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Birth Outcomes among Diabetic Mothers Who Delivered in Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia.

1. Introduction

Diabetes mellitus (DM), which is one of the major non-communicable diseases worldwide, is a metabolic disorder that results from a defect in insulin production, impaired insulin action, or both. Hyperglycemia in pregnancy can include preexisting type 1 diabetes--absolute insulin deficiency--and preexisting type 2 diabetes--defective insulin secretion or insulin resistance (either previously diagnosed or during the first trimester of pregnancy); gestational diabetes mellitus is defined as hyperglycemia that is first diagnosed during pregnancy [1].

The global prevalence of diabetes in pregnancy ranges from 1% to 14%; it develops in 1 in 25 pregnancies and is associated with complications in the period immediately before and after birth [1, 2]. The International Diabetics Federation's (IDM) estimate for live birth with hyperglycemia in pregnancy is 21.4 million, which accounts for 16.8% of the total live births in 2013. Southeast Asia has more prevalence (25.0%) than the regions of North America and Caribbean (10.4%).

Globally, the spread of diabetes is increasing rapidly from an estimated 381 million in 2013 to 422 million in 2016 [2, 3], and of all the pregnancies, 7% are complicated by diabetes and results in prenatal morbidity and mortality [1]. IDF estimated that 16.2% of women in 2015 had some form of hyperglycemia in pregnancy. One in seven births is affected by diabetes in pregnancy. Annually, more than 200,000 DM cases occur worldwide [1, 3].

Diabetes adversely affects women and their babies during pregnancy, labor, and delivery. It is associated with a higher incidence of maternal morbidity, including miscarriage, cesarean deliveries (C/S), birth trauma, pregnancy-induced hypertension (PIH), traumatized labor, obstructed labor, and subsequent development of type 2 diabetes. Also, perinatal and neonatal morbidities increase; these includes macrosomia, congenital anomalies, birth injury, hypoglycemia, intrauterine fetal death (IUFD), still birth, shoulder dystocia, respiratory distress syndrome (RDS), polycythemia, and hyperbilirubinemia [4].

There is no current study that identifies the incident of DM in Ethiopia, but one study done in 1999 revealed that the prevalence of DM was 3.7%, and it assesses only the prevalence of DM [5]. Therefore, this study assesses the prevalence of DM, birth outcomes, and associated factors among mothers that delivered in Tikur Anbessa Specialized Hospital.

2. Materials and Methods

2.1. Study Area, Period, and Design. A cross-sectional study was conducted in Tikur Anbessa Specialized Teaching Hospital, which is a tertiary referral hospital and the largest of all public hospitals in Addis Ababa, the capital city of Ethiopia. The hospital has 1262 rooms and 800 beds. It offers diagnoses and treatment for approximately 370,000-400,000 patients per year in all the wards, one of which is the diabetes center. Around 4600 deliveries are attended each year, and 60% of these are operative deliveries; the health service coverage is 71% and institutional deliveries is 82% [6]. This study was conducted from February 1 to April 30, 2018.

2.2. Population. A total of 14039 records of mothers who delivered after 28 wk of gestation from January 2015 to December 2017 in Tikur Anbessa Specialized Hospital, Addis Ababa, were reviewed to identify DM cases. From all deliveries, 362 mothers were identified with DM cases; of those 362 mothers, 346 cards of the mothers who had complete records were reviewed.

2.2.1. Inclusion Criteria. The cards of the mothers with DM after 28 wkof gestation from January 2015 to December 2017 were included.

2.2.2. Exclusion Criteria. The mothers' records with multiple/twin delivery and with incomplete records of the study variables were excluded.

2.3. Sample Size and Procedure. The sample size was all delivered mothers' records after 28 wk of gestation from January 1, 2015, to December 31, 2017, in Tikur Anbessa Specialized Hospital, Addis Ababa. The study site was selected since it is the largest public hospital with maternal health service and has diabetes center. The required data were extracted from the health management information system delivery registration, postnatal registrations, admission registration, and DM registration in DM center, and the documents of all the delivered mothers who had DM during the study period at obstetrics ward were selected and checked for completeness. The cards which had complete data were identified and consecutively reviewed.

2.4. Operational Definitions. Diabetes mellitus (DM) is a metabolic disorder resulting from a defect in insulin production, impaired insulin action, or both.

Type 1 diabetes mellitus is a metabolic disorder resulting from absolute insulin deficiency.

Type 2 diabetes mellitus is a metabolic disorder resulting from defective insulin secretion or insulin resistance.

Gestational diabetes mellitus (GDM) is any degree of glucose intolerance with its onset during pregnancy.

2.5. Data Collection. Data were collected by a structured checklist developed by the investigators after reviewing different literature studies. The checklist included information on sociodemographic characteristics, past and present obstetric history, and maternal and fetal outcomes. Data were collected through document review from client chart obtained from delivery registration book, postnatal registrations, duty report registration books, and operation logbooks. After card numbers were obtained, documents of all delivered mothers who had DM during the study period at obstetrics and gynecologic ward were searched and checked for completeness of data. Three experienced B.Sc. midwives and two record office staff members collected the data and two supervisors and the principal investigator supervised the process on a daily basis. Before data collection, a two-day training program was given to the data collectors and the supervisors; and a pretest was done on 42 client documents, and appropriate modification was made on the checklist and procedures.

2.6. Data Processing and Analysis. The data were entered in EpiData Version 4.2 and exported to SPSS Version 23.0 for analysis. Descriptive statistics such as frequencies, proportions, measures of central tendency, and measures of variation were used to describe the study variables. Multiple logistic regressions analysis was carried out to examine the associations between the dependent and the independent variables, and the variables with P value less than 0.05 were considered statistically significant.

2.7. Ethical Consideration. Ethical clearance was obtained from the School of Nursing and Midwifery Institutional Health Research Ethical Review Committee, Addis Ababa University. Official letter of cooperation was taken from the School of Nursing and Midwifery for data collection to the respective departments of Tikur Anbessa Specialized Hospital. Throughout the study period, the confidentiality of the data was strictly followed.

3. Results

3.1. Sociodemographic Characteristics. From January 2015 to December 2017, 14039 deliveries were attended in Tikur Anbessa Specialized Hospital, and 362 of the mothers had diabetes. Of these, only 346 cards had complete data and were reviewed. Some (139 (40.2%)) were 30-34 years of age, with the mean age of 30.8 year and standard deviation of 4.7. Almost all the mothers, 345 (99.7%), were married and 174 (50.2%) were housewives. The mean body mass index (BMI) of the women was 26.43 kg/[cm.sup.2], and 46.2% of them had a normal BMI, and 322 (93.1%) were from Addis Ababa (Table 1).

3.2. Maternal Outcomes. One hundred seventy-seven (51.16%) of the labors occurred spontaneously. Many of the mothers (284 (82.1%)) delivered at term (mean gestational age of 37.38 weeks), 200 (57.8%) by cesarean section, and 35% with diabetes-related complication (comorbidity). PIH (90 (26%)) was the main complication of DM in pregnancy, whereas 111 (31.2%) of the mothers were admitted to the Intensive Care Unit (ICU) (Table 2).

GDM had more C/S delivery, PIH, polyhydramnios, and hypothyroidism, whereas DM had more spontaneous onset of labor, preterm labor, traumatized labor, and ICU admission (Table 3).

3.3. Fetal Outcomes. In this study, 337 (97.4%) live births were identified. From these, 219 (63.3%) were born with adverse fetal outcomes: 43 (12.4%) with multiple complications and 10.1% with poor APGAR score at 5 minutes; 65.3% were admitted in the Neonatal Intensive Care Unit (NICU) (Table 4).

3.4. Factors Associated with Maternal Adverse Outcomes among Mothers with Diabetes Delivered at Tikur Anbessa Specialized Hospital. In the multivariate analysis, the mothers with BMI (30-34) or class I obesity were 3.8 times more likely to develop adverse maternal outcomes than class II obesity, and this was statically associated at P < 0.020 and aOR = 95%CI 3.8 (1.29, 8.319). The mothers with a previous history of PIH were 2.1 times more likely to develop adverse maternal outcomes than their counterparts, and this was also statically associated at P < 0.0001 and aOR = 95%CI2.1 (1.03, 4.399) (Table 5).

3.4.1. Fetal Outcome. In the multivariate analysis, the neonates born to housewives were 2.1 times more likely to develop adverse fetal outcomes than those born to employed and statically associated at P < 0.002 and aOR = 95%CI 2.1 (1.32-3.41). Preterm delivery was significantly associated with adverse birth outcomes at P < 0.0001 aOR = 95%CI 9.763 (4.56-20.90) (Table 6).

4. Discussion

The main objective of this study was to assess the outcomes of birth in those women with DM, diagnosed before pregnancy, and associated factors among mothers who delivered in Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia, from January 2015 to December 2017. The study identified 26% of the mothers with PIH complication, which is greater than the finding in Sudan (14%), Saudi Arabia (15%), and Qatar (14.4%) [7-9]. The variations may be due to lack of awareness of prevention of diabetes-related complication among our mothers. About 57.8% of the mothers delivered by cesarean section, and was almost similar with the one found in Saudi Arabia, 68.7% [8]. This might be due to the fear of complication of birth injury in vaginal birth. Instrumental delivery accounted for 2.6%, which was similar to a study reported in Sudan (3%) [7] but lower than that in Cameron (6.4%) [10]. This might be because instrumental delivery was related to macrosomia leading to instrument-assisted vaginal delivery. In our study, maternal ICU admission was 32.1%, and the average length of stay in the hospital was 9 days. This average is greater than the one found in a study done in Sudan, which was 5 days [7]. This might be due to poor maternal blood glucose control and diabetes-related complication or comorbidity and difference related to quality of care provided in our country. In multivariate analysis, the mothers with BMI (30-34) or class I obesity were 3.8 times more likely to develop adverse maternal birth outcomes than those with class II obesity (aOR = 3.8 and 95% CI = 1.29-8.319). The mothers who had a history of PIH were 2.1 times more likely to develop adverse maternal birth outcomes than those without PIH history (aOR = 2.1 and 95% CI = 1.03-4.4).

Macrosomia was the adverse outcome observed in the neonates (22%), many of whom were born from gestational diabetic mothers. The prevalence is higher than the ones reported in Bahrain (15.1%) [11] and Saudi Arabia (11%) [8] but lower than found in Cameron (38.7%) [10] and Sudan (28%) [7]. These variations may be due to the difference in the quality of care that Cameron and those countries were providing.

The extent of the preterm delivery in our study (17.6%) is greater than the magnitude found by a study done in Qatar but smaller than the one reported in Bahrain [9, 11]. The variation might be due to the difference in awareness and quality of maternal health services. The 10.1% low birth weight in this study is almost the similar to the findings in Sudan, Saudi Arabia, and Bahrain [7, 8, 11]. This high prevalence might be because LBW was related to termination of pregnancy because of diabetic complication/diabetic comorbidity. The rate of neonatal admission to the NICU found in our study (65%) is less than that found in Russia (100%) [12] and in Saudi Arabia [8]. This difference might be due to the neonatal healthcare strategy they apply. Still birth occurred in 2.6% fetus of the diabetic mothers, and the figure is almost equal to the ones found in Sudan and Saudi Arabia [7, 8]. The similarity might be due to related poor glycemic control. Birth injury occurred in 1.7% newborns of the diabetic mothers, which was more common to DM. This finding was almost like the finding in Sudan, which was 2% [7]. This maybe due to the instrumental delivery indicated for macrosomia. In the final multivariate model, we found that neonate born to unemployed/housewife mothers were 2.1 times more likely to develop adverse birth outcomes than those to employed were aOR = 2.1 and 95% CI = 1.32-3.41. This might be because the employed mothers had more access to up-to-date information about preventing adverse outcomes than the unemployed ones, as they interact with their employed peers, but the unemployed mothers did not get this chance since they were in the house most of the time. The newborns who were preterm delivered from the diabetic mothers were 9.76 times more likely to experience adverse birth outcomes than their counterparts [(aOR = 9.76 and 95% CI = 4.56-20.90)]. This finding was consistent with the ones reported in Sudan, Saudi Arabia, Bahrain, and Cameron [7, 8,11,13]. This might be because the complications that occur during pregnancy affect the well-being of the fetus in the uterus. Therefore, preterms are more susceptible to adverse outcomes.

5. Conclusion

The prevalence of diabetes mellitus was 362 (2.6%). The study also identified PIH complication (26%), cesarean section delivery (57.8%), instrumental delivery (2.6%), and ICU admission (32.1%) as maternal outcomes; and macrosomia (22%), preterm delivery (17.6%), low birth weight (10.1%), NICU admission (65%), still birth (2.6%), and birth injury (1.7%) as fetal outcomes. Class I obesity and previous history of PIH were significantly associated with the adverse maternal outcome. Preterm delivery and being a housewife mother were associated with adverse fetal outcomes. Therefore, we recommend all the concerned bodies to provide health education to all levels of community about adverse birth outcomes from diabetic pregnant mothers.

https://doi.org/10.1155/2019/6942617

Data Availability

The data used to support the findings of this study have not been made available because of a confidentiality clause in our informed consent that the institution signed prior to the study. The institution head recommended that data from the client file will only be used for the study and will not be available to a third party.

Disclosure

Yitagesu Sintayehu, Bazie Mekonnen, and Woreknesh Daba are the co-first authors.

Conflicts of Interest

The authors declare that they have no conflicts interest.

Authors' Contributions

Bajrond Eshetu designed the study, performed the statistical analysis, and drafted the manuscript. Yitagesu Sintayehu, Bazie Mekonnen, and Woreknesh Daba designed and implemented the study and drafted the manuscript. All authors contributed to data analysis and read and approved the final manuscript.

Acknowledgments

The authors thank Addis Ababa University for their financial support and Tikur Anbessa Specialized Hospital's management and the card room and maternity ward staff members for their cooperation. The authors also thank the data collectors.

References

[1] M. S. Kirkman and W. Schaffner, "Another shot to protect people with diabetes: add hepatitis b vaccination to the checklist," Diabetes Care, vol. 35, no. 5, pp. 941-942, 2012.

[2] IDF, International Diabetes Federation, IDF Diabetes Atlas, IDF, International Diabetes Federation, Brussels, Belgium, 6th edition, 2013.

[3] World Health Organization, Global Report on Diabetes, World Health Organization, Geneva, Switzerland, 2016.

[4] Australian Institute of Health and Welfare, National Maternity Data Development Project: Diabetes Mellitus during Pregnancy Research Brief No. 2. Cat. No. PER 75, AIHW, Canberra, Australia, 2016.

[5] B. Syoum, K. Kiros, T. Haileselase, and A. Leole, "Prevalence of gestational diabetes mellitus in ruralpregnant mothers northern Ethiopia," Diabetes Research and Clinical Practice, vol. 46, no. 3, pp. 247-251, 1999.

[6] Addis Ababa Health Office Report and Tikur Anbasa Specialized University Hospital Maternity Report Ward Report (2015-2017).

[7] A. E. M. Kheir, R. Berair, I. G. I. Gulfan, M. Z. Karrar, and Z. A. O. Mohammed, "Morbidity and mortality amongst infants of diabetic mothers admitted into Soba University Hospital, Khartoum, Sudan," Sudanese Journal of Paediatrics, vol. 12, no. 1, pp. 49-55, 2012.

[8] H. Wahabi, A. Fayed, S. Esmaeil, H. Mamdouh, and R. Kotb, "Prevalence and complications of pregestational and gestational diabetes in Saudi women: analysis from Riyadh mother and baby cohort study (RAHMA)," BioMed Research International, vol. 2017, Article ID 6878263, 9 pages, 2017.

[9] R. Varghese, B. Thomas, M. A. Hail et al., "The prevalence, risk factors, maternal and fetal outcomes in gestational diabetes mellitus," International Journal of Drug Development and Research, vol. 4, no. 3, pp. 356-368, 2012.

[10] M. Djomhou, E. Sobngwi, J. J. N. Noubiap, M. Essouma, P. Nana, and N. J. Fomulu, "Maternal hyperglycemia during labor and related immediate post-partum maternal and perinatal outcomes at the Yaounde Central Hospital, Cameroon," Journal of Health, Population and Nutrition, vol. 35, no. 28, 2016.

[11] B. S. Al Oman, F. H. Al Ammari, and N. M. Dayoub, "Pregnancy outcomes in relation to different types of diabetes mellitus and modes of delivery in macrosomic foetuses in Bahrain," Journal of Taibah University Medical Sciences, vol. 12, no. 1, pp. 55-59, 2016.

[12] E. G. Deryabina, G. V. Yakornova, L. A. Pestryaeva, and N. D. Sandyreva, "Perinatal outcome in pregnancies complicated with gestational diabetes mellitus and very preterm birth: case-control study," Gynecological Endocrinology, vol. 32, no. 2, pp. 52-55, 2016.

[13] M. Hod, A. Kapur, D. A. Sacks et al., "The International Federation of Gynecology and Obstetrics (FIGO) initiative on gestational diabetes mellitus: a pragmatic guide for diagnosis, management, and care," International Journal of Gynecology & Obstetrics, vol. 131, pp. S173-S211, 2015.

Bajrond Eshetu, (1) Yitagesu Sintayehu [ID], (2) Bazie Mekonnen, (3) and Woreknesh Daba (3)

(l) Department of Midwifery, College of Health and Medical Sciences, Dire Dawa University, P.O. Box 1362, Dire Dawa, Ethiopia

(2) Department of Midwifery, College of Health and Medical Sciences, Haramaya University, P.O. Box 235, Harar, Ethiopia

(3) Department of Nursing and Midwifery, College of Health and Medical Sciences, Addis Ababa University, P.O. Box 1176, Addis Ababa, Ethiopia

Correspondence should be addressed to Yitagesu Sintayehu; yitagesu.sintayehu@gmail.com

Received 9 April 2019; Revised 9 July 2019; Accepted 25 July 2019; Published 7 August 2019

Academic Editor: Tzung-Hai Yen

Copyright [C] 2019 Bajrond Eshetu et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Table 1: Sociodemographic characteristics of diabetic mothers.

                      Variable        Frequency   Percent (%)

                        <20               8           2.3
                       20-24             24           6.9
Age                    25-29             92          26.6
                       30-34             139         40.2
                        >35              83           24

                       Normal            160         46.2
BMI                 Over weight          109         31.5
                  Class 1 obesity        63          18.2
                  Class 2 obesity        14           4.1

Address             Addis Ababa          322         93.1
                 Out of Addis Ababa      24           6.9

Occupation           House wife          174         50.2
                      Employed           172         49.8

Marital status        Married            345         99.7
                     Unmarried            1           0.3

Table 2: Maternal outcomes among diabetic mothers.

                        Variables          Frequency    Percent (%)
                                            N = 346

Onset of labor         Spontaneous            177          51.16
                         Induced              169          48.84

GA at time               Preterm               62          17.9
of delivery               Term                284          82.1

                  Spontaneous vaginal         137          39.6
                        delivery
Mode of             Assisted vaginal           9            2.6
delivery                delivery
                           C/S                200          57.8

                           PIH                 90           26
                     Polyhydramnios            5            1.4
                 Tear (traumatize labor)       7             2
                     Hypothyroidism            6            1.7
Maternal            Obstructed labor           1            0.2
complication *       Cardiac disease           3            0.8
                  Chronic renal disease        1            0.9
                         Others                36          10.4
                      ICU admission           111          32.1

* Total may not add to 100% because of multiple responses.

Table 3: Comparing maternal outcomes in GDM and DM mothers.

Maternal outcome                             GDM       Percent (%)
variable                                     N = 157

Onset of labor            Spontaneous        72        40.7
                            Induced          85        50.3

Gestational age at          Preterm          19        30.6
time of delivery              Term           138       48.6

                      Spontaneous vaginal    48        35.0
                            delivery
Mode delivery            Instrumental        3         33.3
                            delivery
                        Cesarean section     106       53.0

Types of C/S             Emergency C/S       48        51.0
                          Elective CS        58        54.3

                              PIH            47        52.2
                         Polyhydramnios      3         60.0
                        Traumatize labor     2         28.6
Maternal                 Hypothyroidism      4         80.0
complication *          Cardiac disease      1         33.3
                        Obstructed labor     0
                         ICU admission       55        49.5

Maternal outcome                             DM N = 189   Percent (%)
variable

Onset of labor            Spontaneous        105          59.3
                            Induced          84           49.7

Gestational age at          Preterm          43           69.4
time of delivery              Term           146          51.4

                      Spontaneous vaginal    89           65.0
                            delivery
Mode delivery            Instrumental        6            66.7
                            delivery
                        Cesarean section     94           47.0

Types of C/S             Emergency C/S       46           49.0
                          Elective CS        47           45.7

                              PIH            43           47.8
                         Polyhydramnios      2            40.0
                        Traumatize labor     5            71.4
Maternal                 Hypothyroidism      1            20.0
complication *          Cardiac disease      2            66.7
                        Obstructed labor     1
                         ICU admission       56           50.5

* Total may not add to 100% because of multiple responses.

Table 4: Fetal outcomes among diabetic mothers.

Fetal outcome variable        Frequency N= 346   Percent (%)

Live birth                    337                97.4
Macrosomia                    61                 17.6
Preterm                       62                 17.9
Low birth weight              35                 10.1
RDS                           32                 9.2
Hypoglycemia                  10                 2.9
Still birth                   9                  2.6
Jaundice                      7                  2
Birth injury                  6                  1.7
Birth defect                  3                  0.9
NICU admission                226                65.3
Apgar score 1st min <7        82                 23.7
Poor Apgar score 5th min      35                 10.1

Total may not add to 100% because of multiple responses.

Table 5: Multivariate logistic regression on factors associated with
maternal outcomes among diabetes.

              Variables       Adverse              COR (95% CI)
                              maternal outcome
                               Yes       No

                15-19           5        3       7.11 (0.16-3.17)
                20-24           45       38     2.37 (0.91-6.14) *
Age             25-29           70       69      1.41 (0.78-2.56)
                30-34           42       50      1.17 (0.68-2.01)
                 >35            8        16              1

            Normal weight       11       3      5.30 (1.44-19.96) *
BMI          Over weight        47       16     4.84 (1.27-18.31) *
           Class I obesity      47       62      1.25 (0.31-5.047)
           Class II obesity     65       95              1

History          Yes            32       4      9.97 (3.44-28.87) *
of PIH            No           138      172              1

     Variables                    AOR (95% CI)

                15-19          2.70 (0.59-12.33)
                20-24           0.86 (0.33-2.21)
Age             25-29           1.0 (0.563-1.92)
                30-34           1.0 (0.622-1.93)
                 >35                   1

            Normal weight       0.84 (0.76-2.55)
BMI          Over weight       0.567 (0.18-1.77)
           Class I obesity    3.80 (1.29-8.319) **
           Class II obesity            1

History          Yes          2.10 (1.03-4.40) **
of PIH            No                   1

** Statistically significant at 95% confidence interval (P < 0.05).

Table 6: Multivariate logistic regression on adverse fetal outcomes
among diabetes mothers.

Variables                              Adverse birth
                                           Outcome

                                        Yes       No

Occupation          Housewife            88       86
                    Employed             64      108
Previous history    Yes                  22       14
of PIH              No                  130      180

Gestational age     Preterm              52       10
                    Term                100      184
Mode of             SVD                  69       68
delivery            Assisted vaginal     4        5
                    delivery
                    Cesarean section     79      121
Current PIH         Yes                  48       42
                    No                  104      152

Variables                                  COR (95% CI)

Occupation          Housewife          5.36 (1.44-19.96) *
                    Employed                    1

Previous history    Yes                 2.17 (1.07-4.41) *
of PIH              No                          1

Gestational age     Preterm             9.56 (4.66-19.6) *
                    Term                        1

Mode of             SVD                         1
delivery            Assisted vaginal    1.268 (0.33-4.93)
                    delivery
                    Cesarean section    1.64 (1.00-2.41) *

Current PIH         Yes                 1.7 (1.03-2.71) *
                    No                          1                      1

Variables                                  AOR (95% CI)

Occupation          Housewife           2.1 (1.31-3.40) **
                    Employed                     1

Previous history    Yes                  1.43 (0.61-3.35)
of PIH              No                           1

Gestational age     Preterm             9.76 (4.56-20.90) **
                    Term                         1

Mode of             SVD                          1
delivery            Assisted vaginal     1.07 (0.65-1.75)
                    delivery
                    Cesarean section     1.48 (0.36-6.20)

Current PIH         Yes                  1.145 (0.65-2.03)
                    No                           1

** Statistically significant at 95% confidence interval (P < 0.05).
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Title Annotation:Research Article
Author:Eshetu, Bajrond; Sintayehu, Yitagesu; Mekonnen, Bazie; Daba, Woreknesh
Publication:Advances in Medicine
Article Type:Clinical report
Geographic Code:7SAUD
Date:Aug 31, 2019
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