1. Cause- Specific Neonatal Deaths
Dr.AbdulRahman Alnemri
Assistant professor paediatric
Consultant Neonatologist
1st international NEONATOLOGY conference November 2008

2. غافر
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3. 4/21/2017

4. Background
Each year 4 million children die in the first 4 weeks of life
Global average of 30-36/1000 Live Birth
Geneva WHO report,2005
Many neonatal deaths are preventable with existing low-cost intervention
Planners and policy makers required reliable cause-of –death information
Int J Epidemiol 2003;
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5. The reduction of child mortality has been included among the Millennium Development Goals(MDG-4) that the United Nations has set to be attained by year With out reduction in global NMR MDG-4 will not be achieved Strategies, which address inequalities both within a country and between countries, are necessary if there is going to be further improvement in global perinatal health.
Report of the Secretary General. New York, NY: United Nations; UN document A756/326
4 million neonatal deaths: when? where? Why? Lancet 2005;365:

6. Causes of Neonatal Deaths
WHO report before 2005 provide little detail with respect to perinatal-neonatal causes of death WHO,the world helth Report:2004Geneva
Neonatal infection the single largest cause of deaths globally national inst of science2003,pp.1-333
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7. Estimating the cause of 4 million neonatal death in the year 2000
NMRs ranged from 2 to 18 per 1000 live births.
Based on 193 countries; the major causes
Infection (sepsis/pneumonia, tetanus, and diarrhea 35%
Preterm birth %
Asphyxia %
98% information on cause of death is lacking because of inadequate vital registration (VR)
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International Journal of Epidemiology 2006;35:706–718

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9. The estimated distribution of causes for 4 million neonatal deaths for the six WHO regions in the year Size of circle represents number of deaths in each region. Afr = Africa, Amr = Americas, Emr = Eastern Mediterranean, Eur = Europe, Sear = Southeast Asia, and W pr = Western Pacific
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10. El Shafei AM, Sandhu AK, Dhaliwal JK. Perinatal mortality in Bahrain
El Shafei AM, Sandhu AK, Dhaliwal JK. Perinatal mortality in Bahrain. Aust N Z J Obstet Gynaecol 1988;28:293–98.
Ebrahim AH. Perinatal mortality in Ministry of Health Hospitals- Bahrain, 1985 and J Bahrain Med Soc 1998;10:95–99.
Kishan J, Soni AL, Elzouki AY, Mir NA. Perinatal mortality and neonatal survival in Libya. J Trop Pediatr 1988;34:32–33.
el-Zibdeh MY, Al-Suleiman SA, Al-Sibai MH. Perinatal mortality at King Fahd Hospital of the University Al-Khobar, Saudi Arabia. Int J Gynaecol Obstet 1988;26:399–407.
Asindi AA, Archibong E, Fatinni Y, Mannan N, Musa H. Perinatal and neonatal deaths. Saudi Med J 1998;19:693–97.
Dawodu A, Varady E, Verghese M, al-Gazali LI. Neonatal audit in the United Arab Emirates: a country with a rapidly developing economy. East Mediterr Health J 2000;6:55–64.
Yassin KM. Indices and sociodemographic determinants of childhood mortality in rural Upper Egypt. Soc Sci Med 2000;51:185–97.
Campbell O, Gipson R, el Mohandes A et al. The Egypt National Perinatal/Neonatal Mortality Study J Perinatol 2004;24:284–89.
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11. Mortality rates in Canadian neonatal intensive care units • Canadian Medical Association or its licensors 22 JANV. 2002; 166 (2)
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12. Infant and NMR in Saudi Arabia
Year
IMR
(NMR)
Rank
% Change
Date
2003
47.94
(12.7) 73 %
2003 est.
2004
13.24
(11)
145
0.00 %
2004 est.
2005
144
-3.25 %
2005 est.
2006
12.81
2006 est.
Source: CIA World Factbook - Unless otherwise noted, information in this page is accurate as of November 1, 2006
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13. Saudi Arabia average position from FIFA World Ranking creation is 38
Date
FIFA Ranking position
Mar 2008 50
Feb 2008
Jan 2008 57
2007 61
2006 64
2005 33
2004 28
2003 26
2002 38
2001 31
2000 36
1999 39
1998 30
1997
1996 37
1995 54
1994 27
1993
Saudi Arabia average position from FIFA World Ranking creation is 38
The Gulf Area countries are on track to meet most of the Millennium Development Goals, although the speed of improvement has slowed since the 1990s.
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15. Neonatal Mortality Rate North Saudi Arabia
NMR account for 60% of all infant deaths
(65.6%) occured in the neonatal period
Three main causes of death were identified: perinatal causes, genetic disorders and infection
44% of infant deaths considered as preventable
Avery’s Neonatology: Pathophysiology& Management of the Newborn. 6th ed. Philadelphia,Pa: Lippincott Williams & Wilkins;2005:459–489
JELLY A. E. (1) ; WARNASURIYA N. (1) Saudi medical journal  1998, vol. 19, no2, pp. 
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16. South Saudi Arabia Department of Pediatrics, Abha Maternity Hospital, Abha
The major death determinants were low birth weight (LBW)/ prematurity, congenital malformation and birth asphyxia.
Respiratory insufficiency (89.9% of cases) and sepsis (36% of cases) were the main causes of neonatal deaths in low birth weight infants.
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Ann Saudi Med 1997;17(5):

17. Causes of neonatal deaths in ACH
South Saudi Arabia
Causes of death
No. of infants
% of total (n=169)
Low birth weight 77
45.5
Congenital malformation 52
30.8
Infection 23
13.6
Birth asphyxia 13
7.7
Meconium aspiration syndrome 2
1.2
Inborn error of metabolism
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Ann Saudi Med 1997;17(5):

18. Factors contributing to death in 77 LBW infants. Conditions
No. of cases
Hyaline membrane disease 33
Sepsis 23
Necrotizing enterocolitis 14
Pulmonary hemorrhage 4
Intraventricular hemorrhage 3
Persistent pulmonary hypertension
Undetermined 10
Ann Saudi Med 1997;17(5):
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19. East P of Saudi Arabia. Neonatal vital statistics: a 5-year review 81-86
The overall neonatal mortality rate declined from 15.6 to 8.1/1000 live births (LB), and after excluding lethal malformations mortality fell from 14.0 to 5.6/1000 LB
Congenital malformations, RDS, and asphyxia were the 3 most common causes of death.
These conditions and severe immaturity account for 74% of deaths.
Dawodu AH Al Umran KAl Faraidy AAnn Trop Paediatr Sep;8(3):
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20. 70.3% of the deaths occurred in the neonatal period
CAUSE-SPECIFIC INFANT MORTALITY RATE IN QATIF AREA, EASTERN PROVINCE, SAUDI ARABIA Hussain Abu Srair, FRCP(C), FAAP; Joshua A. Owa, FNMC (Nig), FWAC; Hussain Ahmed Aman, MD
70.3% of the deaths occurred in the neonatal period
Major causes of IMR were
premature delivery (39.1%)
Infections (25%)
Birth defects (18.8%)
Difficult delivery (4.7%)
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Ann Saudi Med 1995;15(2):

21. Do you know any study?

22. CAPITAL OF Saudi Saudi Med J. 2008 Jun ;29 (6):879-883 18521470
OBJECTIVE: To describe and monitor the causes of neonatal and postneonatal deaths in the Neonatal Intensive Care Unit (NICU) over a 10-year-period. METHODS: This is a descriptive study of all infants who died in the NICU from January 1995 until December 2004 at Riyadh Military Hospital, Riyadh, Kingdom of Saudi Arabia. Data were collected prospectively on all infants admitted to NICU. The cause of death for each infant was discussed and determined by at least 2 consultant neonatologists. Deaths were classified according to the modified Wigglesworth's classification of perinatal death. RESULTS: During the study period, there were live births and 526 deaths, in which % were inborn deaths and % were outborn. Of the inborn deaths, 251 infants died between 1-6 days, 103 died between 7-27 days, and 92 died after 27 days. Lethal malformations led to death in 36%, prematurity and its complications in 42%, hypoxic ischemic encephalopathy in 5%, while other specific diagnoses, combined, led to death in 17% of the cases. CONCLUSION: Prematurity and its complications followed by congenital malformations were the leading causes of death.
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Majeed-Saidan et,al

23. Prematurity and LBW Rate
Spain 1%
Finland , Sweeden, Ireland 4%
Jordan, Japan, Egypt 5%
Oman 6%
UK., USA,Chile 7%
Kuwait 7%
AFHSR 15.5%
Unicef Report 2000
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24. Neonatal Deaths At Armed forces Hospital Programme Southern Region (AFHSR) a sex-year review
Dr.AbdulRAhman Alnemri,MD
Dr.Ibrahim Alhefzi,MD
Dr.Khaled Rashid,MD
Dr.Ahmad Hellal
Dr.Suliman Alfifi, MD
1st international NEONATOLOGY conference November 2008

25. International Journal of Epidemiology 2006;35:706–718
The estimated distribution of causes for 4 million neonatal deaths for the six WHO regions in the year Size of circle represents number of deaths in each region. Afr = Africa, Amr = Americas, Emr = Eastern Mediterranean, Eur = Europe, Sear = Southeast Asia, and W pr = Western Pacific
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International Journal of Epidemiology 2006;35:706–718

26. There are 3 levels of care IC, IMC& feeder and grower
AFH SR NICU, is the tertiary centre in the region accommodate up to 40 newborns
There are 3 levels of care IC, IMC& feeder and grower
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28. Objective
To describe trend in neonatal mortality in AFH Southern region between
1st January 2001 to 31st Dec 2006
Determine the major causes of death in different birth weight group
The data could be used to plan the future direction of perinatal neonatal care at Armed Force hospitals south regions
Compare the outcome with Armed force hospitals programme.
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29. METHODS
Descriptive analysis of data of all neonates died IN neonatal intensive care unit at AFHSR from January 2001 to Dec 2006
All perinatal and neonatal data collected from the maternal and neonatal medical records *
The “underlying cause of death” is derived from the diagnosis listed on each death certificate according to International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), ( 4th edition, Craig D. Puckett: volume 1,2,3 channel publishing Ltd
* Lotus approach 97 data program
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30. METHODS
In cases where the cause of death was in doubt, case notes were reviewed with the doctor who certified the death of the neonate to arrive at a consensus direct cause of death
Exclusion criteria (D.R. DEATHS + STILL BIRTH)
The birth weight of 6-year study period was grouped into 3 groups
ELBW infants below 1000gm
VLBW infants gm
Near term infant more than or equal to 1500gm
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31. General Statistic yr Birth St.birth C.PMR END LND 2001 5599 67 12.2 2011
2002
5708 42
7.18 18 6
2003
6265 41
5.74 4
2004
6322 52
9.4 21
2005
6567 48
8.5 14
2006
6923 72
11.8
16(3.7)
Total
37384
53.7
9.6 19
8.6
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The average perinatal mortality rate was 14 per 1000 total births and the neonatal mortality rate was 9.6 per 1000 live-births

32. General Statistic NICU Mortality Review
year
T. admission
T D (%)
2001
594
40 (6.5)
2002
686
31 (4.5)
2003
833
35 (4)
2004
780
34 (4.3)
2005
675
50 (7.4)
2006
784
57 (7.3)
Total
4352 (11.6%)
247 (5.7)
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33. Inborn Vs out-born NICU Death
58 out-borne neonate Mortality (9) 15.5%
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*Saudi med. j 2003, vol. 24, no12, pp.   

34. CORRECTED MORTALITY *
32.5%
26%
41%
22.5%
58% ELBW*
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35. MORTALITY EAR DISTRIBUTION
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36. Mortality with gestational age
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37. Early Mortality
MEAN 23 DAYS
7- 45 DAYS
MEAN 3.6 DAYS
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38. Causes of all neonatal death
Prematurity < 34wk , MCA multiple cong anomalies, BA+ birth asphyxia
The major death determinants were low birth weight (LBW)/prematurity, stillbirth, congenital malformation and birth asphyxia Saudi medical journal , 1998, vol. 19, no6, pp.   
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39. Admission on birth weight
B. wt
Total admission
Deaths
M R(%)
ELBW
< 1000gm
234 85
36%
405 40
10%
> 1500gm
3713
122
3.3%
Total
4352
247
5.7%
Exclude multiple congenital and lethal deaths Corrected M R = 3.4%
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40. ELBW Mortality (< 1000gm)
Total deaths 85 Average Mortality Rate 36%
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41. Mortality by B wt
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MEAN 670 GM

42. ELBW Deaths (< 1000gm)
77% <750gm
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Total 85/234 MR 36%

43. Causes of Deaths in ELBW
PHE 37%
PNX 12%
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44. Causes of Deaths in ELBW (<1000gm)
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45. Major Risk Factor Antenatal care Antenatal Steroid Growth Retardation
Male Sex
Mode of Delivery
Multiple pregnancy
Ethnic group
In born Vs out born
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46. Survival Deaths 5min Abgar < 7 83 (55.7%) Male 60 (40.3%) Female 89
83 (55.7%)
Male
60 (40.3%)
Female 89
SVD
112 (75%)
C section
37 (25%)
Booked
97 (65%)
Un-booked
52 (35%)
Full steroid 97 No 52
AGA
122 (82%)
IUGR
27 (18%)
5min Abgar <7
55 (64.7%)
Male
51 (60%)
Female P
NSVD
70 (82%)
C. section P
Booked
P <0.1
Un booked
67 (78.8%)
full
24 P <0.0023 No
61 (72%)
AGA (>10th P
IUGR (<10th
67 (78%)
Total 149
Total 85
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47. Comparison of The Survival Rate of ELBW Infants (500 – 999 gm)
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48. Low Birth Wt
1000 gm to 1499 gm
< 34wk

49. Mortality in 1000-1499 gm B wt Total adm Deaths % 1001-1099 74 10 13.5 57 7
12.3 90 9 77
107
6.5
Total
405 40
9.8
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50. Causes of Death in VLBW infant (1000-1499 gm)No %
Prem 25
62.5%
MCA 15
37.5%
Resp. f
PHE 13
52%
Sepsis 9
36%
NEC 2 8%
IVH 1 4%
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51. Prenatal- Neonatal Death
SEPSIS
NEC
MCA
PHE
PNEUMX
IVH
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52. Survival Rate of VLBW Infants RKH Experience 1998 - 2004
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53. Near Term
>1500 gm
> 34 wks

54. Deaths in Near-term infant Mortality
Total admissions = 3713
85% OF TOTAL ADDMISSION
Deaths = 122 (64 early 58 late)
35 (28.6%)* lethal anomalies
M R = 33 / 1000 live birth (3.3%)
** DNR
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55. Near Term Admission
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56. Mortality Rate in Near Term infants >1500gm
B. Wt
Total
No. deaths MR
739 38
4.3%
824 32
3.5%
>2500
2150 52
(42.6%)
2.4%
3713
122
3.3%
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57. B. wt. based Mortality Distribution
L A*
40% IUGR
LA * 35 infant with Lethal Anomalies
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58. Lethal anomalies DNR Diagnosis NO CNS anomalies 10 Trisomy 18 114
thantophoric dysplasia 5
Potter Syndromes
Total 35
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59. Cuases No (%) 45 (37%) 37 (30%) 13(10.5%) 9(7.5%) 9 (7.5%) 4 (3%)
MCA
45 (37%)
B. Asp +PPHN
37 (30%)
IEM WITH L ACID
13(10.5%)
D. hernia
9(7.5%)
COMP. CHD
9 (7.5%)
Hydropes
4 (3%)
Sepsis
AWD
1 (1.5%)
Total
122
MCA = Multiple congenital Anomalies
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60. Risk Factors
The risk factors independently associated near term death included
low birth weight (IUGR) P value < .001
complications during labour p .001
lethal deformities P value 0.001
Infection 0.1
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61. 2007 Changes Separate the unit coverage Isolation Feeding protocol
Inodomethacine prophylaxis

62. CORRECTED MORTALITY

63. Summary Total live birth 37384
Total Admission 4352 = 11.6 % of T. Birth
Total Death 229 (5.3%)
Prematurity is the major cause of mortality(61%) especially ELBE 45%
IVH responsible for early death (45%) while sepsis is the major killer in late death (50%)
Multiple congenital anomalies is the 1st cause of death in near term infant >34wks of gestation 37%
Followed by Prenatal asphyxia with or with out PPHN 30%
Poor antenatal care, multiple congenital anomalies , multiple pregnancy are major risk factors need to be evaluated
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64. Conclusion The perinatal neonatal services cooperation
National registry
Prematurity 15.5%
Antenatal steroid
Sepsis and IVH are the major contributing causes for mortality in ELBW infant
Congenital anomalies is very high
(6 -8/1000 Live Birth)
Need revaluation of the service annually
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65. Acknowledgment Coauthors All NICU rotating residents & Registrars
NICU Head nurse and all Unit nurses
MRS. Zahoor Abdullah Assiri
MRS. Farah
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66. Thanks
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