Predictors and survival of birth asphyxia-related neonatal mortality in rural Ghana: a five-year retrospective cohort study (2018-2023).

BACKGROUND

Birth asphyxia remains a leading cause of neonatal mortality in low- and middle-income countries, particularly in rural settings with limited access to skilled intrapartum and neonatal care. Evidence on survival patterns and predictors of birth asphyxia-related neonatal mortality in rural Ghana is limited. This study assessed neonatal mortality among neonates admitted with birth asphyxia and predictors among neonates admitted with birth asphyxia in rural Ghana.

METHODS

An institution-based multicentre retrospective cohort study was conducted using routinely collected clinical records from 22 Christian Health Association of Ghana (CHAG) district hospitals in rural Ghana. All neonates diagnosed with birth asphyxia and admitted to Neonatal Intensive Care Units (NICUs) of these facilities between January 2018 and October 2023 who met the eligibility criteria were included (n = 211). Survival time was defined as the number of days from NICU admission to death; neonates who survived to discharge were right-censored. Kaplan-Meier estimates were generated and log-rank tests used to assess survival differences across covariates. Multivariable analysis was conducted using Cox proportional hazards regression with cluster-robust standard errors at the hospital level to account for intra-facility correlation. Predictor selection was guided by a conceptual framework incorporating clinical relevance, prior evidence, and potential confounding.

RESULTS

Of the 211 neonates included, 76 (36.0%) died during follow-up and 135 (64.0%) survived to discharge and were right-censored. Deaths were concentrated predominantly in the early post-admission period. In the adjusted Cox proportional hazards model, significant independent predictors of neonatal mortality were: lack of maternal health insurance (HR = 3.56; 95% CI: 2.16-5.84; p < 0.001), non-utilisation of antenatal care (HR = 2.31; 95% CI: 1.49-3.57; p < 0.001), multiparity as a protective factor (HR = 0.52; 95% CI: 0.34-0.80; p = 0.003), absence of partograph-based labour monitoring (HR = 2.01; 95% CI: 1.21-3.34; p = 0.007), delivery at a CHPS compound or home versus hospital (HR = 1.70; 95% CI: 1.29-2.23; p < 0.001), poor foetal progress during labour (HR = 3.21; 95% CI: 1.49-6.94; p = 0.003), head circumference (HR = 0.98; 95% CI: 0.97-0.99; p = 0.005), and five-minute Apgar score (HR = 0.77; 95% CI: 0.68-0.86; p < 0.001).

CONCLUSION

Birth asphyxia-related neonatal mortality in rural Ghana reflects maternal, intrapartum, neonatal, and health-system factors. Strengthening monitoring, resuscitation, referral, and insurance, particularly in peripheral facilities, is critical to reducing deaths and advancing progress toward SDG 3.2.