HARAMAYA UNIVERSITY

SCHOOL OF GRADUATE STUDIES

MAGNITUDE AND FACTORS ASSOCIATED WITH EARLY NEONATAL

DEATH AMONG EARLY NEONATES ADMITTEDTO NEONATAL
INTENSIVE CARE UNIT OF HIWOT FANA SPECIALIZED UNIVERSITY
HOSPITAL HARAR, EASTERN ETHIOPIA

MPH RESEARCH THESIS

ABDULMALIK ABDELA (BSC)

MAY 2022

HARAMAYA UNIVERSITY, HARAR, ETHIOPIA

 HARAMAYA UNIVERSITY
SCHOOL OF GRADUATE STUDIES

Magnitude and Factors Associated with Early Neonatal Death among Early
Neonates admitted to Neonatal Intensive Care Unit of Hiwot Fana Specialized
University Hospital Harar, Eastern Ethiopia

MPH ResearchThesis

Abdulmalik Abdela (Bsc)

College: Health and Medical Sciences

School/Department: Public Health
Program: Reproductive Health
Major Advisor: Nega Assefa (PhD, Associate professor)
Co- Advisor: Desalegn Admassu (PhD, Assistant Professor)

A thesis submitted to the school of public Health, School of Graduate Studies,

Haramaya University, in partial fulfillment of the requirement for the degree of
Master in Reproductive Health

May 2022

Haramaya University, Harar, Ethiopia

APPROVAL SHEET
SCHOOL OF GRADUATE STUDIES
HARAMAYA UNIVERSITY
I hereby certify that I have read and evaluated this thesis entitled ‘Magnitude and Factors
Associated with Early Neonatal Death Among Early Neonates Admitted to Neonatal Intensive
Care Unit at Hiwot Fana Specialized Hospital, Harar, Eastern Ethiopia’ prepared under my
guidance by Abdulmalik Abdela. I recommend that it will be submitted as fulfilling the thesis
requirement.
Nega Assefa (Associate professor, PhD) _________________ ___________
Major advisor Signature Date
Desalegn Admassu (PhD, Assistant Professor) _________________ ___________
Co-advisor Signature Date
As a member of board examiners of MPH thesis open defense examination, I certify that I have
read and evaluated the thesis prepared by Abdulmalik Abdela and examined the candidate.
I recommend that the thesis be accepted as fulfilling the thesis requirement for the degree of
masters of reproductive health.
_______________ ________________ ________________
Chairperson signature date
_______________ _______________ _________________
Internal examiner signature date
_________________ ________________ _____________
External examiner signature date
Final approval and accepted of the thesis are contingent up on the submission of its final copy
tothe council of graduate studies (CGC) through the candidate’s department or school of
graduate
committee (DGC or SGC).

i
 STATEMENT OF THE AUTHOR
By my signature below, I declare and affirm that this thesis is my own work. I have followed all
ethical and technical principles of scholarship in the preparation, data collection, data analysis,
and compilation of this thesis. Any scholarly matter that is included in the thesis has been given
recognition through citation.

This thesis is submitted in partial fulfillment of the requirements for MPH degree at the
Haramaya University. Thethesisis deposited in the Haramaya University Library and is made
available to borrowers under the rules of the library. I solemnly declare that this Thesishas not
beensubmitted to any other institution anywhere for the award of academic degree, diploma, or
certificate.

Brief quotations from this may be made without special permission provided that, accurate and
complete acknowledgment of the source is made. Requests for permission for extended
quotations from or reproduction of this thesisin whole or in part may be granted by the head of
the school or department when in this or her judgments the proposed use of the material is in the
interest of scholarship. In all other instances, however, permission must be obtained from the
author of the thesis.

Name: Abdulmalik Abdela Bushra Signature: __________

Date of submission ___________________________

School/Department:Public Health

ii
 BIOGRAPHICAL SKETCH
In 1994 GC, I was born in Shanan Dhugo, West Hararghe Zone, Ethiopia. Shanan Dhugo Public
School was where I finished my primary education. My secondary school was in Arjo Gudetu,
while my preparatory school was at Nekemte town. By the 2011/12 academic year, I had
completed my preparatory school and had enrolled at Wollega University. In June 2016, I
received my first-degree BSc in Midwifery from Wollega University. I worked as a Family
Health Coordinator in the East Hararghe Zone's Malka Belo Woreda Health Office till I enrolled
in a school of postgraduate study in Reproductive Health.

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ACKNOWLEDGMENTS
I would like to express my gratitude to Haramaya University's College of Health and Medical
Sciences' School of Graduate Studies for providing me with the opportunity and assistance I
needed to complete this research thesis.

Also, I'd like to thank my main advisor, Dr. Nega Assefa (PhD), and my co-advisor, Dr.
Desalegn Admassu (PhD), for their unwavering support and constructive criticism throughout
this thesis work. In addition, I'd like to express my gratitude to the director of Hiwot Fana
Specialized University Hospital, particularly the Health Records Information Officers, for their
support in gathering relevant information regarding the study participants and patient files during
data collection.Also, I'd like to express my gratitude to the librarians at Haramaya University's
College of Health and Medical Sciences for offering recorded materials as well as online access
to get vital resources for this research thesis.

Finally, I would want to offer my profound appreciation to everyone who has helped me with my
study, both directly and indirectly.

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TABLE OF CONTENTS

APPROVAL SHEET ....................................................................................................................... i

STATEMENT OF THE AUTHOR ................................................................................................ ii
BIOGRAPHICAL SKETCH ......................................................................................................... iii
ACKNOWLEDGMENTS ............................................................................................................. iv
TABLE OF CONTENTS ................................................................................................................ v
LIST OF TABLES ........................................................................................................................ vii
ACRONOYMS AND ABBREVIATIONS ................................................................................... ix
ABSTRACT .................................................................................................................................... x
1. INTRODUCTION ................................................................................................................... 1
1.1. Background ...................................................................................................................... 1
1.2. Statement of the problem ................................................................................................. 2
1.3. Significance the study ...................................................................................................... 3
1.4. Objective .......................................................................................................................... 4
1.4.1. General Objective ..................................................................................................... 4
1.4.2. Specific Objectives ................................................................................................... 4
2 LITERATURE REVIEW ........................................................................................................ 5
2.1. Magnitude of Early Neonatal Death................................................................................. 5
2.2. Factors associated with Early Neonatal Death ................................................................. 6
2.2.1. Socio demographic factors ........................................................................................ 6
2.2.2. Obstetrics factors ...................................................................................................... 7
2.2.3. Environmental factors ............................................................................................... 8
2.2.4. Neonatal Factors ....................................................................................................... 8
1.1.1. Conceptual Framework ........................................................................................... 13
2. METHODS AND MATERIALS .......................................................................................... 13
2.1. Study area and period ..................................................................................................... 13
2.2. Study Design .................................................................................................................. 13
2.2.1. Source of population ............................................................................................... 13
2.2.2. Study population ..................................................................................................... 13
2.3. Inclusion and Exclusion criteria ..................................................................................... 14
2.3.1. Inclusion criteria ..................................................................................................... 14
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 2.3.2. Exclusion criteria .................................................................................................... 14
2.4. Sample size determination ............................................................................................. 14
2.5. Sampling Procedure ....................................................................................................... 15
2.6. Data Collection Methods................................................................................................ 16
2.6.1. Data collection tools ............................................................................................... 16
2.6.2. Data collectors and data collection procedures ....................................................... 16
2.7. Study Variables .............................................................................................................. 17
2.7.1. Dependent Variable ................................................................................................ 17
2.7.2. Independent Variables ............................................................................................ 17
2.8. Operational Definitions .................................................................................................. 17
2.9. Data quality control ........................................................................................................ 18
2.10. Methods of data analysis ................................................................................................ 18
2.11. Ethical Considerations.................................................................................................... 19
3. RESULT ................................................................................................................................ 20
3.1. Socio-demographic characteristics ................................................................................. 20
3.2. Maternal and Obstetrics characteristics.......................................................................... 20
3.3. Clinical characteristics of early neonates at admission .................................................. 22
3.4. Magnitude of early neonatal death ................................................................................. 23
3.5. Factors associated with early neonatal death ................................................................. 24
4. DISCUSSION ........................................................................................................................ 27
5. STRENGTH AND LIMITATION ........................................................................................ 31
6. CONCLUSION AND RECOMMENDATION .................................................................... 32
6.1. Conclusion...................................................................................................................... 32
6.2. Recommendation............................................................................................................ 33
7. REFERENCES ...................................................................................................................... 35
8. APPENDICES ....................................................................................................................... 40
8.1. Information sheet and informed consent form for Hospital Medical Director/CEO ..... 40
8.2. Questionnaire ................................................................................................................. 43
8.3. Principal Investigator Curriculum Vitae ........................................................................ 47

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LIST OF TABLES
Table 1: Objective two sample size calculation for magnitude and factors associated with early
neonatal death among babies born at Hiwot Fana Specialized University Hospital in Harar,
Eastern Ethiopia. ........................................................................................................................... 15
Table 2:Sociodemographic characteristics of early neonates and mothers of early neonates
admitted to HFSUH, Harar Ethiopia, November 20 to December 20,2021 (n=432). .................. 20
Table 3:Maternal Obstetrics related characteristics of the mothers who gave birth to early
neonates admitted to HFSUH, Harar Ethiopia, 2021(n=432) ....................................................... 21
Table 4:Clinical characteristics of Early Neonates at admission at HFSUH,2021 ...................... 22
Table 5: Factors associated with early neonatal mortality at Hiwot Fana Specialized
University,2021 ............................................................................................................................. 25
Table 6: Baseline Maternal Socio Demographic characteristics of study participants ................ 43
Table 7: Obstetrics and Gynecologic factors ................................................................................ 43
Table 8: Maternal Medical Factors due to the current pregnancy and postpartum ...................... 44
Table 9: Neonatal Factors ............................................................................................................. 45

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LIST OF FIGURES
Figure 1: A Conceptual framework indicating factors associated with early neonatal death,2021.
....................................................................................................................................................... 13
Figure 2:Causes of admission at NICU of HFSUH, Harar Ethiopia,2021 .................................. 23
Figure 3: Causes of death in % at NICU of HFSUH, Harar Ethiopia,2021................................. 24

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ACRONOYMS AND ABBREVIATIONS
ANC Ante Natal Care
AOR Adjusted Odds Ratio
APGAR Appearance Pulse Grimace Activity Respiration
APH Antepartum Hemorrhage
CI Confidence Interval
COR Crude Odds Ratio
CS Cesarean Section
CSA Central Statics Agency
EDHS Ethiopian Demographic and Health Survey
EMDHS Ethiopian Mini Demographic and Health Survey
END Early Neonatal Death
ENMR Early Neonatal Mortality Rate
IHRERC Institutional Health Research Ethics Review Committee
GA Gestational Age
HFSUH Hiwot Fana Specialized University Hospital
HTN Hypertension
KMC Kangaroo Mother Care
NICU Neonatal Intensive Care Unit
NMR Neonatal Mortality Rate
PMR Perinatal Mortality rate
PROM Premature Rupture of Membrane
SPSS Statistical Package of Social Sciences
UNICEF United Nations international child education and fund
WHO World Health Organization

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 ABSTRACT
Introduction: Early neonatal death is one of the major classifications of neonatal death that
occurs during the first seven days of life, and deaths happening in this period are mainly due to
obstetric causes. Over 3 million early neonatal deaths are anticipated to come about annually.
The substantial causes of early neonatal death were birth asphyxia and respiratory distress
syndrome.In the different corner of Ethiopia many studies were conducted on the neonatal
mortality yet, only few of them were focused on early neonatal mortality indicating limitation of
the evidence on the early neonatal mortality in the country.

Objectives: To estimate magnitude and factors associated with early neonatal death among early
neonates admitted at Neonatal Intensive Care Unit fromSeptember 11, 2018 to September 10,
2021 in Hiwot Fana Specialized University Hospital in Harar, Eastern Ethiopia.
Methods: Institutional based cross- sectional study design was conducted among 440 randomly
selected early neonates. Data were extracted from medical records and neonatal registration book
using a checklist adapted from the world health organization and other different
literatures.Thedata werecleaned, coded and entered to Epi Data version 3.1 and analyzed using
Stata version 15.A descriptive analysis was performed. Bi-variable and multivariableanalysis
were done to identify the association between independent variables and the outcome variable.
Associations between variables were measured using an odds ratio at 95% CI.P-value <0.05 was
used to declare statistical significance.
Result:Magnitude of early neonatal mortality was 10.6% [(95%CI:8,14)]. Being preterm
[AOR=3.5, 95%CI (1.62,7.6), having respiratory distress syndrome
[AOR=4.6,95%CI(2.23,9.26)], being LBW[AOR=3.6,95%CI (1.41,8.04)], low Apgar score at 5
minutes[AOR=3.89, 95%CI (1.88,8,04)], Chorioamnionitis [AOR= 6.2 95%CI,
1.3,30.23)],Receiving CPAP [AOR=5.19, 95% CI (2.39,11.23) and maintenance fluid-fed
newborns [AOR=2.61,95%CI (1.14,5.91)] were factorssignificantly associated with early
neonatal death.
Conclusion: The overall proportion of early neonatal death was high.The study identified that
preterm, maternal complication during labor and delivery like chorioamnionitis, and respiratory
distress syndrome, low birth weight, low Apgar score at 5th minute, newborns received CPAP
and maintenance fluid-fed newborns were independent factors associated with early neonatal
mortality. Health care providers should give special attention for early recognition of
abnormalitiesand manage accordingly during ANC and labor follow up.

x
Key Words: Early neonatal death, NICU, Harar, Ethiopia.

xi
 1. INTRODUCTION

1.1. Background
Early neonatal death is one of the major classification of neonatal death that occurs during the
first seven days of life and death happening in this period are mainly due to obstetric causes
(WHO, 2006). Over 3 million early neonatal deaths are projected to come about annually (WHO,
2006).More than 5 million perinatal deaths happeningworldwide every year, ending preventable
perinatal deaths will continue to beimportant part of the global public health agenda. Therefore,
reducing stillbirths and early neonatal deaths continued to be avital part of the third Sustainable
Development Goal (SDG-3), to end preventable child deaths by 2030 (WHO/UNICEF, 2018,
WHO, 2016c)

Despite the decrease in global mortality in the last decade, early neonatal death (END), still
represents >70% of total postnatal deaths and therefore constitutes a major challenge, especially
for low-income countries.The main direct causes of neonatal deaths globally are neonatal
sepsis(36%), preterm birth (28%), and asphyxia (23%). The distribution of causes of neonatal
death varies with the degree of neonatal mortality and 60–80% of neonatal deaths arise in low
birth weight babies(Lawn et al., 2005). The study conducted in India stated that early neonatal
deaths (END) are just about 36.18 per 1000 live births. The substantial causes of END were birth
asphyxia and respiratory distress syndrome accounted for deaths in first 3 days while deaths from
septicemia were mostly after 3 days of life (Nitin Mehkarkar1, 2018).

The etiology of END varies widely among different areas of the world depending on the degree
of industrialization. Whereas, in rural areas in Africa infection and asphyxia constitute the first
causes of END, and in high-income countries the leading causes are prematurity, congenital
malformations, and sudden unexpected neonatal deaths (Lehtonen et al., 2017). Every Newborn
Action Plan (ENAP) aims to reduce early neonatal deaths to less than 10 per 1,000 live births by
2035(WHO, 2014). Although this target has been met in 94 high-income countries, the majority
of the African countries, including Ethiopia, need to half the rates to reach the target(WHO,
2017).

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In Ethiopia, Despite interventions, newborn mortality in Ethiopia has grown over time (33 per
1000 live births)(EMDHS, 2019). However, a comprehensive study and meta-analysis found that
early newborn mortality is reducing in Ethiopia, despite the high rate of early neonatal mortality
(29.5 per 1000)(Jena et al., 2020). Early age of the newborn, prematurity, low birth
weight,perinatal asphyxia, mode of delivery, hypothermia, late initiation of breastfeeding, and
having antenatal care visitswere the main determinants for early neonatal mortality (Tiruneh et
al., 2021).

1.2. Statement of the problem

In 2019 approximately 6,700 neonatal deaths every day–with about a third of all neonatal deaths
occurring within the first day after birth, and close to three quarters occurring within the first
week of life(UNICEF, 2020) and the highest risk of death is on the first day of life.The early
neonatal period is the most critical in the life of a neonate. This is the period of extra uterine
adaptation during which the neonate is most likely to develop complications(Evelyn, 2014).
Perinatal mortality which includes early neonatal death is a major public health problem,
particularly in developing countries, and has a huge economic, social, and health implications for
families and nations. Thisis because more than 95% of early neonatal deaths occur in developing
countries with the leadingrecords being in South Asia and Sub-Saharan Africa (SSA)(Akombi
and Renzaho, 2019).Despite the decrease in global mortality in the last decade, early neonatal
death (END), still represents >70% of total postnatal deaths and therefore constitutes a major
challenge, especially for low-income countries(WHO, 2020).

Almost a half of neonatal mortality in Sub-Saharan Africa mainly occurs in five countries like
Ethiopia, Nigeria, DR Congo, Uganda and Tanzania. Early neonatal deaths account for three
quarter of all neonatal deaths, and preventing these, depends on attention to the causes of death
that are unique to the first week of life, particularly birth asphyxia and prematurity. According to
the report of United Nations international child education and fund(UNICEF) and Ethiopian
Demographic and Health Survey (EDHS), the neonatal mortality rate accounts 23% and
29%/1000 live births in Ethiopia(UNICEF, 2016, EDHS, 2016)

In Ethiopia three quarter of newborn deaths occur during the first week of life and about 25% to
40% of deaths occur within the first 24 hours. The most common causes of mortality particularly
2
for early neonatal death are prematurity (37%), early onset of neonatal sepsis(28%), and
asphyxia (24%) (Liu et al., 2012).Ethiopia is one of the countries in Africa with the highest
neonatal mortality. Although neonatal mortality was decreased from 39 to 29 between the 2005
and 2016 EDHS, it was remained stable since the 2016 EDHS.But in the current updated 2019
EMDHS survey, it has been increased a little bit to 33 (EMDHS, 2019). In 2013 a study done in
Ethiopia indicated that, Early Neonatal Mortality Rate (ENMR) was 29.2 per 1000
population(Mekonnen et al., 2013).

Early Neonatal death has not been extensively studied in developing countries including Ethiopia
wheremortality rates are tremendously high, and information to improve services is limited.
Nowadays, during the period of SDG the ultimate focus is to reduce neonatal mortality to 12 per
1000 live births globally including Ethiopia which contribute to the attainment of the global
sustainable development goal. A clear knowledge of the magnitude of early neonatal at a local
context is very crucial. Besides, identifying the magnitude is very essential for the prioritization
of local initiatives, which focus on encouraging evidence-based advocacy and effective
interventions targeting early neonataldeath reduction, through local decisionmaking. But most of
the previous studies have been focused on the neonatal in general and perinatal mortality in
particular yet; studies identifying the magnitude of early neonatal death at a large scale are
limited.

Hence, this study is aimed at filling this gap by conducting aninstitutional-based study to
determine the magnitude of earlyneonatal death and identify the factors associated with early
neonatal death.

1.3. Significance the study

The findings of this study may provide some insight into the magnitude of early neonatal
mortality as well as the factors that contribute to early neonatal death. As a result, this study aids
HFSUH and hospital health experts in taking particular account of general preventative
mechanisms of these variables in order to preserve newborns' lives. Similarly, the study's
findings will be critical in driving the development of effective treatments and programs to
expedite progress in the reduction of early newborn death and maternal mortality, particularly in
Eastern Ethiopia and throughout Ethiopia. The findings of this study will also assist HFSUH
3
officials in planning and organizing the institution to focus more on reducing early newborn
mortality. In addition, the results of this study will be utilized as a baseline for future
investigations on early neonatal mortality.

1.4. Objective

1.4.1. General Objective

To assess magnitude and factors associated with early neonatal death among early neonates
admitted to NICU from September 11, 2018 to September 10, 2021inHiwot Fana Specialized
Hospital Harar, Eastern Ethiopia.

1.4.2. Specific Objectives

1. To assess the magnitude of early neonatal death among early neonates admitted to NICU
ofHiwot Fana Specialized University Hospital Harar, Eastern, Ethiopia, 2021.
2. To identify factors associated with early neonatal death among early neonates admitted to
NICU ofHiwot Fana Specialized University Hospital, Harar, Eastern Ethiopia, 2021.

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 2 LITERATURE REVIEW

2.1. Magnitude of Early Neonatal Death

A cross sectional study conducted in Australia on Perinatal health outcomes of East African
immigrant populations reported that 83% of perinatal mortality was recorded during the study
period (Belihu et al., 2016). Findings from institutional based cross section study in Ghana on
Perinatal outcomes of hypertensive disorders in pregnancy revealed that perinatal mortality rate
of 106 per 1000 births was seen(Adu-Bonsaffoh et al., 2017)and also similar study done in South
Sudan on Factors associated with early perinatal mortality has presented Perinatal mortality rate
of 122.3 per 1000 live births (Flora, 2019).

The institutional based study conducted at Wollega University Referral Hospital, Western
Ethiopia indicated that the overall magnitude of early neonatal death was 8%(Elias Merdassa
Roro, 2019). The finding from the study conducted in Mekelle, Northern Ethiopia revealed that
the magnitude of early neonatal death was about 12.65% (Kahsay et al., 2019). Another study
institutional study conducted in Eastern Ethiopia Somali region reported that the proportion of
early neonatal death was 7%(Elmi Farah et al., 2018) and study conducted in Sidama Southern
Ethiopia indicated that the prevalence of early neonatal death was 5%(Alaka Adiso Limaso1,
2020). Also the study conducted in Uganda revealed that the overall proportion of early neonatal
death was 11.7%(Nakibuuka et al., 2012).
Institutional based study conducted in Southern Ethiopia on Perinatal Death and Associated
factors indicated that 17.3% of perinatal death was observed during the study period (Mihiretu et
al., 2017) and another cross sectional study in the northwest Ethiopia on Patterns of admission
and factors associated with neonatal mortality reported that 14.3% of neonatal mortality was
registered, out of which 62.7% deaths occurred in the first 24 hours of age (Demisse et al.,
2017). Findings from the study in Southern Ethiopia on Perinatal outcomes of hypertensive
disorders in pregnancy showed that perinatal mortality rate of 111.1 per 1000 live births has been
observed (Asseffa and Demissie, 2019).Report from community based study conducted in
Southwest part of Ethiopia on Magnitude of Perinatal Mortality was revealed 34.5 (95% CI:
28.9, 41.1) deaths per 1000 births perinatal mortality (Debelew, 2020). Cross sectional study that
was conducted in Southern Ethiopia on Perinatal Mortality and Associated Factors indicated

5
perinatal mortality of 12.6% (95% CI: 11.80, 13.40) (Dessu and Dawit, 2020). Systematic review
conducted in Ethiopia on the effect of antenatal care on perinatal outcomes revealed perinatal
mortality rate of 41 per 1000 total births along with 19 per 1000 live births early neonatal
mortality rate (Shiferaw et al., 2021). An institutional based cross sectional study conducted in
the Northern part of Ethiopia reported that 27.47 % of adverse perinatal outcomes were observed
among which 10.8% had a perinatal mortality outcome (Seyoum et al., 2021) .

2.2. Factors associated with Early Neonatal Death

2.2.1. Socio demographic factors

The cross sectionalstudy conducted in Cuba revealed that newborns born from mothers age less
than 20 years were more likely to die compared to those mother age greater than 20 years
old[AOR=1.85 95%CI (1.01,3.38) (Gaiva et al., 2016).The study conducted in Eritrea revealed
that the maternal age was not significantly associated with early neonatal death[AOR=1.32,
95%CI (0.39,4.46)(Andegiorgish et al., 2020).

A study conducted in Brazil revealed that the sex of neonate is not significantly associated with
neonatal mortality, being male [AOR=0.8,95%CI (0.6,1.2)(p=0.254)] was not significantly
associate with newborn death(Costa et al., 2020). Another study conducted in Guinea-Bissau
revealed that the sex of neonates was associated with newborn death, being female was
[AOR=0.55 95%CI,(0.38,0.79)] had lower risk of death than males (Pinstrup Joergensen et al.,
2018). According to EDHS 2016, male neonates were more likely to die than female neonate and
also gender gap is most pronounced in the neonatal period (within 1 month after birth), when
male children are nearly twice as likely as female children to die (49 deaths compared with 26
deaths, per 1,000 live births, respectively)(EDHS, 2016).

According to a research conducted in Jima, newborns who were from outside the city had a 1.89
times greater risk of mortality [AOR=1.89,95 % CI(1.4,2.5)] than newborns who arrived from
within the city(Seid et al., 2019). While the study conducted in Gondor showed that the place of
residency was not significantly associated with early neonatal mortality[AOR=1.56,95%CI
(0.88,2.77)] (Demisse et al., 2017). Similarly, a study done in Gondor in a separate year found
that residence place was not associated with newborn death[AOR=1.092,95%CI (0.55,2.16)]

6
(Kokeb and Desta, 2016).Another cross-sectional study in Tigray Ethiopia found that mothers in
urban areas had more access to public health care services and were thus more aware of the need
of using health care services to maintain the health of their newborns than mothers in rural
regions. The mortality rate among newborns in urban regions was 64 percent lower than that of
rural residents (AOR = 0.364; 95% CI: (0.136–0.970) (Woldeamanuel and Gelebo, 2019).

2.2.2. Obstetrics factors

Early neonatal death among multiple pregnancies was significantly associated with mortality
when compared to singleton neonates[(AOR) 7.6; 95 percent CI(7.0-8.3)], according to a
systematic review conducted in low and middle-income countries (Bellizzi et al., 2018)].
According to the EDHS 2016, the perinatal death for Primipara is relatively high (EDHS, 2016).
Institutional based study conducted in Northern revealed that Neonates born from primigravida
mothers compared to multi-gravida mothers were 50 % less likely to have perinatal mortality
outcomes (Seyoum et al., 2021).

Another cross-sectional research done at Arba Minch General Hospital found that neonates
delivered to mothers who labored for more than or equal to 18 hours were 2.6 times more likely
to die than those born to mothers who labored for less than or equal to 18 hours(Samuel, 2019).
In addition, mothers who had a prolonged labor were 9 times more likely than their
counterparts[(AOR=8.791, 95% CI (2.248, 34.381)] to experience a perinatal death and also
being multiparity (AOR: 7.40; 95% CI: 2.77 20.26) was also higher risk of death (Dessu and
Dawit, 2020).

Compared to mothers who did not attend ANC, babies delivered to mothers who did were 60%
less likely to have a risk of newborn death (AOR =0.4, 95% CI:0.2-0.8) (Seyoum et al., 2021).
Research done in Southern Ethiopia found that mothers who did not attend ANC were four times
more likely to have newborn death than those who did[(AOR=3.950, 95%CI:1.546,
10.094)](Eshete et al., 2019). Another study showed that having one antenatal visit (AOR=4.40;
95% CI: 1.64, 11.91) are more likely experience early neonatal death (Dessu and Dawit, 2020).
Another cross-sectional research in Jima, Ethiopia found that women who attended four ANC
visits had a lower risk of neonatal mortality than those who did not [(AOR=0:46; 95% CI:0.23,
0.91)] (Debelew, 2020).

7
Another study revealed that having an institutional skilled birth attendant [(AOR= 0.34; 95%
CI:0.19,0.61)] were significantly associated with a reduction of newborn death and similarly,
being a primipara [(AOR=3.38; 95% CI:1.90,6.00)], multipara [(AOR=5:29; 95%
CI:1.46,19.21)], previous history of early neonatal loss [(AOR=3.33; 95% CI:1.27,8.72)], and
obstetric complication during labor [(AOR=4.27; 95% CI:2.40,7.59)] were significantly
increased perinatal mortality (Debelew, 2020). Mode of delivery in instrumental delivery
[(AOR:2.99; 95 % CI: 1.08,8.31)] was shown to have a greater risk of newborn death in a cross
sectional research done at Gondor Teaching Hospital(Demisse et al., 2017). Another research
carried out in Eritrea found that obstetrical complications during delivery were not associated
with newborn death[AOR=1.07 95%CI (0.35,3.24)] (Andegiorgish et al., 2020).
2.2.3. Environmental factors
A studyconducted in Tanzania reported that kangaroo mother care was significantly associated
with early neonatal death(Linda A Winkler1, 2020). Similarly, results from KMC programs in
urban areas where newborns begin KMC after stabilization and better than outcomes reported for
comparable populations not practicing KMC in rural sub-Saharan Africa(Linda A Winkler1,
2020).

2.2.4. Neonatal Factors

In very high mortality nations, the risk of infant death owing to serious infection is around 11
times higher than in low mortality countries. Even while the number of newborn fatalities is
essentially stable throughout mortality levels, the risk of dying from birth asphyxia is around
eight times higher for babies in countries with very high NMRs. With rising NMR, the
proportion of deaths due to prematurity decreases, although this decrease is owing to the
significant number of deaths due to infection in high NMR nations. The chance of death owing
to prematurity is still three times higher in a nation with a high NMR than in a low-mortality one.
In addition to differences in the distribution of causes between nations, there is frequently
(Lehtonen et al., 2017).

The study conducted Latin America revealed that Apgar score less than 7 at 5 minutes
[AOR=1.89,95%CI (1.24,2.86)] were significantly associated with newborn death(Reyes et al.,
2018). Another stud conducted in Brazil showed that Apgar score of less than 7 at
1minutes[AOR=1.1 95%CI (0.7,1.4)] was not associated with neonatal mortality(Costa et al.,
8
2020). Similar study conducted in Ghana teaching Hospital revealed that compared to newborns
with APGAR score of greater than orequal to 8, newborns born with 5-minutes Apgar score 4-7
and lower than 4 had more risk of death(Owusu et al., 2018). Another study conducted in Arba
Minch Hospital southern Ethiopia revealed that newborns with the 5-minutes Apgar score of less
than 5 had 4.4 times more likely to die than those who have greater or equal to Apgar score of
5(Samuel, 2019).
Institutional based cross sectional study conducted in Uganda stated that Intrapartum Asphyxia
29.2%, Hemorrhagic disease of the new born 10.8%, Respiratory distress Syndrome 9.2%,
Meconium Aspiration Syndrome 2.5%, and Hypoxic Ischemic encephalopathy1.7% are highly
associated with perinatal mortality (Nakibuuka et al., 2012)and the same study with the same
design conducted in Southern Ethiopia stated that being pre-term (AOR: 6.78; 95% CI: 2.41,
19.09), birth weight <2,500 gram (AOR: 3.10; 95% CI: 1.48, 6.46) were major risk factors for
perinatal mortality (Dessu and Dawit, 2020). In the same way, mothers with preeclampsia were 8
times more likely to have perinatal death than those who had no history of preeclampsia
[(AOR=7.600, 95% CI (1.739, 33.222)]. Mothers who gave birth to low birth weight were 9
times more likely to have perinatal death as compared to those who gave birth to a normal birth
weight baby [(AOR= 8.8, 95% CI (2.1, 36.5)] (Mihiretu et al., 2017).

A study conducted in Eritrea showed that length of stay at Hospital was significantly associated
with neonatal mortality. Neonates stayed for more than one week were less risk of death than
those who stayed less than 7 days[AOR=0.23, 95%CI 0.11-0.46)(Andegiorgish et al., 2020). A
study done in Jima revealed that those who stayed for less than one week in the NICU had 3.9
fold higher odds of death(AOR=3.9, 95%CI 2.8-5.5)] compared to those who stayed for more
than one week(Seid et al., 2019). Another Institutional based study conducted in Gondar,
Ethiopia on patterns of admission and factors associated with neonatal mortality stated that early
neonatal death was associated with perinatal asphyxia (adjusted odds ratio [AOR=5.97; 95%
CI:3.06,11.64)and early onset of neonatal sepsis [(AOR: 2.66; 95% CI:1.62,6.11)](Demisse et
al., 2017).

9
10
 1.1.1. Conceptual Framework

Distal Factors Proximal Factors

Neonatal relatedfactors: Outcome

Maternal Socio- Maternal Obstetric Factors:
demographic  APGAR score
factors:  Gestational Age  Weight
 Age of mother  Mode of delivery  RDS
 Residence  ANC  Prematurity
 Age of  Parity  Sepsis
Early
neonate  Obstetric Complications  Birth Asphyxia Neonatal
 Sex of neonate  Hypothermia Death
 Jaundice
 Resuscitation
 CPAP
Environmentalfactors:
 KMC
 Radiant warmer

Figure 1: A Conceptual framework indicating factors associated with early neonatal death,2021.
Source: Adapted from different literatures and(UNICEF, 2009).

13
 2. METHODS AND MATERIALS

2.1. Study area and period

The study was conducted at the neonatal intensive care unit of Hiwot Fana Specialized
University Hospital(HFSUH) in Harar, Eastern Ethiopiafrom September 11,2018 to September
10,2021 and data collection period was fromNovember 20 to December20, 2021. The city is
located 525 km towards the east of Addis Ababa, the capital of Ethiopia. Hiwot Fana Specialized
University Hospital (HFSUH) is currently providing different services for approximately 5.8
million peoples in the catchment area. The NICU is one of the Intensive Care Unit (ICU)
services that the hospitalsare currently running. The unit is divided into a septic room, kangaroo
mother care (KMC) room, and critical and subcritical rooms which have 19 neonatal beds and 14
KMC beds. The unit also has 5 incubators,10 radiant warmers,4 phototherapy machines.
Additionally, there are 8 infusers,4 oxygen cylinders, pulse oximetry, glucometer and neonatal
resuscitation equipment.The unit is staffed with 6 pediatricians,pediatric residents(6 R3 and 8
R2),6 neonatal nurses, and 8 clinical nurses. The unit receives high risk newborns from the labor
and delivery ward and also receives neonates referred from other health facilities and homes
(Hospital Management and HMIS,2020).

2.2. Study Design

Institutional basedretrospectivecross- sectional study design was conducted.

2.2.1. Source of population

All early neonates admitted to neonatal intensive care unit at Hiwot Fana Specialized University
Hospital (HFSUH) in Harar.

2.2.2. Study population

All early neonates who were admitted to neonatal intensive care unit atHiwot Fana Specialized
University Hospital (HFSUH) in Harar with complete medical record, Eastern Ethiopia
fromSeptember 11, 2018 to September 10, 2021.

13
 2.3. Inclusion and Exclusion criteria

2.3.1. Inclusion criteria

All early neonates admittedto the NICU of HFSUH between September 11, 2018, to September
10, 2021) were recruited.

2.3.2. Exclusion criteria

Those with incomplete records, referred to other places and those leave against medical
advice(self-discharge) were excluded from the study.

2.4. Sample size determination

Single population formula was used for objective one and double population proportion formula
was used for objective two by using a statistical module of EPI-info statistical software. Then the
largest sample sizewas selected by considering the following parameters:
For Objective 1: The sample size wascalculated by using a single population proportion formula
considering12.6% from previous study (Kahsay et al., 2019),with assumptions of confidence
level at 95%, a margin of error (d) 5% and adding 10% for incomplete records as follows:

Where:
n = sample size,
Z α/2 = critical value at 95% confidence level of certainty (1.96)
p = proportion 12.6% (0.126)
d= margin of error 5% (0.05)
n = (1.96)2(0.126) (0.874)/ (0.05)2=170
When the incomplete record rate of 10% is added to the total sample size then the final sample
size was186.

14
For Objective 2: Using double population proportion formula, sample size was calculated from
factors associated with early neonatal death. The sample size for the second specific objective of
this study was determined by considering factors that are significantly associated with the
outcome variable, two-sided confidence level of 95%, the margin of error of 5%, power of 80%
and the ratio of exposed to unexposed 1:1 using EPI-Info software. Considering 10% for
incomplete records the final sample size for the second objective was determined.

Table 1: Objective two sample size calculation for magnitude and factors associated with early
neonatal death among babies born at Hiwot Fana Specialized University Hospital in Harar,
Eastern Ethiopia.

Proportion of Early neonatal Sample Computed Reference

Variables death size sample size
computed + 10% IR

Exposed Unexposed

Multiple birth Yes No (13.2%) 400 440 (Woday Tadesse

(33.3%) et al., 2021)
Prematurity Yes No (10.02%) 366 403 (Dessu and
(15.56%) Dawit, 2020)
ANC follow Yes No 96 106 (Woday Tadesse
up (11.8%) (37.2%) et al., 2021)

The required sample size for thecurrent study was decided by taking the maximum sample size
bycomparing sample size for first and second objective. The first objective samples size 186 and
the second objective sample size calculation results 440. Then the largest sample size was taken
from second objective, 440.

2.5. Sampling Procedure

Simple random sampling was used to select study participants. The total number of early
neonates admitted to NICU from September 11,2018 to September 10,2021, were 3153.By using
registration book of admitted neonates in NICU, the sampling frame was prepared for all
admitted early neonates using their serial numbers. Out of 3153 total admission 440 early
neonates were selected using a computer-generated random number.

15
A list of study population from registration were reviewed according to date of admission.
Medical records with full information were used and if there is missing chart the next in the
sequence was used.

2.6. Data Collection Methods

2.6.1. Data collection tools

In this study, the data was collected usinga structured data collection checklist which was
adapted from previous study and WHO document review and audit of neonatal death(Eyeberu et
al., 2021, WHO, 2016a) and registration book of admitted early neonates in NICU of HFSUH
which wasprepared in English to extract data from therecords. The structured data
collectionchecklist includesfour sections like socio-demographic characteristic,
Maternalobstetric factors, maternal medical conditions and neonatal factors.

2.6.2. Data collectors and data collection procedures

Prior to data collection, two days training was given for data collectors and supervisors on the
study objectives, subject eligibility criteria and data collection methods. The data was collected
by 6BSc nurses and supervised by 2 BSc nurse. A letter from the college of Medical and Health
sciences was submitted to Hiwot Fana Specialized University Hospital to get permission to
conduct the research. After the submission letter of agreement was signed. Then, a letter from the
management of HFSUH was written to a specific department to allow to get the patient’s card.
Then the department allows us to access the cards. After identifying the card, the data was
extracted using the prepared checklist fromNovember 20, 2021 to December 20,2021.Record
review was conducted the whole day including the weekend. Intensive supervision was done by
principal investigator and supervisor and they had checked the collected data for completeness’,
accuracy, and consistency throughout the data collection period. The overall supervision was
done by the principal investigator.

16
2.7. Study Variables
2.7.1. Dependent Variable
Early Neonatal Death

2.7.2. Independent Variables

Socio demographic factors: Age of mother, residence, age of neonate and sex of neonate

Obstetric factors:Antenatal Care (ANC) follow-up, place of birth, parity, mode of delivery, type
of pregnancy, presentation at delivery, complications during pregnancy, labor and delivery

Environmentalfactors:Kangaroo Mother Care and Radiant Warmer

Neonatal factors: neonatal age at admission, gestational age at birth, sex, the weight of neonate,
date of NICU admission and discharge, Apgar score,respiratory distress syndrome (RDS),
perinatal asphyxia (PNA), prematurity, jaundice, hypothermia and neonatal sepsis.

2.8. Operational Definitions

Early neonatal death is deaths of newborn within the first 7days of life (EDHS, 2016).
Neonatal mortality is the death of a newborn within the first 28 days of life (WHO, 2016a).
Prematurity/Preterm birth refers to a delivery that occurs after 28wks before 37weeks of
gestation(WHO, 2012).
Perinatal deaths include stillbirths (pregnancy loss that occurs after 7 months of gestation) and
early neonatal deaths (deaths of live births within the first 7 days of life(EDHS, 2016).
Still birth is pregnancy loss that occurs after 28 weeks of gestation or one kilogram of newborn
weight (EDHS, 2016).
Normal hemoglobin in pregnant mother is (12-16g/dl).
Anemia in pregnancy is hemoglobin (Hgb) concentration of less than 11 g/dl. That hemoglobin
less than 11 g/dl will be taken as Anemic and greater than 11g/dl was taken as not anemic.
Apgar score:is a method of assessing the condition of newborn at one minute and 5 minutes
after birth and considered <7 not normal and >=7 as normal.

17
Gestational age: is a measure of a pregnancy in weeks from the beginning of the women’s last
menstrual period (LMP). Infant born, before 37weeks are considered as preterm and after
37weeks as term(WHO, 2012).
Respiratory distress:breathing disorder in newborns like fastbreathing,grunting, blue color
flaring(widening) of nostrils with each breath and chest retractions. Normally, the newborns
respiratory rate is 30-60 breaths per minute.

2.9. Data quality control

To assure the quality of data, properly designeddata collection tools was used. Prior toconduct
actual data collection, the structured checklistwas checked by pre-testing on the medical records
of 5% of the sample size at Dilchora Referral Hospital. Findings and experiences from the pretest
were utilized in modifying and reshapingthe research data collection tools. Training was given
for data collectors and supervisors about research objectives, confidentiality of information and
techniques of extraction before data collection. Completeness of the checklist was checked by
the principal investigator and supervisors daily.

2.10. Methods of data analysis

After data collection, the data was coded, cleaned and entered to Epi Data version 3.1 and
analyzed
using Stata version 15. Descriptive statistics was performed to compute summary statistics and
information was presented in table and in text such as frequencies, percent, and standard
deviation.
Bi-variable analysis was performed to selectcandidate variable using P<0.25. Based on this,
candidate variables were included in the final modelof multi-variable analysis to control all
possible confounders. Also, variables that were significant in previous studies and from the
context point of view was included in the final model ofmultivariable analysis even if the above
criteria were not meet. The model goodness of fit wastested by the Hosmer and Lemeshow
statistic test, the model was considered a good fit since it wasfound to be non-significant for
Hosmer andLemeshow (Pearson chi=5.75, p-value=0.6755).Multicollinearity was checked by
using VIF tosee correlation between independent variables, theresult showed that no variables

18
with VIF>10 was observed. Variables with P-value less than 0.05 in the multivariable analysis
were considered as there is a significant association with magnitude of early neonatal death.

2.11. Ethical Considerations

Ethical clearance was obtained from the Institutional Health Research Ethics Review Committee
(IHRERC) of the college of health and medical sciences, Haramaya University. In addition,
official letter of cooperation was submitted to the Hiwot Fana Specialized university Hospital to
obtain permission. Informed voluntary written and signed consent was obtained from the head
of Hiwot Fana Specialized university Hospital. Confidentiality of the patient was ensured using
anonymous data collection throughout the research process. Generally, covid-19 precautions and
prevention measures werekept throughout data collection period.

19
 3. RESULT
3.1. Socio-demographic characteristics
Out of 440 selected early neonates, 3early neonates were self-discharge and 5early neonates had
incomplete medicalrecords. A total of 432 early neonateswere enrolled in the analysis. Median
age of the mothers was 26 years(IQR of 22,30)and majority332(77%) of maternal age
wasbetween 20 to 34 and 65(15%) of themothers were below the age of 20.Out of those, 236
(54.6%) werefrom outside of Harar and238(55.1%)of the early neonates were male.

Table 2:Sociodemographic characteristics of early neonates and mothers of early neonates

admitted to HFSUH, Harar Ethiopia, November 20 to December 20,2021 (n=432).

Variables Frequency Percentage

Age of Mothers in Years
<20 65 15
20-34 332 77
≥35 35 8
Maternal Residence
Harar 196 45.4
Out of Harar 236 54.6
Sex of newborn
Yes 238 55.1
No 194 44.9
Age of newborn at admission
<24 hours 267 62
1-7 days 165 38

3.2. Maternal and Obstetrics characteristics

More than three-fourth 338(78%) of mothers had ANCfollow-up and 71% of mothers had less
than four ANC visits. The majority,381 (88.2%) of the mothershad a singleton pregnancy. About
102(23.6%)mothers were experienced obstetric complications during the current pregnancy. The
most common complications were Premature Rupture of Membrane (PROM) 37(8.6%),
followed by preeclampsia 34(7.9%), Antepartum Hemorrhage (APH) 21(4.9%)and
chorioamnionitis 2.3%Regarding intrapartum characteristics, the majority 312(72.2%) of the
neonates were born at the hospital. More than half, 171(60%) of early neonates were term babies
while 247 (40%) of the early neonates were preterm (Table 3).Out of the 432 delivered early
neonates290(67.1%) of them were delivered through spontaneous vaginal delivery and about

20
124(28.7%) of early neonates were delivered by cesarean section. The median duration of labor
was 12 hours with interquartile range (IQR=6,16 hours) and 273 (63.2%) of early neonates were
born between 4 to 8 hours of the start of labor.
Table 3:Maternal Obstetrics related characteristics of the mothers who gave birth to early
neonates admitted to HFSUH, Harar Ethiopia, 2021(n=432)

Variables Frequency Percentage

(n) (%)
Antenatal care follows up
Yes 338 78
No 94 22
Number of Antenatal care visit (n=338)
1-3 241 71
≥4 97 29
Gestational age at delivery
Term 261 60
Preterm 171 40
Parity (number of births)
Primipara 143 33
Multipara 210 49
Grand Multipara 79 18

Type of pregnancy
Singleton 381 88.2
Multiple 51 11.8
Previous bad obstetrics history
Yes 67 15.5
No 365 84.5
History of early neonatal loss
Yes 30 7
No 402 93
History of still birth
Yes 26 6
No 406 94
Mode of Index delivery
Spontaneous vaginal delivery 290 67.1
Cesarean section 124 28.7
Instrument assisted delivery 18 4.2
Place of index birth
Home 16 3.7
Health center 104 24.1
Hospital 312 72.2
21
 Duration of labor in hours
<4 hours 75 17.4
4-8 hours 273 63.2
>12 hours 84 19.4
Complication during index pregnancy
Yes 102 23.6
No 330 76.4
Complication during pregnancy(n=102)
PROM 37 36.3
Preeclampsia 34 33.3
Antepartum Hemorrhage 21 20
Chorioamnionitis 10 9.8
Complication during labor and delivery(n=432)
PROM 37 8.6
Preeclampsia 34 7.9
Antepartum Hemorrhage 21 4.9
Chorioamnionitis 10 2.3

3.3. Clinical characteristics of early neonates at admission

Overall mean weight of the neonates was 2579.31gm with standard deviationof 756.48gm).
More than halfof the neonate’sweigh ≥2500gmat admission.A total of 267 (62%) of the neonates
were admitted within 24 hours of delivery. The majority, 338 (78%) of the neonates stayed at the
hospital for more than 1day(Table 4).

Table 4:Clinical characteristics of Early Neonates at admission at HFSUH,2021

Variables Frequency Percentage

Weight at Admission in gm
<25000g 195 45
≥25000g 237 55
Apgar score at 5 min
<7 139 33.4
≥7 277 66.6
Hypothermia
Yes 246 57
No 186 43
Newborn heated with radiant warmer
Yes 208 48
No 224 52
Kangaroo Mother Care
Yes 14 3.2
No 418 96.8
22
CPAP
Yes 65 15
No 367 85
Newborns temperature within one hour of
admission
<36.5 275 63.6
36.5-37.5 119 27.5
≥37.5 38 8
Feeding
EBF 218 50.5
BF plus other formula 52 12
Maintenance fluid 162 37.5
Length of stay at hospital
<1 day 94 22
≥1 days 338 78

Causes of admission
Regarding admission problems, more than half 61.8% of the admissions were due to EONS
followed by hypothermia (54.2%). Prematurity was the third cause of admission to NICU, (39.6
%), (Fig.2).

Causes ofAdmission(%)
70.0 61.8
60.0 54.2
50.0 39.6
40.0 30.1
30.0 21.1
20.0 10.4 8.6 8.3 6.0
10.0
0.0

*Macrosomia,birth trauma,neonatal seizureand meconium maspiration syndrome and

hemorrhagic disease of newborn

Figure 2:Causes of admission at NICU of HFSUH, Harar Ethiopia,2021

3.4. Magnitude of early neonatal death

The overall magnitude of early neonatal mortality was46 (10.6% [(95%CI:8,14)]. Out this,
21(45.6%) were died within 24 hours of birth and 8(17%),6(13%),4(8.7%),4(8.7%) and 3(6.5%)
23
were died within 2,3,4,5, and 6 days of their birth, respectively. Neonatal sepsis, lowbirth weight,
and prematurity were identified as top three leading cause of early neonatal mortality.Greater
than 80% were treated by antibiotics. (Fig. 3).

Causes of Early Neonatal Death(%)

60.0 56.5
52.2
50.0
40.0 32.6 30.4 28.3
30.0
17.4 15.2
20.0
8.7
10.0
0.0
EONS Preterm birth Perinatal Hypothermia RF LBW MOF *Other
Asphyxia

*congenital malformation,anemia,hypoglycemia and hemorrhagic disease of newborn

Figure 3:Causes of death in % at NICU of HFSUH, Harar Ethiopia,2021

3.5. Factors associated with early neonatal death

Bivariable and multivariable logistic regression analysis was used to identify factors associated
with early neonatal death. On bivariable analysis, variables like antepartum hemorrhage,
chorioamnionitis, type of pregnancy(number of gestation), previous bad obstetrics history, place
of birth, respiratory distress syndrome, Apgar score at 5th minutes, jaundice, newborn cry at
delivery, resuscitation, asphyxia, early neonatal onset of sepsis, hypothermia, radiant warmer,
kangaroo mother care(KMC), CPAP, feeding ,duration of labor, age of mother, temperature,
parity, newborn weight at admission, gestational age were fulfilled p-value less than 0.25 and
considered for multivariable analysis.
In the multivariable analysis,earlyneonatal mortality was significantly associated with Preterm,
chorioamnionitis, respiratory distress syndrome, newborn weight at admission, Apgar score at 5th
minutes,Newbornsreceived CPAP and neonates’ fed-up maintenance fluid.Preterm neonateswere
3.51 times more likely to die than their counterparts[AOR=3.51, 95%CI (1.62,7.61)],
newbornswith chorioamnionitisduring labor and delivery were 6.2 times more likely to die than
their counterpart[AOR=6.2, 95% CI (1.3,30.23)]. Early neonates with a diagnosis of respiratory
distress syndrome had 4.6 times greater odds of death compared to those neonates without
respiratory distress syndrome[AOR=4.60, 95%CI (2.23,9.52)]. The odds of death among
24
 newborns who had low birth weight(<2500gm) were 3.6times higher than that of neonates who
did not have low birth weight [AOR=4.13, 95%CI (1.05, 16.22)]. Newborns with <7 Apgar score
at fifth minutes had 3.89 times greater odds of death compared to those neonates with >7 Apgar
score at fifth minutes [AOR=2.45, 95%CI (1.88,8.04)]. And similarly, newborns who received
CPAP had 5.19 times morelikely to die when compared to newborns who did not received CPAP
[AOR=5.19, 95% CI (2.39,11.23)]and the odds of neonates’ fed-up maintenance fluid had 2.61
times more likely to die than newborns received breast feeding exclusively [AOR=2.61, 95%
CI(1.14,5.91)].
Table 5:Factors associated with early neonatal mortality at Hiwot Fana
SpecializedUniversity,2021
Variables Early Neonatal Death COR (95% CI AOR (95% CI)
Yes No
Gestational Age
Term 13(3%) 248(57.4%) 1 1
Preterm 33(7.6%) 138(31.9%%) 4.56 (2.32,8.96) *** 3.51(1.62,7.6) **
Chorioamnionitis
Yes 3(0.69%) 7(1.6%) 3.8 (0.95,15.15) * 6.2(1.3,30.23)*
No 43(9.93%) 379(87.73%) 1 1
Type ofpregnancy
Singleton 36(8.33%) 345 (79.86%) 1 1
Multiple 10(2.31%) 41 (9.49%) 2.34 (1.08,5.06) * 0.9(0.32,2.4)
Previous bad
obstetrics history
Yes 12(2.78%) 55 (12.73%) 2.12 (1.05,4.35) * 0.92(0.28,3.16)
No 34(7.87%) 331 (76.62%) 1 1
Respiratory
Distress Syndrome
Yes 24(5.5%) 67(15.5%) 5.2 (2.75,9.81)*** 4.6 (2.2,9.6) ***
No 22(5.1%) 319(73.8%) 1 1
Newborn weight at
admission
<25000gm 35(8.1%) 160(37%) 4.5(2.22,9.11) *** 3.6 (1.41,8.04) **
≥2500gm 11(2.5%) 226(52.3%) 1 1
Apgar at fifth
minutes
<7 26(6.25%) 113(27.16%) 3.5 (1.83,6.74)*** 3.89 (1.88,8.04) ***
≥7 17(4.09%) 260(62.5%) 1 1
25
Newborn cry
Yes 20(4.63%) 250(57.9%) 1 1
No 26(6%) 136(31.5%) 2.4(1.28,4.44)** 0.83(0.31,2.21)
Resuscitation
Yes 25(5.79%) 105(24.3%) 3.2(1.71,5.93)*** 1
No 21(4.9%) 281(65%) 1 0.38(0.14,1.05)
Perinatal Asphyxia
Yes 22(5%) 108(25%) 2.34 (1.26,4.38) ** 0.85(0.33,2.24)
No 24(5.5%) 278(64.3%) 1 1
EONS
Yes 34(7.9%) 233(54%) 1.86 (0.93,3.71) * 1.84(0.81,4.16)
No 12(2.9%) 153(35.4%) 1 1
Hypothermia
Yes 22(5%) 224(52%%) 0.66 (0.34,1.22) 0.54(0.18,1.59)
No 24(5.6%) 162(37.5%) 1 1
Radiant warmer
Yes 17(4%) 191(44.2%) 1 1
No 29(6.7%) 195(45%) 0.6 (0.32,1.12) 1.93(0.63,5.92)
KMC
Yes 5(1.2%) 9(2%) 1 1
No 41(9.5%) 377(87.3%) 0.19(0.06 0.61) ** 0.32(0.07,1.43)
Newborn received
CPAP
Yes 22(5.09%) 43(9.95%) 7.31(3.78,14.14)*** 5.19(2.39,11.23)***
No 24(5.56%) 343(79.40%) 1 1
Feeding
EBF 11(2.5%) 207(47.91%) 1 1
BF plus other 8(1.8%) 44(10.2%) 3.42(1.3,8.9) * 2.84(0.96,8.41)
formula
Maintenance 27(6.25%) 135(31.25%) 3.76(1.81,7.82)*** 2.61(1.14,5.91) *
fluid
Duration of labor
<4 hrs 5(1.1%) 70(16.2%) 0.5(0.19,1.33) 0.36(0.11,1.15)
4-12 hrs 34(7.8%) 239(55.3%) 1 1
>12 hrs 7(1.6%) 77(17.8%) 0.6(0.27 1.5) 0.73(0.27,1.98)

26
 4. DISCUSSION
Magnitude of early neonatal mortality at Hiwot Fana Specialized University Hospital was found
to be 10.6%[(95%CI:8,14)].The overall proportion of early neonatal mortality in this study
almost consistentwith studies conducted in Nekemte 8%(Elias Merdassa Roro, 2019),Mekelle,
Northern Ethiopia (12.65%) (Kahsay et al., 2019), and Uganda 11.7% (Nakibuuka et al., 2012).
Possible reason could be the same at-risk study population for these studies conducted in
Ethiopia.During the neonatal period, the risk of death is highest at the time of birth and gradually
diminishes over the following days and weeks. Within the first 24 hours of delivery, up to 36%
of neonates die, and approximately 73% die within the first week of life(Oza et al., 2014) andthe
same reason can be driven for the study in Uganda.

But the finding was higher than the studies conducted inSomali Region 7% (Elmi Farah et al.,
2018),Jima 3%(Aragaw, 2016), and Sidama 5% (Alaka Adiso Limaso1, 2020). This
maindifference might be attributed to difference in study setting, sample size,and study
period(Zeray et al., 2019).However, the magnitude of early neonatal mortality in thisstudywas
lower than the studies conducted in Wolaita Sodo, Southern Ethiopia 13%(Orsido et al., 2019),
Debre Markos, Northwest Ethiopia 17.7%(Alebel et al., 2020) and Somali region 20%(Elmi
Farah et al., 2018).This discrepancy might be due to the existence of socio-demography and
socio-economic differences across Ethiopian regions regarding health service utilization of
available health services including delivery at health facilities, and seeking health facilities for
sick neonates, anda difference in geographical locations might be a reason(Woday Tadesse et al.,
2021, Adem et al., 2021).Besides this study used data of those neonates only admitted to
neonatal intensive care unit where most critically sick babies are being admitted.

In this study the odds of death among early neonatein preterm neonatal agewas3.5
times[AOR=3.51; 95%CI (1.62,7.6)] more likely to die compared to term neonates. This is in
line with
the fact that preterm newborns have a greater mortality than term newborns (Mengesha et al.,
2016) This finding is consistent with previous studies conducted in public hospitals in Eastern
Ethiopia(Desalew et al., 2020),Mekelle general and Aydercomprehensive specialized hospitals,
northern Ethiopia (Kahsay et al., 2019),Somali region(Elmi Farah et al., 2018)and study

27
conducted in Northern Ethiopia, (Mengesha and Sahle, 2017) and similarly in line with the study
conducted in Eastern Africa Eritrea(Andegiorgish et al., 2020).
This result might be due to immaturity of respiratory and cardiovascular organs, vulnerability to
infection, hypothermia, and lack of skilled medical care during intrapartum, and postpartum
period(WHO, 2016b, You.D. et al., 2015). Another possible reason might be as gestational age
of the neonate decreases at birth, the maturity of the fetus vital organs will be challenged and the
risk of developing life-threatening complications related to prematurity increases and which
could be contributed to increased risk of early neonatal death (Resnik et al., 2008). Similarly,
Organ failure, neurodevelopmental and learning disabilities, vision problems, and long-term
cardiovascular and non-communicable diseases are all risks for preterm babies(Villar et al.,
2014, Behrman and Butler, 2007).

In this study, neonates born from mothers complicated withchorioamnionitis was 6.2 times more
likely to die compared to neonates born from motherswithout pregnancy complicatedwith
chorioamnionitis. In fact, pregnancy complicated with chorioamnionitis leads toa dangerous
blood infection in the mother called bacteremia can cause the baby to be born early as well as
serious complications includes infection,brain damage, or death(Porter et al., 2018, Chan and
Smith, 2018).In thisstudy, the odds of death among early neonates diagnosed with respiratory
distress syndrome had 4.6 times more risk of death when compared with the newborns without
respiratory distress syndrome. This finding is in agreement with the studies conducted in Harar,
(Abdullahi et al., 2021), Gondor(Asmare, 2019).Respiratory distress syndrome is one the
common cause of death in newborns, failure to readily recognize symptoms and treat the
underlying cause of respiratory distress in the newborn can lead to short- and long-term
complications, including chronic lung disease, respiratory failure, and leads to death(Reuter et
al., 2014).

The odds of death among newborns who had low birth weight were 3.6 times more likely
compared with newborns without the condition.In contrast with this study, many facts indicated
that being low birth weight was independently associated with early neonatal death(Geda et al.,
2021, Desalew et al., 2020, Andegiorgish et al., 2020, Seid et al., 2019, Elias Merdassa Roro,
2019, Juan C. Lona Reyes, 2018, Aragaw, 2016, Lukonga and Michelo, 2015). The finding is
also similar with a cross sectional study done in Senegal and Mali which suggested that low birth
28
weight was significantly associated with perinatal death(Tort et al., 2015).The possible
justification is that in fact thatlow birth weight had immaturity of immune systemsand, other
body defense mechanisms that control newborn disease susceptibility(Kliegman et al., 2007).

In this study newborns with low Apgar score at 5 min is 3.9 times more likely to diewhen
compared to newborns with Apgar score of greater than or equal to seven.This is in line with
studies conducted in public hospitals of Eastern Ethiopia; (Desalew et al., 2020) and similarly in
step with the study conducted in Sweden (Cnattingius et al., 2020).In fact, a low Apgar score of
5 minutes is associated with an increased risk of newborn mortality and morbidity, including as
infections, asphyxia-related disorders, and respiratory distress and might suggest a poor response
to resuscitation and signal a poor long-term prognosis(Thorngren-Jerneck and Herbst, 2001). A
lower Apgar score at 5 minutes is also linked to a higher chance of cerebral palsy, epilepsy, or
other developmental problems later on(Li et al., 2012, Persson et al., 2018).

And similarly, newborns who received CPAP had 5.19 times more less likely to die when
compared to newborns who did not received CPAP [AOR=5.19, 95% CI (2.39,11.23).This
finding is in agreement with study conducted in India (Dewez et al., 2020). The possible reason
might be CPAP use can lead to serious complications such as pneumothorax, or nasal trauma(Ho
et al., 2015). Moreover, when CPAP is used with supplemental oxygen, the unregulated use of
oxygen may lead to retinopathy of prematurity (ROP), a major cause of blindness, or
bronchopulmonary dysplasia (BPD) (Hartnett and Lane, 2013, Davidson and Berkelhamer,
2017). CPAP is easy to initiate, but to be effective, CPAP needs to be used continuously for
hours or days. This implies continuous supplies of electricity and medical gases, continuous
clinical monitoring for timely detection of acute complications and long-term follow-up for
chronic complications (WHO, 2015).
In this study the odds of neonates’ fed-up maintenance fluid had 2.61 times more than newborns
received breast feeding exclusively [AOR=2.61, 95% CI (1.14,5.91)].The reason might be
due to the complications may lead to local infection, catheter-related bloodstream infection (CR-
BSI), fluid overload, and complications related to the type and amount of solution or medication
given(Perry et al., 2014). Most complications are avoidable if simple hand hygiene and safe
principles are adhered to for each patient at every point of contact(McCallum and Higgins, 2012)

29
30
 5. STRENGTH AND LIMITATION
The strength of this study was the use of a standard and pretested checklist adapted from the
WHO and national neonatal registration book. This would help to compare the proportion of
early neonatal mortality against the national and international point of view. Again, the study
provides the magnitude of early neonatal mortality at HFSUH.

The limitation was this study might not show a cause-effect relationship because the study design
was cross sectional. The use of medical records of newborns because of incompleteness and
since the study is facility based, the result might lack generalizability to the entire population in
the catchment area.Because of unavailability of information in the records, factors like maternal
medical factors and others were not assessed.

31
 6. CONCLUSION AND RECOMMENDATION
6.1. Conclusion
The study revealed that the overall proportion of early neonatal death was highwhich needs more
attention. The study identified that Preterm, Maternal complication during delivery like
chorioamnionitis, respiratory distress syndrome, low birth weight, low Apgar score at 5th
minutes, Newborns received CPAPand newborn fed-up maintenance fluidwere independent
factors associated with early neonatal mortality. In general, this finding and other studies showed
that Ethiopia is in the challenge to achieve national child and newborn survival strategy and
SDGs. Since most of the early neonatal death is due to preventable and treatable
conditions,proven, cost-effective, interventions should be existed to prevent and treat eachof
these main causes of early neonatal death.

Therefore, improving the obstetric care around birth, improving prompt resuscitation, specialized
care, and strengthening the standardized continuum of care starting from preconceptions to
menopause could prevent neonatal deaths in the study area.

32
 6.2. Recommendation
For Policy makers

 Incorporate general prevention mechanism and develop standard protocols for all
facilities to alert all health professionals working around maternity and NICUs in general.
 Capacity building for neonatology professionals can also be the gateway to improve
service provision at NICU.

For HFSUH and Health Professionals of the Hospital

 It is necessary to raise health-care practitioners' knowledge of regular investigations,

supplements, and management of pregnant women during ANC follow-up.
 The maternity ward should work on improvement within the facility and others of
catchment institutions to increase complete ANC visits, improve obstetric care services,
and early identifications of complications.
 Anticipating risky pregnancies like pregnancy with chorioamnionitis and the provision of
proper and on time interventions
 The hospital management should strengthenquality care services given in the Neonatal
intensive care unit by providing standardized quality care and infection prevention
methods.
 Strengthen early treatment of those sick newborns will reduce early neonatal mortality.
 The management of hospital and university should facilitate training for health care
providers of the hospital and neighboring health facilities.
 Integrated early identifications of obstetric complications and immediate interventions,
strengthen antenatal care services, screening the conditions early during intra-partum and
postnatal period, immediate newborn careas well as improving the quality of a targeted
care for mothers starting from preconception to the postpartum period are essential to
give immediate measures and can reduce deaths associated with preventable risk factors.
 They should also employpartograph on a frequent basis while monitoring labor and
provide prompt newborn care, payingparticular attention to babies with poor Apgar score.

For Other Researchers:

33
 Community based longitudinal study would be helpful to get other unmeasured risk
factors.

34
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 8. APPENDICES
8.1.Information sheet and informed consent form for HospitalMedical
Director/CEO
My name is Abdulmelik Abdela I am studyingmy Masters’ degree of public health in
Reproductive Health at Haramaya University College of Health and Medical Sciences. I kindly
request you to give me your attention; to explain the study and your health institution being
selected as the study setting.
The study title
Magnitude and factors associated with early neonatal death among early neonates admitted to
Neonatal Intensive Care Unit of Hiwot Fana Specialized Hospital in Harar, Eastern Ethiopia,
2021.
Purpose of the study
The study will be conducted through a collection of secondary data already collected on the
patient’s card and register and the aim of this study is to write a thesis as a partial requirement
for the fulfillment of a Masters’ degree program in Reproductive Health for the principal
investigator. The findings of the study will help the hospital to understand magnitude gap among
early neonates and its common factors.
Data collection procedure and duration
I will review records of the babies using a data retrieval form to provide me with pertinent data
that is helpful for the study. There are 28questions to answer where I filled the data retrieval
form by reviewing records. The review in each record may take 20-30 minutes, to collect data for
a single patient.
Risks and benefit of the study
The risk of reviewing in this study is minimal, the only assumed risk will be like time loss by
data collectors during data collection but only taking a few minutes from patient’s card/database
and follow up charts being used by hospitals. There would not be any direct payment for
reviewing in this study. The finding from this study will be contributed to the body of knowledge
that informs the hospital and neonatal program planners and decision makers
Confidentiality

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The information collected in the way explained above will be confidential. There will be no
information that will identify the records in particular. The findings of the study will be general
for the study community and will not reflect anything particular of individual persons. The data
retrieval form will code to exclude showing names. No reference will be made in oral or written
reports that could link participants to the research.
Rights
Participation in this study is voluntary. Your hospital hasfull right to declare reviewing or not
reviewing therecords. If you have allowed me to review the records, you have also full right to
withdraw from the study at any time if any problem is perceived.
Contact address
If there are any questions or enquires any time about the study or procedures, please contact the
investigator by using the following addresses.
Principal investigator: Abdulmalik Abdela Bushra
E-mail: abdum1009@gmail.com
Mobile phone: +251-913111608
Haramaya University College of Health and Medical Science Institutional Research Ethical
Review Committee: Office phone: +251- 254662011, P.O. Box: 235, Harar
Declaration of informed voluntary consent
I have read the participant information sheet. I have clearly understood the purpose of the
research, the procedures, the risks and benefits, issues of confidentiality, the rights of
participating and the contact address for any queries. I have been given the opportunity to ask
questions for things that may have been unclear. I was informed that hospital has the right
towithdraw from the study at any time.I also informed that thehospital has the right to stop this
study from being conducted if any misdeeds and unethical procedures are observed during the
data collection process in the hospital’s premises. Therefore,I declare my voluntary consent on
behalf of Hiwot Fana Specialized University Hospital management to allow this study to be
conducted in our hospital with my signature.
Name of medical director/CEO: ____________________Signature ________ Date_________
Name of Principal Investigator: _____________________Signature ________ Date__________

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 8.2. Questionnaire
Q.NO: __________________________ Name of Hospital: HFSUH
Name and signature of data collector: _______________________ Date ________________
Section 1: Socio Demographic Factors
Table 6: Baseline Maternal Socio Demographic characteristics of study participants

SN Questions Coding Remarks

101 Age ________ years

102 Residence 1. Harar
2. Out of Harar

Section 2: Obstetrics and Gynecologic factors

Table 7: Obstetrics and Gynecologic factors

SN Questions Coding Remarks

201 Antenatal care follows 1.Yes If no skip to Q.202
up? 2.No
201.1 Number of Antenatal _____________visit/s
care visit?
202 Gestational Age at ___________ Weeks.
delivery
203 Parity(Number of births) _________ Children.
204 Complication during 1. Yes If no skip to Q.205
index pregnancy 2. No
If yes to Q.205, what was 204.1Ante partum 1. Yes
the complication? hemorrhage 2. No
(Multiple 204.2Preeclampsia 1. Yes
answers possible) 2. No
204.3Eclampsia 1. Yes
2. No
204.4Chorioamnionitis 1. Yes
2. No
204.5Premature rupture of 1. Yes
membrane 2. No
204.5Other (specify)______
205 Type of pregnancy 1. Singleton
2. Multiple
206 Previous bad obstetrics 1. Yes If No skip to Q.207
history 2. No

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 If yes, type of bad 206.1Early neonatal death 1. Yes
obstetrics history? 2. No
206.2Still birth 1. Yes
2. No
206.3Intrauterine fetal death 1. Yes
2. No
206.4Intrauterine growth 1. Yes
restriction 2. No
206.5Other(Specify):_____

207 Mode of Index delivery 1. Spontaneous vaginal

delivery
2. Cesarean section
3. Instrument assisted
delivery
208 Place of index birth 1. Home
2. Health center
3. Hospital
209 Duration of labor in hrs ______ hrs and
______minutes

Section 3: Maternal Medical Factors

Table 8: Maternal Medical Factors due to the current pregnancy and postpartum
SN Question Coding Remarks
301 Preeclampsia 1. Yes
2. No
302 HIV/AIDS 1. Yes
2. No
303 Anemia 1. Yes
2. No
304 DM 1. Yes
2. No
305 Eclampsia 1. Yes
2. No
306 Sepsis 1. Yes
2. No
307 Postnatal depression 1. Yes
2. No
308 Syphilis 1. Yes
2. No
309 Hypertension 1. Yes
2. No

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Section 4: Neonatal Factors
Table 9: Neonatal Factors

SN Questions Coding Remarks

401 Sex of Newborn 1. Male

2. Female
402 Delivery Date ______/______/______
(DD/MM/YYYY)
403 Admission Date ______/______/______
(DD/MM/YYYY)
404 Age of newborn at admission __________ days
405 Presentation of the fetus at 1. Cephalic
delivery 2. Breech
3. Transverse
4. Other, specify____
406 Weight at Admission(gm) _____________ grams
407 Congenital malformation 1. Yes If no skip to
diagnosed at birth? 2. No Q.408
If yes what type of 407.1 Anencephaly 1. Yes
Congenital malformations 2. No
407.2Spina Bifida 1. Yes
2. No
407.3Neural tube defects 1. Yes
2. No
407.4Other(Specify):_______
408 Respiratory Distress 1. Yes
2. No
409 Apgar score at 1 min 1. <7 3. Unknown
2. ≥7
410 Apgar score at 5 min 1. <7 3. Unknown
2. ≥7
411 Jaundice at admission 1. Yes
2. No
412 Newborn cry immediately at 1. Yes
birth 2. No
413 Bag and mask resuscitation 1. Yes
at birth 2. No
414 Newborns temperature ____________ Co
within 1 hr of admission
415 Peri-natal asphyxia 1. Yes
diagnosed at birth 2. No

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 416 Neonatal Sepsis diagnosed at 1. Yes
admission 2. No
417 Hypothermia diagnosed at 1. Yes
admission 2. No
418 Newborn heated with radiant 1. Yes
warmer 2. No
419 Newborn received kangaroo 1. Yes
mother care 2. No
420 Neonate received continuous 1. Yes
positive airway pressure 2. No
(nCPAP)
421 Neonate received photo 3. Yes
therapy 4. No
Table 5: End line early neonates’ information.
Question Coding and categories Remark
501 Death 1. Yes If no skip to Q.504
2. No
502 Causes of death 1. If yes to Q.501
2.
3.
503 Age at death __________
504 Length of stay at hospital _________ days/hrs.

505 Drugs given 1. Antibiotics

2. Oxygen
506 Feeding during admission 1. Exclusive Breast feeding
2. Breast feeding plus other
formula
3. Maintenance fluid

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 8.3. Principal Investigator Curriculum Vitae
Name: Abdulmalik Abdela Bushra
Mobile: +251913111608
E-mail: abdum1009@gmail.com
Education Background: BSc in Midwifery, Candidate for MPH in RH
1. Personal Information
Sex: Male
Nationality: Ethiopia
Date of Birth: 1994 G.C
Marital Status: Married
2. Education Qualification and Development
YearPlaceDisciplineAward

2012-2016 Wollega University Midwifery BSc

2019- Haramaya University Reproductive Health candidate
 2010-2012, Nekemte Comprehensive School
 2009-11, Arjo Gudetu Secondary School
 Elementary: Bareda Elementary school.

3. Language Skills
LanguageWritingSpeakingReadingListening
English Excellent Excellent Excellent Excellent
Amharic Excellent Excellent Excellent Excellent
Afan Oromo Excellent Excellent Excellent Excellent
4. Work Experience
 Clinton Health Access Initiative(CHAI) Melka Bello Woreda Midwife Mentor
Coordinator, January,2018 to December,2020
 PHEM focal person at Melka Bello WoHO, January 2018 to October 2020.
 Family Health and Nutrition Program Coordinator at Melka Bello
WoHO,Oromia,2020)

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  Transform PHC Ethiopia: Melka Belo HO Woreda Grant Fund Coordinator
January 2020 to February 2021.
 PHCU Director and MCH and labor wards room head ( Jaja health
Center,Oromia,2017-2018)
 Under five /IMNCI service room (jaja health center,Oromia,Sept-Dec,2018MCH,
Delivery, Perinatal and Labor wards room head (Bareda health Center, Oromia,
from 2015/16-2017)
5. Skills
 Basic computer skills (Excellent in MS Office, PowerPoint, Excel )
 Statistical Analytic Software’s (SPSS, EPiData, EPInfo..)
 MCH mentoring ,Couching, Integrated MCH supportive Supervision and Monthly
,weekly reporting with Clinton health Access Initiative(CHAI) (2018-2019)
 Planning, Implementing, evaluating and reporting overall family health Program,
 Maternal Nutrition and Nutrition service with Catholic Relief service
CRS)organization(2019-2019)
 Delivering BEMONC training for health care workers co- with CHAI
organization
 Preparing Review Meeting and Excellent Report preparation and Presentation
 PHD Qualitative research data collection with Haramaya University.
 Motorcycle driving license and Experience

Selected Training and Workshop Attended

 PHEM training with certificate conducted by EPHI at Haramaya University College Of

Medical and Health sciences, Harar, February 2021.
 HMIS training, Harar, conducted by JSI organization co with Oromia Health Beareu, Oct
,2016
 Leadership and Management TOT training conducted by Transform PHC Ethiopia at
Harar, 2020
 BEMONC training on Nov, 2017, Haramaya hospital, conducted by CHAI(Clinton
Health Access Initiative).
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 BEMONC TOT training at Ambo Town conducted by CHAI organization with certificate
 BLENDED and Integrated Nutrition Program training, August 2017, Harar, conducted by
East Hararge zonal health Beareu co with Oromia health Beareu

 Compassionate and Respectful Care training TOT conducted by Ethiopian Midwives

Association co with FMOH at Addis Ababa,2020.
 SAM (SEVERE ACUTE MALNUTRITION) training conducted by East Hararghe Zone
Health Office on Sept,2018
 Expanded Program on Immunization ,immunization In Practice(EPI IIP) training June,
2018, Harar, conducted by World Health organization co with East Hararge zonal health
Beareu,
 All Family Planning training, Conducted By Oromia regional health beareu on Dec,2017,
Adama
 Long Acting Family Planning training, Conducted By Oromia regional health beareu on
Dec,2019, Adama
 Postpartum Family Planning training, Conducted by CHAI(Clinton Health Access
Initiative), on June,2019, on Ambo, with certificate
 Essential Newborn care training conducted by Oromia Regional Health Beareu on
Dec,2018,Adama
 Fistula diagnosis and pelvic organ prolapse training, March, 2017, Harar , conducted by
HAMLIN fistula center,

 School Health training, March ,2018,Deder, conducted ASDEPOG

 Attending Quarterly RM at Zonal, Regional and Federal level under FMOH and other
partners
 I am Senior Member of Ethiopian Midwife Association and East Hararghe Zone
Representative additionally member of EMwA Regional and Federal General Assembly.
6. Hobbies
 Reading Scientific books, magazines.
 Sharing Experience with other people

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 7. Professional Background

My independent research title for undergraduate class; Assessment of the magnitude of

unintended pregnancy and associated factors among pregnant women attending Antenatal care at
Arjo Gudetu health center, Oromia, Western Ethiopia, 2015/16.

Qualitative research data collection on maternal and child health with Catholic Relief Center
Dire Dawa district.

8. References
1. Ahmeddin Mohammed,Head of Melka Belo Health Office
Mobile: +251927206616
2. Wogane Dibaba, CHAI ,Midwife Mentor program manager
Mobile: +251913225908
Email: wegenediba2004@gmail.com
3. Dr. Ziyad Abrahim, Lecturer at Haramaya University
Mobile : +251935626144
Email: ziyadabrahim5@gmail.com

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