Interpretation
The neonatal death rate in the current study is almost similar to the Jordan Perinatal and Neonatal Mortality study using the same cut-off point of gestational weeks ( > = 20 weeks) 5 indicating that the rate has flatten since 2015 and has not shown a significant decline. Despite the tremendous efforts and improved NMR outcome since 1990, still more work is needed to accomplish the Sustainable Developmental Goal by 2030, particularly in regions with high NMR 1 including Jordan.
The main leading cause of neonatal death in the current study was respiratory and cardiovascular disorders followed by congenital malformation and chromosomal abnormalities, and these are similar to the findings in Batieha et al., study (2016) in which congenital anomalies was a leading cause of death.5 Literature revealed that although several congenital anomalies could be avoided, they still are important causes of neonatal deaths.22 Congenital malformation was reported constantly across many classification systems,23 which could be preventable by prenatal folic acid with multivitamin supplements that is proved to decrease the incidence of congenital abnormalities such as neural tube defects.24, 25
Although the current study did not look at the association between Apgar score and NMR, it is expected that respiratory and cardiovascular disorders that contributed to higher neonatal deaths in our study were indirectly related to low Apgar score. Previous studies showed that Apgar score was low in babies with neonatal infections, asphyxia related complications, meconium aspiration respiratory distress, and neonatal hypoglycaemia.26, 27
Neonatal deaths often happen quickly, caused by an illness presenting as an emergency, either soon after the birth or later, due to infections.9
Similar to our findings which showed that the second leading cause of death was low
birthweight and preterm, previous studies also showed that a strong predictor of neonatal death is immaturity as usually reflected by the age in gestational weeks at birth. Neonatal mortality can differ significantly between preterm babies and their counterparts full-term infants born at 39–40 weeks of gestation.10 Moreover, the findings of the national Jordan Perinatal and Neonatal Mortality study 5 are congruent with our findings where preterm, gestational age before 37 weeks, low birthweight, multiple pregnancy were the most common risk factors associated with neonatal deaths. Low birthweight may result from both foetal growth restriction and preterm birth, which are associated with placental dysfunction and subsequent poor foetal outcomes.17 Likewise, a study conducted in 60 low and middle income countries found that NMR was significantly higher among twins versus singleton newborn babies even after adjusting for birthweight.28 Another study in Bangladesh found that NMR was much higher among newborn babies born before 34 gestational weeks, twins or triplets, and first child in the family.29
Mode of delivery was a significant factor in our study in which emergency CS was associated with higher NMR. Previous studies showed that caesarean section rates higher than 10% are not associated with reduction in NMR, and hence should be avoided as much as possible.30 It is worth mentioning that the NMR has increased significantly in the last three decades including Jordan, surpassing the WHO recommendations of 10–15% CS as the maximum rates.31, 32
Interestingly, the current study showed that NMR did not vary significantly according to mother’s age, income, and working status but mother’s high school or less of education was associated with higher rates of neonatal deaths. Incongruent with our findings, maternal age of 30–35 years was associated with higher NMR.29, 33 The latest national study showed that maternal age < 20 years was associated with higher rates of neonatal deaths.5 However, some research suggested that advanced maternal age is associated with placental dysfunction that may increase the risk of neonatal deaths and stillbirths34 or to existing maternal medical condition.35 Also, newborn babies of richer families who also have a high educational level have higher chances to survive than those born to a poor family with lower educational level.36
Despite the fact that the majority of neonatal deaths can be prevented with efficient interventions,37 some disadvantaged women and newborns who are most vulnerable to death and chronic morbidity have poor access to quality healthcare services.19, 38 Nonetheless, understanding the social and geographical pattern of NMR is crucial for stakeholders to increase access to effective interventions with focus on the poorest populations.19, 39 This will ensure that every pregnant woman and newborn baby have equal access to lifesaving interventions.40
For the main maternal diseases or conditions affecting infants, the most common reported condition in the current study was complication of placenta, cord, and membrane, followed by maternal complications of pregnancy, and lastly maternal medical and surgical conditions. Placental dysfunction is linked to intrauterine growth restriction, preterm birth, and birth defects41 resulting in inadequate oxygen supply to the foetus and thus increasing the probability of preterm births and/or low birthweight. Our findings are somehow congruent with the 2016 national study that revealed maternal diseases such as preeclampsia, mother’s hospitalization during the current pregnancy, and poor antenatal care can all lead to neonatal deaths. It is surprising that in the national study, only a third of neonatal deaths had received optimum medical care.5 Other studies conducted in low-middle-income countries like Pakistan have also specified several contributing factors to neonatal deaths such as inadequate training, insufficient medical care, low competence of healthcare providers and a lack of resources.42 Nonetheless, the national study showed also that a large proportion of neonatal deaths are preventable or possibly preventable thus providing optimal intrapartum, and direct postpartum care is likely to result in reduction of NMR.5
However, not all births are registered in Jordan, especially if the birth results in stillbirth or early neonatal death before discharge from the hospital and the majority of neonatal deaths are not reported either.15, 16 About 30% of children < 5 years do not have a birth certificate,18 and parents do not usually issue a death certificate for the majority of neonatal deaths.19 Thus, there is a lack of credible data on causes of stillbirths and neonatal deaths than all-cause mortality data, hindering the development of appropriate interventions to avoid such deaths. The current study fills the gap in such data and hence, encourage stakeholders and policy makers to design and implement timely, evidence-based interventions to regions that register high number of stillbirths and neonatal deaths.
In the current study, having a NMR of 14.1 per 1000 total LB highlights an immediate attention to accelerate appropriate efforts to prevent such deaths. This is vital as recent literature reported that with no improvements in neonatal mortality, 27·8 million neonates will die in the period from 2018 to 2030.1 Yet, if policy makers initiate and implement interventions and improve quality of care to the point that NMR - in the countries that are still behind- would match the SDG target, then 5 million newborn babies could survive. A particular emphasis need to be towards births because a third of all neonatal deaths occur on the day of birth globally and about three-quarters of neonatal deaths occur during the first week of life.19, 43