Neonatal Near Miss and Its Associated Factors among Neonates in Garowe City,Puntland,Somalia,2025: A Cross Sectional Study

Abstract

Background

Neonatal near-miss refers to conditions in which a newborn is on the verge of dying, but survived within 28 days of life. Although the study of neonatal near miss has emerged in many countries, there is limited data about the condition in Garowe, Somalia. Hence, the study aimed to assess the magnitude of neonatal near miss and its associated factors among neonates in Garowe City, Puntland.

Methods

Institution based cross-sectional study was conducted from June 01–29 2024 among randomly selected 375 neonates. Data were collected by trained nurses through face-to-face interview of the mothers or guardians using a pre-tested standard questionnaire. Neonatal near miss was defined as having any of the pragmatic (birth weight <1750g, <33 weeks gestational age,or <5 fifth minute APGAR score) or management criteria (mechanical ventillation, cardiopulmonary resuscitation, nasal continous positive airway pressure, parentral antiobiotics, parentral nutrition, use of vasoactive drugs, or phototherapy within 24 hours of birth). Data were entered into Epidata version 3.1 and exported to Stata version 14.0 for analysis. Bivariable and multivariable logistic regression were done to identify factors associated with neonatal near miss. Level of statistical significance was declared at p-value < 0.05.

Results

The magnitude of neonatal near miss was found to be 48.2% (95% CI: 43%, 53%). Neonates born from daily laborer mothers (AOR = 5.72; 95% CI: 1.73-18.89), from women with history of abortion (AOR = 2.75; 95% CI: 1.37-5.53), and those admitted to the neonatal intensive care unit (AOR = 13.99; 95% CI: 7.36-26.59) were more likely to have neonatal near miss.

Conclusion

Nearly half of neonates in Garowe experienced a near miss event. Maternal occupation, history of abortion, and admission to neonatal intensive care unit were found to be key associated factors. Health care professionals should enhance early identification and follow-up of high-risk pregnancies and newborns, particularly in mothers with a history of abortion or those engaged in physically demanding jobs.

Keywords

Neonatal near-miss associated factors Garowe Somalia

Introduction

Globally, 2.5 million babies died within a month of life, with approximately 2 million of these deaths occurring during the first week of life (WHO, 2018). Though, the numbers of mortality show a huge improvement , up to eight newborns for each death survive with life-threatening complications (Lawn et al., 2013). These events are known as neonatal near-misses (NNM) and are crucial indicators for epidemiologic surveillance as well as the evaluation of healthcare quality (Bakari et al., 2019). Wardlaw et al., 2014

The main causes of neonatal death worldwide are complications arising from preterm birth, asphyxia during labor and sepsis, accounting to 75% of the deaths (WHO, 2023). Internationally, complications arising from preterm birth alone contribute to approximately 35% of neonatal deaths, while birth asphyxia accounts for about 24%; Furthermore, an estimated 14% of newborns are delivered with low birth weight (LBW), with the highest prevalence observed in Asian and African countries (Mengesha & Sahle, 2017; WHO, 2018). These conditions negatively impact childhood growth and development with an increased risk of chronic diseases later in life (Lawn et al., 2013; Bugelli et al., 2021). As a result, they impose social, emotional, and economic burdens on families and communities (Santos et al., 2015). The magnitude of NNM varies widely across studies, primarily due to differences in the criteria used for its identification. Studies that relied solely on pragmatic criteria reported an incidence ranging from 21.4 per 1,000 live births in Brazil (De Lima et al., 2018) to 86.7 per 1,000 live births in Portugal (Da Costa et al., 2022).

Scholars indicate that, the number of newborn babies surviving as NNM event were approximately three to six times higher than the number of newborn babies who died (Haile et al., 2023). In Portugal, the estimated number of survivors as of NNM cases were seven times higher than the number of newborn deaths (Da Costa et al., 2022). Similarly, in Uganda, the NNM rate was estimated to be double than the neonatal mortality rate (Nakimuli et al., 2015). Infants with severe complications can also develop long-term illnesses due to neurological and cognitive effects with a possibility of later life complications such as diabetes, cardiovascular disease, and chronic lung disease, as well as other serious disabilities including blindness or vision problems and hearing loss (Wondimu et al., 2021). The majority of neonatal deaths are preventable, and substantial reductions can be achieved through improving maternal and newborn care (WHO, 2023). Severe infections, low birth weight, and birth asphyxia are among the most common causes of NNM reported in health facilities (WHO, 2018).

In South Central Asia and sub-Saharan Africa, neonatal morbidity and mortality remains high despite reduction of post neonatal mortality (Mengesha et al., 2020;Haile et al., 2023). Similarly, in Ethiopia, complications of preterm birth (22%), intrapartum-related events (32%), infections (20%), and congenital abnormalities (12%) were the leading causes of neonatal mortality (Tekola et al., 2021; Asaye et al., 2023).

Review of the Literature

A hospital-based cross-sectional study in Nepal, involving 1000 mother-newborn pairs revealed a NNM rate of 79 per 1,000 live births (Sushma et al., 2021). An observational study in Morocco among 2,676 neonates revealed that, 88.5% (95% CI: 88.3–90.7) of them had NNM (Chafik, et al., 2023). Asystematic review and meta-analysis by (Deressa & Desta, 2023) found a pooled NNM prevalence of 35.51% (95% CI: 20.32–50.70). Quantitative, facility-based cross-sectional study among 403 neonates admitted to NICU were reported that, just about half (196 (48.6%), 95% CI = (43.79%, 53.5%)) were diagnosed as having NNM using the pragmatic and management criteria (Gutema et al., 2022).

A retrospective cross-sectional study at Debre Tabor General Hospital Ethiopia found a prevalence of 32.2% (95% CI: 28–36) (Tassew et al., 2020). While a similar study in North Shewa zone reported 35.3% (95% CI: 31.9–38.6) per 1,000 live births (Goyomsa et al., 2022). In Addis Ababa, a study across four hospitals showed a prevalence of 25.6% (95% CI: 21.0–30.5) (Legamo & Sendo, 2023). In Jimma Zone, Southwest Ethiopia, two different studies have been reported related findings where, a NNM prevalence was 26.7% (95% CI: 21.6–32.5 (Wondimu et al., 2021). In a study at Injibara General Hospital, Amhara Region, reported a magnitude of 23.3% (95% CI: 19.1–27.7) (Gebrehana Belay et al., 2020). A prospective study in South Ethiopia among 2,704 neonates showed a NNM rate of 45.1 per 1,000 live births (95% CI: 37.7–53.8) (Tekelab et al., 2020). Another study in Adare General Hospital and Hawassa University hospitals reported an overall magnitude of 33.4% (95% CI: 29.7–37.1%) among 604 live births (Tekola et al., 2021). Another research carried out in the East Gojjam zone, in Amhara Region, Ethiopia showed that, the prevalence of NNM was found to be 41.3% (95% CI: 37.1%, 45.3%). (Tesfa et al., 2025).

Many quantitative studies also pointed out that, parental sociodemographic factors (advanced maternal age, residence, paternal and maternal education, maternal and paternal occupation) ; Obstetrics and medical-related factors (history of abortion, maternal medical comorbidity); Fetal-related factors (time of breast feeding initiation, APGAR score) and health system related factors were collectively a significant risk factor for adverse neonatal outcomes, including NNM (Martinelli et al., 2019; Tesfa et al., 2025; Sintayehu et al., 2022; Goyomsa et al., 2022; Endawkie et al., 2023; Fikrie et al., 2022; Asaye et al., 2023;Ahmed & Salih, 2019; Gebrehana Belay et al., 2020).

Although various studies quantify the magnitude of NNM and identify corresponding factors, regional variation and low implementation practice of health policy including differences in socio economic development can create room for regionally specific clinical audit in Puntland, Somalia to determine and identify modifiable risk factors and inform targeted neonatal care improvement.

Methods and Materials

Study Setting and Period

This study was conducted in Garowe City, Puntland, which is located in the northeastern region of Somalia. Garowe is the capital city of the Puntland state and the second largest city of Somalia situated in Nugal with an estimated population of 40,000 to 70.000 (UN habitat 2005). Garowe city has one public governmental hospital, and two private hospitals. These hospitals had major clinical departments like surgery, pediatrics, obstetrics and gynecology, and others. Around 400–550 neonates are born in the selected health institutions per month. The study was conducted from June 1 to 29, 2024.

Study Design and Population

An institutional based cross-sectional study design was conducted. All live-born neonates born in the selected facilities and their mothers or guardians were included in the study. However, neonates who were discharged against medical advice or died were excluded.

Sample Size Determination and Sampling Technique

The sample size was determined using a single proportion formula: n = (Z a/2)² P (1 − P)/W² where n = total sample size, Z = confidence interval (with 95% level of certainty), w = margin of error (5%), and p = proportion of live born neonates surviving from life-threatening conditions or using the magnitude of NNM from the previous study North Shewa zone public hospital Ethiopia was 35.3% (Goyomsa et al., 2022). Thus, n = (1.96)² × 0.353 × 0.647/ (0.05)² = 351. By adding 10% of the nonresponse rate, the final sample size is 386.

All three hospitals in the city were included. The calculated sample size was proportionally allocated for each hospital based on information from the hospitals, an average number of neonates delivered at selected health institutions per month were around 550 and the sampling interval was determined with K = N/n; K average = 550 / 386 = 1.42 = 2; the first neonate was selected by lottery method and then, the data were collected using a systematic sampling technique for every value of two (Figure 1).

Figure 1.

Schematic presentation of sampling procedure to assess neonatal near miss and its associated factors among neonates delivered in Garowe city health facility, Puntland, Somalia, 2024.

Data Collection Procedures

Data were collected by trained interviewer's face-to-face (seven trained BSc nurses) with the supervision of three pediatricians using a structured questionnaire and review medical chart at discharge. The questionnaire was first prepared in English and translated to the local language (Af-Somali) and was translated back to English to check its consistency. The questionnaire contains information on socio-demographic characteristics, obstetric factors, institutional health related factors and fetal health related problems.

Operational Definition

NNM refers to a newborn who experiences a severe, life-threatening complication during the neonatal period but survives the event with the following clear criteria (Rocha et al., 2023); (Santos et al., 2015); Pragmatic Criteria refers birth weight < 1750 g, gestational age < 33 weeks 5th-minute APGAR score < 7 at 5 min (Tesfa et al., 2025), (Pileggi-Castro et al., 2014).;Management Criteria refers mechanical ventilation, cardiopulmonary resuscitation, nasal continuous positive airway pressure, parenteral antibiotics, parenteral nutrition, vasoactive drugs, use of phototherapy within 24 h of life (Tesfa et al., 2025); (Gutema et al., 2022); Clinical Criteria encompass observable signs and symptoms indicating severe neonatal complications, these include: Hypothermia (< 36.50 °C), absence of regular breathing, cardiac arrest, respiratory rate > 70 bpm, bradycardia < 80 bpm, jaundice during the first 24 h (Tesfa et al., 2025; Kale et al., 2017).

Data Quality Control

Data collectors and supervisors were trained on the objective of the study, contents of the questionnaires and how to maintain confidentiality and privacy of the study subjects. The questionnaire was pre-tested on 5% (20) for three days of sampled population in Gol-nugal hospitals and checked for any amendments to be made. The overall data collection process was strictly supervised in each step. The questionnaire was translated to the local language and back translated by individuals with good command of both languages.

Data Analysis

The data were first checked for completeness and internal consistency through cross-checking before being coded and double-entered into Epidata version 3.1. After cleaning for inconsistencies, the dataset was exported to STATA version 14 for statistical analysis. Bivariable logistic regression was performed to examine the crude association between NNM and each independent variable; then, variables with a p-value less than 0.25 in the bivariable analysis were considered as candidates for multivariable logistic regression. Multicollinearity among independent variables was assessed using the variance inflation factor (VIF), and potential interaction effects between variables were examined. The overall model fitness was evaluated using the Hosmer–Lemeshow goodness-of-fit test. Multivariable logistic regression was then conducted to control for possible confounders, and the results were presented using adjusted odds ratios (AOR) with corresponding 95% confidence intervals (CI). Finally, statistical significance was declared at a p-value <0.05.

Results

Socio-Demographic and Child Related Characteristics

A total 375 (97%) of the 386 mother-baby dyads invited participated in the study. The mean maternal age was 28.52 (±SD 7.21) years, with the majority being 20–34 years old (245; 65.33%). In terms of educational status, 72 (19.20%) of the mothers were unable to read and write. Fathers’ educational background showed that, 64 (17.98%) were unable to read and write. In terms of maternal occupation, the majority 219 (58.40%) were housewives. A substantial proportion of the participants 317 (84.53%) resided in urban areas. Most mothers 343 (91.47%) accessed the health facility through self-referral. Among those who were referred, the most common reason was prolonged labor 11 (34.38%). With regard to family income, 93 respondents (24.80%) reported earning less than $100 per month (Table 1).

Table 1.

Sociodemographic Characteristics of Mothers of Neonates among Neonates in Garowe City, Puntland, Somalia (n = 375).

Variable	Category	Frequency	Percentage
Maternal age	<20	42	11.20
	20–34	245	65.33
	>=35	88	23.47
Marital status	Married	289	77.07
	Divorced	62	16.53
	Widowed	24	6.40
Mother education	Unable to read and write	72	19.20
	Non-formal education	90	24.00
	Primary	55	14.67
	Secondary	80	21.33
	Collage or above	78	20.80
Father education	Unable to read and write	64	17.98
	Non-formal education	86	24.16
	Primary	66	18.54
	Secondary	51	14.33
	Collage or above	89	25.00
Mother occupation	Housewife	219	58.40
	Merchant	47	12.53
	Daily laborer	33	8.80
	Government/NGO	44	11.73
	Other #	32	8.53
Father occupation	Casual labor	96	25.94
	government/NGO	113	30.21
	Merchant	94	25.13
	student	32	8.56
	Other##	38	10.16
Residence	Rural	58	15.47
Residence	Urban	317	84.53
Maternal referral status	Self-referred	343	91.47
Maternal referral status	Referred	32	8.53
Reason for referal	HDP	8	25.00
	Breach baby	4	12.50
	Obstructed labor	9	28.13
	Prolonged labor	11	34.38
Estimated monthly family income (USD)	<100	93	24.80
	100_500	163	43.47
	>500	119	31.73

NB. HDP, hypertensive disorders of pregnancy; #- Online business, house and event decoration and nomadic ##_ private employee, forex trade and drivers.

Maternal Medical and Obstetrics Conditions

Among 375 mothers included in the study, the majority 288 (76.80%) were multigravida. Regarding parity, 157 (41.87%) had given birth to more than one child. A history of stillbirth was reported by 86 participants (22.93%), while 94 (25.07%) had experienced at least one abortion. Additionally, 88 mothers (23.47%) reported a previous neonatal loss. Concerning birth spacing, 144 (38.40%) had a birth interval of less than 24 months. The majority of mothers 295 (78.67%) reported attending at least one ANC visit. In terms of mode of delivery, 234 (62.40%) had spontaneous vaginal deliveries. A high proportion of participants 222 (59.20%) reported experiencing an infection during pregnancy, of whom 207 (93.24%) received treatment (Table 2).

Table 2.

Maternal Medical and Obstetrics Conditions among Neonates in Garowe City, Puntland, Somalia (n = 375).

Variable	Category	Frequency	Percentage
Gravidity	Primigravida	87	23.20
Gravidity	Multigravida	288	76.80
Parity	Primapara	121	32.27
	Multipara	157	41.87
	Grand-multipara	97	25.87
History of still birth	Yes	86	22.93
History of still birth	No	289	77.07
History of abortion	Yes	94	74.93
History of abortion	No	281	25.07
History of neonatal loss	Yes	88	23.47
History of neonatal loss	No	287	76.53
Birth interval in months	<24	144	38.40
Birth interval in months	≥24	231	61.60
Received antenatal care (ANC)	Yes	295	78.67
Received antenatal care (ANC)	No	80	21.33
Number of ANC visits	<4	120	40.68
Number of ANC visits	≥4	175	59.32
Reason for attending ANC	No ANC service	19	23.75
	Financial problem	16	20.00
	Lack of knowledge	45	56.25
Gestational age of ANC visit	<12	122	40.40
Gestational age of ANC visit	≥12	180	59.60
Was lab examination done for you during ANC of the current pregnancy?	Yes	261	88.47
	No	34	11.53
Place of ANC visit	Health center	71	24.48
Place of ANC visit	Hospital	219	75.52
TT vaccinated	Yes	173	46.13
TT vaccinated	No	202	53.87
Mode of delivery	Cesarean Section	122	32.53
	Instrumental assisted vaginal delivery	19	5.07
	Spontaneous vaginal delivery	234	62.40
Antepartum hemorrhage (APH)	Yes	18	4.80
Antepartum hemorrhage (APH)	No	357	95.20
Type of APH	Placenta abruption	7	38.89
	Placenta previa	9	50.00
	Other###	2	11.11
Hypertensive disorder of pregnancy (HDP)	Yes	69	18.40
Hypertensive disorder of pregnancy (HDP)	No	306	81.60
Type of HDP	Chronic hypertension	13	18.84
	Gestational hypertension	38	55.07
	Preeclampsia	18	26.09
Diabetes Mellitus (DM)	Yes	25	6.67
Diabetes Mellitus (DM)	No	350	93.33
Type of DM	Gestational DM	14	53.85
	Type 1 DM	4	9.09
	Type 2 DM	8	15.38
Anemia	Yes	78	20.80
Anemia	No	297	79.20
Infection	Yes	222	59.20
Infection	No	153	40.80
Took any medication	Yes	207	93.24
Took any medication	No	15	6.76
Malaria	Yes	9	2.40
Malaria	No	366	97.60

NB. ### Cervical lesion, and coagulation disorder.

Neonatal Characteristics

The majority of neonates were vertex presentation (81.60%). Regarding gestational age, the majority (89.07%) were born between 33 and 41 weeks of gestation. At the fifth minute of life, 80.53% of the neonates had an Apgar score of ≥7 (Table 3).

Table 3.

Neonatal Characteristics among Neonates in Garowe City, Puntland, Somalia (n=375).

Variable	Category	Frequency	Percentage
Fetal presentation	Face/brow/compound	7	1.87
	Breech	44	11.73
	Transverse	18	4.80
	Vertex	306	81.60
Time start breast feeding	>1 Hr.	146	38.93
Time start breast feeding	<1Hr (= here or above)	229	61.07
Umbilical care	Yes	369	98.40
Umbilical care	No	6	1.60
Took eye ointment	Yes	368	98.13
Took eye ointment	No	7	1.87
received vitamin K	Yes	369	98.40
received vitamin K	No	6	1.60
Number of fetus	Twin	41	10.93
Number of fetus	Single	334	89.07
Any birth injury	Yes	20	5.33
Any birth injury	No	355	94.67
Type of birth injury	Brachial plexus injury	4	20.00
	Cephalohematoma	14	70.00
	Gubgaleal hematoma	2	10.00
Gestational age at birth (weeks)	<33	27	7.20
	33–41	334	89.07
	> 42	13	3.73
Sex of baby	Male	183	48.80
Sex of baby	Female	192	51.20
5^th minute APGAR score	>=7	302	80.53
5^th minute APGAR score	<7	73	19.47
birth weight (gram)	<25000 g	140	37.33
birth weight (gram)	>= 2500 g	235	62.67
Neonatal complication	Yes	195	52.00
Neonatal complication	No	180	48.00
Type of Neonatal complication	Perinatal asphyxia	45	23.08
	Respiratory distress syndrome	41	21.03
	Hypothermia	16	8.21
	Meconium aspiration syndrome	46	23.59
	Birth injury	20	10.26
	Hypoglycemia	16	8.21
	Congenital anomaly	16	8.21
Vaccination	Yes	173	46.13
Vaccination	No	202	53.87
Admission of neonatal intensive care unit	Yes	150	44:53
Admission of neonatal intensive care unit	No	208	55.47
Congenital anomaly	Yes	16	4.27
Congenital anomaly	No	359	95.73

Neonatal Near Miss Events

Of 375 neonates, 181 (48.27%) had at least one of the pragmatic or management criteria corresponding with a NNM of 482 per 1000 births. The most frequent NNM events were cardiopulmonary resuscitation 74(19.73%) followed by low 5^th minute Apgar score 73(19.47%) and parentral antibiotic uses 60(16.00%). A small proportion of neonates 27 (7.20%) had extream low birth weight, which is less than 1750 grams (Table 4).

Table 4.

NNM Events among Neonates in Garowe City, Puntland, Somalia (n = 375).

Variable	Category	Frequency	Percentage
Birth weight <1750 gram	Yes	27	7.20
Birth weight <1750 gram	No	348	92.80
Apgar score <7 at 5^th minute	Yes	73	19.47
Apgar score <7 at 5^th minute	No	302	80.53
Gestational age <33 week	Yes	27	7.20
Gestational age <33 week	No	348	92.80
Parentral antibiotic	Yes	60	16.00
Parentral antibiotic	No	315	84.00
Use of nasal CPAP	Yes	21	5.60
Use of nasal CPAP	No	354	94.40
Use of phototherapy	Yes	14	3.73
Use of phototherapy	No	361	96.27
Presence of infection	Yes	45	12.00
Presence of infection	No	330	88.00
Use of parenteral nutrition	Yes	12	3.20
Use of parenteral nutrition	No	363	96.80
Respiratory distress	Yes	43	88.53
Respiratory distress	No	332	11.47
Cardiopulmonary resuscitation	Yes	74	19.73
Cardiopulmonary resuscitation	No	302	80.27
Use of vasoactive drugs	Yes	31	8.27
Use of vasoactive drugs	No	344	91.73
Bile stained vomiting	Yes	12	3.20
Bile stained vomiting	No	363	96.80
Feeding problem	Yes	16	4.27
Feeding problem	No	359	95.73
Use anticonvulsants	Yes	36	9.60
Use anticonvulsants	No	339	90.40
Use of steroids to treat hypoglycemia	Yes	16	4.27
Use of steroids to treat hypoglycemia	No	359	95.73
Use of any blood products	Yes	3	0.80
Use of any blood products	No	372	99.20
Any surgery	Yes	5	1.33
Any surgery	No	370	98.67
Any of the criteria	Yes	181	48.27

Factors Associated with Neonatal Near Miss

In bivariable analysis; mother and father occupation, resident area, mother referral status, monthly family income, history of abortion, mode of delivery, hypertensive disorder during pregnancy, anemia, infection, mother referral status, delivered time, time start to breast feeding, admission to NICU, congenital anomaly and vaccination were associated at p-value <0.25 and considered for multivariable analysis to control for potential confounders. In multivariable analysis, maternal occupation, history of abortion, and neonate admission to NICU remained statistically significant at a p-value <0.05 (Table 5).

Table 5.

Factors Associated with NNM among Neonates born in Garowe City, Puntland, Somalia (n = 375) 2024.

Variables	Category	Neonatal near miss (NNM)		COR (95% CI)	AOR (95% CI)	P value
Variables	Category	Yes	No	COR (95% CI)	AOR (95% CI)	P value
Mother occupation	House wife	99(54.70)	120( 61.86)	1	1	1
	Merchant	23(12.71)	24(12.37)	1.16(0.61,2.18)	0.69 (0.28, 1.69)	0.425
	Daily laborer	26(14.36)	7(3.61)	4.50 (1.87, 10.81)	5.72(1.73, 18.89)	0.004
	Government/NGO	19(10.50)	25(12.89)	0.92(0.47, 1.77)	0.56 (0.22, 1.46)	0.241
	Other	14(7.73)	18(9.98)	0.94 (0.44, 1.99)	0.57(0.57, 1.74)	0.328
Father occupation	Casual laborer	59(32.78)	38(19.59)	1	1	1
	Merchant	45(25.00)	49(25.26)	1.33(0.77, 2.32	1.59(0.65, 3.84)	0.094
	Government/NGO	46(25.56)	67(34.54)	2.26(1.29,3.93)	2.14(0.87, 522)	0.301
	Student	10(5.56)	22(11.34)	0.66(0.28, 1.52)	0.43 (0 .13, 1.42)	0.169
	Other	20(11.11)	18(9.28)	1.61 (0.77, 3.38)	1.79 (0.59, 5.36)	0.297
Resident area	Rural	38(20.99)	20(10.31)	2.31 (1.28, 4.14)	1.40 (0.53,3.70)	0.489
Resident area	Urban	143(79.01)	174(89.69)	1	1	1
Mother referral status	Self-referred	155(85.64)	188(96.91)	1	1	1
Mother referral status	Referred	26(14.36)	6(3.09 )	5.25 (2.10, 13.09)	0.96(0.22, 4.14)	0.959
Estimated monthly family income (USD)	> 500	54(29.83)	65(33.51)	0.52(0.30,0.91)	0.50( 0.18, 1.33)	0.168
	100–500	70(38.67)	93(47.94)	0.47 (0.28,0.79)	0.41(0.16,1.00)	0.051
	>100	57(31.49)	36(18.56)	1	1	1
History of abortion	Yes	121(66.85)	160(82.47)	2.33 (1.44,378)	2.75 (1.37,5.53)	0.004
History of abortion	No	60(33.15)	34(17.53)	1	1	1
Final mode of delivery	Cesarean section	72(39.78)	50(25.77)	2.03 (1.30,3.17)	1.27 (0.66,2.46)	0.463
	Instrumental delivery	12(6.63)	7(3.61)	2.42(0.91,6.37)	0.91(0.20, 4.13)	0.906
	Spontaneous vaginal delivery	97(53.59)	137(70.62)	1	1	1
HDP	Yes	135(74.59)	171((88.14)	2.53(1.46,4.38)	1.36 (0.64, 2.89)	0.422
HDP	No	46(25.41)	23(11.86)	1	1	1
Anemia	Yes	50(27.62)	28(14.43)	2.26(1.35,3.79)	1.82 (0.86,3.83)	0.113
Anemia	No	131(72.38 )	166(85.57)	1	1	1
Infection	Yes	128(70.72)	94(48.45)	2.56(1.67,3.93)	0.96(0.81, 1.81)	0.909
Infection	No	53(29.28)	100(51.55)	1	`1	1
Mother referred from other health institution	Yes	21(11.60)	5(2.58)	4.96(1.82,13.45)	0.87 (0.15, 4.94)	0.879
Mother referred from other health institution	No	160(88.40)	189(97.42)	1	1	1
Delivered on duty time	Yes	49(27.07)	29(14.95)	2.11(1.26,3.52)	1.40(0.67,2.90)	0.365
Delivered on duty time	No	132(72.93)	165(85.05)	1	1	1
Time start breast feeding	<1hr	51(28.18)	95(48.97)	0.40(0.26,0.62)	0.64 (0.33, 1.22)	0.181
Time start breast feeding	>1hr	130(71.82)	99(51.03)	1	1	1
Admission of neonate in NICU	Yes	136(75.14)	31(15.98)	15.89(9.53, 26.48)	13.99 (7.36.26.59)	0.000
Admission of neonate in NICU	No	45(24.86)	163(84.02)	1	1	1
Congenital anomaly	Yes	14(7.73)	2(1.03)	8.04 (1.803, 35.92)	4.74 (0.77, 29.04)	0.092
Congenital anomaly	No	167(92.27)	192(98.97)	1	1	1
TT vaccinated	Yes	53(29.28)	120(61.86)	0.25(0.16, 0.39)	0.51(0.27,0.97)	0.040
TT vaccinated	No	128(70.72)	74(38.14)	1	1

Neonates born to mothers who were daily laborers were about six times (AOR = 5.72; 95% CI: 1.73-18.89) more likely to have NNM compared to those born to housewives. Mothers with a history of abortion were nearly three times (AOR = 2.75; 95% CI: 1.37-5.53) more likely to have a neonate with NNM compared to those without such history. Similarly, neonates admitted to NICU were about fourteen times (AOR = 13.99; 95% CI: 7.36-26.59) more likely to have NNM compared to neonates who were not admitted to NICU (Table 5).

Discussion

This study assessed the magnitude of NNM and its associated factors among neonates in Garowe, Puntland, Somalia. The overall NNM rate was found to be 48.2% (95% CI: 43–53%). Factors such as maternal occupation, history of abortion, and admission to the NICU were significantly associated with NNM.

The magnitude of NNM observed in this study is comparable to findings from East Wollega Zone, Ethiopia (48.6%) (Gutema et al., 2022) and Southern Ethiopia (45.1%) (Tekelab et al., 2020). However, it is higher than the reports from Addis Ababa, Ethiopia (25.6%) (Legamo & Sendo, 2023), Harari Region, Ethiopia (31.4%), East Gojjam, Ethiopia (41.3%) (Tesfa et al., 2025), Uganda (34.1%) (Nakimuli et al., 2015), and Northeastern Brazil (22%) (De Lima et al., 2018), yet lower than other findings from Ghana (70%) (Bakari et al., 2019) and Morocco (88.5%) (Chafik, et al., 2023). These differences may be due to variations in maternal healthcare services access, quality of neonatal services, study settings, and sociodemographic factors.

In this study, maternal occupation was significantly associated with NNM; neonates born to mothers who are daily laborers had 5.7 times higher odds of experiencing NNM compared to those born to unemployed mothers. Similar findings were reported in Dessie Comprehensive Specialized Hospital, Ethiopia (Endawkie et al., 2023) and Hawassa City Governmental Hospitals, Ethiopia (Yeshaneh et al., 2021), where, mothers engaged in labor-intensive or informal jobs faced higher risks. The increased risk could be due to work-related stress, poor nutrition, and limited access to healthcare (Sintayehu et al., 2022).

Moreover, a maternal history of abortion was found to increase the risk of NNM. Neonates born from mothers with abortion history had 2.75 higher odds of developing NNM conditions compared to those without. This aligns with the findings reported from the study conducted in Guji and Borona Zones (Fikrie et al., 2022) and North Shewa Zone (Goyomsa et al., 2022) where, prior abortion raised the risk of NNM. The reason might be due to the direct effect of maternal morbidities such as pain, bleeding, uterine perforation, gastrointestinal and thermoregulatory side effects on the unborn fetus and maternal inability to provide appropriate care for the newborn due to maternal medical conditions (Abebe et al., 2021).

Finally, neonates admitted to NICU had approximately 14 times greater odds of being classified as a NNM compared to those not admitted. This was similar with a study findings from Portugal where, NICU admission reflected severe neonatal illness and higher odds of NNM events (Da Costa et al., 2022). Highlighting that, admission to NICU is a robust indicator of severe neonatal illness and potentially leading to NNM events (Carvalho et al., 2020).

Implication for Practice

This study suggests useful insights for clinical care, health care management, and further research in the areas of NNM management and neonatal care specialization. Clinically, healthcare workers can identify prognostic factors associated with NNM among neonates and implement appropriate interventions; specifically, nurses become better equipped to recognize early warning signs and prioritize high risk neonates for immediate care. They can also create structured follow up plans and educate mothers on danger signs even after discharge. Moreover, nurses can adopt evidence based practices and refine care plan based on real outcomes. Healthcare managers can use this evidence to assess and improve the quality of care provided by clinicians. The finding can provide strong evidence for improving referral pathways, upgrading neonatal units, training program for nurses/midwives and proper resource allocation to the highest risk areas. Researchers can also be encouraged to conduct further advanced research on this critical issue to develop effective strategies to reduce neonatal mortality and mortality in all health care system of the country.

In general, this study finding can improve the quality, readiness and responsiveness of neonatal care. It helps identify gaps before they result in death and support evidence based strategies to strengthen neonatal survival.

Strengths and Limitations of the Study

The strength of this study is the combined use of face-to-face interviews and medical record reviews, which enabled comprehensive collection of sociodemographic and obstetric data. However, the cross-sectional design limits the ability to establish causal relationships, as it does not clarify whether the identified factors occurred before or contributed to the NNM events. Follow up was limited to discharge from respective facilities or 28 days of duration, whichever occurred first. Consequently, neonates who were discharged but subsequently develop NNM within the neonatal period may not have been captured unless they were re-admitted to the participating facility.

Conclusions

Nearly half of neonates born in Garowe experienced a NNM event. Maternal occupation, history of abortion, and admission to NICU were key factors associated with the increased occurrence of NNM. Implementing effective strategies using targeted therapeutic interventions to have healthy neonatal outcomes by enhancing continuum of maternal health care services in all level of health care system is vital. Moreover, attention to mothers having history of abortion in line with her occupation is warranted; additionally, all neonates admitted to NICU need to get great emphasis so as to minimize possible NNM.

Footnotes

Acknowledgments

We thank Haramaya University for its technical support. We would also like to extend our gratitude to the head and staff working at Puntland Garowe City health care institution, data collectors, and supervisors for their collaboration.

ORCID iD

Fentahun Meseret

Ethical Approval and Consent to Participate

Before starting the data collection process, the study protocol was approved by Haramaya University, College of Health and Medical Sciences, Institution Health Research Ethical Review Committee (Ref. No. IHRERC/015/2024). Moreover, an official letter of cooperation was submitted to the selected health institution's head to obtain cooperation and consent to facilitate the study. Voluntary, informed, written, and signed consent was obtained from all study participants/subjects and/or their legal guardians. This study had no danger or negative consequences for the study participants. Confidentiality of information was assured by excluding names and identifiers in the questionnaire. Access to collected information was limited to the principal investigator, and confidentiality was preserved throughout the time. This study was conducted according to the guidelines and regulations of the Declaration of Helsinki.

Author Contribution Statements

MMH made a substantial contribution from conception to data acquisition. All the authors made significant contributions to the study design, analysis, and interpretation of the findings. FM drafted the manuscript. All authors have carefully revised the manuscript. All authors have read and approved the final manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

All relevant data will be available from the corresponding author upon reasonable request.

References

Abebe

Wasie

Yeshaneh

Shitu

Mose

Adane

Workye

Gashu

(2021). Determinant factors of neonatal near miss among neonates in Gurage zone hospitals, Ethiopia: A case-control study. Pediatric Health, Medicine and Therapeutics, 12, 129–139. https://doi.org/10.2147/phmt.s302363

Ahmed

A. E.

Salih

O. A.

(2019). Determinants of the early initiation of breastfeeding in the Kingdom of Saudi Arabia. International Breastfeeding Journal, 14(1). https://doi.org/10.1186/s13006-019-0207-z

Asaye

M. M.

Gelaye

K. A.

Matebe

Y. H.

Lindgren

Erlandsson

(2023). Effect of fetal malposition, primiparous, and premature rupture of membrane on neonatal near miss mediated by grade three meconium-stained amniotic fluids and duration of the active first stage of labor: Mediation analysis. PLoS ONE, 18(5), e0285280. https://doi.org/10.1371/journal.pone.0285280

Bakari

Bell

A. J.

Oppong

S. A.

Bockarie

Wobil

Plange-Rhule

Goka

B. Q.

Engmann

C. M.

Adanu

R. M.

Moyer

C. A.

(2019). Neonatal near-misses in Ghana: A prospective, observational, multi-center study. BMC Pediatrics, 19(1). https://doi.org/10.1186/s12887-019-1883-y

Bugelli

Borgès Da Silva

Dowbor

Sicotte

(2021). The determinants of infant mortality in Brazil, 2010–2020: A scoping review. International Journal of Environmental Research and Public Health, 18(12), 6464. https://doi.org/10.3390/ijerph18126464

Carvalho

O. M. C.

Viana Junior

A. B.

Augusto

M. C. C.

Xavier

A. T. O.

Gouveia

A. P. M.

Lopes

F. N. B.

Carvalho

F. H. C.

(2020). Factors associated with neonatal near miss and death in public referral maternity hospitals. Revista Brasileira de Saude Materno Infantil, 20(3), 839–850. https://doi.org/10.1590/1806-93042020000300010

Chafik

Aslaou

Barich

Laamiri

F. Z.

Barkat

(2023). Factors associated with neonatal near miss: Case of the university hospital center IbnSina of Rabat Morocco 2021. Journal of Neonatal-Perinatal Medicine, 16(1), 105–110. https://doi.org/10.3233/NPM-221167

Da Costa

B. F. C.

Carneiro

B. D.

Ramalho

Freitas

(2022). Characterization of innovation to fight child mortality: A systematic scoping review. International Journal of Public Health, 67, 1604815. https://doi.org/10.3389/ijph.2022.1604815

De Lima

T. H. B.

Katz

Kassar

S. B.

Amorim

M. M.

(2018). Neonatal near miss determinants at a maternity hospital for high-risk pregnancy in Northeastern Brazil: A prospective study. BMC Pregnancy and Childbirth, 18(1), 18–401. https://doi.org/10.1186/s12884-018-2020-x

10.

Deressa

A. T.

Desta

M. S.

(2023). Prevalence and determinants of neonatal near miss in Ethiopia: A systematic review and meta-analysis. PLoS ONE, 18(2), e0278741. https://doi.org/10.1371/journal.pone.0278741

11.

Endawkie

Cherie

Mebratu

Arefaynie

Melake

Adamu

Fentaw

Molla

Tadese

Anbeseaw

Negash

W. D.

Asmamaw

D. B.

(2023). Determinants of neonatal near miss among neonates admitted in Dessie comprehensive and specialized hospitals northeast Ethiopia: A case – control study. Global Pediatrics, 6, 100087. https://doi.org/10.1016/j.gpeds.2023.100087

12.

Fikrie

Amaje

Bonkiye

A. J.

Golicha Wako

Aliyo

Utura

Sirage

Loka

(2022). Determinants of neonatal near misses among neonates admitted to Guji and Borena zones selected public hospitals, southern Ethiopia, 2021: A facility based unmatched case control study design. PLOS Global Public Health, 2(1), e0000168. https://doi.org/10.1371/journal.pgph.0000168

13.

Gebrehana Belay

Limenih

S. K.

Wassie

T. H.

Ambie

B . (2020). Neonatal near miss and its associated factors at Injibara general hospital, Awi zone, Northwest Ethiopia, 2019. Exploratory Research and Hypothesis in Medicine, 000(000), 1–8. https://doi.org/10.14218/erhm.2020.00011

14.

Goyomsa

G. G.

Deriba

B. S.

Wadejo

M. M.

Debela

S. A.

Amhare

A. F.

(2022). Magnitude of NNM and associated factors among newborns delivered at the North Shewa zone public health hospital, central Ethiopia: A multi-level analysis. Frontiers in Public Health, 10, 979636. https://doi.org/10.3389/fpubh.2022.979636

15.

Gutema

E. A.

Getachew Erena

Kasaye

H. K

(2022). Neonatal near miss and associated factors among neonates admitted to neonatal intensive care unit of hospitals in East Wollega, Western Ethiopia, 2019. SAGE Open Medicine, 10(2), 2050–3121. https://doi.org/10.1177/20503121221107463

16.

Haile

T. G.

Gebregziabher

Gebremeskel

G. G.

Mebrahtom

Aberhe

Hailay

Zereabruk

Gebrewahd

G. T.

Getachew

(2023). Prevalence of neonatal near miss in Africa: A systematic review and meta-analysis. International Health, 15(5), 480–489. https://doi.org/10.1093/inthealth/ihad034

17.

Kale

P. L.

de Mello Jorge

M. H. P.

Laurenti

Fonseca

S. C.

da Silva

K. S.

(2017). Pragmatic criteria of the definition of neonatal near miss: A comparative study. Revista de Saude Publica, 51, 111. https://doi.org/10.11606/S1518-8787.2017051006587

18.

Lawn

J. E.

Blencowe

Darmstadt

G. L.

Bhutta

Z. A.

(2013). Beyond newborn survival: The world you are born into determines your risk of disability-free survival. Pediatric Research, 74(1), 1–3. https://doi.org/10.1038/pr.2013.202

19.

Legamo

B. D.

Sendo

E. G.

(2023). A study of neonatal near-misses and the contributing factors among neonates born in public hospitals in Addis Ababa, Ethiopia: A retrospective cross-sectional. Iranian Journal of Neonatology, 14(1), 26–33. https://doi.org/10.22038/IJN.2023.62536.2195

20.

Martinelli

K. G.

da Gama

S. G. N

., do Vale de Almeida

A. H.

Pacheco

V. E.

dos Santos Neto

E. T.

(2019). Advanced maternal age and factors associated with neonatal near miss in nulliparous and multiparous women. Cadernos de Saude Publica, 35(12), e00222218. https://doi.org/10.1590/0102-311X00222218

21.

Mengesha

H. G.

Sahle

B. W.

(2017). Cause of neonatal deaths in Northern Ethiopia: A prospective cohort study. BMC public Health, 17(1), 62. https://doi.org/10.1186/s12889-016-3979-8

22.

Mengesha

H. G.

Vatanparast

Feng

Petrucka

(2020). Modeling the predictors of stunting in Ethiopia: Analysis of 2016 Ethiopian demographic health survey data (EDHS). BMC nutrition, 6(1), 52. https://doi.org/10.1186/s40795-020-00378-z

23.

Nakimuli

Mbalinda

S. N.

Nabirye

R. C.

Kakaire

Nakubulwa

Osinde

M. O.

Kakande

Kaye

D. K.

(2015). Still births, neonatal deaths and neonatal near miss cases attributable to severe obstetric complications: A prospective cohort study in two referral hospitals in Uganda. BMC Pediatrics, 15(1), 44. https://doi.org/10.1186/s12887-015-0362-3

24.

Pileggi-Castro

Camelo

J. S.

Perdoná

G. C.

Mussi-Pinhata

M. M.

Cecatti

J. G.

Mori

Morisaki

Yunis

Vogel

J. P.

Tunçalp

Ö.

Souza

J. P.

WHO Multicountry Survey on Maternal (2014). Development of criteria for identifying neonatal near-miss cases: analysis of two WHO multicountry cross-sectional studies. In BJOG: An International Journal of Obstetrics & Gynaecology (Vol. 121). https://doi.org/10.1111/1471-0528.12637 .

25.

Rocha

N. M.

Kale

P. L.

Fonseca

S. C.

Brito

dos S. (2023). Neonatal near miss and mortality and associated factors: Cohort study of births in the city of Rio de Janeiro, RJ, Brazil. Revista Paulista de Pediatria, 41, e2021302. https://doi.org/10.1590/1984-0462/2023/41/2021302

26.

Santos

J. P.

Cecatti

J. G.

Serruya

S. J.

Almeida

P. V.

Duran

de Mucio

Pileggi-Castro

Jenik

da Silva

A. M.

Martinez

F. E.

de Almeida

Leme

Camelo

J. H.

Suriel

J. S.

Calil

Marba

Coimbra

S. T. M.

Lamy

T. R. S.

Lopez

Z. C.

Olivera

J. M.

de Leon

M. V.

, R. G. P. (2015). Neonatal near miss: The need for a standard definition and appropriate criteria and the rationale for a prospective surveillance system. Clinics, 70(12), 820–826. https://doi.org/10.6061/clinics/2015(12)10

27.

Sintayehu

Abera

Sema

Belay

Guta

Amsalu

Dejene

Kassie

Mulatu

Tiruye

(2022). Factors associated with neonatal near miss among neonates admitted to public hospitals in dire dawa administration, eastern Ethiopia: A case-control study. PLoS ONE, 17(8), e0273665. https://doi.org/10.1371/journal.pone.0273665

28.

Sushma

Norhayati

M. N.

Nik Hazlina

N. H.

(2021). Prevalence of neonatal near miss and associated factors in Nepal: A cross-sectional study. BMC Pregnancy and Childbirth, 21(1), 422. https://doi.org/10.1186/s12884-021-03894-3

29.

Tassew

H. A.

Kassie

F. Y.

Mihret

M. S

. (2020). Neonatal near miss and its predictors among neonates delivered at Debretabor general hospital, Northern Ethiopia; A retrospective analysis. International Journal of Pediatrics (United Kingdom), 2020, 1–8 https://doi.org/10.1155/2020/1092479

30.

Tekelab

Chojenta

Smith

Loxton

(2020). Incidence and determinants of neonatal near miss in south Ethiopia: A prospective cohort study. BMC Pregnancy and Childbirth, 20(1), 354. https://doi.org/10.1186/s12884-020-03049-w

31.

Tekola

A. F.

Baye

Amaje

Tefera

. (2021). Neonatal near misses and associated factors among mother’s who give a live neonate at Hawassa city governmental hospitals, 2019: A facility based cross-sectional study design. BMC Pregnancy and Childbirth, 21(1), 125. https://doi.org/10.1186/s12884-021-03601-2

32.

Tesfa

Akalu

T. Y.

Aynalem

B. Y.

(2025). Neonatal near miss and associated factors among neonates delivered at East Gojjam zone public health hospitals, Northwest Ethiopia. Scientific Reports, 15(1), 1–11. https://doi.org/10.1038/s41598-025-87613-4

33.

Wardlaw

You

Hug

Amouzou

Newby

(2014). UNICEF Report: Enormous progress in child survival but greater focus on newborns urgently needed. Reproductive Health, 11(1), 82. https://doi.org/10.1186/1742-4755-11-82

34.

WHO. (2018). Survive and thrive: transforming care for every small and sick newborn: key findings. In Survive and thrive: transforming care for every small and sick newborn: key findings.

35.

WHO. (2023). Newborns: Improving Survival and Well-being. In Geneva: World Health Organization (Vol. 11, Issue 1). Available online: https://www.who.int/news-room/fact-sheets/detail/newborns-reducing-mortality (Accessed 25 August 2025).

36.

Wondimu

Balcha

Bacha

Habte

(2021). The magnitude of neonatal near miss and associated factors among live births in public hospitals of Jimma zone, Southwest Ethiopia, 2020: A facility-based cross-sectional study. PLoS ONE, 16(5), e0251609. https://doi.org/10.1371/journal.pone.0251609

37.

Yeshaneh

Kassa

Z. Y.

Adane

Fikadu

Wassie

S. T.

Alemu

B. W.

Tadese

Shitu

Abebe

(2021). The determinants of 5th minute low Apgar score among newborns who delivered at public hospitals in Hawassa City, South Ethiopia. BMC Pediatrics, 21(1). https://doi.org/10.1186/s12887-021-02745-6