The first 28 days of life is an extremely susceptible time for a newborn to complete many of the physiologic adjustments required for life outside the uterus, which makes it the most dangerous period in life (1, 2). Neonates in need of serious medical attention are admitted to the neonatal intensive care unit (NICU), which incorporates innovative technology and trained staff to effectively provide specialized care for neonates (3).

Despite the incredible progress made in decreasing under-five mortality, neonatal mortality remains the main and slowly advancing contributor. From 5.3 million under-five deaths, around 47% of deaths occurred in the neonatal period (4). It is urgently required to accelerate the progress of achieving target 3.2 of the sustainable development goals (SDGs), which calls for an accelerated and coordinated continuum of care (5). Unless the progress is fast-tracked, 26 million newborns would die from 2019 to 2030 (4).

Though all efforts were made to decline the deaths of the newborn, current information showed that newborn death is unaverted and not a fastened agenda. An Ethiopia Mini-Demographic Health Survey (Mini-EDHS) report showed that there is an increment in neonatal mortality from 28 in 2016 to 30 per 1,000 live births in 2019 (6). The majority of newborn deaths occur in the early neonatal period, which is a critical time for prevention, control, and monitoring complications arising from the delivery (6). Evidence showed that 70% of the current neonatal deaths could be prevented through the practice of recommended neonatal care practices as it is recognized as an excellent solution to reduce the mortality of newborn babies (7).

Ethiopia missed the target of the national newborn and child survival strategy and is in danger of missing the SDGs target 3.2 on newborn deaths (4). Therefore, it is a critical time to maximize a wide-ranging way of execution of strategies to decrease neonatal death. Furthermore, it is recommended to continuously assess and monitor neonatal health. In addition, it is important to identify the cause and determinant factors of death, which is fundamental for the prevention of newborn death and monitoring public health strategies (8). Different studies were conducted in assessing the prevalence of neonatal mortality, but the perinatal health conditions of neonates were not assessed as they contribute to the causes of neonatal mortality. Even though Ethiopia lies among the highest level of neonatal mortality rate compared with other sub-Saharan African countries, only little is known about the magnitude and related factors of neonatal death. So, the study aimed to assess the magnitude and determinants of neonatal mortality at the Dil Chora Referral Hospital in Dire Dawa City, Ethiopia.

The majority of neonatal mortality in the developing world occurs as a result of poor quality of care during the antenatal, intrapartum, and postpartum periods. Since neonatal mortality has not declined, evidence suggested that continuous assessment is needed. Therefore, this study was intended to assess the prevalence and determinant factors of neonatal mortality at the Dil Chora Referral Hospital, Dire Dawa.

The magnitude of newborn death in the current study was 11.4% (95% CI:9.44–13.36), which was found to be consistent with a study done in Jimma University Medical Center, Southwest Ethiopia at 13.3% (16). However, the finding was lower compared with studies conducted in Ghana at 20.2% (17); Mizan Tepi University Teaching Hospital, Southwest Ethiopia, at 22.8% (11); Hiwot Fana Specialized University Hospital, Eastern Ethiopia, at 14.3% (18); and Gondar Referral Hospital, Northwest Ethiopia, at 23.1% (9). However, the prevalence of neonatal death was higher than studies conducted in the Somali Region, Ethiopia, at 5.7% (19); Gondar, Ethiopia, at 4.4% (12); and in Mekelle, Ethiopia, at 6.6% (20). The discrepancy might be due to the presence of sociocultural and socioeconomic differences across the Ethiopian regions. This variation might also be due to the variation in sample sizes (11, 17). Other possible justification may be the difference in the health service utilization including giving birth at health institutions by skilled care providers and health seeking for sick neonates, the variation in health institution setup (equipment available and skilled persons), and economic disparities among study participants (11, 13, 21). Besides, this study used data of those critically sick babies that were admitted to the neonatal intensive care unit.

This finding shows that newborns delivered from mothers who had pregnancy complications had a higher chance of death. This is comparable with a previous study conducted in the Tigray region, Northern Ethiopia (22). The likely explanation might be due to maternal health care during the antenatal period being a significant determinant of neonatal and maternal health. Moreover, pregnancy-related complications can adversely affect the wellbeing of neonates (23) based on the fact that neonates born from mothers with pregnancy complications were also in danger of being premature, having intrauterine growth restriction (IUGR), and respiratory distress syndrome (RDS) that lead neonates to death (24).

Neonates born from a mother with no ANC visit increases the odds of neonatal death compared with mothers with ANC visits. This finding is supported by a study conducted in the Afar region (21). Women who do not have antenatal care follow-up during pregnancy are more at a menace for pregnancy and intrapartum-related complications, which, in turn, place the newborn at danger of death (25). Therefore, women who complete antenatal care visits have a better chance of prompt detection and management of birth-related problems, and also establishing good health before childbirth and early postnatal period (21, 26). Besides, women who had complete ANC follow-up had an increased likelihood of giving birth by a skilled birth attendant who leads to having quality essential newborn care (ENC), which decreases the odds of neonatal death (16). Moreover, ANC provides an exceptional opportunity for health care providers to counsel mothers on how to recognize warning signs of complications during pregnancy, labor, and delivery. It is also an opportunity to encourage them to plan clean and safe deliveries at health institutions by trained attendants. Additionally, during ANC follow-up, health care providers can provide information regarding postpartum care, newborn care, a neonatal danger sign, danger signs of pregnancy, and appropriate actions to be taken (13).

This study found that neonates with birth weight <2,500 g were at higher odds of death than those having normal or higher birth weight. Other studies have consistently reported similar findings (16, 27, 28). The possible explanation is that low birth weight increases child susceptibility to infection and decreases their immune systems and other body defense mechanisms, which control newborn disease exposure. As a result, neonatal survival is decreased (29). Other possible explanations for this might also be due to the low-birth weight newborns are expected to suffer from hypothermia, infection, and poor immunological function, which increased the risk of neonatal deaths (16, 30).

The odds of death among hypothermic neonates were 2.5 times that of neonates who did not have the conditions. The possible justification is that hypothermia contributes to hypotension, hypoxia, hypoglycemia, bradycardia, disseminated intravascular coagulation, irregular and slow breathing, and shock (31, 32), which, in turn, increase long-term disability and death. Evidence showed that mortality was high among hypothermic neonates compared with normothermic neonates (33). A systematic review and meta-analysis pointed out that decreasing the risk of low birth weight, preterm, and neonates with neonatal problems is important for the prevention of the burdens of hypothermia (32).

This study revealed that neonates born from mothers who had PROM had a higher probability of newborn mortality than neonates born from mothers who did not have PROM. This is comparable with the study conducted in Jimma Specialized Hospital and Arba Minch General Hospital (16, 34). This might be due to PROM increasing the risk of acquiring neonatal sepsis, birth asphyxia, pulmonary hyperplasia, and preterm labor (35). Also, PROM is a risk factor of ascending infection to the uterine cavity, which results in the infection of the fetus (36).

This study revealed that the onset of labor is one determinant factor of neonatal death. The odds of neonatal death from mothers with induced labor were 4.5 times more likely to occur compared with those of spontaneous labor. Consistent findings were reported from a previous study done in Arba Minch General Hospital (37). The possible justification is the reason for induction. Usually, labor is induced if there are pregnancy complications, fetal abnormalities, and labor abnormalities. So, those reasons could contribute to the development of neonatal complications and finally result in neonatal death. The possible reason might be due to the medications provided to induce labor, which tend to cause abnormal or excessive contraction, which reduces the oxygen supply of the baby and causes fetal distress, and lowers the heart rate of the newborn (38).

The strength of the study was the utilization of a standard and pretested data extraction sheet. Again, the study provides the updated prevalence of neonatal mortality at the Dil Chora Hospital.

The limitation of this study is it might not show a cause–effect relationship because the study design was cross-sectional. The use of the medical records of newborns because of the incompleteness, and the study did not identify inborn and referrals may have an impact on the generalization.

The prevalence of neonatal death was high compared with the national target. Factors such as having no ANC follow-up, induced labor, complications during pregnancy, PROM, hypothermia, and birth weight <2,500 g were statistically significant predictors of neonatal death. Majority of the neonatal deaths are resulting from complications arising from pregnancy, labor and delivery, and lack of quality of care at the neonatal intensive care unit. Cultivating the antenatal care services, early detection and treatment, and referral of high-risk pregnancies and newborns could avert newborn deaths.

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.

The studies involving human participants were reviewed and approved by Haramaya University, College of Health and Medical Sciences, Institutional Health Research Ethics Review Committee (IHRERC). The patients/participants provided their written informed consent to participate in this study.

GT conceived the idea of the study and had major roles in the data review, analysis, writing, and preparing of the manuscript. MD, BH, HH, AE, and DT played their role in reanalyzing, writing the final draft of the results, and wrote the manuscript. All authors were involved in reading and approving the final manuscript.

Funding was provided by the Haramaya University.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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