Prevalence of neonatal sepsis among neonates admitted to a neonatal intensive care unit in a university hospital in eastern Ethiopia: A cross-sectional study

Abstract

Background

Neonatal sepsis is a leading cause of neonatal mortality, yet data on its prevalence and associated factors remain limited. This study aimed to assess the prevalence of neonatal sepsis and associated factors among neonates admitted to the neonatal intensive care unit of a university hospital in eastern Ethiopia.

Methods

An institution-based cross-sectional study was conducted on randomly selected neonates admitted to the NICU of Hiwot Fana Comprehensive Specialized Hospital from January 1, 2016 to December 31, 2019. Sociodemographic and feto-maternal data were collected and analyzed using Epi Data 3.1 and Stata 14. Bivariate and multivariate analyses identified factors associated with neonatal sepsis through binary logistic regression, presenting results as adjusted odds ratios (AORs) with 95% confidence intervals (CIs), with statistical significance set at p < 0.05.

Results

Of the 414 neonates included, with a mean age of 3.6 (±2.3 SD) days, 264 (63.7%) were diagnosed with neonatal sepsis. Significant factors associated with neonatal sepsis included; being under seven days old (AOR = 2.18), rural residence (AOR = 1.70), lack of antenatal care (AOR = 0.61), premature rupture of membranes (AOR = 1.66), shorter labor duration (AOR = 0.40), meconium-stained amniotic fluid (AOR = 1.92), birth asphyxia (AOR = 2.25), and neonatal comorbidity (AOR = 1.98).

Conclusion

Nearly two-thirds of NICU-admitted neonates had sepsis, with associations such as age, rural residence, and lack of antenatal care, premature rupture of membranes, shorter labor duration, meconium-stained amniotic fluid, birth asphyxia, and neonatal comorbidity highlighting the need for targeted interventions to improve outcomes.

Keywords

prevalence neonatal sepsis neonates sepsis NICU Ethiopia

Introduction

Neonatal sepsis is a clinical syndrome characterized by infection-related signs and symptoms occurring within the first 28 days of life and is a leading cause of neonatal mortality.¹ It can be classified into early-onset sepsis, which occurs within the first 72 hours, and late-onset sepsis, which occurs after 72 hours.² Global estimates indicate that infections account for approximately 35% of neonatal deaths, whereas other significant causes include preterm birth (28%), intrapartum-related complications (24%), and asphyxia (23%).³

In intensive care units, infection rates can reach as high as 30% among highly immature preterm neonates, making bacterial and fungal sepsis leading causes of morbidity and mortality.⁴ The World Health Organization (WHO) reported that, in 2017, the incidence of neonatal sepsis ranged from 6.5--38 cases per 1,000 live births globally, contributing to a substantial proportion of neonatal deaths.⁵ Neonatal sepsis remains a significant concern in low- and middle-income countries (LMICs),⁶ with sub-Saharan Africa reporting that 17% of all neonatal deaths are attributable to this condition, compared with only 6% in developed countries.⁷ In Ethiopia, neonatal sepsis is a major cause of neonatal mortality, accounting for more than one-third (33%) of all neonatal deaths.⁸

Despite a decline in neonatal mortality from 49 deaths per 1,000 live births in 2000 to 29 in 2016—a 41% reduction over 16 years—neonatal sepsis continues to pose a major public health challenge in resource-constrained environments such as Ethiopia.⁹ Limited data are available regarding the prevalence and risk factors for neonatal sepsis, particularly in our study area. Existing studies have identified several common risk factors, including premature rupture of membranes (PROM), maternal urinary tract infections/sexually transmitted infections (UTI/STI), intrapartum fever, foul-smelling amniotic fluid, and an Apgar score of less than 7.¹⁰ Additional factors include being a preterm neonate, receiving resuscitation at birth, and having a maternal history of UTI/STIs.¹¹

Preventive strategies such as ensuring skilled and clean deliveries, increasing maternal immunization, securing clean umbilical cord cutting, early detection and treatment, and implementing closed medication systems are essential for reducing neonatal sepsis.^12,13 Identifying risk factors and initiating timely treatments can significantly lower neonatal mortality and morbidity.⁷ Therefore, this study aimed to assess the prevalence and factors associated with neonatal sepsis in the neonatal unit of Hiwot Fana Specialized University Hospital in eastern Ethiopia.

Methods

Study setting and population

An institution-based cross-sectional study was conducted from June 20 to July 19, 2020. The reporting of this study conforms to the STROBE statement¹⁴ (Supplemental File). The study was conducted at Hiwot Fana Comprehensive Specialized University Hospital, located 525 kilometers from the capital, Addis Ababa, in eastern Ethiopia. This hospital serves as the primary referral university hospital affiliated with Haramaya University and houses the only neonatal intensive care unit (NICU) in the region during the study period. The NICU comprises a Kangaroo Mother Care Room and an intensive care unit, with a total of 28 beds. It is staffed by four paediatricians, three NICU nurses, six general nurses, and six medical interns.

Population and sampling

The study population comprised all neonates admitted to the NICU from January 1, 2016 to December 31, 2019. Neonates with incomplete medical records were excluded from the study.

The sample size was determined using both a single and double population proportion formula. The maximum sample was achieved by using a double proportion formula by considering the assumptions: 95% confidence level, 80% power, and one-to-one ratio, proportions; premature rapture of membrane (p₁= 52.2%, p₂= 47.8%) based on a study conducted in southern Ethiopia¹⁵ resulting in a maximum sample size of 414.

A sampling frame was created on the basis of the medical registration numbers of all NICU admissions during the specified period. Eligible cases were then selected via simple random sampling facilitated by a computer-generated random list (Figure 1).

Figure 1.

Schematic presentation of sampling procedure of prevalence of neonatal sepsis among neonates admitted to a neonatal intensive care unit in a university hospital in Eastern Ethiopia, 2022 (n=414).

Data collection and quality control

The data was collected using checklist prepared by reviewing different literatures. If maternal information on the neonatal card was incomplete, the maternal card was traced by using neonatal card number. Data were collected by trained research assistants through a review of medical records from neonatal ICU register in NICU. Study was conducted entirely on secondary, anonymous data. The collected data included sociodemographic characteristics, maternal information, neonatal details (clinical or laboratory data), and care-related variables.

The tools were pre-tested in hospital with similar status on 5% of a total sample size. Two days training was given for data collector and supervisors on data collection procedures and coding of the questionnaire. Every day questionnaires were reviewed and checked for completeness by the supervisor and principal investigator. Double data entry was used to ensure validity and compared with the original data.

Operational definition

Neonatal sepsis: refers to generalized bacterial infection documented by a positive blood culture in the first 28 days of life.

Early neonatal sepsis: refers to sepsis presenting in the first 7 days of life.

Late neonatal sepsis: referring to presentation of sepsis after 7 days.

Birth asphyxia: condition of insufficient oxygen and blood flow in a newborn, which is often indicated by a persistently low Apgar score.

Data processing and analysis

The collected data were checked for completeness, coded, and double-entered into Epi Data 3.1 before being analysed via Stata 14. Descriptive analysis was performed to compute proportions and summary statistics. Bivariate and multivariate analyses were conducted to assess the associations between variables and neonatal sepsis. The Hosmer–Lemeshow statistic was used to evaluate model fit. Adjusted odds ratios (AORs) along with 95% confidence intervals (CIs) were estimated to identify factors associated with neonatal sepsis, with statistical significance set at p < 0.05.

Results

Sociodemographic characteristics of neonates and mothers

Among the 414 records reviewed, more than half of the neonates were male (58.9%) and from rural areas (57%). The majority of the neonates were aged 0–7 days (69.6%), with a mean age of 3.6 days (±2.3) (Table 1).

Table 1.

Sociodemographic characteristics of neonates and their mothers in HFCSH, Eastern Ethiopia, 2022 (n=414).

Variables	Category	Frequency	Percent (%)
Maternal age (years)	15-24	182	44
	25-34	181	43.7
	35-44	51	12.3
Neonatal age (days)	0-7 days	288	69.6
Neonatal age (days)	8-28 days	126	30.4
Neonatal sex	Male	244	58.9
Neonatal sex	Female	170	41.1
Place of residence	Urban	178	43.0
Place of residence	Rural	236	57.0

Reproductive and obstetric characteristics

More than half (55.3%) of the neonates were born to multiparous women. Almost two-thirds (64.3%) of the mothers did not have antenatal care follow-up. The majority of the neonates were born in health facilities (92.8%). Among the 414 neonates, 125 (30.2%) were preterm (<37 weeks), and 306 (73.9%) experienced birth asphyxia. A total of 264 neonates (63.7%; 95% CI: 59%–68%) were diagnosed with sepsis. Among those with neonatal sepsis, one in five (20.5%) had a comorbidity, with 67 (80.7%) of these patients having respiratory distress syndrome (RDS). At discharge, 53 neonates (12.8%) had died (Table 2).

Table 2.

Reproductive and obstetric risk factors among neonates admitted to HFCSH in NICU wards, Eastern Ethiopia, 2022 (n=414).

Variables	Category	Frequency	Percent (%)
Parity	Primi	185	44.7
Parity	Multipara	229	55.3
ANC follow up	Yes	148	35.7
ANC follow up	No	266	64.3
Number of ANC visits (n=148)	1^st	71	48
	2^nd	42	28.4
	3^rd	26	17.6
	4^th	9	6.0
Place of delivery	Home	30	7.2
Place of delivery	Health Facility	384	92.8
Mode of delivery	SVD	232	56
	Instrumental VD	49	11.8
	CS	133	32.2
Premature rupture of membrane	Yes	124	30.0
Premature rupture of membrane	No	290	70.0
Duration of labor	less than 24 hr	357	86.2
Duration of labor	greater than 24 hr	57	13.8
Maternal complication	Yes	162	39.1
Maternal complication	No	252	60.9
Type of maternal complication (n=162)	Obstructed labour	65	40.1
	Preeclampsia	37	22.8
	APH	33	20.4
	Eclampsia	6	3.7
	PIH	5	3.1
	Others	16	9.9
Meconium-stained amniotic fluid	Yes	67	16.2
Meconium-stained amniotic fluid	No	347	83.8
History of foul-smelling liquor	Yes	8	1.9
History of foul-smelling liquor	No	406	98.1
Gestational age (weeks)	Term	289	69.8
Gestational age (weeks)	Preterm	125	30.2
Birth asphyxia	Yes	306	73.9
Birth asphyxia	No	108	26.1
Comorbidity	Yes	83	20.0
Comorbidity	No	331	80.0
Type of Comorbidity (n=83)	RDS	67	80.7
	Cardiac dysfunction	5	6.0
	Acute renal failure	3	3.6
	Neurological complication	3	3.6
	Others	5	6.0
Status at discharge	Dead	53	12.8
Status at discharge	Improved	361	87.2
Diagnosed as neonatal sepsis	Yes	264	63.8
Diagnosed as neonatal sepsis	No	150	36.2

Factors associated with neonatal sepsis

Factors associated with neonatal sepsis included neonate age, residence, antenatal care follow-up, duration of labour, premature rupture of membranes, meconium-stained amniotic fluid, birth asphyxia, and neonatal comorbidity.

Compared with those older than seven days, neonates aged less than seven days were 2.18 times more likely to develop neonatal sepsis (AOR = 2.18; 95% CI: 1.10–4.34). Those from rural areas were 1.70 times more likely to develop neonatal sepsis than their urban counterparts were (AOR = 1.70; 95% CI: 1.08–2.67). Neonates born to mothers with antenatal care follow-up were 39% less likely to develop neonatal sepsis (AOR = 0.61; 95% CI: 0.38–0.97), as were those with a shorter duration of labour (<24 hours), who were 60% less likely to develop sepsis (AOR = 0.40; 95% CI: 0.18–0.89).

Additionally, neonates whose mothers experienced premature rupture of membranes and had meconium-stained amniotic fluid were 1.66 (AOR = 1.66; 95% CI: 1.14–2.66) and 1.92 (AOR = 1.92; 95% CI: 1.18–3.43) times more likely to develop neonatal sepsis, respectively. Neonates who experienced birth asphyxia were 2.25 times more likely to have neonatal sepsis (AOR = 2.25; 95% CI: 1.32–3.82). Finally, those with comorbidities were 1.98 times more likely to develop neonatal sepsis than those without (AOR = 1.98; 95% CI: 1.15–3.42) (Table 3).

Table 3.

Analyses of factors associated with neonatal sepsis in neonates admitted to a university hospital in Eastern Ethiopia (n=414).

Variables	Category	Neonatal sepsis		COR (95% CI)	AOR (95% CI)	P-value
Variables	Category	Yes (%)	No (%)	COR (95% CI)	AOR (95% CI)	P-value
Maternal age(years)	15-24	111(61%)	71(39%)	1	1
	25-34	124(68.5%)	57(31.5%)	1.39 (1.02, 1.90)	1.16 (0.70, 1.90)	0.551
	35-44	29(56.9%)	22(43.1%)	0.84 (0.27 1.16)	0.56 (0.27 1.16)	0.594
Neonatal age (days)	0-7 days	210(72.9%)	78(27.1%)	3.59(1.64, 6.43)	2.18 (1.10, 4.34)	0.031*
Neonatal age (days)	8-28 days	54(42.9%)	72(57.1%)	1	1
Residence	Rural	170(72%)	66(28%)	2.3 (1.54, 3.07)	1.70(1.08, 2.67)	0.021*
Residence	Urban	94(52.8%)	84(47.2%)	1	1
Parity	Multipara	156(68.1%)	73(31.9%)	1.52 (1.12, 2.98)	0.77(0.48, 1.25)	0.312
Parity	Primi	108(58.4%)	77(41.6%)	1	1
ANC follow up	Yes	86(58.1%)	62(41.9%)	0.69 (0.37, 0.89)	0.61(0.38, 0 .97)	0.045*
ANC follow up	No	178(66.9%)	88(33.1%)	1	1
PROM	Yes	98 (79%)	26 (21%)	2.82 (1.61, 3.64)	1.66(1.14, 2.66)	0.032*
PROM	No	166(57.2%)	124(42.8%)	1	1
Duration of labor	< 24 hr	226(63.3%)	131(36.7%)	0.86 (0.47, 0.94)	0.40(0.18, 0.89)	0.021*
Duration of labor	>24 hr	38(66.7%)	19 (33.3%)	1	1
Meconium-stained amniotic fluid	Yes	53(79%)	14(21%)	2.44 (1.20, 3.47)	1.92(1.18, 3.43)	0.021*
Meconium-stained amniotic fluid	No	211(60.8%)	136(39.2%)	1	1
Gestational age (weeks)	Term	200(69.2%)	89 (30.8%)	2.14 (1.10, 2.71)	1.11(0.84, 1.94)	0.165
Gestational age (weeks)	Preterm	64(51.2%)	61(48.8%)	1	1
Birth asphyxia	Yes	215(70.3%)	91(29.7%)	2.84 (1.09, 2.88)	2.25(1.32, 3.82)	0.001***
Birth asphyxia	No	49 (45.4%)	59(54.6%)	1	1
Neonatal comorbidity	Yes	63 (75.9%)	20(24.1%)	2.03 (1.34, 3.04)	1.98(1.15, 3.42)	0.012**
Neonatal comorbidity	No	201(60.7%)	130(39.3%)	1	1

COR=Crude odds ratio AOR=Adjusted odd ratio, CI=Confidence interval. Bold and *shows significance of the variables at p-value of <0.05.

Discussion

This study assessed the prevalence of neonatal sepsis among neonates admitted to the neonatal intensive care unit of Hiwot Fana Comprehensive Specialized University Hospital in eastern Ethiopia. The overall prevalence of neonatal sepsis was 63.7% (95% CI: 59%–68%). Neonatal sepsis was more likely among neonates who were younger than seven days, born to mothers without prenatal care, experienced prolonged labour, had a history of meconium-stained amniotic fluid, suffered from birth asphyxia, and had comorbidities.

Our findings are lower than those reported from Ethiopia (77.9%)¹⁶ but higher than those from Nepal (37.12%)¹⁷ and Egypt (40.7%).¹⁸ These differences may be related to variations in healthcare access, quality of care, infection control practices, or socioeconomic factors.

Several maternal- and neonatal-related factors associated with neonatal sepsis were identified. Neonates younger than seven days were more likely to develop sepsis, which is consistent with studies conducted in Shashemene Town, Ethiopia,¹⁶ and Mogadishu, Somalia.¹⁹ This increased vulnerability may be due to the immature immune status of early-born neonates.

Additionally, neonates from rural areas were more likely to develop neonatal sepsis than were those from urban areas, possibly because of better healthcare infrastructure and health-seeking behaviour in urban communities. Our study also revealed that neonates born to mothers with antenatal care (ANC) follow-up were less likely to develop sepsis, which aligns with findings from studies in Uganda²⁰ and India.²¹ Women receiving ANC may have better awareness and management of risk factors.

As expected, neonates born to mothers with premature rupture of membranes (PROM) were more likely to develop sepsis, corroborating studies from Mexico² and the USA.²² This may be attributed to the increased risk of ascending microorganisms into the amniotic sac due to early membrane rupture. Neonates born to mothers with a shorter duration of labor (<24 hours) were less likely to develop sepsis than those with longer labor durations were, which is consistent with studies from the Democratic Republic of the Congo²³ and southern Ethiopia.¹ A shorter labor duration may reduce the risk of meconium and amniotic fluid aspiration.

Moreover, neonates born to mothers with a history of meconium-stained amniotic fluid are more likely to develop sepsis, as shown in studies from Ghana, South Africa, and Mexico,²⁴,²⁵ and.² This is likely due to the risk of aspirating contaminated fluid. Neonates with birth asphyxia are also at increased risk for sepsis, as supported by studies from Mexico² and Jinka, southern Ethiopia.²⁶ Contaminated resuscitation equipment may introduce pathogens into the infant’s lungs. Finally, neonates with comorbidities are more likely to develop sepsis, likely because of a compromised immune system.

Limitations of the study

This study is not without limitations. The generalizability of findings is limited by the use of secondary data, which may include biases from inconsistent or incomplete records. The cross-sectional design restricts the ability to explore temporal links between risk factors and outcomes, and data on the timing of sepsis development were not recorded, complicating our ability to determine whether sepsis developed in the NICU. Early-onset and late-onset cases didn’t separately analysed since timing of sepsis development were not recorded. Relevant variables like antibiotic use, clinical chorioamnionitis, and GBS status were missing.

Conclusion

This study demonstrated that the prevalence of neonatal sepsis at Hiwot Fana Teaching Hospital remains high. We identified several sociodemographic, maternal, and neonatal factors significantly associated with neonatal sepsis, including place of residence, antenatal care (ANC) follow-up, duration of labor, premature rupture of membranes (PROM), meconium-stained amniotic fluid, age less than seven days, birth asphyxia, and neonatal comorbidity.

These findings underscore the urgent need to address modifiable maternal and neonatal factors to reduce the prevalence of neonatal sepsis. Given the high neonatal mortality rate and the goal of achieving a target of 12 neonatal deaths per 1,000 births by 2030, it is critical to implement strategies that mitigate complications associated with neonatal sepsis.

Supplemental material

Supplemental material - Prevalence of neonatal sepsis among neonates admitted to a neonatal intensive care unit in a university hospital in eastern Ethiopia: A cross-sectional study

Supplemental materia for Prevalence of neonatal sepsis among neonates admitted to a neonatal intensive care unit in a university hospital in eastern Ethiopia: A cross-sectional study by Mesud Abrahim, Lemesa Abdisa, Tesfaye Assebe Yadeta, Dawit Firdisa, Abera Kenay Tura in Journal of Public Health Research.

Supplemental material

Supplemental material - Prevalence of neonatal sepsis among neonates admitted to a neonatal intensive care unit in a university hospital in eastern Ethiopia: A cross-sectional study

Footnotes

Acknowledgements

We would like to thank Haramaya University College of Health and Medical Science for allowing us to conduct this study. Additionally, we would like to thank all the hospital management and staff.

ORCID iD

Dawit Firdisa

Ethical considerations

The study was conducted in accordance with the Declaration of Helsinki. Ethical approval for this study was obtained from the Institutional Health Research Ethics Review Committee (IHRERC) of Haramaya University with reference number of IHRERC/139/2020. Before beginning data collection, an official letter was obtained from the College of Health and Medical Sciences and submitted to the responsible body, and after the purpose and the possible benefit of the study were explained, permission to gather data was obtained from the medical director of the respective hospital. There was no mention of patients’ names in the data collection format, and patients’ cards were returned to the card room as soon as the data collection format was filled, which helped secure patients’ information.

Author contributions

MA, LA, and DF designed the study protocol, extracted and analyzed the data, and wrote the first draft of the manuscript. MA, LA, DF, TAY, and AK designed the study, conducted the literature review, statistically analyzed the review, provided critical appraisal, extracted data, and critically revised the manuscript. All authors read and approved the final version before submission.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors without undue reservation.*

Supplemental material

Supplemental material for this article is available online.

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