Neonatal Mortality in an Iranian Referral Level Ш Neonatal Intensive Care Unit: A Cross-Sectional Study

Document Type : Original Article


1 Nursing Care Research Center (NCRC), School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran.

2 Neonatal Health Research Center, Research Institute for Children’s Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran.


Background: Despite the significant improvement in neonatal intensive care, neonatal death is still one of the most important challenges worldwide. Understanding the causes of neonatal mortality is important for health policymakers.
This study aimed to assess neonatal mortality in an Iranian referral level Ш Neonatal Intensive Care Unit (NICU).
Methods: This cross-sectional study was conducted on the neonates who were referred to a level Ш NICU between 2014 and 2019. Data collection was performed by the research assistants, using a pre-designed checklist from the neonatal medical records. All the neonatal records of the patients who died during the infancy period were collected. Data were analyzed using SPSS (version 23).
Results: In total, 388 (12%) out of 3,078 inpatient neonates died In this study. The mean gestational age of neonates who died was 34.9 weeks and 53% of them were males. In addition, 92 (23%) of them died when they aged between 0-7 days and hyponatremia was the most common (30.9%) abnormal laboratory finding among them. The main causes of mortality included sepsis (26%), congenital multiple anomalies (21%), prematurity (20%), surgical procedures (15%), congenital heart disease (8%), inborn metabolic disorder (6%), hypoxic-ischemic encephalopathy (2.8%), and some unknown reasons (1.2 %), respectively. Sepsis, as the most common disorder in neonatal mortality among the patients, was detected in 74 (58.27%) preterm infants, and Acinetobacter was the main microbial detected pathogen. The rate of sepsis was significantly different in different gestational ages (p <0.001).
Conclusion: Based on the obtained results, sepsis, prematurity, and congenital multiple anomalies are the most common causes of mortality among neonates. Causes of mortality during the first month of life were different indicating the need for evidence-based interventions and proper policymaking in the field of neonatal health.


  1. UNICEF. UNICEF data mortality. New York: UNICEF; 2018.
  2. World Health Organization. Newborn health report. Geneva: World Health Organization; 2019.
  3. Marandi SA, Farrokhzad N, Moradi R, Rezaeizadeh G, Shariat M, Nayeri FS. Review of the Iranian newborns' health, survival, and care and future challenges. Arch Iran Med. 2019; 22(7):403-9.
  4. Saeidi R, Heydarian F, Fakehi V. Role of intravenous extra fluid therapy in icteric neonates receiving phototherapy. Saudi Med J. 2009; 30(9):1176-9.
  5. Oestergaard MZ, Inoue M, Yoshida S, Mahanani WR, Gore FM, Cousens S, et al. Neonatal mortality levels for 193 countries in 2009 with trends since 1990: a systematic analysis of progress, projections, and priorities. PLoS Med. 2011; 8(8):e1001080.
  6. Black RE, Cousens S, Johnson HL, Lawn JE, Rudan I, Bassani DG, et al. Global, regional, and national causes of child mortality in 2008: a systematic analysis. Lancet. 2010; 375(9730):1969-87.
  7. Lawn JE, Cousens S, Zupan J, Lancet Neonatal Survival Steering Team. 4 million neonatal deaths: when? Where? Why? Lancet. 2005; 365(9462):891-900.
  8. Bryce J, Boschi-Pinto C, Shibuya K, Black RE, WHO Child Health Epidemiology Reference Group. WHO estimates of the causes of death in children. Lancet. 2005; 365(9465):1147-52.
  9. Muhe LM, McClure EM, Nigussie AK, Mekasha A, Worku B, Worku A, et al. Major causes of death in preterm infants in selected hospitals in Ethiopia (SIP): a prospective, cross-sectional, observational study. Lancet Global Health. 2019; 7(8):e1130-8.

10. Tielsch JM. Global incidence of preterm birth. Low-birthweight baby: born too soon or too small. Berlin, Germany: Karger Publishers; 2015. P. 9-15.

11. Ghorbani F, Heidarzadeh M, Dastgiri S, Ghazi M, Rahkar Farshi M. Survival of premature and low birth weight infants: a multicenter, prospective, cohort study in Iran. Iran J Neonatol. 2017; 8(1):16-22.

12. Kale A, Bonde V. Neonatal sepsis: an update. Iran J Neonatol. 2014; 4(4):39-51.

13. Dandona R, Kumar GA, Bhattacharya D, Akbar M, Atmavilas Y, Nanda P, et al. Distinct mortality patterns at 0–2 days versus the remaining neonatal period: results from population-based assessment in the Indian state of Bihar. BMC Med. 2019; 17(1):140.

14. Stoll BJ. The global impact of neonatal infection. Clin Perinatol. 1997; 24(1):1-21.

15. Jacob J, Kamitsuka M, Clark RH, Kelleher AS, Spitzer AR. Etiologies of NICU deaths. Pediatrics. 2015; 135(1):e59-65.

16. Ajao AE, Adeoye IA. Prevalence, risk factors and outcome of congenital anomalies among neonatal admissions in Ogbomoso, Nigeria. BMC Pediatr. 2019; 19(1):88.

17. Postoev VA, Nieboer E, Grjibovski AM, Odland JØ. Prevalence of birth defects in an Arctic Russian setting from 1973 to 2011: a register-based study. Reprod Health. 2015; 12(1):3.

18. Fallahi M, Mohajerzadeh L, Borhani S, Kazemian M, Roozroukh M, Khaleghnejad-Tabari A, et al. Outcomes of congenital diaphragmatic hernia: an 8-Year experience. Iran J Pediatr. 2017; 27(2):e9144.

19. Sun PF, Ding GC, Zhang MY, He SN, Gao Y, Wang JH. Prevalence of congenital heart disease among infants from 2012 to 2014 in Langfang, China. Chin Med J. 2017; 130(9):1069-73.

20. Majeed-Saidan MA, Atiyah M, Ammari AN, AlHashem AM, Rakaf MS, Shoukri MM, et al. Patterns, prevalence, risk factors, and survival of newborns with congenital heart defects in a Saudi population: a three-year, cohort case-control study. J Congen Cardiol. 2019; 3(1):1-10.

21. Brankovic S, Hadziomerovic AM, Rama A, Segalo M. Incidence of morbidity and mortality in premature infants at the Department of Neonatal Intensive Care of Pediatric Clinic, Clinical Center of Sarajevo Unviersity. Med Arch. 2013; 67(4):286-8.

22. World Health Organization. MCEE methods and data. Sources for child cause of death 2000-2016. Geneva: World Health Organization; 2018.

23. Axelin A. Parents as pain killers in the pain management of preterm infants. Early Hum Dev. 2010; 82:241-7.

24. World Health Organization. Global preterm birth estimates. Geneva: World Health Organization; 2018. 

25. Babaei H, Dehghan M. Study of causes of neonatal mortality and its related factors in the neonatal intensive care unit of Imam Reza hospital in Kermanshah, Iran during (2014-2016). Int J Pediatr. 2018; 6(5):7641-9.

26. Wattad A, Chiang ML, Hill LL. Hyponatremia in hospitalized children. Clin Pediatr. 1992; 31(3):153-7.

27. Storey C, Dauger S, Deschenes G, Heneau A, Baud O, Carel JC, et al. Hyponatremia in children under 100 days old: incidence and etiologies. Eur J Pediatr. 2019; 178(9):1353-61.

28. Kim YJ, Lee JA, Oh S, Choi CW, Kim EK, Kim HS, et al. Risk factors for late-onset hyponatremia and its influence on neonatal outcomes in preterm infants. J Korean Med Sci. 2015; 30(4):456-62.

29. Iqbal Q, Bashir C, Mushtaq S, Ahmad A, Baba AR. Thrombocytopenia and other hematological parameters in culture positive neonatal sepsis and their impact. J Pediatr Infect Dis. 2013; 8(1):25-9.

30. Thanh BYL, Lumbiganon P, Pattanittum P, Laopaiboon M, Vogel JP, Oladapo OT, et al. Mode of delivery and pregnancy outcomes in preterm birth: a secondary analysis of the WHO Global and multi-country surveys. Sci Rep. 2019; 9(1):15556.

31. Puri A, Lal B, Nangia S. A pilot study on neonatal surgical mortality: a multivariable analysis of predictors of mortality in a resource-limited setting. J Indian Assoc Pediatr Surg. 2019; 24(1):36-44.