Pregnancy and the risk of NICU admissions in Nandom Municipality of Ghana: A cross‐sectional retrospective study

Abstract Background Neonatal intensive care units (NICU) are specialized units that provide medical attention to neonates, and thus have become a vital aspect in the provision of critical care to infants who are faced with special challenges following birth. Aim To determine antepartum and intrapartum factors that predispose to NICU admissions in the Nandom Municipal of the Upper West Region of Ghana. Method This was a cross‐sectional retrospective study, spanning from January 1, 2021 to December 31, 2021. Records covering 1777 women who were delivered or had their babies referred to the St. Theresa's Hospital in the Nandom Municipality were involved in the study. Descriptive statistics and multinomial logistic regression analysis were used to compare variables, and statistical significance was determined where the p‐value was less than 0.05. Results From the study, the rate of NICU admission was 10.4%. There was a significant association between mothers who attended less than four antenatal sessions (p = 0.004) and admission to NICU. Nulliparous mothers (p = 0.027) and mothers who presented with multiple pregnancy (p < 0.001) were more likely to have their babies sent to NICU. Both preterm delivery (p < 0.001) and post‐term delivery (p < 0.001) were prone to admission to NICU. Also, instrumental delivery (p < 0.001), cesarean section (p < 0.001), low birth weight (p < 0.001), and male infants (p = 0.003) had an increased risk of being admitted to NICU. Furthermore, severe (p < 0.001) and moderate (p < 0.001) birth asphyxia in the first minute following delivery were significantly associated with NICU admission whereas severely asphyxiated babies at 5 min (p < 0.001) were associated with NICU admission. Conclusion The study revealed a relatively high NICU admission rate in the study area, and the predictors are multifaceted. Tailored intervention programs aimed at curbing these predictors will be required to reduce the rate of NICU admissions in the Nandom Municipality of Ghana.


| INTRODUCTION
Globally, particular attention had been given to reducing childhood mortality in a bid to achieve the Millennium Development Goal (MDG) 4; reducing under-five mortality by two-thirds between 1990 and 2015, and now encapsulated in the Sustainable Development Goal (SDG) number 3 which seeks to ensure healthy lives and promote well-being for all at all ages. 1,2 According to the United Nations, between 1990 and 2015, the global under-five mortality rate declined by more than half, dropping from 90 to 43 deaths per 1000 live births. 3,4 The current infant mortality rate for Ghana in 2022 is 31.768 deaths per 1000 live births, which represents a 2.95% decline from the 2021 estimate of 32.735 deaths per 1000 live births. 5 Studies indicate that deaths within the neonatal period are responsible for the majority of mortalities in children under the age 5 years with a reported rate of 35% in the USA and up to 99% in certain low-income countries. 3,4,6 A child born in sub-Saharan Africa was 10 times more likely to die in the first month than a child born in a high-income country, while a child born in South Asia was nine times more likely to die. 4 Across countries, the risk of dying in the first month of life was about 56 times higher in the highest-mortality country than in the lowest-mortality country. 4 The majority of these neonatal deaths are mostly due to conditions that could be prevented or treated when there is access to simple and affordable interventions. 7 Such interventions have been identified to include vaccination of women of childbearing age against tetanus, healthy and professional delivery care provision, new-born resuscitation skills, ensuring proper exclusive breastfeeding, ensuring clean and infection-free umbilical cord, and effective uptake of requisite new-born vaccines. 8 Others include pre-pregnancy interventions, family planning, prevention and management of sexually transmitted infections including HIV, folic acid fortification, pregnancy interventions, and childbirth interventions. 9 Several factors such as the patient's socio-demographic factors and maternal and neonatal-related factors are known to contribute directly or indirectly to neonatal morbidity and subsequent NICU admissions. 8,9 Many of these factors when predictable in a given healthcare setting, do contribute to the improvement of neonatal healthcare. 10 Maternal factors such as parity, mode of delivery, prevailing medical conditions, and pregnancy-related complications such as antepartum hemorrhage are associated with neonatal admission to the NICU. 11 Similarly, neonatal factors shown to be associated with admission to the NICU include prematurity, low birth weight, intrauterine growth retardation (IUGR), birth asphyxia, meconium aspiration syndrome, and congenital anomalies. 10 Facilities to set up a well-functioning NICU are scarce especially in developing countries. Where they are available, factors associated with neonatal admission to the NICU appear to be variable and could be dependent on the healthcare environment. Knowledge of these associated factors will provide useful information regarding resourcing, preparedness and smooth operation of the NICUs. This study, therefore, explored the "feto-maternal" predictors of NICU  The questionnaire was coded on a Google Form for uniformity and pretesting. After the necessary corrections to the tool, relevant sociodemographic, maternal, and neonatal data for the study were extracted onto a Google Form. In all, a total of 1777 births were reviewed over the study period, and thus served as the sample size.

| Data analysis
The data collected via the Google Form was extracted into Microsoft Excel for data cleaning, and subsequently exported into the IBM Statistical Package for Social Sciences (SPSS) software version 26 for analysis. The variables were categorized and descriptive statistics applied. Where applicable, multinomial logistic analysis was done for differences between the categorical variables and outcome variables, and a p-value below 0.05 was considered statistically significant.   (Table 1).

| Ethical consideration
Although 92.8% (1225/1644) of mothers achieved the recommended 4 or more ANC attendance before delivery, ANC attendance significantly influenced the proportion of babies admitted to the NICU. A higher proportion of babies whose mothers did not attain the minimum ANC attendance (<4 times) was admitted to the NICU (19.3%; p = 0.004) compared to those whose mothers achieved the recommended ANC attendance. The odds of NICU admissions among babies whose mothers failed to adhere to the minimum standards of four times ANC attendance before delivery was twice compared to those who achieved the recommended 4 or more ANC attendance ( Table 2).
By mode of delivery, 74.3% (1312) of the babies were delivered through spontaneous vaginal delivery (SVD), 2.6% (46) by instruments-assisted delivery, whereas caesarian delivery was 23.1% (408). A significantly higher proportion of babies delivered through instruments assisted delivery (43.8% (14/46)) and through caesarian section (20.0% (68/408)) were admitted to the NICU, with odds of 6 and 2 respectively ( where teenage pregnancy was found to be one of the major associated factors to NICU admission. 15 Similarly, although some studies have observed an increased risk of NICU admission of infants born to mothers of advanced age, [16][17][18] this study did not find significant association between advanced maternal age and admission to NICU, a finding similar to the observation made by Wang et al. 19 ANC attendance was found to be associated with NICU admission in our study. Though our review showed that nine out of every 10 women achieved the recommended minimum of 4 ANC attendance per pregnancy, mothers whose ANC attendance was less than four sessions were twice likely to have their babies admitted to the NICU. This is similar to an observation made by Manjavidze et al. 20 23 However, our study did not seek to explain how nulliparity increases the risk of NICU admission. Conversely, there was no significant association between the gravidity of mothers and admission to NICU, contradicting other studies that found gravidity as a risk factor for NICU admission. 24,25 Multiple pregnancy was identified as a significant contributor to the admission of neonates to the NICU. Some studies support the assertion that multiple pregnancy is a risk factor for NICU admission. 26 A study done in Beijing by Su et al. 27 also supports this finding that multiple pregnancy increases the risk of NICU admission. Similarly, the increased risk of NICU admission among mothers with multiple pregnancy is supported by a study on multiple gestations conducted by Refuerzo et al. 28 in the United States of America.
Prematurity was found to have a strong association with admission to NICU from our study. Babies who were born before 37 weeks of gestation were about four times more likely to be admitted to NICU as compared to those who were born at term.
Desalew et al. 7 found preterm delivery as an independent risk factor for admission to NICU. This is demonstrated in the results of this study and similar findings shown by Tette et al. 11 From the results of this study, babies also born after 42 weeks of gestation showed an increased risk of admission to NICU. These babies were about five times more likely to be admitted to NICU as compared to those born at term, as reported by Linder et al. 29 As per the findings of our study, there was an increased risk of NICU admission following cesarean section and instrumental deliv- instrumental delivery influence NICU admission. A study by Sowemimo et al. 13 showed that out of 66 deliveries conducted instrumentally, 45.5% resulted in admission to NICU, also, the risk of adverse neonatal outcome was increased in mothers who had cesarean section. 30 Undoubtedly, there could exist some confounding factors beyond the scope of the current study.
Neonatal factors such as birth weight, sex, asphyxia, and congenital defects were found to be associated with admission to the NICU. Barker et al. 31 in their study showed the link between low birth weight and an increased risk of comorbidities later in life. The incidence of low birth weight could be due to inadequate nutrition by the mother during pregnancy, iron or folate deficiency and low socioeconomic status. 32  According to the results of our study, severe and moderate birth asphyxia were found to be associated with an increased risk for admission to the NICU. After a minute following delivery, babies who recorded Apgar score below 3 were 15 times more likely to be admitted to NICU. Those who were moderately asphyxiated at 1 min were four times as likely to be admitted to NICU as compared to those with mild asphyxia. Birth asphyxia has been shown to increase the likelihood of neonatal morbidity and mortality. 37 A study conducted by Gauchan et al. 38 also found perinatal asphyxia to be a cause for admission to NICU.

| CONCLUSION
In conclusion, the prevalence of NICU admission was 10.4%.
Mothers who attended less than four antenatal sessions had an increased risk of having their babies admitted to NICU. The study found that nulliparity and multiple pregnancy were risk factors for the admission of babies to NICU. Also, preterm babies and those born post-term had an increased risk of admission to NICU, likewise babies delivered by cesarean section and instrumental delivery. Low birth weight babies, male babies, Apgar score, and birth asphyxia were associated with admission of babies to the NICU. These factors could provide the bases for healthcare providers to put in place preventive strategies aimed at reducing neonatal admissions in the study area. Writingoriginal draft.

ACKNOWLEDGMENTS
This study did not receive any sponsorship. Our gratitude to management and staff of St. Theresa's Hospital, Nandom, Ghana, for their support during the study.

CONFLICT OF INTEREST
The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT
The data set for this study is available with the corresponding author, and will be made available upon reasonable request. The corresponding author has full access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.

FUNDING
This study did not receive any external funding.

TRANSPARENCY STATEMENT
The lead author Williams Walana affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.