Infection and Drug Resistance

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Neonatal Sepsis and Its Associated Factors Among

Neonates Admitted to Neonatal Intensive Care
Units in Primary Hospitals in Central Gondar Zone,
Northwest Ethiopia, 2019

Zelalem Agnche, Hedja Yenus Yeshita & Kedir Abdela Gonete

To cite this article: Zelalem Agnche, Hedja Yenus Yeshita & Kedir Abdela Gonete (2020)
Neonatal Sepsis and Its Associated Factors Among Neonates Admitted to Neonatal Intensive
Care Units in Primary Hospitals in Central Gondar Zone, Northwest Ethiopia, 2019, Infection
and Drug Resistance, , 3957-3967, DOI: 10.2147/IDR.S276678

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ORIGINAL RESEARCH

Neonatal Sepsis and Its Associated Factors

Among Neonates Admitted to Neonatal Intensive
Care Units in Primary Hospitals in Central
Gondar Zone, Northwest Ethiopia, 2019
This article was published in the following Dove Press journal:
Infection and Drug Resistance

Zelalem Agnche 1 Background: Neonatal sepsis contributes substantially to neonatal morbidity and mortality and
Hedja Yenus Yeshita 2 is an ongoing major global public health challenge particularly in developing countries. Studies
3 conducted on the proportion and risk factors of neonatal sepsis in Ethiopia are from referral
Kedir Abdela Gonete
1
hospitals, which may not be generalized to primary health care units where a significant propor­
Amhara Regional State, Central Gondar
Zone, West Dembia District, Kolladba tion of mothers give birth in these health facilities. This study sought to determine the proportion
Primary Hospital, Kolladba, Ethiopia; of clinical neonatal sepsis and associated factors in the study areas.
2
Department of Reproductive Health, Methods: Institutional-based cross-sectional study was conducted from March to
Institute of Public Health, College of
Medicine and Health Sciences, University April 2019, in Amhara regional state, central Gondar zone public primary hospitals in
of Gondar, Gondar, Ethiopia; Ethiopia. A total of 352 subjects (mother-neonate pairs) were selected using a systematic
3
Department of Human Nutrition,
random sampling technique and pre-tested and structured questionnaires were used to collect
Institute of Public Health, College of
Medicine and Health Sciences, University data. Multivariable logistic regression analysis was fitted to identify factors associated with
of Gondar, Gondar, Ethiopia neonatal sepsis. Adjusted odds ratio (AOR) with the corresponding 95% confidence interval
(CI) was used to show the strength of associations and variables with p-values of <0.05 were
considered as statistically significant.
Results: The overall proportion of neonatal sepsis was 64.8% (95% CI (59.2, 69.2)). Being
male neonate (AOR=3.7; 95% CI (1.76, 7.89)), history of urinary tract infections during the
index pregnancy (AOR =6, 26; 95% CI (1.16, 33.62)), frequency of per-vaginal examination
greater than three during labor and delivery (AOR=6.06; 95% CI (2.45, 14.99)), neonatal
resuscitation at birth (AOR=6.1; 95% CI (1.71, 21.84)), place of delivery at the health center
(AOR=3.05; 95% CI (1.19, 7.79)), lack of training of health workers on neonatal resuscita­
tion and infection prevention practices (AOR=2.14; 95% CI (1.04, 4.44)), late age of neonate
at onset of illness (AOR=0.05; 95% CI (0.01, 0.21)) and maternal age of 30–34 years
(AOR=0.19; 95% CI (0.047, 0.81)) were significantly associated with neonatal sepsis.
Conclusion: The proportion of neonatal sepsis is high. Maternal, neonatal, and health
service related factors were identified for neonatal sepsis. Therefore, training of health
workers, provision of health care services as per standards, and monitoring and evaluation
of obstetrical/neonatal care during labor and delivery are mandatory.
Keywords: neonatal sepsis, risk factors, neonatal intensive care units

Background
Correspondence: Kedir Abdela Gonete Neonatal sepsis (NS) is defined as systemic inflammatory response syndrome in the
University of Gondar, P.O. BOX: 196, presence of or as a result of suspected or proven infection in a neonate.1 Neonatal
Gondar, Ethiopia
Email [email protected] sepsis contributes substantially to neonatal morbidity and mortality and is an

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ongoing major global public health challenge.2 According expansion of clinical care for babies and mothers.13
to the World Health Organization (WHO), globally Hence, there have been many advances in the prevention,
each year over 4 million neonates died within 28 days of assessment, and treatment of neonatal sepsis in the past
birth.3 Infections are considered to be the leading cause of few decades. However, the morbidity and mortality asso­
neonatal deaths (35%) followed by deaths resulted from ciated with sepsis remain high for susceptible neonates.13
preterm births (28%), intrapartum related complications World Health Assembly resolution (WHA) makes sev­
(24%), and asphyxia (23%).4 eral recommendations including prevention, diagnosis, and
Globally 7% of mortality in children under 5 years and treatment of sepsis in national health systems, training all
15% in neonates were related to sepsis and meningitis in health professionals on infection prevention and patient
2016.4 Sepsis is the commonest cause of neonatal mortal­ safety, promoting research, and others. Therefore, sepsis
ity and is probably responsible for 30–50% of the total is considered as a good example of a crosscutting
neonatal deaths each year in developing countries.4 It is approach for measurable reductions in neonatal
estimated that in 2012 about 6.9 million neonates were mortality.14
diagnosed with a possible serious bacterial infection need­ In Ethiopia, various efforts have been made to reduce
ing treatment and 2.6 million of these occurred in Sub- neonatal morbidity and mortality. However, some studies
Saharan Africa.5,6 conducted in referral hospitals of the country showed that
In Ethiopia; prematurity (37%), infection (28%), and neonatal morbidity and mortality related to neonatal sepsis
asphyxia (24%) are the most common causes of death in are still high.15
neonates. Neonatal conditions which used to account for Despite a considerable burden of neonatal sepsis in our
a quarter of under-five deaths in 2004 have recently setting, there were no studies conducted to assess the
increased to 43%. According to the current united nation proportion and associated factors of neonatal sepsis
estimate in Ethiopia, the neonatal deaths were reduced among neonates admitted in NICUs to recently established
slowly by 48% in 2013 from 1990 as compared to primary hospitals in Ethiopia. Therefore, this study was
a significant reduction rate of under-five mortality by 67%.7 carried out to determine the proportion of neonatal sepsis
Ethiopia demographic and health survey (EDHS, 2016) and factors contributing to it among neonates in central
reported that the neonatal mortality rate was 29/1000 live Gondar Zone public primary hospitals of the Amhara
birth, which was reduced slowly from 39/1000 in 2005 and region in Ethiopia.
37/1000 live births in 2011. Particularly Amhara region of
the country was at the top in infant and neonatal mortality
rates (NMRs). It was 67 and 47 per 1000 live births,
Methods
respectively.8 Study Design, Setting, and Period
Neonatal sepsis also has an economic impact that An Institutional-based cross-sectional study was con­
resulted from increased medical costs, prolonged hospital ducted in the Amhara region at central Gondar zone public
stay, and potentially poor long-term neurodevelopmental primary hospitals in Ethiopia from March to April 2019.
outcomes. Despite this fact, the world is witnessing These hospitals were established recently in the last few
a steady decline in the number of neonatal deaths due to years. They are providing preventive, promotive, and cura­
sepsis.9,10 tive health care services to the population in the central
Multiple factors including maternal, fetal, and environ­ Gondar zone of the region and serve as a referral center for
mental factors have been associated with increased risk of the local health centers in the area. These primary hospi­
infections in neonatal life.11 tals are found in five districts (Dembiya, Chilga, Wogera,
Early identification of the risk factors for neonatal Delgi, and East Belesa) in the central Gondar zone of the
sepsis would enable clinical diagnosis and treatment aim­ region. They are 781, 780, 787, 832, and 867 km away
ing to reduce neonatal morbidity and mortality.5 The from Addis Ababa, the capital city of Ethiopia towards the
implementation of certain clinical strategies is also effec­ Northwest, respectively. All hospitals have a total number
tive in reducing the incidence of neonatal sepsis.12 of 341 health workers. The neonatal intensive care units of
The burden of neonatal sepsis and its complications each hospital have five neonatal beds for neonatal admis­
can be averted and the target of Sustainable Development sion and have three clinical staff (one physician and two
Goals for child survival can be achieved through the clinical nurses) and one cleaner. More than three thousand

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Dovepress Agnche et al

neonates were admitted to these hospitals annually to get the interviewer-administered structured Amharic version
medical services. questioner that contains detailed questions comprising all
the variables of the study. The admission diagnosis of
Study Population and Sampling Procedure neonates was taken from the diagnosis of the physician
All neonates admitted to neonatal intensive care units in in the unit. The data collectors cross verify the diagnosis
central Gondar Zone primary hospitals were included in of neonatal sepsis with reviewed neonate’s medical record
the study. The sample size was determined by using to ascertain the final clinical diagnosis of neonatal sepsis
a single population proportion formula and the proportion before they collect the data.
was taken from the previous literature in Ethiopia. The WHO IMNCI criteria were applied to assess babies
According to a study conducted at Gondar University for clinical sepsis. The IMNCI criteria use the following
teaching hospital, the prevalence of neonatal sepsis was clinical features to make a diagnosis of clinical neonatal
69.7%.23 By considering 95% confidence interval (CI), 5% sepsis: not feeding well, convulsions, drowsy or uncon­
marginal error, and 5% non-response rate. Therefore the scious, the movement only when stimulated or movement
final minimum adequate sample size was 352. at all, fast breathing (60 breaths per min), grunting severe
The study participants included 352 mother-neonate chest in-drawing, raised temperature > 38 °C, hypothermia <
pairs who were admitted to NICUs during the study period 35.5 °C, central cyanosis or could be severe jaundice, severe
and consented to participate in the study. The study abdominal distension or localizing signs of infection were
enrolled neonates from birth to 28 days of age. Neonates diagnosed as having neonatal sepsis.6,17
with sepsis admitted for two or more times during the A retrospective review of the history was taken to find
study period were considered to be excluded to avoid out if the neonate had the symptoms suggestive of neona­
double counting. However, there were no such cases in tal sepsis since birth. A conclusion of clinical neonatal
this study. The study populations were neonates admitted sepsis was ascertained if the baby had any one of the
and treated in NICUs in central Gondar zone public pri­ symptoms of sepsis listed in the IMNCI criteria and
mary hospitals in Ethiopia. According to the data obtained admitted in NICUs. Medical documents from the health
from these hospitals in 2018, the annual number of neo­ units attended were also used to get information on the
nates admitted in neonatal intensive care units (NICUs) of presentation of the patient to the health units and the
these hospitals was estimated to be 3000 ie on average 375 treatment received.
neonates were estimated to be admitted during the study Data were checked for its completeness and accuracy
period. A systematic random sampling technique was used during data collection. Close supervision of trained data
to select study subjects during the study period. In this collectors (five diploma nurses) was undertaken by the
study neonatal sepsis is asserted when a medical diagnose trained supervisors (two BSc nurses). The supervisor
of the neonate is stated as “neonatal sepsis” by the physi­ strictly supervised the data collection process and provided
cian in the neonate’s medical record chart. on-site advice and feedback to the data collectors on daily
basis. The daily exchange of information between the
Data Collection Tool, Measurements, and principal investigator and supervisors was undertaken by
Quality Management telephone. The principal investigator had had regular
The tool was developed from different kinds of literature onsite supervision of supervisors and data collectors on
to gather the desired information from the sample popula­ weekly basis.
tion. The questionnaire was initially prepared in the
English language and translated into Amharic (local lan­ Operational Definitions
guage) and again it was retranslated back to the English Neonatal sepsis: Neonates presented with any one of the
language to check for any inconsistencies or distortions in systemic manifestations of danger signs:- not feeding well,
the meaning of words and concepts. Two days of training convulsions, drowsy or unconscious, the movement only
were given to five data collectors (clinical nurses, when stimulated or no movement at all, fast breathing (60
diploma) and two supervisors (BSc nurses) before the breaths per min), grunting severe chest in-drawing, raised
beginning of data collection. Data collectors collected the temperature > 38 °C, hypothermia < 35.5 °C, central
data from the mother or caregiver of the neonates by using cyanosis or could be severe jaundice, severe abdominal

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distension or localizing signs of infection were diagnosed Table 1 Socio-Demographic Characteristics of Neonates
as having neonatal sepsis.6,17 Admitted to Neonatal Intensive Care Units (NICUs) of Central
Gondar Zone Primary Hospitals, Northwest Ethiopia, 2019
Early onset of sepsis: If sepsis is occurring from birth
to 7 days of age. Variables Frequency Percent
Late onset of sepsis: If sepsis is occurring between 8 Age 0–7 days 278 82.2
and 28 days of age.18 8–28 days 60 17.8

Sex Male 200 59.2

Data Management and Analysis Female 138 40.8
Questionnaires were checked daily for completeness and
Place of delivery Home 28 8.3
accuracy. All data were double entered, cleaned, edited, Health center 98 29
coded, and entered into EPI INFO version 7.0 and Hospital 212 62.7
exported to SPSS version 20.0 for analysis by the binary
Gestational age < 37 weeks 120 35.5
logistic regression model. Both bivariate and multivariable 37–42 weeks 218 64.5
analyses were used to see the association of different
Birth weight <1500 g 43 12.7
variables. Categorical variables were summarized into per­
1500–2499 g 138 40.8
centages and proportions. The continuous variables were 2500 −3499 g 137 40.5
summarized into means, medians, standard deviation, and ≥ 4000 g 20 5.9
ranges, and the results were presented with tables and
figures. The proportion of clinical neonatal sepsis was
obtained by calculating the proportion of neonates with
Mothers Socio-Demographic and
symptoms and signs of clinical neonatal sepsis out of the
total number of neonates who were admitted to NICUs
Economic Characteristics
The median age of mothers of the neonate was 26 years
during the study period. Bivariate analysis was used to
with an interquartile range of 8 years and 4 months.
determine the association between neonatal sepsis and
Among the participants, one-third of neonate’s mother
various independent variables including maternal factors,
114 (33.7%) were in the age range of 25 to 29 years.
neonatal factors, and service related factors. Continuous
More than half of 195 (57.7%) them were from rural
independent variables were categorized and associations
areas (Table 2).
established using Chi-squared tests. This was similarly
done for categorical variables. An adjusted odds ratio
with 95% confidence interval was used to measure the Mothers Medical and Obstetric
degree of association between variables. P-value of < Conditions
0.05 was considered as statistically significant during mul­ In this study, more than half of the mothers 202 (59.8%)
tivariable logistic regression. were multiparous women. The majority of the mothers 314
(92.9%) had at least one ANC follow-up at the time of
Results pregnancy and 10 (3%) of them were positive with HIV
AIDS. Among the positive mothers, the majority 7 (70%)
Neonatal Characteristics were from urban areas. About one-third101 (29.9%) of
A total of 338 mother-neonates pairs were included in five
them had a history of PROM during the index pregnancy
primary hospitals in the central Gondar Zone making the
and nearly three-fourths of 247 (73.1%) neonates were
response rate of 96%. The median age of neonates was 2
delivered by spontaneous vaginal delivery (Table 3).
days with an interquartile range of 4 days. Among all
participants, more than half of 200 (59.2%) were male
neonates with male to female ratio 1.4:1. Nearly two- Medical Procedures Related to Neonatal
thirds of neonates were born at hospitals 212 (62.7%). Health Care Services
Similarly, nearly two-thirds of 218 (64.5%) neonates None of the neonates were on mechanical ventilation. About
were term and the remaining one-third 120 (35.5%) were 2.7% of neonates had a history of end tracheal intubation for
preterm. Low birth weight was illustrated among 53.5% of resuscitation and 61 (18%) were on oxygen therapy through
neonates (Table 1). an intranasal oxygen catheter or face mask (Table 4).

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Table 2 Socio-Demographic and Economic Characteristics of Table 3 Medical and Obstetrical Characteristics of Mothers of
Mothers of Neonates Admitted to NICU in Central Gondar Neonates Admitted to NICU in Central Gondar Zone Primary
Zone Primary Hospitals, Northwest Ethiopia, 2019 Hospitals, Northwest, Ethiopia, 2019
Variables Frequency Percent Variables Frequency Percent

Residence Urban 143 42.3 Parity I 136 40.2

Rural 195 57.7 II 58 17.2
III and more 144 42.6
Maternal age 15–19 years 46 13.6
20–24 years 82 24.3 Antenatal care Yes 314 92.9
25–29 years 114 33.7 No 24 7.1
30–34 years 46 13.6
HIV test result Positive 10 3
≥ 35 years 50 14.8
Unknown 311 92
Marital status Married 322 95.3 Negative 17 5
Unmarried 16 4.7
VDRL/RPR status Reactive 20 5.9
Maternal Unable to read and 136 40.2 Non-reactive 272 80.5
educational level write Unknown 46 13.6
Able to read and 87 25.7
Mode of delivery Spontaneous 247 73.1
write
vaginal delivery
Primary education 57 16.9
Cesarean section 38 11.2
Secondary education 45 13.3
Instrumental 53 15.7
Certificate and 13 3.8
above Duration of labor < 6 hours 118 34.9
6 −12 hours 87 25.7
Occupation Housewife 256 75.7
12–24 hours 108 32
Government 45 15.3
˃ 24 hours 25 7.4
employee
NGO (private) 14 4.1 Frequency of PV* ≤ 3 times 143 42.3
Others* 23 6.8 exam during labor >3 times 195 57.7

Monthly income < 900 birr 97 28.7 History of foul Yes 19 5.6
900–1200 birr 78 23.1 smelling liquor No 319 94.4
1201–2050 birr 79 23.4
History of PROM** Yes 101 29.9
> 2050 birr 84 24.8
No 237 70.1
Religion Orthodox 330 97.7
History of high grade Yes 74 21.9
Muslim 8 2.3
fever during No 264 78.1
Note: *Merchant, daily labourer, and house servant. pregnancy
Notes: *Per-vaginal, **premature rupture of membrane.

The Proportion of Neonatal Sepsis and

birth, gestational age, birth weight, maternal age, maternal
Clinical Characteristics of Neonates
Two-thirds of the neonates158 (72.1%) were admitted marital status, parity, ANC follow-up, duration of labor, his­
within one week of age and the overall proportion of tory of UTI/STIs, history of PROM, history of foul smelling
Neonatal sepsis was 64.8% (95% CI (59.2, 69.2)). Of liquor, birth asphyxia, place of delivery and training of health
these, 158 (72.1%) were early onset neonatal sepsis. works at NICUs fulfilled the variable screening criteria
Gross congenital malformation like neural tube defect, (p-value < 0.2) and entered into multivariable logistic regres­
cleft palate, and hydrocephalus was also found in 7 sion analysis. Consequently, the age of the neonate, sex of
(2.1%) of neonates (Table 5 and Figure 1). neonates, maternal age, history of UTIs, frequency of PV
examination, resuscitation at birth, and getting care from
Factors Associated with Neonatal Sepsis trained health workers were significantly associated with neo­
All the variables which fulfilled the chi-square assumption natal sepsis at multivariable with less than 0.05 p values.
were fitted into bivariable and multivariable logistic regres­ Accordingly, the sex of neonates showed a significant
sion. Residency, age of the neonate, sex of neonate, place of association with the risk of the onset of neonatal sepsis.

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Table 4 Medical Procedures are Done for Neonates Who Were

Admitted to NICU in Central Gondar Zone Primary Hospitals,
Northwest Ethiopia, 2019
Variables Frequency Percent

Mechanical ventilation No 338 100

Oxygen administration Yes 61 18

No 277 82

Endotracheal tube intubation Yes 9 2.7

No 329 97.3

Nasogastric tube insertion Yes 21 6.2 Figure 1 The proportion of neonatal sepsis among neonates admitted in central
No 317 93.8 Gondar zone primary hospitals, Northwest Ethiopia, 2019.

Central venous catheterization Yes 50 14.8

No 288 85.2 sepsis decreased by 95% among neonates whose age is
less than one week compared to those aged greater than
a week [AOR = 0.05; 95% CI[(0.01, 0.21)]].
Table 5 Clinical Characteristics of Neonates Who Were Maternal age was significantly associated with neonatal
Admitted to Central Gondar Zone Primary Hospitals, sepsis. Neonates from older mother whose age is 30–34
Northwest Ethiopia, 2019 years were 81% less likely to develop neonatal sepsis
Variables Frequency Percent when compared to neonates from mothers whose age is
35 years and older [AOR=0.19; 95% CI (0.05, 0.81)].
Birth injury Yes 26 7.7
No 312 92.3 Place of delivery also has a significant effect on neo­
natal sepsis. Neonates delivered in the health center were
Birth asphyxia Yes 56 16.6
No 282 83.4
three times more likely to develop sepsis compared to
those delivered at the hospital [AOR=3.05; 95% CI
Gross congenital malformation Yes 7 2.1
(1.19, 7.79)].
No 331 97.9
Finally, neonates who get care by health workers who
Cry at birth Yes 271 80.2 had no training on NICU/IPPs were 2 times more likely to
No 67 19.8
develop sepsis as compared to neonates who get care by
trained health professionals. [AOR = 2.14; 95% CI [(1.04,
4.44)]] (Table 6).
The odds of having neonatal sepsis among male neonates
were 3.7 times higher as compared to female neonates
[AOR = 3.73; 95% CI (1.76, 7.89)] Discussion
This study showed that neonates born to mothers who Neonatal sepsis contributes substantially to neonatal mor­
had UTIs during the index pregnancy had 6 times higher bidity and mortality and is a major global public health
odds of developing sepsis as compared to those neonates challenge.10 In this study, the overall proportion of neona­
born from mothers who did not have a UTIs during the tal sepsis was 64.8% (95% CI (59.2, 69.2)).
index pregnancy [AOR =6.26; 95% CI[(1.16, 33.62)]]. This finding is in line with a study conducted in
Likewise, increased odds of neonatal sepsis was noted Gondar (67.9%).16 The possible reason for having similar
among mothers who have a history of more than three results might be due to similarities of study population
PV examination during labor compared to mothers who studied in the same area and the period in which the
had PV examination less than or equal to three [AOR = studies were conducted. This finding is, however, much
6.06; 95% CI [(2.45, 14.99)]]. higher than the findings of studies from Uganda (11%),6
Similarly, those neonates who were resuscitated at birth India (32%),11 Tanzania (31.4%),5 and Nigeria (34%).19
had 6 times higher odds of developing sepsis compared to This difference might have been contributed by methodo­
those neonates who were not resuscitated [AOR = 6.110; logical differences and the difference in diagnostic mod­
95% CI[(1.71, 21.84)]]. Nevertheless, the odds of neonatal ality to confirm neonatal sepsis. In contrast to the finding

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Table 6 Bivariable and Multivariable Analysis of Factors Associated with Neonatal Sepsis Among Neonates Admitted at Central
Gonad Zone Primary Hospitals, Northwest Ethiopia, 2019
Variables Neonatal Sepsis N (%) COR (95% CI) AOR (95% CI)

Yes No

Residence Urban 105 (31.1) 38 (11.2) 1 1

Rural 114 (33.7) 81 (24) 0.51 (0.32, 0.81) 0.75 (0.34, 1.66)

Parity I 97 (28.7) 39 (11.5) 1.49 (0.90, 2.47) 1.21 (0.41, 3.62)

II 32 (9.7) 26 (7.7) 0.74 (0.398, 1.370) 0.58 (0.18, 1.88)
III 90 (26.6) 54 (16) 1 1

Duration of labor < 6 hours 82 (24.3) 36 (10.7) 1 1

6–12 hours 41 (12.1) 46 (13.6) 0.39 (0.22, 0.69) 0.47 (0.181, 1.19)
12 −24 hours 75 (22.2) 33 (9.8) 0.99 (0.57, 1.76) 0.66 (0.25, 1.77)
>24 hours 21 (9.6) 4 (3.4) 2.31 (0.74, 7.19) 1.02 (0.21, 4.93)

Frequency of PV examination ≤ 3 times 84 (24.9) 59 (17.5) 1 1

>3 times 135 (39.9) 60 (17.8) 1.58 (1.01, 2.48) 6.06 (2.45, 14.99)**

Sex of neonate Male 139 (41.1) 61 (18) 1.65 (1.05, 2.59) 3.73 (1.76, 7.89)**
Female 80 (23.7) 58 (17.2) 1 1

Gestational age < 37 weeks 66 (19.5) 54 (16) 0.52 (0.32, 0.82) 0.98 (0.35, 2.78)
37–42 weeks 153 (45.3) 65 (19.3) 1 1

History of birth asphyxia Yes 31 (9.2) 25 (7.4) 0.62 (0.35, 1.11) 0.55 (0.18, 1.68)
No 188 (55.6) 94 (27.8) 1 1

History of oxygen administration Yes 45 (13.3) 16 (4.4) 1.67 (0.89, 3.09) 2.06 (0.642, 6.59)
No 174 (51.5) 103 (30.5) 1 1

History of NG tube insertion Yes 20 (5.9) 1 (0.3) 11.86 (1.57, 89.51) 10.36 (0.81, 132.78)
No 199 (58.9) 118 (34.9) 1 1

History IV catheterization Yes 42 (12.4) 8 (2.4) 3.29 (1.49, 7.27) 2.81 (0.89, 8.93)
No 177 (52.4) 111 (32.8) 1 1

History of neonatal resuscitation Yes 37 (10.9) 12 (3.6) 1.81 (0.91, 3.63) 6.11 (1.71, 21.84) *
No 182 (53.8) 107 (31.7) 1 1

Training of Health workers Yes 112 (33.1) 39 (11.5) 1 1

No 107 (31.7) 80 (23.7) 2.17 (1.35, 3.42) 2.14 (1.04, 4.44)*

Marital status Married 204 (60.4) 118 (34.9) 1 1

Not married 15 (4.4) 1 (0.3) 8.68 (1.13, 66.52) 0.14 (0.01, 1.42)

Maternal age category 15 −19 yrs. 36 (10.7) 10 (3) 1.14 (0.44, 2.95) 0 0.97 (0.16, 5.95)
20 −24 yrs. 51 (15.1) 31 (9.2) 0.52 (0.24, 1.14) 0.32 (0.07, 1.57)
25–29 yrs. 76 (25.5) 38 (11.2) 0.63 (0.29, 1.35) 0.63 (0.18, 2.29)
30 −34 yrs. 18 (5.3) 28 (8.3) 0.20 (0.08, 0.49) 0.19 (0.05, 0.81)*
≥ 35 yrs. 38 (11.20) 12 (3.6) 1 1

VDRL test result Reactive 17 (5) 3 (0.9) 2.62 (0.75, 9.18) 1.33 (0.18, 10.13)
Unknown 16 (4.7) 30 (8.9) 0.25 (0.13, 0. 48) 0.31 (0.11, 0.92)
Non-reactive 186 (55) 86 (25.4) 1 1

History of UTIs Yes 10 (3) 5 (1.5) 1.01 (0.34, 3.03) 6.26 (1.16, 33.62) *
Unknown 5 (1.5) 11 (3.3) 0.23 (0.08, 0.68) 0.06 (0.01, 0.31)**
Negative 204 (60.4) 103 (30.5) 1 1

(Continued)

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Table 6 (Continued).

Variables Neonatal Sepsis N (%) COR (95% CI) AOR (95% CI)

Yes No

Birth weight <1500 g 24 (7.1) 19 (5.6) 0.57 (0.29, 1.14) 0.76 (0.18, 3.19)
1500–2499 g 87 (25.7) 51 (15.1) 0.77 (0.45, 1.26) 1.11 (0.40, 3.03)
≥ 2500 g 108 (32) 49 (14.5) 1 1

Foul-smelling vaginal discharge Yes 9 (2.7) 10 (3) 0.47 (0.18, 1.18) 0.24 (0.05, 1.08)
No 210 (62.1) 109 (32.2) 1 1

Neonatal age in days ≤ 7 days 163 (48.2) 115 (34) 0.10 (0.04, 0.29) 0
>7 days 56 (16.60) 4 (1.2) 1 0.05 (0.01, 0.21)**1

History of PROM Yes 73 (21.6) 28 (8.3) 1.62 (0.98, 2.70) 1.82 (0.706, 4.69)
No 146 (43.2) 91 (26.9) 1 1

Place of delivery Home 14 (4.1) 14 (4.1) 0.57 (0.26, 1.26) 4.06 (0.69, 23.86)
Health center 70 (20.7) 28 (8.3) 1.43 (0.85, 2.39) 3.05 (1.19, 7.79) *
Hospital 135 (39.9) 77 (22.8) 1 1
Notes: *Significant at < 0.05 α-values, **Significant at < 0.01 α-value.

of these studies the prevalence of neonatal sepsis in neonatal resuscitation at birth was a significant risk factor
Bishoftu (72.2%)20 and Shashemene (77.9%)15 were for neonatal sepsis. Resuscitation procedures at birth pose
much higher than the current finding. This higher preva­ a greater risk of neonatal sepsis. Many life-supporting pro­
lence is likely since these study sites are referral hospitals, cedures such as suctioning and endotracheal intubations can
most frequently receiving neonates with complications as lead to transient and persistent bacteremia.22 Newborn
well as complicated pregnancies. Furthermore, these dif­ infants are especially vulnerable to nosocomial infections
ferences could be due to the difference in sample size, because of their intrinsic susceptibility to infection as well
socio-demographic, and economic status of the study as the performance of invasive procedures for neonatal
population and access to health facilities.15 resuscitation to which they are subjected.23 Studies from
In this study, neonates born from mothers who had China, Korea, and Ethiopia revealed that different medical
a history of urinary tract infections (UTIs) during the procedures which are undertaken below the optimal level of
index pregnancy were six times more likely to develop asepsis (sterility or disinfection) for the management of
neonatal sepsis. This finding is in agreement with the neonatal health problems predispose the neonate to a great
findings of studies conducted previously in Mekelle21 risk of neonatal sepsis15,24,25 This might result from poor
and Bishoftu20 which revealed that maternal urinary tract practices and non-adherence to guideline by health profes­
and sexual infections were a significant factor for the sionals during resuscitation that may predispose the neonate
development of neonatal sepsis. This finding may support with a greater risk of developing sepsis.23
the reason that maternal health problem is often associated Furthermore, in this study neonatal age was found to be
with neonatal sepsis, especially if untreated during the a significant factor for neonatal sepsis. Neonates whose
third trimester pregnancy or labor. Hence, neonatal sepsis ages were less than or equal seven days were 95% less
may result from the colonization of the birth canal by the likely to develop neonatal sepsis compared with the age of
infectious agent.20,22 neonates greater than seven days of age. This finding is in
This study also identified significant associations line with finding from a study in Ghana23 and Shashemene
between neonatal resuscitation and neonatal sepsis. The (Ethiopia)15 which revealed that the probability to develop
odds of developing neonatal sepsis among neonates who sepsis increased with increasing neonatal age. Nosocomial
have a history of neonatal resuscitation at birth were six and community acquired neonatal infections occur after 3
times higher as compared to neonates who were not resus­ days of life. Consequently, this will affect the prevalence
citated. This finding was in agreement with studies from of late onset neonatal sepsis.26 This is also supported by
Bangladesh,22 Tanzania5 and Ghana23 which identified the finding from this study which revealed that the

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Dovepress Agnche et al

majority of neonates were delivered in the health institu­ to be screened based on a risk approach and treated with
tions. This may in turn increase the possibility to develop intrapartum antibiotic prophylaxis.31 Furthermore, the dif­
neonatal sepsis after discharged from these institutions at ference in the level of knowledge about maternal and
a late age. neonatal health among health workers in hospitals and
Per-vaginal examination (PV) during labour and deliv­ health centers and the level of adherence of health workers
ery was found to be a significant factor for neonatal sepsis. to guidelines and protocols on IPPs to prevent infections in
Neonates from mothers who had a history of PV examina­ newborns might be the possible reason for this finding.
tion greater than three were six times more likely to Maternal age was also significantly associated with
develop neonatal sepsis. This finding was in line with neonatal sepsis. Neonates from mothers whose age was
finding from a study in Bangladesh in which neonates of from 30–34 years were 81% less likely to develop neona­
mothers who have a history of vaginal examination greater tal sepsis as compared to those neonates from mothers
than three was found to be 2.5 times more likely to older than 35 years. However, studies from Bangladesh22
develop neonatal sepsis.22 Vaginal organisms can be intro­ and Tanzania5 showed that the attack rates of sepsis
duced into the cervical canal even during sterile condi­ increased significantly among neonates born from mothers
tions. Hence, babies are at risk from ascending infection less than 20yrs of age. This difference may result from the
thought to be caused by vertical transmission from an high number of mothers less than 20 years of age in
infected mother. Therefore, the vaginal examination can Bangladesh (67%), and Tanzania (17.7%) as compared to
increase the risk of harm for women and their babies.27 the current finding (13.6%) in Ethiopia. The sample size
However, a study in Mekelle, Ethiopia reported that there and methodological difference may also have an impact on
was no significant association between PV examination this difference.
and neonatal sepsis21 This may also result from differing Training of health workers in NICUs in all matters
in study settings where the quality of obstetrical and neo­ related to neonatal health and infection prevention, in
natal health care services provided to mothers and neo­ particular, was significantly associated with neonatal sep­
nates in primary hospitals differs to that of referral sis. Pathogenic agents can be transmitted by direct contact
hospitals. or indirectly via contaminated equipment, intravenous
The sex of neonates was significantly associated with fluids, medications, blood products, or enteral feedings.26
neonatal sepsis. This study found that being male was 3.7 Poor practices and non-adherence to guidelines by health
times more likely to develop neonatal sepsis as compared professionals during resuscitation and other medical pro­
to their counterparts. This finding is in agreement with the cedures may predispose the neonate with a greater risk of
finding of a study in Australia. It reported that the risk of developing sepsis.23 This might not be different from the
neonatal sepsis was found to increase three times more in finding of the current study.
male neonates as compared to female neonates.28 Male sex Residence, ANC, parity, duration of labor, mode of
is associated with a higher risk of neurological, pulmonary, delivery, foul smelling liquor, birth asphyxia, PROM,
cardiovascular, and infectious morbidities as well as over­ gestational age, and birth weight were not found to be
all mortality when compared to female infants of similar predictors of neonatal sepsis in this study. This is against
preterm gestation.29 Important differences in the immune the findings of studies on risk factors of neonatal sepsis in
response between male and female preterm neonates have different parts of the world.15,19–23
also been noted.30 However, the etiology of sex-specific
differences in disease remains relatively undetermined and Conclusion
is likely multifactorial, with genetic, immunological, and The proportion of neonatal sepsis is high. Late neonatal
hormonal influences playing key roles.28 age at onset of sepsis, being male sex, 30 −34 years of age
The place of birth was found to be statistically signifi­ of the mother, neonatal resuscitation at birth, history of
cant with neonatal sepsis. Neonates delivered at the health urinary tract infections during pregnancy, frequency of
center were three times more likely to develop sepsis as per-vaginal examinations greater than three times during
compared to neonates delivered at hospitals. This finding labor and delivery, and place o delivery (health center)
is in agreement with findings from studies in Nigeria19 and were identified risk factors for neonatal sepsis. Therefore,
Ethiopia.3,19 This might be due to the reason that neonates training of health workers, provision of health care ser­
who were delivered at the health center may be less likely vices as per standards, and monitoring and evaluation of

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Infection and Drug Resistance 2020:13 3965
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Agnche et al Dovepress

obstetrical/neonatal care during labor and delivery are Acknowledgments

mandatory. The authors would like to thank the study participants,
data collectors, and the supervisor.
Limitations of the Study
Since the study was done on admitted neonates, these find­ Author Contributions
ings may lack generalizability to the entire population in the All authors contributed to data analysis, drafting or revis­
catchment area. Additionally, Clinical diagnosis of neonatal ing the article, have agreed on the journal to which the
sepsis may overestimate the proportion of neonatal sepsis. article was submitted, gave final approval of the version to
be published, and agree to be accountable for all aspects of
the work.
Abbreviations
ANC, Antenatal Care; APGAR, Appearance; Pulse;
Funding
Grimace; Activity and respiration; CNS, Central Nervous
The authors have declared that there was no funding.
System; EDHS, Ethiopia Demographic and Health Service
Survey; EONS, Early Onset Neonatal Sepsis; HEW,Health
Disclosure
Extension Workers; HIV, Human Immune Deficiency
We, the authors, declare that there is no competing
Virus; LMICs, Low and Middle Income Countries;
interest.
LONS, Late Onset Neonatal Sepsis; NICU, Neonatal
Intensive Care Unit; NMR, Neonatal Mortality Rate; NS,
Neonatal Sepsis; PMTCT, Prevention of Mother to Child
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