(2024) 24:559
Ayfokru et al. BMC Pediatrics
https://doi.org/10.1186/s12887-024-05023-3

BMC Pediatrics

RESEARCH

Open Access

Incidence and predictors of mortality
among neonates with congenital heart disease
in Ethiopia: a retrospective cohort study
Abatwoy Ayfokru1*, Sisay Shewasinad1, Fuad Ahmed1, Mitku Tefera2, Genet Nigussie3, Emawaysh Getaneh4,
Leweyehu Alemaw Mengstie1, Wegayehu Zeneb Teklehaimanot1, Worku Abemie Seyoum1,
Mohammed Tessema Gebeyehu1, Metages Alemnew5 and Bekahegn Girma1

Abstract
Background Neonatal mortality poses a significant public health challenge in sub-Saharan Africa, with congenital
heart disease emerging as the leading cause of morbidity and mortality among neonates, especially in countries
like Ethiopia. Despite efforts to reduce neonatal mortality rates, Ethiopia continues to experience an increased mortality rate, particularly among neonates with congenital heart disease. This study aims to investigate the incidence
and predictors of mortality in this vulnerable population within Ethiopia.
Method A retrospective cohort study was conducted at an institution, involving 583 randomly selected neonates
diagnosed with congenital heart disease. In the current study, the dependent variable was survival status. Data entry
utilized EpiData data version 4.6, and analysis was performed using STATA version 16. Probability of death was compared using the log-rank test and Kaplan-Meier failure curve. Significant predictors were identified using bivariable
and multivariate Cox regression. Model fitness and proportional hazard assumptions were evaluated using the CoxSnell graph and Global test, respectively. Associations were assessed by adjusted hazard ratios with 95% confidence
intervals.
Results The study participants were followed for 4844 days. The mortality rate was 9.9%. The incidence density
was 11.9 per 1000 person-days of observation. Neonatal sepsis (AHR: 2.24; 95% CI [1.18–4.23]), cyanotic congenital
heart disease (AHR: 3.49; 95% CI [1.93–6.28]), home delivery (AHR: 1.9; 95% CI [1.06–3.6]), maternal history of gestational diabetes mellitus (AHR: 1.94; 95% CI [1.04–3.61]), and having additional congenital malformations (AHR: 2.49;
95% CI [1.33–4.67]) were significant predictors for neonatal mortality.
Conclusion and recommendation The incidence density of mortality was high compared to studies conductedin developed countries. Neonatal sepsis, type of congenital heart disease, place of delivery, maternal history of gestational diabetes mellitus, and having an additional congenital malformation were significant predictors of mortality among neonates with congenital heart disease. Therefore, healthcare providers should pay special attention
to patients with identified predictors. Furthermore, the Federal Ministry of Health, stakeholders, and policymakers
should collaborate to address this issue.
Keywords Congenital heart disease, Neonate, Mortality, Incidence, Predicators, Ethiopia*Correspondence:
Abatwoy Ayfokru
ayfokruabatwoy@gmail.com
Full list of author information is available at the end of the article© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to theoriginal author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images orother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of thislicence, visit http://creativecommons.org/licenses/by/4.0/.

Ayfokru et al. BMC Pediatrics(2024) 24:559

Background
Congenital heart diseases (CHDs) involve major structural abnormalities in the heart or intrathoracic great
vessels due to congenital anomalies, which disrupt
blood flow through the heart and body [1, 2]. CHDs
represent a prevalent category of congenital defects,
constituting approximately one-third of all major congenital anomalies [3]. It has two types a cyanotic andcyanotic [4, 5].
Approximately 30–40% of neonates with congenital
heart disease (CHD) exhibit symptoms during theirfirst year of life, with 60% of these cases being diagnosed within the first month after birth [6]. The mortality rate of newborns diagnosed with congenital
heart disease (CHD) continues to be a pressing global
issue. Despite significant progress in medical treatments, newborns with CHD still confront heightenedrisks of mortality due to the intricate nature of theircardiac abnormalities. Globally, CHD contributes toaround 25% of all neonatal deaths related to congenital
anomalies, and its incidence is increasing, underscoring a considerable gap in diagnostic capabilities, especially in Africa [1].
As a result, CHD significantly affects the daily routines and financial stability of family members, leading
to a decline in their quality of life. Moreover, neonateswith heart disease often experience challenges suchas malnutrition, infections, and pulmonary hypertension, particularly in low-income countries like
Ethiopia, complicating the treatment process further.
Altogether, caring for these neonates presents a formidable challenge [7–10].
Globally, over the last 15 years 1.35 million live births
are diagnosed with CHD every year [5]. Majority wereborn in locations that included Africa with little or nocare. Due to this, 90% of newborns with CHD received
inadequate medical care [11] and 30% of neonates with
CHD die in the neonatal period [3, 12, 13].
In Africa, where only 20 cardiac centers found, the incidence and mortality of neonates with CHD is increased[14, 15] and underreported [11, 14]. In Ethiopia, where
the magnitude of neonatal mortality is increased inrecent years there is one cardiac center which servedfor 56 million people [9]. Due to this and other factors
the mortality of neonates with CHD in Ethiopia is still
unknown [16, 17].
The country has instituted various services such aspreconception, essential newborn, antenatal, and postnatal care to alleviate the burden of mortality [18, 19].
Nevertheless, mortality rates remain high, and there
is insufficient evidence regarding the incidence andpredictors of mortality among neonates with CHD in

Page 2 of 11

Ethiopia. Consequently, this study aimed to explore theincidence and predictors of mortality among neonateswith CHD in Ethiopia.

MethodStudy area and period

This study was conducted at Amhara regional state of
Ethiopia. As indicated by the 2020 Health and Health
Related Indicators report published by the Ministry of
Health (MoH), Amhara region is a home to 82 hospitals,
861 health centers, and 3,565 health posts. Among these
hospitals, the University of Gondar, Dessie, Felege-Hiwot,
Tibebe-Ghion, Debre Markos, Woldia, Debre Tabor, andDebre Berhan are classified as Comprehensive Specialized Hospitals. The current study was conducted in theabove specialized comprehensive hospitals which provide
cardiac service.
Study design

Institutional based retrospective cohort study was
conducted.
Source population

The source population included all neonates diagnosed
with congenital heart disease admitted to the neonatal
intensive care units (NICUs) of Comprehensive Specialized Hospitals in the Amhara region.
Study population

Neonates diagnosed with congenital heart disease were
specifically chosen for admission to the NICU wards of
selected Comprehensive Specialized Hospitals in the
Amhara regional state.
Eligibility criteria

All newly diagnosed and admitted neonates with congenital heart disease from January 1­ st 2018 to Decemthber ­30 2022 were included. Infants lacking complete
records of the outcome variable were excluded fromconsideration.
Sample size determination

The sample size required for this study was determined
by STATA version 16 (Cox model), based on the following assumptions: a hazard ratio (HR) of 1.4 for theselected covariate of interest (maternal educational status) and a probability of failure (death) of 0.186 fromstudy done in Ethiopia [20], a standard deviation (SD)of 0.4, a margin of error of 5%, and a confidence interval(CI) of 95% to achieve 80% power. Accounting for a 10%
non-response rate, the final sample size required for thisstudy was determined to be 587.

Ayfokru et al. BMC Pediatrics(2024) 24:559

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Fig. 1 Schematic presentation of the sampling for incidences and predictor of mortality among neonates with CHD in Ethiopia, 2024E(α,β,ψ)n = PE(S(t),L(t),R,L)
E = (Z1−α2+Z1−β)2Log(HR)2q1q0

prepared in English. The data were collected by healthcare professionals stationed at treatment centers.

Sampling technique and sampling procedure

Operational definitions

Four specialized hospitals were randomly selected using alottery method. Study participants were chosen throughsystematic random sampling, where the sampling interval
for each hospital was determined by dividing the numberof eligible participants by the allocated sample size. Initial
participants were selected using a systematic approachat every 12th interval (calculated as 7176/587 = 12). The
first participants were chosen by lottery, and subsequent
selections occurred every 12th interval until the desired
sample size was achieved (Fig. 1).

In this study, the date of admission served as the starting point for follow-up, which extended until the infantreached 28 days of life.
Event death of neonates with congenital heart disease
while in the hospital.

Data collection tool and procedure

Time scale

Data from NICU registration books were collected using
a pretested, pre-structured checklist. This checklist
encompassed socio-demographic, maternal behavioral
and medical, obstetric, and neonatal variables. The retrospective follow-up period was determined by the timefrom CHD admission to discharge. Data recordings were
included based on eligibility criteria. The questionnaire,
adapted from literature and guidelines [21–29], wasCensored neonates with congenital heart disease who
were improved, discharged, or against medical treatment,
and referred to others center.
days.

Co‑morbidities Newborns with CHD and have other illnesses such as sepsis and under nutrition [30].
Congenital heart defect Major or minor congenital
anomalies defined as anatomical structural and functional defect present at birth which was confirmed bypediatricians or echocardiography [31].

Ayfokru et al. BMC Pediatrics(2024) 24:559

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Table 1 Socio-demographic related characteristics for mortality of neonates with congenital heart disease in Ethiopia, 2024 (n = 583)
Characteristics

Category

Survival status
CensoredMaternal age

Frequency
(%)

Death

<= 20 Year

31

6

37 (6.35)

20 = 34 Year

215

21

236 (40.48)>=35 Year274

36

310 (53.17)

Sex of neonates

Male

168

22

190 (32.59)

Female35736393 (67.41)

Age of neonates<=7 day146

33

179 (30.70)> 7 day379

25

404 (69.30)

Marital Status

Married459

47

506 (86.79)

Residency

Single9413 (2.23)

Divorced

347

41 (7.03)

Widowed15

7

23 (3.95)

Urban

77

19

96 (16.47)

Rural

448

39

487 (83.53)

Data quality control

The checklist was pre-tested with 5% of participants outside the study area to ensure data quality. It was thenstandardized and validated with input from clinical andacademic experts. The study’s tool was validated and confirmed reliable.

Data collectors and supervisors, senior BSc nurses with
NICU experience, were chosen for each hospital. They
underwent one-day training on the study’s objectives,
data collection tools, methods, and ethical considerations. Supervisors oversaw the data collection, and spotchecks were conducted by the principal investigator andTable 2 Maternal behavioral and medical related characteristics for mortality of neonates with congenital heart disease in Ethiopia,
2024 (n = 583)
Characteristics

Category

Survival Status
CensoredHistory of Alcohol intake during Pregnancy
History of Smoking intake during this pregnancy
History of Chewing chat during this pregnancy

Death

Frequency
(%)

Yes

85

21

106 (18.18)

No

440

37

477 (81.82)

Yes

127

8

135 (23.16)

No

398

50

448 (76.84)

Yes

114

4

118 (20.24)

No

411

54

465 (79.76)

GDM

Yes

52

20

72 (13.35)

No

473

38

511 (87.65)

Hypertensions

Yes

11

6

17 (2.92)

No

509

57

566 (97.08)

Cardiac problems

Yes

34

6

40 (6.86)

No

491

52

543 (93.14)

Syphilis

Yes

30

7

37 (6.35)

No

495

51

546 (93.65)

HIV/AIDS

Yes

37

20

57 (9.78)

No

488

38

526 (90.22)

TB

Yes

17

5

22 (3.77)

No

508

53

561 (96.23)

AnemiaYes

33

5

38 (6.52)

No

492

53

545 (93.48)

History of CHD

Yes

110

19

129 (22.13)

No

415

39

454 (77.87)

Ayfokru et al. BMC Pediatrics(2024) 24:559

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supervisors to ensure completeness and consistency ofthe collected data.
Data processing and analysis

After ensuring data completeness and consistency,
they were coded and entered into EpiData version 4.6,
then exported to STATA version 16 for cleaning andanalysis, using summary statistics, text, graphs, andtables.
Multicollinearity was assessed using variance inflation factors. Descriptive statistics, Kaplan-Meiergraphs, and log-rank tests were performed. The proportional hazard assumption was tested using Schoenfeld residuals (global test), and model fitness wasevaluated with a Cox-Snell residual test. Bivariable
and multivariate Cox proportional hazard regression
models identified predictors, presenting results with
Adjusted Hazard Ratios (AHR) and 95% ConfidenceIntervals (CI).

Results
A total of 587 neonate’s charts were scrutinized, of which
583 were eligible and complete with a response rate of
99.32%.
Socio‑demographic characteristics of mother of neonate

In this study, 310 neonates (53.17%) had mothers aged
over 35 years, and 506 (86.79%) were born to marriedmothers. Furthermore, 404 participants (69.3%) wereover seven days old, and 393 (67.41%) were female. Additionally, 418 (83.53%) of the study participants lived inrural areas (Table 1).
Maternal behavioral, medical and obstetric related factors

Among the neonates, 18.18% were born to mothers who
consumed alcohol during pregnancy, and 20.24% wereborn to mothers who chewed khat. 13.35% had motherswith gestational diabetes mellitus, and 6.66% had mothers with cardiac problems. Furthermore, 9.78% were born

Table 3 Obstetric related characteristics for mortality of neonates with congenital heart disease in Ethiopia, 2024 (n = 583)
Characteristics

Category

Survival status
Censored

ANC follow Up visits

Death

Frequency
(%)

Yes

266

35

301 (51.63)

No

259

23

282 (48.34)

Ferrous sulphate with folic acidprovided

Yes

283

22

305 (52.35)

No

242

36

278 (47.68)

Obstetric U/S performed within
24 WK of GA

Yes

116

13

129 (22.13)

No

409

45

454 (77.87)

Gravidity

Prim gravid

70

7

77 (13.21)

Multi gravid

455

51

506 (86.79)

History of Abortion

Yes

89

17

106 (18.18)

No

436

41

477 (81.82)

History of neonatal death

Yes

90

18

108 (18.52)

No

435

40

475 (81.48)

History of APH

Yes

36

7

43 (7.38)

No

489

51

540 (92.62)

History of prolonged labour

Yes

38

6

44 (7.55)

No

487

52

539 (92.45)

History of Premature Raptureof membranes

Yes

32

12

44 (7.55)

No

493

46

539 (92.45)

History of RH Factors

Yes

49

6

55 (9.43)

No

476

52

528 (90.57)

Types of birthSingle25218

270 (46.31)

multiple273

40

313 (53.69)

Mode of delivery

SVD

409

43

452 (77.53)

C/S

116

15

131 (22.47)

Place of delivery

Home

133

32

165 (28.30)

Health center

1487

155 (26.59)

Hospital244

19263 (45.11)

Ayfokru et al. BMC Pediatrics(2024) 24:559

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to HIV-infected mothers, and 22.13% had a family history of congenital heart disease (Table 2).
Most of the mothers of the neonates (506, 86.79%)
had two or more pregnancies, 452 (77.53%) experienced spontaneous vaginal births, and 301 (51.63%) hadreceived antenatal care (ANC) follow-up. Additionally,
108 neonates (18.52%) were born to mothers who had ahistory of neonatal death. Lastly, 165 neonates (28.30%)
were born at home (Table 3).
Neonatal related characteristics

Among the newborns with CHD in the NICU, 389(66.72%) had low birth weight, 260 (44.60%) had neonatal sepsis, 172 (29.50%) had PNA, 320 (54.89%) wereborn prematurely, and 49 (8.10%) had another cardiac
anomaly. The mean birth weight at admission was
2253 g (Table 4).
Overall survival function and probability

The overall mean survival time of neonates admitted
to NICU in the study was 8 days with 90.3% (95% CI
0.86–0.93) a SD ± 0.015. This study also showed that theprobability of neonatal survival at the 7th and 14th day of
hospital stay was 92.5% (95% CI 89 94) SD ± = 0.013) and
82.1% (95% CI: 76–86) SD ± = 0.025), respectively. At the
20 days of hospital stay, the overall survival probabilityof neonates was 74.1% (95% CI: 65–80) with a standard
error of 0.039 (Annex 1).
To assess the survival difference between selectedcovariates Kaplan Meier graph and log rank test were
done. According to both Kaplan Meier graph and log
rank test there is survival difference between neonates who had comorbidity and hadn’t; neonates who
had comorbidity had low survival rate (Log rank test;
Pr > chi2 = 0.0001). Moreover, neonates who had acyanotic CHD had less survival rate. However, there wasno survival difference between neonates (log rank test
result; Pr > ­chi2 = 0.00) (Fig. 2).
Survival status of neonates with CHD

A total of 583 neonates with CHD were followed fromadmission to 28 days with 4844 person day observations.
In the current study, 58 (9.79%) of neonates died and 525(90.05%) of them censored (Fig. 3). The median survival

Table 4 Neonatal related characteristics for mortality of neonates with CHD in Ethiopia, 2024 (n = 583)
Characteristics

Gestational age
5th minutes Apgar score Status

Birth weight
Time of Diagnosis to CHD
Types of CHD
Others congenital malformation
Comorbidity
Types of intervention to CHD
Air way Resuscitation needed during delivery
Perinatal asphyxia
SepsisSevere acute malnutrition

Category

Survival status

Frequency(%)

CensoredDeath<=37 WK

285

35

320 (54.89)>=37WK240

23

263 (45.11)

Normal32

840 (6.86)

Moderate296

17313 (53.69)

Severs190

40

230 (39.45)<=2500351

38389 (66.72)>=2500174

20194 (33.28)

Early diagnosis

192

25

217 (37.22)

Late diagnosis

333

33

366 (62.78)

Cyanotic CHD

84

33

117 (20.07)

A cyanotic CHD

441

25

466 (79.93)

Yes

35

14

49 (8.40)

No

490

44

534 (91.60)

Yes

250

41

291 (49.91)

No

275

17

292 (50.09)

Medical459

55

514 (88.16)

Surgical64569 (11.84)

Yes

323

51

374 (64.15)

No

202

7

209 (35.85)

Yes

165

7

172 (29.50)

No

360

51

411 (70.50)

Yes

217

43

260 (44.60)

No

308

15

323 (55.40)

Yes

108

25

133 (22.81)

No

417

33

450 (77.19)

Ayfokru et al. BMC Pediatrics(2024) 24:559

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Fig. 2 Kaplan meier graph for selected predictors of mortality to neoates with CHD in Ethiopia, 2024

time was at 7 days (Fig. 4). The overall incidence density
rate of mortality was 11.9 [95% CI (9.00–15.00)] per 1000
person days observation. The incidence density rate ofmortality among cyanotic CHD neonates and a cyanotic
CHD was 37.3 and 6.3 per 1000 person day observations
respectively.
Predictors of mortality for neonates with CHD

Before conducting the analysis, multicollinearity, model
fitness, and proportional hazard assumption wereassessed. The model was fitted and verified using the
Cox-Snell graph (Fig. 5), confirming that the assumption was not violated (with a global test value of 0.6337).

Additionally, the Variance Inflation Factor (VIF) was
found to be 1.06.
In the bivariable Cox regression model, ten variables
were considered: gestational diabetic mellitus (GDM),
place of delivery, presence of other congenital malformation, sepsis, need for resuscitation during delivery, typeof CHD, maternal HIV status, maternal alcohol intake,history of neonatal death, and premature rupture ofmembrane. These variables were eligible and selected for
multivariate analysis. However, only five of them place ofdelivery, sepsis, type of CHD, presence of other congenital malformations, and GDM remained significant predictors for mortality among neonates with CHD.

Ayfokru et al. BMC Pediatrics(2024) 24:559

Page 8 of 11

a mortality rate 1.9 times higher [AHR: 1.94; 95% CI(1.04–3.61)] than their counterparts. Lastly, neonateswith other congenital malformations were 2.5 times more
likely to die [AHR: 2.49; 95% CI (1.33–4.67)] than those
without such malformations (Table 5).

Fig. 3 Survival status of neonates with CHD in Ethiopia, 2024 (n =583)

Neonates diagnosed with sepsis had a hazard 2.24
times greater than their counterparts [Adjusted Hazard Ratio (AHR): 2.24; 95% CI (1.18–4.23)]. Those withcyanotic congenital heart disease faced a 3.5 times higher
risk of mortality [AHR: 3.49; 95% CI (1.93–6.28)] compared to those with non-cyanotic CHD.
Additionally, neonates born at home exhibited a
1.9 times higher hazard of death [AHR: 1.9; 95% CI(1.06–3.6)] than those delivered in a healthcare institution. Neonates with a maternal history of GDM had

Fig. 4 Median survival time for neonates with CHD in Ethiopia, 2024

Discussion
The aim of this study was to assess the incidence andpredictors of mortality among neonates with CHD in
Ethiopia. The mortality rate among neonates with CHD
was 9.79%. The mortality incidence among neonates withcongenital heart disease was 11.9 [95% CI (0.009–0.015)]
per 1000 person-days of observation. Additionally, themedian survival time was 7 days.
The Mortality rate revealed in this study was low ascompared to studies conducted in Developing countries[23]. However, the rate was high as compared to studies conducted in Taiwan [32]. This variability could be
attributed to differences in the quality and availability ofcardiac services, as well as disparities in population characteristics. It’s worth noting that the study conducted indeveloping countries focused solely on critical neonateswith CHD.
The incidence reported in this study was in line withstudies conducted in China [33, 34], Norway [35] andTurkey [36]. However, it is was higher as compared tostudies conducted in Europe [37], Spain [38], Sri lanka[39], united states of America (USA) [40], France [41] andBrazil [42]. Lastly, it low as compared to study done globally [43] and Brazil [44]. The potential explanation mightstem from considerable disparities in socioeconomic
status, study settings, and the presence of specializedAyfokru et al. BMC Pediatrics(2024) 24:559

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Fig. 5 Cox-Snell residual cumulative hazard graph for neonates with CHD in Ethiopia, 2024

Table 5 Bivariable and multivariate analysis result for predictors of mortality to neonates with CHD in Ethiopia, 2024 (n = 583)
Characteristics

Category

CHR (95%CI)

Alcohol

Yes

1

No

0.40 (0.23–0.69)

Yes

1

No

0.21 (0.12–0.36)

No

1

yes

0.24(0.14-0 0.41)

1.94 (1.04–3.61)*

No

0.48 (0.27–0.84)

1.03 (0.47–2.27)

Yes

1

No

0.37 (0.19–0.70)

A cyanotic

1

Cyanotic

5.76 (3.42–9.70)

No

1

Yes

0.25 (0.13–0.46)

No

1

Yes

0.28 (0.12–0.61)

Health center

1

Home

4.27 (1.88–9.69)

No

1

Yes

4.16(2.31–7.49)

HIV/AIDS
Gestational diabetic mellitus
Premature Rapture of membrane
History of Neonatal death
Types of CHD
Others congenital malformation
History of resuscitation Needed during delivery
Place of delivery
SepsisAHR (95% CI)

0.55 (0.29 − 1.04)
0.67 (0.35–1.28)

Yes

0.82 (0.42–1.60)
3.49 (1.93–6.28)*
2.49 (1.33–4.67)*
1.43 (0.76–2.88)
1.9 (1.06–3.60)*
2.24 (1.18–4.23)**significant predictors for mortality of neonates with CHD

cardiac surgeons and facilities. Furthermore, it could be
attributed to variances in neonatal intensive care unit
conditions and maternal healthcare service utilization.
Neonates who had neonatal sepsis had more risk for
mortality. This finding was in line with studies conductedin Ethiopia, [27, 45–47], Indonesia [48] and USA [49].

This might be due to the distinct cardiovascular pathophysiology observed in children with congenital heartdisease (CHD) compared to their peers without CHD,
the standard diagnosis and management protocols forsepsis cannot be applied directly to this population which
underestimates the effect of sepsis.

Ayfokru et al. BMC Pediatrics(2024) 24:559

Neonates with cyanotic congenital heart disease hadhigher mortality rate. This finding was consistent with astudy done in Georgia (69) and Spain (59). This similarity arises from the fact that infants with CHD have critical
early difficulties that necessitate emergency care because
their aorta pumps mixed blood, which raises the chanceof mortality.
Home delivered neonates with CHD had more hazardof mortality. This finding was supported by studies conducted in sub-Sahara Africa [50] and Ethiopia [51]. This
could be because newborns delivered at home may notreceive immediate resuscitation, thereby increasing therisk of birth complications.
Neonates born to mothers with a history of maternal
gestational diabetes mellitus (GDM) exhibited a heightened risk of mortality. This study’s discovery aligns withresearch conducted in Ethiopia [51]. This correlation
may stem from GDM leading to hypoglycemia at birth,
respiratory distress, polycythemia, elevated bilirubinlevels, and an increased likelihood of preterm birth [52].
Finally, neonates with congenital heart disease (CHD)
who also presented with additional congenital malformations faced a higher risk of mortality. This discovery
is corroborated by studies conducted in Ethiopia [47]and Finland [53]. This phenomenon could be attributed
to the increased mortality risk associated with neonates
bearing additional congenital malformations, whichconsequently impacts the prognosis of CHD adversely.
While this study encompassed a large population andemployed a follow-up approach, it encountered several
limitations. Firstly, because of its retrospective design,certain maternal predictors like educational and nutritional status were not assessed. Secondly, managing missing values posed a challenge. Lastly, we did not track
neonates discharged before 28 days of life, potentiallyleading to an underestimation of the incidence rate.

Conclusion
The current research revealed higher mortality and incidence density rates compared to studies in developed
nations. Additionally, factors such as sepsis, place of birth,maternal history of GDM, other congenital malformations,and type of CHD were identified as significant predictors
for neonatal CHD mortality. To address this issue, collaboration between the Federal Ministry of Health, stakeholders, and the Ethiopian Cardiac Association is essential toenhance the quantity and quality of cardiac centers in the
country. Moreover, healthcare providers should prioritize
neonates with sepsis, additional congenital malformations,and cyanotic CHD. Lastly, reducing home deliveries can beachieved by expanding ANC service coverage.

Page 10 of 11

Abbreviations
ANC	Antenatal Care
AHR	Adjusted Hazard Ratios
CHD	Congenital Heart Disease
CHR	Crude hazard ratio
GDM	Gestational Diabetes Mellitus
NICU	Neonatal intensive care unitsUSA	United States of America
VIF	Variance Inflation Factor

Supplementary Information
The online version contains supplementary material available at https://​doi.​
org/​10.​1186/​s12887-​024-​05023-3.
Supplementary Material 1.
Supplementary Material 2.
Acknowledgements
We greatly acknowledge Debre Berhan University, data collectors andsupervisors.
Authors’ contributions
AA, SS, and FA conceived the idea and were involved in data collection,
entry, analysis, and drafting. MT, GN, EG, LAM, WZT, WA, MTG, MA and
BG contributed to manuscript preparation and the revision of the final
version. All authors have reviewed and approved the final manuscript for
publication.
Funding
The author didn’t receive any fund for this study.
Availability of data and materials
The data set analyzed during the current study is available from the corresponding author upon reasonable request.

Declarations
Ethics approval and consent to participate
We adhered to the Declaration of Helsinki guidelines. Ethical approval was
granted by the Institutional Review Board of Asrat Woldeyes Health Sciences
campus Debre Berhan University. Approval was obtained from each hospital,and letters of permission and informed consent were obtained from the
medical directorate of each hospital on behalf of the neonates. Measures weretaken to ensure the confidentiality and anonymity of the data.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Author details
1
Department of Pediatrics and Child Health Nursing, School of Nursing
and Midwifery, Asrat Woldeyes Health Sciences campus, Debre Berhan University, Debre Berhan, Ethiopia. 2 Department of Midwifery, Debre Berhan Health
Science College, Debre Berhan, Ethiopia. 3 Department of Nursing, MidaWoremo Primary Hospital, Amhara region, Ethiopia. 4 Department of Midwifery,
School of Nursing and Midwifery, Asrat Woldeyes Health Sciences campus,
Debre Berhan University, Debre Berhan, Ethiopia. 5 School of medicine, Asrat
Woldeyes Health Sciences campus, Debre Berhan University, Debre Berhan,
Ethiopia.
Received: 12 June 2024 Accepted: 19 August 2024

Ayfokru et al. BMC Pediatrics(2024) 24:559

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