Neonatal mortality in The Gambia and Burkina Faso: insights to incidence and risk factors from clinical trial data

Introduction: Neonatal mortality remains unacceptably high globally, particularly in Sub Saharan Africa. We evaluated the incidence and risk factors for neonatal mortality in The Gambia and Burkina Faso to provide context specific evidence to inform public health policy and programmes in West Africa. Methods: We conducted secondary data analyses of the PregnAnZI2 trial which was a phase III, double blind, randomised clinical trial implemented across 10 government health facilities in urban Gambia and rural Burkina Faso. Pregnant women without known acute or chronic health conditions were enrolled during active labour and their neonates were actively followed up to 28 postnatal days. We calculated Neonatal Mortality Rates (NMR) and generated Kaplan-Meier survival curves to assess the timing of neonatal deaths. Logistic regression was applied to identify risk factors associated with early (0 to 72 hours) neonatal deaths, adjusted for potential confounders. Results: 12,105 neonates born from 11,983 women were included in the analyses. Overall, 144 infants died during the neonatal period (NMR 11.5 per 1,000 live births), with 82% (118/144) of deaths occurring during the first 72 hours (early neonatal deaths). Risk factors for early neonatal mortality were low Apgar score at 1 minute (aOR 49.85, 95% CI 32.2 to 77.6) and 5 minutes (aOR 92.38, 95% CI 56.6 to 151.3) which are proxy for intrapartum related asphyxia, congenital malformations (aOR 11.44, 95% CI 6.4 to 19.4), and low birth weight (aOR 4.09, 95% CI 2.6 to 6.3). Other risk factors associated with early neonatal mortality included maternal history of stillbirth (cOR 4.95, 95% CI 2.6 to 8.8) and delivery at a tertiary referral centre (aOR 1.35, 95% CI 0.3 to 5.0). Conclusion: We observed high neonatal mortality in both urban and rural West African settings, even among women considered to be at low risk of complications. Intrapartum related asphyxia, congenital malformations and low birth weight were important contributors to early neonatal deaths. There is an urgent need for targeted interventions to address preventable risk factors linked to neonatal mortality in West Africa, especially intrapartum related asphyxia.