Losing a newborn within the first three days of life, during which high neonatal mortality occurred, was shocking for the family, community at large and is devastating globally. Especially in developing countries, addressing this issue was difficult tasks for several factors. The study aimed to determine the incidence and determinants in the first three days among babies delivered in referral hospitals. In this study, 810 neonates born at the referral hospitals were included during the study period, and male predominance was noted in 53.5% of the study participants. This is in line with studies carried out in Pakistan (63%), South Africa (57.8%), in India (63.3%), in St Paul’s Hospital Millennium Medical College (61.1%) and University of Gondar hospital (58.3), Ethiopia. Natural selection response to differential survival prospects  and cultural and social factors  was a discrepancy between female and male babies. Our study’s causes of neonatal deaths were neonatal jaundice, complications such as birth trauma and congenital anomaly, asphyxia, umbilical sepsis, and neonatal sepsis, which are in line with the causes found in Ghana [30, 31], and Uganda .
In our study, 122 neonates were lost their lives within the first three days of life, giving an overall newborn mortality rate of 151/1000 total births, and the stillbirth rate was 103.7/1000 total births. This figure shows a significant decline from a study conducted in the Tikur Anbesa specialized hospital (225/1000 live births) , and (302/1000 live births). This decline might be due to the impacts of different interventions for the last six years. However, it was much higher than the global neonatal mortality rate in 2016 , and in studies conducted in Southern Ethiopia [35, 36], Eastern Ethiopia , Southwest Ethiopia , Sudan , Uganda , Zambia  and Ghana. Our study is also much higher than a finding of a systematic review of PMR in Ethiopia that indicated 75/1000 live births at the institutional level, 43/1000 total births with follow up studies, 59.1/1000 total births in the Amhara region, and 29.5/1000 total births among early newborns (up to 7 days) . The variances might be attributed to study designs, health service coverage, socioeconomic factors, and PMR’s definition in other studies. The higher PMR in this study might also be because of the admission of complicated mothers and the consideration of PMR up to 3 days in referral hospitals. This finding implies that the situation of neonatal mortality is still not progressing as anticipated in referral hospitals and strengthen the argument made by the study conducted in Jimma Zone  and a previous systematic review , which concluded that “health facility delivery had no significant effect on neonatal mortality.” However, this study’s findings should be interpreted vigilantly because of the stillbirth rate reports among admitted term pregnant women in referral hospitals, and possible misclassification of pregnancy outcomes (e.g., severe asphyxia of neonates) might overestimate the actual burden of stillbirth in the study area. Though there might be due to differences based on some factors, we suggest tailored and targeted interventions by all stakeholders at different levels.
Regarding the determinants of neonatal mortality within the first 72 hours, gestational age at the first antenatal care visit was a risk factor. Women who came between 17 and 28 weeks of gestation for the first visit were 1.67 times more likely to lose their child than those who started the initial antenatal care visit before 16 weeks of pregnancy. This finding is similar to studies conducted in Tigray regional state , Felege Hiwot referral hospital , and Gaza-Strip . This result infers that the earlier the start of prenatal care visits, the more the mothers will have time to complete four follow-ups, which will help us a new method of obstetric problems, which suggests the recent WHO recommendation of positive pregnancy experiences . Thus, this study suggests the early start of the antenatal visit and possible consideration of the new WHO recommendation for antenatal care visits in Ethiopian referral hospitals.
Maternal complications within 24 hours were also a significant risk factor for newborn mortality. Of these, the experience, postpartum haemorrhage, fistula development within the first 24 hours, and obstructed labour were found to be three times, four times, and more than twice risky for newborns death within the first 72 hours of life. Our study’s findings regarding fistula and postpartum haemorrhage as risks for neonatal mortality were unique in this finding. The possible reason for neonatal mortality among mothers facing postpartum haemorrhage and fistula might be intrapartum asphyxia. In cases of maternal complications, the attention of health care providers diverts to saving the mother, and in some cases, neonates would not get adequate care, which leads them to intrapartum asphyxia. However, future research should be conducted to get the exact cause of neonatal mortality in such complications. However, this study’s results, which identified obstructed labour as a risk of neonatal mortality, were similar to studies conducted in Hawassa University hospital, Ethiopia , and tertiary hospitals in Tanzania . These findings might be due to asphyxia and other related consequences of prolonged labour leading to premature neonatal death.
Moreover, mothers who were not monitored with partograph during labour were nearly three times the risk of newborn mortality than their counterparts. This result was supported by a study in Addis Ababa  and Tigray regional state . This outcome entails feto-maternal health should be monitored with the start of the active first stage of labour for timely management of prolonged labour, and its consequences will be early identified as prevention and control of early neonatal death.
Furthermore, direct admission was 39% less risk of newborn mortality than those admitted from referral to another health facility. In other words, mothers who require a referral were either suffer from severe obstetric problems or transfer time. We extend the time to receive skilled care. Besides, less than one hour of maternal first delay to visit health was 39% less risk of newborn death. This result was similar to a study in Tigray Northern Ethiopia, showing that seeking skilled care at the start of labour was protective for perinatal mortality , Uganda , and India. This result indicates that the first delay in maternal death also contributes to early neonatal death. We suggest that healthcare providers pay attention to newborns’ care with significant intrapartum asphyxia, including respiratory, temperature, and nutritional support.
Despite the indications of the Ghanian study , this study has some inherent limitations. First, though this study was unique in addressing the first three days of life with a follow-up study design to determine the risk factors of early neonatal mortality, being only at the tertiary level of care may elevate the actual incidence estimate of premature neonatal death of the region. Second, the study was based on tertiary hospitals and may not show the picture of secondary and primary hospitals, and data were only collected up to 72 hours of the life of the newborns and, therefore, cases occurring after 72 hours were missed. Third, a mixed-method study design should have been used to identify the issues related to mothers and health care providers’ perceptions of the quality of services provided in the referral hospitals. Further longitudinal studies focusing on early neonatal death should explore health system factors, maternal factors, and obstetric factors, especially in the first three days.