Annually four million infants die in the first four weeks of life, around the world, while
99% of these deaths occur in low and middle-income countries. The rate
of neonatal death is one of the most important health indexes of a country. In 2000,
this rate was 2/1000 in Japan, 21/1000 in China, 57/1000 in Pakistan and
18/1000 in Indonesia. ⁽¹⁾

Neonate refers to the first 28 days after birth and neonatal death is one of the biggest
health problems, which may be neglected. Annually, 20,000 infants die in Iran and
if the estimation of still birth is added, the mortality (from 22 weeks of pregnancy
to 28 days after birth) will increase to more than 35000 neonates, so this is considered as the third common factor of mortality.^(2,3,4)

The neonatal mortality rate is 18.3/1000 in Iran at present (2000, DHS) and in
spite of the reduction in this rate, in infants and children under 5 years during the last 15 years, neonatal mortality has remained stable and accounts for 50% of deaths
in children under 5 years of age.⁽⁵⁾ Prematurity, low weight, congenital malformation and infectious diseases are factors affecting neonatal death in Iran.^(2,6) The index of
neonatal death did not reduce in Fars Province during these years and
even an increase was observed in some areas of the province. This index was
16.41/1000 in rural areas of the Province in 2001 and the most common causes
were prematurity and malformation.⁽⁷⁾ So, this study was conducted to determine
the causes and factors affecting neonatal death in the region, for intervention
measures and future programs.

In a descriptive and analytical study, a questionnaire was provided to record and
evaluate the causes of neonatal death which were provided for all hospitals and
urban and rural health centers from the beginning of the year 2004. The
collected questionnaires were sent to the Office of Fars Province Neonatal Death
Committee for evaluation and correction and accuracy. Data were entered
in Access Software and were statistically analyzed. The population of this study
was all dead neonates recorded in Fars Province.

The reasons and factors affecting neonatal death among 417 recorded
cases in urban and rural areas are presented in Tables 1-4 and figures 1-3.
In figure 1 the rate is based on births and percentage according to total death.
The most common cause of neonatal death was prematurity (57.07%) and the
lowest one was low birth weight (3.84%). This frequency is demonstrated in Table 1 and was higher in males.

Figure 2 shows that the highest neonatal mortality rate was in the families whose mother's age was in the age group 18-35. The highest rate of births in 2004 was in this age group.

Table 2 shows neonatal death based on birth order. The highest mortality rate was in the first birth followed by second and third orders respectively. Of course it should be noticed that the first, second and third births (particularly the first) were seen more often. Regarding the importance of neonatal death in the first, second and third orders, they were reported separately in Table 2.

The data in Table 3 showed that 67% of neonatal mortality rates were in the
gestational age of 37 weeks in 2004. Although prematurity was recognized as the most important factor of neonatal death in Fars Province, attention and accuracy in completing the questionnaire for causes of death causes would be important. Fig 3 shows neonatal mortality rate in different age groups, from which 30% of neonatal deaths occurred in the first day and 42.45% after 1-7 days. Generally, 85% of neonatal deaths occurred in the first week and 50% in the first 24 hours after birth.
6
Table 4 shows the relationship between neonatal death and birth weight. 52% of neonatal deaths occurred in the less than 2500 g weight group, whereas, no
mortality was seen in 18.5% of neonates in relation to birth weight. 89.69% of
births and 81.77% of mortalities were in hospitals showing the high percentage of labor in hospital, which seems reasonable. On the other hand, infants with
medical problems are usually admitted to hospitals with the above mentioned
causes. The most common cause of death in infants in the present study, was related to the physicians (48.68%); and midwives (47.24%); explaining the mortality rate of the majority of infants in the hospitals. It is notable that 2.88% of dead infants were delivered by untrained personnel. In the present study, it was shown that the percentage of normal labor (62.35%) was more than that by Caesarian section (3.18%).

The findings of this study showed that the most common causes of neonatal
death were prematurity and malformation, which are similar to the previous
studies in Iran and in the world. In relation to this, evaluations on 96,797 cases of
neonatal death in 45 countries and 56 studies on 13,685 cases of death in 29
countries, have established seven classifications for the main causes of neonatal
death including severe infections, neonatal tetanus, diarrhoea, asphyxia,
prematurity and congenital malformation.⁽⁸⁾

The results of the present study used the same classification. It is notable that
based upon the above-mentioned classification, in the countries with neonatal
mortality rate of 45/1000, more than 50% of deaths have been due to severe
infections, neonatal tetanus and diarrhoea, whereas, in the countries with neonatal
death less than 15/1000, severe infections covered less than 20% of death
causes, and malformations and prematurity were also of importance. ⁽⁹⁾ Neonatal
death occurrence in Iran was affected by four main diseases and disorders
including prematurity, low birth weight (which accounted for 71% of deaths), congenital malformations, laboring injuries and infections that were similar to neonatal death causes patterns in developed countries. ^(1,6,10)

The present study, the comparison between death causes and sex of dead
neonates showed that the only difference was between prematurity and infant
sex, in which the prematurity was reported more in males and other death causes
were equal in both sexes. These results may be due to this aspect that the
(8) females had a more desirable biological capacity during the neonatal period than males. ⁽¹¹⁾ but care was given more for males than females. ⁽¹²⁾

It was shown that 85.13% of neonatal deaths occurred in mothers aged 18-35
years. Regarding the marriage age in Iran, these findings do not seem out of place.
Also, similar results were obtained from another study conducted in 2002, while
the causes of deaths were prematurity and malformation and 79.5% of dead
infants had mothers aged 18-35 years and the majority of deaths also
occurred in the first birth orders⁽¹³⁾, while in the present study 43.29% of neonatal
deaths were reported in the first order too.

In the studies conducted on the direct causes of neonatal death in 2000, it was
shown that 28% of neonates had gestational ages less than 37 weeks. It is
notable that in the countries with more than 29/1000 of death, the cause by
infection was more than prematurity as the cause of death, and prematurity was
seen even less in countries with few neonatal deaths, which may be
due to concealed deaths due to prematurity in the group with infection. ^(9,14)

In the present study, 67.14% of infants died in the first 37 weeks of pregnancy, which is similar to international results.

Low birth weight is also one of the indirect and important causes of neonatal
death while 18 million low birth weight infants are born annually ⁽¹⁴⁾, whereas, only
one half of the newborns were weighed at the time of birth⁽¹⁵⁾ and although low
birth weight included 14% of newborn infants, this figure covered 60-80% of dead
infants. ⁽¹³⁾ In the present study, it was shown that 52% of neonatal death occurred in
(9) weights lower than 2500 g, whereas, 18.46% of dead infants had no recorded
weight in this study.

Finally, regarding interventions to reduce neonatal death in the countries with
high and stable neonatal deaths and with regards to the results of available studies and the present one, it was shown that programs in remote and low income areas and with, more pregnancies at risk, more attention seems necessary to care for first births and during the first week of birth. More care during the pregnancy period is needed to reduce preterm labor. Hospitals far from the centers with newborn intensive care should be equipped, folic acid administration three months before pregnancy would be beneficial, and equipment and emergency ambulances with portable incubators to transport a newborn to more equipped centers would reduce the risk of mortality rate.

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The authors would like to thank Dr. Davood Mehrabani for editorial assistance. ¹⁰