Factors associated with post-neonatal mortality in Ethiopia: Using the 2019 Ethiopia mini demographic and health survey.

BACKGROUND: Post-neonatal mortality is the number of deaths of infants aged 28 days through 11 months and is expressed as post-neonatal deaths per 1000 live births per year. This study aimed to identify the factors that influence post-neonatal death using the 2019 Ethiopia mini demographic and health survey (EMDHS2019).
METHODS: The study included 2126 post neonates born from mothers who had been interviewed about births in the five years before the survey. The survey gathering period was carried out from March 21, 2019, to June 28, 2019. The data were first analyzed with a chi-square test of association, and then relevant factors were evaluated with binary logistic regression models and the results were interpreted using adjusted odds ratio (AOR) and confidence interval(CI) of parameters.
RESULTS: The prevalence of post neonatal death was 16% (95% CI: 15.46, 17.78). The study also showed that not vaccinated post-neonates (AOR = 2.325, 95% CI: 1.784, 3.029), mothers who were not receiving any tetanus injection (AOR = 2.891, 95% CI: 2.254, 3.708), mothers age group 15-24(AOR = 1.836, 95% CI: 1.168, 2.886), Afar (AOR = 2.868, 95% CI: 1.264, 6.506), Somali(AOR = 2.273, 95% CI: 1.029, 5.020), Southern Nations, Nationalities, and People's Region(SNNP) (AOR = 2.619, 95% CI: 1.096, 6.257), 2-4 birth orders (AOR = 1.936, 95% CI: 1.225, 3.060), not attend antenatal care(ANC) visit (AOR = 6.491, 95% CI: 3.928, 10.726), and preceding birth interval less than 24 months (AOR = 1.755, 95% CI: 1.363,2.261) statistically associated with a higher risk of post neonatal death. Although not given anything other than breast milk (AOR = 0.604, 95% CI 0.462, 0.789), urban residents (AOR = 0.545, 95% CI: 0.338, 0.877), single births (AOR = 0.150, 95% CI: 0.096, 0.234), less than 3 children in a family (AOR = 0.665, 95% CI 0.470, 0.939) and the head of the male household (AOR = 0.442, 95% CI: 0.270, 0.724) were statistically associated with a lower risk of post-neonatal mortality.
CONCLUSIONS: It is highly suggested that maternal and child health care services (including antenatal care visits, postnatal care visits, and immunization) be strengthened and monitored during the early stages of infancy. Mothers from Somali, Afar, and SNNP regions, as well as multiple births, rural residents, and those giving birth to a child with a birth gap of fewer than 24 months, demand special care.

Background

The useful and inexpensive indicator of population health is infant mortality. Infant mortality represents not only the health of the newborn but also the general well-being of society [1]. Post-neonatal mortality is the number of deaths of infants aged 28 days through 11 months and is expressed as post-neonatal deaths per 1000 live births in a year [2]. The prevalence of negative social, economic, and environmental conditions throughout the first year of life is reflected in the high postnatal mortality rate [3]. Infants’ immune systems are substantially weaker than those of adults, making them much more sensitive to environmental and social problems. Furthermore, they are unable to care for themselves and must rely on others. As a result, children are usually the group that suffers the most from bad living conditions [4].

The infant mortality rate is very high in less developed countries as compared to developed countries [5, 6]. Children are more likely to die in their first month of life (neonatal), with an average global rate of 17 deaths per 1,000 live births in 2020, down from 37 deaths per 1,000 in 1990. In 2020, the risk of dying after the first month and before reaching the age of one (post-neonatal) was predicted to be 11 deaths per 1,000, while the risk of dying after reaching the age of one year and before reaching the age of five years (infant) was estimated to be 9 deaths per 1,000. Post neonatal deaths only slightly decrease each year in the world [7, 8]. However, some developing countries like Ethiopia are still far behind [9, 10].

The risk of post-neonatal mortality in African countries is 55 per 1000 live births, and this is more than five times higher compared to European countries where the rate is 10 per 1000 live birth [11, 12]. In Ethiopia, one in every 17 children dies before their first birthday [13]. The Ethiopian Demographic and Health Survey (EDHS), which was conducted in 2000, 2005, and 2011, revealed a significant decrease in newborn mortality [14]. The study carried out in different parts of the world [6, 15–20] revealed that the combined effect of birth order, the preceding birth interval, sex of the child, the maternal age at birth, the working status, parental education, the breastfeeding status, Mother’s age, household wealth, religion, family size, were the important determinants associated with the risk of child mortality. These studies contributed to our understanding of many aspects of determinants of infant mortality in the world specifically, in Ethiopia. However, as far as our knowledge there is no study done on the post-neonatal mortality rate in Ethiopia using the binary logistic regression model. Furthermore, the previous study in Ethiopia was limited to small-scale survey data or focused more on descriptive statistical analyzes. Therefore, the present study focuses on investigating the factors associated with post-neonatal mortality in Ethiopia using the 2019 Ethiopia mini demographic and health survey (EMDHS2019).

Methods

Study area and data source

In the EMDHS, a community-based cross-sectional study was carried out from March 21, 2019, to June 28, 2019. Nine regional states (Afar, Tigray, Amhara, Oromia, Somali, Southern Nations, Nationalities, and People’s Region (SNNPR), Benishangul Gumuz, Gambella, and Harari) and two city administrations (Addis Ababa and Dire Dawa) are found in the country.

The sampling frame used for the 2019 EMDHS is a frame of all census enumeration areas created for the 2019 Ethiopian population and housing census conducted by the Central Statistical Agency (CSA). The survey used a two-stage stratified sampling technique. Each region was stratified into urban and rural areas, yielding 21 sampling strata. Samples of enumeration areas (EA) were selected independently in each stratum in two stages. A total of 305 EAs (212 in rural areas and 93 in urban areas) were chosen in the first stage, with probability proportional to EA size and independent selection in each sampling stratum. A household listing operation was carried out for all selected EAs. The generated list of households was used as a sampling frame for the second stage’s selection of households. In the second step of the selection process, a specific number of 30 households in each group were chosen with an equal likelihood of systematic selection. A detailed methodology has been presented in the 2019 EMDHS final report [21]. In this study, a total weighted sample of 2126 post-neonates from mothers who were interviewed about births in the preceding 5 years before the survey was included in this analysis for this study Fig 1.

Fig 1

The way of selecting a sample in the study.

Inclusion and exclusion criteria

In the study, infants with complete data between the ages of 28 days and 11 months were included. Children older than 1 year and less than 28 days are not included in this study. Additionally, our analysis excludes post-neonates whose events (alive or dead) were missing (Fig 1).

Variables of the study

Dependent variables. The outcome variable of this study was post-neonatal death in months. Post-neonatal mortality is the number of deaths of infants aged 28 days through 11 months and is expressed as post-neonatal deaths per 1000 live births in a year. The outcome variable is coded as (0 = death and 1 = alive).

Independent variables. The Expected explanatory variables that were included in this study are socioeconomic, demographic, health, and environmental-related factors (Table 1).

Table 1

Coding and description of explanatory variables.

No	Variable	Description	Code
1	Region	Region of the household	1 = Tigy
			2 = Afar
			3 = Amhara
			4 = Oromia
			5 = Somali
			6 = Benishangul-Gumuz
			7 = SNNP
			8 = Gambela
			9 = Harari
			10 = Addis Abeba
			11 = Dire Dawa
2	Place of residence	Type of place of residence	1 = Urban, 2 = Rural
3	Source of water	Type of source for drinking water	0 = protected,1 = unprotected
4	Toilet facility	Types of toilet facility	0 = no use,1 = use toilet facility
5	Mother’s Education	Mother’s years of education	0 = No education 1 = Primary
			2 = secondary 3 = Higher and above
6	Place of delivery	Place of delivery	0 = Home
			1 = Health Sector
7	Number of ANC visit	Number of ANC visit	0 = No ANC visit
			1 = 1–4
			2 = greater than 4
8	Tetanus Injection	Tetanus Injection during pregnancy	0 = No
			1 = Yes
9	Child Vaccinated	Child ever Vaccinated	0 = No
			1 = Yes
10	Wealth index	Wealth index of household	0 = Poor
			1 = Medium 2 = Rich
11	Sex	Sex of child	1 = Male,2 = Female
12	Birth order	Birth order of child	0 = first order
			1 = 2–4
			2 = greater than 4
13	Marital status	Marital status of the mother	1 = Married
			2 = Others
14	Age at first birth	Mothers age at first birth	0 = less than 16
			1 = 17–32
			2 = 33–49
The current	The current age of the mother	The current age of the mother	0 = 15–24
			1 = 25–34
			2 = 35–49
16	Duration of breastfeeding	Duration of breastfeeding	0 = Never breastfed
			1 = Still breastfeeding
			2 = Others
17	Type of birth	Number of children that have a mother at a time of single delivery	0 = Single birth
			1 = Multiple birth
18	Preceding birth interval	Preceding birth interval (months)	0 = less than or equal to 24
			1 = greater than 24
19	Household head	Head of the household	1 = male
			2 = female
20	No of children	Number of living children	0 = less than or equal to 3
			1 = greater than 3
21	Given anything other than breast milk	Give a child anything other than breast milk	0 = No
			1 = Yes

Data management and analysis

After permission was granted for a reasonable request that explained the purpose of our study, the data were retrieved from the MEASURE DHS program’s official database (https://www.dhsprogram.com/data). The data from the 2019 EMDHS are open to all registered users. We extracted the response variable post-neonatal death and potential predictor variables after downloading the data. SPSS version 21 was used to extract our data set. After extracting data, Statistical analysis was performed. To describe the study participants, descriptive statistics such as frequencies, %ages, and charts were used. This study also used a combination of the chi-square test to determine whether the response variable was associated with different cofactors. Moreover, a multivariable binary logistic regression model must correspond to a response variable with two categories (post-neonatal mortality with two categories of yes or no).

A binary logistic regression model was used to determine the factors associated to post neonatal mortality. The outcome of the risk factor was reported in terms of an adjusted rating ratio with a significance level of 5% (95% CI). In the univariate analysis, a significance level of 25% was considered a candidate for the multivariate analysis of data analysis. All variables with p values ≤ 0.05 were considered statistically significant.

For a binary response Yi and a quantitative explanatory variable X, j = 1, 2… M and I = 1, 2… N, let π = P(X) denote the “success probability” when X takes the values X. The problem with the linear model is that the probability model E(Y) is used to approximate a probability value πi = P(Y = 1) within the intervals 0 and 1, while E(Y) Is not constrained. Therefore, we apply the logit transformation where the transformed quantity lies in the interval from minus infinity to positive infinity and is modeled as

β = the coefficient of the ith predictor variable determines the rate of increase or decrease of X On the log of the odds Yi = 1, controlling for the other X’s [22].

Ethical considerations

The study used secondary data analysis of publicly available survey data from the DHS program, and ethical approval and participant consent were not necessary for this study. We requested the DHS program, and permission was granted to download and use the data for this study from http://www.dhsprogram.com. There is no name of individuals or household addresses in the data files. Therefore, ethical approval was not necessary for this study.

Results

Socio-demographic characteristics

A total of 2126 post neonates took part in the study. Post-neonatal deaths occurred in 339 cases (16%). The highest proportions of post-neonatal deaths were found in Somali and Benishagul regional states (2.7%) and (2.1%) respectively. Rural residents had the highest %age of post-neonatal mortality (12.6%). Furthermore, half of those polled are uneducated (58.8%), and 60% of those polled are low-income (poor). More than half of the women (57.8%) did not have access to a safe/protectedly of drinking water and half of those polled used a toilet facility (Table 2).

Table 2

Sociodemographic characteristics of post neonatal mortality (EMDHS2019).

		Child is alive
		No	Yes
Variables	Categories	Frequency (%)	Frequency (%)
Age in 5-year groups	15–24	104(4.9)	507(23.8)
	25–34	144(6.8)	934(43.9)
	35–49	91(4.3)	346(16.3)
Region	Tigray	14(0.7)	112(5.3)
	Afar	35(1.6)	288(13.5)
	Amhara	23(1.1)	140(6.6)
	Oromia	41(1.9)	240(11.3)
	Somali	57(2.7)	242(11.4)
	Benishangul	45(2.1)	154(7.2)
	SNNPR	27(1.3)	220(10.3)
	Gambela	35(1.6)	128(6)
	Harari	29(1.4)	119(5.6)
	Addis Adaba	6(0.3)	36(1.7)
	Dire Dawa	27(1.3)	108(5.1)
Type of place of residence	Urban	72(3.4)	292(13.7)
	Rural	267(12.6)	1495(70.3)
Highest educational level	No education	191(9.0)	1059(49.8)
	Primary	122(5.7)	546(25.7)
	Secondary	17(0.8)	129(6.1)
	Higher	9(0.4)	53(2.5)
Source of drinking water	Protected	218(10.3)	1010(47.5)
	Unprotected	121(5.7)	777(36.5)
Type of toilet facility	No	148(7)	915(43)
	Yes	191(9)	872(41)
Wealth index combined	Poor	193(9.1)	1084(51)
	Middle	45(2.1)	251(11.8)
	Rich	101(4.8)	452(21.3)
	Married	310(14.6)	1670(78.6)
	Others	29(1.4)	117(5.5)
Sex of household head	Male	299(14.1)	1428(67.2)
	Female	40(1.9)	359(16.9)

Obstetric characteristics

Mothers in the first birth order had the lowest rate of post-neonatal death (4%). The proportion of male and female post neonates was (9.2% and 6.8%) respectively. The majority (11%) of post-neonatal deaths were attributed to women who didn’t receive tetanus injections during pregnancy. Furthermore, most mothers (38%) said they only had 1–4 prenatal checks while pregnant. In another regard, the majority of women (60.2%) gave birth at home and the majority of children (46.9%) were breastfed by their mothers. The highest proportion of deaths (12%) occurs in post-neonates who have never been immunized. Furthermore, all covariates are presented in (Table 3).

Table 3

Obstetric characteristics of post neonatal mortality (EMDHS2019).

		Child is alive
		No	Yes
Variables	Categories	Frequency (%)	Frequency (%)
of tetanus injections before birth	No	235(11.1)	784(36.9)
	Yes	104(4.9)	1003(47.2)
Give a child anything other than breast milk	No	247(11.6)	1459(68.6)
	Yes	92(4.3)	328(15.4)
Ever had vaccination	No	256(12)	1019(47.9)
	Yes	83(3.9)	768(36.1)
Place of delivery	Home	197(9.3)	1082(50.9)
	Health Sector	142(6.7)	705(33.2)
Age of mother at first birth	less than 16	111(5.2)	593(27.9)
	17–32	222(10.4)	1187(55.8)
	33–49	6(0.3)	7(0.3)
Birth order number	First-order	86(4)	354(16.7)
	2–4	119(5.6)	790(37.2)
	greater than 4	134(6.3)	643(30.2)
Type of birth	Single birth	295(13.9)	1748(82.2)
	multiple births	44(2.1)	39(1.8)
Sex of child	Male	195(9.2)	937(44.1)
	Female	144(6.8)	850(40)
Number of antenatal visits during pregnancy	No antenatal visits	79(3.7)	572(26.9)
	1–4	69(3.2)	740(34.8)
	greater than 4	191(9)	475(22.3)
Preceding birth interval (months)	< = 24	111(5.2)	388(18.3)
	> 24	228(10.7)	1399(65.8)
Duration of breastfeeding	Never breastfed	146(6.9)	79(3.7)
	Still breastfeeding	10(0.4)	988(46.5)
	Others	193(9.1)	710(33.4)
Number of living children	less than or equal to 3	194(9.1)	907(42.7)
	greater than 3	145(6.8)	880(41.4)

Results of the binary logistic regression model

Binary logistic regression models were fitted utilizing categorical predictor variables that were found to be significant in the bivariate analysis using the enter selection (Likelihood ratio) approach. Table 4 summarizes the findings. Tetanus injection during pregnancy, giving the child anything other than breast milk, child vaccination, age of mother, region, birth order, type of birth, number of ANC visits, preceding birth interval, duration of breastfeeding, number of children, and head of household had statistically significant associations with post-neonatal deaths. When compared to vaccinated post neonates, the odds of post neonatal death were 2.325 times (AOR = 2.325, 95% CI: 1.784, 3.029) higher among those who had never been vaccinated. Mothers who did not receive tetanus injections during pregnancy had a 2.891 (AOR = 2.891, 95% CI: 2.254, 3.708) times higher risk of death after delivery than mothers who received any tetanus treatment during pregnancy. When comparing post neonates who were not given anything other than breast milk to post neonates who were given anything other than breast milk, the odds of post neonatal death were 0.604 times (AOR = 0.604, 95% CI:0.462,0.789) lower. When comparing women aged 15–24 to mothers aged 35–49, the risks of post neonatal death were 1.836 (AOR = 1.836, 95% CI 1.168, 2.886) times greater. When compared to post neonates in Dire Dawa city administrations, post neonates in Afar 2.868 (AOR = 2.868, 95% CI 1.264, 6.506), Somali 2.273 (AOR = 2.273, 95% CI 1.029, 5.020), and SNNP 2.619 (AOR = 2.619, 95% CI 1.096, 6.257) regions were more likely to die. When compared to rural people, the odds of post neonatal death in urban residents were 0.545 (AOR = 0.545, 95% CI 0.338, 0.877). Children born in the 2–4 birth order had 1.936 (AOR = 1.936, 95% CI: 1.225, 3.060) times greater chances of post neonatal mortality than those born in the five and above birth orders. The odds of post-neonatal death among singletons were 0.150 (AOR = 0.150, 95% CI: 0.096, 0.234) times lower as compared to multiple births. Compared to mothers who had five or more ANC visits, the risk of post-neonatal mortality was 6.491 times higher (AOR = 6.491, 95% CI: 3.928, 10.726). Furthermore, the death of post-neonatal children for mothers with 1–4 ANC visits was 2.533 times higher (AOR = 2.533, 95% CI: 1.636, 3.923) than for mothers with five or more ANC visits. Children born within 24 months of the previous birth interval had a 1.755 (AOR = 1.755, 95% CI 1.363–2.261) times greater risk of post-neonatal death than those born within 25 months. Those who never breastfed had a 6.799 (AOR = 6.799, 95% CI: 4.9549, 331) times higher risk of post-neonatal death compared to other post-neonates. In a household with fewer than three children, the odds of post-neonatal death were 0.665 (AOR = 0.665, 95% CI, 0.470, 0.939) times greater than in a family with four or more children. The head of household was also a significant element in this study. The heads had a 0.442(AOR = 0.442, 95% CI: 0.270, 0.724) times lower risk of post-neonatal death than female household heads (Table 4).

Table 4

Logistic regression model for post neonatal death in Ethiopia (EMDHS2019).

Variables(Categories)	B	S.E.	Sig.	Exp(B)	95% C.I.for EXP(B)
					Lower	Upper
Tetanus injection during pregnancy(No)	1.062	.127	.000	2.891	2.254	3.708
Give the child anything other than breast milk(No)	-0.505	0.137	.000	0.604	0.462	0.789
Child vaccinated(No)	0.844	0.135	.000	2.325	1.784	3.029
Age of mother(15–24)	0.608	0.231	.008	1.836	1.168	2.886
Age of mother(25–34)	0.043	0.309	.890	1.044	0.569	1.915
Region(Tigray)	0.472	0.548	.389	1.603	0.548	4.691
Region(Afar)	1.054	0.418	.012	2.868	1.264	6.506
Region(Amhara)	-0.492	0.497	.322	0.611	0.231	1.620
Region(Oromia)	0.274	0.418	.512	1.316	0.579	2.988
Region(Somali)	0.821	0.404	.042	2.273	1.029	5.020
Region(Benishangul)	-0.517	0.443	.243	0.596	0.251	1.420
Region(SNNPR)	0.963	0.444	.030	2.619	1.096	6.257
Region(Gambela)	-0.044	0.463	.924	0.957	0.386	2.371
Region(Harari)	0.559	0.444	.208	1.749	0.733	4.173
Region(Addis Ababa)	0.834	0.677	.218	2.303	0.611	8.685
Residence(Urban)	-0.607	0.243	.013	0.545	0.338	0.877
BORD(First order)	0.065	0.332	.846	1.067	0.557	2.043
BORD(2–4)	0.661	0.234	.005	1.936	1.225	3.060
Type of birth(Single birth)	-1.90	0.229	.001	0.150	0.096	0.234
Number of ANC visits (No)	1.870	0.256	.000	6.491	3.928	10.726
Number of ANC visits (1–4)	0.929	0.223	.000	2.533	1.636	3.923
Preceding birth interval(less than 24 months)	0.563	0.129	.005	1.755	1.363	2.261
Duration of breastfeeding(Never)	1.917	0.162	.000	6.799	4.954	9.331
Duration of breastfeeding (Still feeding)	8.093	46.6	.286	2980.8	0.002	0.103
No of children(less than 3)	-0.409	0.176	.021	0.665	0.470	0.939
Head of household(Male)	-0.817	0.252	.001	0.442	0.270	0.724

Sig = significant (p<0.05), Exp(B) = exponential of B (odds ratio), S.E = standard error and CI = confidence interval.

Assessment of goodness of fit of the model

After fitting the logistic model to categorical data, it is necessary to assess the suitability, adequacy, and utility of the model. To deal with this, we have a couple of options. The most often used approaches include Pearson’s Chi-square, likelihood ratio tests (LRT), and Hosmer and Lemeshow Goodness of Fit tests. Based on the results in Table 5, the null hypothesis that there is no difference between the model with just a constant and the model with independent variables has been rejected. Because the r-square statistic for logistic regression models cannot be obtained precisely, these approximations are used instead. To a maximum of 1, larger pseudo-r-square values imply that the model can explain more of the variation. The statistical values of Cox & Snell (Pseudo R-square = 0.37) and Nagelkerke (Pseudo R-square = 0.641) were reasonable in this investigation, indicating that the model explained part of the variation in Table 6. Table 7 shows that the Hosmer-Lemeshow goodness of fit test does not yield a significant result. As a result, the model fits the data.

Table 5

Omnibus tests of model coefficients.

	Chi-square	Df	Sig.
Step	5.419	1	.002
Block	995.759	26	.000
Model	995.759	26

Table 6

Model summary.

Step	-2 Log-likelihood	Cox & Snell R Square	Nagelkerke R Square
	869.866a	.374	.640

Table 7

Hosmer and Lemeshow test.

Chi-square	Df	Sig.
4.440	8	.815

Discussion

This study aims to identify determinants of post-neonatal death using data from the EMDHS2019. To investigate factors that affect post-neonatal mortality, both descriptive and binary logistic regression models were used. The descriptive statistics showed that the magnitude of post neonatal mortality was 16%. The binary logistic regression model revealed that tetanus injection during pregnancy, giving a child anything other than breast milk, child vaccinated, age of mother, region, birth order, type of birth, number of ANC visits, preceding birth interval, duration of breastfeeding, number of children, and head of household had statistically significant associations with post neonatal deaths.

A major determinant of post-neonatal death was the number of ANC visits. The risk of newborn death is significantly reduced as the frequency of ANC visits increases. This study’s findings are consistent with those of previous studies [23-28]. This outcome could be explained by the fact that ANC visits are required to improve the health of mothers and fetuses by lowering pregnancy complications. Long birth intervals had a lower risk of post-neonatal death than short birth intervals, and the risk of post-neonatal death decreased as the prior birth interval grew. The risk of obstetric complications is higher in mothers with short birth intervals than in mothers with longer birth intervals [29]. In Ethiopia, the order of birth had a huge impact on post-neonatal death. With an increase in the post-neonatal birth order, the probability of post-neonatal mortality increased. As the mother’s child care responsibilities grow, the amount of child care provided is expected to decrease. This finding corroborated previous research findings [30, 31].

Giving a child anything other than breast milk was found to be the cause of post-neonatal mortality. The findings corroborate previous studies [32, 33]. Breastfeeding is a child’s first line of defense against mortality and disease, protecting them from respiratory infections, gastrointestinal illnesses, and other negative health consequences [34, 35]. The female household head was linked to a higher rate of post-neonatal mortality. This finding was consistent with a study from the year before [36-38]. This is because female-headed households are more likely to face food insecurity and are less likely to be properly vaccinated [39]. As a result, they are vulnerable to vaccine-preventable sickness and death. This shows that female-headed families will have difficulty making decisions on post-neonatal health because they will be preoccupied with other domestic and social responsibilities. The probability of post-neonatal death increased with each unit increase in the age of the household head. This could be because as people get older, the likelihood of providing child care decreases.

When compared to mothers who did not receive a tetanus shot during pregnancy, mothers who received a tetanus shot were less likely to lose their babies during the post-neonatal period. The outcome is in line with expectations [40-42]. This could be because tetanus vaccination produces protective antibodies against post-neonatal tetanus. The study found that post neonates born in large families have a much higher risk of post neonatal mortality than those born in small families. As a result, the risk of post-neonatal mortality increases in tandem with the size of the family. Because large households are more likely to share facilities, this is the case. Several studies corroborate our findings [43-45]. Post neonates who were breastfed by their mother had a lower chance of death than those who were never breastfed. This could be explained by the fact that nursing protects babies from infectious disorders since breast milk is high in antibodies and white blood cells. This outcome is consistent with previous findings [24, 26, 46]. The type of birth was found to be a statistically significant predictor of postnatal death. The risk of post-neonatal death was higher in multiple births than in single births. Multiple births have a lower weight competition due to food consumption [47]. This result is also similar to [48]. Vaccinated post-neonates have a decreased risk of death than non-vaccinated post-neonates, which is consistent with earlier research findings [43, 47].

The mother’s age was found to be a significant predictor of post-neonates’ death. Post-neonatal death was higher in the younger mother (early age) than in the older mother. This outcome is consistent with earlier findings [49-51]. Physical and physiological immaturity, as well as a higher likelihood of insufficient weight gain during pregnancy, are plausible explanations for this finding [52]. The findings also revealed that the location of birth was a significant risk factor for post-neonatal mortality. The risk of post neonatal death was greater in rural neonates than in urban neonates. This is because newborns in urban areas have greater access to health care and other key health-related amenities that are required for neonatal survival [29]. These studies also agree with the previous study [42, 53]. Furthermore, statistically, geographical regions were linked to post-neonatal death. Compared to the Dire dawa city administration, mothers from the Somali, Afar, and SNNP regions had a higher incidence of post neonatal death. The implementation of effective health policies varies by location, which could be the cause of this geographical variation. This is similar to prior studies [54-56].

This study finding have important policy implications, especially in determining the program needs for a sustainable decline in post-neonatal mortality rate, and in monitoring public health interventions. It is important to look beyond identifying associated factor with death of post-neonates. Increasing mother’s education and empowerment may help reduce childhood mortality. Reducing motherhood in younger ages and increasing the spacing between births are also necessary to reduce post-neonatal deaths. Some other important contextual factors such as quality and care of health facility, cultural practices, customs, environmental conditions, etc. could not be addressed in this study due to the unavailability of data in the DHS. The authors suggest further studies considering these unobserved factors that are likely to be associated with post-neonatal mortality to better understand the association between family and community level factors and post-neonatal mortality in Ethiopia. Interventions and strategies should be targeted focusing on these characteristics to improve child health outcomes as well as the future betterment of Ethiopia.

Conclusions

The result of this study showed that Tetanus injection during pregnancy, giving a child anything other than breast milk, child vaccination, age of mother, region, birth order, type of birth, number of ANC visits, preceding birth interval, duration of breastfeeding, number of children, and head of household had statistically significant associations with post neonatal mortality. It is highly suggested that maternal and child health care services (including ANC, PNC, and immunization) be strengthened and monitored during the early stages of infancy. Multiple births, rural inhabitants, and giving birth to a kid with a birth gap of less than 24 months, demand special care. We recommend also health institutions made effort to give awareness to mothers about contraceptive use and breastfeeding to reduce post-neonatal mortality.

Policies and programs that aim to address regional differences in post-neonatal mortality must be vigorously developed and implemented. Special attention must be paid to the Afar, Somali, and SNNP regions to achieve this.

(SAV)

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19 May 2022

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5. Review Comments to the Author

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Reviewer #1: Thank you for the opportunity to review the study entitled " Factors associated with Post-Neonatal mortality in Ethiopia: Using 2019 Ethiopia mini demographic and health survey”.

The honorable authors have discussed the infant mortality as a sensitive indicator of population health. The current study is noteworthy owing two facts: 1. Post-neonatal mortality is an essential index for community health in all societies 2. Since some developing countries have not reached their goal for providing required infrastructures, this study could have some information for policymakers to implement at the society level. The introduction part has emphasized the potential advantages of the current study well. The methods and results have comprehensively described the methods and findings. From an overall point of view, binary logistic regression has some limitations, although due to the overall design of study, applying other methods of analysis is not possible. The paper is well written, and the Discussion section has comprehensively described the observed results, although attention to the following issues could improve the quality of the paper:

Comments:

1. The article has lots of punctuation issues (like in abstract section, lines 11,12), which should be corrected in the whole manuscript.

2. As the keywords of the study, the authors should provide more keywords. Also, Binary Logistic Regression is not a good keyword in this regard.

3. The whole instruction part is one paragraph, which might be hard for the reader to follow the clues of the study. The introduction should be divided into two to three paragraphs.

4. The discussion part of the study has described the findings well. However, one of the essential content of this study is its application at the society level. The authors should add two sections at the end of the discussion section. First, they should provide comprehensive data from countries with successful strategies that could effectively control infant mortality. So, these strategies could be used for developing countries. Second, the authors should provide a paragraph for policymakers. This should contain some strategies and concepts for policymakers to be implemented at society level.

5. Providing DOI for references is highly encouraged.

Reviewer #2: Thank you for giving me the opportunity to review this paper. It was a cross-sectional investigation in Ethiopia on factors associated with post-neonatal mortality using 2019 Ethiopia mini demographic and health survey data. It is an important public health issue in less developed regions of the world, and lessons learned from such studies could be valuable for other similar countries. However, there are several major and minor issues regarding this manuscript, and it is not suitable for publication in its current form. The draft needs thorough and careful major revisions to provide a more suitable manuscript.

Major concerns:

General language editing and revisions regarding grammar and syntax are highly recommended by a native speaker or an expert since there are several grammatical errors and typos in the text.

In the abstract section, the authors have mentioned that “The goal of this study was to identify the factors that influence post neonatal death using EMDHS2019.” The EMDHS2019 survey needs to be defined and explained in the methods of the abstract. The methods section in the abstract is vague and needs more details and descriptions.

As mentioned in the methods section of the study, 2126 “post neonates” were included in the final analyses. However, in the methods of the abstract section, it has been mentioned as 2126 “women aged 15 to 49.” Please make them identical and provide more explicit methods. Based on the results, it seems that “women” were studied, not specifically the post neonates.

I wonder why the women were analyzed in this study!! It would be much better to perform analyses based on the number of the post neonates. i.e., of the total 2126 included women, how many births did they have? Then, you could examine how many of the total birth numbers in the included population died during the post-neonatal period. Please revise the methods and the results in this regard to provide better estimates. For example, “n” number of born children were assessed in the included 2126 women, of which “n” percent passed away in the post-neonatal period instead of mentioning 16% of women experienced post-neonatal deaths among their children. In the first paragraph of the discussion section, the authors have also mentioned that “the magnitude of post-neonatal mortality was 16%.” However, it is not an accurate interpretation since women were assessed, not children. All these parts need major revisions.

In figure 1, it has been captured that 5753 women were eligible. Please describe in the methods how these women were selected and what were the inclusion and exclusion criteria.

Regarding the data source, it is mentioned in some parts that EMDHS data were assessed. In the methods section, it has been mentioned that EMDHS was a secondary source of data. This section lacks an explicit and comprehensive description of the main data source and the means of data collection. Please provide more explanations around the data collection process and inclusion and exclusion criteria.

Please provide research ethics related to this study in the methods section. Did consent forms were obtained from the subjects?

In methods, Dependent variables: “The outcome variable of this study was post neonatal death in months. The outcome variable coded as (0=death and 1=alive)”. Please explain death in “how many” months after birth was defined as post-neonatal death in this study. You need to vividly define the post-neonatal death period, for example, deaths from birth to “n” months after birth.

In the statistical analysis section, please specify and name the tests that were utilized. Were they logistic regression analyses? Please mention them clearly in the methods section.

In the binary logistic regression section of the results, in the sentence “When comparing children born with single births to children born with multiple births, the odds of post-neonatal death were.150 (AOR =.150, 95 percent CI: .096, .234) times lower.” What do you mean by “single births and multiple births”? Please define them and make them clear.

Minor issues:

In the first line of the background section, instead of “the most sensitive indicator,” please mention “a useful or important indicator…” as the cited reference 1 also concluded that it is a useful and inexpensive indicator, not necessarily “the most sensitive” one.

Background lines 13,14; please define the age of one and five. Are they “years”? Besides, “infancy” does not apply to the age of five years, which has been written in parentheses. Please reword this sentence to provide a more explicit one for the readers. In the following sentence, “Post neonatal only slightly…,” please mention “post-neonatal deaths.”

In the last sentences of the background section, please mention “our” knowledge instead of my knowledge.

It is redundant to provide the expanded term for EMDHS each time in the manuscript. As you wrote it down once in the background, please write down the abbreviation afterward in the methods and other sections.

In the binary logistic regression section of the results, correct the values such as .545 to 0.545 in the text. Please edit all the values and provide the correct form.

Reviewer #3: This paper aimed to identify the factors that influence postneonatal death using the 2019 Ethiopia mini demographic and health survey. As a developing country in Africa, Ethiopia needs more consideration from health policies to decrease the burden of diseases. In developing countries maternal and neonatal diseases are still imposing a considerable burden. Therefore, considering related studies to investigate the ongoing neonatal and maternal diseases is critical. The study carries out important messages, but to make the paper suitable to be published some issues should be addressed. The comments are as follows.

Major issues:

The paper needs some editing in English fluency and the draft should become more professional. As an example: “However, as far as my knowledge” my determiners should be changed to our, because authors are more than one person. Similar situations can be found in other parts of the draft.

Table 4 has results basically copied from all presented by SPSS software, I suggest just using practical results in this table with the format that is popular with other published papers.

Minor issues:

In the abstract, some abbreviations were used without defining them, which possibly most readers are not familiar with them.

The background part of the abstract can be reduced to two sentences because, except for the aim sentence, the information presented here is not necessary for the abstract part.

Please add the inclusion and exclusion criteria to the methods part.

If in this study all the respondents are mothers, I suggest replacing “respondents” with “mothers” in the manuscript.

The ANC and PNC visits were mentioned in the discussion which is very important. I suggest discussing more the numbers of this study and comparing it with other studies and other similar countries

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Reviewer #2: No

Reviewer #3: No

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30 May 2022

Authors' responses to the comments of the Editors and Reviewers

To begin, I am grateful for your thoughtful review and evaluation of this study, Factors Associated with Post-Neonatal Mortality in Ethiopia: Using the 2019 Ethiopia Mini Demographic and Health Survey. We revised our manuscript in response to the reviewers' comments and suggestions. The following is a point-by-point response to the remarks and suggestions of reviewers and editors.

We trust that we have satisfactorily addressed them and that the manuscript is now ready for publishing.

Response to academic editor suggestions and comments

Comment1: Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

Response1: We appreciate your suggestion. The file names were changed to conform to the style criteria. We should now have no deviations from the style criteria.

Comment2: Please amend your current ethics statement to address the following concerns: Did participants provide their written or verbal informed consent to participate in this study?

Response2: Thank you for this suggestion. The study used secondary data analysis of publicly available survey data from the DHS program, ethical approval, and participant consent were not necessary for this study. We requested the DHS program, and permission was granted to download and use the data for this study from http://www.dhsprogram.com.Therefore, no need for written or verbal informed consent to participate in this study.

Comment3: In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found.

Response3: Thank you for this suggestion. The data in this study were secondary and are available in the public domain at (https://www.dhsprogram.com/data). If you need specific data(sample) used in this study, we will submit.

uploaded minimal data set as a Supporting Information file.

Comment4: There are several grammatical errors and typos in the text.

Response4: Thank you for your important comments. We repeatedly read the whole document and consider all the corrections and the language is edited by professionals.

Response to Reviewers’ comments and suggestions

Dear reviewers, we are contented and appreciate your careful and thorough reading of this manuscript and we would like to say thank you for your thoughtful and constructive comments and suggestions. Based on your comments and suggestions, we carefully corrected the manuscript and addressed every comment one by one. We made rephrasing in some parts of the paragraphs of the manuscript accordingly.

Reviewer #1

Comment1: The article has lots of punctuation issues (like in the abstract section, line 11,12), which should be corrected in the whole manuscript.

Response1: Thank you dear reviewer for your important comments. We repeatedly read the whole document and consider all the corrections.

Comment2: As the keywords of the study, the authors should provide more keywords. Also, Binary Logistic Regression is not a good keyword in this regard.

Response2: Thank you, dear reviewer, for improving our manuscript. In the revised manuscript, we have made changes based on your feedback.

Comment3: The whole instruction part is one paragraph, which might be hard for the reader to follow the clues of the study. The introduction should be divided into two to three paragraphs.

Response3: Thank you for your suggestions. Based on your recommendation we divided it into three paragraphs.

Comment4: The authors should add two sections at the end of the discussion section. First, they should provide comprehensive data from countries with successful strategies that could effectively control infant mortality. So, these strategies could be used in developing countries. Second, the authors should provide a paragraph for policymakers. This should contain some strategies and concepts for policymakers to be implemented at the society level.

Response4: Thank you for your constructive comments. We have incorporated the comments in the revised manuscript at the end of discussion and conclusion parts.

Comment5: Providing DOI for references is highly encouraged.

Response5: Thank you for your important suggestion. We incorporated DOIs of each reference.

Reviewer #2:

Comment1: General language editing and revisions regarding grammar and syntax are highly recommended by a native speaker or an expert since there are several grammatical errors and typos in the text.

Response1: Thank you for your important comments. We repeatedly read the whole document and consider all the corrections and the language is edited by professionals.

Comment2: The methods section in the abstract is vague and needs more details and descriptions

Response2: Thank you dear reviewer for your constructive comments. We accepted your comments and gadetailedail explanation in the revised manuscript.

Comment3: As mentioned in the Methods section of the study, 2126 “post neonates” were included in the final analyses. However, in the methods of the abstract section, it has been mentioned as 2126 “women aged 15 to 49.” Please make them identical and provide more explicit methods.

Response3: We appreciate all of your insightful and critical feedback. It is a critical comment. We went over all of the errors in the manuscript. ETKR (child dataset) with 5753 infants was used. Dear Reviewer! If we were to use the ETIR dataset (women dataset), your suggestion would be the best method to proceed. However, we did not use a women's data set for this study.

Comment4: In figure 1, it has been captured that 5753 women were eligible. Please describe in the methods how these women were selected and what the inclusion and exclusion criteria were?

Response4: Thank you for your comments. First of all, the data was not women, those 5753 data were child datasets. So, we have made changes. We included inclusion and exclusion criteria in the revised manuscript.

Comment5: Please provide more explanations around the data collection process and inclusion and exclusion criteria.

Response5: Thank you for your recommendation. We made a change to the revised manuscript and included the points that you have raised.

Comment6: Please provide research ethics related to this study in the methods section. Did consent forms obtained from the subjects?

Response6: Thank you for your comments. Based on your request, we have included Ethical considerations in the methods section. Since, the study used secondary data analysis of publicly available survey data from the DHS program, ethical approval, and participant consent were not necessary for this study.

Comment7: Please explain death in “how many” months after birth was defined as post-neonatal death in the outcome variable.

Response7: Thank you for your constructive comments. We have put the specified period on the revised document.

Comment8: In the statistical analysis section, please specify and name the tests that were utilized. Were they logistic regression analyses? Please mention them clearly in the methods section

Response8: Thank you for these interesting comments. We described it in detail in the revised manuscript.

Comment9: When comparing children born with single births to children born with multiple births, the odds of post-neonatal death were.150 (AOR =.150, 95 percent CI: .096, .234) times lower.” What do you mean by “single births and multiple births”? Please define them and make them clear.

Response9: Thank you for your comments. We have made changes in the description of independent variables as well as in the result parts.

Comment 10: About Minor issues:

Response 10: Thank you dear reviewer for all your interesting comments and suggestions. We have read the whole document repeatedly and made revisions for all your minor issues.

Reviewer #3:

Comment1: The paper needs some editing in English fluency and the draft should become more professional

Response 1: Thank you dear reviewer for your constructive comments and suggestions. We repeatedly read the whole document and consider all the corrections and the language is edited by professionals.

Comment2: Table 4 has results copied from all presented by SPSS software, I suggest just using practical results in this table with the format that is popular with other published papers.

Response 2: Thank you for your interesting comments. We have changed the format of all tables based on references from different published articles.

Comment3: About minor issues:

Response 3: Thank you for your insightful comments. The issues you identified are critical and have a big impact on the article's quality. We accepted everything and made changes to the updated document.

Sincerely,

On behalf of all authors,

Kenaw Derebe Fentaw

Submitted filename: Response to reviewer.docx

Click here for additional data file.

28 Jun 2022

1 Jul 2022

I attached line by line response for reviewer #3 comments.

Submitted filename: Response to reviewer.docx

Click here for additional data file.

12 Jul 2022

Factors associated with Post-Neonatal mortality in Ethiopia: Using 2019 Ethiopia mini demographic and health survey

PONE-D-22-07946R2

Dear Dr. Fentaw,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Reviewer #3: All comments have been addressed

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Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

**********

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The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: Yes

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Reviewer #3: I read the revised version of the manuscript entitled “Factors associated with Post-Neonatal mortality in Ethiopia: Using 2019 Ethiopia mini demographic and health survey”. I want to thank the authors for their tremendous efforts in revising the drafts. I think all my comments have been addressed, and the paper is in an acceptable format now.

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Reviewer #3: No

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15 Jul 2022

PONE-D-22-07946R2

Factors associated with Post-neonatal mortality in Ethiopia: Using the 2019 Ethiopia mini demographic and health survey

Dear Dr. Fentaw:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

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