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Background
To this date, there are 4 systematic reviews and meta-analyses studies about the burden and associated factors of birth asphyxia in Ethiopia. However, findings of these studies are inconsistent which is difficult to make use of the findings for preventing birth asphyxia in the country. Therefore, umbrella review of these studies is requi...
Contexts in source publication
Context 1
... quality of the included SRM studies Table 3 shows methodological quality of the included SRM studies, evaluated using the AMSTAR tool for assessment of the methodological quality of SRM studies [36]. The quality scoring was done out of 11 points and ranged from 8 to 10, with a mean score of 9.1 points, indicating an overall moderate quality. ...Context 2
... AMSTAR criteria most frequently satisfied across the review studies were those about the priori design, duplicate study selection and data extraction, appropriateness of methods used to combine studies' findings and disclosure of conflict of interest. The AMSTAR criteria less frequently satisfied were the ones about search comprehensiveness, included and excluded studies provided and scientific quality of the included studies used appropriately in formulating conclusions (table 3). AMSTAR Assessment of Multiple Systematic Reviews Q1: A priori design; Q2: Duplicate study selection and data extraction; Q3: Search comprehensiveness; Q4: Inclusion of grey literature; Q5: Included and excluded studies provided; Q6: Characteristics of the included studies provided; Q7: Scientific quality of the primary studies assessed and documented; Q8: Scientific quality of included studies used appropriately in formulating conclusions; Q9: Appropriateness of methods used to combine studies' findings; Q10: Likelihood of publication bias was assessed; Q11: Conflict of interest -potential sources of support were clearly acknowledged in both the systematic review and the included studies ...Citations
... 2 In addition to the high mortality rate, birth asphyxia is responsible for considerable neonatal morbidities due to severe hypoxic-ischemic multi-organ damage. 3 The immediate effects of birth asphyxia include neonatal hypoxia, hypercarbia, acidosis, hypotension, and ischemia. Long-term morbidities include cerebral palsy, motor disorders, developmental delays, speech delays, hearing impairments, blindness, feeding impairment, learning disabilities, mental retardation, and behavioral and emotional disorders. ...
... Long-term morbidities include cerebral palsy, motor disorders, developmental delays, speech delays, hearing impairments, blindness, feeding impairment, learning disabilities, mental retardation, and behavioral and emotional disorders. 3 In 1952, Dr. Virginia Apgar invented a scoring system for assessing the clinical status of newborn infants. This system provides a standardized assessment for infants after delivery to identify those who require resuscitation. ...
Objective
To evaluate the prevalence and factors associated with low fifth-minute Apgar scores in central Sudan.
Methods
A cross-sectional study (enrolled 438 newborns) was conducted at Wad Medani Hospital, Sudan. A questionnaire was used to collect sociodemographic, obstetric, clinical, and neonatal data. Apgar scores were calculated. A multivariate analysis was performed.
Results
Thirty-five (8.0%) newborns had low fifth-minute Apgar scores. The multivariate analysis showed that low birth weight was the only factor associated with a low fifth-minute Apgar score (AOR = 17.61; 95% CI: 5.98-51.88). Maternal age, parity, education level, history of miscarriage, residence, maternal body mass index, mode of delivery, maternal anemia, time of the membrane’s rupture, color of liquor, and newborn sex were not associated with a low fifth-minute Apgar score.
Conclusion
The present study showed that 8.0% of newborns delivered at anonymized peer review had a low fifth-minute Apgar score, which was associated with low birth weight.
... In addition, this meta-analysis revealed that Antepartum hemorrhage (APH) and maternal anemia increase the risk of birth asphyxia mortality. This result is consistent with findings from studies conducted in Iran, Tanzania, and Ethiopia, which also revealed that APH increases birth asphyxia mortality [36][37][38][39]. Similarly, the results from systematic reviews and meta-analyses in South Asian countries, low-and middle-income countries, and Europe, which showed that maternal anemia increases mortality due to birth asphyxia, align with the current meta-analysis [40][41][42]. ...
Background
Birth asphyxia is the second leading cause of neonatal mortality worldwide, including in Ethiopia, and remains a significant public health concern. Despite the availability of national data on neonatal mortality in Ethiopia, there remains a gap in understanding the specific incidence and predictors of mortality among asphyxiated neonates. To address this information gap, this meta-analysis was conducted to assess the incidence and predictors of mortality among asphyxiated neonates in Ethiopia.
Methods
This systematic review and meta-analysis was conducted in accordance with the PRISMA guidelines. Relevant studies were identified through various databases, including PubMed, CINAHL, Scopus, EMBASE, and Google Scholar. Data analysis of pooled estimates for mortality incidence and its predictors was performed via STATA 17 software with the DerSimonian and Laird model. Heterogeneity was assessed via Cochrane’s Q-test and the I² statistic. Additionally, publication bias was evaluated through funnel plots, Egger’s test, and Doi plots.
Results
Out of 68 identified studies, only 10 met the eligibility criteria, including a total of 4,866 participants. The pooled incidence rate of birth asphyxia mortality was 4 per 100 person-days (95% CI: 3–5), which was 35,754 person-days of observation. Furthermore, predictors of birth asphyxia mortality included: pregnancy complications (HR 1.52, 95% CI: 1.41–1.64), labor complications (HR 1.29, 95% CI: 1.15–1.44), severe hypoxic-ischemic encephalopathy (HR 1.67, 95% CI: 1.51–1.85), neonatal seizures (HR 1.23, 95% CI: 1.11–1.38), and comorbidities in neonates (HR 1.31, 95% CI: 1.24–1.39).
Conclusion
In the current study, the pooled incidence of birth asphyxia mortality was high, falling short of the Sustainable Development Goals target and highlighting the need for immediate intervention. Additionally, pregnancy and labor complications, severe hypoxic-ischemic encephalopathy, neonatal seizures, and neonatal comorbidities were identified as predictors of birth asphyxia mortality. These findings underscore the urgent need to enhance early detection and intervention for pregnancy- and labor-related complications, as well as severe neonatal complications related to asphyxia, in to reduce mortality.
... Neonatal asphyxia is a major contributing factor in most neonatal deaths. Consistent with this, Ethiopia has a high incidence of birth asphyxia (22.52%), which is the second most common cause of neonatal death [14]. While most asphyxiated babies recover, prolonged exposure to prenatal hypoxia-ischemia can cause multi-organ damage [4]. ...
Background
Neonatal asphyxia is a leading cause of early neonatal mortality, accounting for approximately 900,000 deaths each year. Assessing survival rates, recovery time and predictors of mortality among asphyxiated neonates can help policymakers design, implement, and evaluate programs to achieve the sustainable development goal of reducing neonatal mortality to 12/1,000 live births by 2030. The current study sought to ascertain the survival status, recovery time, and predictors of neonatal asphyxia.
Methods
A retrospective follow-up study conducted in Debre Berhan Comprehensive Specialized Hospital, which carried out from May 20th to June 20th, 2023 using records of asphyxiated babies in NICUs from January 1st, 2020 to December 31st, 2022, involving a sample size of 330. Pre-structured questionnaires created in Google Form were used to collect data, and STATA Version 14.0 was utilized for data entry and analysis, respectively. The Kaplan–Meier survival curve, log rank test, and median time were calculated. A multivariable Cox proportional hazards regression model was fitted in order to determine the predictors of time to recovery. Variables were statistically significant if their p-value was less than 0.05.
Results
Three hundred thirty admitted asphyxiated neonates were followed a total of 2706 neonate -days with a minimum of 1 day to 18 days. The overall incidence density rate of survival was 9.9 per 100 neonates’ days of observation (95% CI: 8.85–11.24) with a median recovery time of 9 days (95% CI: 0.82–0.93). Prolonged labor (Adjusted hazard ratio (AHR: 0.42,95%CI:0.21–0.81), normal birth weight (AHR:2.21,95% CI: 1.30–3.70),non-altered consciousness (AHR:2.52,CI:1.50–4.24),non-depressed moro reflex of the newborn (AHR:2.40,95%CI: 1.03–5.61), stage I HIE (AHR: 5.11,95% CI: 1.98–13.19),and direct oxygen administration via the nose (AHR: 4.18,95% CI: 2.21–7.89) were found to be independent predictors of time to recovery of asphyxiated neonates..
Conclusion
In the current findings, the recovery time was prolonged compared to other findings. This implies early diagnosis, strict monitoring and provision of appropriate measures timely is necessary before the babies complicated into the highest stage of hypoxic –ischemic encephalopathy(HIE) and managing complications are the recommended to hasten recovery time and increase the survival of neonates.
... 21 The pooled umbrella review estimated a prevalence rate of 22.52%. 24 In Nigeria, Kenya, and Ethiopia, distinct prevalence rates of birth asphyxia were reported, emphasizing the regional disparities in healthcare outcomes. 25,26 The prevalence in specific Ethiopian regions such as Dire Dawa, Jimma, and Gondar varied significantly. ...
Background: Birth asphyxia stands out as a significant factor contributing to morbidity and mortality among newborns. However, the determinants of birth asphyxia have not been thoroughly investigated within the local context, particularly in this specific area. Hence, this study aims to identify these determinants to tackle the issue effectively.
Objectives: The goal of this study is to pinpoint the determinants of birth asphyxia at Bekoji Public Hospital in Bekoji Town, Arsi Zone, Oromia Region, Southeast Ethiopia, in 2023.
Methods: A case-control study was conducted between June 1, 2023, and August 30, 2023. A total of 198 newborns (75 cases and 123 controls) at Bekoji Public Hospital were selected using a systematic random sampling technique. Data collection involved a checklist for record review and an interviewer-administered questionnaire. The data were entered into Epi Data version 7.1 and analyzed using SPSS version 25. Variables with a P-value < 0.25 were subjected to multivariable regression analysis. The Odds Ratio estimated with a 95% Confidence Interval was utilized to indicate the strength of association, with a significance level set at P < 0.05.
Results: 196 mothers of newborns (73 cases and 123 controls) were interviewed, resulting in a response rate of 98.9%. Factors such as prolonged duration of labor (AOR=2.54; [95% CI: 1.78, 6.39]), delivery by Caesarean section (AOR=0.64; [95% CI: 0.004, 1.114]), presence of stained amniotic fluid (AOR=0.473; [95% CI: 0.180, 1.242]), and non-cephalic fetal presentation (AOR=2.12; [95% CI: 1.019, 3.80]) were identified as predictors of birth asphyxia. Additionally, being male (AOR=1.885; [95% CI: 0.899, 3.950]) was also found to be a predictive factor for birth asphyxia.
Conclusion and recommendations: Duration of labor, fetal presentation, type of amniotic fluid, mode of delivery, and the gender of newborns emerged as significantly associated factors with birth asphyxia. As a result, interventions targeting these factors, particularly focusing on duration of labor and fetal presentation, should be rigorously implemented.
... According to a comprehensive review, the incidence of asphyxia was 18% in East Africa and 22.52% in Ethiopia [10]. Additionally, according to 2019 Ethiopian Mini Demographic Health Survey (EDHS) report the neonatal mortality rate has slightly increased from 29 deaths per 1,000 live births in the 2016 EDHS report to 30 in 2019 [11], with birth asphyxia accounting for 13.5% of neonatal mortality cases [12], In developing countries, it continues to be a serious global clinical problem and about 29% of early neonatal deaths and 23.3% of all neonatal deaths were caused by it [13][14][15]. ...
Background
Neonatal asphyxia is one of preventable causes of neonatal mortality throughout the world. It could be improved by early detection and control of the underlying causes. However, there was lack of evidence on it in the study setting. Thus, the aim of this study was to assess the magnitude and predictors of neonatal asphyxia among newborns at public hospitals of Wolaita Zone in Southern Ethiopia.
Method
A facility-based cross-sectional study was done among 330 mothers with neonates in selected public hospitals. A systematic random sampling technique was used to select the study participants. Data were collected through an interviewer-administered questionnaire and checklist. The collected data were entered into EpiData version 4.6 and exported to SPSS version 26 for analysis. Logistic regression was fitted to examine the association between explanatory variables and outcome variable. In multivariable logistic regression, AOR with 95% CI was reported, and p < 0.05 was used to declare statistically significant variables.
Results
The magnitude of neonatal asphyxia was 26.4% with 95% CI: (21.8, 30.9). In multivariable logistic regression analysis primiparity (AOR = 2.63 95%CI 1.47, 4.72), low-birth-weight (AOR = 3.45 95%CI 1.33, 8.91), preterm birth (AOR = 3.58 95%CI 1.29, 9.92), and premature rupture of membranes (AOR = 5.19 95%CI 2.03, 13.26) were factors significantly associated with neonatal asphyxia.
Conclusions
In this study, the magnitude of neonatal asphyxia was high. From the factors, premature rapture of the membrane, parity, birth weight of the newborn, and gestational age at birth were significantly associated with neonatal asphyxia. Attention should be given to early detection and prevention of neonatal asphyxia from complicated labor and delivery.
... is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint deaths are significantly caused by perinatal asphyxia (PNA). Similar to this, Ethiopia continues to have a high burden of birth asphyxia (22.52%), which has been identified as the second leading cause of neonatal mortality [12].The study done in a hospital of Southeast Nigeria found that 61.3% of newborns survived and were sent home [13]. Another retrospective study done in Nigeria showed that 25.5% of newborns died and 63.9% of newborns were discharged [14]. ...
Background
Even though there have been inquiries into the survival rates of asphyxiated neonates in Africa, there is scarce data concerning the recovery duration for asphyxiated newborns in developing nations and the factors affecting this process. Consequently, the objective of this study is to ascertain the time it takes for asphyxiated neonates to recover and identify its predictors.
Methods
Conducting a retrospective follow-up investigation, the study took place at Debre Berhan Comprehensive Specialized Hospital from January 1 st , 2020 to December 31 st 2022, involving a sample size of 330. The analysis included the computation of the Kaplan-Meier survival curve, the log-rank test, and the median time. Additionally, a multivariable Cox proportional hazard regression model was employed to determine the survival status.
Results
in this study, among the 330 participants (100%), a total of 270(81.8%) successfully survived throughout the entire cohort. Predictors are independent of each other, affecting the time to recovery and survival of asphyxiated neonates, encompassed prolonged labor (AHR: 0.42, 95%CI:0.21-0.81), normal birth weight (AHR:2.21, 95% CI: 1.30-3.70),non-altered consciousness (AHR:2.52, CI:1.50-4.24), non-depressed moro reflex of the newborn (AHR:2.40, 95%CI: 1.03-5.61), stage I HIE (AHR: 5.11, 95% CI: 1.98-13.19), and direct oxygen administration via the nose (AHR: 4.18, 95% CI: 2.21-7.89).
Conclusion
The duration for recovery seems to be slightly prolonged in comparison to other research findings. This underscores the significance of vigilant monitoring, early preventive interventions, and swift actions to avert the progression of infants to the most severe stage of HIE.
... Neonates delivered by caesarean section (C/S) had more than 7 times the odds of developing HIE than those delivered vaginally. This is consistent with several studies conducted in Cameroon, Istanbul, and Northern Ethiopia [15,32,38] . This finding may reflect the fact that C/S is often performed as an emergency intervention when there is foetal distress or other complications that may compromise the oxygen supply to the foetus. ...
Background
Hypoxic-ischaemic encephalopathy (HIE) is a severe condition that results from reduced oxygen supply and blood flow to the brain, leading to brain injury and potential long-term neurodevelopmental impairments. This study aimed to identify the maternal and neonatal factors associated with hypoxic-ischaemic encephalopathy among Neonates.
Methods
The authors conducted a case-control study in 15 public hospitals with 515 neonates and mothers (175 cases and 340 controls). The authors used a questionnaire and clinical records created and managed by Kobo software to collect data. The authors diagnosed hypoxic-ischaemic encephalopathy (HIE) by clinical signs and symptoms. The authors used logistic regression to identify HIE factors.
Results
Hypoxic-ischaemic encephalopathy (HIE) was associated with maternal education, ultrasound checkup, gestational age, delivery mode, and labour duration. Illiterate mothers [adjusted odds ratio (AOR)= 1.913, 95% CI: 1.177, 3.109], no ultrasound checkup (AOR= 1.859, 95% CI: 1.073, 3.221), preterm (AOR= 4.467, 95% CI: 1.993, 10.012) or post-term birth (AOR= 2.903, 95% CI: 1.325, 2.903), caesarean section (AOR= 7.569, 95% CI: 4.169, 13.741), and prolonged labour (AOR= 3.591, 95% CI: 2.067, 6.238) increased the incidence of HIE.
Conclusion
This study reveals the factors for hypoxic-ischaemic encephalopathy among neonates in Ethiopia. The authors found that neonates born to illiterate women, those who experienced prolonged labour, those whose mothers did not have ultrasound checkups during pregnancy, those delivered by caesarean section, and those born preterm, or post-term were more likely to develop hypoxic-ischaemic encephalopathy. These findings indicate that enhancing maternal education and healthcare services during pregnancy and delivery may positively reduce hypoxic-ischaemic encephalopathy among neonates.
... The majority of neonatal deaths are significantly caused by perinatal asphyxia (PNA). Similar to this, Ethiopia continues to have a high burden of birth asphyxia (22.52%), which has been identified as the second leading cause of neonatal mortality [12].The study done in a hospital of Southeast Nigeria found that 61.3% of newborns survived and were sent home [13]. Another retrospective study done in Nigeria showed that 25.5% of newborns died and 63.9% of newborns were discharged [14]. ...
Background
Even though there have been inquiries into the survival rates of asphyxiated neonates in Africa, there is scarce data concerning the recovery duration for asphyxiated newborns in developing nations and the factors affecting this process. Consequently, the objective of this study is to ascertain the time it takes for asphyxiated neonates to recover and identify its predictors.
Methods
Conducting a retrospective follow-up investigation, the study took place at Debre Berhan Comprehensive Specialized Hospital from January 1st, 2020 to December 31st 2022, involving a sample size of 330. The analysis included the computation of the Kaplan-Meier survival curve, the log-rank test, and the median time. Additionally, a multivariable Cox proportional hazard regression model was employed to determine the survival status.
Results
in this study, among the 330 participants (100%), a total of 270(81.8%) successfully survived throughout the entire cohort. Predictors are independent of each other, affecting the time to recovery and survival of asphyxiated neonates, encompassed prolonged labor (AHR: 0.42 ,95%CI:0.21–0.81), normal birth weight (AHR:2.21 ,95% CI: 1.30–3.70),non-altered consciousness (AHR:2.52 ,CI:1.50–4.24) ,non-depressed moro reflex of the newborn (AHR:2.40 ,95%CI: 1.03–5.61), stage I HIE (AHR: 5.11 ,95% CI: 1.98–13.19) ,and direct oxygen administration via the nose (AHR: 4.18 ,95% CI: 2.21–7.89).
Conclusion
The duration for recovery seems to be slightly prolonged in comparison to other research findings. This underscores the significance of vigilant monitoring, early preventive interventions, and swift actions to avert the progression of infants to the most severe stage of HIE.
... Additionally, the prevalence of hemolytic disease of the newborn and other jaundice among neonates was 1,074 in 2019. This was also shared by Ethiopian study, which reported the overall pooed prevalence of perinatal asphyxia as 24.06% among 49,417 neonates [28]. The highest and the lowest burden of all neonatal disorders except preterm birth had occurred in Oromia and Harari region respectively. ...
Background: Despite tremendous efforts to reduce neonatal mortality worldwide and in 24 Ethiopia, there is the country is one of the countries with highest neonatal morbidity and health 25 losses. Never the less, the past three decades’ national trend and subnational distribution of 26 neonatal morbidity and mortality and its health loss in Ethiopia, was not well documented. 27 Hence, this study had aimed to analyze the trend and distributions as well as health losses 28 resulting from neonatal morbidity in the past three decades in Ethiopia, 2019. 29 Objective: To assess the national trend and sub national distributions of neonatal morbidity and 30 neonatal mortality in the previous three decades by using Global Burden of Diseases, 2019 data. 31 Methods: The data sources were primary and secondary data related to risk factors, morbidity, 32 disability, deaths, Disability Adjusted Life Years, Years Lived with Disability and Years Life Lost 33 were collected form case studies and case series, household surveys, socio-demographic surveys 34 and surveillances, health facilities surveys, Health facility observations and interviews and 35 published and unpublished literatures. The prevalence, deaths and health losses were calculated 36 by using embedded model. The study period covered from 1990 to 2019. Results were presented 37 buy using texts, tables and graphs. 38 Results: Seventy percent of neonatal disorders had occurred among early neonates aged 0 to 6 39 days. Between 1990 and 2019, the national prevalence of neonatal disorders had increased by 40 47% in to 28,319 (95% UI, 25646-30,361). Bet Similarly, the highest number of neonatal deaths 41 caused by neonatal sepsis had shifted from Southern Nations Nationalities and Peoples region to 42 Oromia region while Harari remains to bear the lowest burden in the last three decades. The 43 highest and the lowest YLL as a result of neonatal disorders had occurred in Oromia 44 [(2,753,038,95% UI, 2,184,142-3,497-926) and Amhara 1,360,847 [(95% UI, 95% UI, 45 1,062,660-1,762,028)] regions respectively. Unlike other regions, Addis Ababa had the highest 46 (52%) prevalence of preterm birth in 2019 47 Conclusion and Recommendation: About seven in ten of neonatal death had occurred among 48 early neonates indicating narrowed occurrence of the event. The highest and the lowest number 49 of neonatal death and health loss had occurred in Oromia and Harari regions respectively. The 50 main causes of death were neonatal sepsis and other infections, neonatal preterm, hemolytic 51 disease and other jaundice and neonatal encephalopathy and trauma. Hence, Contextualized, 52 locally accepted innovative early neonatal care is crucial to avert the event.
... The 8.1% rate of birth asphyxia found in this study is lower when compared to other LMICs: a study in Ethiopia reports a pooled prevalence of 22.52%, 18% in other East African countries and 9.1% in some Central African countries [53,54]. The lower burden of asphyxia in STP may be due to differences in case definition, as in this study, birth asphyxia was only based on a fifth minute APGAR score less than 7, whereas other studies also used other criteria, such as umbilical cord pH < 7-or 20-min Apgar score less than 7 or multiorgan failure in the first 72 h or convulsion in the first 24 h of life [53]. ...
... The 8.1% rate of birth asphyxia found in this study is lower when compared to other LMICs: a study in Ethiopia reports a pooled prevalence of 22.52%, 18% in other East African countries and 9.1% in some Central African countries [53,54]. The lower burden of asphyxia in STP may be due to differences in case definition, as in this study, birth asphyxia was only based on a fifth minute APGAR score less than 7, whereas other studies also used other criteria, such as umbilical cord pH < 7-or 20-min Apgar score less than 7 or multiorgan failure in the first 72 h or convulsion in the first 24 h of life [53]. APGAR scoring is also vulnerable to midwife evaluation and therefore susceptible to higher scoring for better health-related outcomes [26,27]. ...
Background
Newborns with one-or-more adverse birth outcomes (ABOs) are at greater risk of mortality or long-term morbidity with health impacts into adulthood. Hence, identifying ABO-associated factors is crucial for devising relevant interventions. For this study, ABOs were defined as prematurity (PTB) for gestational age <37 weeks, low birth weight (LBW) <2.5 kg, macrosomia >4 kg, asphyxia for a 5-minute Apgar score <7, congenital anomalies, and neonatal sepsis. This study aimed to assess factors associated with ABOs among babies delivered at the only hospital of Sao Tome & Principe (STP), a resource-constrained sub-Saharan-Central African country.
Methods
A hospital-based unmatched case‒control study was conducted among newborns from randomly selected mothers. Newborns with one-or-more ABO were the cases (ABO group), while healthy newborns were the controls (no-ABO group). Data were collected by a face-to-face interview and abstracted from antenatal care (ANC) pregnancy cards and medical records. Multivariable logistic regression analysis was performed to identify ABO-associated factors considering a level of significance of α = 0.05.
Results
A total of 519 newborns (176 with ABO and 343 no-ABO) were enrolled. The mean gestational age and birthweight of cases and controls were 36 (SD = 3.7) weeks with 2659 (SD = 881.44) g and 39.6 (SD = 1.0) weeks with 3256 (SD = 345.83) g, respectively. In the multivariable analysis, twin pregnancy [aOR 4.92, 95% CI 2.25–10.74], prolonged rupture of membranes [aOR 3.43, 95% CI 1.69–6.95], and meconium- fluid [aOR 1.59, 95% CI 0.97–2.62] were significantly associated with ABOs. Eight or more ANC contacts were found to be protective [aOR 0.33, 95% CI 0.18–0.60, p<0.001].
Conclusion
Modifiable factors were associated with ABOs in this study and should be considered in cost-effective interventions. The provision of high-quality ANC should be a priority. Twin pregnancies and intrapartum factors such as prolonged rupture of membranes and meconium-stained amniotic fluid are red flags for ABOs that should receive prompt intervention and follow-up.
