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OPEN Congenital anomalies

among newborn babies
in Felege‑Hiwot Comprehensive
Specialized Referral Hospital, Bahir
Dar, Ethiopia
Daniel Mekonnen1, MollaTaye2* & Walelegn Worku3

Congenital anomaly is a structural or functional defect which could occur in any organ system. The
aim of this study was to determine the prevalence and associated factors of congenital anomalies
among newborn babies delivered at Felege-Hiwot Comprehensive Specialized Referral Hospital, Bahir
Dar, Ethiopia. A cross-sectional study design was used to review medical records/charts of 11,177
new born babies born at the delivery ward of Felege-Hiwot Comprehensive Specialized Referral
Hospital, Ethiopia. The data were collected using an abstraction form. A bivariate analysis was done
to assess factors associated with congenital anomalies. Variables whose p-value < 0.2 were included
in the multivariable analysis to identify the effects of confounders. P-values < 0.05 were considered
statistically significant. A total of 11,177 newborn babies and their mothers were included in the
study and the proportion of congenital anomalies was found to be 0.62%. The most (46.4%) prevalent
congenital anomaly was neural tube defects. Newborn birth weight < 1.25 kg [AOR, 32.6, 95% CI 11.9–
89.0], and newborn weight < 2.5 kg [AOR, 2.67, 95% CI 1.54–4.65], antenatal visits [AOR, 4.0, 95% CI
2.39–6.69] and urban residence [AOR, 2.1, 95% CI 1.28–3.55] were statistically significant factors. In
conclusion, neural tube defects were anomalies prevalent in this study. Antenatal visits, birth weight
and residence were factors associated with congenital anomalies.

Abbreviations
CA Congenital anomaly
CAs Congenital anomalies
CI Confidence interval
ANC Antenatal care
MPH Master of public health
WHO World Health Organization
MRI Magnetic resonance imaging
CT scan Medical examination by using computer to produce inside body image
OR Odds ratio

Congenital anomalies (CAs) also known as birth defects are any body organ system structural and functional
abnormality, which may be detected during pregnancy, delivery or later in ­life1,2. A congenital anomaly (CA)
causes neonatal and infant morbidity and mortality. The World Health Organization (WHO) estimated that in
2008 about 260,000 babies born with birth defect die during the first 28 days of l­ ife3.
­ efect4,5. It is also estimated that 3–7% of children
Globally, about one in every 33 babies are born with a birth d
are born with birth defects a­ nnually6. The prevalence of CAs varies from one country to another and even among
regions of the same ­country7–9. A study in the United States of America and the United Kingdom showed the
prevalence of CAs was 6% and 3.3%, r­ espectively10. In addition, the prevalence of CAs varies among communities

1
Department of Public Health, Haramaya University, Dire Dawa, Ethiopia. 2Department of Anatomy,
School of Medicine, College of Medicine and Health Sciences, The University of Gondar, Central Gondar,
Ethiopia. 3Department of Occupational and Environmental Health, Institute of Public Health, College of Medicine
and Health Sciences, The University of Gondar, Central Gondar, Ethiopia. *email: mollataye2@gmail.com

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which do the same jobs and have similar living styles and ­areas1,6,7. Moreover, the problems have a significant
socio-economical and psychological impact on individuals, families and c­ ommunities6.
The exact etiologies of many of the CAs are unknown although the causes of a few CAs are known to be
related to multifactorial origins and ­genetic7,11–14 and environmental ­factors12,15–17. Likewise, consanguineous
marriages and chromosomal defects like nervous system problems were reported as causes of C ­ As18,19. However,
such marriages are not common among Ethiopian women due to social and cultural norms.
In addition, a family history of birth defects has been associated with an increased risk of having another child
with congenital anomalies, with a recurrence rate ranging between 2 and 5% for neural tube defects and Down
syndrome, ­respectively20. Similarly, Fouzia et al., (2013) reported that neural tube defects were more prevalent
among families in low socioeconomic and educational s­ tatus21.
Births of children with anomaly are stressful situations for parents as well as the community. In Ethiopia,
many children die and becoming disabled by CAs. Furthermore, when mothers have babies with CAs, com-
munities attribute it to sin or God’s anger; as a result, parents are likely to feel anxious and guilty. However, the
problem is not given due attention by policy makers and researchers. The aim of this study was to assess the
proportion and associated factors of CAs among babies newborn at Felege-Hiwot Comprehensive Specialized
Referral hospital, Bahir Dar, Ethiopia.

Methods
Study area. The study was conducted in Bahir Dar, the capital of the Amhara Regional state, 560 km from
Addis Ababa, the capital of Ethiopia. The city is bounded by the Blue Nile River and Lake Tana. The city is divided
into seven sub cities and has seven health centers and two hospitals (one public and one private). According to
the 2011 ­census22, the city had a total population of 273,000, the majority of whom were Amhara. In 2002, the
city was awarded the UNESCO Cities for Peace Prize for addressing the challenges of rapid urbanization. Felege-
Hiwot Comprehensive Specialized Referral, a tertiary level hospital, provides various services including delivery.
The hospital provides a large number of deliveries using its patient diagnosing devices, such as ultrasound, x-ray,
electrocardiography machine, Medical examination by using computer to produce inside body image (CT scan)
by radiologists, pediatricians and other experienced medical doctors who can diagnose CAs.
Chat chewing seemed the most common practice in Bahir Dar. According to the 2011 Ethiopia Demographic
and Health Survey, the prevalence of alcohol consumption was (78%) among women in the region, which is
secondary to Tigray region (86%)22.

Study design. A retrospective cross-sectional study design was used to assess the quantitative proportion
of a CA and their associated factors.

Study and source population. The population and participants of the study were all newborn babies
who were delivered at Felege-Hiwot hospital from Sept. 2009 to Aug. 2014. The inclusion criteria was all new
born Ethiopian babies and the exclusion criteria was babies who are not Ethiopian and who are not delivered at
Felege-Hiwot Comprehensive Specialized Referral Hospital.

Sample size and method. All new born babies delivered in Felge-Hiwot Comprehensive Specialized
Referral hospital from Sept. 2009 to Aug. 2014 were included in the study. Medical records/charts were reviewed
to identify new born babies with CAs.

Data collection procedures and techniques. Data were collected from hospital records/charts using
data abstraction forms. The charts of the mothers of the newborns were reviewed carefully before the required
data were collected by the primary investigator and trained nurses/midwives. The principal investigator super-
vised the process daily and excluded incomplete data.

Data processing and analysis. The data were checked for completeness and records without main vari-
ables were considered as incomplete and rejected. The data were entered into Epi-info 3.5.1 software and trans-
ferred to SPSS version 20 for analysis. A bivariate analysis was carried out to assess the statistical significance
between the independent and outcome variables by using a 95% CI and the Odds Ratio (OR) to determine the
variables which could be included in the multivariable analysis. All variables with a p-value < 0.2 in the bivariate
analysis were included in the multivariable logistic regression analysis. All significant variables in the bivariate
variables were computed together to prevent confounders. P-values < 0.05 were taken as a statistically significant
factor for CAs.

Data quality control. The data were collected carefully by the principal investigator and nurses/midwives
who were trained for 2 days prior to data collection. A strict process supervision and daily data checkups were
carried out by the principal investigator. Incomplete data were filled again by data collectors; however, data
which were not recorded (missed) on charts/recording logbooks by health workers were rejected.

Ethical considerations. Ethical clearance and waiver were obtained from the Institutional Review Board
of Addis Continental Institute of Public Health and Haramaya University joint master of public health program
ethical clearance committee and was submitted to medical director/manager of Felege-Hiwot Comprehensive
Specialized Referral hospital. Finally, the hospital manager/medical director permitted the investigators to use
the data. Since the study was conducted by reviewing charts/medical records, waiver and informed consent was

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Characteristics Frequency (%)

Mother age(n = 11,177)
15–24 years 2209 (19.8%)
25–34 years 8041 (71.9%)
≥ 35 years 927 (8.3%)
Residence (n = 11,177)
Urban 2965 (26.5%)
Rural 8212 (73.5%)
Marital status (n = 893)
Never married 12 (1.3%)
Married 880 (98.7%)
Mother education (n = 628)
No formal education 371 (59.1%)
Formal education 257 (40.9%)
Mother occupation (n = 1587)
Farmer 749 (47.2%)
Office work 280 (17.6%)
House wife 558 (35.2%)

Table 1.  Socio-demographic characteristics of newborn baby’s mothers delivered at Felege-Hiwot

Comprehensive Specialized Referral hospital, from Sept. 2009 to Aug. 2014, Bahir Dar, Ethiopia.

obtained from the hospital manager/medical director to collect the required information from the study sub-
ject’s charts who didn’t present in the hospital during the data collection period. In addition, informed consent
was also obtained from baby’s mothers who were present in the hospital for medical service at the time of data
collection. Furthermore, the study was carried out according to national and international ethical guidelines.
After obtaining permission from the hospital manager/medical director, relevant data were gathered from
the hospital records/charts. Information taken from the study subjects’ charts were kept anonymous by omitting
their names and other identifications. All of the information was kept confidential, only the researchers and data
collectors had access to it.

Ethical approval and consent to participate. This study granted ethical approval from Addis Conti-
nental Institute of Public Health and Haramaya University joint MPH program ethical clearance committee. The
hospital manager and medical director gave permission.

Results
A total of 11,177 newborn babies delivered at Felege-Hiwot Comprehensive Specialized Referral hospital from
Sept. 2009 to Aug. 2014 and their mothers were included in the study. Out of these, 69 babies were identified
with congenital anomalies. The overall proportion of congenital anomalies were 0.62%. Of the total 69 babies
with CAs, 52% were male. The number of newborn babies and their mothers included in each variable varied
based on the completeness of the data documented in the charts/recording logbooks.

Socio‑demographic characteristics. The majority (71.9%) of the babies mothers were between 25 and
34 years old, with the mean age of 28.08 years and standard deviation of 4.59. Almost three fourths (73.5%) of
the mothers lived in rural areas and about 47.2% of them were farmers (Table 1).

Maternal characteristics. Out of the 11,177 mothers, 96 (0.9%) were known diabetic and 1207 (10.8%)
delivered by caesarean section (CS); 2647 (23.7%) had one and more antenatal (ANC) visits; out of 1342 of the
mothers, 1339 (99.8%) took multivitamins (Table 2).

Newborn baby characteristics. Of newborn babies the birth weight of 2322 (20.8%) newborn babies
was < 2.5 kg.; 596 (5.3%) of the babies were twins; and 6901 (61.7%) were female. Babies alive and died/still births
were 10,087 (90.2%) and 1089 (9.8%), respectively (Table 3).

The proportion of CAs among newborns. Out of the 11,177 participants, 69 had CAs. Thus, the observed
proportion of CAs was 0.62% of which neural defects (46.4%), followed by unspecified congenital anomalies
(20.3%), and cleft lip/palate (2.9%). Of the neural tube defects, anencephaly and spina bifida accounted for
(24.64%), (21.74%), respectively and hydrocephalus (primarily secondary to spina bifida, but some may have
hydrocephalus without spina bifida) was 19 (27.54%). CAs found registered as congenital malformations and
defects and anomalies were considered as unspecified congenital anomalies (Table 4).

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Characteristics Frequency (%)

Parity (n = 11,177)
One 2233 (20%)
Two 4344 (38.9%)
Three 3293 (29.5%)
Four and above 1307 (11.7%)
Antenatal care visits
None 8530 (76.3%)
≥ 1 visits 2647 (23.7%)
Maternal health status during pregnancy
None 11,081 (99.1%)
Known diabetic 96 (0.9%)
Mode of delivery
Vaginal 9970 (89.2%)
CS 1207 (10.8%)
Mothers who took multivitamin and foliate during pregnancy (n = 1342)
None 3 (0.2%)
Took multivitamin/folate 1339 (99.8%)

Table 2.  Reproductive characteristics of newborn baby’s mothers delivered at Felege-Hiwot Comprehensive

Specialized Referral hospital, from Sept. 2009 to Aug. 2014, Bahir Dar, Ethiopia.

Infant characteristics Frequency (%)

Child sex (n = 11,177)
Male 4276 (38.3%)
Female 6901 (61.7%)
Birth weight
< 2.5 kg 2322 (20.8%)
≥ 2.5 kg 8855 (79.2%)
Infant birth status
Alive 10,087 (90.2%)
Died/still birth 1090 (9.8%)
Pregnancy status
Singleton 10,581 (94.7%)
Twins 596 (5.3%)
Birth order
One 3045 (27.2%)
Two 4813 (43.1%)
Three 2502 (22.4%)
Four and above 817 (7.3%)

Table 3.  Characteristics of newborn babies born at Felege-Hiwot Comprehensive Specialized Referral

hospital, from Sept. 2009 to Aug. 2014, Bahir Dar, Ethiopia.

Types of congenital anomalies Frequency (%)

Neural tube defects (32 (46.4%))
Anencephaly 17 (24.64%)
Spina bifida 15 (21.74%)
Unspecified congenital anomalies 14 (20.3%)
Cleft lip/palate 2 (2.9%)
Club feet 2 (2.9%)
Total 69 (100%)

Table 4.  The magnitude of congenital anomalies among newborn babies delivered at Felege-Hiwot
Comprehensive Specialized Referral hospital, from Sept. 2009 to Aug. 2014, Bahir Dar, Ethiopia.

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Congenital anomaly Odds ratio

Variables Yes No Crude (95%CI) Adjusted (95% CI)
Mothers age (n = 11,177)
15–24 years 23 (1%) 2186 (99%) 1 1
25–34 years 38 (0.5%) 8003 (99.5%) 0.45 (0.26, 0.76)* 0.56 (0.32, 0.96)
≥ 35 years 8 (0.9%) 919 (99.1%) 0.83 (0.86, 1.86) 0.53 (0.22, 1.26)
Residency
Urban 30 (1.0%) 2935 (99.0%) 2.14 (1.32, 3.45)** 2.16 (1.33, 3.51)**
Rural 39 (0.5%) 8173 (99.5%) 1 1
Child sex
Male 36 (0.8%) 4240 (99.2%) 1 1
Female 33 (0.5%) 6868 (99.5%) 0.56 (0.35, 0.90)* 0.59 (0.37, 0.95)*
Birth weight
< 2.5 kg 38 (1.6%) 2284 (98.4%) 4.74 (2.94, 7.62)*** 4.56 (2.76, 7.55)***
≥ 2.5 kg 31 (0.4%) 8824 (99.6%) 1 1
Mode of delivery
Vaginal 57 (0.6%) 9913 (99.4%) 1 1
C-section 12 (1.0%) 1195 (99.0%) 1.74 (0.93, 3.26)* 2.20 (1.16, 4.19)*
Pregnancy status
Singleton 61 (0.6%) 10,520 (99.4%) 1 1
Twins 8 (1.3%) 588 (98.7%) 2.34 (1.12, 4.92)* 1.36 (0.64, 2.92)
Antenatal care visits
No visit 30 (0.4%) 8500 (99.6%) 0.24 (0.14, 0.38)*** 0.24 (0.14, 0.39)***
≥ 1visit 39 (1.5%) 2608 (98.5%) 1 1

Table 5.  Factors associated with congenital anomalies, Felege-Hiwot Comprehensive Specialized Referral
Hospital, Bahir Dar, Sept. 2009 to Aug. 2014. Statistical significance at: *p-value < 0.05; **p-value < 0.01;
***p-value < 0.001.

Factors associate with CAs. Maternal factors significantly associated with CAs included urban residence
adjusted odds ratio (AOR = 2.16; CI 1.33–3.51; p < 0.01) and lack of ANC visits (AOR = 0.24; CI 0.14–0.39;
p < 0.001), whereas, such baby factors included female sex (AOR = 0.59; CI 0.37–0.95; p < 0.05) and less than 2.5
kg birth weight (AOR = 4.56; CI 2.76–7.55; p < 0.001) (Table 5).

Discussion
This study revealed the proportion of CAs and associated factors among new babies delivered at Felege-Hiwot
Comprehensive Specialized Referral hospital, Bahir Dar, Ethiopia. The aim of the study was to assess the situation
and the causes of CAs among babies born at the hospital and to provide recommendations to concerned bodies
to take preventive measures. The proportion of CAs noted in this study was 0.62%, lower than the findings of
studies conducted in Addis Ababa, ­Ethiopia23, the University of Gondar comprehensive specialized hospital,
­Ethiopia24 and Addis Ababa and the Amhara region, E ­ thiopia1. Since both studies used record reviews, the dif-
ference in the proportion of CAs might be due to poor recording systems of the health facilities. In addition, the
low proportion of CAs seen in the present study might be due to health care providers’ failure to record babies
with CAs or perhaps due to negligence/carelessness or low ability of birth attendants to diagnose CAs. Moreo-
ver, the difference in frequency may be due to the fact that this study was conducted in one hospital just like
the study conducted at the University of Gondar, while the studies conducted in Addis Ababa and the Amhara
region, Ethiopia were done in many health facilities. The finding of current study was higher than that of Nigeria
(0.4%)25. The justification for the differences might be methodological because studies vary by being facility or
population based or retrospective or prospective. In addition, this difference might be due to environmental and
genetic factors, diagnosing capability of health care providers and geographical settings. Again, this difference
in the proportion of CAs could also be due to no use or use of folic acid/multivitamin during early pregnancy
by one of the groups of participants.
Furthermore, our finding was the lowest of the studies conducted in East A ­ frica26 and a facility based retro-
spective cross-sectional study in N­ igeria27, which reported 2.5 and 2.8% of prevalence, respectively. These vari-
ations were due to the fact that the studies were influenced by bias or incomplete data because the methodology
they used were retrospective cross-sectional. Moreover, these variations in the frequency were perhaps due to
poor health facility recording ability/experience.
As has been observed in this study, maternal residence, environmental factors, sex of baby, birth weight,
Caesarean-section (C-section) delivery, antenatal care visits, and maternal age had significant associations with
CAs. From these findings we can learn that CAs are major problems of the community and needs the attention
of the Ministry of Health, regional health bureau, zonal health departments and policy makers.

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In this study, hydrocephalus was the most frequently observed anomaly followed by anencephaly and spina
bifida. According to WHO report, neural tube defects (hydrocephalus, anencephaly and spina bifida) were the
most prevalent anomalies w ­ orldwide28. Besides, a study conducted in T
­ anzania20 reported that central nervous
system (CNS) defects commonly affect the organ system. In contrast, a study in U ­ ganda29 pointed out that CNS
defects did not commonly affect the organ system. This difference may be due to genetic and environmental
factors.
In this study, maternal residence had a significant association with CAs which vary from place to place or
with geographical locations; Urban resident mothers were 2.16 times more likely to have infants with CAs than
rural ­dwellers3. This may be due to environmental factors, such as air pollution, radiation, exposure to chemicals
and/or to pesticides.
In this study, more male babies (52%) were affected by CAs than female ones (48%). In contrast, a study
conducted in Tanzania indicated that females were more affected by CAs than ­males20. However, a study done
in Egypt reported that males were more likely to be affected than ­females30. This study findings were in line with
findings of the present study.
In our study, only 20.8% of the babies free from CAs had < 2.5 kg birth weight, while 0.4% of babies had CAs.
On the other hand, a study done in Egypt reported that about 71% of the infants had ­CAs30. In the present study,
infants with < 2.5 kg birth weight were 4.56 times more likely to have CAs. A facility-based study conducted in
Mekele, Ethiopia found that low birth weight was a significant contributing factor to C ­ As31. In contrast, a retro-
14
spective study done in Tanzania found that ≥ 2.5 kg birth ­weight was a significant contributing factor to CAs.
That might be due to methodological differences or perhaps because the secondary data used was incomplete or
due to maternal and fetal health conditions.
In the present study, 10.8% of the mothers had caesarean-section (C-Section). In another study conducted
in Egypt 23.1% of the mothers had C-section, Breech presentations were noted in three-fold of the babies with
­CAs30. In this study, C-sections were 2.20 times more likely to be performed on babies with CAs.
Antenatal care was another significant contributing factor to CAs to which a negative relation was observed
in this study, but many studies including WHO reports stated that it was vital for the prevention of some types
of ­CAs4,20,28. Similarly, a study carried out in Nigeria showed that all mothers who had babies with CAs had ANC
­visit27. Again, another study reported that 67.7% of mothers who had babies with CAs made no ANC v­ isits21. The
possible explanation for this negative association might be that all antenatal care records were not documented
by health care providers.
In this study, maternal advanced age was not associated with CAs. This finding was in line with that a study
conducted in Addis Ababa and the Amhara region, ­Ethiopia32. Basically, the present study showed that 9.8% of
babies were stillbirths/died due to adverse birth outcomes, which were not specified. The adverse birth outcomes
could be due to CAs. Therefore, birth attendants must specify the causes of death of every newborn in the charts/
logbooks. In addition, the Ministry of Health and regional health bureau should give training to birth attendants
on CAs and ways of recording data. Lastly, we suggest that the interpretations of this finding should consider the
number of adverse birth outcomes (deaths/stillbirths).
The limitation of the present study was that the data used were secondary which makes it difficult to generalize
the findings in relation to the general population. The other limitation was that the cause and effect relationship
could not be developed.

Conclusion
This study revealed that neural tube defects (hydrocephalus, anencephaly and spina bifida) were the commonest
anomalies in the study area and require due attentions. Low birth weight, baby sex, no ANC visits and urban resi-
dence were factors related with CAs. In addition, babies with CAs were more likely to be born through C-section.
This study noted that many newborn babies were died/stillbirth due to unspecified causes. This suggests that
the chance of death of newborn babies with CAs could be higher than that of babies born alive. Therefore, we
recommend that the Ministry of Health, concerned bodies, policy makers and the Government of the country
should give due attention to CA cases.

Data availability
The data set supporting this study are available in the manuscript.

Received: 5 December 2020; Accepted: 6 May 2021

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Acknowledgements
We would like to thank the manager and medical director of Felege-Hiwot Comprehensive Specialized Referral
Hospital for their permission and support. We wish to acknowledge to Gynecology and Obstetrics ward health
professionals and record room workers for their assistant and support. We would like to express our deep appre-
ciation and acknowledgement to Addis Continental Institute of Public Health and Haramaya University joint
MPH program for their financial support.

Author contributions
Conceived the idea: D.M., W.W. Designed the study methodology: D.M., W.W. Conducted the study: D.M., W.W.
Analyzed the data: D.M., W.W., M.T. Interpreted the results: D.M., W.W., M.T.. Wrote the draft manuscript: D.M.,
W.W., M.T. Revised and edited the final manuscript: M.T. Approved the manuscript: D.M., W.W., M.T.

Funding
This study received money from Addis Continental Institute of Public Health and Haramaya University joint
MPH program for data collection only. The authors declare that they have received no funds for the publica-
tion of this manuscript and that they have no external source of fund for both data collection and publication.

Competing interests
The authors declare no competing interests.

Additional information
Correspondence and requests for materials should be addressed to M.
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