Analysis of Determinants of Neonatal Mortality in Afar and Somalia Regions, Ethiopia

Background: Children face the highest risk of dying in their first month of life. Ethiopia is one of the sub-Saharan countries with highest newborn deaths. Afar and Somalia regions in Ethiopia are among the regions with high death rates of newborn children. This study aimed to analyse and identify determinants of neonatal mortality in Afar and Somalia regions, Ethiopia. Methods: This study used 2016 Ethiopian Demographic and Health Survey data for the analysis. The multivariable logistic regression model was used to identify the significant determinants of neonatal mortality. Adjusted odds ratio with a 95% confidence interval and p-value < 0.05 in the multivariable logistic regression model was reported to declare the statistical significance and strength of association between neonatal mortality and determinants. Original Research Article Regesa et al.; JPRI, 34(1B): 63-71, 2022; Article no.JPRI.83622 64 Results: A total of 2567 newborn children were included in this study. Mortality rate among newborns in the first month was 41 per 1000 live births in Afar and Somalia regions. Health facility delivery (AOR: 0.634; 95% CI: 0.409–0.982), being female (AOR: 0.206; 95% CI: 0.073–0.528), multiple births (AOR: 3.958; 95% CI: 2.293–11.208), small size at birth (AOR: 1.208; 95% CI: 1.003–1.728), secondary and above educational level of mothers (AOR: 0.484; 95% CI: 0.294– 0.797) were statistically significant determinants neonatal mortality. Conclusions: In this study, sex of child, place of delivery, birth type, size at birth, mother’s educational level were found to be statistically significant determinants of neonatal death in Afar and Somalia regions, Ethiopia. Mothers with no education should be given health education and institutional delivery should be encouraged to improve the survival of the neonates in Afar and Somalia regions, Ethiopia.


Results:
A total of 2567 newborn children were included in this study. Mortality rate among newborns in the first month was 41 per 1000 live births in Afar and Somalia regions. Health facility delivery (AOR: 0.634; 95% CI: 0.409-0.982), being female (AOR: 0.206; 95% CI: 0.073-0.528), multiple births (AOR: 3.958; 95% CI: 2.293-11.208), small size at birth (AOR: 1.208; 95% CI: 1.003-1.728), secondary and above educational level of mothers (AOR: 0.484; 95% CI: 0.294-0.797) were statistically significant determinants neonatal mortality. Conclusions: In this study, sex of child, place of delivery, birth type, size at birth, mother's educational level were found to be statistically significant determinants of neonatal death in Afar and Somalia regions, Ethiopia. Mothers with no education should be given health education and institutional delivery should be encouraged to improve the survival of the neonates in Afar and Somalia regions, Ethiopia.  [3]. In sub-Saharan Africa, the neonates face challenges in a diversity of lethal clinical conditions that seek serious interventions [4]. World Health Organization (WHO) and United Nations Children's Fund (UNICEF) recommend home visits by skilled health workers during a baby's first week of life to improve newborn survival [3].
According to 2016 Ethiopian Demographic Health Survey (2016 EDHS), neonatal mortality declined from 49 deaths per 1,000 live births in 2000 to 29 deaths per 1,000 births in 2016, a reduction of 41% over the past 16 years. However, there are some regions where still the neonatal mortality rate is high [5].
Reduction in neonatal mortality rates were observed among all regions of Ethiopia except Afar and Somalia regions over the past five years. In Afar and Somalia regions, in 2011, the neonatal mortality rates were 33 deaths per 1000 births and 34 deaths per 1000 births respectively [23], and increased to 38 deaths per 1000 births and 41 deaths per 1000 births respectively in 2016 [5]. Moreover, Afar and Somalia regions are among the regions with high neonatal mortality rates in Ethiopia [5]. Neonatal mortality is a core indicator of neonatal health and wellbeing [1]. Hence, identifying the determinants of neonatal mortality is important to design intervention programmes which can increase the neonatal survival. Therefore, this study aimed to analyse and identify the determinants of neonatal mortality in Afar and Somalia regions based on the evidence from the 2016 Ethiopian Demographic and Health Survey.

Data Source
The study used 2016 Ethiopia Demographic and Health Survey (EDHS) data which were collected from January 18, 2016 to June 27, 2016. The 2016 EDHS data is openly available from the measure DHS website (https:// dhsprogram.com). The survey was implemented by the Central Statistical Agency (CSA) at the request of the Federal Ministry of Health. The primary objective of the 2016 EDHS was to provide up to date estimates of key demographic and health indicators.

Variables of the Study
The response variable of this study was neonatal mortality. It is coded as 1 if the liveborn neonate died within 28 days of life and 0 if the newborn alive in the first month of life). The independent variables included in this study were sex of child, birth type, size of child at birth, birth order, place of residence, place of delivery, mode of delivery, age of mother, educational level of mother, marital status, maternal anaemia, religion, parity and household wealth index.

Statistical Data Analysis
The data were analysed using SPSS version 25. The background characteristics of the respondents were described using frequency and percent. Both bivariate logistic regression and multivariable logistic regression analyses were conducted. Those variables found to be significant (p < 0.05) in bivariate logistic regression analysis were considered in the multivariable logistic regression analysis. Adjusted Odds Ratio with a 95% confidence interval in the multivariable logistic regression analysis was reported to declare the statistical significance and strength of association between neonatal mortality and determinants.
The goodness of fit test was checked using the Hosmer-lemeshow test. The multi-collinearity was checked using the variance inflation factor.

RESULTS
A total of 2567 neonates were included in this study. Among 2567 neonates included in the study, 105 died in the first month of the life, which indicates 41 deaths per 1000 live births. Out of the total neonates included in the study, 1373(53.5%) of them were males. More than four-fifth (2182 (85.0%)) of them were born at home. Majority 2555 (99.5%) of them were born vaginally. 2507(97.7%) of them were singletons. 949 (37.0%) of them had size of below average at birth. Regarding birth order, 1048 (40.8%) of them had birth order of second to forth. More than half (1615 (62.9%)) of them were born to families were the total number of ever born children were four or more. About half (1296 (50.5%) of them were born to mothers who aged 25-34 years. Majority (2172 (84.6%)) of them were born to mothers living in rural areas. More than four-fifth (2193(85.4%)) of them were born to mothers with no education. 2446 (95.3%) of them were born to mothers who were married or living together with partners. More than ninetenth (2521 (98.2)) of them were born to Muslim mothers. More than three-fourth (2082 (81.1%)) of mothers were with wealth index of poor (Table  1).
In this study, 60(4.4%) neonatal mortalities occurred among males. 92(4.2) neonatal mortalities occurred among neonates born at home. 8.3% of neonatal mortalities occurred among neonates delivered by caesarean. 11(18.3%) neonatal mortalities occurred among neonates with multiple births. 77(8%) neonatal mortalities occurred among neonates with size of average and below at birth. 26(5.7%) neonatal mortalities occurred among those whose birth order was first. 13(5.3%) neonatal mortalities occurred among those who born to the mothers with parity of one. 33(6.0%) neonatal mortalities occurred among those who born to the mothers aged 35 and above years. 98(4.5%) neonatal mortalities occurred among neonates residing in rural areas. 14(4.8%) neonatal mortalities occurred among neonates born to mothers with primary education. 98 (4.0%) neonatal mortalities occurred among neonates born to mothers who were married or living together with partners. 104 (4.1%) neonatal mortalities occurred among neonates born to Muslim mothers. 92(4.4%) neonatal mortalities occurred among neonates from poor families ( Table 2). Bivariate analysis revealed that sex of child, birth type, birth order, size at birth, educational level of mother, place of delivery and household wealth were associated with neonatal mortality. Multivariate logistic regression analysis revealed that sex of child, place of delivery, birth type, size at birth, and educational level of mother were significantly associated with neonatal mortality (

DISCUSSION
Ethiopia is a country among the five countries that accounted for half of all new-born deaths in the world [2]. Afar and Somalia regions are the regions among with high neonatal mortality in Ethiopia [5]. A total of 2567 newborn children were included in this study. Of the total, 105 died in the first month of the life, which shows that the neonatal mortality rate in Afar and Somalia regions was 41 per 1000 live births. This result is consistent with result of prior study [17]. However, it is higher than the results of the studies [12,24,25]. This could be due to that Afar and Somalia regions of Ethiopia are underdeveloped regions where maternal and child health care services are relatively low compared to other regions of Ethiopia.
This study found that sex of child, birth type, size at birth, place of delivery and educational level of mother were statistically significant determinants of neonatal mortality.
Female neonates were less likely to die than male neonates. This is consistent with studies [13,16,19,20,22,24]. This might be due to the fact that males being biologically weaker and more susceptible to diseases and mortality than the females.
Neonates born to mothers who attained secondary education and above were less likely to die than neonate born to mothers who did not have formal education. This result is consistent with studies [7,16,20,22,[25][26][27][28]. This could be due to that educated mothers may more attend ANC and PNC, and deliver at health facilities compared to uneducated mothers.
Neonates with small size at birth were more likely to die than neonates with large size at birth. This is consistent with studies [25,28,29]. Multiple births were more likely to die in the first month of birth than singletons. This is consistent with studies [6,13,20,22,25]. Neonates born at health facilities were less likely to die than neonates born at home. This is consistent with the studies [25,29,30]. This could be due to that mothers who give birth at health facilities may be given health information regarding the care of the child.

CONCLUSION
The aim of this study was to analyse and identify determinants of neonatal mortality in Afar and Somalia regions, Ethiopia. Neonatal mortality was significantly associated with sex of child, birth type, size at birth, place of delivery and educational level of mother in Afar and Somalia regions, Ethiopia. Mothers with no education should be given health education and institutional delivery should be encouraged to improve the survival of the neonates in Afar and Somalia regions, Ethiopia.

LIMITATION
In this study, some of important factors like number of ANC visits during pregnancy, preceding birth interval, and others were not included in the analysis due to high missing values in the secondary data used for this study.

AVAILABILITY OF DATA
Data used for the analysis of this study are available from corresponding author upon reasonable request.

CONSENT
It is not applicable.

ETHICAL APPROVAL
It is not applicable.