The motive of our study was to identify morbidity and causes of neonatal death of inborn neonates admitted to a neonatal care unit at a tertiary hospital in Northern Tanzania. Our main results are largely consistent with the global pattern of mortality [2, 5], with birth asphyxia, prematurity, and infection as the most important single causes of neonatal death. Our results should be interpreted bearing in mind that it includes only inborn neonates delivered at a tertiary health facility. Neonates who are admitted at a tertiary hospital NCU represent the important subgroup of neonates who have high risk of morbidity and mortality.
Our finding that birth asphyxia was the leading cause of death is consistent with a previous study from a university and tertiary care hospital in Tanzania . In contrast, the global pattern and studies from university and tertiary care hospitals find prematurity to be the leading cause of death [5, 22–24]. One explanation of the high number of deaths due to asphyxia in our data may be the definition criteria for asphyxia that we used, which included some of the preterm babies. In some studies [21, 24], all preterm babies who die are classified with prematurity as cause of death. Of particular interest is the high number of deaths attributable to asphyxia in normal birth weight infants in our study (one third of all deaths) because they may represent a potential for prevention. Basic training on newborn resuscitation skills and proper newborn resuscitation immediate after birth has proved to reduce mortality among babies born with birth asphyxia up to 40% [25–27]. A recent study in six developing countries showed that training on Essential Newborn Care which includes training on basic resuscitation had no effect on early neonatal mortality. However, there was a significant reduction in the rate of stillbirths primarily fresh, most likely as an effect of resuscitation of babies who would have been misclassified as stillbirths before training . On the other hand, there was no additional effect of training in the Neonatal Resuscitation Program once the Essential Newborn Care training was already in place . Training on newborn resuscitation immediately after birth is highly needed in Tanzania, where only 16% of health care services reported that they offer newborn respiratory support .
Prematurity was the second most important cause of death. Management of premature babies requires high specialized equipment, highly trained personnel and financial support [26, 30]. In high income countries where ventilation technology and the use of surfactant have been implemented, the survival of premature babies has improved . RDS is a known very frequent complication of preterm babies due to lung immaturity, and babies with RDS had the highest case fatality in our study, which is also reported elsewhere [16, 24, 31, 32]. The high case fatality in babies with RDS reflects the inadequate care of these neonates in developing countries [30, 33].
Some specific and simple measures has been identified which could be implemented to reduce deaths related to low birth weight and preterm in low income countries [27, 34, 35]. These include among others prophylactic use of steroid during premature labour, antibiotic for premature rupture of membrane, early breast feeding, treatment of infection, hospital-based kangaroo mother care, prevention of hypothermia, feeding and nutritional support. A recent meta-analysis review found hospital-based Kangaroo mother care (skin-to-skin contact) implemented within the first week of life for stable preterm and low birth weight neonates was effective and could reduce neonatal mortality up to 51% .
Mortality due to infection was low compared to the global pattern as well as the pattern in low income countries [10, 16, 23, 25]. The low number of deaths due to infection might in part be explained by the inclusion of only inborn neonates, since appropriate treatment of infection or suspected infection can start with a minimum of time delay after delivery.
In a previous study from the same NCU where both inborn and outborn neonates were included one fifth of the deaths were due to infection . Furthermore, the use of Gentamycin and Cloxacillin instead of Gentamycin and Ampicillin  introduced in the early 2000 for neonatal infections in the department may have played a role in increased survival in infected neonates. A similar change in antibiotic treatment in Nigeria resulted in a 32% reduction in mortality associated with septicaemia . The routine transfer to NCU of all neonates at risk of infection or suspected infection due to premature/prolonged rupture of membrane for antibiotic prophylaxis , might also have contributed to low mortality due to infection in this setting. We have previously shown that babies of mothers with premature/prolonged rupture of membrane had a 2 fold risk of being transferred to NCU for antibiotic prophylaxis due to risk of infection .
The majority of women in low income countries do not access early ultrasound scan for screening of congenital malformation, and there are very few early terminations of pregnancies due to severe/fatal congenital malformations. Availability of management/surgery for neonates with severe congenital malformations is limited, and under the prevailing circumstances we suggest that few of these deaths could have been prevented.