Tirore et al. BMC Pediatrics(2024) 24:511
https://doi.org/10.1186/s12887-024-04992-9

BMC Pediatrics

RESEARCH

Open Access

Incidence of mortality and its predictors
among preterm neonates in nigist eleni
mohammed memmorial comprehensive
specialized hospital, Hossana, Ethiopia:
a prospective follow-up study
Lire Lemma Tirore1*, Desta Erkalo1, Selamu Abose2, Lamesginew Mossie Melaku3, Essayas Mulugeta3,
Abriham Shiferaw1, Aklilu Habte1 and Menaseb Gebrehaweria Gebremeskel4
Abstract
Background Preterm birth is the leading cause of neonatal mortality accounting for 35% of all neonatal deaths
worldwide, and the second most frequent cause of death for under five children. Despite different efforts, preterm
neonatal mortality is still persistently high in Ethiopia. Little is known about death and its predictors among preterm
neonates in the study area.
Objective This study is aimed at estimating the incidence of mortality and its predictors among preterm neonates
admitted to the NICU of NEMMCSH.
Methods and materials : A hospital-based prospective follow-up study was conducted from January to November
2022. A total of 197 preterm neonates were selected consecutively and followed. The Kaplan-Meier survival and failure
curves were used to describe the proportion of deaths over time and to compare groups. The independent effects ofcovariates on the hazard of death were analyzed using a multivariable Cox proportional hazard model.
Results Preterm neonates were followed for 1840 person-days. The mean time to death was 5.68 days (SD = 5.54).
The incidence of mortality was 26.08 (95% CI: 19.65, 34.61) per 1000 person days. Preterm neonates of mothers witheclamsia (AHR = 3.03), preterm neonates who have not received KMC (AHR = 2.26), and preterm neonates who havenot exclusively breastfed (AHR = 4.4) had higher hazards of death as compared to their counterparts.
Conclusion and recommendation : The mean time to death was 5.68 days (SD = 5.54). The incidence of mortality
was 26.08 per 1000 person days. Eclamsia, KMC, and exclusive breastfeeding were significant predictors of deathamong preterm neonates. The role of KMC in reducing mortality rates and improving outcomes has to be emphasized
for mothers and families. Caregivers have to ensure that mothers and families receive adequate support and resources
to facilitate KMC, including access to lactation support, counseling, and assistance with practical aspects of caregiving.

*Correspondence:
Lire Lemma Tirore
ganetlemma@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-NonCommercial-NoDerivatives 4.0
International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you
give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified thelicensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. 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 thematerial. 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 this licence, visit http://
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Tirore et al. BMC Pediatrics(2024) 24:511

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Counseling and practical support to enhance exclusive breastfeeding initiation and continuation have to bestrengthened. Special attention has to be given to the preterm neonates of mothers with eclampsia.
Keywords Time to death, Preterm neonate, Incidence, Predictors

Introduction
A live birth that occurs before 37 weeks of pregnancy isreferred to as a preterm birth. It can occur spontaneously
or be medically induced through elective cesarean birthor labor induction [1–3].
A premature newborn’s death during the first 28 daysof life is known as preterm neonatal mortality [4]. Preterm delivery is still a major global public health issue
due to its substantial role in the morbidity and death ofnewborns [5].
Preterm infants are at high risk for both short- andlong-term complications, such as low birth weight,
increased caloric needs, feeding difficulties [6], immature digestion and impaired absorption of carbohydrates
and lipids [7], breathing problems [8, 9], cerebral palsy,
impaired brain function, developmental delay, poorer
cognitive function [10–12], vision and hearing problems[8, 12], perinatal asphyxia, respiratory distress syndrome(RDS), increased risk of sudden infant death, problems
controlling body temperature, heart problems, hypoglycemia, and infections [12, 13].
Preterm infants place a heavy financial burden on families and hospitals because they require specialized medical care in a neonatal intensive care unit (NICU) and are
more likely to need a prolonged hospital stay (days tomonths) [14–17].
An estimated 15 million (11%) preterm births worldwide (or 1 in 10 deliveries) take place each year (at a paceof 29 newborns each minute). 90% of preterm deliveries take place in low- and middle-income nations. SubSaharan Africa and South Asia account for 12.7 million
preterm births, or about 85% of all preterm birth [18,19]. The majority of sub-Saharan countries are seeing an
increase in preterm birth rates [20].
Various policies, and programs are implemented worldwide with the aim of preventing and treating preterm
birth and lowering mortality rates [21, 22]. Even so, itremains the leading cause of neonatal mortality accounting for 35% of all neonatal deaths worldwide, and the second most frequent cause of death for children under fiveaccounting for 18% of all deaths [22–24]. Preterm delivery and its complications cause 1 million deaths in children under the age of five every year [25]. The likelihoodof survival for a preterm baby is primarily determinedby their place of residence; in low-income nations, over
90% of extremely preterm babies pass away in the firstfew days of life. However, in high-income nations, thedeath rate is less than 10% [19]. 13% of under-five deathsin sub-Saharan Africa and 25.5% in South Asia are attributed to preterm birth mortality [26].
The mortality rate for children under five has significantly decreased, but the fall in neonatal mortality has
been sluggish, particularly in many low-income nations.
Regretfully, families and medical professionals in manynations continue to believe that any premature baby will
eventually die [27].
The trend of newborn death rates in Ethiopia stayedlargely unchanged. In 2005, it was 39; in 2011, it was 37;
in 2016, it was 29, and in 2019, there were 30 mortalities
per 1000 live births [28]. One-third of these deaths arecaused by prematurity [29]. Due to the prolonged hospital stays and long-term complications on the newborn’s
health, preterm deliveries place a strain on society’s
healthcare resources [30].
Birth weight, gestational age, mode and place of delivery, HIV, exclusive breastfeeding (EBF), postnatal surfactant administration, presence of anomalies, multiple
pregnancies, non-cephalic presentation, neonatal sepsis, respiratory distress, and a low APGAR score have all
been found to be predictors of death in preterm neonatal
deaths [14, 31–36].
Target #3.2 of Sustainable Development Goal 3 calls forending all preventable deaths of newborns and children
under the age of five by 2030, and addressing the problem
of preterm birth is crucial to reaching this goal [37]. Welldesigned, context-specific, representative cohort studies
from low- and middle-income countries on preterm birth
are therefore required to address data gaps on preterm
birth, learn from successes, and adopt best fit models in
low- and middle-income settings, as the majority of theevidence on care for preterm babies comes from highincome settings [5, 38].
In Ethiopia, a large number of preterm birth-related
deaths are avoidable, particularly deaths of moderate-to
late-preterm births (32–37 weeks) [39].
Ethiopia has adopted the target to lower preterm birthrelated deaths by 2030 [40].
The country is implementing a number of policies andinitiatives, such as an expanded Neonatal Intensive Care
Unit (NICU), integrated management of neonatal andpediatric disorders, and a quality improvement program,to address newborn fatalities and accomplish the goal.
Preterm infant mortality remains stubbornly high despite
these measures.
Besides these efforts, preterm neonatal mortality is still
persistently high [35, 41]. Every year, 320,000 prematureTirore et al. BMC Pediatrics(2024) 24:511

births occur, and direct preterm problems result in thedeaths of 23,100 children under the age of five [42].
Although some studies were done in Ethiopia on theincidence and predictors of preterm death, the risk factors were different across the studies. The majority ofthese studies used secondary data, which is prone tomissing data and variables. There is no information about
the incidence and predictors of preterm death in the
study area.
Understanding the consequences of preterm births andthe factors that increase their risk of death and morbidity
affects how healthcare providers treat expectant mothers
and their babies and facilitates the efficient use of available resources. It contributes to improving newborn careand lowering unfavorable outcomes in these kinds of difficult births. Estimating the incidence of mortality andits predictors among preterm neonates admitted to the
NICU of NEMMCSH is the aim of this study.

Methods and materials
Study area and period

This study was carried out at NEMMCSH, which islocated in Hossana town, Haddiya zone, from January
to December 2022. Hossana Town, the capital of Central Ethiopia, is situated 230 km from Addis Ababa, thecapital of Ethiopia. In addition to providing general andspecialty medical care, NEMMCSH is a public hospitalthat serves as a teaching hospital for medical and other
health science students. The neonatal Intensive Care Unit
(NICU) offers newborn care services to both inborn andout born term and preterm neonates. A hospital-based
prospective follow-up study was carried out.
Treatment protocols in NICU

The treatment protocol in a Neonatal Intensive Care Unit
(NICU) varies depending on the specific medical conditions and needs of the newborn. NICUs are specialized
units that provide intensive medical care for prematureor ill newborns. Many premature infants have underdeveloped lungs and may require assistance with breathing.
This can include mechanical ventilation and continuous
positive airway pressure (CPAP). Premature babies often
struggle to maintain their body temperature. Incubators
or radiant warmers are used to keep the baby’s temperature stable. Continuous monitoring of vital signs suchas heart rate, respiratory rate, and oxygen saturation is
crucial in the NICU. This helps healthcare providers
promptly address any changes in the baby’s condition.
Neonates in the NICU are susceptible to infections, so
strict infection control measures are implemented. This
includes proper hand hygiene, aseptic techniques, andthe judicious use of antibiotics. Many newborns experience jaundice, a yellowing of the skin and eyes due toelevated bilirubin levels. Phototherapy may be used toPage 3 of 15

treat jaundice. NICUs often emphasize family-centeredcare, involving parents in the care of their newborns.
This includes education on baby care, involvement indecision-making, and support for emotional well-being.
Medications may be administered to address specificmedical conditions or to support the baby’s physiological
functions [43].
Population

All preterm neonates admitted to the NICU of
NEMMCSH were the source population whereas all
preterm neonates admitted to the NICU at NEMMCSH
from January to November 2022 comprised the study
population.
Inclusion and exclusion criteria

Preterm neonates admitted to the NICU during thetime of data collection were included in the study. Preterm neonates of mothers who are unable to speak andthose with no immediate caregiver were excluded fromthe study because there are some variables measured byinterviewing either mothers or caregivers.
Sample size determination and sampling techniqueUsing Stata version 14, the sample size was calculatedwith respect to a hazard ratio of 2.186 for gestational age,a standard deviation of 0.186, a 95% confidence interval,
a 5% probability of type I error, 80% power, and a 29.31%
probability of success (death). Taking into account the
aforementioned criteria, a total of 197 preterm neonates
were included in the study [44].
Data collection tool and technique

Until the required sample size was attained, the study
participants were consecutively recruited into the study.
Interviewer administered questionnaire and checklist
were used to collect the data. The aforementioned datacollection tool were adapted from different studies. Upon
admission, the data collectors recruited study subjects
and continued to follow them throughout their stay inthe facility, documenting all clinical events until theneonates die or censored. Data collection was done bytrained nurses and supervision was done by two publichealth experts. Up until the neonatal death or censorship,
newborn data were prospectively gathered from medical records. The neonates were followed for a maximumof 28 days from birth. To assure the quality of the data,
the data collection tool was evaluated by pediatricians,
and 1 day of training was given to the data collectors andsupervisors about general research protocols. The Principal investigator reviewed the data before entering it toensure it was consistent and complete.

Tirore et al. BMC Pediatrics(2024) 24:511

Study variables

Dependent variable Mortality of preterm neonates.
Independent variables maternal age, place of residence,marital status, level of education, occupation, monthly
income and sex of neonates, multiple pregnancy, parity,history of abortion and/or preterm birth, Birth interval,
prolonged labour, ANC visits, human immunodeficiency
virus (HIV) status, DM and place of delivery, mode ofdelivery, type of birth attendant, antenatal corticosteroid use, neonatal postnatal age at admission, anomalies,
KMC, BMI, birth weight, 1 and 5-minute APGAR score
and resuscitation history, gestational age, obstetric haemorrhage, eclampsia and preeclampsia, mal-presentation,
feeding problem, asphyxia, neonatal sepsis, hypothermia,
jaundice, HR, RR, SPO2, and hypoglycemia.
Data analysis Data were entered into Epi-data for Windows and analyzed using Stata version 14. Percentages
and frequencies were used to summarize categoricalvariables. The results were presented in tables, texts, andgraphs based on the nature of the variables. The distribution of the continuous variables was checked by a box
plot. Mean with standard deviation and median withinterquartile range were used to summarize normally andnon-normally distributed continuous variables, respectively. The Kaplan-Meier Survival and failure curve wasused to describe the proportion of deaths over time andto compare groups.
Multivariable Cox proportional hazards regression The independent effects of covariates on the hazardof death were analyzed using the multivariable Cox proportional hazards model. Variables with p-value < 0.25 inbivariable cox proportional hazards analysis were considered for multivariable cox proportional hazards analysis.
Adjusted hazard ratios with their 95% confidence interval (CI) were estimated, and a p-value less than 0.05 wasused to declare the presence of a significant association
between predictors and preterm neonatal death.

Page 4 of 15

Assessing model assumptions The proportional hazard
assumption states that the effect of the covariate is thesame over time. It was tested using the global test runningthe estat phtest command in stata. The assumption was
satisfied (p-value: 0.2042).
Operational definitions

Definitions of the terms are given in the table below(Table 1).

Results
Socio-demographic characteristics of the study
participantsMore than half (51.27) of the neonates were males,
and 82.23% were aged less than 24 h at admission. The
median gestational age was 35 weeks (IQR: 34 weeks,
35.8 weeks), and 90.82% were born at or after 32 weeks ofconception. 86.29% of the neonates were born at a healthfacility. The mean age of the mothers was 28.74 years(SD: 5.72 years), and more than half (55.33%) of themwere from rural areas (Table 2).
Maternal medical and obstetrics related characteristics

All mothers had ANC follow up and 66.33% of the neonates were born to mothers who had > = 3 ANC follow
up. 31.98% of the women had multiple pregnancies, and43.65% of the neonates were born to multipara mothers. More than three-fourths (77.66%) of the neonates
were born to mothers who had not taken corticosteroids during pregnancy. More than half (21.32%) of themothers had prolonged labor, and 3.55% of the mothers
had obstetric hemorrhage. 22.34% of the neonates wereborn to mothers who had a history of abortion or preterm birth, and 13.71% and 9.64% of the women had preeclampsia and eclampsia, respectively (Table 3).
Neonatal admission diagnosis and treatment relatedcharacteristics

Nearly three-fourth (75.63%) of the neonates were hypothermic at admission and 74.62% of them had neonatal
sepsis. More than one-third (38.58%) of the neonates
had jaundice and hypoglycemia, and nearly one-fourth

Table 1 Operational definition of the terms
Terms
Jaundice
Gestational age
Neonatal sepsis
Event
Discharged (Recovered)Time to deathTime zero
CensoredMedian time of death

Definitions
A medical condition characterized by yellowing of the skin and whites of the eyes
A time from the LNMP to the date of delivery.
Is a serious medical condition in newborn babies characterized by a systemic infection that affects the blood stream.
Death of preterm neonate
Those who left the hospital with clinical improvement confirmed by a physician.
The time from admission to when the neonate died.
The time when a neonate is being admitted to the NICU.
A neonate lost to follow-up, discharged, or alive until after 28 days.
Is the time when 50% of the neonates have died.

Tirore et al. BMC Pediatrics(2024) 24:511

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Table 2 Frequency and percentage distribution of sociodemographic characteristics of the neonates and their mothers in NEMMHS,
2022
VariableAge at admission
Sex of neonates
Gestational age
Mother age

Occupation

Education

Place of residence
Marital status

Place of delivery

Category< 24 h>=24 hMale
Female< 32 weeks>= 32 weeks< 20 years
20–34
above 34
house wife
student
employermerchant
unable to read and write
primary
secondary
Tertiary and above
Urban
Rural
marriedWidowed or divorced
SingleHome
Health institutionsof them had asphyxia (24.87%). More than one-third(34.04%) of the neonates had received CPAP, and 83.25%
were given early antibiotics. More than half (58.88%) ofthem had received KMC, and 29.44% were resuscitated(Table 4).
Incidence of mortality

The mean duration of admission was 9.42 days (SD = 6.64)
and the mean time to death was 5.68 days (SD = 5.54).
The total person-day observation was 1840 days. Out of
197 neonates, 48 of them died. The incidence of mortality was 26.08 (95% CI: 19.65, 34.61) per 1000 persondays. The incidence of mortality was the highest (46.13
per 100 person days) within the first 24 h. Between 2nd
to 7th, 8th to 14th, 15th to 21st, and 22nd to 28th, theincidence of mortality was 29.65, 24.39, 11.42, and 18.86
per 1000 person days, respectively. The cumulative probability of mortality within the first 7, 14, 21, and 28 days
was 0.1715, 0.3077, 0.3569, and 0.4664, respectively. The
Kaplan-Meir graph increases rapidly during the first 5days and between the 8th and 14th days, showing mostneonates died during these periods (Figs. 1 and 2).
The cumulative probability of deaths were higher
among neonates who were born to mothers who had
mal-presentation, eclampsia, and neonates who had not

Survival status
Died (%)
41(20.81)
7(3.55)24(12.18)
24(12.18)6(3.05)42(21.32)1(0.51)33(16.92)
13(6.67)
23(11.68)
9(4.57)11(5.58)5(2.54)11(5.58)
13(6.60)
12(6.09)12(6.09)25(12.69)
23(11.68)
42(21.32)2(1.02)4(2.03)8(4.06)40(20.30)

Total (%)
Censored (%)
121(61.42)
28(14.21)
77(39.09)
72(36.55)
13(6.60)
136(69.04)
8(4.10)113(57.95)
27(13.85)
76(38.58)
26(13.20)
38(19.29)9(4.57)30(15.23)
49(24.87)
33(16.75)
37(18.78)
84(42.64)
65(32.99)
138(70.05)
4(2.03)7(3.55)19(9.64)130(60.99)

162(82.23)
35(17.77)
101(51.27)
96(48.73)
19(9.64)
178(90.36)9(4.62)146(74.87)
40(20.51)
99(50.25)
35(17.77)
49(24.87)
14(7.11)41(20.81)
62(31.47)
45(22.84)
49(24.87)
109(55.33)
88(44.67)
180(91.37)
6(3.05)11(5.58)
27(13.71)
170(86.29)

exclusively breast fed, were not resuscitated and neonateswith 1 min APGAR score of 4–7(Figs. 3, 4, 5, 6 and 7).
Predictors of mortality

In a bivariable cox regression ANC, preeclampsia,
eclampsia, malpresentation, KMC, hypoglycemia, andexclusive breast feeding were considered for multivariable cox regression. In multivariable Cox regression,eclampsia, exclusive breast feeding, and KMC were
found to be significant predictors of death among preterm neonates.
Preterm neonates of mothers with Eclampsia had 3.03
times higher hazards of death as compared to neonates ofmothers without Eclampsia (AHR = 3.03).
The hazards of death were 2.26 times higher for preterm neonates who have not received KMC as comparedto those who have received the care (AHR = 2.26). Preterm neonates who have not exclusively breastfed had 4.4
times higher hazards of death as compared to neonates
who have exclusively breastfed (AHR = 4.4) (Table 5).

Discussion
Preterm neonates were followed for 1840 person-days.
The mean time to death was 5.68 days (SD = 5.54). The
incidence of mortality was 26.08 (95% CI: 19.65, 34.61)
per 1000 person days. This is nearly similar to theTirore et al. BMC Pediatrics(2024) 24:511

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Table 3 Frequency and percentage distribution of maternal medical and obstetrics related characteristics in NEMMCSH, 2022
Variable
Number of ANC visits

Multiple pregnancy
ParityProlonged labor
Mal-presentation
Corticosteroid intake
Antepartum hemorrhage
Preeclampsia
Eclampsia
History of abortion or preterm birthMaternal sero status
Maternal Diabetes mellitus

Type of birth attendantCategory

Total (%)

1
2
>=3
yes
no
primipara
multipara
grand multipara
Yes
No
Yes
No
yes
No
Yes
No
Yes
No
Yes
No
Yes
No
positive
negative
yes

Survival status
Died (%)
5(2.54)11(5.58)
32(16.24)
18(9.14)30(15.23)
19(9.64)19(9.64)10(5.08)13(6.60)
35(17.77)
9(4.57)39(19.80)
13(6.60)
35(17.77)
3(1.57)45(22.84)
4(2.03)44(22.34)
7(3.55)41(20.81)
15(7.61)33(16.75)
4(2.03)44(22.34)
10(5.08)

Censored (%)
8(4.06)43(21.83)
98(49.75)
45(22.84)
104(52.79)
65(32.99)
67(34.01)
17(8.63)
29(14.72)
120(60.91)
11(5.58)
138(70.05)
31(15.74)
118(59.90)
4(2.03)145(73.60)
23(11.68)
126(63.96)
12(6.09)137(69.54)
29(14.72)
120(60.91)
12(6.09)137(69.54)
16(8.12)Noskilledunskilled

38(19.29)
38(19.29)
10(5.08)

133(67.51)
128(64.97)
21(10.66)

incidence of death reported from studies in Addis Ababa,
Ethiopia [45] and Northern Ethiopia [46].
KMC, exclusive breastfeeding, and Eclampsia weresignificant predictors of death among preterm neonates.
The hazards of death were higher for preterm neonates
who have not received KMC as compared to those whohave received KMC. This finding is in line with the findings in studies done at Aksum Hospital [47], University of
Gondar [48] and Addis Ababa public hospitals [45], andSouthern Ethiopia [49].
The increased risk of mortality in preterm newborns
who have not undergone Kangaroo Mother Care (KMC)
could be attributed to inadequate control of body temperature and breathing. Premature babies frequently
face challenges in regulating their body temperature, andwithout KMC, they may be at a higher risk of experiencing hypothermia or hyperthermia, both of which canlead to fatal outcomes [50, 51]. The physical contact withthe mother’s chest can improve the infant’s respiratory
rhythms, decreasing the likelihood of respiratory difficulties or issues. Premature babies who have not undergone
Kangaroo Mother Care (KMC) are more susceptible to13(6.60)
54(27.41)
130(65.99)
63(31.98)
134(68.02)
84(42.64)
86(43.65)
27(13.71)
42(21.32)
155(78.68)
20(10.15)
177(89.85)
44(22.34)
153(77.66)
7(3.55)190(96.45)
27(13.71)
170(86.29)
19(9.64)
178(90.36)
44(22.34)
153(77.66)
16(8.12)181(91.88)
26(13.20)171(86.8)
166(84.26)
31(15.74)

respiratory distress, which raises the chances of mortality[52, 53].
Inadequate nutrition, heightened susceptibility toinfections, and elevated stress levels may also contribute to the elevated mortality risks in premature newborns who have not undergone Kangaroo Mother Care
(KMC). Infants who have not experienced KMC are at ahigher risk of malnutrition, increasing their vulnerability
to infections and other health issues [54, 55]. Prematurebabies are at a higher risk of infections, and KMC has
been linked to a decreased occurrence of infections. The
soothing impact of KMC can alleviate stress in premature infants. Newborns who have not received KMC may
experience heightened stress levels, which can impact
their physiological functions and overall well-being [56,57].
Preterm neonates who have not initiated exclusive
breastfeeding have greater hazards of death as comparedwith those who have initiated exclusive breastfeeding.
Similar findings were observed in studies done in Tanzania [58], Ghana [59], India [60] and two systematic
reviews [61, 62].

Tirore et al. BMC Pediatrics(2024) 24:511

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Table 4 Frequency and percentage distribution of neonatal admission diagnosis and treatment related characteristics in NEMMCSH,
2022
Variable
Neonatal sepsis
Jaundice
Hypoglycemia
Anomaly
1 min APGAR score
5 min APGAR score

KMC
exclusively
breast feed
CPAP
Early antibiotic provision
Birth weight

Hypothermia
Asphyxia

Category
Yes
No
Yes
No
Yes
No
Yes
No
3–6
>=7
<3
3–6
>=7
Yes
No
Yes
No
Yes
No
Yes
No
< 100
1000–1499
1501–2499>=2500
Yes
No
yes
No

The increased likelihood of infections resulting fromweakened immunity could clarify the greater mortality
risks in premature newborns who have not exclusively
breastfed [63].
The hazards of death were higher among preterm neonates of mothers who have eclampsia compared to neonates of mothers without eclampsia. A similar finding
was observed in a study done in Addis Ababa [64].
The insufficient blood supply to the placenta and challenges during labor and delivery could account for thehigher risks of mortality among premature newborns.
Babies born prematurely to mothers with Eclampsia may
experience complications such as low birth weight, respiratory issues, and underdeveloped organs, increasing
their chances of mortality. Additionally, inadequate placental blood flow can lead to intrauterine growth restriction (IUGR), which is linked to low birth weight and aheightened risk of neonatal death. Eclampsia can result
in labor and delivery complications like placental abruption or fetal distress, further contributing to negative outcomes for the newborn [65].

Survival status
Died (%)
36(2018.27)
12(6.09)15(7.61)33(16.75)
24(12.18)
24(12.18)5(2.54)43(21.83)
28(14.21)
20(10.15)
3(1.52)8(4.06)37(18.78)
11(5.58)
37(18.78)
12(6.09)32(16.24)
18(9.57)
27(14.36)
38(19.29)
10(5.08)
2 (1.02)14(7.11)32(16.24)
036(18.27)
12(6.09)24(12.18)
24(12.18)

Total (%)
Censored (%)
111(56.35)
38(19.29)
61(30.96)
88(44.67)
52(26.40)
97(49.24)
10(5.08)139(70.56)
73(37.06)
76(38.58)
016(8.12)133(67.51)
105(53.30)
44(22.34)
122(61.93)
21(10.66)
46(24.47)
97(51.6)
126(63.96)
23(11.68)2(1.02)27(13.71)
111(56.35)
9(4.57)113(57.36)
36(18.27)
25(12.69)
124(62.94)

147(74.62)
50(25.38)
76(38.58)
121(61.42)
76(38.58)
121(61.42)15(7.61)
182(92.39)
101(51.27)
96(48.73)
3(1.52)24(12.18)
170(86.29)
116(58.88)
81(41.12)
134(68.02)
53(26.90)
64(34.04)
124(65.96)
164(83.25)
33(16.75)
4(2.04)41(20.81)
143(72.59)
9 (4.570
149 (75.63)
48(24.37)
49(24.87)
148(75.13)

Conclusion and recommendation
Preterm neonates were followed for 1840 person-days.
The mean time to death was 5.68 days (SD = 5.54). The
incidence of mortality was 26.08 (95% CI: 19.65, 34.61)
per 1000 person days. Eclampsia, KMC, and exclusive
breastfeeding were significant predictors of death among
preterm neonates. Awareness should be created for parents and caregivers about the benefits and importance of
KMC for preterm neonates. The role of KMC in reducing mortality rates and improving outcomes has to beemphasized for mothers and families. Caregivers have toensure that mothers and families receive adequate support and resources to facilitate KMC, including access tolactation support, counseling, and assistance with practical aspects of caregiving. Early and thorough nutritional
assessments for preterm neonates are essential to identify those who may face challenges with exclusive breastfeeding. Counseling and practical support to enhancebreastfeeding initiation and continuation have to bestrengthened. Special attention has to be given to thepreterm neonates of mothers with eclampsia.

Tirore et al. BMC Pediatrics(2024) 24:511

Fig. 1 Cumulative survival probability among preterm neonates in NEMMCSH, 2022

Fig. 2 Cumulative probability of mortality among neonates admitted to NEMMCSH, 2022

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Tirore et al. BMC Pediatrics(2024) 24:511

Fig. 3 Cumulative probability of mortality by mal-presentation among neonates admitted to NEMMCSH, 2022

Fig. 4 Cumulative probability of mortality by one minute APGAR score among neonates admitted to NEMMCSH, 2022

Page 9 of 15

Tirore et al. BMC Pediatrics(2024) 24:511

Fig. 5 Cumulative probability of mortality by eclamsia status of mothers among preterm neonates admitted to NEMMCSH, 2022

Fig. 6 Cumulative probability of mortality by resuscitation among preterm neonates admitted to NEMMCSH, 2022

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Tirore et al. BMC Pediatrics(2024) 24:511

Fig. 7 Cumulative probability of mortality by exclusive breastfeeding among preterm neonates admitted to NEMMCSH, 2022

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Tirore et al. BMC Pediatrics(2024) 24:511

Page 12 of 15

Table 5 Predictors of mortality among preterm neonates in NEMMCSH, 2022
VariableAge at admission
Sex of neonates
Gestational age
Mother age

Place of residence
Marital status

Place of delivery
Hypothermia
Asphyxia
Number of ANC visits

Multiple pregnancy
ParityProlonged labor
Mal-presentation
Corticosteroid intake
Antepartum hemorrhage
PrEclampsia
Eclampsia
History of abortion or preterm birthMaternal sero-status
Maternal Diabetes mellitus
Type of birth attendant
Neonatal sepsis
Jaundice

Category< 24 hors>=24 hMale
Female< 32 weeks>= 32 weeks< 20 years
20–34 years
Above 34 years
Urban
Rural
MarriedWidowed or divorced
SingleHome
Health institutions
Yes
No
yes
No
1
2
>=3
yes
no
primipara
multipara
grand multipara
Yes
No
Yes
No
yes
No
Yes
No
Yes
No
Yes
No
No
Yes
Negative
PositiveNo
yesskilledunskilled
Yes
No
Yes
No

CHR (95% CI)
1.87(0.35, 1.98)
1
1.48(0.87, 2.87)
2.58 (0.33, 3.78)
1
1
0.91(0.26, 2.22)
0.16(0.042, 1.83)
0.34( 0.12, 4.13)
10.79(0.42, 1.98)
0.29(0.13, 1.56)
1
1.48(0.51, 2.79)
1
2.58(0.50, 3.78)
1
3.56(0.51, 4.98)
1
1.82(0.45, 1.98)
1.87(0.25, 2.88)
1
1.32(0.79, 2.77)
1
10.69 (0.23, 1.79)
0.89 (0.39, 1.55)
1.72(0.40, 2.38)
1
1.16(0.042, 1.63)
1
2.37 (0.73, 3.53)
1
2.37 (0.73, 3.53)
1
2.32(1.5, 3.65)
1
4.76(2.13, 5.78)
11
1.25(0.64, 2.67)
1
2.15(0.81, 3.90)
11.36(0.51, 3.98)
1
2.78(0.50, 3.95)
1.87(0.45, 1.68)11
1.42(0.77, 2.67)
1

AHR (95% CI)

12.69(0.74, 9.77)
1
3.03(1.52, 9.09)*
1

Tirore et al. BMC Pediatrics(2024) 24:511

Page 13 of 15

Table 5 (continued)
Variable
Hypoglycemia
Anomaly
1 min APGAR score
KMC
Exclusively
breast feed
CPAP

Category
Yes
No
Yes
No
3–6
>=7
Yes
No
Yes
No
Yes
No

Supplementary Information

The online version contains supplementary material available at https://doi.
org/10.1186/s12887-024-04992-9.
Supplementary Material 1
Acknowledgements
We would like to thank Wachemo University for giving us the opportunity to
conduct this study.
Author contributions
L.L. conceived the study and prepared the first draft of the manuscript. L.L.,
A.S., D.E., S.A., A.H., L.M., E.M., and M.G. did data acquisition, statistical analysis,
manuscript editing, and manuscript review.
Fundingno funding.
Data availability
All data generated or analysed during this study are included in this publishedarticle [and its supplementary information files].

Declarations
Ethics approval and consent to participate
We will obtain ethical approval was obtained from the Institutional Review
Board (IRB) of Wachemo University. Research Ethics Review Committeeof WCU. A letter of permission was obtained from the clinical Director of
NEMMCSH. Detailed informed consent (with a summary of the study andbenefits of the study in the local language) was obtained from caregivers ofpreterm neonates. All information collected from patient was kept strictly
confidential, and the names of patients were not included in the checklist. All
methods were performed following the relevant guidelines and regulations
and complied with the Declaration of Helsinki.
Consent for publication
N/A.
Competing interests
The authors declare no competing interests.
Author details
1
Department of Public Health, Wachemo University, Hossana, Ethiopia
2
Department of Midwifery, Wachemo University, Hossana, Ethiopia
3
Department of Pediatrics, Wachemo University, Hossana, Ethiopia
4
Department of Public Health, Adigrat University, Adigrat, Ethiopia
Received: 6 February 2024 / Accepted: 2 August 2024

CHR (95% CI)
2.59 (1.33, 4.78)
1.91(0.36, 2.32)
1
10.72(0.40, 1.28)
15.37 (2.73, 10.53)
1
7.34 (3.81, 14.13)
10.79(0.43, 1.96)

AHR (95% CI)
1.76(0.40, 1.92)

1
2.26(1.04, 4.90)*
1
4.40(2.09, 9.24)*

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