full, not tense Tense Total score LOC: loss of consciousness; IPPV: intermittent positive pressure ventilation Table 2 shows that most newborns in our study presented to the hospital within the first 24 hours of life (58.6%, n=41), with a mean presentation age of 27.1 ± 23.3 hours. The study population showed a slight male predominance (male to female ratio 1.2:1). Majority of the deliveries (75.7%, n=53) occurred outside the study facility. Regarding labour characteristics, sentinel events were documented in a substantial proportion of cases (77.1%). Vaginal delivery was the most common mode of delivery (52.9%, n=37), and half of the mothers were first-time mothers (primiparous, 50%, n=35). The maternal demographic profile showed that most mothers were under 35 years of age (84.3%, n=59), had received some form of education and were employed in various occupations. Table 2: Demographic profile of Neonates with HIE Parameters Frequency n (%) Mean( x̄ )±SD Age at presentation <24 hours 24-<48 hour 48-72 hours 41 (58.6) 14 (20.0) 15 (21.4) 27.1 ± 23.3 hours Birth weight Low (4.0kg) 9 (12.9) 58 (82.9) 3 (4.2) 3.09 ± 0.5kg Gender Male Female 38 (54.3) 32 (45.7) Place of delivery Inborn Outborn 17 (24.3) 53 (75.7) Mode of delivery Normal vaginal Assisted vaginal Caesarean section 37 (52.9) 5 (7.1) 28 (40.0) Sentinel events in labour Present Absent 54 (77.1) 16 (22.9) Maternal age 18- 35 years 40 (57.1) 19 (27.1) 11 (15.8) 28.7 ± 5.7 years Parity Primiparous Multiparous Grand multiparous 35 (50.0) 24 (34.3) 11 (15.7) Mother’s HEA Primary Secondary Tertiary 4 (5.7) 41 (58.6) 25 (35.7) Mother’s occupation Unemployed Trader Civil servant Others 20 (28.9) 21 (30.0) 18 (25.7) 11 (15.7) HEA: highest educational attainment The results in Table 3 below, shows thatinborn babies had significantly better outcomes (88.2% no adverse outcomes) compared to outborn babies who had higher rates of adverse outcomes (35.8%) and death (20.8%). Similarly, the severity of HIE was significantly associated with outcomes as 76.3% of newborns with mild HIE had no adverse outcomes, 50% of those with moderate HIE had adverse outcomes while 50% of those with severe HIE died. Furthermore, the 5 th minute Apgar score was a strong predictor of outcome; 72.1% of newborns with scores greater than seven had no adverse outcomes; while those with scores less than seven, 40.7% had adverse outcome and 33.4% died. In addition, with regards to occurrence of sentinel events in labour, 20.4% of babies with sentinel events during labour died compared to 6.3% who did not have such events. However, age at presentation and gender were not significantly associated with outcomes. Table 3: Newborn’s demographic and clinical characteristics associated with adverse outcomes Parameters No adverse outcomes Adverse outcomes Dead Total P value Age at presentation <24 hours 24-<48 hour 48-72 hours 22 (53.6%) 7 (50.0%) 9 (60.0%) 10 (24.4) 5 (35.7%) 5 (33.3%) 9 (22.0%) 2 (14.3%) 1 (6.7%) 41 (58.6%) 14 (20.0%) 15 (21.4%) 0.673 Gender Male Female 18 (47.3%) 20 (62.5%) 12 (31.6%) 8 (25.0%) 8 (21.1%) 4 (12.5%) 38 (54.3%) 32 (45.7%) 0.420 Place of delivery Inborn Outborn 15 (88.2%) 23 (43.4%) 1 (5.9%) 19 (35.8%) 1 (5.9%) 11 (20.8%) 17 (24.3%) 53 (75.7%) 0.005* HIE severity Mild HIE Moderate HIE Severe HIE 29 (76.3%) 7 (43.7%) 2 (12.5%) 6 (15.8%) 8 (50.0%) 6 (37.5%) 3 (7.9%) 1 (6.3%) 8 (50.0%) 38 (54.2%) 16 (22.9%) 16 (22.9%) 7 <7 31 (72.1%) 7 (25.9%) 9 (20.9%) 11 (40.7%) 3 (7.0%) 9 (33.4%) 43 (61.4%) 27 (38.6%) <0.0001* Sentinel labour events Present Absent 31 (57.4%) 7 (43.7%) 12 (22.2%) 8 (50.0%) 11 (20.4%) 1 (6.3%) 54 (77.1%) 16 (22.9%) 0.075 *Statistically significant More so, normal vaginal delivery was associated with more adverse outcomes (40.6%) and mortality (21.6%) compared to caesarean delivery, 17.9% adverse outcomes and 14.3% mortality, respectively (Table 4). Additionally, mother’s occupation was significantly associated with management outcomes: newborns whose mothers were traders had best outcomes (76.2% no complications, 4.8% mortality), while newborns of unemployed mothers had high adverse outcomes (30%) and the highest mortality (30%). Babies born by mothers in the "others" category- mostly low income earners; showed the highest adverse outcomes (63.6%). Table 4: Maternal factors associated with HIE outcomes Parameters No adverse outcomes Adverse outcomes Dead Total P value Maternal age 18-35 years 22 (55.0%) 9 (47.4%) 7 (63.6%) 10 (25.0%) 8 (42.1%) 2 (18.2%) 8 (20.0%) 2 (10.5%) 2 (18.2%) 40 (57.1%) 19 (27.1%) 11 (15.8%) 0.584 Parity Primiparous Multiparous Grand multiparous 19 (54.3%) 13 (54.2%) 6 (54.5%) 12 (34.3%) 6 (25.0%) 2 (18.2%) 4 (11.4%) 5 (20.8%) 3 (27.3%) 35 (50.0%) 24 (34.3%) 11 (15.7%) 0.656 Mode of delivery Normal vaginal Assisted vaginal Caesarean section 14 (37.8%) 5 (100.0%) 19 (67.8%) 15 (40.6%) 0 5 (17.9%) 8 (21.6%) 0 4 (14.3%) 37 (52.9%) 5 (7.1%) 28 (40.0%) 0.032* Mother’s HEL Primary education Secondary education Tertiary education 3 (75.0%) 20 (48.8%) 15 (60.0%) 1 (25.0%) 14 (34.1%) 5 (20.0%) 0 (0.0%) 7 (17.1%) 5 (20.0%) 4 (5.7%) 41 (58.6%) 25 (35.7%) 0.626 Mother’s occupation Unemployed Trader Civil servant Others 8 (40.0%) 16 (76.2%) 11 (61.1%) 3 (27.3%) 6 (30.0%) 4 (19.0%) 3 (16.7%) 7 (63.6%) 6 (30.0%) 1 (4.8%) 4 (22.2%) 1 (9.1%) 20 (28.9%) 21 (30.0%) 18 (25.7%) 11 (15.7%) 0.020* *Statistically significant In relation to serum biochemical profile (Table 5), newborns with hypermagnesemia appeared to have less adverse outcomes and mortality compared to those with normal serum magnesium, although this did not reach statistical significance. Random blood glucose, on the other hand showed significant association with management outcomes as newborns with hypoglycemia and hyperglycemia had significantly poorer outcomes compared to those with normal random blood glucose. Table 5: Role of serum biochemical parameters in predicting short-term outcomes in neonates with HIE Laboratory parameters No adverse outcomes Adverse outcomes Dead Total P value Serum magnesium Normal magnesium High magnesium 26 (54.2%) 12 (54.5%) 14 (29.2%) 6 (27.3%) 8 (16.6%) 4 (18.2%) 48 (68.6%) 22 (31.4%) 0.980 Random blood glucose Normoglycemia Hypoglycemia Hyperglycemia 36 (67.9%) 1 (7.7%) 1 (25.0%) 13 (24.5%) 6 (46.2%) 1 (25.0%) 4 (7.6%) 6 (46.2%) 2 (50.0%) 53 (75.7%) 13 (18.6%) 4 (5.7%) <0.0001* *Statistically significant Discussion This study revealed an alarming 17.7% case fatality rate among patients diagnosed with hypoxic ischaemic encephalopathy, highlighting the critical nature of this condition. Comparable high rates have been documented across other developing countries with Ekwochi et al. documenting 18% in Enugu Nigeria,(1) and Hafsa et al. , reporting 16.4% in Rawalpindi Pakistan.(33)These consistently high fatality rates likely stem from limited access to therapeutic hypothermia; an evidence-based treatment proven effective for moderate to severe HIE.(2, 34–37) This modality of treatment has been shown to significantly reduce mortality and major disability associated with HIE.(38–40) However, our findings contrast with several other studies that reported notably lower case fatality rates ranging from 8.5% to 14%.(32, 41, 42) The lower case fatality in the aforementioned studies could be due to use of therapeutic hypothermia as a standard treatment for babies with HIE; also two of the studies had a larger sample size. Furthermore, among survivors of HIE in our study, the most common short-term adverse outcomes included seizures (80%), absence of nutritive suckling (65%), poor Moro reflex (25%), respiratory distress requiring support (20%), and altered consciousness (15%). This finding compares differently to the observation of Teixeira et al. , who reported that at discharge of their HIE survivors, 14% were on anti-seizure drugs; 23.3% had no feeding skills; 23.3% had abnormal neurological examination; while 2.1% required oxygen support.(41) Additionally, Grass et al. , reported a median seizure prevalence of 32.3% in a large multicentre study.(42) The lower prevalence of short-term adverse outcome noted in the cited studies could be due to use of induced hypothermia as a treatment modality for HIE and probably the availability of better skilled manpower. Our study also revealed that, adverse outcomes in HIE cases were significantly associated with outborn delivery, severity of encephalopathy, and low fifth-minute Apgar scores. These findings likely reflect inadequate infrastructure, poorly planned delivery and limited neonatal resuscitation expertise at referral centers coupled with delayed presentation. This result agrees with the findings of several other researchers who noted that adverse outcome in HIE is significantly associated with outborn delivery status, HIE severity, Apgar scores and mode of delivery.(1, 32, 33, 41)The relationship between gender and HIE outcomes remains controversial in literature. One study demonstrated significantly worse outcomes in males;(33) while another reported higher mortality in females.(1)In our study, although males showed a trend toward poorer outcomes, this difference was not statistically significant. The discrepancy in previous findings may be attributed to demographic variations, particularly a higher male-to-female ratio (2:1) and larger sample size in one study;(33) while the increased female mortality in the other study remained unexplained.(1) Furthermore, our study indicated that significant maternal variables associated with early adverse outcomes in newborns with HIE were normal vaginal delivery and maternal occupation. These findings may be due to the fact that most of the vaginal deliveries occurred outside hospital where trained birth attendants are limited in number and supervision may be inadequate, potentially resulting in more adverse outcomes; also mothers that were unemployed or those from a low socioeconomic background are likely to make poor health choices due poverty, ignorance and poor health seeking behaviours which will certainly predispose them to adverse labour outcomes. Our findings align with previous research showing higher death rates in asphyxiated infants delivered vaginally(1, 43). Other studies have also found that mothers' of low socioeconomic status significantly worsens outcomes for these babies.(43, 44) However, Suppiej et al. ,(32) and Devi et al. ,(45) reported different results, noting that emergency cesarean deliveries increased the risk of severe outcomes in HIE babies. This contradiction may be explained by the underlying maternal or fetal complications that necessitated the choice of emergency cesarean procedure in the first place and delayed presentation to the hospital. Our study demonstrated a significant association between abnormal blood glucose levels and poor outcomes in neonates with HIE. Infants presenting with either hypoglycemia or hyperglycemia experienced higher rates of complications and mortality compared to those maintaining normoglycemia. These findings align with established pathophysiological mechanisms: hypoglycemia compromises recovery by depriving vulnerable neurons of essential energy, elevating seizure risk, and disrupting cerebral perfusion; while hyperglycemia induces damage through oxidative stress during reperfusion, exacerbates cerebral edema, increases intracranial pressure, and amplifies inflammatory responses. This relationship between glycemic dysregulation and adverse outcomes in HIE is consistently supported by multiple previous investigations, reinforcing the critical importance of glucose homeostasis in the management of these vulnerable neonates.(1, 46–48) More so, we noted that asphyxiated newborns with hypermagnesemia had less adverse outcomes and mortality compared to those with normal serum magnesium levels; although this was not statistically significant. Many researchers concur with this observation noting that higher serum magnesium in neonates with HIE reduced the risk of abnormal motor examination and seizure;(49) while hypomagnesemia reduced survival rate of the affected neonates.(50) Drawing from our research results, we recommend the following actionable interventions to enhance early outcomes for neonates with hypoxic-ischemic encephalopathy in resource-constrained environments: Community-based interventions and initiatives This approach focuses on strengthening healthcare at the community level through three key strategies: training traditional birth attendants (TBAs) in rural areas to identify feto-maternal danger signs, perform basic neonatal resuscitation and refer early, cases that are beyond their scope, to tertiary health facilities; implementing public education campaigns targeting vulnerable populations about labour danger signs and skilled birth attendance; and developing mobile health initiatives using SMS reminders for antenatal care and emergency transportation coordination for high-risk pregnancies. These approaches, when driven by community ownership and participation, have been proven effective in enhancing perinatal/neonatal health outcomes by many researchers.(51, 52, 61, 53–60) 2. Healthcare system improvements for neonatal care This will be achieved through standardized referral protocols to minimize delays and improve pre-transfer stabilization; establishment of specialized neonatal transport teams with portable temperature and glucose monitoring; and expansion of point-of-care glucose testing with clear management protocols across all delivery settings. These initiatives when put into action have the potentials to improve outcomes for babies with perinatal asphyxia as demonstrated by many studies.(62–65) 3. Establishing standardized clinical management protocols for neonatal HIE This comprehensive approach addresses the clinical management of hypoxic-ischemic encephalopathy through three targeted protocols: implementing strict glucose management guidelines with regular monitoring and prompt intervention for blood glucose abnormalities; developing magnesium sulfate administration protocols for moderate-to-severe HIE based on study findings showing improved outcomes with hypermagnesemia; and establishing evidence-based guidelines for optimal oxygen therapy- CPAP and mechanical ventilation, particularly for neonates experiencing respiratory distress at the tertiary and secondary health facilities. Strict adherence to such management protocol, has resulted to streamlining of care; reducing delays in providing high quality care; enhancing communication among neonatal care providers; and improving overall outcome for asphyxiated babies, as suggested by many studies.(4, 66–70) 4. Training and capacity building for HIE management This aims to strengthen healthcare provider capabilities through: implementing regular simulation-based drills for all delivery room personnel to master neonatal resuscitation techniques for asphyxiated newborns; and training diverse healthcare workforce to utilize simplified HIE scoring systems for rapid severity assessment and appropriate clinical decision-making. These interventions ensure consistent, high-quality care across different healthcare settings and are supported by several studies.(71–74) Limitations This research was conducted at a single healthcare facility, potentially restricting the applicability of our findings to other clinical environments. Due to resource constraints, we were unable to perform arterial blood gas analysis on cord blood samples- a key method for biochemically confirming asphyxia. Our diagnosis of HIE relied on the Thompson scoring system, which contains subjective elements that may have introduced bias in patient classification. Additionally, as our tertiary care center typically receives complex referrals, our patient population likely included a disproportionate number of severe cases, possibly inflating both the prevalence of severe HIE and the case fatality rate observed in our study. Conclusion Our research demonstrated that birth outside the hospital setting, HIE severity, low Apgar scores at five minutes, blood glucose abnormalities, and specific maternal characteristics were significantly associated with early adverse outcomes in neonatal HIE; all contributing to the high case fatality rate observed in our study. Declarations Clinical trial number not applicable Conflict of interest : the authors declare no conflict of interest. Ethical Approval Ethical clearance was obtained from the Nnamdi Azikiwe University Teaching Hospital Ethics Committee with reference number NAUTH/CS/66/VOL.15/VER.3/100/2022/. Funding: no funding was received for this research. Author Contribution Conceptualization, OCK, OBT and UC; methodology, OCK, OBT, OUC and EOA; data collection, OCK, OBT, NSC, OUC, UC, ESI, EOA and AOI; statistical analysis and result writing, OCK, OBT, ESI and EES; writing—original draft preparation, OCK, OBT, UC, EES and EOA; writing—review and editing, OCK, OBT, EST, AOI, OUC, ESI and NSC; supervision, EES and EST. All authors have read and agreed to the published version of the manuscript. Acknowledgement We express our profound appreciation to the parents who placed their newborns in our care, enabling this vital research. Our deepest gratitude goes to the Special Care Baby Unit staff whose exceptional dedication has been instrumental in treating critically ill neonates. This research is dedicated to all families affected by hypoxic-ischemic encephalopathy, with the sincere hope that our findings will advance clinical practice and ultimately improve outcomes for these vulnerable patients. Data Availability The data for this study will be made available by the corresponding author upon reasonable request. References Ekwochi U, Asinobi NI, Osuorah CDI, Ndu IK, Ifediora C, Amadi OF, et al. Incidence and Predictors of Mortality Among Newborns With Perinatal Asphyxia: A 4-Year Prospective Study of Newborns Delivered in Health Care Facilities in Enugu, South-East Nigeria. Clin Med Insights Pediatr. 2017;11:117955651774664. Tagin MA, Woolcott CG, Vincer MJ, Whyte RK, Stinson DA. Hypothermia for neonatal hypoxic ischemic encephalopathy: An updated systematic review and meta-analysis. Arch Pediatr Adolesc Med. 2012;166(6):558–66. Ogunkunle TO, Odiachi H, Chuma JR, Bello SO, Imam A. Postnatal Outcomes and Risk Factors for In-Hospital Mortality among Asphyxiated Newborns in a Low-Resource Hospital Setting: Experience from North-Central Nigeria. Ann Glob Heal. 2020;86(1):63. Pius S, Bello M, Ambe JP, Machoko Y, Clement AY, Genesis R, et al. Pilot Study: Magnesium Sulphate Administration and Early Resolution of Hypoxic Ischemic Encephalopathy in Severe Perinatal Asphyxia. Open J Pediatr. 2019;09(01):89–102. Ogunfowora O, Ogunlesi T. Hypoxic Ischaemic Encephalopathy among Asphyxiated Nigeran Newborns. Niger Hosp Pract. 2011;7:5–6. Ezenwa BN, Olorunfemi G, Fajolu I, Adeniyi T, Oleolo-Ayodeji K, Kene-Udemezue B et al. Trends and predictors of in-hospital mortality among babies with hypoxic ischaemic encephalopathy at a tertiary hospital in Nigeria: A retrospective cohort study. PLoS One [Internet]. 2021;16(4 April):1–20. Available from: http://dx.doi.org/10.1371/journal.pone.0250633 Ugwu GIMG, Abedi HO, Ugwu EN. Incidence of birth asphyxia as seen in central hospital and GN children’s clinic both in Warri Niger Delta of Nigeria: an eight year retrospective review. Glob J Health Sci. 2012;4(5):140–6. Gebregziabher GT, Hadgu FB, Abebe HT. Prevalence and Associated Factors of Perinatal Asphyxia in Neonates Admitted to Ayder Comprehensive Specialized Hospital, Northern Ethiopia: A Cross-Sectional Study. Int J Pediatr (United Kingdom). 2020;2020. Kawakami MD, Sanudo A, Teixeira MLP, Andreoni S, de Castro JQX, Waldvogel B, et al. Neonatal mortality associated with perinatal asphyxia: a population-based study in a middle-income country. BMC Pregnancy Childbirth. 2021;21(1):1–10. Peebles PJ, Duello TM, Eickhoff JC, McAdams RM. Antenatal and intrapartum risk factors for neonatal hypoxic ischemic encephalopathy. J Perinatol Off J Calif Perinat Assoc. 2020;40(1):63–9. Acun C, Karnati S, Padiyar S, Puthuraya S, Aly H, Mohamed M. Trends of neonatal hypoxic-ischemic encephalopathy prevalence and associated risk factors in the United States, 2010 to 2018. Am J Obstet Gynecol. 2022. Locatelli A, Lambicchi L, Incerti M, Bonati F, Ferdico M, Malguzzi S, et al. Is perinatal asphyxia predictable? BMC Pregnancy Childbirth. 2020;20(1):1–8. Lorain P, Bower A, Gottardi E, Dommergues M, Helias LFL, Guellec I et al. Risk factors for hypoxic – ­ ischemic encephalopathy in cases of severe acidosis: A case – ­ control study. 2022;(September 2021):471–8. Barrois M, Patkai J, Delorme P, Chollat C, Goffinet F, Le Ray C. Factors associated with neonatal hypoxic ischemic encephalopathy in infants with an umbilical artery pH less than 7.00. Eur J Obstet Gynecol Reprod Biol. 2019;236:69–74. Parker S-J, Kuzniewicz M, Niki H, Wu YW. Antenatal and Intrapartum Risk Factors for Hypoxic-Ischemic Encephalopathy in a US Birth Cohort. J Pediatr. 2018;203:163–9. Torbenson VE, Tolcher MC, Nesbitt KM, Colby CE, EL-Nashar SA, Gostout BS, et al. Intrapartum factors associated with neonatal hypoxic ischemic encephalopathy: A case-controlled study. BMC Pregnancy Childbirth. 2017;17(1):1–7. Wang J, Tao E, Mo M, Ding W, Yuan J, Wang M, et al. Perinatal Risk Factors Influencing Neonatal Hypoxic Ischemic Encephalopathy in Southern China: A Case-Control Study. Am J Perinatol. 2021;38(S 01):e182–6. Aslam S, Strickland T, Molloy EJ. Neonatal encephalopathy: Need for recognition of multiple etiologies for optimal management. Front Pediatr. 2019;7(MAR). Douglas-Escobar M, Weiss MD. Hypoxic-Ischemic Encephalopathy A Review for the Clinician. JAMA Pediatr. 2015;169(4):397–403. Kliegman R. Nelson textbook of pediatrics 20th edition. 2016. Clinical Guidelines - Queensland Health Q. Maternity and Neonatal Clinical Guideline. Queensl Heal [Internet]. 2017;1–39. Available from: . Accessed June, 2020. Shim GH. Which factors predict outcomes of neonates with hypoxic-ischemic encephalopathy following therapeutic hypothermia? Clin Exp Pediatr. 2021;64(4):169–71. Seo SY, Shim GH, Chey MJ, You SJ. Prognostic factors of neurological outcomes in late-preterm and term infants with perinatal asphyxia. Korean J Pediatr. 2016;59(11):440–5. Merchant N, Azzopardi D. Early predictors of outcome in infants treated with hypothermia for hypoxic-ischaemic encephalopathy. Dev Med Child Neurol. 2015;57(S3):8–16. Allen KA, Brandon DH. Hypoxic Ischemic Encephalopathy: Pathophysiology and Experimental Treatments. Newborn Infant Nurs Rev. 2011;11(3):125–33. Liu L, Johnson HL, Cousens S, Perin J, Scott S, Lawn JE et al. Global, regional, and national causes of child mortality: An updated systematic analysis for 2010 with time trends since 2000. Lancet [Internet]. 2012;379(9832):2151–61. Available from: http://dx.doi.org/10.1016/S0140-6736(12)60560-1 Moshiro R, Mdoe P, Perlman JM. A Global View of Neonatal Asphyxia and Resuscitation. 2019;7(November):1–6. Li B, Concepcion K, Meng XZL. Brain-immune interactions in perinatal hypoxic-ischemic brain injury. Prog Neurobiol. 2018;176(1):139–48. Rainaldi MA, Perlman JM. Pathophysiology of Birth Asphyxia. Clin Perinatol. 2016;43(3):409–22. Mota-Rojas D, Villanueva-García D, Solimano A, Muns R, Ibarra-Ríos D, Mota-Reyes A. Pathophysiology of Perinatal Asphyxia in Humans and Animal Models. Biomedicines. 2022;10(2). Gorovenko NG, Rossokha ZI, Podolskaya SV, Pokhylko VI, Lundberg GA. The Role of Genetic Determinant in the Development of Severe Perinatal The Role of Genetic Determinant in the Development of Severe Perinatal Asphyxia 1. 2010;(April 2022). Suppiej A, Vitaliti G, Talenti G, Cuteri V, Trevisanuto D, Fanaro S et al. Prognostic risk factors for severe outcome in the acute phase of neonatal hypoxic-ischemic encephalopathy: A prospective cohort study. Children. 2021;8(12). Hafsa Niaz J, Jalil QU, Zaman, Khan F, Basheer, Shahzad Akhtar NH, CLINICAL PROFILE AND SHORT TERM OUTCOME OF HYPOXIC ISCHEMIC ENCEPHALOPATHY AMONG BIRTH ASPHXIATED BABIES IN A TERTIARY CARE HOSPITAL. Pak Armed Forces Med J. 2021;71(1):24–8. Lemyre B, Chau V. Hypothermia for newborns with hypoxic-ischemic encephalopathy. Paediatr Child Heal. 2018;23(4):285–91. Nair J, Kumar VHS. Current and emerging therapies in the management of hypoxic ischemic encephalopathy in neonates. Children. 2018;5(7). Davidson JO, Wassink G, van den Heuij LG, Bennet L, Gunn AJ. Therapeutic hypothermia for neonatal hypoxic-ischemic encephalopathy - Where to from here? Front Neurol. 2015;6(SEP). Papile LA, Baley JE, Benitz W, Cummings J, Carlo WA, Eichenwald E, Kumar P, Polin RA, Tan RCWK. Hypothermia Neonatal Encephalopathy Pediatr [Internet]. 2014;133(6):1146–50. pediatrics.org/cgi/doi/10.1542/peds.2014-0899 . Available from: www. Davies A, Wassink G, Bennet L, Gunn A, Davidson J. Can we further optimize therapeutic hypothermia for hypoxic-ischemic encephalopathy? Neural Regen Res. 2019;14(10):1678–83. Coetzee M. Hypoxic-ischaemic encephalopathy: Identifying newborns who will benefit from therapeutic hypothermia in developing countries. SAJCH South Afr J Child Heal. 2018;12(4):175–80. Laptook AR, Shankaran S, Tyson JE, Munoz B, Bell EF, Goldberg RN, Parikh NA, Ambalavanan N, Pedroza C, Pappas A, Das A, Chaudhary AS, Ehrenkranz RA, Hensman AM, Van Meurs KP, Chalak LF, Khan AM, Hamrick SEG, Sokol GM, Walsh MC, Poindexter BB, Faix RG, Wat HR. Effect of Therapeutic Hypothermia Initiated After 6 Hours of Age on Death or Disability Among Newborns With Hypoxic-Ischemic Encephalopathy: A Randomized Clinical Trial. 2018;318(16):1550–60. Teixeira L, Soares H, Flor-de-lima F, Vilan A. Perinatal hypoxic-ischemic encephalopathy: severity determinants and outcomes. 2014;3(2):1–9. Grass B, Brotschi B, Hagmann C, Birkenmaier A, Schwendener K, Adams M, et al. Centre-specific differences in short-term outcomes in neonates with hypoxic-ischaemic encephalopathy. Swiss Med Wkly. 2021;151:w20489. Uleanya ND, Aniwada EC, Ekwochi U. Short term outcome and predictors of survival among birth asphyxiated babies at a tertiary academic hospital in Enugu, South East, Nigeria. Afr Health Sci. 2019;19(1):1554–62. Adebami OJ. Maternal and fetal determinants of mortality in babies with birth asphyxia at Osogbo. Southwest Nigeria. 2016;4(July 2015):270–6. Devi K, Sathishkumar K. Factors Influencing Outcome of Neonates with Perinatal Asphyxia in a Tertiary. Care Hosp. 2024;(March). Wang C, Jiang H, Wu J, Yu Z, Li Q, Jiang CM. Association between glycemia and outcomes of neonates with hypoxic-ischemic encephalopathy: a systematic review and meta-analysis. BMC Pediatr. 2024;24(1):699. Ali MAM, Farghaly MAA, El-Dib I, Karnati S, Aly H, Acun C. Glucose instability and outcomes of neonates with hypoxic ischemic encephalopathy undergoing therapeutic hypothermia. Brain Dev. 2024;46(8):262–7. Lee IC, Yang JJ, Liou YM. Early blood glucose level post-admission correlates with the outcomes and oxidative stress in neonatal hypoxic-ischemic encephalopathy. Antioxidants. 2022;11(1). Gandhi DKchand, Singh DAK, Mehta DA, Sharma DB, Tiwari DHC. Association between Serum Magnesium level and outcome in birth asphyxia. Pediatr Rev Int J Pediatr Res. 2020;7(7):365–74. Kumr DV, Yelamali BC, Pol R. Serum calcium and magnesium levels in predicting short term outcome of term neonates with Hypoxic Ischemic Encephalopathy. Medica Innov [Internet]. 2018;7(1):44–7. Available from: http://lib.usim.edu.my/usim-ez-proxy?url=http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=131717530&site=ehost-live&scope=site Metwally AM, Abdel-Latif GA, Mohsen A, El Etreby L, Elmosalami DM, Saleh RM, et al. Strengths of community and health facilities based interventions in improving women and adolescents’ care seeking behaviors as approaches for reducing maternal mortality and improving birth outcome among low income communities of Egypt. BMC Health Serv Res. 2020;20(1):1–15. Bangal VB, Borawake K, Gavhane SP, Aher SH. Use of mobile phone for improvement in maternal health: a randomized control trial. Int J Reprod Contracept Obstet Gynecol. 2017;6(12):5458. Esamai F, Mwangi A, Nangami M, Tabu J, Ayuku D, Were E. Improving maternal and child health outcomes through a community involvement strategy in Kabula location, Bungoma County, Kenya. Dialogues Heal [Internet]. 2022;1(July):100026. Available from: https://doi.org/10.1016/j.dialog.2022.100026 Kassim AB, Newton SK, Dormechele W, Rahinatu BB, Yanbom CT, Yankson IK, et al. Effects of a community-level intervention on maternal health care utilization in a resource-poor setting of Northern Ghana. BMC Public Health. 2023;23(1):1–12. Ateudjieu J, Nelson J, Fodjo S. The benefits of traditional birth attendants on maternal and fetal outcomes in sub-Saharan Africa: A systematic review and meta-. Anal Registration : 2023;1–21. Ameyaw EK, Amoah PA, Ezezika O. Effectiveness of mHealth Apps for Maternal Health Care Delivery: Systematic Review of Systematic Reviews. J Med Internet Res. 2024;26:1–19. Hao J, Yang L, Wang Y, Lan Y, Xu X, Wang Z, et al. Mobile Prenatal Education and Its Impact on Reducing Adverse Pregnancy Outcomes: Retrospective Real-World Study. JMIR mHealth uHealth. 2023;11:1–12. Lassi ZS, Bhutta ZA. Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes. Cochrane Database Syst Rev. 2015;2015:3. Dwivedi R, Shamim MA, Dwivedi P, Banerjee AR, Goel AD, Vyas V et al. Maternal and Child Health Training of Traditional Birth Attendants and Pregnancy Outcomes: A Systematic Review and Meta-analysis. J Epidemiol Global Health. 2024. Sibley LM, Sipe TA, Brown CM, Diallo MM, McNatt K, Habarta N. Traditional birth attendant training for improving health behaviours and pregnancy outcomes. Cochrane Database Syst Rev. 2007;(3). Wilson A, Gallos ID, Plana N, Lissauer D, Khan KS, Zamora J et al. Effectiveness of strategies incorporating training and support of traditional birth attendants on perinatal and maternal mortality: Meta-analysis. BMJ. 2012;344(7840). Gohiya P, Ubriani N, Dwivedi R. Impact of Early Referral on Immediate Outcome of Asphyxiated Newborns. J Clin Neonatol. 2021;10(1):1–4. Organization WH. Standards for improving the quality of care for small and sick newborns in health facilities [Internet]. 2020. 60 p. Available from: https://apps.who.int/iris/bitstream/handle/10665/334126/9789240010765-eng.pdf?sequence=1&isAllowed=y Kanyesigye H, Kabakyenga J, Mulogo E, Fajardo Y, Atwine D, MacDonald NE, Bortolussi R, Migisha RNJ. Improved maternal-fetal outcomes among emergency obstetric referrals following phone call communication at a teaching hospital in south western Uganda: a quasi-experimental study. BMC Pregnancy Childbirth. 2022;22(1):684. Lin XY, Yang Z, Shi FQ, Li F. [Impact of different referral timing on the pregnancy outcomes of severe pre-eclampsia in the referral system]. Zhonghua fu chan ke za zhi. 2022;57(3):164–71. Okonkwo I, Okolo A. Postnatal Magnesium Sulfate in Asphyxiated Newborns in Benin City Nigeria: Effect on Mortality. Int J Pediatr Neonatal Care. 2018;4(1). Siddiqui MAS, Butt TK. Role of intravenous magnesium sulphate in term neonates with hypoxic ischemic encephalopathy (hie) in a low-income country: A randomised clinical trial. J Coll Physicians Surg Pakistan. 2021;31(7):817–20. Iqbal N, Younus J, Malik M, Fatima B, Imran A, Maqbool S et al. The Neuroprotective Efficacy of Postnatal Magnesium Sulfate in Term or Near-Term Infants With Moderate-to-Severe Birth Asphyxia. Cureus. 2021;13(8). Rahman A, Ray M, Madewell ZJ, Igunza KA, Akelo V, Onyango D, Murila F, Mwebia W, Ogbuanu IU, Ojulong J, Kowuor D, Kaluma E, Samura S, El Arifeen S, Gurley ES, Hossain MZ, Islam KM, Biswas R, Assefa N, Teferi T, Eshetu K, Madrid L, Kotloff KL, Tapia MD, Ke RC. Adherence to Perinatal Asphyxia or Sepsis Management Guidelines in Low- and Middle-Income Countries. jama Netw open. 2025;8(5). Woolf SH, Grol R, Hutchinson A, Eccles MGJ. Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. BMJ. 1999;318(7182):527–30. Kikaya V, Katembwe F, Yabili J, Mbwanya M, Dhuse E, Gomez P, et al. Effectiveness of Capacity-Building and Quality Improvement Interventions to Improve Day-of-Birth Care in Kinshasa, Democratic Republic of the Congo. Glob Heal Sci Pract. 2024;12(1):1–13. USAID. Building Capacity to Improve Maternal, Newborn, and Child Health and Family Planning Outcomes. 2018; Available from: https://publications.jsi.com/JSIInternet/Inc/Common/_download_pub.cfm?id=16224&lid=3 Patel A, Bang A, Kurhe K, Bhargav S, Prakash A, Arramraj S, et al. Comparison of perinatal outcomes in facilities before and after Global Network’s Helping Babies Breathe Implementation Study in Nagpur, India. Volume 19. BMC Pregnancy and Childbirth; 2019. Davneet Sihota RL, Him G, Dominguez L, Harrison, Tyler Vaivada ZAB. Effectiveness of Neonatal Resuscitation Training Programs, Implementation, and Scale-Up in Low- and Middle-Income Countries. Neonatology. 2024;122(1):52–83. Additional Declarations No competing interests reported. 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22:53:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8663752/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8663752/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101630837,"identity":"72c82cda-f1e5-4837-8151-619b42a139cc","added_by":"auto","created_at":"2026-02-02 05:26:22","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":73091,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlow-chart of the study group\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8663752/v1/ec07020c72fab553aa01f52b.jpg"},{"id":101752845,"identity":"aa8e6384-27ee-4c82-b47d-32f83f87f3ca","added_by":"auto","created_at":"2026-02-03 10:34:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1342758,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8663752/v1/56d35558-e077-4ddf-82fd-0f2a7f8dd978.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Early Adverse Outcomes of Neonatal Hypoxic-Ischemic Encephalopathy in a Resource- Constrained Setting","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePerinatal asphyxia remains a major cause of neonatal death globally, disproportionately affecting developing regions like Sub-Saharan Africa where survivors often face long-term health challenges,(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) including cerebral palsy, seizures, mental disorders, vision and hearing impairment, and cognitive and learning disabilities.(\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eHypoxic-ischemic encephalopathy (HIE) is a syndrome of neurologic dysfunction which complicates perinatal asphyxia;(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) it is the commonest cause of neonatal encephalopathy.(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) Survival rates in babies with HIE depend not just on severity, but also on factors like place of birth, quality of prenatal care, underlying cause, gestational age, maternal health and age, economic status, and access to timely specialized care.(\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) Factors predisposing to HIE can be antenatal,(\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), perinatal,(\u003cspan additionalcitationids=\"CR14 CR15 CR16\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) or a combination of both.(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) During hypoxic\u0026ndash;ischaemic injury, excessive glutamate release over-stimulates neuronal glutamate receptors, triggering excitotoxic enzyme cascades that damage cell membranes and intracellular structures, leading to the clinical manifestations of HIE.(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) Using the modified Sarnat and Sarnat staging system, HIE is categorized into three levels of increasing severity.(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eManagement outcomes in neonatal HIE depends on several factors including; need for advanced resuscitation and abnormal neurological examination;(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) presence of seizures- clinical or electrophysiological, low APGAR scores and poor electroencephalogram background activity;(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) severity of HIE and the clinical status of the neonate at birth.(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) A hospital-based retrospective study done in Nigeria found that place of delivery, booking status of mother, gestational age at birth, age of infant at presentation and severity of HIE significantly predict in-hospital mortality in babies with HIE.(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eApproximately 20\u0026ndash;30% of infants with HIE die in the neonatal period, with about 33\u0026ndash;50% of survivors left with permanent neuro-developmental abnormalities.(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) HIE accounts for 6% to 9% of all neonatal deaths and 21% to 23% of deaths in term infants. While HIE affects 1.5\u0026ndash;2.5 per 1000 births in developed countries,(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) rates increase dramatically to over 26 per 1000 births in resource-limited settings,(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) with one hospital-based study in Sagamu, Ogun State Nigeria reporting an even higher prevalence of 35.9%.(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) It is still a scientific puzzle why some asphyxiated newborns develop HIE while others do not. However, some researchers have suggested variation in newborns\u0026rsquo; compensatory thresholds and intrinsic resistance of the brain to severe asphyxia;(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) complex relationship between the neonatal brain and the immune system during the perinatal period;(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) developmental maturity of the brain(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) and possibly intrinsic genetic factors of the neonates,(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) as plausible explanations.\u003c/p\u003e \u003cp\u003eIdentifying neonates with HIE at higher risk of severe neurological impairment or death is a major focus of research, as this will set the tune for determining management modalities including neuro-protective therapies, prognostication and anticipatory counseling of caregivers.(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) We studied the interplay between some identified risk factors and clinical findings at presentation in influencing early adverse outcomes in newborns with HIE in a tertiary health institution in Nigeria. Understanding these factors will not only guide clinicians in predicting management outcomes but also in deciding which interventions are most urgent for affected newborns.\u003c/p\u003e \u003cp\u003eThe objectives of the study therefore include:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eto determine case fatality rate and prevalence of major short-term adverse outcomes among newborns with HIE;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eto evaluate neonatal (age, gender, place of delivery, sentinel events in labour, 5th minute Apgar score, HIE severity) and maternal (age, parity, mother\u0026rsquo;s educational level and occupation and mode of delivery) factors associated with adverse outcomes in neonatal HIE;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eto assess the relationship between serum biochemical parameters (including magnesium and random blood glucose levels) and short-term adverse outcomes in neonates with HIE;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTo propose actionable interventions based on study findings to improve early management outcomes among newborns with HIE in resource-limited settings\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eStudy area\u003c/p\u003e \u003cp\u003e This was a hospital-based prospective study conducted at the Special Care Baby unit (SCBU) of the Nnamdi Azikiwe University Teaching Hospital (NAUTH), Nnewi, Anambra State. NAUTH is a Federal tertiary health institution located in the commercial city of Nnewi, Anambra State. The facility offers specialized healthcare while serving as a referral center for primary and secondary health facilities in the state and neighboring regions. The SCBU is equipped with 15 incubators, four resuscitaire, two handheld pulse oximeters, four phototherapy units, four apnea monitors, three bubble CPAP machines and different oxygen delivery systems with piped oxygen supply. The SCBU Protocol for management of HIE involves respiratory support with free flow intranasal oxygen or continuous positive airway pressure; anti-seizure drugs; prophylactic antibiotics; dextrose-containing intravenous fluid for caloric support and nasogastric tube feeding when appropriate.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eNewborn participation and enrolment\u003c/h2\u003e \u003cp\u003eThe study population comprised of seventy term newborns with HIE (both in-born and out-born) admitted into the SCBU within 72hours of delivery, who met the inclusion criteria. The study duration spanned nine months from September, 2023 to May, 2024. In the present study, a diagnosis of HIE was based on abnormal neurologic examination during the first 72hours of life as judged by application of the Thompson score (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) and any one of the following:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWeak/poor cry at birth.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eNeed for assisted ventilation initiated at birth and continued for at least 5minutes\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eEligible newborns with HIE received comprehensive evaluation including medical history and clinical examination, then were classified using the Thompson score (mild HIE: 1\u0026ndash;10; moderate HIE: 11\u0026ndash;14; severe HIE: \u0026ge;15).\u003c/p\u003e \u003cp\u003e \u003cb\u003eExclusion Criteria\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAll newborns with evidence of septicemia (e.g. temperature instability, abdominal swelling, abnormal bleeding, petechiae rash), intrauterine infection, congenital anomalies, necrotizing enterocolitis\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eNewborns who were clinically anaemic\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eNewborns of diabetic mothers\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eNewborn babies of mothers who received opioids, other depressant medications or general anesthesia.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eAfter obtaining written informed consent from each participating mother in her preferred language and voluntariness assured, eligible newborns were enrolled consecutively into the study and monitored daily until discharge or death.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eResearch variable\u003c/h3\u003e\n\u003cp\u003eThe following information was obtained on admission or at subsequent reviews using a structured researcher administered questionnaire. These include the outcome and predictor variables. \u003cb\u003eOutcome variables\u003c/b\u003e \u0026ndash; this is the final outcome of newborns admitted for HIE in the special care baby unit during the study period. This includes death; survived without complications; or survived with complications such as respiratory distress, absence of a nutritive suckling reflex, altered level of consciousness, seizures and poor Moro reflex. These were recorded on the 7th day of admission.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePredictor variables\u003c/b\u003e \u0026ndash; these are independent variables that are related to newborn management outcomes. They include birth and demographic variables, clinical parameters, laboratory parameters, and HIE scores.\u003c/p\u003e \u003cp\u003eLaboratory parameters include random blood glucose using capillary blood obtained by heel prick and read using a glucometer (Fine test auto-coding premium, OSANG Healthcare Co., Ltd., Korea), normal range 73-109mg/dl. Serum magnesium- estimated using the xylidyl blue spectrophotometric method, normal range 1.50-2.30mg/dl.\u003c/p\u003e\n\u003ch3\u003eTreatment protocol for asphyxiated neonates with HIE\u003c/h3\u003e\n\u003cp\u003ePerinatal asphyxia is a neonatal emergency condition. Upon admission, affected newborns are resuscitated as required including giving intermittent positive pressure ventilation using a bag-valve-mask device. Once regular breathing is achieved, other components of care mainly supportive are given.\u003c/p\u003e \u003cp\u003eAffected newborn were followed up by a daily clinical examination (mainly with the Thompson score parameters recorded at presentation, 24 hours and 48 hour later) and short-term outcomes recorded on day 7 of admission.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eThe collected data were initially entered into Microsoft Excel, cleaned and subsequently exported and analyzed using statistical package for social science (SPSS) version 25 (IBM Corp., Armonk, New York, USA). Descriptive statistics of frequency count, percentages, mean and standard deviation was used to summarize demographic characteristics. The Fisher\u0026rsquo;s exact test and Chi-square (χ2) analysis were used to determine association between variables. P values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered as statistically significant.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical Consideration\u003c/h3\u003e\n\u003cp\u003e Approval for this study was obtained from the NAUTH Ethics Committee with reference number NAUTH/CS/66/VOL.15/VER.3/100/2022/057. Informed consent was obtained from every mother-newborn dyad following adequate explanation of the research objectives, potential benefits of participation, and assurance that the study posed minimal risk to their newborns. Participation in the study was entirely voluntary and no form of financial inducement was involved. Voluntary withdrawal at any stage of interaction was guaranteed for all subjects without any adverse consequence for the newborns. All information was handled with strict confidentiality.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAmong the 603 neonates admitted into the SCBU during the study period, 200 were diagnosed with perinatal asphyxia; however, 100 of them were excluded based on the eligibility criteria (Figure 1). A further 30 babies were excluded as they did not meet the criteria for diagnosis of HIE; thus, a final analysis included 70 newborns. Thirty-two out of 70 (45.7%) had short-term adverse outcome; among these 37.5% (n =12) died within seven days of admission given a case fatality rate of 17.1%, while 62.5% (n =20) developed at least one adverse complication. The prevalence of major short-term adverse outcomes include: seizure- 80% (16/20), absent nutritive suckling \u0026ndash; 65% (13/20), poor Moro reflex- 25% (5/20), respiratory distress- 20% (4/20) and altered consciousness- 15% (3/20).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: The HIE Score (Thompson score)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSign/Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHypertonia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHypotonia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFlaccid\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLOC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHyper alert\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLethargic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eComatose\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSeizures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInfrequent\u0026lt; 3 per day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFrequent\u0026gt;2 per day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePosture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFisting/cycling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStrong distal flexion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDecerebrate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMoro\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePartial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGrasp\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePoor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSucking reflex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePoor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAbsent \u0026plusmn; bites\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRespiration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHyperventilation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBrief apnoea\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIPPV (apnoea)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFontanel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFull, not tense\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTense\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eLOC: loss of consciousness; IPPV: intermittent positive pressure ventilation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 shows that most newborns in our study presented to the hospital within the first 24 hours of life (58.6%, n=41), with a mean presentation age of 27.1 \u0026plusmn; 23.3 hours. The study population showed a slight male predominance (male to female ratio 1.2:1). Majority of the deliveries (75.7%, n=53) occurred outside the study facility. Regarding labour characteristics, sentinel events were documented in a substantial proportion of cases (77.1%). Vaginal delivery was the most common mode of delivery (52.9%, n=37), and half of the mothers were first-time mothers (primiparous, 50%, n=35). The maternal demographic profile showed that most mothers were under 35 years of age (84.3%, n=59), had received some form of education and were employed in various occupations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Demographic profile of Neonates with HIE\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003eParameters\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eFrequency n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eMean(\u003cstrong\u003ex̄\u003c/strong\u003e)\u0026plusmn;SD\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge at presentation\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026lt;24 hours\u003c/p\u003e\n \u003cp\u003e24-\u0026lt;48 hour\u003c/p\u003e\n \u003cp\u003e48-72 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e41 (58.6)\u003c/p\u003e\n \u003cp\u003e14 (20.0)\u003c/p\u003e\n \u003cp\u003e15 (21.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e27.1\u003cstrong\u003e\u0026plusmn;\u003c/strong\u003e23.3 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBirth weight\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eLow (\u0026lt;2.5kg)\u003c/p\u003e\n \u003cp\u003eNormal (2.5-4.0kg)\u003c/p\u003e\n \u003cp\u003eLarge (\u0026gt;4.0kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9 (12.9)\u003c/p\u003e\n \u003cp\u003e58 (82.9)\u003c/p\u003e\n \u003cp\u003e3 (4.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3.09\u003cstrong\u003e\u0026plusmn;\u003c/strong\u003e0.5kg\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003cp\u003eFemale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e38 (54.3)\u003c/p\u003e\n \u003cp\u003e32 (45.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlace of delivery\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eInborn\u003c/p\u003e\n \u003cp\u003eOutborn\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e17 (24.3)\u003c/p\u003e\n \u003cp\u003e53 (75.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMode of delivery\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNormal vaginal\u003c/p\u003e\n \u003cp\u003eAssisted vaginal\u003c/p\u003e\n \u003cp\u003eCaesarean section\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e37 (52.9)\u003c/p\u003e\n \u003cp\u003e5 (7.1)\u003c/p\u003e\n \u003cp\u003e28 (40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSentinel events in labour\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003ePresent\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAbsent\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e54 (77.1)\u003c/p\u003e\n \u003cp\u003e16 (22.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal age\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e18- \u0026lt;30 years\u003c/p\u003e\n \u003cp\u003e30 - 35 years\u003c/p\u003e\n \u003cp\u003e\u0026gt;35 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e40 (57.1)\u003c/p\u003e\n \u003cp\u003e19 (27.1)\u003c/p\u003e\n \u003cp\u003e11 (15.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e28.7\u003cstrong\u003e\u0026plusmn;\u003c/strong\u003e 5.7 years\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParity\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003ePrimiparous\u003c/p\u003e\n \u003cp\u003eMultiparous\u003c/p\u003e\n \u003cp\u003eGrand multiparous\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e35 (50.0)\u003c/p\u003e\n \u003cp\u003e24 (34.3)\u003c/p\u003e\n \u003cp\u003e11 (15.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMother\u0026rsquo;s HEA\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003cp\u003eTertiary\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4 (5.7)\u003c/p\u003e\n \u003cp\u003e41 (58.6)\u003c/p\u003e\n \u003cp\u003e25 (35.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMother\u0026rsquo;s occupation\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eUnemployed\u003c/p\u003e\n \u003cp\u003eTrader\u003c/p\u003e\n \u003cp\u003eCivil servant\u003c/p\u003e\n \u003cp\u003eOthers\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e20 (28.9)\u003c/p\u003e\n \u003cp\u003e21 (30.0)\u003c/p\u003e\n \u003cp\u003e18 (25.7)\u003c/p\u003e\n \u003cp\u003e11 (15.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eHEA: highest educational attainment\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe results in Table 3 below, shows thatinborn babies had significantly better outcomes (88.2% no adverse outcomes) compared to outborn babies who had higher rates of adverse outcomes (35.8%) and death (20.8%). Similarly, the severity of HIE was significantly associated with outcomes as 76.3% of newborns with mild HIE had no adverse outcomes, 50% of those with moderate HIE had adverse outcomes while 50% of those with severe HIE died. Furthermore, the 5\u003csup\u003eth\u003c/sup\u003e minute Apgar score was a strong predictor of outcome; 72.1% of newborns with scores greater than seven had no adverse outcomes; while those with scores less than seven, 40.7% had adverse outcome and 33.4% died. In addition, with regards to occurrence of sentinel events in labour, 20.4% of babies with sentinel events during labour died compared to 6.3% who did not have such events. However, age at presentation and gender were not significantly associated with outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Newborn\u0026rsquo;s demographic and clinical characteristics associated with adverse outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"667\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eParameters\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003eNo adverse outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003eAdverse outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eDead\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge at presentation\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026lt;24 hours\u003c/p\u003e\n \u003cp\u003e24-\u0026lt;48 hour\u003c/p\u003e\n \u003cp\u003e48-72 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e22 (53.6%)\u003c/p\u003e\n \u003cp\u003e7 (50.0%)\u003c/p\u003e\n \u003cp\u003e9 (60.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10 (24.4)\u003c/p\u003e\n \u003cp\u003e5 (35.7%)\u003c/p\u003e\n \u003cp\u003e5 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9 (22.0%)\u003c/p\u003e\n \u003cp\u003e2 (14.3%)\u003c/p\u003e\n \u003cp\u003e1 (6.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e41 (58.6%)\u003c/p\u003e\n \u003cp\u003e14 (20.0%)\u003c/p\u003e\n \u003cp\u003e15 (21.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.673\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003cp\u003eFemale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18 (47.3%)\u003c/p\u003e\n \u003cp\u003e20 (62.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e12 (31.6%)\u003c/p\u003e\n \u003cp\u003e8 (25.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8 (21.1%)\u003c/p\u003e\n \u003cp\u003e4 (12.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e38 (54.3%)\u003c/p\u003e\n \u003cp\u003e32 (45.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.420\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlace of delivery\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eInborn\u003c/p\u003e\n \u003cp\u003eOutborn\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15 (88.2%)\u003c/p\u003e\n \u003cp\u003e23 (43.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (5.9%)\u003c/p\u003e\n \u003cp\u003e19 (35.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (5.9%)\u003c/p\u003e\n \u003cp\u003e11 (20.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e17 (24.3%)\u003c/p\u003e\n \u003cp\u003e53 (75.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.005*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHIE severity\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMild HIE\u003c/p\u003e\n \u003cp\u003eModerate HIE\u003c/p\u003e\n \u003cp\u003eSevere HIE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e29 (76.3%)\u003c/p\u003e\n \u003cp\u003e7 (43.7%)\u003c/p\u003e\n \u003cp\u003e2 (12.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6 (15.8%)\u003c/p\u003e\n \u003cp\u003e8 (50.0%)\u003c/p\u003e\n \u003cp\u003e6 (37.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3 (7.9%)\u003c/p\u003e\n \u003cp\u003e1 (6.3%)\u003c/p\u003e\n \u003cp\u003e8 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e38 (54.2%)\u003c/p\u003e\n \u003cp\u003e16 (22.9%)\u003c/p\u003e\n \u003cp\u003e16 (22.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.0001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5\u003csup\u003eth\u003c/sup\u003e minute Apgar score\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026gt;7\u003c/p\u003e\n \u003cp\u003e\u0026lt;7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e31 (72.1%)\u003c/p\u003e\n \u003cp\u003e7 (25.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9 (20.9%)\u003c/p\u003e\n \u003cp\u003e11 (40.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3 (7.0%)\u003c/p\u003e\n \u003cp\u003e9 (33.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e43 (61.4%)\u003c/p\u003e\n \u003cp\u003e27 (38.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.0001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSentinel labour events\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003ePresent\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e31 (57.4%)\u003c/p\u003e\n \u003cp\u003e7 (43.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e12 (22.2%)\u003c/p\u003e\n \u003cp\u003e8 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e11 (20.4%)\u003c/p\u003e\n \u003cp\u003e1 (6.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e54 (77.1%)\u003c/p\u003e\n \u003cp\u003e16 (22.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.075\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e*Statistically significant\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMore so, normal vaginal delivery was associated with more adverse outcomes (40.6%) and mortality (21.6%) compared to caesarean delivery, 17.9% adverse outcomes and 14.3% mortality, respectively (Table 4). Additionally, mother\u0026rsquo;s occupation was significantly associated with management outcomes: newborns whose mothers were traders had best outcomes (76.2% no complications, 4.8% mortality), while newborns of unemployed mothers had high adverse outcomes (30%) and the highest mortality (30%). Babies born by mothers in the \u0026quot;others\u0026quot; category- mostly low income earners; showed the highest adverse outcomes (63.6%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4: Maternal factors associated with HIE outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"667\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eParameters\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003eNo adverse outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003eAdverse outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eDead\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal age\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e18-\u0026lt;30 year\u003c/p\u003e\n \u003cp\u003e30-35 year\u003c/p\u003e\n \u003cp\u003e\u0026gt;35 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e22 (55.0%)\u003c/p\u003e\n \u003cp\u003e9 (47.4%)\u003c/p\u003e\n \u003cp\u003e7 (63.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10 (25.0%)\u003c/p\u003e\n \u003cp\u003e8 (42.1%)\u003c/p\u003e\n \u003cp\u003e2 (18.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8 (20.0%)\u003c/p\u003e\n \u003cp\u003e2 (10.5%)\u003c/p\u003e\n \u003cp\u003e2 (18.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e40 (57.1%)\u003c/p\u003e\n \u003cp\u003e19 (27.1%)\u003c/p\u003e\n \u003cp\u003e11 (15.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.584\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParity\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003ePrimiparous\u003c/p\u003e\n \u003cp\u003eMultiparous\u003c/p\u003e\n \u003cp\u003eGrand multiparous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e19 (54.3%)\u003c/p\u003e\n \u003cp\u003e13 (54.2%)\u003c/p\u003e\n \u003cp\u003e6 (54.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e12 (34.3%)\u003c/p\u003e\n \u003cp\u003e6 (25.0%)\u003c/p\u003e\n \u003cp\u003e2 (18.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4 (11.4%)\u003c/p\u003e\n \u003cp\u003e5 (20.8%)\u003c/p\u003e\n \u003cp\u003e3 (27.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e35 (50.0%)\u003c/p\u003e\n \u003cp\u003e24 (34.3%)\u003c/p\u003e\n \u003cp\u003e11 (15.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.656\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMode of delivery\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNormal vaginal\u003c/p\u003e\n \u003cp\u003eAssisted vaginal\u003c/p\u003e\n \u003cp\u003eCaesarean section\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14 (37.8%)\u003c/p\u003e\n \u003cp\u003e5 (100.0%)\u003c/p\u003e\n \u003cp\u003e19 (67.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15 (40.6%)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e5 (17.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8 (21.6%)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e4 (14.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e37 (52.9%)\u003c/p\u003e\n \u003cp\u003e5 (7.1%)\u003c/p\u003e\n \u003cp\u003e28 (40.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.032*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMother\u0026rsquo;s HEL\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003ePrimary education\u003c/p\u003e\n \u003cp\u003eSecondary education\u003c/p\u003e\n \u003cp\u003eTertiary education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3 (75.0%)\u003c/p\u003e\n \u003cp\u003e20 (48.8%)\u003c/p\u003e\n \u003cp\u003e15 (60.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (25.0%)\u003c/p\u003e\n \u003cp\u003e14 (34.1%)\u003c/p\u003e\n \u003cp\u003e5 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003cp\u003e7 (17.1%)\u003c/p\u003e\n \u003cp\u003e5 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4 (5.7%)\u003c/p\u003e\n \u003cp\u003e41 (58.6%)\u003c/p\u003e\n \u003cp\u003e25 (35.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.626\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMother\u0026rsquo;s occupation\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eUnemployed\u003c/p\u003e\n \u003cp\u003eTrader\u003c/p\u003e\n \u003cp\u003eCivil servant\u003c/p\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8 (40.0%)\u003c/p\u003e\n \u003cp\u003e16 (76.2%)\u003c/p\u003e\n \u003cp\u003e11 (61.1%)\u003c/p\u003e\n \u003cp\u003e3 (27.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6 (30.0%)\u003c/p\u003e\n \u003cp\u003e4 (19.0%)\u003c/p\u003e\n \u003cp\u003e3 (16.7%)\u003c/p\u003e\n \u003cp\u003e7 (63.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6 (30.0%)\u003c/p\u003e\n \u003cp\u003e1 (4.8%)\u003c/p\u003e\n \u003cp\u003e4 (22.2%)\u003c/p\u003e\n \u003cp\u003e1 (9.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e20 (28.9%)\u003c/p\u003e\n \u003cp\u003e21 (30.0%)\u003c/p\u003e\n \u003cp\u003e18 (25.7%)\u003c/p\u003e\n \u003cp\u003e11 (15.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.020*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e*Statistically significant\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn relation to serum biochemical profile (Table 5), newborns with hypermagnesemia appeared to have less adverse outcomes and mortality compared to those with normal serum magnesium, although this did not reach statistical significance. Random blood glucose, on the other hand showed significant association with management outcomes as newborns with hypoglycemia and hyperglycemia had significantly poorer outcomes compared to those with normal random blood glucose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5: Role of serum biochemical parameters in predicting short-term outcomes in neonates with HIE\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"667\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eLaboratory parameters\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003eNo adverse outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003eAdverse outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eDead\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSerum magnesium\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNormal magnesium\u003c/p\u003e\n \u003cp\u003eHigh magnesium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e26 (54.2%)\u003c/p\u003e\n \u003cp\u003e12 (54.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14 (29.2%)\u003c/p\u003e\n \u003cp\u003e6 (27.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8 (16.6%)\u003c/p\u003e\n \u003cp\u003e4 (18.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e48 (68.6%)\u003c/p\u003e\n \u003cp\u003e22 (31.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.980\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRandom blood glucose\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNormoglycemia\u003c/p\u003e\n \u003cp\u003eHypoglycemia\u003c/p\u003e\n \u003cp\u003eHyperglycemia\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e36 (67.9%)\u003c/p\u003e\n \u003cp\u003e1 (7.7%)\u003c/p\u003e\n \u003cp\u003e1 (25.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e13 (24.5%)\u003c/p\u003e\n \u003cp\u003e6 (46.2%)\u003c/p\u003e\n \u003cp\u003e1 (25.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4 (7.6%)\u003c/p\u003e\n \u003cp\u003e6 (46.2%)\u003c/p\u003e\n \u003cp\u003e2 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e53 (75.7%)\u003c/p\u003e\n \u003cp\u003e13 (18.6%)\u003c/p\u003e\n \u003cp\u003e4 (5.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.0001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e*Statistically significant\u003c/strong\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study revealed an alarming 17.7% case fatality rate among patients diagnosed with hypoxic ischaemic encephalopathy, highlighting the critical nature of this condition. Comparable high rates have been documented across other developing countries with Ekwochi \u003cem\u003eet al.\u003c/em\u003e documenting 18% in Enugu Nigeria,(1) and Hafsa \u003cem\u003eet al.\u003c/em\u003e, reporting 16.4% in Rawalpindi Pakistan.(33)These consistently high fatality rates likely stem from limited access to therapeutic hypothermia; an evidence-based treatment proven effective for moderate to severe HIE.(2, 34\u0026ndash;37) This modality of treatment has been shown to significantly reduce mortality and major disability associated with HIE.(38\u0026ndash;40) However, our findings contrast with several other studies that reported notably lower case fatality rates ranging from 8.5% to 14%.(32, 41, 42) The lower case fatality in the aforementioned studies could be due to use of therapeutic hypothermia as a standard treatment for babies with HIE; also two of the studies had a larger sample size. Furthermore, among survivors of HIE in our study, the most common short-term adverse outcomes included seizures (80%), absence of nutritive suckling (65%), poor Moro reflex (25%), respiratory distress requiring support (20%), and altered consciousness (15%). This finding compares differently to the observation of Teixeira \u003cem\u003eet al.\u003c/em\u003e, who reported that at discharge of their HIE survivors, 14% were on anti-seizure drugs; 23.3% had no feeding skills; 23.3% had abnormal neurological examination; while 2.1% required oxygen support.(41) Additionally, Grass \u003cem\u003eet al.\u003c/em\u003e, reported a median seizure prevalence of 32.3% in a large multicentre study.(42) The lower prevalence of short-term adverse outcome noted in the cited studies could be due to use of induced hypothermia as a treatment modality for HIE and probably the availability of better skilled manpower.\u003c/p\u003e\n\u003cp\u003eOur study also revealed that, adverse outcomes in HIE cases were significantly associated with outborn delivery, severity of encephalopathy, and low fifth-minute Apgar scores. These findings likely reflect inadequate infrastructure, poorly planned delivery and limited neonatal resuscitation expertise at referral centers coupled with delayed presentation. This result agrees with the findings of several other researchers who noted that adverse outcome in HIE is significantly associated with outborn delivery status, HIE severity, Apgar scores and mode of delivery.(1, 32, 33, 41)The relationship between gender and HIE outcomes remains controversial in literature. One study demonstrated significantly worse outcomes in males;(33) while another reported higher mortality in females.(1)In our study, although males showed a trend toward poorer outcomes, this difference was not statistically significant. The discrepancy in previous findings may be attributed to demographic variations, particularly a higher male-to-female ratio (2:1) and larger sample size in one study;(33) while the increased female mortality in the other study remained unexplained.(1)\u003c/p\u003e\n\u003cp\u003eFurthermore, our study indicated that significant maternal variables associated with early adverse outcomes in newborns with HIE were normal vaginal delivery and maternal occupation. These findings may be due to the fact that most of the vaginal deliveries occurred outside hospital where trained birth attendants are limited in number and supervision may be inadequate, potentially resulting in more adverse outcomes; also mothers that were unemployed or those from a low socioeconomic background are likely to make poor health choices due poverty, ignorance and poor health seeking behaviours which will certainly predispose them to adverse labour outcomes. Our findings align with previous research showing higher death rates in asphyxiated infants delivered vaginally(1, 43). Other studies have also found that mothers\u0026apos; of low socioeconomic status significantly worsens outcomes for these babies.(43, 44) However, Suppiej \u003cem\u003eet al.\u003c/em\u003e,(32) and Devi \u003cem\u003eet al.\u003c/em\u003e,(45) reported different results, noting that emergency cesarean deliveries increased the risk of severe outcomes in HIE babies. This contradiction may be explained by the underlying maternal or fetal complications that necessitated the choice of emergency cesarean procedure in the first place and delayed presentation to the hospital.\u003c/p\u003e\n\u003cp\u003eOur study demonstrated a significant association between abnormal blood glucose levels and poor outcomes in neonates with HIE. Infants presenting with either hypoglycemia or hyperglycemia experienced higher rates of complications and mortality compared to those maintaining normoglycemia. These findings align with established pathophysiological mechanisms: hypoglycemia compromises recovery by depriving vulnerable neurons of essential energy, elevating seizure risk, and disrupting cerebral perfusion; while hyperglycemia induces damage through oxidative stress during reperfusion, exacerbates cerebral edema, increases intracranial pressure, and amplifies inflammatory responses. This relationship between glycemic dysregulation and adverse outcomes in HIE is consistently supported by multiple previous investigations, reinforcing the critical importance of glucose homeostasis in the management of these vulnerable neonates.(1, 46\u0026ndash;48) More so, we noted that asphyxiated newborns with hypermagnesemia had less adverse outcomes and mortality compared to those with normal serum magnesium levels; although this was not statistically significant. Many researchers concur with this observation noting that higher serum magnesium in neonates with HIE reduced the risk of abnormal motor examination and seizure;(49) while hypomagnesemia reduced survival rate of the affected neonates.(50)\u003c/p\u003e\n\u003cp\u003eDrawing from our research results, we recommend the following actionable interventions to enhance early outcomes for neonates with hypoxic-ischemic encephalopathy in resource-constrained environments:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003eCommunity-based interventions and initiatives\u003c/strong\u003e\u003c/p\u003e\n \u003c/li\u003e\n\u003c/ol\u003e\n\u003cdiv\u003e\n \u003cp\u003eThis approach focuses on strengthening healthcare at the community level through three key strategies: training traditional birth attendants (TBAs) in rural areas to identify feto-maternal danger signs, perform basic neonatal resuscitation and refer early, cases that are beyond their scope, to tertiary health facilities; implementing public education campaigns targeting vulnerable populations about labour danger signs and skilled birth attendance; and developing mobile health initiatives using SMS reminders for antenatal care and emergency transportation coordination for high-risk pregnancies. These approaches, when driven by community ownership and participation, have been proven effective in enhancing perinatal/neonatal health outcomes by many researchers.(51, 52, 61, 53\u0026ndash;60)\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003e2. Healthcare system improvements for neonatal care\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv\u003e\n \u003cp\u003eThis will be achieved through standardized referral protocols to minimize delays and improve pre-transfer stabilization; establishment of specialized neonatal transport teams with portable temperature and glucose monitoring; and expansion of point-of-care glucose testing with clear management protocols across all delivery settings. These initiatives when put into action have the potentials to improve outcomes for babies with perinatal asphyxia as demonstrated by many studies.(62\u0026ndash;65)\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003e3. Establishing standardized clinical management protocols for neonatal HIE\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv\u003e\n \u003cp\u003eThis comprehensive approach addresses the clinical management of hypoxic-ischemic encephalopathy through three targeted protocols: implementing strict glucose management guidelines with regular monitoring and prompt intervention for blood glucose abnormalities; developing magnesium sulfate administration protocols for moderate-to-severe HIE based on study findings showing improved outcomes with hypermagnesemia; and establishing evidence-based guidelines for optimal oxygen therapy- CPAP and mechanical ventilation, particularly for neonates experiencing respiratory distress at the tertiary and secondary health facilities. Strict adherence to such management protocol, has resulted to streamlining of care; reducing delays in providing high quality care; enhancing communication among neonatal care providers; and improving overall outcome for asphyxiated babies, as suggested by many studies.(4, 66\u0026ndash;70)\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003e4. Training and capacity building for HIE management\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv\u003e\n \u003cp\u003eThis aims to strengthen healthcare provider capabilities through: implementing regular simulation-based drills for all delivery room personnel to master neonatal resuscitation techniques for asphyxiated newborns; and training diverse healthcare workforce to utilize simplified HIE scoring systems for rapid severity assessment and appropriate clinical decision-making. These interventions ensure consistent, high-quality care across different healthcare settings and are supported by several studies.(71\u0026ndash;74)\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\"\u003e\n \u003ch2\u003eLimitations\u003c/h2\u003e\n \u003cp\u003eThis research was conducted at a single healthcare facility, potentially restricting the applicability of our findings to other clinical environments. Due to resource constraints, we were unable to perform arterial blood gas analysis on cord blood samples- a key method for biochemically confirming asphyxia. Our diagnosis of HIE relied on the Thompson scoring system, which contains subjective elements that may have introduced bias in patient classification. Additionally, as our tertiary care center typically receives complex referrals, our patient population likely included a disproportionate number of severe cases, possibly inflating both the prevalence of severe HIE and the case fatality rate observed in our study.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur research demonstrated that birth outside the hospital setting, HIE severity, low Apgar scores at five minutes, blood glucose abnormalities, and specific maternal characteristics were significantly associated with early adverse outcomes in neonatal HIE; all contributing to the high case fatality rate observed in our study.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eClinical trial number\u003c/h2\u003e \u003cp\u003enot applicable\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003e \u003cb\u003eConflict of interest\u003c/b\u003e:\u003c/strong\u003e \u003cp\u003ethe authors declare no conflict of interest.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthical Approval\u003c/strong\u003e \u003cp\u003e Ethical clearance was obtained from the Nnamdi Azikiwe University Teaching Hospital Ethics Committee with reference number NAUTH/CS/66/VOL.15/VER.3/100/2022/.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eno funding was received for this research.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConceptualization, OCK, OBT and UC; methodology, OCK, OBT, OUC and EOA; data collection, OCK, OBT, NSC, OUC, UC, ESI, EOA and AOI; statistical analysis and result writing, OCK, OBT, ESI and EES; writing\u0026mdash;original draft preparation, OCK, OBT, UC, EES and EOA; writing\u0026mdash;review and editing, OCK, OBT, EST, AOI, OUC, ESI and NSC; supervision, EES and EST. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe express our profound appreciation to the parents who placed their newborns in our care, enabling this vital research. Our deepest gratitude goes to the Special Care Baby Unit staff whose exceptional dedication has been instrumental in treating critically ill neonates. This research is dedicated to all families affected by hypoxic-ischemic encephalopathy, with the sincere hope that our findings will advance clinical practice and ultimately improve outcomes for these vulnerable patients.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data for this study will be made available by the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eEkwochi U, Asinobi NI, Osuorah CDI, Ndu IK, Ifediora C, Amadi OF, et al. Incidence and Predictors of Mortality Among Newborns With Perinatal Asphyxia: A 4-Year Prospective Study of Newborns Delivered in Health Care Facilities in Enugu, South-East Nigeria. Clin Med Insights Pediatr. 2017;11:117955651774664.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTagin MA, Woolcott CG, Vincer MJ, Whyte RK, Stinson DA. Hypothermia for neonatal hypoxic ischemic encephalopathy: An updated systematic review and meta-analysis. Arch Pediatr Adolesc Med. 2012;166(6):558\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOgunkunle TO, Odiachi H, Chuma JR, Bello SO, Imam A. Postnatal Outcomes and Risk Factors for In-Hospital Mortality among Asphyxiated Newborns in a Low-Resource Hospital Setting: Experience from North-Central Nigeria. Ann Glob Heal. 2020;86(1):63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePius S, Bello M, Ambe JP, Machoko Y, Clement AY, Genesis R, et al. Pilot Study: Magnesium Sulphate Administration and Early Resolution of Hypoxic Ischemic Encephalopathy in Severe Perinatal Asphyxia. Open J Pediatr. 2019;09(01):89\u0026ndash;102.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOgunfowora O, Ogunlesi T. Hypoxic Ischaemic Encephalopathy among Asphyxiated Nigeran Newborns. Niger Hosp Pract. 2011;7:5\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEzenwa BN, Olorunfemi G, Fajolu I, Adeniyi T, Oleolo-Ayodeji K, Kene-Udemezue B et al. Trends and predictors of in-hospital mortality among babies with hypoxic ischaemic encephalopathy at a tertiary hospital in Nigeria: A retrospective cohort study. PLoS One [Internet]. 2021;16(4 April):1\u0026ndash;20. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.1371/journal.pone.0250633\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0250633\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUgwu GIMG, Abedi HO, Ugwu EN. Incidence of birth asphyxia as seen in central hospital and GN children\u0026rsquo;s clinic both in Warri Niger Delta of Nigeria: an eight year retrospective review. Glob J Health Sci. 2012;4(5):140\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGebregziabher GT, Hadgu FB, Abebe HT. Prevalence and Associated Factors of Perinatal Asphyxia in Neonates Admitted to Ayder Comprehensive Specialized Hospital, Northern Ethiopia: A Cross-Sectional Study. Int J Pediatr (United Kingdom). 2020;2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKawakami MD, Sanudo A, Teixeira MLP, Andreoni S, de Castro JQX, Waldvogel B, et al. Neonatal mortality associated with perinatal asphyxia: a population-based study in a middle-income country. BMC Pregnancy Childbirth. 2021;21(1):1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeebles PJ, Duello TM, Eickhoff JC, McAdams RM. Antenatal and intrapartum risk factors for neonatal hypoxic ischemic encephalopathy. J Perinatol Off J Calif Perinat Assoc. 2020;40(1):63\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAcun C, Karnati S, Padiyar S, Puthuraya S, Aly H, Mohamed M. Trends of neonatal hypoxic-ischemic encephalopathy prevalence and associated risk factors in the United States, 2010 to 2018. Am J Obstet Gynecol. 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLocatelli A, Lambicchi L, Incerti M, Bonati F, Ferdico M, Malguzzi S, et al. Is perinatal asphyxia predictable? BMC Pregnancy Childbirth. 2020;20(1):1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLorain P, Bower A, Gottardi E, Dommergues M, Helias LFL, Guellec I et al. Risk factors for hypoxic \u0026ndash; \u0026shy; ischemic encephalopathy in cases of severe acidosis: A case \u0026ndash; \u0026shy; control study. 2022;(September 2021):471\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarrois M, Patkai J, Delorme P, Chollat C, Goffinet F, Le Ray C. Factors associated with neonatal hypoxic ischemic encephalopathy in infants with an umbilical artery pH less than 7.00. Eur J Obstet Gynecol Reprod Biol. 2019;236:69\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParker S-J, Kuzniewicz M, Niki H, Wu YW. Antenatal and Intrapartum Risk Factors for Hypoxic-Ischemic Encephalopathy in a US Birth Cohort. J Pediatr. 2018;203:163\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTorbenson VE, Tolcher MC, Nesbitt KM, Colby CE, EL-Nashar SA, Gostout BS, et al. Intrapartum factors associated with neonatal hypoxic ischemic encephalopathy: A case-controlled study. BMC Pregnancy Childbirth. 2017;17(1):1\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang J, Tao E, Mo M, Ding W, Yuan J, Wang M, et al. Perinatal Risk Factors Influencing Neonatal Hypoxic Ischemic Encephalopathy in Southern China: A Case-Control Study. Am J Perinatol. 2021;38(S 01):e182\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAslam S, Strickland T, Molloy EJ. Neonatal encephalopathy: Need for recognition of multiple etiologies for optimal management. Front Pediatr. 2019;7(MAR).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDouglas-Escobar M, Weiss MD. Hypoxic-Ischemic Encephalopathy A Review for the Clinician. JAMA Pediatr. 2015;169(4):397\u0026ndash;403.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKliegman R. Nelson textbook of pediatrics 20th edition. 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClinical Guidelines - Queensland Health Q. Maternity and Neonatal Clinical Guideline. Queensl Heal [Internet]. 2017;1\u0026ndash;39. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003c/span\u003e\u003cspan address=\"http://www.health.qld.gov.au/qcg%0Awww.health.qld.gov.au/qcg%0Awww.health.qld.gov.au/qcg%0Awww.health.qld.gov.au/qcg\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed June, 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShim GH. Which factors predict outcomes of neonates with hypoxic-ischemic encephalopathy following therapeutic hypothermia? Clin Exp Pediatr. 2021;64(4):169\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSeo SY, Shim GH, Chey MJ, You SJ. Prognostic factors of neurological outcomes in late-preterm and term infants with perinatal asphyxia. Korean J Pediatr. 2016;59(11):440\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMerchant N, Azzopardi D. Early predictors of outcome in infants treated with hypothermia for hypoxic-ischaemic encephalopathy. Dev Med Child Neurol. 2015;57(S3):8\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAllen KA, Brandon DH. Hypoxic Ischemic Encephalopathy: Pathophysiology and Experimental Treatments. Newborn Infant Nurs Rev. 2011;11(3):125\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu L, Johnson HL, Cousens S, Perin J, Scott S, Lawn JE et al. Global, regional, and national causes of child mortality: An updated systematic analysis for 2010 with time trends since 2000. Lancet [Internet]. 2012;379(9832):2151\u0026ndash;61. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.1016/S0140-6736(12)60560-1\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(12)60560-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoshiro R, Mdoe P, Perlman JM. A Global View of Neonatal Asphyxia and Resuscitation. 2019;7(November):1\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi B, Concepcion K, Meng XZL. Brain-immune interactions in perinatal hypoxic-ischemic brain injury. Prog Neurobiol. 2018;176(1):139\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRainaldi MA, Perlman JM. Pathophysiology of Birth Asphyxia. Clin Perinatol. 2016;43(3):409\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMota-Rojas D, Villanueva-Garc\u0026iacute;a D, Solimano A, Muns R, Ibarra-R\u0026iacute;os D, Mota-Reyes A. Pathophysiology of Perinatal Asphyxia in Humans and Animal Models. Biomedicines. 2022;10(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGorovenko NG, Rossokha ZI, Podolskaya SV, Pokhylko VI, Lundberg GA. The Role of Genetic Determinant in the Development of Severe Perinatal The Role of Genetic Determinant in the Development of Severe Perinatal Asphyxia 1. 2010;(April 2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSuppiej A, Vitaliti G, Talenti G, Cuteri V, Trevisanuto D, Fanaro S et al. Prognostic risk factors for severe outcome in the acute phase of neonatal hypoxic-ischemic encephalopathy: A prospective cohort study. Children. 2021;8(12).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHafsa Niaz J, Jalil QU, Zaman, Khan F, Basheer, Shahzad Akhtar NH, CLINICAL PROFILE AND SHORT TERM OUTCOME OF HYPOXIC ISCHEMIC ENCEPHALOPATHY AMONG BIRTH ASPHXIATED BABIES IN A TERTIARY CARE HOSPITAL. Pak Armed Forces Med J. 2021;71(1):24\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLemyre B, Chau V. Hypothermia for newborns with hypoxic-ischemic encephalopathy. Paediatr Child Heal. 2018;23(4):285\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNair J, Kumar VHS. Current and emerging therapies in the management of hypoxic ischemic encephalopathy in neonates. Children. 2018;5(7).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavidson JO, Wassink G, van den Heuij LG, Bennet L, Gunn AJ. Therapeutic hypothermia for neonatal hypoxic-ischemic encephalopathy - Where to from here? Front Neurol. 2015;6(SEP).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePapile LA, Baley JE, Benitz W, Cummings J, Carlo WA, Eichenwald E, Kumar P, Polin RA, Tan RCWK. Hypothermia Neonatal Encephalopathy Pediatr [Internet]. 2014;133(6):1146\u0026ndash;50. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003epediatrics.org/cgi/doi/10.1542/peds.2014-0899\u003c/span\u003e\u003cspan address=\"pediatrics.cgi/doi/10.1542/peds.2014-0899\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Available from: www.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavies A, Wassink G, Bennet L, Gunn A, Davidson J. Can we further optimize therapeutic hypothermia for hypoxic-ischemic encephalopathy? Neural Regen Res. 2019;14(10):1678\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCoetzee M. Hypoxic-ischaemic encephalopathy: Identifying newborns who will benefit from therapeutic hypothermia in developing countries. SAJCH South Afr J Child Heal. 2018;12(4):175\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaptook AR, Shankaran S, Tyson JE, Munoz B, Bell EF, Goldberg RN, Parikh NA, Ambalavanan N, Pedroza C, Pappas A, Das A, Chaudhary AS, Ehrenkranz RA, Hensman AM, Van Meurs KP, Chalak LF, Khan AM, Hamrick SEG, Sokol GM, Walsh MC, Poindexter BB, Faix RG, Wat HR. Effect of Therapeutic Hypothermia Initiated After 6 Hours of Age on Death or Disability Among Newborns With Hypoxic-Ischemic Encephalopathy: A Randomized Clinical Trial. 2018;318(16):1550\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTeixeira L, Soares H, Flor-de-lima F, Vilan A. Perinatal hypoxic-ischemic encephalopathy: severity determinants and outcomes. 2014;3(2):1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrass B, Brotschi B, Hagmann C, Birkenmaier A, Schwendener K, Adams M, et al. Centre-specific differences in short-term outcomes in neonates with hypoxic-ischaemic encephalopathy. Swiss Med Wkly. 2021;151:w20489.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUleanya ND, Aniwada EC, Ekwochi U. Short term outcome and predictors of survival among birth asphyxiated babies at a tertiary academic hospital in Enugu, South East, Nigeria. Afr Health Sci. 2019;19(1):1554\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdebami OJ. Maternal and fetal determinants of mortality in babies with birth asphyxia at Osogbo. Southwest Nigeria. 2016;4(July 2015):270\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDevi K, Sathishkumar K. Factors Influencing Outcome of Neonates with Perinatal Asphyxia in a Tertiary. Care Hosp. 2024;(March).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang C, Jiang H, Wu J, Yu Z, Li Q, Jiang CM. Association between glycemia and outcomes of neonates with hypoxic-ischemic encephalopathy: a systematic review and meta-analysis. BMC Pediatr. 2024;24(1):699.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAli MAM, Farghaly MAA, El-Dib I, Karnati S, Aly H, Acun C. Glucose instability and outcomes of neonates with hypoxic ischemic encephalopathy undergoing therapeutic hypothermia. Brain Dev. 2024;46(8):262\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee IC, Yang JJ, Liou YM. Early blood glucose level post-admission correlates with the outcomes and oxidative stress in neonatal hypoxic-ischemic encephalopathy. Antioxidants. 2022;11(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGandhi DKchand, Singh DAK, Mehta DA, Sharma DB, Tiwari DHC. Association between Serum Magnesium level and outcome in birth asphyxia. Pediatr Rev Int J Pediatr Res. 2020;7(7):365\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKumr DV, Yelamali BC, Pol R. Serum calcium and magnesium levels in predicting short term outcome of term neonates with Hypoxic Ischemic Encephalopathy. Medica Innov [Internet]. 2018;7(1):44\u0026ndash;7. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://lib.usim.edu.my/usim-ez-proxy?url=http://search.ebscohost.com/login.aspx?direct=true\u0026amp;db=a9h\u0026amp;AN=131717530\u0026amp;site=ehost-live\u0026amp;scope=site\u003c/span\u003e\u003cspan address=\"http://lib.usim.edu.my/usim-ez-proxy?url=http://search.ebscohost.com/login.aspx?direct=true\u0026amp;db=a9h\u0026amp;AN=131717530\u0026amp;site=ehost-live\u0026amp;scope=site\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMetwally AM, Abdel-Latif GA, Mohsen A, El Etreby L, Elmosalami DM, Saleh RM, et al. Strengths of community and health facilities based interventions in improving women and adolescents\u0026rsquo; care seeking behaviors as approaches for reducing maternal mortality and improving birth outcome among low income communities of Egypt. BMC Health Serv Res. 2020;20(1):1\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBangal VB, Borawake K, Gavhane SP, Aher SH. Use of mobile phone for improvement in maternal health: a randomized control trial. Int J Reprod Contracept Obstet Gynecol. 2017;6(12):5458.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEsamai F, Mwangi A, Nangami M, Tabu J, Ayuku D, Were E. Improving maternal and child health outcomes through a community involvement strategy in Kabula location, Bungoma County, Kenya. Dialogues Heal [Internet]. 2022;1(July):100026. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.dialog.2022.100026\u003c/span\u003e\u003cspan address=\"10.1016/j.dialog.2022.100026\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKassim AB, Newton SK, Dormechele W, Rahinatu BB, Yanbom CT, Yankson IK, et al. Effects of a community-level intervention on maternal health care utilization in a resource-poor setting of Northern Ghana. BMC Public Health. 2023;23(1):1\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAteudjieu J, Nelson J, Fodjo S. The benefits of traditional birth attendants on maternal and fetal outcomes in sub-Saharan Africa: A systematic review and meta-. Anal Registration : 2023;1\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmeyaw EK, Amoah PA, Ezezika O. Effectiveness of mHealth Apps for Maternal Health Care Delivery: Systematic Review of Systematic Reviews. J Med Internet Res. 2024;26:1\u0026ndash;19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHao J, Yang L, Wang Y, Lan Y, Xu X, Wang Z, et al. Mobile Prenatal Education and Its Impact on Reducing Adverse Pregnancy Outcomes: Retrospective Real-World Study. JMIR mHealth uHealth. 2023;11:1\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLassi ZS, Bhutta ZA. Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes. Cochrane Database Syst Rev. 2015;2015:3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDwivedi R, Shamim MA, Dwivedi P, Banerjee AR, Goel AD, Vyas V et al. Maternal and Child Health Training of Traditional Birth Attendants and Pregnancy Outcomes: A Systematic Review and Meta-analysis. J Epidemiol Global Health. 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSibley LM, Sipe TA, Brown CM, Diallo MM, McNatt K, Habarta N. Traditional birth attendant training for improving health behaviours and pregnancy outcomes. Cochrane Database Syst Rev. 2007;(3).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilson A, Gallos ID, Plana N, Lissauer D, Khan KS, Zamora J et al. Effectiveness of strategies incorporating training and support of traditional birth attendants on perinatal and maternal mortality: Meta-analysis. BMJ. 2012;344(7840).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGohiya P, Ubriani N, Dwivedi R. Impact of Early Referral on Immediate Outcome of Asphyxiated Newborns. J Clin Neonatol. 2021;10(1):1\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrganization WH. Standards for improving the quality of care for small and sick newborns in health facilities [Internet]. 2020. 60 p. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://apps.who.int/iris/bitstream/handle/10665/334126/9789240010765-eng.pdf?sequence=1\u0026amp;isAllowed=y\u003c/span\u003e\u003cspan address=\"https://apps.who.int/iris/bitstream/handle/10665/334126/9789240010765-eng.pdf?sequence=1\u0026amp;isAllowed=y\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKanyesigye H, Kabakyenga J, Mulogo E, Fajardo Y, Atwine D, MacDonald NE, Bortolussi R, Migisha RNJ. Improved maternal-fetal outcomes among emergency obstetric referrals following phone call communication at a teaching hospital in south western Uganda: a quasi-experimental study. BMC Pregnancy Childbirth. 2022;22(1):684.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLin XY, Yang Z, Shi FQ, Li F. [Impact of different referral timing on the pregnancy outcomes of severe pre-eclampsia in the referral system]. Zhonghua fu chan ke za zhi. 2022;57(3):164\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkonkwo I, Okolo A. Postnatal Magnesium Sulfate in Asphyxiated Newborns in Benin City Nigeria: Effect on Mortality. Int J Pediatr Neonatal Care. 2018;4(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSiddiqui MAS, Butt TK. Role of intravenous magnesium sulphate in term neonates with hypoxic ischemic encephalopathy (hie) in a low-income country: A randomised clinical trial. J Coll Physicians Surg Pakistan. 2021;31(7):817\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIqbal N, Younus J, Malik M, Fatima B, Imran A, Maqbool S et al. The Neuroprotective Efficacy of Postnatal Magnesium Sulfate in Term or Near-Term Infants With Moderate-to-Severe Birth Asphyxia. Cureus. 2021;13(8).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRahman A, Ray M, Madewell ZJ, Igunza KA, Akelo V, Onyango D, Murila F, Mwebia W, Ogbuanu IU, Ojulong J, Kowuor D, Kaluma E, Samura S, El Arifeen S, Gurley ES, Hossain MZ, Islam KM, Biswas R, Assefa N, Teferi T, Eshetu K, Madrid L, Kotloff KL, Tapia MD, Ke RC. Adherence to Perinatal Asphyxia or Sepsis Management Guidelines in Low- and Middle-Income Countries. jama Netw open. 2025;8(5).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWoolf SH, Grol R, Hutchinson A, Eccles MGJ. Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. BMJ. 1999;318(7182):527\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKikaya V, Katembwe F, Yabili J, Mbwanya M, Dhuse E, Gomez P, et al. Effectiveness of Capacity-Building and Quality Improvement Interventions to Improve Day-of-Birth Care in Kinshasa, Democratic Republic of the Congo. Glob Heal Sci Pract. 2024;12(1):1\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUSAID. Building Capacity to Improve Maternal, Newborn, and Child Health and Family Planning Outcomes. 2018; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://publications.jsi.com/JSIInternet/Inc/Common/_download_pub.cfm?id=16224\u0026amp;lid=3\u003c/span\u003e\u003cspan address=\"https://publications.jsi.com/JSIInternet/Inc/Common/_download_pub.cfm?id=16224\u0026amp;lid=3\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel A, Bang A, Kurhe K, Bhargav S, Prakash A, Arramraj S, et al. Comparison of perinatal outcomes in facilities before and after Global Network\u0026rsquo;s Helping Babies Breathe Implementation Study in Nagpur, India. Volume 19. BMC Pregnancy and Childbirth; 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavneet Sihota RL, Him G, Dominguez L, Harrison, Tyler Vaivada ZAB. Effectiveness of Neonatal Resuscitation Training Programs, Implementation, and Scale-Up in Low- and Middle-Income Countries. Neonatology. 2024;122(1):52\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Hypoxic-ischemic encephalopathy, neonatal outcomes, predictors, resource-limited setting, Nigeria","lastPublishedDoi":"10.21203/rs.3.rs-8663752/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8663752/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eHypoxic-ischemic encephalopathy (HIE) remains a leading cause of neonatal mortality and long-term neurological disability, particularly in resource-limited settings. Understanding factors associated with early adverse outcomes is crucial for optimizing management strategies.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo identify maternal and neonatal factors associated with early adverse outcomes in newborns with HIE in a Nigerian tertiary health institution.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA prospective hospital-based study was conducted at Nnamdi Azikiwe University Teaching Hospital, Nnewi, from September 2023 to May 2024. Seventy term newborns with HIE admitted within 72 hours of delivery were enrolled. HIE diagnosis was based on abnormal neurological examination using the Thompson score. Data on demographic characteristics, maternal factors, and biochemical parameters were collected and analyzed using SPSS version 25. Fisher's exact test and Chi-square analysis was used to determine associations between variables, with p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 considered significant.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong 70 newborns, 45.7% (32/70) experienced short-term adverse outcomes. The case fatality rate was 17.1% (12/70), while 28.6% (20/70) developed complications including seizures (80%), absent nutritive suckling (65%), poor Moro reflex (25%), respiratory distress (20%), and altered consciousness (15%). Place of delivery was significantly associated with adverse outcomes (p\u0026thinsp;=\u0026thinsp;0.005), with outborn neonates exhibiting a higher risk compared with inborn neonates. Both HIE severity and a 5-minute Apgar score\u0026thinsp;\u0026lt;\u0026thinsp;7 were significantly associated with adverse outcomes (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for both). Maternal factors significantly associated with adverse outcomes included mode of delivery (p\u0026thinsp;=\u0026thinsp;0.032) and maternal occupation (p\u0026thinsp;=\u0026thinsp;0.020). Random blood glucose levels showed significant association with outcomes (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while serum magnesium levels did not (p\u0026thinsp;=\u0026thinsp;0.980).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eHIE severity, a low 5-minute Apgar score, outborn delivery status, and abnormal blood glucose levels were significantly associated with early adverse outcomes in neonatal HIE. These findings emphasize the importance of skilled birth attendance, early recognition, and prompt glucose monitoring in improving outcomes for affected newborns in resource-limited settings.\u003c/p\u003e","manuscriptTitle":"Early Adverse Outcomes of Neonatal Hypoxic-Ischemic Encephalopathy in a Resource- Constrained Setting","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-02 05:26:18","doi":"10.21203/rs.3.rs-8663752/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-20T11:16:49+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-19T13:41:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-18T11:16:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"305986175899086894652258040154621865670","date":"2026-02-04T20:33:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"138330543675640682411345040244514927489","date":"2026-02-02T10:57:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"126355734537663257170447954056276287468","date":"2026-01-30T09:11:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"99285747147367246581772110879126462759","date":"2026-01-29T04:00:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"130254595550955157247079277249528675707","date":"2026-01-29T02:04:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"213710316398066538369326073676746398072","date":"2026-01-28T10:42:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-28T07:33:30+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-27T09:07:18+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-27T08:00:07+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-27T07:59:16+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2026-01-21T22:40:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"94234e64-039c-4674-8eb8-d054b736172d","owner":[],"postedDate":"February 2nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-18T19:24:07+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-02 05:26:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8663752","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8663752","identity":"rs-8663752","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}