In developing countries like Ethiopia, rates of neonatal mortality are several folds higher compared to developed nations, ranging ranges between 23.4 per 1000 live births to 44 per 1000 live births [21-24]. However, accurate epidemiological data is not adequate, and the exact magnitude neonatal mortality in pastoral communities of Ethiopia is not clearly known. Thus, this study aimed to assess the prevalence and associated factors of neonatal mortality in pastoral communities of Ethiopia, within the Afar region. Prevalence of neonatal mortality in the Afar region were high compared to the national mortality figure. The multivariable logistic regression found that the lack of ANC follow up, neonates delivered by caesarean section, neonates who had a body temperature of less than 36.5C at the first hour of admission, neonates who stayed less than five days in the NICU and neonates with PNA were all the independent predictors of neonatal mortality in the Afar region.
Moreover, the prevalence of neonatal mortality was found to be 14.6% (95%CI: 11.0, 18.4). This finding is similar with a study conducted in Gondar university teaching hospital, Northwest Ethiopia (14.3 %) [20] and a retrospective chart review done in Felege Hiwot referral hospital, Bahir Dar (13.3%) [25]. But, the finding is higher than the prevalence of neonatal mortality reported in the Somali region, Ethiopia (5.7%) [26], a study done in Jimma zone, Southwest Ethiopia (3.2%) [18], a study done in North Gondar, Northwest Ethiopia (4.4%) [22], and a study done in Ayder referral hospital, Mekelle (6.6%) [17]. The difference could be explained by methodological differences among studies and dissimilarity in sociocultural elements such as health service utilization, difference in hospital settings (equipment available and skilled persons), economical variations among study participants of the study areas as well as a difference in geographical locations.
On the other hand, the prevalence of neonatal mortality in this study is lower than a study conducted in Mizan Tepi university teaching hospital (22.8%) [21], and a study conducted in Gondar university teaching hospital (23.1%) [16]. The variations may be justified by increased awareness of the community upon utilization of available health services including delivery at health facilities, and seeking health facilities for sick neonates and children.
Furthermore, it was found that the identified major causes of neonatal mortality were prematurity (43.9%), early onset neonatal sepsis (35.1%), perinatal asphyxia (PNA) and low birth weight (21.1%). This is similar with a study conducted in Mizan Tepi university teaching hospital having prematurity (31%), neonatal sepsis (29.7%), low birth weight (15.3%) and PNA (7.7%) as the leading causes of death [21]. This could be explained by the majority of neonatal deaths in developing countries are related to conditions of labor, intrapartum and the immediate newborn care practices. From this, it can be seen that neonatal survival interventions are not targeting the intrapartum as well as immediate and early neonatal periods, and as a direct result, neonatal mortality has not declined in the needed manner.
The multivariable logistic regression analysis showed that neonatal mortality was significantly associated with lack antenatal care follow up. The rate of neonatal mortality was 4.7 times greater among mothers who did not have ANC follow up compared to those mothers had ANC follow up (AOR 4.69, 95% CI 1.77, 12.47). This finding is similar with a study conducted in North Shoa zone, Amhara region [27], and a study conducted in Jimma zone, Southwest Ethiopia [18]. This can be explained by the fact that women not having antenatal care follow up during pregnancy are more at risk for prone pregnancy and intrapartum related problems, which in turn, can put the newborn at risk of death. Therefore, women with adequate antenatal care visits have a better chance of early detection and management of the birth related problems.
Additionally, it was found that neonatal mortality was related to the hospital length of stay. Neonates who stayed for more than 5 days in the neonatal intensive care unit (NICU) had a 77% reduction in mortality rates when compared to those who stayed for less than five days (AOR 0.23: 95%CI 0.08, 0.66). This finding is in line with a study conducted in Jimma university medical center which stated that neonates who stayed for less than seven days in the NICU had 3.9 times higher risk of neonatal mortality when compared to those who stayed for seven or more days [28]. This can be explained because most neonatal deaths happen in the early neonatal periods (0-6 days of life) than in the late neonatal period of life (7-28 days) [19, 20]. Thus, due attention should be given for neonates in the early neonatal period to reduce neonatal mortality in the health facilities.
In addition, this study revealed that the odds of death among neonates who had a body temperature less than 36.5C at the first hour of admission was 10.7 times greater than compared to those neonates who had a normal body temperature (36.5-37.5oc) (AOR 10.75: 95%CI 3.75, 30.80). This is consistent with a retrospective cohort study conducted in southern Ethiopia referral hospitals which state that neonates who had a temperature of less than 36.5 at admission had higher risk of death than neonates with normal temperature (36.5 to 37.5) [29]. This can be justified by neonates who are in a hypothermic state may be more prone to different infections. As result, they are more likely to become septic and die when compared to neonates with normal body temperatures.
Moreover, this study found that neonates when delivered by cesarean section were 3.6 times at greater risk of death than neonates born spontaneously by vaginal delivery (SVD) (AOR 3.59: 95%CI 1.22, 10.55). This finding is similar with a study conducted at Pakistan, where delivery using C-section had increased risk of neonatal mortality [30]. This might be related to neonates born via C-section without clear indications such as prolonged labor, fetal distress, obstructed labor and other medical problems during pregnancy. These neonates delivered through C-section are at greater risk of birth asphyxia than neonates born with birth canal. Therefore, neonates born through C-section had a high probability of death than neonates delivered through the natural birth canal. However, this result is contrary with a study conducted in southern Ethiopia referral hospital NICU, where neonates delivered using C-section had 66% less chance of risk of death compared to SVD (AOR 0.34: 95% CI 0.19, 0.61) [29]. This can explained by timely decision making rather than simply waiting for vaginal delivery, which may save the life of the neonate and the mother. Thus, delivering through C-section with clear indications can reduce the risk of death by early identification and intervention of birth related complications such as prolonged labor.
Finally, neonates with a history of perinatal asphyxia (PNA) had 7.2 times greater risk of death when compared to those who had no history of PNA. This is consistent with a study conducted in southern Ethiopia referral hospitals [29], which found that neonates with PNA had 2 times higher risk of death than their counterparts. This finding is also similar with a study conducted in Jimma university medical center, which revealed neonates who had a history of birth asphyxia had 5 times greater risk of death [28]. This may be due to the fact that besides commencement of adequate efforts after admission, neonates with respiratory problems like birth asphyxia had a greater risk for a poor prognosis and death compared to neonates admitted with other medical problems. Therefore, neonates with a respiratory distress have higher chance of death when compared to those who do not experience any respiratory distress.
Study limitations: the study was conducted based on patient chart reviews, which may not display all factors pertaining to neonatal mortality. So, the results may not be fully representative of the community’s neonatal mortality. In addition, there is a potential to miss neonatal deaths particularly with those whose discharge status were incomplete.