(2024) 24:542
Kyasimire et al. BMC Pediatrics
https://doi.org/10.1186/s12887-024-05014-4

BMC Pediatrics

RESEARCH

Open Access

Clinical profiles, incidence and predictorsof early neonatal mortality at Mbarara Regional
Referral Hospital, south‑western Uganda
Lydia Kyasimire1*, Leevan Tibaijuka2, Moses Ochora1, Musa Kayondo2, Elias Kumbakumba1,
Josephine Nantongo3 and Stella Kyoyagala1

Abstract
Background The current neonatal mortality rate in Uganda is high at 22 deaths per 1000 live births, while it had
been stagnant at 27 deaths per 1000 live births in the past decade. This is still more than double the World HealthOrganization target of < 12 deaths per 1,000 live births. Three-quarters of new born deaths occur within the first weekof life, which is a very vulnerable period and the causes reflect the quality of obstetric and neonatal care. At Mbarara
Regional Referral Hospital (MRRH), the modifiable contributors and predictors of mortality remain undocumented,
yet neonates make the bulk of admissions and contribute significantly to the overall infant mortality rate. We therefore examined the clinical profiles, incidence and predictors of early neonatal mortality of neonates admitted at MRRH
in south-western Uganda.
Methods We conducted a prospective cohort study at the Neonatal Unit of MRRH between August – November, 2022 among neonates. We consecutively included all live neonates aged < 7 days admitted to neonatal unit
and excluded those whose outcomes could not be ascertained at day 7 of life. We obtained baseline data including;maternal social-demographic and obstetric information, and performed neonatal physical examinations for clinicalprofiles. We followed up neonates at 24 and 72 h of life, and at 7 days of life for mortality. We summarized the clinical profiles and incidence of mortality as frequencies and percentages and performed modified Poisson regression
analysis to identify the predictors of early neonatal mortality.
Results We enrolled 384 neonates. The majority of neonates were in-born (68.5%, n = 263) and were admitted
within 24 h after birth (54.7%, n = 210). The most common clinical profiles at admission were prematurity (46%,n = 178), low birth weight (LBW) (44%, n = 170), sepsis (36%, n = 139), hypothermia (35%, n = 133), and birth asphyxia(32%, n = 124). The incidence of early neonatal mortality was at 12.0%, 46 out of the 384 neonates died. The predictors of early neonatal mortality were hypothermia, [adjusted Risk Ratio: 4.10; 95% C.I (1.15–14.56)], birth asphyxia,[adjusted Risk Ratio: 3.6; 95% C.I (1.23–10.73)] and delayed initiation of breastfeeding, [adjusted Risk Ratio: 7.20; 95% C.I(1.01–51.30)].
Conclusion Prematurity, LBW, sepsis, birth asphyxia and hypothermia are the commonest admission diagnoses.
The incidence of early neonatal mortality was high, 12.0%. We recommend targeted interventions by the clinical care team at MRRH to enable timely identification of neonates with or at risk of hypothermia to reduce incidence of adverse outcomes. Intrapartum care should be improved in order to mitigate the risk of birth asphyxia.
*Correspondence:
Lydia Kyasimire
klynda1603@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
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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/.

Kyasimire et al. BMC Pediatrics(2024) 24:542

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Breastfeeding within the first hour of birth should be strengthened were possible, as this is associated with vast
benefits for the baby and may reduce the incidence of complications like hypothermia.
Keywords Early Neonatal Mortality, Clinical profiles, Predictors of early neonatal mortality

Introduction
The neonatal period, which lasts from the day of birththrough the first 28-days of life, is when a child’s survival and health are most at risk [1]. Neonatal mortality
accounts for 57% of the global infant mortality and 40%of all under-5 mortality [2].
The first week of life is a very vulnerable period which
accounts for nearly three-quarters of new-born deaths,
with one-third occurring on the first day of life [2, 3].
Sub-Saharan Africa has the greatest mortality rates and atenfold risk of neonatal death compared to the developed
countries [2]. Similar to the Uganda’s stagnant neonatal
mortality rate over the past 10 years, sub-Saharan Africa
has a neonatal mortality rate of 27 deaths per 1,000 live
births since 2019 [3]. The neonatal mortality rate in
Uganda has however improved to 22 deaths per 1000 live
births [4]. This is however, more than twice the Sustainable Development Goal target for neonatal mortality set
at less than 12 deaths per 1,000 live births [5].
The maternal risk factors like extremes of age—teenagers and advanced maternal age (> 35 years),
multiparity and short birth intervals, as well as
delayed initiation of breastfeeding are among the factors reported to have increased the risk of neonatal
mortality [6]. The other risk factors include place ofbirth, neonatal characteristics like gestational age,birth weight and Apgar score [7, 8].
Scant setting specific data on neonatal characteristics
and predictors of mortality in the LMICs impacts theefforts directed towards improving neonatal outcomes [9,10], which would be crucial in directing the timely essential interventions to reduce early neonatal mortality [11].
This study therefore aimed to describe the clinical profile
of neonates and determine the incidence and predictorsof early neonatal mortality among neonates admitted to
the MRRH neonatal unit.
Materials and methods
Study setting and design

We conducted a prospective cohort study of live neonates admitted to the neonatal Unit of Mbarara Regional
Referral Hospital (MRRH) from August, 2022 to November, 2022.
MRRH is a government funded public hospital, situated in Mbarara city in southwestern Uganda, 260 kms
from Kampala, the capital city of Uganda. The hospital

has a catchment population of 3.4 million people, and a
494-bed capacity. The hospital serves as a teaching hospital for Mbarara University of science and Technology(MUST) and other tertiary health training institutionsin the region. MRRH receives patients from all the districts of Ankole and Kigezi subregions in southwestern
Uganda, and part of greater Masaka subregions in central
Uganda including Mbarara, Isingiro, Bushenyi, Buhweju,
Ibanda, Kiruhura, Mitoma, Ntungamo, Rwamapara,
Sheema, Rubirizi, and Lyantonde. The hospital provides
services to patients from 2 refugee camps (Nakivaale,
Oruchinga) who are from Rwanda, Burundi, Congo,
Somalia, Sudan, and Ethiopia.
The obstetrics and gynecology department at MRRH
houses the maternity ward and a high risk obstetrics unitthat is located about 20 m from the neonatal unit, while
the operating theatre is approximately 40–50 m fromthe neonatal unit. The high-risk obstetrics unit manages
mothers with complicated pregnancies. The maternity
ward conducts 800–1000 deliveries every month [7].
The Obstetrics and Gynaecology department comprises
14 obstetricians, 33 residents, 12 intern doctors, and 19
midwives (with 10 working on any given day).
Sick neonates are transferred to the neonatal unit by
the caretaker or a midwife from theatre or labour suit.
There are no facilities for providing oxygen support or
warmth while the neonate is in transit to the neonatal
unit.
The Paediatric ward is managed by a team of 10 paediatricians, 20 paediatric residents, 8 intern doctors and
10 nurses. The neonatal unit is staffed with 2 paediatricians, and 6 nurses. The nurses work in 8-to-12-h shifts,
and on average each shift has 2 nurses. The unit has 3intern doctors and 3 paediatric resident doctors on rotational basis. The neonatal unit functions as a level II unit,
however receives neonates that require advanced respiratory and cardiovascular support. According to hospitalrecords, the neonatal unit admits close to 3,000 neonates
every year (60% of overall paediatric admissions), therefore approximately 250 sick neonates are admitted every
month.
About two-thirds of the neonates admitted to this newborn unit are born at MRRH, and the remaining third
are either referred in from other medical centres or are
brought in directly from the local populations. The neonatal unit is a 49-bed capacity unit, divided into 4 sections, the high dependency unit, 26 cots (for both veryKyasimire et al. BMC Pediatrics(2024) 24:542

sick term and preterm babies), 8-bed capacity Kangaroo
mother care room for stable preterm and a unit for stable terms with 15 beds. The unit sometimes admits up tothrice its capacity, with neonates sharing infant warmers
and cots. The neonatal unit had recently received a donation of medical equipment, and currently has 14 neonatal
phototherapy machines, 4 radiant warmers, 8 infusion
pumps, 5 monitors. Along with 14 back-up oxygen concentrators, there is a supply of medical oxygen in oxygen
cylinders. The unit does not have a mechanical ventilator and Continuous Positive Airway Pressure machines(CPAP), as well as blood gas machines. The unit uses
bubble CPAP with cold unblended oxygen, which is
locally developed for neonates with respiratory distresssyndrome (RDS), as the main stay of treatment for RDS.
Exogenous surfactant is not available, due to resource
limitations. The nursing services offered include provision of intravenous antibiotics (commonly ampicillin
and gentamycin), intravenous fluids, phototherapy andnasal gastric tube feeding. Mothers feed their babies on
a 2-hourly basis. Neonates once discharged are followed
up routinely through the neonatal clinic, every Thursday.
Study population and eligibility criteria

This prospective cohort study included neonates admitted to the neonatal unit of MRRH. We included all live
neonates within the first 7 days of life, including neonates with congenital anomalies. Both in-born and outborn neonates were included in this study. Runaways andself-discharges that could not be contacted on the 7th
day of life were considered as lost to follow up and were
excluded from the final analysis.
Sample size estimation and sampling

The sample size was calculated using Open Epi version
3, specifically employing the sample size determination for cohort studies. The calculations were based ona previous study conducted among neonates admitted at
Mulago National Referral Hospital in Uganda, with theproportion of mortality among out-born neonates (34%)
and proportion of mortality among in-born neonates(20%) [8], we estimated a total sample size of 384 (128 out
born and 256 inborn) neonates. We assumed 80% power,
95% confidence interval and the ratio of the unexposed(inborn neonates) to exposed (out born neonates) of 2.
We therefore consecutively enrolled 384 live neonates.
Study variables
Clinical profiles

The clinical profiles were the neonatal clinical characteristics and diagnoses obtained at the time ofadmission. These included hypothermia (axillary temperature < 36.5°c, taken with a lithium battery-operated

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digital thermometer), hypoglycaemia (random blood
sugar < 2.2 mmol/dl) in a capillary blood sample from aheel prick for blood glucose testing using an electronic
glucometer [12], admission weight, gestation age, neonatal sepsis, as well as jaundice, abnormal bleeding, congenital anomaly, and birth asphyxia (5 min APGAR score lessthan 7)/ Hypoxic ischemic encephalopathy (HIE), prematurity, respiratory distress syndrome. The gestation age
was calculated from the last normal menstrual period,or estimation from obstetrics ultra sound scan, if available and a Ballard score was used to assess neonates witheither a last normal menstrual period or obstetric scan.
A neonate was considered preterm if delivered before 37
completed weeks of gestation, and a birth weight below
2.5 kg was considered low birth weight. These were
defined as per Integrated Management of childhood illnesses (IMCI) [12, 13].
Neonatal diagnoses were defined as 1) RDS—presence of any of: fast breathing, grunting, subcostal andintercostal recession, cyanosis and reduced air entry
in bilateral lung fields starting in the first four hours oflife, chest radiographs (x-rays) were not done [12, 13].; 2)birth asphyxia—a 5-min Apgar score of less than 7 [14];3) jaundice/hyperbilirubinemia—yellowing of eyes and/or body requiring phototherapy or serum bilirubin levels above 15 mg/dL according to the WHO’s Integrated
Management of Childhood Illnesses (IMCI) algorithm[12]; 4) sepsis—we diagnosed sepsis clinically, by examining for one or more of the clinical characteristics listed;change in level of activity, bulging fontanelle,history of
convulsions, feeding difficulty, temperature ≥ 37.5 °Cor < 35.5 °C, fast breathing / respiratory rate ≥ 60 bpm,
severe chest in drawing, grunting and/or.
cyanosis according to the WHO’s Integrated Management of Childhood Illnesses (IMCI) algorithm [12], blood
cultures were not done. The cause of death was defined as
the clinical condition directly and immediately leading to
the death of the neonate as documented in the neonate’s
medical chart/records.
Predictor variables

Neonatal predictors; gestational age, sex, Apgar score at
5 min, birth weight, breastfeeding status, temperature.
Maternal and obstetric predictors included maternal age,level of education, marital status, occupation, number ofantenatal care (ANC) contacts, mode of delivery, parity,and maternal HIV serostatus.
Outcome/ dependent variable

The outcome variable of interest was early neonatal
death/ mortality. We defined the early neonatal deathas death of a neonate any time from admission to 7 days
after birth. We obtained information on early neonatal

Kyasimire et al. BMC Pediatrics(2024) 24:542

death from the neonate’s chart for the neonates who werestill admitted in the neonatal unit, and followed up byphone for those discharged home.
Recruitment and follow‑up of participants

We approached mothers/caretakers at the point ofadmission, after the neonate had been initiated on careand stabilised, to obtain permission to participate in the
study. Alongside the clinical care team, we performed acomplete evaluation of the neonate, including history
and the physical exam. We approached mothers/caretakers only for information missing from the patient
charts. We followed up the enrolled neonates at 24 and
72 h, and on the 7th day of life to ascertain outcome ofinterest, whether the neonate was dead or alive, throughobservation and chart review. We followed up the neonates discharged home via a phone call. We collected
and managed data using a pretested data collection toolin Research Electronic Data Capture (Redcap) [15]. The
study team research assistants used android phones
with pre-installed Redcap to collect data. We checkedcollected data for completeness every day. The research
assistants were experienced nurses in regard to newborn care, and had attained a certificate of good clinicalpractice.
Data management and analysis

Data were exported to STATA 17 (StataCorp, College Station, Texas, USA) for cleaning and analysis. We reported

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the baseline socio-demographic, obstetric, and neonatal characteristics of the participants using proportions.
We described the clinical profiles as frequencies andpercentages, and presented in a graph. We reported theincidence of early neonatal deaths as a percentage of thetotal number of neonates enrolled to the end of the follow up period of the study. To determine the predictorsof early neonatal mortality, we used the modified Poisson
regression analysis to perform both univariable and multivariable analysis and reported crude and adjusted risk
ratios respectively. In the final multivariable model, we
included all exposure variables with a p-value < 0.2 at univariable analysis, as well as age, based on biological plausibility. To assess collinearity in our multivariable model,
we employed the variance inflation factor (VIF) method,
considering VIF > 5 as indicative of collinearity. The predictors of early neonatal mortality in the multivariable
model were considered statistically significant if variables
had a p-value < 0.05.

Results
We screened 447 neonates for inclusion into the study
between August – November, 2022, and enrolled 384
neonates after excluding neonates beyond the first weekof life. We excluded 63 neonates who were aged beyond
the first 7 days of life. We lost 15 neonates (3.9%) to follow up, and analysed 369 neonates for incidence and predictors of mortality (Fig. 1).

Fig. 1 Study flow chart showing recruitment, exclusion, and follow-up of participants, at Mbarara Regional Referral Hospital, August – November,
2022

Kyasimire et al. BMC Pediatrics(2024) 24:542

Maternal socio‑demographic and obstetric characteristics

The mean age of the mothers was 26 years, with majority (73.4%) aged between 20 to 34 years. Less than 10%of the mothers had tertiary level education and 3.4% had
not attained any level of education. Majority (95%) of themothers were married and more than half (57.8%) had noemployment. Majority of the mothers had a parity of 2 to
4 (44%), a third of them were first time mothers. Majority (70%) of the mothers had 4 or more antenatal care
contacts, but majority (66%) had their first antenatal care
contact in the second trimester of pregnancy. Additionally, 10% of the mothers were HIV positive, and majority
carried a singleton pregnancy. Just over half of the mothers (58%) had normal vaginal deliveries. The common
pregnancy complications were spontaneous pretermlabour (22%), preeclampsia (23%), and antepartum hemorrhage (17%) (Table 1).

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Table 1 Socio-demographic and obstetric characteristics ofmothers whose neonates were admitted at MRRH between
August – November, 2022 (n = 384)
Variable
Maternal age in years  < 2053 (13.8%)

20–34

282 (73.4%)   > 35

Of the 384 neonates enrolled during the study period, justover half (53.6%) of the babies were term (> 37 weeks),and had a normal birth weight (50.5%). The most prevalent gender was male, with 56.7%. Only 11.6% of theneonates had Apgar < 7 at 5 min. It was noted that 62%of the neonates had not breast fed within the initial hourof life. Majority of the neonates (68.5%) were delivered at
MRRH, while the rest were born in other health facilities(Table 2).

Clinical profiles of the neonates admitted at MRRH

Close to half of the babies enrolled, (46%) were preterm
neonates and 44% were low birth weight. The other diagnostic categories at admission included sepsis (36%),
hypothermia (35%), birth asphyxia (32%), and respiratory
distress syndrome (RDS) 25%. Additional admission clinical conditions included jaundice (10%), hypoglycemia(9%) and congenital anomalies (6%). Of the 24 neonates
admitted with congenital anomalies, 4 had spina bifida,
clubfoot (n = 4), omphalocele (n = 4), gastroschisis (n = 2),congenital heart disease—Tetralogy of Falot (n = 1), congenital hydrocephalus (n = 5), anencephaly (n = 1), cleft
lip and palate (n = 3 (Fig. 2).

Characteristics of in‑born versus out‑born neonates
admitted to MRRH

There was a significant difference in characteristics of
in-born versus out-born neonates in terms of preterm
rupture of membranes, pre-eclampsia/eclampsia, caesarean delivery, birth asphyxia and neonatal jaundice.

49(12.8%)

Formal Education level
Uneducated

13 (3.4%)

Primary

166 (43.3%)

Secondary

155 (40.5%)

Tertiary

49 (12.8%)

Married365 (95.1%)

House hold monthly income (Uganda shillings)
250,000–500,000

66 (17.2%)

50,000–250,000

147 (38.3%)   < 50,000

Baseline characteristics of the neonates

Frequency (%)

171 (44.5%)

Parity1

139 (36.2%)

2–4

169 (44.0%)  ≥ 5

76 (19.8%)

Number of antenatal care visitsNone

4 (1.1%)

1–3

114 (28.6%)   ≥ 4270 (70.3%)

Gestation at first antenatal care visit (n = 380)
1st trimester

120 (31.6%)

2nd trimester

251 (66.1%)

3rd trimester5(1.3%)

Twin pregnancy

48 (12.6%)

HIV sero-positive

32 (8.4%)

Obstetric complications
Spontaneous preterm labour88 (22.9%)

Preeclampsia

23 (6.0%)

Antepartum haemorrhage (placenta previa
and abruption)
No obstetric complication

17 (4.4%)
256(66.7%)

Mode of delivery
Caesarean section

156 (40.6%)

Vertex vaginal delivery

223 (58.1%)

Breech vaginal delivery

5 (1.3%)

Referred from another health unit

103(26.8%)

More in-born neonates were delivered from motherswith pre-eclampsia/eclampsia (8.4% versus 0.8%), wereborn by caesarean Sect. (52.1% versus 15.7%) and suffered birth asphyxia (36.1% versus 24.0%). However,preterm rupture of membranes (5.7% versus 12.4%) andneonatal jaundice (8.0% versus 15.7%) were more common among out-born neonates (Table 3).

Kyasimire et al. BMC Pediatrics(2024) 24:542

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Table 2 Baseline characteristics of neonates admitted at MRRH
between August – November, 2022 (n = 384)
Variable

Frequency (%)

Gestational age (weeks)
Preterm (< 37)

178 (46.4%)

Term (≥ 37)

206 (53.6%)

Neonatal age at admission
Within 24 h
24–72 h   > 72 h < 7 days

210 (54.7%)
133 (34.7%)
41 (10.7%)

Sex of the neonate
Female166(43.3%)

Male217(56.7%)

Birth weight (kilograms)
Big baby (≥ 4)

20 (5.2%)

Normal (2.5 to < 4)

194(50.5%)

Low birth weight ( < 2.5)

170(44.3%)

Apgar score at 5 min < 7

41 (11.6%)

Breast feeding initiated in the first 1 h

62(37.6%)

Place of birthIn-born (born at MRRH maternity ward)
Out-born (born at other health facilities and referredin)

263 (68.5%)
121(31.5%)

Early neonatal mortality at MRRH

Overall, 46/384 (12.0%) neonates died in the first weekof life. The out born neonates had a mortality of 11.6%(14/121), while the inborn neonates had a mortality of
12.2% (32/263). Of the neonates who died, 12 (26%)

died in the first 24 h of life, 15 (33%) died between 24
to 72 h, while the rest died after the first 72 h. Over
half of the neonates who died (56.5%, n = 26) were preterm neonates (gestational age < 37 weeks). Of these,
8 were late preterm (34- < 37 weeks), 3 (moderate preterm, 32- < 34 weeks), 9 (very preterm, 28- < 32 weeks)
and 6 (early preterm, < 28 weeks). Majority of the neonates died following complications of birth asphyxia(39%, n = 18) and respiratory distress syndrome (RDS)(32%, n = 15). Sepsis contributed to the least number ofneonatal deaths (n = 1). Five of the neonates with congenital anomalies died, they included; congenital heartdisease—Tetraloty of Falot (n = 1), gastroschisis (n = 2),
anencephaly (n = 1), and congenital hydrocephalus(n = 1) (Fig. 3).
Predictors of early neonatal mortality among neonates
admitted at the neonatal unit of MRRH between August –November, 2022

At multivariable analysis; hypothermia, birth asphyxia
and late breast-feeding initiation (1 h after delivery)
were independent predictors of early neonatal mortality. Hypothermia increased the risk of early neonatal mortality by four times, [adjusted Risk Ratio:
4.10; 95% C.I (1.15–14.56), p = 0.029], birth asphyxia
increased the risk of early neonatal mortality by 3.6
times, [adjusted Risk Ratio: 3.6; 95% C.I (1.23–10.73),
p = 0.020] and delayed initiation of breastfeeding was
associated with seven-fold increase in risk for earlyneonatal mortality, [adjusted Risk Ratio: 7.20; 95% C.I(1.01–51.30), p = 0.049] (Table 4).

Fig. 2 Clinical profiles of the neonates admitted to MRRH neonatal unit from August- November, 2022 (n = 384); *the clinical profiles were
not mutually exclusive; RDS: Respiratory distress syndrome; TTN: transient tachypnea of the newborn; LBW: Low birth weightKyasimire et al. BMC Pediatrics(2024) 24:542

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Table 3 Characteristics of in-born versus out-born neonates admitted to MRRH between August – November, 2022 (n = 384)
Variable

In-born (N = 263)

Out-born (N = 121)n/N (%)n/N (%)

P-value

Multiple pregnancy

28 (10.7%)

20 (16.5%)

0.110

Preterm rupture of membranes

15 (5.7%)

15 (12.4%)

0.023*

Spontaneous preterm labour58 (22.1%)

30 (24.8%)

0.550

Preeclampsia/eclampsia

22 (8.4%)

1 (0.8%)0.004*

Antepartum hemorrhage

14 (5.3%)

3 (2.5%)

0.210

Malpresentation

14 (5.3%)

3 (2.5%)0.210

Chorioamnionitis

2 (0.8%)2 (1.7%)0.420

Caesarean section

137 (52.1%)

19 (15.7%)

Vaginal delivery

126 (47.9%)

102 (84.3%)

138 (52.5%)

68 (56.2%)

Female106 (40.5%)

60 (49.6%)

Male

156 (59.5%)

61 (50.4%)

Big baby (≥ 4)

12 (4.6%)8 (6.6%)

Normal (2.5- < 4)

127 (48.3%)

67 (55.4%)

Low birth weight (< 2.5)

124 (47.1%)

46 (38.0%)

Mode of delivery

Preterm births (< 37 weeks)< 0.001*

Sex of the neonate

0.500
0.094

Birth weight (kilograms)

0.220

Apgar score at 5 min < 7

31 (12.2%)

10 (10.2%)

0.600

Respiratory distress syndrome

69 (26.2%)

27 (22.3%)

0.410

Birth Asphyxia

95 (36.1%)

29 (24.0%)

0.018*

Hypothermia

95 (36.1%)

38 (31.4%)

0.370

Hypoglycemia

28 (10.6%)

7 (5.8%)0.120

Neonatal jaundice

21 (8.0%)19 (15.7%)

0.021*

Neonatal sepsis

97 (36.9%)42 (34.7%)

0.680

*

p < 0.05

Fig. 3 Causes associated with early neonatal mortality at MRRH (n = 46). HIE: Hypoxic Ischemic encephalopathy; RDS: Respiratory distress syndrome

Kyasimire et al. BMC Pediatrics(2024) 24:542

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Table 4 Multivariable analysis of predictors of early neonatal mortality among neonates admitted at MRRH
Variable

Died (N = 46)

Univariable analysisn/N (%)

Crude RR (95% C.I)

P-value

Adjusted RR (95% C.I)

P-value

0.882

0.93 [0.25,3.46]

0.911

Multivariable analysis

Maternal age (years)   < 206(13.0%)0.9 (0.42–2.12)

20–34

34 (73.9%)

Ref   > 34

6 (13.0%)

1.08 (0.48–2.44)   ≥ Secondary

26 (56.5%)

Ref   ≤ Primary

20 (43.5%)

0.66(0.37–1.18)   ≥ 427 (58.7%)

Ref   < 419 (41.3%)

1.68 (0.98–2.90)

Vaginal births

29 (63.0%)

Ref

C-section

17 (37.0%)

1.08(0.62,1.90)

Inborn32 (69.6%)

Ref

Out born

14 (30.4%)

0.91 (0.50–1.65)

Term (≥ 37)

26 (56.5%)

Ref

Preterm (< 37)

20 (43.5%)

1.49 (0.86–2.58)

Female18 (40.0%)

Ref

Male

27 (60.0%)

1.12 (0.64–1.97)

Ref
0.841

-

-

Formal Education
Ref
0.161

0.82[0.37,1.83]

0.630

Antenatal care contacts
Ref
0.059

1.15[0.48,2.75]

0.749

Mode of delivery
Ref
0.770

1.02[0.39,2.70]

0.964

Place of birth
Ref
0.767

1.13[0.35,3.61]

0.835

Gestational age (weeks)
Ref
0.150

0.60[0.09,4.01]

0.595

Sex of neonate
Ref
0.677

1.50[0.35,6.39]

0.580

Respiratory distress syndromeNo

24 (52.2%)

Ref

Yes

22 (47.8%)

2.65 (1.56–4.50)

No

15 (32.6%)

Ref

Yes

31 (67.4%)

3.83 (2.15–6.81)

No

38 (82.6%)

Ref

Yes

8 (17.4%)

2.04 (1.03, 4.00)

Early (< 1 h)

1 (6.3%)Ref

Late (> 1 h)

15 (93.8%)

9.29 (1.25–69)

Ref< 0.001**

1.13[0.50,2.57]

0.772

Hypothermia
Ref< 0.001**

4.10 [1.15,14.56]

0.029*

Hypoglycemia
Ref0.046*

0.79[0.13,4.76]

0.796

Breastfeeding initiation
Ref
0.006*

7.20[1.01,51.30]

0.049*

Birth weight (kilograms)   ≥ 2.5

Ref   < 2.5

1.14 (0.66–1.95)

Ref
0.644

0.96[0.07,12.54]

0.974

Birth asphyxia
No

15 (32.6%)

Ref

Yes

31 (67.4%)

4.43(2.49,7.89)

RR Risk Ratio, Ref Reference group, CI Confidence Interval*

p < 0.05**

p < 0.001

Ref< 0.001**

3.63[1.23,10.73]

0.020*

Kyasimire et al. BMC Pediatrics(2024) 24:542

Discussion
This prospective cohort study examined the clinical profile of neonates and determined the incidence and predictors of early neonatal mortality among live neonates
admitted to the neonatal unit at a tertiary hospital in a
low-resource setting in southwestern Uganda. The results
showed that the bulk of neonatal admissions had a diagnosis of prematurity, low birth weight, sepsis, hypothermia and birth asphyxia. Every 1 in 10 neonates died in theearly neonatal period, and hypothermia, birth asphyxia
and late initiation of breastfeeding were independent
predictors of early neonatal mortality. Overall, these findings highlight the need for targeted implementation of
the intrapartum and neonatal care protocols. This will
ensure timely identification of the neonates at increased
risk of adverse outcomes while in-utero and duringlabor, and hence prevent birth asphyxia. These findings
highlight the need to strengthen the warm chain by optimizing early interventions that correct and prevent complications associated with preterm and low birth weight
neonates, especially hypothermia. These interventions
include thermal control of the delivery room temperature during deliveries, use of dry and pre-warmed towels, immediate skin to skin contact of baby and mother,
as well resuscitation of neonates under warmers [16].
These practices are vital to reduce early neonatal mortality especially in the low resource settings.
In the current study, preterm and low birth weight
neonates accounted for almost half of the neonatal
admissions, followed by hypothermia, sepsis and birthasphyxia. Our findings are consistent with previous studies conducted in sub-Saharan Africa including at Kiwoko
hospital in Uganda and in Ghana, with prematurity
responsible for almost half of the admissions [17, 18].
The significant number of preterm and low birth weight
neonates admitted highlight the need for clinical care
preparedness and investment in feasible practices likeadministration of antenatal corticosteroids to high risk
pregnancies (as practiced at our study site) and essential
neonatal care interventions through providing the warm
chain including kangaroo mother care, timely resuscitation of the neonates and encouraging early initiation ofbreast feeding [7].
Neonatal sepsis was noted in one third of the neonatal admissions. Our results are consistent with studies done in other low resource settings and for example
in Kenya and other sub-Saharan African countries [3,19]. This similarity could be attributable to the similarpoor socio-economic status, with similar challenges inaccessing equitable health care for the mothers and theirneonates and harmful practices that predispose to sepsis. For example the level of neonatal care provided bythese facilities is perhaps limited by absence of advanced

Page 9 of 12

diagnostic facilities, or practices that abate sepsis in the
neonates. In low resource settings, the high prevalence ofsepsis may be due to multiple risk factors attributable tothe suboptimal obstetric care for the mothers and their
new-borns, coupled with harmful traditional therapeutic practices to the neonates like superficial skin cuts,
uvulectomy, false teeth extraction, use of herbal remedies
for skin care and application of cow dung to the cord,
among others [20]. Routine hand-washing before handling of the baby by caregivers prevents sepsis, but may
not be optimally practiced in our setting [21, 22]. Mothers with risk factors predisposing their neonates to sepsis should be identified early, and preventative measures
like administration of prophylactic antibiotics taken to
reduce occurrence of neonatal sepsis.
We found that 12.0% of the neonates died. This finding is consistent with other studies in the low resource
settings including Mulago (central Uganda), and Kenya,
and India that reported the early neonatal mortality rate
ranging from 10–12% [23–25]. This similarity of results
could be because the study settings are similar in socioeconomic status, with similar health care challenges. For
example limited resources in terms of funds and personnel to adequately provide at minimum level 2 neonatal
care—through changes in practice, routine audits, procurement of basic equipment, training and dedicating of
neonatal unit staff as noted from other regional hospitalin Uganda and other low income countries [26–28]. The
main causes of early neonatal death are consequences ofmaternal obstetric complications like obstructed labour,
cord prolapse, preterm rupture of membranes, antepartum haemorrhage and complicated deliveries, among
others [3]. This is a reflection on the quality of obstetriccare mothers received.
We report a similar incidence of mortality for both thein-born and out-born neonates; this is consistent with astudy in India [23]. Studies at Kiwoko and Mulago hospitals, in Central Uganda, however reported higher mortality in out-born neonates—up to twice that of in-born
neonates [8, 17]. This disparity could be explained by
the advancement in care for mothers and neonates in
the past 10 years with strengthening of support supervision to the lower level health facilities and improving thereferral systems, mainly encouraging in-utero transfer ofhigh risk pregnancies for delivery at centres with expertise and equipment to provide optimal care for the mothers and neonates. Additionally, this could be explained by
the significant number of in-born neonates that were theresult of high risk pregnancy conditions like preeclampsia/eclampsia which were associated with delivery of very
sick neonates with life threatening conditions like birthasphyxia which were significant contributors to mortality
in our study.

Kyasimire et al. BMC Pediatrics(2024) 24:542

Our study found more than half of the mortalities tohave occurred in the first 72 h which is in keeping withliterature from other studies. Generally, studies reportthat more than 3 quarters of neonatal deaths occur
within the first week of life [23, 29, 30]. Evidence fromliterature demonstrates that severe respiratory issues,
hypothermia, hypoglycaemia, a delayed foetal to neonatal circulatory transition, and respiratory distress of prematurity are the commonest causes of early new born
deaths [25, 30]. In this study, a third of the neonates had
hypothermia, asphyxia or RDS. Furthermore, one third of
the mothers in this study presented with obstetrics complications. Evidence from literature shows that maternal
obstetric complications increase the risk of early neonatal
deaths [31].
The independent predictors for early neonatal mortality were hypothermia, birth asphyxia and delayed initiation of breastfeeding. Similar to our study findings, priorstudies have reported hypothermia on admission has
been reported to be associated with early neonatal mortality [32–35]. Hypothermia is a major clinical concern
in the preterm, low birth weight and/ or sick neonates
due to a large surface area to body mass ratio, reduced
subcutaneous fat, a thin and immature skin, a high body
water content, as well as immature metabolism [25]. In
our study, 73.9% (n = 99) with hypothermia were preterm
neonates. Hypothermia affects multiple body systems
including the cardiopulmonary (bradycardia, apnoea),
the central nervous system (lethargy, poor feeding), thevascular system, as well the metabolic system, causing
hypoglycaemia, hypoxia and metabolic acidosis, all whichcause death [36]. Insufficient knowledge as opposedto lack of resources is the root cause of hypothermia,
according to WHO [37]. Studies have demonstrated that
hypothermia is a risk factor for early neonatal mortality[38], and more to this, the European guidelines on neonatal resuscitation emphasise good thermal control duringresuscitation, so as to optimise good outcomes [16]. Thisimplies that early recognition and prevention of hypothermia in these babies with focused management will
reduce the cases of hypothermia, and subsequently theincidence of neonatal mortality at MRRH.
Birth Asphyxia accounted for one third of our admissions and predicted early neonatal mortality—subsequently contributing to a third of the mortality in ourstudy. Our results are similar to studies done in Uganda[8, 17, 32], and Ethiopia [10]. Birth asphyxia is a major
cause of neonatal mortality in resource constrained areasfor various reasons that include inadequate obstetrics
health coverage, social cultural norms that cause delaysin accessing emergency obstetrics and neonatal care [39].
The 3 delays in accessing obstetric care [40], inconsistencies in management of labour, system factors like poor

Page 10 of 12

resource allocations and management, high levels of
illiteracy and shortage in health workers are important
indirect causes of birth asphyxia in resource limited settings [41]. These results highlight the need to strengthen
intrapartum care through labor monitoring and timely
detecting of fetal distress, prioritise and build capacity
for new-born resuscitation and initial new-born care following birth. Promoting early referrals of mothers withobstetric complications, and early seeking of care bymothers, will help curb the rate of birth asphyxia.
Delayed initiation of breastfeeding (> 1 h) increases therisk of early neonatal mortality sevenfold in our study.
This is in agreement with several studies done in Uganda[7, 42], India [43], and Ethiopia [10, 35], that reportincreased odds of death for neonates with delayed initiation of breastfeeding. Neonatal mortality can be reduced
by 20 to 30% if early initiation of breastfeeding is practiced [43, 44]. Therefore, programmes and activities that
promote early initiation of breastfeeding will go a longway in curbing early neonatal mortality.
The strength of this study is that it was conducted as aprospective study of both inborn and out-born neonates
at a tertiary referral centre—with a large number of neonates admitted and referred in from surrounding healthfacilities with no outward transfers. We were therefore
able to determine predictors of mortality from the identified variables, among the neonates. The other strength
is that the attrition rate was minimised by the short follow up period. However, this study was limited by thefact that it was carried out in a single centre, therefore
the results may not be representative of the rest of theregions in Uganda.

Conclusions
The commonest cause of neonatal admissions were lowbirth weight, prematurity, sepsis, hypothermia and birthasphyxia. The early neonatal mortality rate was very high,
12.0%, with similar mortality among the inborn and out
born neonates. The causes of death were mainly birthasphyxia and RDS. Hypothermia, birth asphyxia anddelayed initiation of breastfeeding were the predictors ofearly neonatal mortality in our study.
Our study findings highlight the need of clinical careteams to identify neonates with or at risk of hypothermia, and optimise early interventions to correct orprevent it. This includes focused assessment of neonates, proper use of available facilities (infant warmers, clean and dry linen), and promotion of Kangaroo
mother care, with continuous monitoring, until resolution. There is need for integrated maternal-paediatriccare when planning deliveries of mothers with highrisk pregnancies in order to provide timely emergency

Kyasimire et al. BMC Pediatrics(2024) 24:542

neonatal care. Maternal and paediatric clinical careteams should ensure that neonates without severe morbidity should be supported to breastfeed within the firsthour life. Continued support supervision to peripheral
facilities should be strengthened in order to ensure
timely referral of mothers with high-risk pregnancies,
in-utero referral of likely preterm deliveries, and safe
transfer of sick neonates.
Abbreviations
CPAP	Continuous positive airway pressure
IMCI	Integrated management of childhood illnesses
KMC	Kangaroo mother care
LBW	Low birth weight
LMIC	Low and middle income countries
LNMP	Last normal menstrual period
MMR	Maternal mortality ratio
MRRH	Mbarara Regional Referral Hospital
MUST	Mbarara University of Science and Technology
RDS	Respiratory distress syndrome
TTN	Transient tachypnoea of the newbornWHO	World Health Organisation
Acknowledgements
The authors acknowledge the departments of Paediatrics and Child Health,and Obstetrics and Gynecology of Mbarara University of Science and Technology, and the administration of Mbarara Regional Referral Hospital for theirinvaluable support throughout this study. We also acknowledge Ms. Flora
Habyara and Ms. Maureen Muhindo for participating in data collection.
Authors’ contributions
LK, LT, JN and SK contributed to the conception and design of the study. LT
performed formal data analysis. LK drafted the manuscript. LK, LT, JN and SK
contributed to study implementation and data acquisition. EK, MO, and MK
critically reviewed and revised the manuscript for key content. All authors
read and approved the final manuscript.
Funding
This study did not receive any external funding. LT is supported by the
Mbarara University Research Capacity Initiative (MURCI) Program funded by
the Fogarty International Centre of the National Institute of Health (NIH) under
grant number D43TW011632. The funders had no role in study design, datacollection and analysis, decision to publish, or preparation of the manuscript.
Availability of data and materials
The datasets used during this study are available from the corresponding
author upon reasonable request.

Declarations
Ethics approval and consent to participate
The study was approved by the Research Ethics Committee of Mbarara University of Science and Technology under reference number MUST-2022–449.
Administrative clearance was obtained from the office of the Hospital Directorof MRRH. Written informed consent for involvement in the study was obtained
from the mothers/caretakers of all the participants before enrolment. Participants’ confidentiality was ensured through use of unique identifiers rather
than names and data were entered in Redcap, which was password protected.
Participant recruitment, informed consent process, data collection, andconfidentiality measures were all conducted in accordance with the ethicalprinciples outlined in the Helsinki Declaration.
Consent for publication
Not applicable.

Page 11 of 12

Competing interests
The authors declare no competing interests.
Author details
Department of Paediatrics and Child Health, Mbarara University of Scienceand Technology, P.O. Box 1410, Mbarara, Uganda. 2 Department of Obstetrics
and Gynaecology, Mbarara University of Science and Technology, Mbarara,
Uganda. 3 Department of Paediatrics and Child Health, Mbarara Regional Referral Hospital (MRRH), Mbarara, Uganda.
1

Received: 12 October 2023 Accepted: 14 August 2024

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