Factors associated with neonatal near miss among neonates admitted to public hospitals in dire Dawa administration, Eastern Ethiopia: A case-control study.

INTRODUCTION: The neonatal near-miss cases are subject to factors that are major causes of early neonatal deaths. For every death, more newborns suffer a life-threatening complication. Nearly 98% of neonatal death unduly existed in developing countries. Though there were few prior studies in other regions, they failed in identifying the factors of NNM. Besides, there has been no prior study in the study area. Therefore, this study aimed to assess factors associated with neonatal near-miss.
METHODS: A case-control study was employed on a total of 252 cases and 756 controls using a systematic random sampling technique. Data were collected using pre-tested and interview administered questionnaires adapted from similar studies and medical records from December 2020 -March 2021. Pragmatic and management criteria definition of neonatal near miss were utilized. Epi-Data version 3.1 and SPSS version 23 were used for data entry and analysis respectively. Bivariable and multivariable analyses were done to identify factors associated with a neonatal near-miss by using COR and AOR with a 95% confidence interval. Finally, the statistical significance was declared at a p-value < 0.05.
RESULTS: There were a response rate of 100% for both cases, and controls. Factors that affects neonatal near miss were non-governmental/private employee (AOR, 1.72[95%CI: 1.037, 2.859]), referral in (AOR, 1.51[95%CI: 1.079, 2.108]), multiple birth (AOR, 2.50[95%CI: 1.387, 4.501]), instrumental assisted delivery (AOR, 4.11[95%CI: 1.681, 10.034]), hypertensive during pregnancy (AOR, 3.32[95%CI: 1.987, 5.530]), and male neonates (AOR, 1.71[95%CI: 1.230, 2.373]), paternal education of secondary school (AOR, 0.43[95%CI: 0.210, 0.868]) and college/above (AOR, 0.25[95%CI: 0.109, 0.578]), monthly income (1500-3500 birr) (AOR, 0.29[95%CI: 0.105, 0.809]) and >3500 birr (AOR, 0.34[95%CI: 0.124, 0.906]).
CONCLUSION: Maternal occupation, paternal education, income, referral, multiple births, mode of delivery, hypertension during pregnancy, and sex of the neonate have identified factors with neonatal near-miss. Better to create job opportunities, improving education, and income generation. Counseling on multiple birth and hypertension, and minimizing instrumental delivery should be done at the health facility level.

Introduction

A Neonatal near miss (NNM) case refers to a neonate that presents with a severe life-threatening complication during the neonatal period but survives by chance or treatment [1,2]. The term near-miss in pediatrics and neonatology is mostly used in the context of almost adverse events and potential adverse events in the intensive care unit [3].

Worldwide, about 3.6 million neonates are estimated to die in the fifirst 4 weeks of life every year and the majority continue to die at home, uncounted. Out of an estimated, 7.6 million death in under-five children about two-thirds of mortality occurs in the neonatal period and the highest percentage of death happened on the first day and first month of life [4-7]. Likewise, the low- and middle-income countries carry an excessive risk of death and account for three-quarters of neonatal deaths [7,8]. Nearly 98% of neonatal death unduly existed in developing countries and sub-Saharan African countries hold the highest burden of neonatal near misses and deaths [6].

Three major causes of neonatal deaths (infections, complications of preterm birth, and intrapartum-related neonatal deaths or “birth asphyxia”) account for more than 80% of all neonatal deaths globally [7,9]. However, the most common causes of neonatal deaths are often preventable [9]. While neonatal mortality is a significant problem in developing countries, for every death there are many more newborns who narrowly miss dying and may suffer long-term consequences as a result [2]. Neonatal near misses, known as miracle babies are newborns who survive from a life-threatening condition [2,10,11].

Neonatal mortality declined in all regions but slower than child mortality. The global neonatal mortality rate dropped from 37 [12,13], deaths per 1,000 live births in 1990 to 19 in 2016 [14,15]. However, there exists a marked variation in the reduction of neonatal mortality rate across regions and countries and the highest rate of mortality rate reaches 28 deaths per 1,000 live births [6].

Neonatal near-miss cases occur more often than neonatal deaths and could enable a more comprehensive analysis of risk factors, short-term outcomes, and prognostic factors in neonates born to mothers with severe obstetric complications [1]. Substantial variations in the mortality among neonates with life-threatening conditions at birth were observed suggesting the intra-hospital quality of care issues. The near-miss concept and indicators provided information that could be useful to evaluate the quality of care and set priorities for further assessments and health care improvement for newborn infants [16].

Furthermore, studying factors associated with near misses has paramount importance to measure the quality of health services, as it is associated with adverse birth outcomes. Even though certain studies have been conducted in the country and assessed near-miss cases, as far as the investigators’ knowledge was concerned there were no studies conducted on factors associated with neonatal near-miss among neonates in the Dire Dawa Administration. Since the study will explain factors associated with neonatal near misses, study results serve as an input for the health bureaus, health offices/departments, local NGOs, and other stakeholders working in Dire Dawa administration in planning and implementation of preventive and intervention strategies to improve maternal and neonatal health. Moreover, the study can also be used as a baseline framework for further studies that will be conducted in similar setups.

Methods and materials

Study area and period

The study was conducted in the public hospitals of Dire Dawa administration, Easter Ethiopia, from December 2020 to March 2021. Dire Dawa is found at 515 km to the east of Addis Ababa, the capital city of Ethiopia. It has a projected total population of 506,640; there are 2 public hospitals with 510 expected delivery per month and 15 health centers. These 2 hospitals have both pediatric admission ward and neonatal ICU that are serving for the study area and neighboring areas [17].

Study design and population

A hospital-based case-control study was employed among neonates who were admitted to public hospitals of the Dire Dawa Administration. Selected neonates who were admitted to the public hospital of Dire Dawa administration and available during the data collection period were included in the study. Mothers or caregivers incapable to give information about the newborn and neonates who were not been found with their mothers (caregivers) were excluded from the study.

Selection of cases and controls

Cases (NNM)

Neonates who were admitted to the hospital according to NNM definition, neonates with at least one of the neonatal near miss criteria (with the presence of at least one pragmatic marker and/or management severity criteria) but survived from this condition within the first 28 days were cases [18]. The pragmatic criteria include birth weight <1750gm, an APGAR score <7 at 5th minutes of life and GA < 33 weeks and management severity criteria include: parenteral antibiotic therapy, nasal continuous positive airway pressure (CPAP), any intubation, and phototherapy within 24 hrs. of life, cardiopulmonary resuscitation (CPR), use of vasoactive drugs, anticonvulsants, surfactant, blood products, steroids for the treatment of refractory hypoglycemia, surgery, use of antenatal steroid, use of parenteral nutrition, identification of congenital malformation according to the ICD-10 if considered a near-miss case by another criterion and admission to the NICU [19]. Additionally, data from the record was retrieved to identify the cases and different exposures.

Controls

Neonates who were admitted to the post-natal or neonatal ward and identified by a pediatrician or neonatologist or gynecologist or resident as a healthy babies (have no complication indicated for selection of case) were enrolled as a control. For each near-miss case, three controls within the same day of the near-miss event were selected.

Sample size determination and sampling procedures

The sample size was computed by using sample size determination in an unmatched case-control study in the Epi info7 software Stat Calc. with the assumptions of a 95% level of confidence, power of 80%, the ratio of cases to control 1:3, and percent of controls exposed 6 and percent of cases with exposure 12.7 taken from others similar study (18). Based on the above assumptions the estimated sample size was 229 cases and 687 controls. After considering the non-response of 10%, the final sample size used for this study was 252 cases and 756 controls. Therefore, the sample size for this study was 1008. A Consecutive sample method was employed to take mothers with neonates.

Data collection tools, procedures, and quality control

Data were collected by a pre-tested, structured interviewer-administered questionnaire and standard abstraction checklist, which were developed, from different works of literature [18,20]. The questionnaire was prepared in English and then translated to the local languages (Afan Oromo, Amharic, Af Somali) and back-translated to English to ensure the consistency of the thought of the questions. The questionnaire contains information related to socio-demographic characteristics of parents, health care services, obstetrics-related characteristics of the mothers, and a medical card review of the maternal and newborn condition. Data were collected by 6 midwives who have experience in maternal and neonatal care and non-staffs in the study setting.

To ensure the data quality, the tool was translated into the local languages. Additionally, pre-testing was done on 13 cases and 38 controls during the data collector training and modified based on the findings accordingly. The questionnaires were checked for completeness and consistency. Data collection was supervised by the principal and co-investigators regularly throughout the data collection period. Finally, double data entry was done to minimize errors during data entry.

Operational definition of variables

Neonate: a newborn age period that is birth to 28 days.

Neonatal near miss: defined as the presence of at least one pragmatic marker or management severity criteria [19].

Pragmatic markers criteria: It is the severity of a criterion that is used to classify a neonate as a neonatal near miss. It includes birth weight < 1750 g, an APGAR score < 7 at 5 min, and Gestational Age < 33 weeks [19].

Management severity criteria: It is a criterion based on the management base. It includes parenteral antibiotic therapy, nasal continuous positive airway pressure (CPAP), any intubation, and phototherapy within 24 hrs. of life, cardiopulmonary resuscitation (CPR), use of vasoactive drugs, anticonvulsants, surfactants, blood products, steroids for the treatment of refractory hypoglycemia, surgery, use of antenatal steroid, use of parenteral nutrition, identification of congenital malformation according to the ICD-10 if considered a near-miss case by another criterion and admission to the NICU [19].

Medical complications during pregnancy: include diabetes mellitus, hypertension, tuberculosis, cardiac disease, malaria, anemia, and some other related medical conditions observed during this pregnancy [19].

Data analysis

The Collected data were checked for completeness, coded, entered, and cleaned using Epi-Data version 3.1, and exported to SPSS version 23 for analysis. Descriptive statistics were used to describe the frequency distribution of each of the variables mentioned earlier. The association between the outcome variables (i.e. neonatal near-miss) and independent variables was analyzed using a binary logistic regression model. Covariates having a p-value of 0.25 or less will be retained and entered into the multivariable logistic regression analysis using forward stepwise approach methods. The Hosmer and Lemeshow goodness-of-fit test were used to assess whether the necessary assumptions for the application of multiple logistic regression were fulfilled and a p-value > 0.05 was considered a good fit. The result was presented as adjusted odds ratios with 95% confidence intervals. A p-value<0.05 was considered for significantly associated factors with the outcome variable.

Ethical considerations

Ethical clearance was first sought from the Research and Ethical Review Committee of the college of medicine and health sciences, Dire Dawa University with ethics reference number, ም/ማ/አ/ም/ፕ300/879/2013. Next, a permission letter was collected from the respective Health Bureaus and communicated with hospitals. After discussing the issue of confidentiality data collectors were taken informed, voluntary, written, and signed consent from the hospital head and participants or guardians of the minors after taking assent from the minors before the start of data collection. Participants were informed that they have the full right to refuse or discontinue participating in the study and as there would not be any marker to identify any participants’ privacy would be kept during interviews and responses would be kept confidential. All personal information was de-identified and kept separately, so every effort was made to maintain confidentiality throughout the study period and afterward. Furthermore, this study was conducted in accordance with the Declaration of Helsinki.

Result

Sociodemographic characteristics of neonates mothers

A total of, 252 cases and 756 controls were involved in the study and provide a response rate of 100% for both cases, and controls. The mean age and a standard deviation of neonate’s mother were 25.90 ± 5.19 for the whole study participants and 25.97 ± 5.12 for cases and 25.87 ± 5.21 for controls.

One hundred ninety-five (77.4%) of the neonate’s mothers for cases and 664 (87.6%) for controls were urban residents. The majority of participants, 62.7% in cases and 55% in controls are housewives. In the case of marital status, only 1.2% in cases and 1.1% in controls are currently single. Regarding maternal educational status, 9.9% of cases and 15.3% of controls attended college and above (Table 1).

Table 1

Sociodemographic characteristics of mothers whose neonates were admitted to public hospitals of Dire Dawa Administrative, Eastern Ethiopia, 2021.

Variables	Total N (%)	Cases (n = 252)	Controls (n = 756)
Age
15–24	412(40.9)	110(43.7)	302(40.0)
25–34	513(50.9)	118(46.8)	395(52.2)
≥35	83(8.2)	24(9.5)	59(7.8)
Resident
Urban	859(85.2)	195(77.4)	664(87.8)
Rural	149(14.8)	57(22.6)	92(12.2)
Maternal educational status
No formal education	177(17.6)	76(30.2)	101(13.4)
Primary (1–8)	360(35.7)	92(36.5)	268(35.4)
Secondary (9–12)	330(32.7)	59(23.4)	271(35.8)
College and above	141(14.0)	25(9.9)	116(15.3)
Maternal occupation
Housewife	574(56.9)	158(62.7)	416(55.0)
Merchant	95(9.4)	18(7.1)	77(10.2)
Government employer	157(15.6)	31(12.3)	126(16.7)
Non-governmental/private	157(15.6)	39(15.5)	118(15.6)
Daily laborer	25(2.5)	6(2.4)	19(2.5)
Marital status
Currently Single	11(1.1)	3(1.2)	8(1.1)
Currently Married	997(98.9)	249(98.8)	748(98.9)
Paternal education status (n = 997)
No formal education	118(11.8)	52(20.9)	66(8.8)
Primary (1–8)	197(19.8)	74(29.7)	123(16.4)
Secondary (9–12)	389(39.0)	83(33.3)	306(40.9)
College and above	293(29.4)	40(16.1)	253(33.8)
Religion
Orthodox	285(28.3)	67(26.6)	218(28.8)
Muslim	658(65.3)	169(67.1)	489(64.7)
Protestant	44(4.4)	13(5.2)	31(4.1)
Catholic	21(2.1)	3(1.2)	18(2.4)
Family monthly income
<1500 ETB	21(2.1)	10(4.0)	11(1.5)
1500–3500 ETB	236(23.4)	83(32.9)	153(20.2)
>3500 ETB	751(74.5)	159(63.1)	592(78.3)

Key: ETB, Ethiopian Birr.

Maternal and child health, and obstetric factors

Among participants, in 85.3% of cases and 89% of controls pregnancies are planned and wanted. Of multi-para mothers’, 38.9% of cases and 40.9% of controls have birth intervals of less than 24 months. ANC follow-up was attended in 94% of cases and 97.1% of controls at least one time. Of the total neonates, 64.7% are males from cases and 51.7% from controls. Regarding mode of delivery, 63.5% of cases and 64% of controls were delivered by spontaneous vaginal delivery (Table 2).

Table 2

Maternal and child health, and health care service characteristics of participants in public hospitals of Dire Dawa Administrative, Eastern Ethiopia, 2021.

Variables	Total N (%)	Cases (n = 252)	Controls (n = 756)
Pregnancy status
Planned and wanted	888(88.1)	215(85.3)	673(89.0)
Unplanned but wanted	120(11.9)	37(14.7)	83(11.0)
Gravidity
Primi-gravida	365(36.2)	103(40.9)	262(34.7)
Multi-gravida	532(52.8)	112(44.4)	420(55.6)
Grand multi-gravida	111(11.0)	37(14.7)	74(9.8)
Birth interval (in months) (643)
<24	260(40.4)	58(38.9)	202(40.9)
24–60	361(56.1)	87(58.4)	274(55.5)
>60	22(3.4)	4(2.7)	18(3.6)
Antenatal care visit
Yes	971(96.3)	237(94.0)	734(97.1)
No	37(3.7)	15(6.0)	22(2.9)
Number of antenatal care visits
No visit	37(3.7)	15(6.0)	22(2.9)
1–3 visit	475(47.1)	127(50.4)	348(46.0)
≥4 visit	496(49.2)	110(43.7)	386(51.1)
Referred in
Yes	578(57.3)	173(68.7)	405(53.6)
No	430(42.7)	79(31.3)	351(46.4)
Labor status
Spontaneous	839(83.2)	206(81.7)	633(83.7)
Induced	169(16.8)	46(18.3)	123(16.3)
Duration of labor
Elective cesarean section	87(8.6)	28(11.1)	59(7.8)
Precipitative	55(5.5)	14(5.6)	41(5.4)
Normal duration	824(81.7)	195(77.4)	629(83.2)
Prolonged	42(4.2)	15(6.0)	27(3.6)
Mode of delivery
Spontaneous vaginal delivery	644(63.9)	160(63.5)	484(64.0)
Instrumental delivery	24(2.4)	11(4.4)	13(1.7)
Cesarean section delivery	340(33.7)	81(32.1)	259(34.3)
Presentation
Cephalic	954(94.6)	236(93.7)	718(95.0)
Non-cephalic	54(5.4)	16(6.3)	38(5.0)
Sex of neonate
Male	554(55.0)	163(64.7)	391(51.7)
Female	454(45.0)	89(35.3)	365(48.3)
Neonatal birth trauma
Yes	9(0.9)	8(3.2)	1(0.1)
No	999(99.1)	244(96.8)	755(99.9)
NRFHB
Yes	184(18.3)	182(72.2)	2(0.3)
No	824(81.7)	70(27.8)	754(99.7)

Keys: NRFHB, None Reassuring Fetal Heart Beat.

Presences of current or history of maternal obstetric complication

In the current study, no one has a stillbirth history in cases, while 1.6% of controls have it. In the case of abortion, among participants, 12.3% of cases and 11.6% of controls have at least one abortion history. About 7.1% of cases and 4.1% of controls were multiple births. Anemia was found in 15.5% of cases and 20.5% of controls (Fig 1).

Fig 1

Presences of current or history of maternal obstetric complication of participants in public hospitals of Dire Dawa Administrative, Eastern Ethiopia, 2021.

Neonatal near miss diagnostic criteria distribution

According to our findings, out of neonatal near-miss cases, 93.7% of them were admitted to NICU followed by an APGAR score of less than 7 (64.3%). Additionally, 22.8% of neonatal near-miss cases were less than 1750gm in weight and 4.4% of cases were given anticonvulsant drugs (Fig 2).

Fig 2

Neonatal near miss diagnostic Criteria distribution among the case of the participants in public hospitals of Dire Dawa Administrative, Eastern Ethiopia, 2021.

Factors associated with the neonatal near miss

In bivariable logistic regression, age of the mother, residence, maternal educational status, maternal occupation, paternal educational status, family monthly income, number of pregnancies, having ANC follow-up, referral in, multiple births, mode of delivery, having a previous cesarean delivery, presence of hypertension in pregnancy, and sex of the neonate was eligible for multivariable analysis.

In the multivariable logistic analysis, maternal occupation, paternal educational status, family monthly income, referral in, multiple births, mode of delivery, hypertension during pregnancy, and sex of the neonate were significantly associated with NNM.

Mothers who were non-governmental/private employees were 2 times more likely to have NNM cases compared to being housewives (AOR, 1.72[95%CI: 1.037, 2.859]). Having paternal education of secondary school (9–12) and college/above were less likely to develop NNM cases compared to those with no formal education (AOR, 0.43[95%CI: 0.210, 0.868]) and (AOR, 0.25[95%CI: 0.109, 0.578]) respectively. Having monthly family income 1500–3500 Ethiopian birr and >3500 Ethiopian birrs were less likely to have NNM cases compared to those have less than 1500 Ethiopian birr monthly income (AOR, 0.29[95%CI: 0.105, 0.809]) and (AOR, 0.34[95%CI: 0.124, 0.906]) respectively.

Mothers of the neonates referred from other facilities were 1.5 times more likely to have NNM cases than those not referred (AOR, 1.51[95%CI: 1.079, 2.108]). Having multiple births was 2.5 times more likely to have NNM cases than having a singleton birth (AOR, 2.50[95%CI: 1.387, 4.501]). Giving birth through instrumental assisted delivery was 4 times more likely to have NNM cases than giving birth through spontaneous vaginal delivery (AOR, 4.11[95%CI: 1.681, 10.034]). The odds of NNM were 3.32 among mothers who have hypertensive during pregnancy as compared to those with no hypertensive during pregnancy (AOR, 3.32[95%CI: 1.987, 5.530]). Furthermore, being male neonates is about 2 times more likely to be NNM cases compared to female neonates (AOR, 1.71[95%CI: 1.230, 2.373]) (Table 3).

Table 3

Multivariable analysis of the factors associated with neonatal near-miss among neonates admitted in public hospitals of Dire Dawa Administrative, Eastern Ethiopia, 2021.

Variables	Cases (n = 252)	Controls (n = 756)	COR (95%)	AOR (95%)	p-value
Age
15–24	110	302	1
25–34	118	395	0.82(0.608, 1.107)	0.94(0.649, 1.353)	0.729
≥35	24	59	1.12(0.662, 1.883)	1.02(0.521, 1.992)	0.957
Resident
Urban	195	664	1	1
Rural	57	92	2.11(1.462, 3.045)	1.12(0.714, 1.748)	0.627
Maternal educational status
No formal education	76	101	1	1
Primary (1–8)	92	268	0.46(0.312, 0.667)	0.73(0.415, 1.273)	0.264
Secondary (9–12)	59	271	0.29(0.192, 0.436)	0.57(0.282, 1.151)	0.116
College and above	25	116	0.29(0.169, 0.484)	0.69(0.282, 1.690)	0.417
Maternal occupation
Housewife	158	416	1	1
Merchant	18	77	0.62(0.357, 1.061)	1.16(0.624, 2.145)	0.644
Government employer	31	126	0.65(0.420, 0.999)	1.70(0.891, 3.226)	0.108
Non-governmental/private	39	118	0.87(0.580, 1.306)	1.72(1.037, 2.859)	0.036 *
Daily laborer	6	19	0.83(0.326, 2.120)	1.03(0.362, 2.931)	0.956
Paternal education status (n = 997)
No formal education	52	66	1	1
Primary (1–8)	74	123	0.76(0.480, 1.214)	0.94(0.507, 1.738)	0.841
Secondary (9–12)	83	306	0.34(0.222, 0.533)	0.43(0.210, 0.868)	0.019 *
College and above	40	253	0.20(0.123, 0.329)	0.25(0.109, 0.578)	0.001 *
Family monthly income
<1500 Ethiopian Birr	10	11	1	1
1500–3500 Ethiopian Birr	83	153	0.60(0.243, 1.463)	0.29(0.105, 0.809)	0.018 *
>3500 Ethiopian Birr	159	592	0.30(0.123, 0.708)	0.34(0.124, 0.906)	0.031 *
Gravidity
Primi-gravida	103	262	1	1
Multi-gravida	112	420	0.68(0.498, 0.924)	0.77(0.516, 1.134)	0.182
Grand multi-gravida	37	74	1.27(0.806, 2.006)	0.94(0.509, 1.746)	0.852
ANC visit
Yes	237	734	1	1
No	15	22	2.11(1.078, 4.137)	1.32(0.611, 2.832)	0.483
Referred in
Yes	173	405	1.90(1.403, 2.567)	1.51(1.079, 2.108)	0.016 *
No	79	351	1	1
Multiple births
Yes	25	36	2.20(1.294, 3.748)	2.50(1.387, 4.501)	0.002 *
No	227	720	1	1
Mode of delivery
SVD	160	484	1	1
Instrumental	11	13	2.56(1.124, 5.827)	4.11(1.681, 10.034)	0.002 *
Cesarean section	81	259	0.95(0.696, 1.286)	1.03(0.703, 1.504)	0.887
Previous cesarean section
Yes	30	141	1	1
No	222	615	1.70(1.112, 2.590)	1.20(0.707, 2.051)	0.494
Hypertensive during pregnancy
Yes	42	43	3.32(2.110, 5.212)	3.32(1.987, 5.530)	0.001 *
No	210	713	1	1
Sex of neonate
Male	163	391	1.71(1.273, 2.297)	1.71(1.230, 2.373)	0.001 *
Female	89	365	1	1

*significantly associated at p-value <0.05;

ANC, Antenatal Care; SVD, Spontaneous Vaginal Delivery.

Discussion

Studying factors affecting neonatal near-miss cases is crucial to tackling the cause of the neonatal problems. Therefore, this study showed the most important factors affecting near-miss cases in Dire Dawa Administrative public hospitals. The finding of the present study in the multivariable logistic analysis showed that maternal occupation, paternal educational status, family monthly income, referral in, multiple births, mode of delivery, hypertension during pregnancy, and sex of the neonate were significantly associated with NNM.

In the current study, maternal occupation, non-governmental and private employment was significantly associated with a neonatal near miss. This is in line with the study conducted in Hawasa city [21]. This might be due to the adverse effects of occupational stress on fetal growth and development. This is supported by those mothers in hard-working conditions who might be a risk factor for adverse birth outcomes when compared to mothers of housewives. Other study evidence for the adverse effects of occupational stress on fetal growth and development also supports this [13].

Neonates delivered from mothers referred from other health facilities had higher odds of a neonatal near miss than those not referred in. This finding was in line with the studies conducted in Uganda and Gurage Zone [22,23]. This might be due to the delayed/absence of referral on time to the next facility and interruption of care given to the mothers until they arrive at the next facility. Having multiple births is a factor significantly associated with neonatal near misses. This is similar to the study finding in South Africa [1]. This might be due to that multiple pregnancies are expected to affect fetal outcomes in terms of underweight, preterm delivery, and asphyxia.

Mode of delivery is significantly associated with neonatal near misses. Mothers delivered through instrumental delivery were more likely to develop neonatal near-misses than spontaneous vaginal delivery. This finding was similar to studies conducted in different settings, in Brazil, Johannesburg, Southeast Brazil, Hawasa, northeast Brazil, Gamo and Gofa zones, Uganda, Ambo, Gurage Zone, Jima, Thailand, Morocco, and Ethiopia [10,12,18,20-22,24-30]. This might be because most of the neonates indicated for instrumental delivery are due to abnormal labor progress, which affects the fetal outcomes, and maybe the professionals are not skilled enough, maybe the mothers are frightened by the indications that happen later in worse conditions for the fetuses. A neonate delivered from mothers having hypertension during pregnancy was more likely to face neonatal near misses. This finding was in line with studies conducted in a different studies, in Uganda, Gondar, Southeast Brazil, and Jima [22-24,27]. This might be because neonates delivered from hypertensive mothers may be affected by the impact of the maternal hypertensive and its management (drugs). Additionally, this might be due to hypertension during pregnancy may cause complications to fetuses during intrauterine life like intrauterine growth restriction and in extrauterine life such as preterm delivery which is more likely to be LBW and also causes birth asphyxia [31]. However, inconsistent with the Hawasa city study. This might be due to the sample size difference, which is our study has almost two times higher than their study.

Another factor significantly associated in this study was paternal educational status, which was having paternal education of secondary school and college/above had a significant association. This variable was tested and failed to associate with other studies (10, 27). This association might be due to that having better education in husbands leads to better awareness of maternal health care access and better income to afford the care to get a better follow-up to identify risk factors.

Family monthly income was a factor significantly associated with NNM, which is having a better family monthly income was less likely to have NNM. This might be having a better income leads to accessing better maternal health care services in a different area or nearby their residency even in private facilities since they can afford it. This finding is supported by the study conducted in south Ethiopia [32].

Male neonates had a significant factor for having neonates with a near miss as indicated in this study. Neonatal hypoglycemia and immediate neurological complications were significantly more frequent in males. For term small for gestational age, low 5-min APGAR scores (<7) at 39–40 weeks were higher for males compared with females, as was hypoglycemia [33].

This study showed the gaps in previous studies to show the factors that could affect neonatal near-miss cases. Therefore, this study identified some new variables that were not identified by other studies, such as paternal educational status and being a male neonate to fill the previously mentioned gaps. However, this study is unable to follow neonates with near misses until the end of 28 days of life to see their outcomes, consider seasonality as a risk factor of NNM, and did not incorporate some of the variables that are needed to be addressed in the community, such as wealth index, nutritional status, and cultural aspects.

Conclusion

Maternal occupation, paternal education, income, referral in, multiple births, mode of delivery, hypertension during pregnancy, and sex of the neonate have been identified factors with neonatal risk factors. The respective body needs to generate income, by creating job opportunities, improving education through giving educational scholars, early screening and managing multiple pregnancies and pregnancy-induced hypertension, minimizing instrumental delivery through careful (expertise) assessment of the indications, creating a system of referral decrease or early referral and give focus for male newborns.

Data sharing statement

All related data has been presented within the manuscript. The data set supporting the conclusions of this article is available from the corresponding Author (Yitagesu Sintayehu) upon reasonable request.

The dataset from which the results of the study were produced (SPSS file).

(SAV)

Click here for additional data file.

The data collection tool (questionnaire and checklist) in English.

(DOCX)

Click here for additional data file.

The letter of ethical clearance taken to conduct this study.

(PDF)

Click here for additional data file.

19 May 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

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

Reviewer #4: Yes

**********

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

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Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

Reviewer #4: No

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: General comments

Dear authors on your scholarly work; you have brought an important study problem with good findings that have public health importance in the area of practice. Moreover, the manuscript has been written in good English. However, it still needs improvement for mainly grammar usage so that its readership becomes increased if published.

Some of the language use errors which the authors made consistently include.

Eg.

a. Card review……… instead of chart review

b. Bivariate and multivariate ….. instead of bivariable and multivariable

Specific comments

1. Background of the abstract doesn’t clearly show the existing numerical burden of the problem in Dire Dawa town or other regional states of Ethiopia even. Generally, burden of neonatal near miss should be stated numerically followed by the objectives showing the research gap the authors would like to address.

2. The fourth sentence of the background that reads as ‘However, little studies were done in other areas, but they failed in identifying the proximate factors and not done in Dire Dawa Administration’ should be rewritten as: Though there were few prior studies in other regions, they failed in identifying the proximate factors. Besides, there has been no prior study in the study area.

3. Methods of abstract should include sampling technique, measurement of neonatal nearmiss and type of data collection tool (adapted or adopted)

4. Result of abstract: please include response rate in the first sentence of the result section.

Introduction

5. Well written except the need for further synthesis of redundant concepts.

Methods

6. Data collection tools, procedures, and quality control: It would be more self explanatory and easily understandable if the authors showed pictorial presentation (flow chart) of the sampling procedure to reach a response rate of 100%. Please upload your data collection tools as additional file than annexing it in the manuscript. Kindly state the exact number of cases and controls rather than mentioning the routine statistics i.e. 5% of the sample size.

7. Ethical consideration: kindly have a separate upload of the ethical letter as an additional file. Moreover, what beneficent actions did the authors provide the mothers and the facilities in return for the interviews and chart reviews?

8. Results

How were you able to measure monthly income because you haven’t planned principal component analysis?

9. Conclusion

Well supported by the findings

Reviewer #2: Title : Factors associated with neonatal near miss among neonates admitted to public hospitals in Dire Dawa administration, Eastern Ethiopia: a case-control study

Thank you for the opportunity for giving me to review the above title. I found the topic is interesting and has implications for low-income countries. However, the manuscript needs extensive language revisions.

Abstract

- Line 21- The near-miss cases are subject to factors…… can you say it neonatal near miss instead of near-miss since there are other miss e.g maternal near miss.

- I do not think by chance is appropriate word to use. Please get rid of the word ‘chance’

- Line 29 – say medical record instead of ‘card’

- Line 30 – Multivariate is not the correct word , replace it by ‘multivariable analysis’

- Line 31-32 -the authors need to re-write the sentence

- Line 33 – no need of mentioning in the abstract about p-values. Please take it out from the abstract.

- Line 35 -39 – can you make the C.Interval to two digits rather than three.

- I don’t recommend stating adjusted ratios and CI in the abstract. It would be better if you could mention the factors associated with NNM without AOR.

- Line 41 to 43 -seems repetition of results. I would recommend to state in other ways.

- Better to create job opportunities, improving education, income generation. How? In any particular way?

- …… minimizing instrumental delivery. How?

Background

- I would start the background with paragraph 4 ‘Worldwide, about 3.6 million neonates are estimated to die in the first 4 weeks of life every year and the majority continue to die at home, uncounted.’

- The authors need to change the order of the paragraphs in order to make it easy for readers

- It needs language revision

Methods

- Can you add more information about study facility such as availability of ICU units , paediatrics admission and number of deliveries per year ?

- Line 111 -12 – not clear

- Line 116 – 120 – It is long sentence. Can you make it two sentences?

- Line 121 – 127 – Repetition of background information. It would be good if the authors mention the criteria of NNM only in methods part. Please take it out from the background.

- Line 137- please include reference.

- Line 148- ‘Data were collected by 6 midwives who have experience in maternal and neonatal care’. Are the midwives hospital staff?

- Line 150 -153- Please make it two sentence.

- Can you include reference number for ethics approval?

- ‘This might be due to that the adverse effects of occupational stress on fetal

growth and development. Do you have reference for this ? Can we say private /non-governmental employment increase the risk of adverse outcomes?

- Line 302 _ having paternal education of secondary school and college/above had a significant association. Reduce or increase the odds of NNM ?

- Line 303 – references ?

- Line 309- Male neonates had a significant…… Please start in new paragraph

Lien 310 -311- This might be due to the increased

- 311 birth weight, cesarean sections, and operative deliveries were significantly higher for males. Is this from your findings or other ? If other, you need to cite reference .

- Line 315 - show the proximate factors….. What are the proximate factors? I didn’t see it in the background or methods. You need to state what are the proximate factors

- Line 316 -318 - Therefore, this study identified some new variables were not identified by others study, such as paternal educational status, Family monthly income and being male neonate to fill the previously mentioned gaps. This is not true . other studies have also reported the association between NNM and education and family income. For instance, in the article ‘Incidence and determinants of neonatal near miss in south Ethiopia: a prospective cohort study’ the authors stated income was associated with NNM.

- The authors need to explain the limitation of the study

-

Reviewer #3: The article is important because the neonatal near miss concept must to be present as a tool for evaluating neonatal care. It is the first step in building management strategies to reduce mortality and long-term sequelae. In the conclusions, my suggestion for the authors, would work more in local y practical suggestions for improving and avoid some causes.

Unfortunatlly many and the main causes are more structural, as poverty or education , but some evidencies show the necesity for improve the quality of care as a early screening and manage multiple pregnancy and pregnancy-induced hypertension,

Reviewer #4: It is a very interesting study concerning an important issue such as neonatal near miss (NNM). I have some concerns which could improve the paper and become it more suitable por publication.

INTRODUCTION is too long, should be shortened to 4 or 5 paragraphs focusing in the main point, NNM. Even though the authors are using correct references for definition, some misunderstanding occurs when they cite totally different concepts such as SIDS (sudden infant death syndrome), that has to be erased. Some epidemiological numbers are repetitive.

METHODS are very correct, defining very well area of the study, study design and selection of cases and controls.

Statistical approach is adequate, including a sample size calculation that was respected to obtain an adequate power for the study.

It is interesting the concern with the transcultural adaptation of the questionaire, very appropriate.

The concept of NNM are absolutely correct, well utilized, data analysis adequate and ethical aspects were well considered and approached.

RESULTS and DISCUSSION are interesting, not difficult to understand, because the adjusted analysis identified factors that really could interfere in the occurence of NNM or neonatal death. Even though male sex is classicaly reconized as an significant risk factor, the explanations are speculations. A new literature search should better address this point.

In my opinion, the main point in which I disagree are the explanations for assisted vaginal deliveries (AVD) as a risk factors. WHO is working with a Task Force to increase and improve AVB use worldwide, and seems to be that the main difficulty, to indicate AVD in a more appropriate time, during second period of the labour. I would study better this point and rewrite explanations. May be the professionals are not skilled enough, may be the mothers are frightened by the indications that happen lately in worse conditions for the fetuses and so on.

All at all is a good study, that deserves to be published correcting the main issues.

I suggest a professional English edition.

**********

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Reviewer #1: Yes: Wubet Alebachew Bayih

Reviewer #2: No

Reviewer #3: Yes: Suzanne J Serruya

Reviewer #4: No

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Submitted filename: General comments.docx

Click here for additional data file.

17 Jun 2022

Response to Reviewers’

Title: “FACTORS ASSOCIATED WITH NEONATAL NEAR MISS AMONG NEONATES ADMITTED TO PUBLIC HOSPITALS IN DIRE DAWA ADMINISTRATION, EASTERN ETHIOPIA: A CASE-CONTROL STUDY." [Manuscript ID PONE-D-21-33319]

To: The editor-in-chief, PLOS ONE

From: Authors

Subject: Revision of the manuscript

Dear Sir/ Madam,

We hope everything is fine. We appreciate and thank to the academic editor and reviewers for investing their time and energy to review and make comments on our manuscript. It is with great pleasure to receive the invaluable and constructive comments for our manuscript.

As per your request for a separate cover letter, the comments with their point-by-point responses are put below here. In addition, the detailed changes made are highlighted in the “revised manuscript with track changes” by activating the “track changes” feature to easily identify the changes/ improvements. Moreover, the manuscript without track change is prepared. We accepted and tried to incorporate all of the comments provided. Therefore, we are kindly requesting you to review our revised manuscript; especially the “manuscript without track change”. If there is/are any unaddressed issue you welcome, we are ready to accept your comment.

No Comments Responses

Editor

Journal requirements:

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. Thank you for your concern. It meets PLOS ONE’s style requirements.

2. You indicated that you had ethical approval for your study. In your Methods section, please ensure you have also stated whether you obtained consent from parents or guardians of the minors included in the study or whether the research ethics committee or IRB specifically waived the need for their consent. Thank you for your concern. We have received ethical approval. For minors we have taken consent from their guardians after taking assent from the minors. This is also approved by the ethical review committee.

Review Comments to the Author

Reviewer 1

- Some of the language use errors which the authors made consistently include.

Eg.

a. Card review…… instead of chart review

b. Bivariate and multivariate ….. instead of bivariable and multivariable Thank you for the comment. We addressed it and incorporated in the manuscript.

1. Background of the abstract doesn’t clearly show the existing numerical burden of the problem in Dire Dawa town or other regional states of Ethiopia even. Generally, burden of neonatal near miss should be stated numerically followed by the objectives showing the research gap the authors would like to address. Thank you for the comment. Dear, as you know there is restrictions of word in abstract, we are unable to include as your comment. However, it is possible to find main body of the document.

2. The fourth sentence of the background that reads as ‘However, little studies were done in other areas, but they failed in identifying the proximate factors and not done in Dire Dawa Administration’ should be rewritten as: Though there were few prior studies in other regions, they failed in identifying the proximate factors. Besides, there has been no prior study in the study area. Thank you for the comment. We did per the comment and incorporated in the main document.

3. Methods of abstract should include sampling technique, measurement of neonatal nearmiss and type of data collection tool (adapted or adopted) Thank you for the comment. We did all comments per the comment and incorporated in the main document.

4. Result of abstract: please include response rate in the first sentence of the result section Thank you for the comment. We did per the comment and incorporated in the main document.

5. Data collection tools, procedures, and quality control: It would be more self explanatory and easily understandable if the authors showed pictorial presentation (flow chart) of the sampling procedure to reach a response rate of 100%. Please upload your data collection tools as additional file than annexing it in the manuscript. Kindly state the exact number of cases and controls rather than mentioning the routine statistics i.e. 5% of the sample size. Thank you for the comment. We did per the comment and incorporated in the main document. Also, the too is uploaded.

6. Ethical consideration: kindly have a separate upload of the ethical letter as an additional file. Moreover, what beneficent actions did the authors provide the mothers and the facilities in return for the interviews and chart reviews? Thank you for the concern. We did per the comment and incorporated in the main document. Also, it is uploaded.

There is no direct benefit given to mother or the facility except the consent receiving from both the facility and mothers. The benefit of both of them might be future interventions of the finding of the study.

7. How were you able to measure monthly income because you haven’t planned principal component analysis? Thank you for the concern. We know it should be assessed with principal components, but we simply asked them their estimated monthly incomes. This might be our limitation.

We wonders your comment and have a great respect. For any unaddressed comments, always we are ready/voluntary to correct again. So, please common in any inquiry. Thank.

Reviewer 2

- Line 21- The near-miss cases are subject to factors…… can you say it neonatal near miss instead of near-miss since there are other miss e.g maternal near miss. Thank you for the concern. We did per the comment and incorporated in the main document.

- I do not think by chance is appropriate word to use. Please get rid of the word ‘chance’ Thank you for the concern. We did per the comment and incorporated in the main document.

- Line 29 – say medical record instead of ‘card’ Thank you for the concern. We did per the comment.

- Line 30 – Multivariate is not the correct word , replace it by ‘multivariable analysis’ Thank you for the concern. We did per the comment.

- Line 31-32 -the authors need to re-write the sentence Thank you for the concern. We did per the comment.

- Line 33 – no need of mentioning in the abstract about p-values. Please take it out from the abstract. Thank you for the concern. We did per the comment.

- Line 35 -39 – can you make the C.Interval to two digits rather than three. I don’t recommend stating adjusted ratios and CI in the abstract. It would be better if you could mention the factors associated with NNM without AOR. Thank you for the concern. We did for the 2 digit decimals. However, in most literatures it is advisable to indicate the measure of association (AOR and CI) in abstract since it is the short cut of the whole results. Unless it will overlaps with concussion.

- Line 41 to 43 -seems repetition of results. I would recommend to state in other ways. Thank you for the comment and we do have respect for your comment. However, the detailed presented in the result section, the conclusion need to be stated by putting all factors as it indicated.

- Better to create job opportunities, improving education, income generation. How? In any particular way? Thank you for the comment. For the sec of word number, we added the details in the main document conclusion.

- …… minimizing instrumental delivery. How? Thank you for the comment. For the sec of word number, we added the details in the main document conclusion.

- I would start the background with paragraph 4 ‘Worldwide, about 3.6 million neonates are estimated to die in the first 4 weeks of life every year and the majority continue to die at home, uncounted.’ The authors need to change the order of the paragraphs in order to make it easy for readers Thank you for the concerns and we do have a respect to your comment. But, background need to be start with outcome variable definition (introducing what mean your outcome variable), then showing the magnitude of the problem. So, as you seen on the first paragraph it is the definitions of the outcome variable; second paragraph, the criteria to diagnose (identify) the cases and the third paragraph shows the venerability period where the risk of neonatal death will occur. Then the rest paragraphs are showing the magnitude of the problem from world to local area. Therefore, we hope that the flow of the paragraphs are in correct order. Any way, if still is not convincing we will try to rearrange it. Thank you again.

- It needs language revision Thank you for the concern. We tried to revise it.

- Can you add more information about study facility such as availability of ICU units, paediatrics admission and number of deliveries per year ? Thank you for the concern. We have added the information in the main document.

- Line 111 -12 – not clear Thank you for your detailed revision. We were missed some phrases and now it is complete and clear.

- Line 116 – 120 – It is long sentence. Can you make it two sentences? Thank you for the comment. We have made accordingly in the main document.

- Line 121 – 127 – Repetition of background information. It would be good if the authors mention the criteria of NNM only in methods part. Please take it out from the background. Thank you for the comment. We accepted the comment and we removed from the background.

- Line 137- please include reference. Thank you for the comment. We added the reference.

- Line 148- ‘Data were collected by 6 midwives who have experience in maternal and neonatal care’. Are the midwives hospital staff? Thank you for the comment. The data collectors are not the hospital staffs. They were recruited from other area. This also know indicated in main document.

- Line 150 -153- Please make it two sentence. Thank you for the comment. We accepted the comment and we made accordingly.

- Can you include reference number for ethics approval? Thank you for the comment. We have include reference number for ethics approval (ም/ማ/አ/ም/ፕ300/879/2013).

- ‘This might be due to that the adverse effects of occupational stress on fetal

growth and development. Do you have reference for this? Can we say private /non-governmental employment increase the risk of adverse outcomes? Thank you for the comment. We linked this sentence with the second sentence of the same paragraph that have reference number 15. As we know Private/non-governmental organizations are business-oriented organizations most of the time workers are more loaded than governmental works (governmental organization control is weaker than the private).

- Line 302 _ having paternal education of secondary school and college/above had a significant association. Reduce or increase the odds of NNM ? Thank you for the concern. Under the subtitle of factors associated with the neonatal near miss, we clearly indicated that as ‘Having paternal education of secondary school (9-12) and college/above were less likely to develop NNM cases compared to those with no formal education’.

- Line 303 – references ? Thank you for the comment. We added the refrence.

- Line 309- Male neonates had a significant…… Please start in new paragraph Thank you for the comment. We did it.

-Lien 310 -311- This might be due to the increased Thank you for the comment. Since it was our personal suggestions, we removed from the document.

- 311 birth weight, cesarean sections, and operative deliveries were significantly higher for males. Is this from your findings or other ? If other, you need to cite reference .

- Line 315 - show the proximate factors….. What are the proximate factors? I didn’t see it in the background or methods. You need to state what are the proximate factors Thank you for the comment. Since we were inappropriately used. We removed the word proximate from the document.

- Line 316 -318 - Therefore, this study identified some new variables were not identified by others study, such as paternal educational status, Family monthly income and being male neonate to fill the previously mentioned gaps. This is not true . other studies have also reported the association between NNM and education and family income. For instance, in the article ‘Incidence and determinants of neonatal near miss in south Ethiopia: a prospective cohort study’ the authors stated income was associated with NNM. Greatly we want to thanks you for your detailed review. We were missed this reference. Know we added this reference and corrected per the comment in the document.

- The authors need to explain the limitation of the study Thank you again for your comment. The last sentence of the discussion section is the limitation of the study.

We wonders your comment and have a great respect. For any unaddressed comments, always we are ready/voluntary to correct again. So, please common in any inquiry. Thank.

Reviewer 3:

The article is important because the neonatal near miss concept must to be present as a tool for evaluating neonatal care. It is the first step in building management strategies to reduce mortality and long-term sequelae. In the conclusions, my suggestion for the authors, would work more in local y practical suggestions for improving and avoid some causes.

Unfortunatlly many and the main causes are more structural, as poverty or education , but some evidencies show the necesity for improve the quality of care as a early screening and manage multiple pregnancy and pregnancy-induced hypertension, Thank you for your all the insight you shown us on the our work. Directly or indirectly we addressed the improvement of the service quality through a early screening and manage multiple pregnancy and pregnancy-induced hypertension, and minimizing instrumental delivery through careful (expertise) assessment of the indications our finding related recommendations in locally practical recommendations. This to maintain our result and recommendation agreement.

Great thanks again. If not addressed you well come again, we are ready to accept your comment.

Reviewer 4:

INTRODUCTION is too long, should be shortened to 4 or 5 paragraphs focusing in the main point, NNM. Even though the authors are using correct references for definition, some misunderstanding occurs when they cite totally different concepts such as SIDS (sudden infant death syndrome), that has to be erased. Some epidemiological numbers are repetitive. Thank you for your constructive comment. We have tried to minimize the paragraph by removing some overlapping concepts in the document.

METHODS are very correct, defining very well area of the study, study design and selection of cases and controls. Thank you for your constructive support.

Statistical approach is adequate, including a sample size calculation that was respected to obtain an adequate power for the study.

It is interesting the concern with the transcultural adaptation of the questionaire, very appropriate.

The concept of NNM are absolutely correct, well utilized, data analysis adequate and ethical aspects were well considered and approached. Thank you for your constructive support.

RESULTS and DISCUSSION are interesting, not difficult to understand, because the adjusted analysis identified factors that really could interfere in the occurence of NNM or neonatal death. Even though male sex is classicaly reconized as an significant risk factor, the explanations are speculations. A new literature search should better address this point. Thank you again for the constructive comment. We only one reference to support for male neonate findings. However, we removed one sentence that might speculate.

In my opinion, the main point in which I disagree are the explanations for assisted vaginal deliveries (AVD) as a risk factors. WHO is working with a Task Force to increase and improve AVB use worldwide, and seems to be that the main difficulty, to indicate AVD in a more appropriate time, during second period of the labour. I would study better this point and rewrite explanations. May be the professionals are not skilled enough, may be the mothers are frightened by the indications that happen lately in worse conditions for the fetuses and so on. Thank you again for the constructive comment. This is might be because of we compared AVD with SVD. Any way we have taken directly your recommendation by removing our second sentence that describes the instrumental risk.

All at all is a good study, that deserves to be published correcting the main issues. Thank you again for the constructive comment.

I suggest a professional English edition. Thank you again for the constructive comment. We have tried to rephrase it.

We wonders your comment and have a great respect. For any unaddressed comments, always we are ready/voluntary to correct again. So, please common in any inquiry. Thank.

Thank you,

Authors

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

15 Aug 2022

FACTORS ASSOCIATED WITH NEONATAL NEAR MISS AMONG NEONATES ADMITTED TO PUBLIC HOSPITALS IN DIRE DAWA ADMINISTRATION, EASTERN ETHIOPIA: A CASE-CONTROL STUDY

PONE-D-21-33319R1

Dear Dr. Sintayehu,

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Kind regards,

Simone Garzon

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: All comments have been addressed

Reviewer #4: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Yes

Reviewer #4: Yes

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

Reviewer #3: N/A

Reviewer #4: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

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

Reviewer #4: Yes

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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

Reviewer #4: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: The issue of neonatal near miss needs to gain visibility. If the health services are able to establish neonatal surveillance and train care teams, we would not only improve mortality indicators as well as the subsequent development of newborns. The results shown that the factors that affects

neonatal near miss are strongly related to social determinants such as maternal occupation or paternal education shows the importance of having sectoral policies and social programs to protect pregnant women.

Reviewer #4: I consider that the main issues have been addressed and the manuscript is suitable for publication. Neonatal near miss is an important concept developed in order to assess quality of infantile-maternal services/maternities, but also permits investigators to compare units worldwide, i.e., has a valuable academic importance.

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Reviewer #3: No

Reviewer #4: No

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19 Aug 2022

PONE-D-21-33319R1

FACTORS ASSOCIATED WITH NEONATAL NEAR MISS AMONG NEONATES ADMITTED TO PUBLIC HOSPITALS IN DIRE DAWA ADMINISTRATION, EASTERN ETHIOPIA: A CASE-CONTROL STUDY

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