university of ghana sschool of

SSCHOOL OF PUBLIC HEALTH

COLLEGE OF HEALTH SCIENCES

UNIVERSITY OF GHANA

F.\(,TORS ASSOCIATED WITH NEONATAL SEPSIS AT THE WAR MEMORIAL

HOSPITAL

PRESENTED

BY

AGONGO IBRAHIM HARUNA

(10267657)

A J)lSSERTATION SUBMITTED TO THE SCHOOL OF PUBLIC HEALTH,

liNIVERSITY OF GHANA, LEGONIN PARTIAL FULFILLMENT OF THE

REQUIREMENT FOR THE A WARD OF MASTER OF SCIENCE (CLINICAL TRIALS)

DEGREE

DECEMBER,2017

University of Ghana http://ugspace.ug.edu.gh

Factors associated with Neonatal Sepsis at the War Memorial Hospital

OECLARA TlON

This research is the result of my own independent work under the sole supervision of Dr. Francis

Anto with due acknowledgement paid to all reference sources. I declare that this work either in

whole or in part has not been presented for the award of any degree nor is currently being

submitted in candidature elsewhere for another degree.

AGONGO IBRAHIM HARUNA

DR. FRANCIS ANTO

ACADEMIC SUPERVISOR

UNIVERSITY OF GHANA

Si . ~~ (A - L1-. gnature ... ~~.':"1. ......... .

Date: .J.bL~}.~r ........ .



ABSTRACT

l\eonatal sepsis is one of the leading causes of morbidity and mortality among both term and

preterm infants. The current study was carried out to identify factors associated with neonatal

sepsis among neonates admitted to the Navrongo War Memorial Hospital.

A retrospective cross sectional study involving the review of hospital records of neonates

admitted to the Neonatal Intensive Care Unit (NICU) of the hospital between January, 2015 and

June. 2017 \1\ as undertaken. All neonates that were diagnosed as neonatal sepsis were considered

as cases and tho~c with conditions other than neonatal sepsis were considered as controls. Data

\1\ cre collccted on maternal. neonatal and delivery factors likely to be associated with neonatal

sepsis onto a data collection form specifically designed for this study. Data entry was done in

M~ excel and analyzed lIsing STA TA version 14 software.

Data on 243 mother and new-born pairs were analyzed and the prevalence of neonatal sepsis

found to be 56.4%. Factors found to be associated with sepsis were: asphyxia, low birth weight,

pretcrm dcli\ery. place of delivery and assisted ventilation. It is expected that when these factors

arc cncctivel~ addressed. the problem of neonatal sepsis can be reduced and in the long term

neonatal morbidity and mortality reduce.

iii



DEDICATION

This labour is dedicated to my family for their prayer and psychological support.

IV



ACKNOWLEDGEMENT

Conducting this study would not have been possible without the help of some individuals and

groups. I therefore deem it necessary to express my sincere gratitude to them for their immense

support and contributions towards the successful completion ofthis research work.

\:1) first thanks goes to the almighty God for protecting and guiding me throughout the whole

pw(;ess. My second thanks go to my academic supervisor Dr. Francis Anto, who is the brain

behind thi~ ~lIC\:cssful research work. [t is under his strict and excellent supervision, critique and

\:ontributions that this work has been completed successfully.

[ would also like to express my profound gratitude to my family for their immense support and

prayers.

Furthermore. my heartfelt thanks go to the respondents who agreed to participate in the study for

their understanding and cooperation throughout the study. Not forgetting the management and

stan' "I \\ ar Memorial Hospital for their approval to carry out my research.

I also acknowledge all authors whose publications I referenced in my dissertation.



TABLE OF CONTENTS

ACKNOWLEDGEMENT ............................................................................................................... i

LIST OF TABLES .......................................................................................................................... ii

L\BU: ............. . .. iii

LIST 01· FIGURLS ....................................................................................................................... iv

LIST OF ABBREViATIONS ......................................................................................................... v

C~IAPTER ONE ............................................................................................................................ vi

1.0: INTRODUCTION .............................................................................................................. I

1.1: PROHLE\l STATEMENT ............................................................................................... 2

1.2: .JlSrIFIC AnON .. . .................................................................................................... 3

1.2: Conceptual Framcwork: .................................................................... 6

1.3: Narrath'c on the conceptual framework .......................................................................... 7

1.4: Pu rpose of the study ........................................................................................................... 9

1.5: Specific Objectives ............................................................................................................. 9

CHAP1'l::R 1 \\'() .......................................................................................................................... 10

1.0.l.it~raturc revicw ... . .......................................................................................... 10

2.1: Overview of Neonatal Sepsis ........................................................................................... 10

2.1.1: Definition and cJassifications .................................................................................... 10

2.1.2: Epidemiology ............................................................................................................. 10

2.1.3: Factors for neonatal sepsis ...................................................................................... II

vi



2.1.4: Aetiology of neonatal sepsis ...................................................................................... 11

2.1.5: Clinical manifestations of neonatal sepsis ............................................................... 13

2.1.6: Diagnosis of Neonatal Sepsis .................................................................................... 13

2.2: .\Iaternal factors associated with neonatal sepsis ........................................................ 14

2.3: :\ewborn Factors of Neonatal Sepsis .............................................................................. 15

CHAPTERTIIREE...... ...... .. .................................................................... 29

3.0: METHODOLOGY ........................................................................................................... 17

3.1: Study Design ....................... . ......................................................................................... 17

3.2: Research Setting.. . ................................................................................ 17

3.3: Stud~ f>upulation ..

3.4: Inclusiun Criteria

. .......................................................................... 22

........................................................................... 22

3.5: Exclusion Criteria ..................................................................... .. .................................. 22

3.6: Study Variables ........

3.7: Sampling Technique.

. ........................................................................................ 23

. ................................................................................ 23

3.8: Sample size estimation .... .. ........................... 25

3.9: Ethical Standards .... .. ................................ 26

3.10: Cunsenting Process .............................. . .. ........................................ 26

3.11: Prh'acy and Confidentiality .............................. .. . ..................................... 26

3.12: Potential risks/benefits of the study ............. .. . .................................................... 26

3.\3: \'oluntary Withdrawal ................................ .. . ...................................... 27

vii



3.14: Data Storage/Security and Usage ................................................................................. 27

3.15: Data Processing ............................................................................................................. 27

3.16: Data l\ianagement and Analysis .................................................................................. 27

CHAPTER FOUR .............................. .. ...................................................................... 29

4.0: PRESE:'iT ATION OF RESULTS. " ......................................................................... 29

4.1: Neonatal Factors ............ " ,., .......................................................................................... 29

4.2: 'I ultinriate anal~sis of neonatal factors ....................................................................... 31

4.3: 'laternal Factors ...... " ... , .................................................................................... 33

4.4: \]ultilariate analysis of maternal factors ...................................................................... 35

4.5: Perinatal Factors ................................................. .. ....................................................... 36

4.6: Multivariate analysis of perinatal factors ..................................................................... 38

_TABLE 4.6: \lultivariate Analysis Of Neonatal Factors Associated with Neonatal

Sepsis .......................................................................................................... 39

CIIAPTI':R 1,1\'1, .......................................................................................................................... 39

S.O: D1SCl SSION .. . .................. ' ...................................................................... 40

CHAPTER SIX ............................................................................................................................. 47

6.0:CONCLUSI0N AND RECOMMETIONS ....................................................................... 47

6.0: COi\CLl'SION .............................................................................................................. 47

6.1: RECOMMENDATIONS ··· .. · .... · ........................................................... 48

viii



LIST OF FIGURES

FIGlJRE 1 CAlJSES OF !'oIEONATAL :\IORTALITY .............................................................................. 3 Figure 2 A CONCEPTUAL FRAMEWORK ON FACTORS ASSOCIATED WITH NEONATAL SEPSIS AT THE WAR MEMORIAL HOSPIT AL.. ............................................... 6

FIGlRE 3 GHA 'A MAP SHOWING THE UPPER EAST REGION, B: MAp OF KASSENA - NANKANA

,It ,,< IPALrI \ . ..... . ....................................•.....••••••.••••.•••..••............... 20

/'11. I IU . .t: '},\P OF KASSE' \ - N\'\I\..\N" EAST MUNICIPAL SHOWING SURROUNDING

( ()\1\1l 'ITn." ................................................................................ 21

XI


WHO

:'I.1(T

WMH

KNEM

UN

EOS

LOS

l''\'I>P

STls

UTls

GHS

LMICs

CNS

Gl'

SPV

VI>

CS


LIST OF ABBREVIATIONS

World Health Organization

Neonatal Intensive Care Unit

War Memorial Hospital

Kassena Nankana East Municipal

United Nations

Early Onset Sepsis

Late Onset Sepsis

United Nations Development Program

Sexual Transmitted Infections

Urinary Tract Infection

Ghana Health Service

Low and Middle Income Countries

Central Nervous System

Genitourinal

Spontaneous Virginal Delivery

Vacuum Delivery

Caesarean Section

xiii



CHAPTER ONE

1.0: INTRODUCTION

Naher and Khamael (2013) defined neonatal sepsis as any systemic bacterial infection confirmed

by a positive blood culture in the four weeks of life. Traditionally, it has been associated with

bacteremia. although it may be caused by other microorganisms such as viruses and fungi

(McYlillan, Fcigin. DeAngelis, & Jones, 2006). Naturally, the biological and physiological

aCli\ iIi," "f the placenta and the amniotic fluid accords the normal fetus a protective barrier

against infectious microbes. The fetus only loses that natural immunity afforded it after the fetus

is been introduced to the infectious environments. There is also geographical variations in the

microorganisms responsible for neonatal sepsis, a greater proportion remains the gram negative

bacteria and the burden of neonatal sepsis been worsened by a proven heightened resistance of

the bacterial strains to existing antibiotics used the management of diagnosed sepsis quite

difficult.

The plalcnta and amniotic sac provides the fetus a highly protective barrier against infectious

microbes until birth where the fetus loses that immunity as the neonate migrate through the

delivery canal during spontaneous vaginal delivery into infectious environs.

('he microbes responsible for NNS may differ among geographical regions, however. in second

and third world countries, gram-negative bacteria remains the main source of infections.

Additionally. the bacterial responsible for NNS are quite difficult to manage because they

develupcd an increased resistance 10 the commonly used antimicrobials used for the management

uf neunatal sepsis have developed increased resistance.



Neonate~. especially those born prematurely (also called preterm) are highly susceptible to

sepsis. which is partly ascribed to immaturity of neonatal immune system. In 2013, a majority of

deaths that were recorded in 2013, 51.8 % were attributed to infections and this whooping

proportion out 6.3 million children died under before they attained five years of age. Out of this

statistics. _po" died within their first twenty eight (28) days of life. It was estimated that 2\.9

neonates died per 1000 live births within the first 6 days of life in the year 2013. Despite the fact

that globall) child mortality is on a decline. neonatal mortality has remained relatively stagnant

in Africa in the last decade. (UNICEF, WHO, World Bank, UN Population Division, 2014.

Subject to the age of onset, neonatal sepsis is further categorized into early onset sepsis when

neonatal infections sets in with the first seventy two hours of life whereas late onset of sepsis sets

in after seventy two hours of life (Kliegman. Behrman, Jenson. & Stanton, 2011).

I.arl) -onset sepsis is connected with the contraction of infectious microbes that are colonized in

the mother's birth canal. whereas late onset sepsis (LOS) is associated with perinatally acquired

infectious microbes whcre the neonate was nurtured. Late onset of sepsis is therefore healthcare

facility or community acquired.

Equally important to the study are considerations pertaining to critical socio-cultural conditions,

dynamics and outlooks, such as attitudes and perceptions. Various studies have shown that the

socio-cultural orientation of a people could also inform their overall perception on the incidence

of diseases and management efforts (Madge, 2008). These constitute a critical component in the

overall etllJrt to appreciate the existence. patterns as well as trends of health related issues in a

given population. Thus, people perceive the incidences of health phenomena variously

depending to a significant extent on their socio-cultural context and orientation.



Surely, strategic measurers that can prevent, ensure early identification and treatment of neonatal

infections are vital to increase neonatal survival. These strategies however remains a major

setback in the developing world because poor diagnoses and inadequate resources to censure

comprehensive neonatal care.

It i.., thl!n:fore increasingly clear that this phenomenon represents a worrying source of concern,

for parents. communities, health practitioners and policy makers since everybody is at risk in

these endemic areas, with high poverty levels and already overburdened health care systems.

Intrapartum related deaths

Preterm birth complications

Infections

Other neonatal conditions

Congenital abnormalities

FIGllRE 1 CAUSES OF NEONATAL MORTALITY

Source: UNICEF. Child info Monitoring the Situation of Children and Women website.


Factors associatcd with Neonatal Sepsis at the War Memorial Hospital

Infections, low birth rate and prematurity remains the leading causes of neonatal infections and

deaths in low resource countries, thus likely are increasing the proportion of deaths due to

neonatal infections. Hence, Gebremedhin et al (2015) therefore concluded that. "early

identification of factors associated with neonatal sepsis and early institution of treatment. thereby

I.:an imprm e neonatal morbidity and mortality. Hence, strengthening of the existing risk based

prevcntion strategies a~ well as advances of institutional delivery practices are crucial"

1.1: PIWBLE:\I STATEMENT

Thc main aim of the Ghana national action plan and new born health strategy was a 5%

reduction per year of all neonatal morbidity from 32 per 1000 live births in the year 2011 to 21

per 1000 live births by the year 2018. The Jl:tion plan itemized the three primary conditions

responsible for nconatal mortality as sepsis neonatorum (31 %), complications from preterm

deli, er). (29%) and intrapartum events coupled with birth asphyxia as 27%.

While the mortality rate in Accra is already below the target (20 per 1,000), that in some other

regions including the Upper East, Upper West and Volta is still high. In the War Memorial

Hospital of the Kassena-Nankana Municipality of the Upper East Region for example, 54% of

admissions at the Neonatal Intensive Care Unit is due to neonatal sepsis with a case fatality of

18% (WMH 2015. Annual Report). Neonatal sepsis is connected with huge health care

cxpenditure. lengthened hospitalization. (Danielsen, et al. 2014), and possibly poor long-term

central nervous system developmental outcomes (Gebremedhin et aI., 20 IS) and long-lasting

p~}chological impact on parcnb. The main objective of the current study is to identify individual

and facility factors likely to influence sepsis at the War Memorial Hospital, in the Kassena

l"ankana Municipality and indeed Ghana.

4



1.2: JUSTIFICATION

This study seeks to provide evidence based information on the factors associated with neonatal

sepsis. This will add to the knowledge and understanding of factors likely to influence

occurrence of neonatal sepsis which can be used to improve the efficiency of health education

programs both for mothers and healthcare providers.

The observations from this study may provide fundamental knowledge and interventions needed

to reduce the incidence of hospitalizations due to neonatal sepsis. Knowing the factors for

neonatal sepsis can help us to be aware about various situations when we are at a higher risk of

suffering from neonatal infections.


MATERNAL ...

RELATEDFACTORS ..

.. Maternal age

(year)

. :J:;level of education ~1 . .nI level

· ..... I.,·;·~., .. A. bnor.mal plilcenta r .~xperienced > . .I!! :fthreatened . ~,t abortion

.. Caesarean delivery

.,:' Parity

.. Maternal

residential area

History of

infectious diseases

.. Foul smelling

Jlquor

insurance status

. ted WI·th Neonatal Sepsis at the War Memorial Hospital Factors asSOCla:

NEONATE-RelATED

.. Gestational age

~~~; ~::~:~::~::nt d"I"~' ,. Hea1thcare. acquired infections

. "" (C~oiSinf~cti~n) ";", As~isted ventilation

<'., ~ M~dicaIO(Surgical procedllre~. ~);J1~ < ~. ~

FIGURE 2: A CONCEPTUAL FRAMEWORK ON FACTORS ASSOCIATED WITH NEONATAL SEPSIS AT THE WAR MEMORIAL HOSPITAL

6



1.3: Narrative on the conceptual framework

J'hc frame \\ ork in figure 2 addresses the various factors that can cause neonatal sepsis among

neonates. The residential area ofa woman has more to do with her family income and

this can influence their exposure to neonatal sepsis since these infective microbes thrive well in

poor and crowded residential areas, so if she lives in a poor (poor sanitation, overcrowded)

neighborhood she is more susceptible to infections that can be transmitted to the neonate either

prenatally or postnatal. Also, if maternal occupation involves working in an environment with

hcav) microbial loads which harbors these infective organisms (bacterial, viruses, and fungus)

example. \\orking on the ward, laboratory farm or poor sanitary enclaves and she does not wash

her clothes or hands or even cut her fingernails properly, she will be exposing herself to

microbial infections that can easily be transmitted to the neonate.

It can be argued that educated women adhere to personal hygiene more since they are formerly

educated on the effects of poor hygiene. Hence their neonates are comparatively protected from

neonatal sepsis. On the other hand women that are not educated are very prone to sepsis because

they lack basic infection prevention practices.

I he following factors can also cause sepsis neonatorum among pregnant women, they were

hO\\c\\:r not looked into due to limited data on them from pregnant women, they includes

availability of health facility in a locality which can also shape maternal infectious conditions

such HIV/AIDS, hepatitis status, sickling status as presence in a community since its presence

will be diagnosed and controlled in the general community.



The availability of well experienced health professionals, presence of quality equipment at the

tacilit) arc all factors that can influence early diagnoses of infectious maternal conditions before

a pregnant "oman \ isits any other referral hospital .The quality of equipment presents at the

facility, the lc\d of training and experience of these health care professionals possess to examine

the pregnant woman, request for the appropriate laboratory test and to diagnose it appropriately

are all factors that can aid in the diagnosis of obstetrical complications such as placenta prove,

premature rapture of membranes, foul smelling liquor etc. and immediate and appropriate

measure, taken to curb neonatal sepsis.

The framework demonstrates ho" health services and cultural factors can affect and influence

neonatal ,cpsis among nc\\ borns amongst them are history of instrument delivery, healthcare

aCljuired infections (cross infection) assisted ventilation medical or surgical procedures that tends

to introduce nosocomial infections to new borns within their first 28 days of life. These mostly

occur due to poor infection control and prevention practices as most health care practitioners fail

to practice comprehensive aseptic techniques during health care delivery.

Equally worth mentioning are neonate-related factors that predisposes them to sepsis. Among

thcm arc gcstational age at delivery. toetal distress, Apgar score ::;:5, product of multiple

pregnancie,. post mature (:;:.:42 wks.), premature (::;:37 wks.), neonates height (cm). birth weight

lI.g) gcstational age (wks.) and Sex of neonate (female/male) contributes significantly to the

development of neonatal sepsis. These are vital because foetal related factors such as asphyxia,

weight of baby at delivery, preterm delivery, place of delivery, history of cord infection and male

circumcision among others are thought to link with neonatal sepsis.

8



1.4: Purpose of the study

The main objective of this study is to determine the factors associated with neonatal sepsis at the

War Mcmorial Hospital (WMH).

1.5: Specific Objectives

I. To dctennine maternal factors associated with neonatal sepsis at the WMH.

2. To identify newborn factors associated with neonatal sepsis.

3. To idcntify health facility factors associated with neonatal sepsis

9



CHAPTER TWO

Literature review

2.1: Overview of Neonatal Sepsis

2.1.1: Definition and classifications

According to Mane. Nagdeo, and Thombare (2010), neonatal sepsis or sepsis neonatorum refers

to a constellation of clinical and laboratory findings associated with systemic infection occurring

within thc tirst 28 days of life. Traditionally, it has been associated with bacteremia, although it

ma~ bc .:aused by other microorganisms such as viruses and fungi (McMillan, Feigin,

DeAngelis. & Jones. 2006). Neonatal sepsis is classified into two major categories: early onset

and late onset sepsis. This classification is structured on the time of onset of scientific

manifestations. In literature, there are variations in the periods used to differentiate between early

and late onset sepsis. Some define early-onset sepsis (EOS) as sepsis occurring within the first

threc days of life and late-onset sepsis (LOS) occurring after the first three days in life

(Kliegman. Behrman. Jenson. & Stanton, 2011) whereas other definitions use 48 hours for EOS,

whilt, s,lme use 9 days as a cut ofT age (Vergnano, Sharland. Kazembe, Mwansambo, & Heath,

1005). I!u\\cver. there is slight agreement as to what age limits apply, with early onset ranging

from two days to one week after delivery (Haque, 2007).

2.1.2: Epidemiology

Globally, the incidence of neonatal sepsis ranges from 1 to 10 per 1000 live births

(Afsharpaiman. Torkaman, Saburi, Farzaampur, Amirsalari, & Kavehmanesh, 2012); however,

there b a significant variation between countries, with higher rates reported in low-middle

income countries. In Africa. the incidence of NNS varies from 6.S to 23 per 1000 live births. In

developed nations, the incidence of NNS ranges from 6 to 9 per 1000 live births. The

10



contribution of EOS and LOS cases to the overall incidence of NNS also differs significantly

between ditTerent neonatal institutions, Tiskumara, Fakharee. Liu, Nuntnarumit, Lui, Hammoud,

Lee, Chow. Shenoi. and Halliday (2009).According to Ballot. Nana, Sriruttan, and Cooper

(2012) LOS occurred more frequently than EOS in South Africa. A one year prospective study of

neonatal infections in eight neonatal units in Asia, showed that 90% of the cases of neonatal

~epsis were of late onset (Tiskumara et al.. 2009).

2.1.3: Factors for neonatal sepsis

'\e()nate~ are regarded as immune compromised individuals (Ballot. Nana, Sriruttan, & Cooper,

2012) because they have a series of defects in their specific and nonspecific immunity, which

predisposes them to infection (G. Shah, Budhathoki. Das, & MandaI, 2006). Their immune

dysfunction is characterized amongst others by decreased phagocytic activity of white cells,

decreased cytokine production and impaired immunoglobulin production. Physical barriers to

inti:ctions such as the skin are weak and thin. and may be easily interrupted. Beside their inherent

rredi~position to sepsis, there are many other pre- and intrapartum obstetric complications

a~sociated with an increased risk of infection in newborn infants. The following are some of the

factors associated with neonatal sepsis: preterm birth and low birth weight, prolonged rupture of

membranes, maternal Group B Streptococcus (GBS) colonization, chorioamnionitis and invasive

procedures.

2.1 A: Aetiology of neonatal sepsis

()rganism~ causing neonatal sepsis differ significantly between different geographical locations

and even in the same location, the causes change over time. A ten year survey of neonatal sepsis

in a tertiary care neonatal unit in India, showed that I'n the fi fi Irst Ive (5) years of the study

EnterobaCleraerogenes was the most common cause of late-onset sepsis whereas

11



Staphylocucclisaurem' became the main organism causing LOS in the later five (5) years (Ballot,

Nana. Srirunan, & Cooper, 2012). Another example is that of two studies at a tertiary hospital in

South Africa. done seven 7 years apart. Between 2002 and 2003, the most common gram

negative organisms causing LOS was E.coli and seventy years later, the most common LOS was

Klebsiella species.

In the la~l de':Jde of the study, the overall percentage of sepsis caused by E.coli and group B

1/rt'ptl}(UlCU.I decreased. There was a marked increase in the number of coagulase negative

.l'Iaphylococcus. with no episodes of sepsis from Streptococcus pneumoniae and Streptococcus

pyogenes which were commonly observed in the early years of the survey. Overall, gram

negative organisms are a more common cause ofNNS in low income countries. They are mainly

represented by Klebsiella, Escherichia coli, Pseudomonas, and Salmonella. Of the gram positive

organisms. Staphylococ(·u.1 aureus, coagulase negative staphylococci, Streptococcus

pneumoniae. and StreptocoCClil pyogenes are most commonly isolated. The causes also differ

greatly according to the age of the infant at onset. Early onset sepsis is more likely to reflect

organisms acquired vertically from the mother, while late onset sepsis most likely reflects

organisms acquired in the home, hospital or community Group B streptococcus was the leading

cause of EOS in the 1980's (Cloherty, Eichenwald, & Stark, 2008). The decline in the incidence

of CBS has seen gram negative enteric bacteria becoming the leading cause of EOS. Enteric

gram negative organisms causing EOS include E. coli, Klebsiella and Pseudomonas~

Staphylococci and Entero('Ucci can be found in EOS, but are more commonly associated with

LOS (('\ohert). Fichenwald et al( 2008).

12



2.1.5: Clinical manifestations of neonatal sepsis

Generally. early clinical manifestations of neonatal sepsis are often negligible, subtle, and

nonspecific and can be easily misunderstood as being due to other neonatal conditions (Rasul,

Hassan. & Habibullah. 2007). The clinical manifestations of infection depend on the body's

inflammatory response and the virulence of the infecting organism. Although the initial clinical

manitCstation may involve only inadequate symptoms, it may be an acute disastrous

manife~tation \\ ith multiple-organ dystunction. Neonatal sepsis may manifest with systemic

inflammator) response syndrome (SIRS). This is a clinical syndrome characterized by the

presence of two or more of the following: (a) fever or hypothermia, (b) tachycardia, (c)

tachypnea or hyperventilation, and (d) abnormal white blood cells or increase in immature forms

(McMillan. Feigin, DeAngelis, & Jones, 2006).

2.1.6: Diagnosis of Neonatal Sepsis

DO\;umentation of a positive microbiological culture in a patient with clinical features

suggesti\ e of sepsis is the tirst diagnostic criterion that must be met for a diagnosis of sepsis to

be made. Ho\\ever. this has many challenges, which include delay in the availability of results

(Ng. 2004). Early diagnosis and treatment of neonatal sepsis are critical to improve neonatal

outcome (Pammi et al(2011). An ideal diagnostic test for neonatal sepsis should therefore have

the follo\\ ing properties: (a) be rapid; (b) be sensitive and specific, (c) be able to detect all

organi~m~ relevant to neonatal sepsis; and (d) not be affected by maternal antibiotics. A wide

variety of" hematological and biochemical markers have been investigated for the evaluation of

clinical sepsis. In current practice, some writers have suggested that the presence of one clinical

sign (compatible with infection) along with a biochemical marker (C-reactive protein (CRP)

value > 1 0 giL)' ffi' m IS su IClent to make the diagnosis of early- and late-onset neonatal clinical

13



septicemia. Other diagnostic procedures include microbiological culture, C-reactive protein,

complete blood count. and procalcitonin (PCT).

2.2: Maternal factors associated with neonatal sepsis

Usuall~. early-onset neonatal sepsis is related to maternal conditions and late-onset is mostly

related with the medical and surgical factors which includes invasive and non- invasive

procedures (Auriti et al 20 10 and Girma 2016). Several studies, both retrospective and

prospective have sought to determine the maternal factors associated with neonatal sepsis.

Mate et al (2014) conducted a prospective case control study to investigate the factors of

neonatal sepsis in the Asutifi District, a typical rural Ghanaian setting in the Brong Ahafo Region

of Ghana. Employing a semi-structured check list, both clinical and demographic data were

~llllected from 196 neonates (96 with NNS as cases and 100 controls without sepsis as control)

and respcl:tiH! mothers. The maternal factors that were significantly associated with sepsis

neonatorum were foul smelling liquor, meconium stained amniotic fluid, parity, history of

UTI/STI and maternal age.

Additionally. Chan et al (2013) conducted a global systematic review and meta-analysis to

estimate the risk of neonatal infection in the first seven days of life among newborns of mothers

with bacterial infection or colonization during the intrapartum period. Maternal colonization and

premature rupture of fetal membranes were found to be associated with neonatal sepsis. With a

case control study design. Ishida et al (2013) also found amniotic fluid and prolonged rupture of

fctal membranes to be associated with neonatal sepsis. On the other hand, history of maternal

UTI/STI during the index pregnancy also showed a statistical significant association with

neonatal sepsis (Gebremedhin et aI2016). This study showed that, neonates born to mothers who

had UTI/STI during the index pregnancy had five (5) times higher odds of developing sepsis

14



compared to those neonates born to mothers who did not have a UTI I STI during the index

pregnancy.

2.3: ~ewborn Factors of Neonatal Sepsis

Leal et al (2012) conducted a cohort study to assess risk and prognostic factors for neonatal

sepsis pre\ailing at a medical unit in Southeastern Mexico. After a logistic regression analysis,

newborn factors for sepsis included low birth weight; prematurity; abnormal amniotic fluid;

premature membrane rupture. Similarly, factors associated with early-onset sepsis included

preterm delivery; low birth weight; meconium-stained amniotic fluid (MSAF) and first birth in

South Africa (Schrag et al (20[2). Another study in Ghana by Mate'etal' (2014) revealed that

neonatal factors that were significantly associated with sepsis include male sex, preterm , not

crying immediately after birth, low birth weight <2S00g and an APGAR score less than seven

(7). On the contrary, a study conducted in Bishoftu General Hospital indicated that, preterm

neonatc~ did not show any significant association with the occurrence of neonatal sepsis (Woldu

et al (2014). This could be due to the difference in study design used, health care delivery

systems, and awareness of the community regarding the prevention strategy of sepsis and the

numbers of admission of the preterm neonates during the study period.

2.4: Hospital factors associated with neonatal sepsis

Ilospital acquired or nosocomial infections are still a major cause of morbidity and mortality in

neonatal intensive care units (NICUs). This is very common in low income countries due to poor

h) gienic conditions in healthcare facilities and practice of poor aseptic techniques by healthcare

professionals. This trend has led to higher levels of neonatal sepsis and mortality in sub-Saharan

Africa. Usually, early-onset neonatal sepsis is associated with prenatal background

characteristics such as maternal prolonged or premature rupture of membrane; whereas late-onset

lS



is mainly related to the medical and surgical conditions or other procedures required by neonates

such as resuscitation at birth, and intravenous access after birth (Jabiri et al (2016). According to

Auriti et al (2010). invasive therapeutic procedures in the NICU. as well as the moment of onset

of infection. \\ ith respect to the start of the procedure, and the time between the start of the

procedure and the onset of intection. can be relevant factors as well. Previous studies have

identified health facility factors such as period of hospital stay and medical procedures such as

central venous catheter. mechanical ventilation and prolonged parenteral nutrition to be

associated with neonatal sepsis.

Leal et al (2012) conducted a retrospective study including 8033 neonates admitted to a neonatal

intensive care unit in southeastern Mexico. Mechanical ventilation and history of instrumentation

"en: found III be associated with neonatal sepsis. Similarly, according to Mhada et al (2012), for

neonates who were been admitted in health care facilities, history of instrumentation or invasive

procedures \\ere notable factors for neonatal sepsis in Tanzazia. Additionally, the presence of

central catheters for more than four days, parenteral nutrition for more than seven days, were

associated with late-onset neonatal sepsis in Canadian intensive care units (J. Shah et al (2015).

16



CHAPTER THREE

METHODOLOGY

3.1: Stud~ Design

A retrospective cross-sectional study design was used in this study that reviewed medical

records of neonates with or without sepsis admitted on the Neonatal Intensive Care Unit (NICU)

of the Navrongo War Memorial Hospital (WMH) between January 2015 and June 2017.

Cases were defined as those who \\cre diagnosed with sepsis whereas those diagnosed with

conditions other than neonatal sepsis were classified as controls. Further review was then carried

on the maternal. neonatal and delivery factors likely to be associated with neonatal sepsis. To

a~l:crtain thc accuracy of the data ten (10) neonate's folders were selected at random by

con~idcring c\ cry 60lh neonates recorded in the admission and discharge books over the study

period. A follow up was made to their homes to confirm the information recorded in the books

including information related to socio-demographic and maternal factors. Data collection was

done within four weeks in June/ July 2017 and recorded on a data collection form specifically

designed for this study. This was done after an informed consent had been obtained from the

mother~.

3.2: I{c~careh Setting

('he study was carried out at the WMH the only hospital in the Kassena Nankana Municipality

and served as a referral center for all health facilities in the Municipality and adjoining districts

including Balsa and Sissala West. The Kassena Nankana Municipality has a total of 19 health

facilities and 20 functional CHPS centers.

17



The War Memorial Hospital has a total bed capacity of 169 distributed in the various units as

indicated in Table 3.1.

WARD Emergency Children ward Female Medical ward Female surgical Ward Male medical Ward Male Surgical Ward Operating Theatre Reco~er:- Unit 'vIaternity Ward Labour Ward \iconatal and Intensive Care Unit TOTA!.

NUMBER OF BEDS 12 34 20 18 14 14 4 3 26 9 15 169

TABLE 3: 1: HOSPITA L BEl} STATE AT THE WAR MEMORIAL HOSPITAL, NAVRONGO

Source: (War Memorial Hospital June 2017)

The Hospital has staff strength of 342 as shown in the Table 3.2 below.

CATEGORY OF STAFF !),'ctors I'h~ ,ilian Assistant \1id\\ i"cs Cienl!ral Nurses Enrolled nurses Orientation nurses Pharmacy Staff Casual staff Laboratory Staff X-ray TOTAL

NUMBER OF STAFF 2 5 26 83 72 74 8 62 8 2 342

I' \SLE 3: 2: STAFF STRENGTH OFTHE WAR MEMORIAL HOSPITAL AS AT 1ST JUNE, 2017

"'oun:e: (War \ lemorial Hospital June 2017)

18



The War Memorial Hospital is located in Kassena-Nankana East, (FIGURE I. A). The

Municipality is about 40 km away from Bolgatanga, the regional capital of Upper East Region of

Ghana. (tigure I b). It is located between latitude 10°30' and II ° 00' North and 1 °00' and 10

30'

West longitude of the Sahelian Savannah. The municipality covers a land area of 1,674 square

kilometers.

The population according to estimate from the 2010 Population and Housing Census, is 109,944

representing 10.5% of the region's total population. Males constitute ~8.8% and females

repre~ent 51.::%. About 72.7% of the population lives in rural localities. The Municipality has a

Iota I Fertility Rate of3.4. The General Fertility Rate is 97.9 births per 1000 women aged 15-49

year~ \\hich i~ ~Iightly higher than the region's figure of 97.5. The Crude Birth Rate (CBR) is

23.1 per 1000 population.

There are a total of 19,790 households with average household size of5.4 persons per household.

Children constitute the largest proportion of the household composition accounting for 44.7

percent. Extended households (head, spouse(s), children and heads relative) constitute 40.2% of

the total number of households in the Municipality and this is followed by nuclear households

(head. spouse(s) and children) 20.7%.

In the municipality, 82.7% of households are engage in agriculture. In the rural localities, 93.1 of

households are agricultural households while in the urban localities, 56.8% of households are

into agriculture. Most households in the Municipality (96.1 %) are involved in crop farming with

Poultry (chicken) as the dominant animal reared in the municipality.

19



"lap of !CasHDa-Nukaaa DistriCt_· __ ~..,

Road. c=lClu,t

_~:::.:vronQO

~OI'trlci80und"ry

FIGlIU: 3: GHA:\A MAP SHOWING THE UPPER EAST REGION, B: MAP OF KASSENA - NAN KANA Ml:NICIPAUT\

(SOURCE: GOOGlE MAP, 2016)

20



DISTRICT MAP OF KASSENA NANKANA EAST

BURKINA FASO

TALENSI

\

J au .... 8ASOuTH W!:5 T MAMPRUS!

LEGE NO

• DI.lrlctCapf181 . D"itrlctBounttary

FI(.l RE 4: \IAP OF KASSENA - NANKA:'IIA EAST MUNICIPAL SHOWING SURROUNDING

CO\l'IL:'IiITIES. (SOURCE: GOOGLE MAP, 2016)

21



3.3: Stud)' Population

~conate~ that were admitted in the War Memorial Hospital between the periods January 2015 to

June 2017.

3.4: Inclusion Criteria

I. All neonates admitted to the intensive care unit during the study period

3.5: Exclusion Criteria

I \I.'onate., \\ ith incomplete patient information such as socio-demographic

2. Neonates with unconfirmed diagnosis

22


Factors associated ,dth Neonatal Sepsis at the War Memorial Hospital

3.6: Study Variables

Variable

Neonatal sepsis

Maternal age

"ex of the neonate

Age of the neonate

Place of delivery

,\ntenatal Care

Operational Definition

Newborn infections occurring within the first

Type Variable

four weeks of life (28 days). Dependable

Mothers age at the time of registering at ANC of the cum:nt child-as recorded in the ANC book Independent

This ",as defined as either male or female Independent

Age in days of neonate at the time of admission at the hospital Independent

The environment where the neonate was delivered Independent

The number of pregnancy visits to a healtheare institution Independent

of Scale Measurement

Categorical

Continuous

Binary

Continuous

Binary

Home

Hospital Categorical

1'Alil:I':33: Dn:I~ATlON OF VARIABLES AND THEIR SeAL OF MEASUREMENTS

3.7: Sampling Technique

A systematic sampling technique was used to select the participants in the study. The sampling

interval was determined by dividing the total study population of 618 neonates by the number of

required sample size (243) of the study. Hence the sampling interval arrived at was two (2). A

,implc random sampling was applied to get the random start of the second person by balloting

hel\\ecn the first two (2) neonates admitted within the study period from the list of 618 in

sequence. The remaining 241 study participants were then selected after every second study

participant. This was done successively from January 2015 to June 2017.

23

of



The data collection tool had four (4) sections: Section A: Socio-demographic characteristics of

mother of neonate. Section B: Obstetric information of mother. Section C: Neonatal information,

Section D: delivery and immediate perinatal information. Neonate's mothers folders were

occasionally retrieved using their medical records number to augments neonates whose medical

n:curJs \\cre incomplete. Data on both neonates admitted for sepsis as well as those admitted for

other condition~ \\ ere extracted from the relevant record books. On each day of data collection,

vital medical information was retrieved starting from the earlier ones - from January, 2015 and

proceeded to the latest ones June 2017. With the help of trained research assistants (midwives

and pediatric nurses), the exercise continued until the required sample size was obtained.

Data on socio-demographic characteristics including maternal educational level, maternal

occupation. and maternal medical history were extracted from the record books. Other maternal

related data extracted were: age. delivery by caesarean section, gestational age, parity, history of

infectious disea~c~. and number of antenatal visits. Also, neonate-related factors such as neonatal

gestational age. neonatal sex, history of foetal distress, APGAR score, premature (::::37 weeks),

post mature (~42 weeks) and birth weight (kg) were extracted. Additionally, information on

umbilical cord condition. male circumcision condition, place of birth and other invasive medical

procedures that have the potential of introducing infection were all covered.

ro a~certain the accuracy of the data, ten neonates' folders were selected at random and a follow

up made to their homes to confirm the information found in the documents reviewed, especially

socio-demographic data. The chosen ten study participants medical records numbers were

retrieved from the admissions and discharge books and their mothers folders retrieved from the

medical records department. This was successful because their mother's folders contained

comprehensive information about some of their medical records, residential address and phone

24



contacts. [he principal investigator then contacted the parents of those sampled neonates through

a phone call and arrangements made on their convenient dates, venues and time at the client's

convenience. Written informed consent was obtained prior to collection of data from the

parents/caregiver. An opportunity was offered to parents to make any further inputs that might be

of essence. The home visit activity was undertaken within one week after all the data were

~ollected.

3.8: Samplc ..;ilC cstimation

The sample size for the study was calculated by using Yamane (1967) formula for sample size

determination. According to Yamane (1967), the sample size can be calculated if the population

size of the target group is known by using the formula below:

N n = -1-+-N-C e-:2-)

\\herc n required sample ~i/c

,~ population size

e= alpha level

According to the annual reports of War Memorial Hospital for the two and half years, number of

new-borns admitted was 618. With an alpha level of 0.5, the sample size was calculated below;

618 n = -:----:-~.,__ __ 1 + 618(0.05 2)

= 243

2S



3.9: Ethical Standards

The study was conducted in full conformity with the Declaration of Helsinki and or with local

regulatory requirements which ever afforded the greatest protection to the study participants, the

community and credibility of data. Ethical approval and clearance was obtained from the Ghana

Health "'cn icc Ethical Revic\\ Committee with ethical clearance approval number GHS-ERC:

60/12/2016 and approval date 21 st march 2017, before the study commenced. Permission was

also granted by the War Memorial Hospital management for the work to be carried out at the

facility prior to data collection.

3.10: Consenting Process

\\ritten informed consent was obtained from parents/guardians whose homes were visited for

verilication of information by the Principal Investigator and field assistants. Permission was also

obtaincJ from carc flrovider~ before data collection.

3.11: Privacy and Confidentiality

Medical information about individual that were obtained during the course of the study were

strictly confidential and were not disclosed to third parties. Confidentiality was ensured by the

usc of study participants code and numbers for the identification of each study participants. The

study participants codes and numbers were also used for participants data for the study

participants individual CRFs. No names or personal identifiers were collected from the medical

records books and folder~.

3.12: Potential risks/benefits of the study

This study involved a review of medical records of neonates and we do not foresee any direct

risks to the child's participation in this study except for the fact that some of the information

26



collected was personal. This study was expected to provide data on factors associated with

infe\:tion~ in ne\\ boms aged between 0 to 28 days and shall contribute to the content of health

education programs both for mothers and healthcare providers in the Kassena Nankana

Municipality and the nation.

3.13: Voluntary Withdrawal

It was anticipated that some study participants might withdraw from the study for certain

reasons, Study participants were told about their right to withdraw freely from the study at any

stage of the study. Withdrawals were anticipated to have no significant effect on the results of

the ~tud); however, substantial withdrawals may reduce the study population.

3.14: Data Storage/Security and Usage

Data were collected in hardcopies (CRFs) from the NICU by trained field assistants and the

Principal Investigator, sealed in an envelope and locked in a drawer. The PI was the only person

who had access to the key of this drawer. Soficopies of data either in STAT A 14 IC software

were pass worded. Data collected is solely for academic purposes.

3.15: Data Processing

\ II data were entered into Microsoft Excel and imported into STAT A 14 IC software.

Appropriated label names were assigned to each variable in STAT A, before analysis was carried

out.

3.16: Data Management and Analysis

Data cleaning was done after data entry by running frequencies and checking for out of range

documentations. Both descriptive and inferential statistical analysis was done. Descriptive results

took the form of frequencies, percentage distribution, means, and standard deviations and

27



presented in tables. A bivariate analysis was done to determine the association between the

independent variables (maternal, neonatal and delivery perinatal factors) and the outcome

variable (neonatal sepsis or no sepsis). Those variables which showed significant association at

5% significance level with neonatal sepsis were entered for further analysis. A multivariate

regression analysis was employed. The degree of association between dependent and

independent variables were examined using odds ratio with 95% confidence interval. A P-value

< 0.05 \\a~ considered as significance level for associations between the independent variables

and the outcome variable.

28



CHAPTER FOUR

4.0: PRESENT A TlON OF RESULTS

This chapter provides a summary of maternal, neonatal and perinatal factors for neonatal sepsis

in neonates. Data from 243 mother and newborn pairs were analyzed. The prevalence of

neonatal sepsi~ in the study population was 56.4%. The mean age of mothers in the study

population was 26.8 ± 0.46 years.

4.1: Neonatal Factors

[n this study, the neonatal factors that were assessed included sex of baby, asphyxia, first and

fifth minute APGAR scores, weight and height of baby at delivery and outcome of delivery.

With respect to sex of baby, there were more male neonates as compared to female neonates in

the study regardkss of the diagnosis. More than one-half (56.9%) of the neonates diagnosed with

ncunatal ,cp~i~ were males. Likewise, 57.5% of neonates who were not diagnosed with neonatal

,cp~i~ "cre male~ (Table 4).

Fetal distress (asphy:\ia) was more prominent among neonates who were not diagnosed with

neonatal sepsis as compared to those who were diagnosed with neonatal sepsis.

The first minute Apgar score, an assessment of how well babies tolerated the delivery process

was comparatively higher among patients diagnosed with neonatal sepsis as compared to those

diagnosed" ith conditions other than neonatal sepsis. As illustrated in Table 3 below, 75.8% of

babies with neonatal sepsis recorded an Apgar score of 2 or more whereas 71.7% of those

\\ ithout neonatal sepsis recorded that same score.

29



Assessment of how well babies were doing immediately post-delivery was done using the fifth

minute Apgar score. Babies without neonatal sepsis had a similar fifth minute Apgar score to

babic~ \\ ith neonatal sepsis.

Furthermore neonates diagnosed with neonatal sepsis had a higher birth weight and height at

delivery as compared to neonates diagnosed with other conditions excluding neonatal sepsis.

Bivariate analysis revealed that the first and fifth minute APGAR scores, height at delivery, sex

of bab) as \\ell as the outcome of delivery were not significant factors of neonatal sepsis in the

study population (Table 4.1 ).

30


· t d w,'th Neonatal Sepsis at the War Memorial Hospital Factors assoCla e

Sepsis LN 137 No sepsis LN 106 P value

Independent variables (%) (%)

Males 78 (56.93) 61 (57.55) Sex

Females 0.924 59 (43.07) 45 (42.45)

Asphpia Present 17 (12.41) 34 (32.08) P<O.OOI Absent

120 (87.59) 72 (67.92)

1'1 minute .\I'(;AR Score 34 (24.82) 30 (28.30)

2 57 (41.61) 52 (49.06)

24 (22.64) 0.174

46 (33.57)

5th minute APGAR Score 9 (6.57) 6 (5.66)

2 42 (30.66) 28 (26.42) 0.706

86 (62.77) 72 (67.92)

Weight at delivery(kg) <2.5 67 (48.91) 66 (62.26) ~2.5

70 (51.09) 40 (37.74) 0.031

Height at delivery(cm) <50 61 (44.53) 58 (54.72) 0.099 ~50

76 (55.47) 48 (45.28)

Outcome of delivery Alive 136 (99.27) 102 (96.23) Dead

1(0.73) 4 (3.77) 0.097

TABLE 4. I: BIVARIATEA!\IALYSIS OF NEONATAL FACTORS

4.2: Multivariate analysis of neonatal factors

Multivariate analysis revealed that asphyxia and weight of baby at delivery were significant

factors of neonatal sepsis in the study population. First, the odds of neonatal sepsis among

31



neonates who showed signs of fetal distress was three (3) times the odds of neonatal sepsis

among those who did not show any signs of fetal distress ( Table 4.2). Secondly. the odds of

having neonatal sepsis were 50% higher among neonates whose weight at delivery was less than

2.5kg as compared to neonates whose weight at delivery was 2.5kg or more (Table 4.2). Table

4.2 below provides a summary of multivariate analysis with computed odds ratios (OR) and

adjusted odds ratios (AOR).

Independent variable OR (P value) [95%CI] AOR (P value) [95%CI]

Asphyxia Present 3.33 (P<O.OO I) [1.74-6.39] 3.65 (P<O.OOl) [1.88-7.12]

Absent 1.00 1.00

Weight at delivery(kg) <2.5 1.57 (0.027) [1.05-2.34 ] 1.70 (0.011) [ 1.13-2.57]

~2.5 1.00 1.0

lIistol') of cord Positive 2.65 (P<O.OOI) [1.92-5.31 ] 3.15 (P<O.OOI) [1.83-6.52]

infections Negative 1.00 1.00

i\lale circumcision Positive 5.10 (P<O.OOI) [2.27-7.34] 3.71 (P<O.OOI) [1.92-7.14]

Negative 1.00 1.00

Assisted ventilation Yes 2.18 (0.015) [1.16-4.09] 3.\0 (0.010) [ 1.88-8,48]

No 1.00 1.00

Instrument delivery Yes 0.18 (0.032) [0.03-0.86] 0.14 (0.063) [0.06-1.08]

No 1.00 1.00

TABLE 4.2: MULTIVARIATE ANALYSIS OF NEONATAL FACTORS ASSOCIATED WITH NEONATAL SEPSI

32



~.3: Maternal Factors

In this study, the maternal factors that were examined were age, highest education level, health

insurance status, use of insecticide treated net during last pregnancy, use of insecticide treated

net previous night before the study. number of pregnancies, number of deliveries, number of still

births. number of prcterm births. number of hospitalizations during current pregnancy, number

of past abortions, sickling status, H IV status, hepatitis B status, syphilis status, gestational age at

deli\cr). place of delivery and prolonged membrane rapture.

Majority of the mothers in this study were married regardless of diagnoses. With respect to age

and level of education, mothers whose children were diagnosed with neonatal sepsis were older

and had a higher educational background as compared to those whose children did not have

~cp,i, (rable 4.3). The proportion without health insurance was higher among women whose

~hildrcll had nCllnatal sepsis (0.073) as compared to women whose children were not diagnosed

with neonatal sepsis (0.009).

Furthermore. the proportion that used insecticide treated nets during the last pregnancy and on

the night prior to data collection, was higher among mothers whose children did not have

neonatal sepsis as compared to those whose children were diagnosed with neonatal sepsis (Table

·U). The number of pregnancies and deliveries were comparatively higher among women whose

children \\iere diagnosed with neonatal sepsis than those whose children were diagnosed with

wnditions other than neonatal sepsis. In addition. the prevalence of still births was higher among

women with children with neonatal sepsis as compared to those who did not have children

diagnosed \\ ith neonatal sepsis (Table 4.3).

In the study, women who did not have children with neonatal sepsis recorded a higher number of

preterm births (11) as compared to those who had children with neonatal sepsis (4). Also, the

33



number with a history of more than one abortion was higher among women whose children did

not have neonatal sepsis as compared to women who had neonatal sepsis. The frequency of

ho~pitalizations was also higher among children without neonatal sepsis as compared to children

diagnosed \\ ith neonatal sepsis.

The prevalence of HIV and Hepatitis B infections were higher among women with children

diagnosed with neonatal sepsis as compared to women without neonatal sepsis. On the contrary,

the prevalence of s}philis infection was lower among women whose children were diagnosed

with neonatal sepsis as compared to those who had children without neonatal sepsis (Table 4.3).

rhe number of babies who \\erc delivered at term (38·42 weeks) was higher among those

diagn()~cd with neonatal sepsis as compared to those without neonatal sepsis.

In this stud). the prevalence of prolonged membrane rapture was higher among mothers whose

babies had neonatal sepsis as compared to mothers whose babies did not have neonatal sepsis.

Also, delivery at clinics and hospitals was higher among

34



Il:N 137 Il:N 106

N(%) N (Ofu)

Hepatitis B Status Positive 4 (4.04) 3 (4.41)

l-------+:-:-:-::-:-::----il P value

0.906

Negative 95 (95.96) 65 (95.59)

S~philis Status Positive I (0.85) 2 (2.44) 0.366

Negative 116(99.15) 80 (97.56)

Gestational age 97 weeks 45 (32.85) 52 (49.06) 0.035

At delivery 38-42 weeks 82 (59.85) 47 (44.34)

>42 weeks 10 (7.30) 7 (6.60)

Place of delivcr')' Home 2 (1.46) 0(00.00) 0.001

Clinic 52 (37.96) 18 (16.98)

Ilospital 83 (60.58) 88 (83.02)

Prolonged membrane Rupture Yes 0(00.00) 1(0.94) 0.254

No 136 (100.00) 105 (99.06)

Mode of delh CIJ SYD 101 (74.26) 85 (80.19) 0.045

CIS 35 (25.74) 18 (16.98)

YD 0(00.00) 3 (2.83)

TABLE 4.3: BAY ARIATE ANALYSIS OF MATERNAL FACTORS

~A: MuIthariate analysis of maternal factors

\l11ltivariate analysis revealed that the odds of neonatal sepsis associated with use of insecticide

treated nets, gestational age at delivery and mode of delivery, decreased after adjusting for

possible .:onfollnders and effect modifiers in this study. On the contrary, the odds of neonatal

sepsis associated with being insured increased after adjusting for possible confounders and effect

modifiers (Table 4.4). Likewise, the odds of neonatal sepsis associated with increasing number

of pretcrm births increased during multivariate analysis. Also, the odds of neonatal sepsis

associated with clinic delivery increased from 3.06 (CI: 1.66-5.67) to 4.01 (el: 1.19-4.21)

35



Factor

Health Insurance Insured

Not insured

ITN use last night Used ITN

Did not use [TN

Number of preterm One or more births Nil

Gestational age >42 weeks at deliwry 38-42 weeks

~37 weeks

Place of delh ery Clinic Hospital Home

\Iode of delivery CIS VD SVD

Odds ratio

8.86

1.00

2.17

1.00

0.55

1.00

1.15

1.00

1.00

4.10

1.00

1.00

1.62

1.19

1.00

P-value

(0.032)

(0.067)

(0.010)

(0.312)

(0.001)

(0.053)

(0.061)

95% CI

[0.99-9.66]

[0.80-5.84]

[0.17-1.75]

[ 1.04-1.28]

11.19-4.21]

[0.55-1.84]

[0.78-5.98]

rABLE .. U: MULTIVARIATE ANALYSIS OF MATERNAL FACTOR ASSOCIATED

WITH NEONATAL SEPSIS

4.5: Perinatal Factors

In this study .. the perinatal factors that were examined included history of cord infections, male

circumcision .. assisted ventilation use, IV medication use and instrument delivery.

36



As illustrated in Table 9. the prevalence of umbilical cord infections was lower among neonates

diagnosed with neonatal sepsis (52.6%) as compared to those diagnosed with conditions other

than sepsis (79.3%).

Likewise. the proportion of circumcised males in the study population was lower among

neonates diagnosed with neonatal sepsis (0.42) as compared to those diagnosed with conditions

othcrthan neonatal sepsis (0.78).

rhe percentage of neonates with neonatal sepsis who required the use of assisted ventilation in

the past was higher than that of neonates without neonatal sepsis (Table 4.5).

Also, the prevalence of IV medication use was lower among neonates diagnosed with neonatal

sepsis (93.4%) as compared to those who were not diagnosed with neonatal sepsis (96.2%).

Finally. the percentage delivered by instrument was higher among neonates who were not

diagno~ed with neonatal sepsb (8.49%) as compared to those who were diagnosed with neonatal

~epsb ( 1.48%).

Bi\ ariate analysis revealed that history of cord infections, instrument delivery. male

circumcision and assisted ventilation had an influence on neonatal sepsis.

37


. H 'tal Factors associated with Neonatal Sepsis at the War Memonal OSpl

Independent \ariable

--Histo~ of cord

infections

Male circumcision

IV medications

Instrument delivery

Sepsis

Sepsis LN=137

1:\ (%) .. Positive 72 (52.55)

Negative 65 (47.45)

Positive 58 (42.34)

Negative 79 (57.66)

Yes 116 (84.67)

No 21 (15.33)

Yes 128 (93.43)

No 9 (6.57)

Yes 2 (1.48)

No 135 (98.52)

No Sepsis

No sepsis LN

N(%)

84 (79.25)

22 (20.75)

83 (78.30)

23 (21.70)

76 (71.70)

30 (28.30)

102 (96.23)

4 (3.77)

9 (8.49)

97 (91.51)

106 Pvalue

P<O.OOI

P<O.OOI

0.014

0.337

0.030

--- --------- ---------------------------

TABLE 4.5: BAVARITF. ANALYSIS OF PERINATAL FACTORS ASSOCIATED WITH

..,rl'''IIS

·t6: !\Iultivariate analysis of perinatal factors

The odds of neonatal sepsis associated male circumcision and instrument delivery reduced after

adjusting for potential confounders in multivariate analysis.

38



With respect to the association between a positive history of cord infections and neonatal sepsis,

the adjusted odds ratio (OR= 3.15; P<O.OOl) was higher the crude odds ratio (OR= 2.65;

P<O.OO I). Also. the odds of neonatal sepsis for assisted ventilation use also increased after

adju.,ting for potential confounders in multivariate analysis (OR=2.18, P=0.015; AOR=3.10,

P °0.0 I 0). Table 10 below provides a summary of multivariate analysis for perinatal factors of

neonatal sepsis.

Independent variable OR (P value) [95%CI] AOR (P value) [95%CI]

History of cord Positive 2.65 (P<O.OOI) [1.92-5.3 I] 3.15 (P<O.OOl) [1.83-6.52]

infections Negative 1.00 1.00

Mall' circumcision Positive 5.10 (P<O.OOI) [2.27-7.34] 3.71 (P<O.OOI) [1.92-7.14]

Negative 1.00 1.00

Assisted \cntilation Yes 2.18 (0.015) [ 1.16-4.09] 3.10 (0.010) [ 1.88-8.48]

No 1.00 1.00

Instrument dclivery Yes 0.18 (0.032) [0.03-0.86] 0.14 (0.063) [0.06-1.08]

No 1.00 1.00

TABLE 4.6: MULTIVARIATE ANALYSIS OF NEONATAL FACTORS ASSOCIATED

WITH NEONATAL SEPSIS.

39



CHAPTER FIVE

5.0: DISCUSSION

I his stud: ~llught to determine the neonatal, maternal and perinatal factors associated with

neunatal infections in the War Memorial Hospital, Navrongo. Neonatal factors that were

assessed included sex of baby. asphyxia, first and fifth minute APGAR scores, weight and height

of baby at deliver). The prevalence of neonatal sepsis in this cross-sectional study was found to

be 56.4% and more than half(56.9%) of the neonates diagnosed with neonatal sepsis were males.

These findings agree with what has been reported in earlier studies on neonatal sepsis. In a cross

sectional study conducted in Ethiopia by Gebrehiwot et al. (2012), a much higher prevalence of

11~L1l1atal 'cp~i, (81.8%) was reported. With regard to the association of neonatal sepsis with sex,

the male gender was predominantly affected in the present study and this has been commonly

reported in other studies. According to Ogunlesi and Ogunfowora (2010), the majority of

neonates who were diagnosed with neonatal sepsis were males. Moreover, neonatal sepsis was

found to have an association with the male gender (Dhumal et al (2012; Jumah & Hassan,

2007).While the scientific explanations on why male neonates stand a higher risk of developing

neonatal infections may not be obviously tacit, other authors have cited male circumcision as a

pu~sible contributing factor to neonatal sepsis in males (Becker et al (2009). Other authors

advocate that since the male gender is a factor for prematurity and low birth weight (Lawn et al

(2010) and as these factors have also been connected with neonatal sepsis, then it is likely that

the relationship between sex and neonatal sepsis is mediated by birth weight and prematurity.

However. some people hold on to the declaration that female babies may have robust immunity

than males despite the scanty evidence to support this claim. As indicated by Bouman et al

(2004). sexual dimorphism from the human immune response is quite clear; female produces the

40



more active of cellular immune which makes them more resistant to infections. That

nol\\ ithstanding, a study in India did not find a significant relationship between sex and neonatal

sep~is (Chacko & Sohi, 2005): hence, the findings from the present study could be attributed to

the fact that majority of the neonates were males.

After logistic regression analysis, only asphyxia (p<O.OOl) and weight of baby at delivery

(p=O.O II) were found to be significant factors of neonatal sepsis in the study population. With

respect to weight of baby at delivery, the odds of neonatal sepsis among babies with low birth

weight «::!500g) was twice the odds of neonatal sepsis among those with a comparatively higher

birth "cight (::-2500g) in this study. These findings have also been corroborated by other studies

on neonatal sepsis. Hayun et al (2015) reported birth weight as a significant factor for neonatal

sepsis. This is also in tandem with the findings of Sitka et aI., (2013) where birth weight was a

significant factor of neonatal sepsis in a similar study conducted in the Srong Ahafo Region of

Ghana.

Similarl). birth weight and asphyxia (low APGAR score) were identified as fetal

tJ(tm~ of nCllnatal sep!>is (Satar ct al (2010). Again, Haque (20 I 0) reported birth weight as a

lactor of neonatal sepsis where the low birth weight have a risk of early onset neonatal sepsis

compared to the normal birth weight. However, findings from other studies contradict what was

found in the current study. According to Leal et al. (2012a) birth weight is not a factor neither to

early onset neonatal sepsis or late onset neonatal sepsis.

This trend could be attributed to the fact that neonates with lower birth weight tend to have

immature or less developed immune systems and a lower tendency to fight infections. This

increascs the susceptibility of neonates with lower birth weight to sepsis. In addition, physicians

41



may have difficulty in diagnosing sepsis early and accurately among low birth weight or preterm

babies due to lack of highly sensitive and specific markers (Haque, 2010). Moreover, low birth

weight and preterm neonates are more likely to receive parenteral nutrition via intravenous

cannulation and this may predispose them to higher risk of infection.

Though age of neonate and history of invasive procedures were not found to be factors of

neonatal sepsis in the present study, these factors have been widely reported as factors of

neonatal sepsis in the recent past. According to Leal et al. (2012a),for neonates who were

admitted in health care facilities in southeastern Mexico, age at admission and history of

instrumentation or invasive procedures were notable factors of neonatal sepsis. Again, age of

neonates and history of invasive procedures emerged as factors of neonatal sepsis in Ethiopia

(Woldu ct al20 17).

Furthermore. the odds of neonatal sepsis among neonates who showed signs of fetal distress was

about 4 times the odds of neonatal sepsis among those who did not show any signs of fetal

di~tress. l.eal and colleagues also found birth asphyxia to be a significant factor of neonatal

~ep~i, in a similar study (Leal et al.. 2(12). Respiratory distress predisposes infants to hypoxia

and a consequcntial growth of anaerobic pathogens and facultative anaerobes acquired from

mothers. The growth of bacteria such as Escherichia coli, Staphylococcus aureus

Acinetobuc:ter. Klebsiella and Streptococcus contribute significantly to the development of

neonatal sepsis (Li et aI., 2013; Najeeb et aI., 2012).

Despite meconium stained amniotic fluid not emerging as a significant factor of neonatal sepsis

in this study, its importance cannot be downplayed since fetal distress was associated with

neonatal sepsis. According to Perry et al (2013), meconium stained amniotic fluid is a significant

predictor of neonatal infection. Normally, the amniotic fluid is expected to remain clear'

42



ho\\cvcr. ""hen there is fetal distress, it could be stained with meconium. There is also recent

evidence that the prescnce of meconium in amniotic fluid increases the chance of the fetus being

born with low Apgar score, which has earlier been associated with neonatal sepsis (AI Dasoky et

al (2009).

Prior studies have linked neonatal sepsis to maternal factors such as parity, maternal age,

prolonged membrane rapture, preterm delivery and place of delivery (Gebremedhin et al (2016;

\.eal el al.. 2012: Shah. Budhathoki & Mandai, 2006). In the present study, preterm delivery,

place of deliver) and health insurance status of mother were all found to be significant factors of

neonatal sepsis in this study.

With respect to health insurance in the present study, the odds a neonate whose mother had

health insurance having neonatal sepsis was 9 times the odds of a neonate whose mother was

uninsurcd having neonatal sepsis. Due to Ghana's economy, expensive antibiotics of higher

efTicacy and quality are usually not covered by the health insurance scheme. Mothers who are

not insured tend to buy the expensive and more efficacious brands of antibiotics more than

mothers who are insured. This could have accounted for the lower odds of neonatal sepsis among

uninsured mothers. It is also worth noting that most of the mothers were insured with very few

(II) uninsured and so the few numbers could also have affected the statistical analysis and so the

findings should be interpreted with caution.

In this study. the odds of neonatal sepsis increased with increasing number of pre term deliveries,

making preterm delivery a factor for neonatal sepsis. This is consistent with the finding of Shah

el al (2006) where preterm delivery was a factor of nconatal sepsis. This trend is expected since

the predisposition of preterm dclivcry to neonatal sepsis has been widely explained by scientific

evidence. According to Petrova and Mehta (2007), preterm babies either have dysfunctional

43



neutrophils or a limited capacity in increasing the production of neutrophils in order to respond

to infections.

The odds of having neonatal sepsis were higher among mothers who delivered at a clinic as

compared to those who delivered at a home in this study. This is because mothers have a higher

~'hance of acquiring health-care associated infections (nosocomial infections) at clinics than at

home. '-iimilar findings have been reported other studies on factors of neonatal sepsis. A study

,llnducted in Bishoftu. Oromia suggested that the proportion of neonates who were born at

health center had higher risk of neonatal sepsis compared to home delivery (Woldu et al (2017).

In an unmatched case control study conducted in Ethiopia by Gebremedhin et al (2016). a

significant number of neonates born at health center developed sepsis with 5.7 times higher odds

of developing sepsis compared to neonates born in hospitals. This might be due to the reason that

neonates who were delivered at health center were less likely to be screened based on a risk

approach and to be treated with intrapartum antibiotic prophylaxis as compared to those

delivered in hospitals. I kmever. only two women delivered at home in the current study and that

would have affected the statistical outcome.

Maternal education and employment status were not factors for neonatal sepsis in the current

study. This is inconsistent with earlier findings where maternal education and employment status

were significant factors of neonatal sepsis. Shah et al (2006) reported in a case control study in

Nepal that maternal literacy and employment status were associated with neonatal sepsis. This is

because. \\omen with formal education are more likely to understand issues related to childcare

and good hygiene better than illiterate women (Onyedibe et al (2012). Furthermore. it is

believed that women who are employed and financially empowered may have the capability to

44



provide good nutrition to their babies, improves their immunity and ability to fight infections

(Orwenyo et al 20 II)

In contrast to findings from other studies, maternal factors such as history of sexually transmitted

infections. prolonged membrane rapture, gestational age, and number of still births and mode of

deliver ""ere not found to be significant predictors of neonatal sepsis. This may due to a smaller

sample size used in this study.

Perinatal factors that were examined in this study included history of cord infections, assisted

ventilation use, IV medication use and instrument delivery. Logistic regression analysis revealed

history of cord infections and assisted ventilation to be significant factors of neonatal sepsis.

rhe odds of having neonatal sepsis were 3 times higher among neonates with a positive history

of umbilical cord infections as compared to those without a history of umbilical cord infections.

Chan and colleagues also reported a relationship between the development of neonatal sepsis and

bacterial infection in the mother and that infection in the mother can lead to colonization of the

umbilical cords of babies (Chan et aI., 20\3).Following the colonization of the umbilical cord,

the fetus is likely to ingest some of these bacteria during the transfer of blood containing oxygen

and nutrients from the mother to the fetus. This may predispose them to infections

(bnamghorashi ct al (2012).

Also. the odds of neonatal sepsis among neonates who required assisted ventilation was found to

be 3 times the odds among those who did not require such therapy in this study.

Neonates with fetal distress or birth asphyxia require assisted ventilation to alleviate symptoms

of hypoxia. Prolonged mechanical ventilation has been shown to increase susceptibility of

individuals to respiratory infections. The dissemination of harmful pathogens into organs of

45



neonates with poor defense mechanisms may result in neonatal sepsis leads to sepsis (Leal et a1..

2012).

46



CHAPTER SIX

CONCLUSION AND RECOMMETIONS

6.0: CO,\CLUSION

I he stud) has established that neonatal, maternal and perinatal factors had contributed

immensely to the development of neonatal infections.

In contrast to other findings, factors such as sex of baby, first and fifth minute APGAR scores,

height of baby at delivery, outcome of delivery, maternal age, maternal educational level,

mllther"s marital status. mother's sickling status, mother's STI status, number of pregnancies,

number of deliveries, usc of insecticide treated net during pregnancy, number of hospitalizations

during current pregnancy. gestational age at delivery, number of multiple births, number of still

births, number of past abortions. prolonged membrane rapture, male circumcision, intravenous

medicines use and mode of delivery had no significant association predictors of neonatal sepsis

in this study.

On the other hand. this study established a strong relationship amongst the succeeding factors;

asphyxia. weight of baby at delivery. preterm delivery. place of delivery, mother's health

in~uranec status. history of cord infections. assisted ventilation use and neonatal sepsis.

This strongly suggests the necessity of routine sepsis assessment and evaluation in neonates born

with the above-mentioned physical and physiological characteristics.

Also. these significant factors must be addressed extensively in the implementation of policies

and strategies to lessen the burden of neonatal sepsis at the War Memorial hospital and indeed

Ghana.

47



6.1: RECOW\IENDATIONS

Based on the abo\ c findings. the succeeding recommendations can be considered;

I. "IJtfof \var Memorial hospital should be trained on comprehensive infection prevention

control and strategies.

2. Mothers attending the War Memorial hospital should be sensitized on the need to seek

early antenatal care to avoid obstetric related complications such as cord infections,

prcterm delivcry and birth asphyxias.

3. Mothers attending the \\ ar Memorial hospital should be encouraged to maintain a healthy

dict during pregnancy in order to avoid low birth weight.

4. Mothers attending the War Memorial hospital must be encouraged to take intermittent

preventive treatments such as SP, iron and folic acid supplements during pregnancy.

5. Hcalth care providers at the War Memorial hospital must strictly observe aseptic

practices by ensuring a clean environment during service delivery at the labour ward and

nurserie~.

6. Future researchers and other stake holders who are interested in neonatal health should

expand the scope of coverage other than clients admitted on NICU alone. And that of the

vie\\ ~ of health service providers should be incorporated in decision making on matters

related to comprehensive neonatal care.

48



/{EFRE~CES

AI;'harpaiman, S .. Torkaman, M .. Saburi, A., Farzaampur, A., Amirsalari, S., & Kavehmanesh,

Z. (2012). Trends in incidence of neonatal sepsis and antibiotic susceptibility of causative

agents in two neonatal intensive care units in Tehran, IR Iran. Journal of clinical

neonatology, 1(3), 124.

AI Dasoky, H. A., AI Awayshseh, F. N., Kaplan, N. M., AI Rimawi, H. A., Agha, R., & Abu

Scttch, M. (2009). Risk factors for neonatal sepsis in tertiary hospital in Jordan. JRMS,

16(3),16-19.

Auriti, C. Ronchctti, M. P., Pezzotti, P., Marrocco, G., Quondamcarlo, A., Seganti, G., ...

Arioni, C. (20 lOa). Determinants of nosocomial infection in 6 neonatal intensive care

units: an Italian multicenter prospective cohort study. Infection Control & Hospital

Epidemiology, 31(9),926-933.

Auriti, c., Ronchetti, M. P., Pezzotti, P., Marrocco, G., Quondamcarlo, A., Seganti, G., ...

Arioni, C. (2010b). Determinants of nosocomial infection in 6 neonatal intensive care

units: an Italian multicenter prospective cohort study. Infection Control & Hospital

Epidemiology, 31(09),926-933.

Ballot, D. E., Nana, T.. Sriruttan, c., & Cooper, P. A. (2012). Bacterial bloodstream infections in

neonatc~ in a developing country. ISRN pediatrics, 2012.

Hc~kcr, J. U .• Theodosis. Coo Jacob, S. T., Wira, C. R., & Groce, N. E. (2009). Surviving sepsis

in lo\\-income and middle-income countries: new directions for care and research. The

Lancet infectious diseases, 9(9), 577-582.

Bouman. A .. Schipper, M .. Heineman, M. J., & Faas, M. M. (2004). Gender difference in the

non-specific and specific immune response in humans. American Journal of

Reproductive Immunology, 52( I), 19-26.

Chacko, B .. & Sohi, I. (2005). Early onset neonatal sepsis. Indian journal of pediatrics. 72( 1),

23-26.

49



Chan. G. J .. Lee. A. c.. Baqui, A. H., Tan, J .• & Black, R. E. (2013). Risk of early-onset neonatal

infection with matemal infection or colonization: a global systematic review and meta

anal) sis. PLoS Med. 10(8), e1001502.

Cloherty, J. P., Eichenwald, E. c., & Stark, A. R. (2008). Manual of neonatal care: Lippincott

Williams & Wilkins.

Dhumal, P., Ujagare, M., Gandham, N., Nagdawane, R., Sardar, M., Sharma, M., & Jadhav, S.

(2012). Incidence and antimicrobial susceptibility pattern of neonatal septicaemia from

tertiary care hospital of India. International Journal of Medical and Clinical Research.

3(7), '207.

Gebremedhin, D., Berhe, H .. & Gebrekirstos, K. (2016). Risk Factors for Neonatal Sepsis in

Public Hospitals of Mekelle City, North Ethiopia, 2015: Unmatched Case Control Study.

P/oS 0111', /1(5), e0154798.

Girma, T. (2016). Prevalence and associated factors of neonatal sepsis among neonates in

neonatal intensive care unitat selected governmental hospitals in addis ababa. ethiopia.

2016. AAU, 2016.

Haque, K. N. (2007). Defining common infections in children and neonates. Journal of HOJpital

Infection, 65, 110-114.

Haque. K. N. (2010). Neonatal sepsis in the very low birth weight preterrn infants: Part 2:

Review of definition, diagnosis and management. J Med Sci. 3(1), 11-27.

lIuyun. \1.. Ala~ir). E .. Daud, D., Febriani, D. B .. & Madjid, D. (2015). The risk factors of early

onset neonatal sepsis. American Journal of Clinical and Experimental Medicine, 3(3), 78-

82.

Ishida, Y.-i., Yukizaki, c., Okayama, A., & Kataoka, H. (2013). Glutathione As Preventive and

Therapeutic Target of Adult T-Cell LeukemialLymphoma and Its Regulation by

Camosol, a Functional Food Ingredient. DIETARY SOURCES. ROLE IN CELLULAR

FUNCTIONS AND THERAPEUTIC EFFECTS, 127.

Jabiri, A., Wel\a, H. L., Semiono, A., Saria, A., & Protas, J. (2016). Prevalence and factors

associated with neonatal sepsis among neonates in Temeke and Mwananyamala Hospitals

in Dar es Salaam, Tanzania. Tanzania Journal of Health Research. 18(4}.

Jumah, D .. & Hassan, M. (2007). Predictor~ of mortality outcome in neonatal sepsis. Medical

Journal of Basrah University. 25, 11-18.

50



Kliegman. R .. Behrman, R .. Jenson. H .. & Stanton. B. (2011). Part 42. Section 3. Chapter 690.

Disorders Involving Defective Bone Resorption. Nelson Textbook of Pediatrics.

Philadelphia. PAt USA: Saunders: Elsevier.

Lawn, J. E., Kerber. K .. Enweronu-Laryea, c., & Cousens. S. (2010). 3.6 million neonatal

deaths-what is progressing and what is not? Paper presented at the Seminars in

perinatology.

Leal, Y. A .. Alvarez-Nemegyei. J., Velazquez. J. R., Rosado-Quiab. U., Diego-Rodriguez, N.,

Paz-Baeza. E .. & Davila-Velazquez. J. (2012a). Risk factors and prognosis for neonatal

sepsis in southeastern Mexico: analysis of a four-year historic cohort follow-up. BMC

pregnanc)' and childbirth. 12( 1).48.

Leal. Y. A .. Alvarez-Nemegyei. J., Velazquez, J. R .• Rosado-Quiab, U., Diego-Rodriguez. N .•

Paz-Baeza. E., & Daviia-VelazqucL. J. (2012b). Risk factors and prognosis for neonatal

sepsis in southeastern Mexico: analysis of a four-year historic cohort follow-up. BMC

pregnancy and childbirth. 12(1). 1.

Mane. A .• Nagdeo. N .. & Thombare, V. (2010). Study of neonatal septicemia in a tertiary care

hospital in rural Nagpur. Journal of recent advances in applied sciences, 25.

Mate. S .. Kpikpitse. Mupepi. D., & Semuatu, M., S. (2014). Neonatal sepsis in rural ghana: A

ca~e control study of risk factors in a birth cohort. International Journal of Research In

Medical and Health Sciences, .,1(5).

:'vkMillan. J. A .. Feigin, R. D .. DeAngelis. c., & Jones, M. D. (2006). Oski's pediatrics:

{Jl"lndplej' & practice: Lippincott Williams & Wilkins.

Mhada, T. V .• Fredrick, F .. Matee. M. I.. & Massawe. A. (2012). Neonatal sepsis at Muhimbili

National Hospital. Dar es Salaam, Tanzania; aetiology. antimicrobial sensitivity pattern

and clinical outcome. BMC Public Health, 12( I). 904.

Naher, H .. & Khamael, A. (2013). Neonatal sepsis; the bacterial causes and the risk factors.

International Research Journal of Medical Sciences, 1(6), 19-22.

'\g. 1'. c. (2004). Diagnostic markers of infection in neonates. Archives of Disease in Childhood

Fetal and Neonatal Edition, 89(3), F229-F235.

Ogunle~i. T. A., & Ogunfowora, O. B. (2010). Predictors of mortality in neonatal septicemia in

an underresourced setting. Journal of the National Medical ASsociation, 102(10). 915.

S1


Factors associated \\ith Neonatal Sepsis at the War Memorial Hospital

Onyedibe. K .. Utoh-Nedosa. A .. Okolo. M., Onyedibe. K .. Ita, O. I., Udoh, U. A .•... Egah. D.

Z. (2012). Impact of socioeconomic factors on neonatal sepsis in los, Nigeria. Jos

Journalo/Jfedicine. 6(2). 54-58.

Orwenyo. G. K. (20 II). Maternal/actors predisposing 10 early-onset Neonatal sepsis at

Kenyalla national hospital Maternity unit. University of Nairobi, Kenya.

Pammi. M .• Flores, A., Leeflang, M., & Versalovic, J. (2011). Molecular assays in the diagnosis

of neonatal sepsis: a systematic review and meta-analysis. Pediatrics, peds. 2011-1208.

PL·rr}. S. I.. Hockenberry. M. 1.. Lowdermilk. D. L.. & Wilson, D. (2013). Maternal child

nursing ('(lr<.>: Elsevier Health Sciences.

Petrova. A .. & Mehta. R. (2007). Dysfunction of innate immunity and associated pathology in

neonates. The Indian Journal 0/ Pediatrics, 74(2), 185-191.

Rasul, C. H., Hassan, M. A., & Habibullah, M. (2007). Neonatal sepsis & use of antibiotic in a

tertiary care hospital. Pakistan Journal 0/ Medical Sciences, 23( I), 78.

Satar. M .. & 6z1U, F. (2012). Neonatal sepsis: a continuing disease burden. The Turkishjournal

o/pediatrics, 54(5),449.

Schrag. S. 1 .• Cutland, C. L.. Zell, E. R., Kuwanda, L., Buchmann, E. J., Velaphi, S. C., ...

Team. P. T. (2012). Risk factors for neonatal sepsis and perinatal death among infants

enrolled in the prevention of perinatal sepsis trial. Soweto. South Africa. The Pediatric

/fI1i!cti()u.~ disease journal. 31(8). 821-826.

Shah, G .. Budhathoki, S .. Das, B., & Mandai, R. (2006). Risk factors in early neonatal sepsis.

Shah, J., Jefferies, A. L., Yoon. E. W., Lee, S. K., Shah, P. S., & Network, C. N. (2015). Risk

factors and outcomes of late-onset bacterial sepsis in preterm neonates born at< 32 weeks'

gestation. Americanjournal o/perinatology, 32(07),675-682.

Tiskumara, R .. Fakharee, S., Liu, C., Nuntnarumit, P., Lui, K. M., Hammoud. M., ... Halliday,

R. (2009). Neonatal infections in Asia. Archives 0/ Disease in Childhood-Fetal and

N<.>(matal Edition, 94(2). F144-FI48.

Utomo. \1. T. (2010). Risk factors of neonatal sepsis: a preliminary study in Dr. Soetomo

huspital. Indonesian Journal of Tropical and Infectious Disease, I (I), 23-26.

Vergnano. S .• Sharland, M., Kazembe. P .• Mwansambo, c., & Heath, P. (2005). Neonatal sepsis:

an international perspective. Archives 0/ Disease in Childhood-Fetal and Neonatal

Edition, 90(3), F220-FF224.

52



Woldu. '-1. A .. Guta. M. 8., Lenjisa, 1. L.. Tegegne, G. T.. Tesafye. G., & Dinsa. H. (2014).

Assessment of the incidence of neonatal sepsis, its risk factors, antimicrobials use and

clinical outcomes in Bishoftu General Hospital, neonatal intensive care unit, Debrezeit

Ethiopia. Pediatrics & Therapeutics, 2014.

Woldu. M. A., Guta. M. B., Lenjisa. 1. L., Tegegne, G. T., Tesafye, G., & Dinsa, H. (2017).

Assessment of the incidence of neonatal sepsis, its risk factors, antimicrobials use and

clinical outcomes in Bishoftu General Hospital, neonatal intensive care unit, Debrezeit

Ethiopia. International Journal of Contemporary Pediatrics, 1 (3), 135 -141 .

53



APPENDICES

APPENDIX I: PARTICIPANT INFORMATION AND CONSENT FORM

I STUDY TITLE Factors Associated with Neonatal Sepsis at the War Memorial Hospital

-I'VESTIGATOR Agongo Ibrahim Haruna

i I SLPERVISOR Dr. Francis Anto, Department of

I

Epidemiology, School of Public Health

INTRODUCTION

My name is Agongo Ibrahim Haruna and I am a graduate student from the School of Public

health. Lniversity of Ghana. Legon. I am undertaking a research study on the topic "Factors

associated with neonatal sepsis at the War Memorial Hospital". The purpose of the study is

to identif) the maternal factors. neonatal related factors and the medical and perinatal factors

associated with neonatal sepsis at the War Memorial Hospital.

This informed consent is to ensure that you understand the purpose and your responsibilities in

the research before you decide if you want to be part or not.

Belore agreeing to participate. it is important that you understand the following explanation of

the study.

Voluntary participation: Participation is voluntary and you are free to withdraw from the study

at any time without being penalized in any way.

54



What is involved: Your child medical records are being selected to take part in this study and

you will be asked some questions about the child and your knowledge about neonatal infections.

Possible risks: There are no foreseen direct risks involved in your child's participation in this

~tudy t::\.:ept for your time and the need to provide some personal information which may be a

lorm of inconvenience to you. How\:\ t,'r. this study is expected to provide data on factors

a~~ociated \\ ith infections in newborns aged between 0 to 28 days and will contribute to the

content of health education programs both for mothers and healthcare providers,

Possible benefits: By participating in this study, you can assess your level of knowledge about

the factors. danger signs and symptoms of neonatal sepsis as well as preventive measures of

neonatal sepsis.

Confidentialit)·: The information that will be extracted from the Childs medical records is

totall:- confidential and will not be disclosed to any unauthorized persons. It will only be used for

research purposes. No information will bc specifically connected to you, your child or family.

For further questions, you may contact me: Agongo Ibrahim Haruna, School of Public Health,

University of Ghana, Legon. Tel: +233204847255.

Yuur rights as a participant

If you have any question about your rights as a study participant, you can contact the

Administrator ofGHS Ethical Review Committee at the following addresses:

55



Hannah Frapping

GHS Ethical Committee

Research and Development Division

Ghana Health Service

P. O. Box MB 190

Accra.

Office: +23330268109

Mobile: r 233244516482. Email: [email protected].

I voluntarily consent for my child to participate in this study.

Signaturerrhumbprint of parent/caretaker ...................................................... .

Name .................................................................................. ..

Signature/Right thumbprint of witness of participant. ......................... .

"am of officer conducting interview ............................................... ..

Dale ...

56



APPENDIX II: STUDY QUESSIONNAIRE

CHECKLIST FOR RECORD REVIEW ON FACTORS ASSOCIATED WITH

,\FO,\ATAL SEPSIS AT THE WAR MEMORIAL HOSPITAL, NAVRONGO

SHTIO~ A:-IDENTIFICATION

1. Name of Health FaciIity: ________________ NAME_HF

2. Location of Health Facility: _____ _

3. Name of Interviewer: _________________ NAME]I

4. Name of Research Assistant: ______ _

:\. Oate Record Review:

6. Client Medical records Number:

-----r--r--.,....~ __ -LJ. _ J.--I

STUDY_ID

7. Address of client (from hospital records): __________ CLIENT_ID

SECTIO"i B: SOCIO-DF.l\IOGRAPHIC CHARACTERISTICS

8. Contact address (Village): ______ _ _ ______ VILLAGE_ID

9. Age of mother:

10. Educational level of mother I.Primary [ 2.Secondary l j3.Tertiary[ MAT _EDU

11. Maternal marital status: 1. Single [ : 2.Married [-]3.Divorced I MARRIED

12. Mothers occupation: ---____________ MAT_OCCUP

57



13. Mother's health insurance status: 1. Insured 02. Not insured 0 MAT_HI

I~. Does mother owe an [TN? 1. Yes 0 2. No~)

15. Docs mother sleep under it during last pregnancy? 1. Yes 1 2. No

16. Did mother sleep under ITN last night? I. YesD 2. No

SECTION C: MATERNAL OBSTETRIC INFORMATION

17. How many times has the mother been pregnant?

18. Number of deliveries including current one?

19. "umber of children alive including current one?

20. Number of multiple births

21. Number of abortions:

22. Mode of delivery

23. Number of preterm births

CD

CD

IT] CIJ

24. Was there any hospitalization during pregnancy of current child?

I. Yes 2. No

25. [fyes, what illness? ---------------------------26. Did mother experienced threatened abortion during pregnancy?

NO]RG

NO _ CHLDALIVE

NMBIRTHS

NSTILLBIRTHS

I. Yes 2. No -1 J ABORT[ON_HIST

58



27. History of any chronic illness (diabetes, hypertension): ________ HIST. COX

28. An) intestinal worm infestation during pregnancy of current child:

1. Yes 2. No

29. Maternal sickling status: 1. AA 0 2. AS 0 3. AC 0 4. SC I

HIST_WORM

SICKLING

30. Maternal Retro status: I. Positive 0 2. Negative D 3. Not Done 0 MATRETRO

31. If yes. "hat treatment was given? ______________ RX_GIVEN

32. Maternal Hepatitis B status: 1.Positive 0 2. Negative 03. Not doneD HEP B

33. Maternal VDRL status: I.Positive 2. Negative 0 3. Not done 0 VORL

34. Any other illness during the last pregnancy? ___________ OTHER_DX

35. Gestational age at delivery (in week)? IT]

36. Date of delivery? -. I --'_ ............. ---L--I

GA_DEL

(DDIMMIYY)DO_DELIVERY

37. Place of delivery? I. Home J 2. Clinic 3. Hospital. PLACE_DEL

PROLONG_ROM 38. Prolonged Rupture of Membranes'? I. Yes 0 2. No

39. Mode of delivery? 1. SVD 0 2. CIS :..J 3.Vacuum Iinstrument 0 DEL_MODE

40. Meconium stained amniotic fluid? I. Yes 0 2. No. [.=J

SECTIO:\· D: NEONATAL INFORMATION

59



41. Sex ofbab) '.' I. Male 2. Female 0

42. History offetal distress (asphyxia)? I. Present 0 2. Absent 0 ASPHYSIA

43. APGAR score at first minute D APGAR_IMlN

-1-1. APGAR score at fifth minute: D APGAR_5MlN

IT] 45. Weight of baby at delivery (kg): IT] WT_BABY

46. Height of baby at delivery (em) D HT_BABY

47. Color of baby at delivery: IT] COLOR_BABY

48. Head circumference (em): HEAD_CIRCU

49. Outcome of delivery? I. Alive :J 2. Dead 0 DEL_OUTCOME

SF.CTIO~ D: PERINATAL AND HEALTHCARE ACQUIRED INFECTIONS FACTORS

50. Ili~lllr) of Cord infections? I. Present 1_.1 2. Absent 0 CORD _INFECTION

51. History of male circumcision: I. Yes 0 2. No D

52. History of assisted ventilation? 1. Present D 2. Absent 0 RESUSClT A TION

53, Was the baby given intravenous medications: I. Yes' 2. No .

54. History of instrument delivery: I. Yes 2. No ; INST_DEL

60



55. Diagnosis on admission ____________ --11 DIAG_ADM

56. -'ource of admission: IClinic~ 2.Laborward 03.PNC 0 4. MatemityD

DM_SOURCE

61


university of ghana sschool of

Documents