Birth Asphyxia Research in Developing Countries: Research Gaps and Potential
Zulfiqar Bhutta of The Aga Khan University, Karachi, Pakistan, presented a review of community studies of perinatal and neonatal health. This review was published recently in Pediatrics (1). Dr. Bhutta focused his presentation on studies of perinatal asphyxia in developing countries.
Dr. Bhutta began by pointing out, as others had discussed in the symposium, that approximately 23% of neonatal deaths are due to birth asphyxia. He described the methods for obtaining those data which made it clear that there was a major need for detailed accurate data regarding the global picture of mortality and morbidity of birth asphyxia. He also pointed out the need for studies not only at the community level but also at mid-level (clinics and hospitals).
The difference between efficacy and effectiveness studies was discussed and Dr. Bhutta indicated that there are very few effectiveness studies of birth asphyxia in developing countries. There is an urgent need for such studies.
Very little data was available on handicaps resulting from birth asphyxia. Dr. Bhutta cited one study in Pakistan in which it was found that 2.8% of all children under five years of age had a significant handicap and one third of those children had a history of a delayed cry after birth or a convulsion in the first week of life. If these statistics are found in developing countries throughout the world it would represent a major global health and economic problem. Although data is limited it is likely that the number of children who developed handicaps as a result of birth asphyxia is probably greater than the number of children who die from birth asphyxia. Therefore, handicapping as a result of birth asphyxia should be treated as a major global problem.
In addition to the problems of death and handicapping from birth asphyxia there are also a large number of still births. These incidences likely equal or exceed the number of children dying from birth asphyxia.
Dr. Bhutta estimated the total annual burden from birth asphyxia (i.e. death, handicaps, stillbirths) may exceed three million. He emphasized the need to obtain accurate data as a basis for successful health systems research.
Review of the literature indicated a major need for accurate statistics to determine the actual incidence of birth asphyxia world wide. This requires not only a system for collecting data but also a universally acceptable definition of birth asphyxia and the related issue of stillborn incidence and etiology.
There is need to determine the role of maternal infections and nutrition in the etiology of stillbirths and neonatal asphyxia. Dr. Bhutta indicated that studies of micronutrients (Zinc and Vitamin A) (2,3) suggest that supplementing maternal diets with these nutrients may benefit the outcome of low birth weight infants. Clearly very little is known about the effect of maternal malnutrition on asphyxial outcomes.
Dr. Bhutta reviewed the publication of Martines et al (4) which stated that a major improvement in neonatal mortality could be achieved by improvements at a community level (e.g. training health care workers).
Dr. Bhutta identified research priorities, included the need for critical evaluation of asphyxia intervention and prevention strategies and studies to improve community and health system facilities. He felt that specific issues requiring research and critical evaluation include:
1. Measures used to manage the asphyxiated infant:
- Effectiveness and need for airway suction
- Optimum temperature
- Evaluation of bag and mask resuscitation
- When should it be initiated?
- Air vs. Oxygen
3. Disability rates: Any program evaluating the effectiveness of therapy should include the effect on disability rates. Are we going to shift the mortality-handicapping disorder?
4. After care: It is clear that damage due to birth asphyxia takes place for hours after the incident. Therefore the post-incidence management of asphyxiated infants becomes most important. All aspects of after care available in developing countries must be studied and evaluated.
In summary, Dr. Bhutta said that his review of the literature suggested several “grand challenges”:
- Develop an effective tool for recognizing intra-uterine hypoxia
- Develop a rapid diagnostic tool for diagnosing birth asphyxia in a primary care setting
- Develop an effective tool kit for resuscitation in the community
- Give attention to after care of asphyxiated infants
- Determine and implement cost-effective and simple monitoring and after care
- Determine indicators for health systems that capture the range of asphyxia
1. Bhutta ZA, Darmstadt GL, Hasan BS, Haws RA. Community-based interventions for improving perinatal and neonatal health outcomes in developing countries: a review of the evidence.Pediatrics. 2005 Feb;115(2 Suppl):519-617. Review.
2. Rahmathullah L, Tielsch JM, Thulasiraj RD, Katz J, Coles C, Devi S, John R, Prakash K, Sadanand AV, Edwin N, Kamaraj C. Impact of supplementing newborn infants with vitamin A on early infant mortality: community based randomised trial in southern India.BMJ. 2003 Aug 2;327(7409):254.
3. Sazawal S, Malik P, Jalla S, Krebs N, Bhan MK, Black RE.
Zinc supplementation for four months does not affect plasma copper concentration in infants.Acta Paediatr. 2004 May;93(5):599-602.
4. Martines J, Paul VK, Bhutta ZA, Koblinsky M, Soucat A, Walker N, Bahl R, Fogstad H, Costello A; Lancet Neonatal Survival Steering Team. Neonatal survival: a call for action.Lancet. 2005 Mar 26-Apr 1;365(9465):1189-97.