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Abstract
Introduction Birth injury is a significant public health problem in Africa, with a high incidence and associated mortality and morbidity. Systematic reviews that indicate the incidence, contributing factors and outcomes of birth injury in Africa provide valuable evidence to policy-makers and programme planners for improving prevention and treatment strategies. Therefore, this review is aimed to evaluate the incidence, contributing factors and outcomes of birth injury among newborns in Africa.
Methods and analysis The data will be searched and extracted from JBI Database, Cochrane Database, MEDLINE/PubMed, CINAHL/EBSCO, EMBASE, PEDro, POPLINE, Proquest, OpenGrey (SIGLE), Google Scholar, Google, APA PsycInfo, Web of Science, Scopus and HINARI. Unpublished studies and grey literature will be searched from different sources. This systematic review will include quantitative observational studies, registry and census data, and experimental studies that report on the prevalence or incidence in Africa from 1 January 1990 to 30 September 2023. The Joanna Briggs Institute (JBI) quality appraisal checklist will be used to select eligible studies. Two researchers will independently appraise and extract the data from included studies and resolve discrepancies through discussion. Heterogeneity will be assessed using forest plots and the I2 statistic. If substantial heterogeneity is present, a random-effects model will be used to pool the data. Subgroup analyses will be used to explore the potential sources of heterogeneity. Publication bias will be assessed using funnel plots and Egger’s regression test. The software package used to conduct the meta-analysis will be JBI SUMARI. An association will be considered significant if the p<0.05.
Ethics and dissemination Ethical clearance is not needed for this systematic review and the results will be shared with relevant stakeholders to maximise reach and impact.
PROSPERO registration number CRD42023123637.
- NEONATOLOGY
- Neonatal intensive & critical care
- Non-accidental injury
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STRENGTHS AND LIMITATIONS OF THIS STUDY
The review is comprehensive and covers a large geographical area.
The review methods are clearly described and reproducible.
A strong appraisal tool is used to assess the quality of the included studies.
The review uses appropriate methods to synthesise the data from the included studies.
The main limitation of this review is that it only includes quantitative evidence.
Introduction
A birth injury is any physical injury that a baby sustains before, during or immediately after childbirth. Birth injuries can range in severity from mild to severe and can affect any part of the body.1–3 Some of the more common birth injuries include brachial plexus injury, subconjunctival haemorrhage, caput succedaneum, cephalohaematoma, facial nerve palsy and fractures. Most birth injuries are minor and resolve on their own without treatment. However, some birth injuries can be serious and require ongoing medical care.4–7
Globally, an estimated 2.5 million newborns die each year from birth trauma. This accounts for 46% of all deaths in children under the age of 5.3 Birth trauma can occur during any stage of labour and delivery, but it is most common during the second stage, when the baby is passing through the birth canal.3 8
Birth injury is a significant public health problem in Africa, with a high incidence and associated mortality and morbidity. The incidence varies widely, with the highest reported rates in Ethiopia (12.3%–16.9%)9–14 and Nigeria (67.2%).15 Other studies have reported lower rates, such as 5.7% in Nigeria16 and 1.84% in Cameroon.17
A number of factors have been identified as predictors of birth injury in Africa. Maternal and fetal factors including macrosomia,14 15 17–19 place of birth,20 short height of the mothers,10 parity,9 12 educational status,9 place of residence,12 antenatal care,9 occupational status,9 sex of the neonate,10 14 birth weight,10 11 13 gestational diabetic mellitus10 and night-time birth.10 On the other hand, labour and delivery-related factors were duration of labour,10 11 15 fetal distress,10 12 instrumental delivery,10 11 13 14 17 cord prolapse,10 birth attended by residents,10 shoulder dystocia,11 fetal presentation and position.12–14
Evidence on the incidence/prevalence of birth injury, contributing factors and outcomes is essential for policy-makers and programme planners to integrate into the healthcare system and design appropriate interventions. Given the limited evidence on birth injury in Africa, this systematic review will be the first to fill these gaps and generate evidence to support existing practice and identify areas for improvement.
A preliminary search of three electronic databases MEDLINE (PubMed), the Cochrane Database of Systematic Reviews and JBI Evidence Synthesis) was conducted to identify systematic reviews on the topic. The search yielded a single systematic review, which only reported a pooled prevalence and the most common neonatal birth trauma in Ethiopia.21 This review does not assess the predictors of neonatal birth trauma and included only neonatal birth trauma that happened at health institutions without considering home delivery. However, there is no current or underway systematic review in Africa on this topic.
Review objective
The objective of this systematic review is to evaluate the incidence, contributing factors and outcomes of birth injury among newborns in Africa.
Methods and analysis
Protocol design and registration
The proposed systematic review will be conducted in accordance with the Joanna Briggs Institute (JBI) methodology for systematic reviews of prevalence and incidence.22 Then the findings will be reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA)23 24 (online supplemental file 1) and Meta-analysis Of Observational Studies in Epidemiology group guidelines25 (online supplemental file 2). The review title was registered in international prospective register of systematic reviews and the registration number is CRD42023123637.
Supplemental material
Supplemental material
Inclusion criteria
The inclusion criteria will be determined by the CoCoPop mnemonic (Condition, Context and Population) as this review will assess prevalence and incidence data.
Participants/population
The participants for this systematic review will be neonates.
Condition
This systematic review will consider studies that report on the prevalence and/or incidence, contributing factors and outcomes of state condition.
Context
The systematic review will include studies conducted in Africa.
Types of studies
This systematic review will include observational studies (such as cohort studies and cross-sectional studies), registry and census data, and experimental studies that report on the prevalence or incidence.
Search strategy
This systematic review will search for both published and unpublished studies on the prevalence or incidence of birth injury in Africa. The search will be conducted in three steps.
Initial search
A limited search of MEDLINE (PubMed) and CINAHL (EBSCO) will be conducted to identify relevant articles. The search terms used in this initial search will be based on the titles, abstracts and index terms of relevant articles.
Full search
The search terms identified in the initial search will be adapted to create a full search strategy for each included database and/or information source (see table 1).
Search strategy
Reference list screening
The reference lists of all included studies will be screened for additional relevant studies. Studies published from 1 January 1990 to 30 September 2023 in English language will be included in this systematic review. All the available data sources such as electronic databases, conference proceedings, websites, search engines or other online sources and contact with study authors will be used to retrieve the needed information. The information will be searched in databases including JBI Database, Cochrane Database, MEDLINE/PubMed, CINAHL/EBSCO, EMBASE, PEDro, POPLINE, Proquest, OpenGrey (SIGLE), Google Scholar, Google, APA PsycInfo, Web of Science, Scopus and HINARI. Unpublished studies and grey literature will be searched from institutional libraries and repositories, preprint websites and personal contact with the authors.
Study selection
The first step is to find and remove duplicate citations. This can be done using a reference management software such as EndNote. Next, two independent reviewers (AM and SS) will look at the titles and abstracts of all the citations to find the ones that might be relevant to the review. The inclusion criteria for the review will be used to decide if the citations are relevant. The full texts of the potentially relevant sources will then be retrieved and their citation details will be imported into the JBI SUMARI software.26 Two independent reviewers (AM and SS) will look at the full texts of the retrieved studies to decide if they meet the inclusion criteria for the review. If a study is excluded from the review, the reasons for exclusion will be recorded and reported in the systematic review. If the reviewers disagree about whether a study should be included, they will discuss it until they agree. The results of the search and the study inclusion process will be reported in full in the final systematic review and presented in a PRISMA flow diagram27 (online supplemental file 3).
Supplemental material
Assessment of methodological quality
Eligible studies will be critically appraised by two independent reviewers (AM and SS) at the study level modify as appropriate if appraisal will occur at the outcome level for methodological quality in the review using standardised critical appraisal instruments (CAIs) from JBI.22 The JBI CAIs are a suite of tools for appraising the quality of evidence in different types of studies. They are designed to be rigorous and comprehensive, while also being user-friendly and practical. Authors of papers will be contacted to request missing or additional data for clarification, where required. Any disagreements that arise will be resolved through discussion. The results of critical appraisal will be reported in narrative form and in a table. Studies will be scored using a quality appraisal checklist, and only studies with a score of 50% or higher will be included in the systematic review and meta-analysis of prevalence. If the two assessors (AM and SS) disagree on a score, they will review the study together to investigate the source of the disagreement. If they are still unable to agree, the average of their scores will be used. Studies that do not meet a quality threshold will be excluded from the systematic review and meta-analysis, but they will be reported narratively and in table form.
Data extraction
To minimise errors during data extraction, two independent reviewers (AM and SS) will use the standardised data extraction tool for prevalence and incidence available in JBI SUMARI to extract data from the studies included in the review22 (see box 1). The data extracted will include specific details about the condition, populations, study methods and proportions of interest to the review question and specific objectives. Any disagreements that arise between the reviewers (AM and SS) will be resolved through discussion. Authors of papers will be contacted to request missing or additional data, where required.
Data extraction instrument
Citation details
Authors.
Title.
Journal.
Year.
Issue.
Volume.
Pages.
Generic study details
Study design.
Country.
Setting/context.
Year/time frame for data collection.
Participant characteristics (study inclusion/exclusion information).
Condition and measurement method.
Description of main results (n/N).
Data synthesis
Studies will be pooled in a statistical meta-analysis using JBI SUMARI, where possible. The effect size will be expressed as a proportion with a 95% CI around the summary estimate. Forest plots and the I2 statistic will be used to assess heterogeneity, which is the variation in the results of the individual studies included in a meta-analysis. If there is a lot of heterogeneity, a random-effects model will be used to pool the data. This model takes into account the heterogeneity between the studies and produces a summary estimate that is more generalisable to the wider population. Subgroup analyses will be used to explore the potential sources of heterogeneity. This involves dividing the studies into different groups based on certain characteristics, such as the study population, study design or method of measurement. Then the results of the subgroup analyses will be compared with see if there is a difference in the effect size between the groups. Funnel plots and Egger’s regression test will be used to assess publication bias, which is the tendency for studies with positive results to be published more often than studies with negative results. A result will be considered statistically significant if the p<0.05. If it is not possible to combine the results of the individual studies in a meta-analysis, the findings will be presented in a narrative form, including tables and figures to help visualise the data, where appropriate.
Assessing certainty in the findings
The Grading of Recommendations Assessment, Development and Evaluation approach will be used to assess the quality of the evidence that has been pooled or summarised.28
Patient and public involvement
No patient involved.
Ethics and dissemination
This systematic review does not require ethical clearance because it does not involve any direct interaction with human subjects. The results of the review will be published in a reputable peer-reviewed journal, presented at different scientific research conferences and disseminated to academic and other relevant institutions to maximise their reach and impact.
Discussion
Birth injuries are a significant problem in Africa that affect newborns and their families. They are a major cause of neonatal mortality and morbidity and can have long-term consequences for the affected child, including physical and cognitive disabilities. Newborns with birth injuries may require long-term medical care and rehabilitation, and families often face financial and emotional challenges. Therefore, more recent systematic reviews are needed to assess the burden of birth injuries in Africa, identify the risk factors and investigate the possible outcomes, in order to develop effective prevention and treatment strategies.
Amendments
The authors may believe that some amendments or modifications will be needed, but the details of any amendments or discrepancies and the reasons for them will be clearly reported in the systematic review.
Ethics statements
Patient consent for publication
Acknowledgments
The authors acknowledge Jimma University and Arba Minch University for providing the privilege to access the JBI SUMARI.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors AM conceived the research question, wrote the methodology and introduction, and drafted the protocol. SS assisted with the search process, and AM and SS performed the critical revision, reviewed and approved the final protocol for submission for publication.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.