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.
In this study, out of 810 babies born at the referral hospitals of Amhara regional states, 122 neonates were lost their lives within the first three days of life, giving an overall newborn mortality rate of 151/1000 births. Similarly, the stillbirth rate was 672.1/100 births. This figure shows a significant decline from a study conducted in the Black lion hospital (225/1000 live births) . This decline might be due to the impacts of different interventions for the last six years across the country. However, it was much higher than the global neonatal mortality rate in 2016 , and in studies conducted in Southern Ethiopia [23, 24], Eastern Ethiopia , Southwest Ethiopia , Sudan , Uganda  and Zambia . The variances might be attributed to study designs, health service coverage, and socioeconomic factors. This finding might also be because of the admission of complicated mothers 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, the findings of this study should be interpreted vigilantly because the reports of stillbirth rate 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 found to be 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 as compared to 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. This will, in turn, 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 of postpartum hemorrhage, development of fistula within the first 24 hours, and obstructed labor were found to be three times, four times, and more than twice risky for new-borns death within the first 72 hours of life. The finding of our study regarding fistula and postpartum hemorrhage as risks for neonatal mortality was unique in this finding. The possible reason for neonatal mortality among mothers facing postpartum hemorrhage 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, the results of this study, which identified obstructed labor as a risk of neonatal mortality, was similar to studies conducted in Hawassa University hospital, Ethiopia , and tertiary hospitals in Tanzania . This is due to asphyxia and other related consequences of prolonged labor that leads to premature neonatal death.
Moreover, mothers who were not monitored with partograph during labor were nearly three times the risk of newborn mortality as compared to their counterparts. This result was supported by a study in Addis Ababa , and a study in Tigray regional state . This outcome entails feto-maternal health should be monitored with the start of the active first stage of labor for timely management of prolonged labor, 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 labor was protective for perinatal mortality . This result indicates the first delay in the road to maternal death were also has a significant contribution in the early neonatal death. We suggest that health care providers should pay attention to the care for newborns with significant intrapartum asphyxia, including respiratory, temperature, and nutritional support.
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 estimate of the actual incidence 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 the perception of mothers and health care providers on the quality of services provided in the referral hospitals. Thus, Future research should be conducted to encompass the full 28-day postnatal period, mixed-method, and compare the neonatal mortality at the primary, secondary, and tertiary level of care.