neonatal period ( the first 28 days after birth ) , which is the period of various physiological adaptations to the extrauterine life , is a vulnerable time . more than 10 million children die before the age of 5 years , 8 million of whom die before the age of 1 year and more than half of these deaths occur in the first 4 weeks after birth . about 98% of the neonatal deaths occur in developing countries . according to the world health organization ( who ) , the rate of deaths is 30 times more in the countries with the highest rate compared to the countries with the lowest rate . according to the reports of ministry of health and medical education , the index of neonatal death in iran is 16 - 20 deaths out of 1000 survived births , which is higher than that in developed countries . who has urged iran to halve its neonatal death rate by 2015 . risk factors in studying neonatal death are categorized into three groups : prenatal , intrapartum , and postnatal factors . all over the world , infection , preterm delivery , and birth asphyxia contribute to about 87% of neonatal deaths . in most societies , congenital malformations and premature birth babies with low birth weight ( lbw ) and extremely lbw account for 6 - 7% and 1% of babies death , respectively . these causes , however , are the second and third reasons , respectively , which are responsible for one half of the neonatal deaths . prematurity is responsible for about 60 - 80% of neonatal deaths all over the world in babies without congenital anomalies . in many cases , neonatal diseases are caused by respiratory problems , of which hyaline membrane disease ( hmd ) can be mentioned as the foremost . about 1.3% of all neonatal deaths are caused by hmd or its complications in premature newborns . have mentioned five main causes of neonatal death , including prematurity , internal bleeding , septicemia , respiratory distress syndrome , and congenital anomalies , while gheibi et al . have reported prematurity ( 68% ) , hmds ( 51% ) , asphyxia ( 13% ) , sepsis ( 13% ) , and congenital cardiac malformations ( 8% ) as the most important causes of neonatal death . the baby 's gender has also been considered as an important factor in his or her death . one of the most important issues in babies death is suitable management and timely referral of newborn babies with high - risk levels and being hospitalized in neonatal intensive care unit ( nicu ) . nicu is a critical section in a hospital , dealing with infections ( e.g. septicemia , pneumonia , surgical infections , and other infections ) that are difficult to control . in the usa , management , appropriate care , and supportive cares are the important factors in preventing babies death . rostami et al . have reported that the rescue chances of the babies who have received preventive nasal continuous positive airflow pressure ( ncpap ) are three times higher than the other babies . considering that an analytical and comprehensive study has not been done about the role of neonatal risk factors and the therapy given for hospitalized neonatal death in west azerbaijan , the study is case  control study , wherein the case group included 250 died babies who were hospitalized in the nicu during 2007 - 2009 . the control group also included 250 newborn babies who were hospitalized in the same unit and were discharged alive and healthy after they were given appropriate treatment . only the newborn babies from shahid motahhari therapy - training center were selected in order to homogenize the sample and eliminate some threatening factors ( factors involved in referral , death , etc . ) . data collection was carried out through a researcher - designed questionnaire which was designed based on other studies and scholars points of view . inclusion criteria included the babies complete profiles , and the criteria for exclusion included their incomplete profiles . the questionnaire contained six sections ( mother 's and baby 's demographic information , causes of hospitalization , during - treatment complications , therapeutic actions , and causes of death ) for alive babies and five sections for dead ones . chi - square test , odds ratio ( or ) , and logistic regression were applied to analyze how the variables were related . based on single - variable analysis , neonatal risk factors affecting the newborn babies hospitalized in the nicu are as follows : 51.6% of case babies and 18.3% of control babies had first - minute apgar score of less than 6 , which proved to have a significant correlation with babies death ( p < 0.001 ) . about 9.6% of babies of case group and 2.4% of babies in the control group had during - birth asphyxia which proved to have a significant correlation with neonatal death ( p = 0.001 ) [ table 1 ] . the distribution of independent variables by independent variables ; p value based on chi - square test in this study , one of the factors causing death of babies hospitalized in the nicu was hmd ; 77.6% of case babies and 44.8% of control babies suffered from this disease ( p < 0.001 ) . fourteen percent of case babies and 2% of control babies had sepsis which showed a significant relation with babies death ( p < 0.001 ) . moreover , 58.8% of case babies and 71.5% of control babies were born through cesarean section which also proved to have a significant effect ( p < 0.001 ) [ table 1 ] . congenital anomalies have been recognized as one of the significant risk factors of death of babies hospitalized in the nicu . eight percent of case babies and 2.8% of control babies were reported to have congenital anomalies ( p < 0.001 ) [ table 1 ] . regarding therapeutic actions , the results of the study also showed that having ncpap played a significant role in decreasing death of babies hospitalized in the nicu ( p < 0.001 ) . there was also a significant relation between supportive cares and neonatal death ( p < 0.001 ) . increased number of pregnancies also had a significant effect on neonatal death ( p < 0.001 ) [ table 1 ] . variables like lbw , baby 's gender , blood group , history of preterm labor , and consanguinity had no significant role in the death of neonates hospitalized in the nicu . in order to gauge the key effects of the mentioned factors , the adjusted or calculated from advanced logistic regression model was measured through advance selection method . the results showed that the or of neonatal death was 4.02 times greater for neonates with first - minute apgar score of less than 6 compared to those with first - minute apgar score of 6 and more , for asphyxia , the or was 6.16 , for hmd it was 4.08 , and for sepsis it was 6.42 . applying ncpap and multiparity led to a decrease in the death of neonates hospitalized in the nicu [ table 1 ] . in the present study , the most important neonatal risk factors affecting neonatal death were found to be sepsis , birth asphyxia , hmd , first - minute apgar score of less than 6 , congenital anomalies , and delivery method . in our study , the most common risk factor for neonatal deaths was sepsis which raised the risk of death by infection to 6.42 times more than the other causes . , sepsis and its complications were reported to be the first cause of death , but in the investigations of nayeri et al . and amin et al . , sepsis had higher ratings . this may be due to the factor that premature babies are prone to infection , but it should be more investigated because of the high number of deaths resulting from it . this spread of sepsis has been reported to be in 1 - 10 cases out of 1000 live births , but 10 - 50% of deaths occur because of it . the second risk factor in the present study was at birth asphyxia , which is in line with tariq and kundi 's study which mentioned sepsis and neonatal asphyxia as the main causes of death , but in the studies carried out by sereshtedari et al . , it was the cause of the 16% deaths in 18 provinces of the country , in bangladesh approximately 26% of neonatal deaths are caused by asphyxia . the other serious clinical problem is respiratory difficulty , and in this study , it manifested as respiratory distress and hmd . in our study , it was the third risk factor of infant death . the study of abdul in malaysia showed that this problem with sepsis is the most important cause of infants death . there is also a second leading cause of infant death in tariq and kundi 's study , and respiratory distress syndrome which were studied by kumar et al . in india , jehan et al . in pakistan , naghavi in 18 provinces of iran , javanmardi et al . in isfahan , amani et al . in ardebil , and in the studies of nayeri et al . in tehran and sereshtedari one of the causes of infant death , low apgar score at birth , is increasingly mentioned in many studies to be a risk factor . low apgar score at birth could be correlated to factors such as neonatal infections , birth asphyxia , meconium aspiration , respiratory distress syndrome , and other causes which may result in infant mortality . in our study , ncpap was applied in the control group two times more than in the case group , which resulted in a decrease of babies death by 0.43 . in their study , rostami et al . also reported that applying preventive ncpap to newborn babies will increase their survival chances by three times . congenital anomalies was found to be in the second position in the studies of sharifi , hematyar and yarjo , javanmardi et al . in esfahan , and naghavi 's study in 18 provinces . it was mentioned as the second and first cause in the studies of sareshtedati et al . and 's study , congenital anomalies and infection were mentioned as the leading factors of infant death . the rate of abnormalities in our study compared with other studies , which shows that it is a less important factor in the incidence of neonatal death . this may be due to high morbidity and mortality caused by other factors such as immaturity , lack of attention and careful examination at the time of birth , lack of screening for neonatal abnormalities , and not performing autopsy in dead neonates . death rate in babies with lbw is about 40 times higher than in babies with normal weight . unlike these studies this finding is in correlation with that of nayeri et al . in the present study , normal vaginal delivery was higher in the case group than that in the control group . this finding shows that cesarean section can be better when there is an emergency case or prematurity . although emergency cesarean section is performed to save the lives of the mother and baby , the selection is not always uncomplicated . in a study , it has been reported that two - third of babies who died were born through cesarean section . in our study , despite the high level of infant mortality in males , there was no significant relation between gender and the cause of death . an important risk factor that was investigated in this study was the number of pregnancies . the results of this investigation showed that death rate decreased as the number of pregnancies increased . number of births higher than 5 , pregnancy number above 3 , and high rate of birth were mentioned as effective factors causing babies death in studies conducted by shirvani and khosravi , chaman et al . , and titaley et al . , respectively . appropriately carrying out care and supportive cares can be effective factors in preventing babies death . in our study , 51.6% of case babies and 2.3% of control babies had received supportive care from birth . higher death rate in case babies can be due to bad physical conditions and other threatening factors . the results of the study show that incorrect methods of transfer can increase the death rate . in this study , special attention was devoted to increasing the care standards in order to decrease the death rate . according to the results of the study that took into consideration factors such as age , occupation , consanguinity , blood group , preterm delivery background , and sex in two groups with equal distribution , it can be concluded that factors related to accompanying diseases and care during delivery play a significant role in neonatal death . therefore , regarding the fourth goal of millennium development , decreasing babies death to two - fourths by 2015 in countries with high rate of mortality , it seems to be better to spot pregnancies with high risk of babies death through pre - delivery care and to transfer mothers who are likely to bear premature or sick babies to centers that have nicus . in cases where it is impossible to specify whether a delivery is risky before birth , the subsequent hospitalization problems can be prevented by providing appropriate conditions of transfer and therapeutic actions in intensive care units . the major risk factors in this study ( sepsis , asphyxia during birth , hmd , congenital anomaly , and apgar score less than 6 in the first minute of birth ) are considered as the major complications of preterm labor and preterm infants . so , strict preventive programs should be undertaken for premature preterm labor and preterm infants ; taking care of the infants in four stages ( before conception , during pregnancy , during delivery , and thereafter ) can be highly effective as well .
background : a newborn is highly fragile whose death can be caused by embryonic , intrapartum , and postpartum factors . identifying the causes of death is the first step to be taken in order to decrease the death rate . 
 the present study was aimed at finding out how neonatal factors and therapeutic actions affect death of newborn babies.materials and methods : the is a case - control study where the case group included 250 dead neonates who were hospitalized in the neonatal intensive care unit during 2007 - 2009 . 
 the control group also included 250 newborn neonates who were hospitalized in the same unit and were discharged alive and healthy after they were treated appropriately . 
 researcher - designed questionnaires including demographic characteristics of mothers and infants , causes of hospitalization , treatment and its complications , and causes of death were used to collect the required data . 
 chi - square test , odds ratio ( or ) , and logistic regression were applied to analyze how the variables were related . 
 p < 0.05 were considered significant . 
 statistical analyses were carried out using software spss 16.0.results:the results of advanced logistic regression model showed that first - minute apgar less than 6 ( or = 4.02 ) , existence of birth asphyxia ( or = 6.16 ) , hyaline membrane disease ( or = 4.08 ) , and sepsis ( or = 6.42 ) increased the death rate of neonates hospitalized in the intensive care unit , and applying nasal continuous positive airway pressure and multiparity decreased the death rate of newborn babies . 
 there was no significant correlation between variables such as low birth weight , consanguinity , blood group , pr eterm labor history , and baby 's gender , and the death rate of neonates.conclusions:the results of the study show that factors such as low apgar score , asphyxia , hyaline membrane disease , sepsis , prematurity and congenital anomalies , and method of delivery have a positive effect on the death of neonates . 
 they also prove that suitable management and carrying out appropriate therapeutic actions and intensive care decrease the death rate of newborn babies .