Prevalence for the Risk of Neonatal Death and Associated Factors under Treatment in Public Hospitals in Amhara Region, North-West, Ethiopia

Awoke Seyoum Tegegne^1* and Getu Degu Alene^2
*Correspondence: Awoke Seyoum Tegegne, Department of Statistics, Bahir Dar University, Bahir Dar, Ethiopia, Tel: 0919779451, Email:

Keywords

Neonatal • Mortality • Risk of neonatal death • Ethiopia • Prevalence • Death • Prematurity

List of Abbreviations

EDHS: Ethiopian Demographic Health Survey; SPSS: Statistical Package for Social Science; NNM: Neonatal Mortality; TBAs: Traditional Birth Attendants; SDG: Sustainable Development Goal; SRS: Simple Random Sampling; WHO: World Health Organization

Introduction

The neonatal period, accounted for the first 28 days of life, is one of the highest risks of mortality for the human lifespan [1]. Neonatal death is the probability that a child born in a specific year or period will be died in the first 28 completed days of life per 1000 live births. The neonatal deaths may be early neonatal death (death occurred in the first seven days of life) and late neonatal deaths (deaths occurred after the seventh day but before the 28th days of life). It is also termed as the death of a neonate within the first month of life and is expressed as neonatal deaths per 1000 live births [2].

Globally each year over four million neonates died within 28 days of birth. Every minute 20 children under five die, leading to eight million deaths before they reach their fifth birthday due to the conditions which could be either avoided or treated. Neonatal mortality accounts for two-thirds of deaths of infants, and nearly two-fifths of all deaths in under-five children [3]. Neonatal mortality was the cause of 38% of all under-five deaths. Previous studies indicate that about 2.8 million neonatal death take place in the world every year [4,5], and this had a contribution of 60% for infant deaths [6]. As far as international public health policy and programs are concerned neonatal death do not get attention proportional to its health and economic burden [7].

Among the neonatal mortalities, 99% occur in low and middle income countries, whereas half of the deaths occur at home [8,9]. Sub-Saharan Africa accounts the highest level of neonatal mortality in the world. This region has the highest risk of neonatal death in the first 28 days of life and showing the least improvement [10]. High mortality, high fertility and low life expectancy characterize the demography, as in most sub-Saharan African countries [11].

Ethiopia is one of the six countries which account for 50% of neonatal mortalities in under five children [12]. According to EDHS in 2016, Ethiopia is among the highly prevalent countries with the highest number of neonatal mortality accounts for 29 deaths per 1000 live births.

There is scarcity of researches on neonatal mortality in the study area. Most of the reports for any program planning and implementation have been used the EDHS data which is done every five years of period [13].

Most of the previous studies are institutional based which are based on secondary data and few studies on the community-based. Hence, the main objective of current study was to assess prevalence and associated factors for neonatal mortality in Amhara region, Ethiopia. This community-based study used the WHO verbal autopsy to identify the factors associated with the neonatal mortality in the study area.

Materials and Methods

Study area and period

A study was conducted in Amhara National Region. The region consists of about 12 zones. There are 17 government hospitals selected randomly for data collection in the region with proper documentation of neonatal death rate result. The study was conducted for women whose follow ups were in the periods between October 2021 - June 2023. The data have been collected in 17 governmental Hospitals [14]. The study was conducted from March to May 2023.

Study design

Community-based cross-sectional study was conducted for current investigation.

Study population

The randomly selected women who gave birth in the last 12 months and caregivers in the public hospitals were the study population.

Sample size determination

A single population proportion formula was used for sample size determination and to do this

The significant independent variables were checked by using epi info [15]. From the above epi info result, the larger one was residence with sample size 866. The total sample size by considering the design effect 1.5 was 1299. Hence, the total sample of 1299 was distributed with probability proportional to size.

Sampling procedure and technique

Multi-stage sampling technique was implemented for the sampling procedure. The 12 woredas were divided into either town or rural and 25 % of the woredas were selected using simple random sampling technique and among the hospitals in the region about 17 were randomly selected. In those selected hospitals, about 25% of patients were selected with simple random sampling that was proportional to patients in each hospital. The lists of women who give birth in the last 12 months have been registered by health extension workers. Using such sampling technique, 1299 women were selected and included under current study.

Variables included in the study

Dependent variable: The variable of study under current investigation was neonatal mortality, whether the neonates died or not. Hence, it has two possible outcomes (death or not).

Independent variables: Socio-demographic factors include occupation, residence, marital status, maternal age, maternal education and antenatal follow up, income level. Maternal and health care service factors include a family history of neonatal mortality, maternal diseases, tetanus toxic vaccination. Obstetric factors include complication of pregnancy, mode of delivery, parity, place of delivery, attendant at delivery, the complication of labor and history of abortion. Neonatal factors include infection, congenital malformation, and age of neonate at delivery time, breastfeeding, birth weight, and birth interval, sex of neonate and birth order of neonate at birth.

Data collection technique

The data were collected through a pre-tested interviewer-administered structured questionnaire. The verbal autopsy was developed and validated by WHO to make every baby count: Audit and review of stillbirths and neonatal deaths by capturing basic information on all births and deaths, as well as identifying the leading cause of death in selected cases for implementing ways to improve the quality of maternal and newborn care.

Data collection procedure

The data were collected by interview administered questioner methods. In the data collection process, 17 health professionals have participated and two to three physicians (doctors) were participated in data collection. One day training was given for data collectors about variables included under investigation and on how to use verbal autopsy questioner and data collection.

The descriptive result was presented in the form of tables and graphs. Binary logistic regression analysis was conducted to discover the effect of each study variable on the outcome variable. Variables having p-value <0.05 were considered as significantly associated with outcome. The model adequacy check was done through Hosmer and Lemeshow test.

Use of experimental animals and human participants

The Bahir Dar University, College of Sciences, Ethical approval and licensing board approved the experiments and ethical issues in this investigation. Hence, it is confirmed that all experiments were performed in accordance with relevant guidelines and regulations.

Results

Socio-demographic characteristics of respondents

Among the total 1299 live births, 1242 of them included in the study. Fifty seven of them were non-respondents due to different reason and the total response rate for the study was 95.6%. Of the total 1242 live-births included in the analysis, 1058(85.2) were from the rural residence. The majority, 657(53.3%) of the mothers of the neonates were in the age group of 20-34 years. About 1116(90.7%) of women were married. More than half of the mothers, 717(57.9%), didn’t attend any formal education. The great majority, 1013(81.7%) of the mothers were housewives.

Maternal and obstetric factors

Among the mothers of neonate 419(33.7%) of them had no ANC visit at all. Nearly half of them had 1-3 visit 618(49.8%) and 205(16.5%) of them had 4 or more ANC visit in their current pregnancy. Majority of women started there ANC visit in the second three months which were (50.4%). Less than half of women had PNC (35.2%). More than half 812 (65.4%) of women had a total birth of two to four births

Of the total women majority of them had no vaginal bleeding in the last three months of pregnancy 1155 (94.9%). About 187(15.1%) of women had high blood pressure during pregnancy and 65 (5.2%) of women had blurred vision. Among those women, 27(2.2%) of them had a febrile illness. Only 23 (1.9%) of women had heart diseases and 19 (1.5%) of women had diabetic mellitus.

Among the participants, majority of them were delivered at home which was 767 (61.8 %) and more than half 765 (61.6%) delivered by the non-skilled attendant. About 1125 (90.6%) of them had a normal vaginal delivery. Around half 625 (50.3%) women delivered within 12-23 hours after the labor was started. Only 54 (4.3%) of women were delivered after 24 hours. About 12 (46.2%) of neonates were died at hospital. Likewise 38.5% of neonates were died at home which indicates this much figure were died at home without getting appropriate medical treatment from highly skilled human power at health institutions. Besides, 7.7% of neonates were died on the way to the health institutions (Table 1).

About 54% of the neonates were females, 85.2% of them had normal birth size and 14.8% had smaller than the smaller than normal physical size. Regarding the duration of pregnancy 1049 (84.5%) of them were delivered in ≥ 37 completed weeks and 193 (15.5%) of them were delivered in less than 37 weeks. From all neonates, only 108 (8.7%) of them had within one hour breastfeeding initiation whereas the rest 1134 (91. 3%) had after one hour breastfeeding initiation report. Finally, among the 1242 live births in the last 12 months, 26 neonates died with 20.9 per 1000 live births.

From the total of 26 deaths occurred, VAs were implemented for 23 cases. Initially, the two physicians were involved in assigning on the most probable cause of death but they agreed for only for 17 cases from 23 cases, for 6 cases the probable causes were different between the physicians. As a result, those cases were given to the third physician and three cases were agreed with one of the two physicians the rest three cases were not similar and classified as unspecified cause of death. With this, birth asphyxia 5 (19.2%), neonatal infections (sepsis and tetanus) 8 (30.8%), prematurity 6 (23.1%) and congenital malformation 1 (3.8%) unspecified cause 3 (11.5%) were the leading causes of neonatal mortality, 3 (11.5%) of them were unknown causes.

Bi-variable analysis of variables associated with neonatal mortality

From socio-demographic factors; the duration of pregnancy, number of births given by a given mother, history of previous neonatal death, antenatal care, delivery place, history of abortion, sex of neonates, tetanus vaccination were significantly affected the risk of neonatal death in the bivariate data analysis and were taken to data analysis in the multivariate data analysis.

Multivariable analysis of factors associated with neonatal mortality

From the total 16 variables that were entered in the bi-variable analysis, only eight of them were entered to multivariable analysis. The significant variables affected the variable of interest is indicated Table 2 and described as follows.

The risk of preterm neonatal death was 4.54 times that of risk of neonatal death delivered at the expected time (AHR 4.54, 95% CI፡ 1.57, 13.17, p-value=0.005).

The risk of neonatal death with mothers who had two up to four births was decreased by 72% as compared to risk of neonatal death with mothers who gave birth greater than four times (AHR=0.28, 95% CI፡ 0.08, 0.99, p-value=0.008). However, the risk of neonatal death with prim parous was 4.21 times the risk of neonatal death with mothers who gave birth greater than four (AHR=4.21, 95% CI፡ 1.39, 12.7, p-value=0.011).

The risk of neonatal death with mothers who had a previous neonatal death history was 3.50 times (AHR=3.50, 95% CI፡ 1.33, 9.20, p-value=0.011) that of the risk of neonatal death with mothers without previous neonatal death history. Similarly, the risk of neonatal death with mothers without antenatal care was 3.20 times that of the risk of neonatal death with mothers who had antenatal care (AHR=3.20, 95% CI፡ 1.10, 9.30, p-value=0.033).

The risk of neonatal death delivered out of health institution was 4.17 times that of the risk of neonatal death delivered at health institution (AHR=4.17, 95%CI፡ 1.24, 14.08, p-value=0.02).

The risk of neonatal death with mothers who had history of abortion was 4.60 times that of mother without abortion history (AHR=4.60, 95%CI፡ 1.90, 11.32, p-value=0.001) (Table 2).

Discussion

The current study revealed that the risk of neonatal death was 20.9 per 1000 live births. A study in Addis Ababa showed that the neonatal mortality was 23.3% [16] which indicates the risk in Addis Ababa is greater than the current result. The finding is also lower than a report from EDHS 2016 report. These discrepancies may arise due to the study area, sample size difference, study period and the place where information was gathered and type of design used [17-21].

One of the most common contributing factors of neonatal death in this study was duration of pregnancy. Hence, a neonate who was delivered before the expected date may be exposed for different risks and this further leads to death as compared to those neonates whose delivery was at the expected date. This finding is in line with the findings of several other studies [16,22-24]. A study conducted with 2016 EDHS data analysis revealed that, the risk of preterm neonatal death was 15.07 times that of the risk of the term neonatal death [25]. This result is also similar with result obtained in the study conducted in Felege Hiwot Referral Hospital, Bahir Dar which states the neonates who were born before expected time were two times higher to be died than who were delivered term [26]. This is happened due to being preterm will expose the neonate for different conditions as they have many physiologic challenges to adapt extra uterine life due to poor lung maturation, resulted in unable to breathe and hypoxia, and also they are exposed to different fatal conditions like hypothermia, different cardiovascular problem, hyper bilirubinuria, an immature immune defense which exposes them to infections, poor feeding [27].

Place of delivery was another predictor variable affected the risk of neonatal death in current investigation. Hence, the risk of neonatal death with mothers delivered outside of the health institution was greater than that of risk of neonatal death with mothers who delivered in the health institution. This result is consistent with researches conducted previously [17,28,29]. This result is also consistent with another study [22]. The potential reason for this might be delivering at health institution has a lot of advantages on the side of saving neonates life as there is a skilled professional in such institutions.

The number of delivery/birth order given by the mother significantly affected the risk of neonatal death in this investigation. The risk is higher for neonates with mothers at the first birth and those mothers who gave more than four delivery was by far greater that the risk of neonates with mothers whose delivery is between two and four given that the other conditions constant. In several studies, birth order of a neonate leads to controversial research findings of neonatal death [22,30]. Some studies showed that first birth was at the higher risk of neonatal death while others showed that higher-order births were at higher risk [31]. A result in this study is consistent with another study conducted in India [32] which states that neonates with first and higher-order births experienced a high risk of death.

In this investigation, antenatal care plays important role in regard to neonatal death reduction which is similar thought with other studies [16,33-38]. This may be due to proper prenatal and postnatal visit which help in early detection and management of the problems related to the mother as well as neonate which ultimately improves the neonatal outcome. This result is consistent with another previously conducted research [30].

History of previous neonatal death affected the variable of interest. Hence, neonates born from mothers with previous neonatal death have greater risk as compared to those neonates born from mother without history of previous neonatal death. This result is consistent with another study conducted in West Gojjam which states that previous history of neonatal mortality was significantly associated with neonatal mortality [30]. This result is also consistent with other previously conducted studies [9,39,40]. The potential reason for this might be the fact that mothers who had previous neonatal death may have stress and this further lead to other complications.

Abortion history of mothers has significant effect for the variable of interest (risk of death of neonates). Hence, the risk of neonatal death for mothers with previous abortion history was greater as compared to that of the risk of neonatal death with mothers without previous abortion history. The potential reason for this might be the fact that mothers with previous abortion history may lead to metal stress and related disease which might further leads to another abortion. This result is similar to another study conducted in India [41].

Conclusion

The descriptive data analysis in this study showed that the neonatal mortality was 20.9 per 1000 live births. The risk of neonatal death was significantly associated to mothers’ order of births, durational of pregnancy, antenatal care follow-ups, place of birth, neonatal death history and abortion history.

Due attention should be given for mothers with previous abortion history, previous history of neonatal death, mothers with first birth and those mothers who had more than four delivery previously. More attention should be also given for mothers whose delivery was outside of the health institutions or mothers delivered by unskilled persons. Attention should be given for mothers without antenatal care follow-ups.

Heath related education should be forwarded to mother with reproductive age to deliver at heath institution with proper antenatal care. Counselling should be given for mothers with previous history of abortion and neonatal death history to be free from stress during their pregnancy.

Limitation of Study

This study was not without limitation. One of the limitation was some important variables related to neonatal death are not included here. The authors recommended further research related to factors associated to risk of neonatal death including additional variable not included in current study such as education level of mothers.

Declaration Section

Ethics approval and consent to participate

Ethical approval was obtained from the Bahir Dar University College of Sciences. First formal letter was written from Bahir Dar University College of Sciences Research and Community service vice dean to Amhara region health bureau. Then the letter of cooperation was obtained from health bureau to 17 public hospitals. This study was permitted by concerned bodies and waived the consent to participate as the data were secondary in source.

Availability of Data

The data used in current investigation are available within the hands of corresponding author.

Funding

This research was not funded by any agent.

Authors Contributions

Awoke Seyoum Tegegne participated in developing the proposal, data collection, analysis and wrote the manuscript. Getu Degu Alene participated in data analysis, editing the manuscript carefully and gives constructive comments for the betterment of the manuscript. All authors read and approved the manuscript to be submitted to this journal.

Consent for Publication

Not applicable.

Competing Interests

The author(s) declare that there is no a financial and non-financial competing interest between authors of between authors and any agent or individual.

References

1. Oestergaard, Mikkel Zahle, Mie Inoue, Sachiyo Yoshida and Wahyu Retno Mahanani, et al. "Neonatal mortality levels for 193 countries in 2009 with trends since 1990: A systematic analysis of progress, projections, and priorities." Plos Med 8 (2011): e1001080.

Google Scholar, Crossref, Indexed at

2. World Health Organization. “The world health report; Make every mother and child count.” Geneva (2005).
3. Lawn, Joy E., Hannah Blencowe, Shefali Oza and Danzhen You, et al. "Every Newborn: Progress, priorities, and potential beyond survival." Lancet 384 (2014): 189-205.

Google Scholar, Crossref, Indexed at

4. You, Danzhen, Gareth Jones, Kenneth Hill and Tessa Wardlaw, et al. "Levels and trends in child mortality, 1990–2009." Lancet 376 (2010): 931-933.

Google Scholar, Crossref, Indexed at

5. Abubakar, I., T. Tillmann and A. Banerjee. “Global, regional and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: A systematic analysis for the Global Burden of Disease Study 2013.” Lancet 385 (2015): 117-171.

Crossref, Indexed at

6. Lunze, Karsten, David E. Bloom, Dean T. Jamison and Davidson H. Hamer. "The global burden of neonatal hypothermia: Systematic review of a major challenge for newborn survival." BMC Med 11 (2013): 1-11.

Google Scholar, Crossref, Indexed at

7. Shiffman, Jeremy. "Issue attention in global health: The case of newborn survival." Lancet 375 (2010): 2045-2049.

Google Scholar, Crossref, Indexed at

8. Martines, Jose, Vinod K. Paul, Zulfiqar A. Bhutta and Marjorie Koblinsky, et al. "Neonatal survival: A call for action." Lancet 365 (2005): 1189-1197.

Google Scholar, Crossref, Indexed at

9. Lawn, Joy E., Simon Cousens and Jelka Zupan. "4 million neonatal deaths: When? Where? Why?." Lancet 365 (2005): 891-900.

Google Scholar, Crossref, Indexed at

10. Andargie, Gashaw, Yemane Berhane, Alemayehu Worku and Yigzaw Kebede. "Predictors of perinatal mortality in rural population of Northwest Ethiopia: A prospective longitudinal study." BMC Public Health 13 (2013): 1-7.

Google Scholar, Crossref, Indexed at

11. Ringheim, Karin, Charles Teller and Erin Sines. "Ethiopia at a crossroads: Demography, gender, and development." Policy brief (2009).

Google Scholar          

12. Black, Robert E., Saul S. Morris and Jennifer Bryce. "Where and why are 10 million children dying every year?." Lancet 361 (2003): 2226-2234.

Google Scholar, Crossref, Indexed at

13. Wakgari, Negera and Eshetu Wencheko. "Risk factors of neonatal mortality in Ethiopia." Ethiop J Health Dev 27 (2013): 192-199.

Google Scholar, Indexed at

14. Alemayehu, Mulunesh and Wubegzier Mekonnen. "The prevalence of skilled birth attendant utilization and its correlates in North West Ethiopia." BioMed Res Int 2015 (2015): 436938.

Google Scholar, Crossref, Indexed at

15. Seid, Sheka Shemsi, Shemsedin Amme Ibro, Abdulwahid Awol Ahmed and Adugna Olani Akuma, et al. "Causes and factors associated with neonatal mortality in Neonatal Intensive Care Unit (NICU) of Jimma University medical center, Jimma, south West Ethiopia." Pediatric Health Med Ther (2019): 39-48.

Google Scholar, Crossref, Indexed at

16. Worku, Bogale, Assaye Kassie, Amha Mekasha and Birkneh Tilahun, et al. "Predictors of early neonatal mortality at a neonatal intensive care unit of a specialized referral teaching hospital in Ethiopia." Ethiop J Health Dev 27 (2012): 200-207.

Google Scholar, Indexed at

17. Diallo, A. H., N. Meda, W. T. Ouedraogo and S. Cousens, et al. "A prospective study on neonatal mortality and its predictors in a rural area in Burkina Faso: Can MDG-4 be met by 2015?." J Perinatol 31 (2011): 656-663.

Google Scholar, Crossref, Indexed at

18. Hoque, Monjurul, Shahnaz Haaq and Rafiqul Islam. "Causes of neonatal admissions and deaths at a rural hospital in KwaZulu-Natal, South Africa." S Afr J Infect Dis 26 (2011): 26-29.

Google Scholar, Crossref, Indexed at

19. Orsido, Tujare Tunta, Netsanet Abera Asseffa and Tezera Moshago Berheto. "Predictors of Neonatal mortality in Neonatal intensive care unit at referral Hospital in Southern Ethiopia: A retrospective cohort study." BMC Pregnancy Childbirth 19 (2019): 1-9.

Google Scholar, Crossref, Indexed at

20. Mengesha, Hayelom Gebrekirstos, Alem Desta Wuneh, Wondwossen Terefe Lerebo and Tesfay Hailu Tekle. "Survival of neonates and predictors of their mortality in Tigray region, Northern Ethiopia: Prospective cohort study." BMC Pregnancy Childbirth 16 (2016): 1-13.

Google Scholar, Crossref, Indexed at

21. Basiri, Behnaz, Farzaneh Esna Ashari, Maryam Shokouhi and Mohammad Kazem Sabzehei. "Neonatal mortality and its main determinants in premature infants hospitalized in neonatal intensive care unit in Fatemieh Hospital, Hamadan, Iran." J Compr Pediatr 6 (2015).

Google Scholar, Crossref, Indexed at

22. Kebede, Bekana, Abebaw Gebeyehu, Hardeep Rai Sharma and Sisay Yifru. "Prevalence and associated factors of neonatal mortality in North Gondar Zone, Northwest Ethiopia." Ethiop J Health Dev 26 (2012): 66-71.

Google Scholar

23. Kokeb, Mehretie and Teshome Desta. "Institution Based prospective cross-sectional study on patterns of neonatal morbidity at Gondar University Hospital Neonatal Unit, North-West Ethiopia." Ethiop J Health Sci 26 (2016): 73-79.

Google Scholar, Crossref, Indexed at

24. Lozano, Rafael, Mohsen Naghavi, Kyle Foreman and Stephen Lim, et al. "Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: A systematic analysis for the Global Burden of Disease Study 2010." Lancet 380 (2012): 2095-2128.

Google Scholar, Crossref, Indexed at

25. Wolde, Haileab Fekadu, Kedir Abdela Gonete, Temesgen Yihunie Akalu and Adhanom Gebreegziabher Baraki, et al. "Factors affecting neonatal mortality in the general population: Evidence from the 2016 Ethiopian Demographic and Health Survey (EDHS)—multilevel analysis." BMC Res Notes 12 (2019): 1-6.

Google Scholar, Crossref, Indexed at

26. Tewabe, Tilahun, Yenatfanta Mehariw, Eyerusalem Negatie and Bertukan Yibeltal. "Neonatal mortality in the case of Felege Hiwot referral hospital, Bahir Dar, Amhara Regional State, North West Ethiopia 2016: A one year retrospective chart review." Ital J Pediatr 44 (2018): 1-5.

Google Scholar, Crossref, Indexed at

27. Chewaka, Lalisa. "Preventable causes of neonatal mortality and associated factors among neonates admitted to neonatal intensive care units of addis ababa governmental hospitals from 2011-2015 gc: A retrospective study." PhD diss., Addis Ababa University (2016).

Google Scholar          

28. Edmond, Karen M., Maria A. Quigley, Charles Zandoh and Samuel Danso, et al. "Aetiology of stillbirths and neonatal deaths in rural Ghana: Implications for health programming in developing countries." Paediatr Perinat Epidemiol 22 (2008): 430-437.

Google Scholar, Crossref, Indexed at

29. Mekonnen, Yared, Biruk Tensou, Daniel S. Telake and Tedbabe Degefie, et al. "Neonatal mortality in Ethiopia: Trends and determinants." BMC Public Health 13 (2013): 1-14.

Google Scholar, Crossref, Indexed at

30. Yirgu, Robel, Mitike Molla and Lynn Sibley. "Determinants of neonatal mortality in rural Northern Ethiopia: A population based nested case control study." Plos One 12 (2017): e0172875.

Google Scholar, Crossref, Indexed at

31. Kamal, SM Mostafa, M. Ashrafuzzaman and S. A. Nasreen. "Risk factors of neonatal mortality in Bangladesh." J Nepal Paediat Soc 32 (2012).

Google Scholar, Crossref, Indexed at

32. Arokiasamy, Perianayagam and Abhishek Gautam. "Neonatal mortality in the empowered action group states of India: Trends and determinants." J Biosoc Sci 40 (2008): 183-201.

Google Scholar, Crossref, Indexed at

33. Kolola, Tufa, Meseret Ekubay, Endalamaw Tesfa and Wogene Morka. "Determinants of neonatal mortality in north Shoa zone, Amhara regional state, Ethiopia." Plos One 11 (2016): e0164472.

Google Scholar, Crossref, Indexed at

34. Nascimento, Renata Mota do, Álvaro Jorge Madeiro Leite, Nádia Maria Girão Saraiva de Almeida and Paulo César de Almeida, et al. "Determinants of neonatal mortality: A case-control study in Fortaleza, Ceará State, Brazil." Cad Saude Publica 28 (2012): 559-572.

Google Scholar, Crossref, Indexed at

35. El Awour, Imad, Yehia Abed and Majdi Ashour. "Determinants and risk factors of neonatal mortality in the Gaza Strip, occupied Palestinian territory: A case-control study." Lancet 380 (2012): S25-S26.

Google Scholar, Crossref, Indexed at

36. Kayode, Gbenga A., Evelyn Ansah, Irene Akua Agyepong and Mary Amoakoh-Coleman, et al. "Individual and community determinants of neonatal mortality in Ghana: A multilevel analysis." BMC Pregnancy Childbirth 14 (2014): 1-12.

Google Scholar, Crossref, Indexed at

37. Målqvist, Mats. "Neonatal mortality: An invisible and marginalised trauma." Glob Health Action 4 (2011): 5724.

Google Scholar, Crossref, Indexed at

38. Ghosh, Rohini and Arun Kumar Sharma. "Intra-and inter-household differences in antenatal care, delivery practices and postnatal care between last neonatal deaths and last surviving children in a peri-urban area of India." J Biosoc Sci 42 (2010): 511-530.

Google Scholar, Crossref, Indexed at

39. Marsh, David R., Gary L. Darmstadt, Judith Moore and Pat Daly, et al. "Advancing newborn health and survival in developing countries: A conceptual framework." J Perinatol 22 (2002): 572-576.

Google Scholar, Crossref, Indexed at

40. Sines, Erin, Uzma Syed, Steve Wall and Heidi Worley. "Postnatal care: A critical opportunity to save mothers and newborns." Policy Perspectives on Newborn Health 1(2007).

Google Scholar

41. Kapoor, Mudit, Rockli Kim, Tanushree Sahoo and Ambuj Roy, et al. "Association of maternal history of neonatal death with subsequent neonatal death in India." JAMA Netw Open 3 (2020): e202887-e202887.

Google Scholar, Crossref, Indexed at