Neonatal Mortality And Associated Factors In A Pastoral Region, Afar, Ethiopia: A Health Facility Based Study

Abstract Background: Neonatal mortality is public health issue in developing countries, such as Ethiopia. Unfortunately, the issue is noticeably under-reported and underestimated, so the true gravity of the situation cannot be acknowledged. Subsequently, Afar in Ethiopia contributes the largest burden of under-five mortality when compared to other regions in the country. Regrettably, there is no current information to the rates and predictors of neonatal mortality for the region. Thus, this study aims to assess neonatal mortality and associated factors in pastoral communities residing in Afar, Ethiopia. Methods: A health facility based retrospective cross sectional study was conducted on 403 neonates admitted to the neonatal intensive care unit (NICU) from May 1 st 2015 - May 2nd 2019. Medical records were reviewed and audited for both mothers and neonates to collect data using standardized data extraction checklist. The medical records were selected using a systematic random sampling technique. Binary logistic regression with odds ratio and 95% Confidence interval was calculated to assess the association between neonatal mortality and associated factors. Finally, the statistical significance level was declared at a p-value <0.05. Results: 391 medical records of newborns were included with data complete rate of 97.02%. The prevalence of neonatal mortality was 14.6% (95% CI 11.0%-18.4%). Lack of antenatal care (ANC) follow up (AOR = 4.69: 95%CI 1.77, 12.47), giving birth through cesarean section (AOR 3.59, 95%CI 1.22, 10.55), having a temperature less than 36.5 o C within the first hour of admission (AOR 10.75, 95%CI 3.75, 30.80), perinatal asphyxia (AOR 7.16, 95%CI 2.22, 23.10) and/or having a length of stay greater than five days in the hospital (AOR 0.23, 95%CI 0.08, 0.66) were signiﬁcantly associated with neonatal mortality.

Even though developing nations, such as Ethiopia, have made progress in the reduction of under-five mortality rates by more than fifty percent at the end of 2015, the neonatal mortality rates have still not reduced enough [7,13]. In addition, over 67% of neonatal deaths in Ethiopia are mainly due to preventable causes such as extreme maternal age, prematurity, low-birth-weight, newborn infections, short birth space, birth asphyxia and/or birth trauma [14][15][16][17]. Birth asphyxia, neonatal infections and prematurity are the three leading causes of neonatal mortality accounting for 93% of deaths in the first month of life [18]. Moreover, a prospective cohort study conducted in Butajira district, south central Ethiopia and a study conducted in Gondar referral hospital found that more than 70% of neonatal deaths occurred during the early neonatal period (0-6 days) and more than 30% were in the late neonatal period (7-27 days). Of the total number of neonatal mortality, 54% occurred in the first 24 hours of life [19,20] In 2018, in Ethiopia, the rate of neonatal mortality ranges between 23.4 per 1000 live births to 44 per 1000 live births [21][22][23][24]. In 2016, though the rate of neonatal mortality decreased from 54 to 29 per 1000 live births at national level, the Afar regional state has the second highest neonatal mortality rate (38 per 1000 live births) next to the Amhara regional state [23]. From this, it can be seen that neonatal mortality is still a public health problem in Ethiopia and the problem is expected to be higher in pastoral communities, where there is no evidence-based studies besides the national survey.
Finally, there are no specific studies conducted to assess the burden and contributing factors for neonatal mortality in the pastoral communities within the Afar region.
Therefore, this study intends to assess the prevalence of neonatal mortality and its associated factors in this region and, hopefully, will generate evidence that will help to develop different strategies to reduce the burden of neonatal mortality in regional and national levels.

Study settings and participants
An institution based five years retrospective cross-sectional study (i.e. 1 st May 2015 up to 2 nd May 2019) was conducted from 1 st May to 2 nd June 2019 to assess neonatal mortality rates and associated factors among neonates admitted in randomly selected public hospitals (Dubti referral and Aysaita district hospitals) found in Afar, Ethiopia. The hospitals are located 598kms, and 658kms away from the capital city, Addis Ababa, respectively. Annually, these hospitals serve more than a half million people.
All systematically selected neonates who were admitted in the randomly selected government hospitals' neonatal intensive care unit from 1 st May 2015 -2 nd May 2019 and those who had a complete medical record were included in the study. However, all neonates who had no discharge summary note and confirmed stillbirths were excluded from this study.
The sample size was calculated using a single population proportion formula. In order to have an adequate sample size, we have taken P= 50% with the basic assumptions of 95% confidence interval (the Critical value Zα/2= 1.96), 5% margin of error and the researchers added 5% to compensate the incomplete data. Then, the calculated sample size became 403 (384×0.05 + 384).
Where: n = the required sample size, Z α/2= the standardized normal distribution curve value for the 95% confidence interval, P= the proportion of neonatal mortality among the general newborns, and d= degree of precision (the margin of error between the sample and population).
The two public hospitals were randomly selected from five hospitals found in Afar regional state. The medical records of the admitted newborns were selected using a systematic sampling technique with every 5 th interval (i.e. from 2,015 total medical records in the last five years). The sample was proportionally allocated for each hospitals. The index medical record of newborn was selected using a lottery method from 1-5. Thus, the study participants were recruited using the 3 rd , 8 th , 13 th , 18 th , … until the required sample size was satisfied based on the inclusion criteria.

Data collection tools and procedures
The data extraction checklist was developed after reviewing of the NICU admission and delivery registration log books. The chart review checklist included sociodemographic characteristics, maternal factors (age, ANC follow up, mode of delivery, place of delivery, maternal HIV status, parity, multiple delivery, gravidity), fetal factors (sex, birth weight, status at birth, diagnosis of disease, gestational age, APGAR scores at birth, neonates HIV status) and health care providers related factors (medication given at admission, vital signs taken at admission, scheduled prescribed medications).
Training was provided over two days for data collectors and supervisors. The checklist was pretested on 5% of the samples at non-selected public hospitals, where a panel of experts verified content validity of the instruments, and the required revisions were made.
Data was collected by trained midwifes using a standardized and structured reviewer administered checklist.

Definitions:
Completed data: a data that has at least complete discharge summary about the admitted neonate including possible cause of death Neonate: a new born baby within 28 days of life.
Neonatal mortality: the death of an infant that happened after birth but before 28 days of life.
Still birth: neonate born without evidence of life at birth.

Data processing and management
Data collected was cleaned for errors, entered into Epi-Data version 3.1 and exported into SPSS version 23.0 for statistical analysis. Descriptive statistics were done and the results were presented with texts, tables, mean and standard deviation.
A bivariate logistic regression analysis was done to identify variables that had a p < 0.25 to be considered in the multivariable logistic regression model. Correlation between independent variables was checked. The model fitness was assessed. Multivariable logistic regression analysis was done to identify factors associated with neonatal mortality. The findings of the final model were reported with an odds ratios (OR) and corresponding 95% Confidence Interval. Finally, a statistically significant level was declared at a p <0.05 in the final regression model.

Study Participants Sociodemographic Characteristics
A total of 391 neonatal charts were reviewed and 97% fulfilled the completeness criteria.
In this study, it was found that 251 (64.2%) of the neonates were males. In addition, the majority of neonates [317 (81.1%)] were admitted into the neonatal intensive care unit (NICU) at less than 7 days of age. The mean age of mothers was 26.05 (SD±5.35) and 321 (82.1%) of mothers resided in urban areas (see Table 1).

Maternal health related conditions
The maternal chart review revealed that more than two thirds of the mothers [239 (3.3%) of mothers had known recorded medical illnesses during pregnancy (see Table 2).

Fetal health related conditions
The neonatal chart review found that 92 (23.5%) of neonates were preterm and 118 (30.2%) of the neonates had a birth weight less than 2.5kg. In addition, 270 (69.1%) of the neonates had a resuscitation event at birth and only 10 (2.6%) of the admitted neonates were retroviral infection exposed. Moreover, the study identified the leading causes of neonatal admission in the NICU. The leading causes of admission were; early onset neonatal sepsis (43.5%), low birth weight (27.1%) and prematurity (23.5%) (See Table   3).

Cares given for neonates immediately after admission
It was found that the majority of neonates were given antibiotics within one hour of admission 372 (95.1%) and 355 (90.8%) of the neonates were given IV fluids containing glucose. In addition, 310 (79.3%) of neonates were supplemented with oxygen and 12 (3.1%) of admitted neonates were given phototherapy. Here, we reassured that one neonate may be given more than one care immediately after admission. Such as, antibiotics and IV fluid or oxygen and antibiotics and so on (see Figure 1).

Neonatal outcomes at discharge and causes of neonatal mortality
This study revealed that the overall prevalence of neonatal mortality was 14.6% (95%CI: 11.0, 18.4). Moreover, the neonatal mortality rate was 35.1 per 1000 live births in the selected NICUs. When we look the five years trend of neonatal mortality, it is still steadily increasing from 2015 to 2019 (17.5% to 29.8%). In addition, 300 (76.7%) of the neonates were discharged within 5 days of admission and the mean length of stay in NICUs was 4.16 days ±3.07 SD. Furthermore, the study showed that the leading causes of neonatal mortality were prematurity (43.9%), early onset neonatal sepsis (35.1%), low birth weight (33.4%) and perinatal asphyxia (21.1%) (See Table 4).

Factors associated with neonatal mortality
After checking for model multi-collinearity and model fitness, variables with a p-value < 0.25 were entered into the final model. The multivariable logistic regression analysis showed that lack of ANC follow up, giving birth through cesarean section, having a temperature less than 36.5 o C at the first hour of admission, perinatal asphyxia (PNA) and length of stay in the NICU for less than five days after admission were the independent predictors of neonatal mortality. to die compared to neonates who stayed for less than five days (AOR=0.23: 95%CI 0.08, 0.66) (see Table 5).

Discussion
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 [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 (36.5-37.5 o c) (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 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.

Conclusions
In conclusion, this study found that there is a high prevalence of neonatal mortality when compared to the national and regional data. The majority of neonatal deaths occurred in the first five days of life with the leading causes due to early onset neonatal sepsis, low birth weight and prematurity.
Neonates born from mothers who did not receive any ANC, delivered by caesarean section, had a body temperature of less than 36.5C within the first hour of admission, had a length of stay less than five days in the NICU and presented with PNA were significant predictors of neonatal mortality.
Moreover, the majority of newborn deaths resulted from preventable and treatable conditions such as birth asphyxia, prematurity, intrapartum associated factors and neonatal infections. Thus, health care providers should give due attention for neonates admitted to neonatal intensive care units by taking vital signs routinely such as temperature. In addition, the health facility management should strengthen the quality of cares given in neonatal intensive care units to improve the outcome of admitted patients.
Finally, promotion of ANC follow ups for all pregnant women should be given focus in pastoral communities such as in the Afar region. Furthermore, prospective studies supplemented with qualitative methods are recommended.

ANC
Antenatal Care permission letter was written from the Regional Health Bureau to the randomly selected Hospitals. Finally, an official permission letter was obtained from each hospital to proceed with the data collection. Informed consent was not applicable for the study since the data was collected with medical chart review. Confidentiality was maintained by keeping records in a secured manner and avoiding personal identifiers.

Consent for Publication
Not applicable Availability of data and materials All materials and data related to this article were included and well supplemented during manuscript preparation.
Competing interests: The authors declare that they have no competing interests.

Funding
Not applicable.
Authors' contributions: AW, YM and CSD conceived and designed the study. AW and YM supervised the data collection and they performed the data analysis, interpretation of data and drafted the manuscript. AW and CSD authors had critically reviewed the manuscript. All authors read and approved the final manuscript.   Others* = NEC 2 , Congenital anomalies 1 , anemia 1 , hypoglycemia 1 and hyperthermia 1 .
Note: One neonate can have more than one cause.