Mortality and associated factors among neonates admitted to the neonatal intensive care unit at a large urban hospital in southern Zambia

Abstract

Neonatal mortality is a significant contributor to under-five deaths in sub-Saharan Africa. Despite progress, evidence on survival dynamics and clinical determinants among hospitalized neonates in Zambia remains limited, particularly in resource-constrained tertiary settings. To determine the incidence of neonatal mortality and identify independent clinical predictors of death among neonates admitted to a tertiary neonatal intensive care unit (NICU) in southern Zambia. This retrospective cohort study analyzed 690 neonates admitted to Livingstone University Teaching Hospital between May 2025 and January 2026. Survival probabilities were estimated using Kaplan–Meier methods over 5215 neonate-days, and independent predictors were identified via Cox proportional hazards regression. The mortality proportion was 13.0% (95% CI 10.6–15.8), with an incidence rate of 17.3 per 1000 neonate-days. Most deaths occurred within the first 14 days of admission, primarily driven by neonatal sepsis (32.2%) and birth asphyxia (26.7%). In multivariable analysis, CPAP requirement was an independent predictor of mortality (aHR = 2.75; 95% CI 1.22–6.24), reflecting illness severity. Conversely, increased gestational age (aHR = 0.85; 95% CI 0.79–0.91) and higher 5-min Apgar scores (aHR = 0.85; 95% CI 0.75–0.96) significantly improved survival. Neonatal mortality in this setting is high and driven by preventable conditions, with a critical period of risk during the first two weeks of hospitalization. The mortality rate exceeds expected standards for tertiary care in similar settings, highlighting gaps in early stabilization and infection control. Strengthening perinatal respiratory support and timely sepsis management is critical to reducing facility-based neonatal deaths in line with national and global targets.