Why Are Babies Dying in the First Month after Birth? A 7-
Year Study of Neonatal Mortality in Northern Ghana
Paul Welaga1*, Cheryl A. Moyer2, Raymond Aborigo1,5, Philip Adongo3, John Williams1,
Abraham Hodgson1, Abraham Oduro1, Cyril Engmann4
1Navrongo Health Research Centre, Ghana Health Service, Navrongo, Ghana, 2Global REACH and the Department of Medical Education, University of Michigan Medical
School, Ann Arbor, Michigan, United States of America, 3School of Public Health, University of Ghana, Legon, Ghana, 4Department of Paediatrics and Maternal Child
Health, Schools of Medicine and Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America, 5Jeffrey Cheah School of Medicine and
Health Sciences, MONASH University, Sunway Campus, Malaysia
Objectives: To determine the neonatal mortality rate in the Kassena-Nankana District (KND) of northern Ghana, and to
identify the leading causes and timing of neonatal deaths.
Methods: The KND falls within the Navrongo Health Research Centre’s Health and Demographic Surveillance System
(HDSS), which uses trained field workers to gather and update health and demographic information from community
members every four months. We utilized HDSS data from 2003–2009 to examine patterns of neonatal mortality.
Results: A total of 17,751 live births between January 2003 and December 2009 were recorded, including 424 neonatal
deaths 64.8%(275) of neonatal deaths occurred in the first week of life. The overall neonatal mortality rate was 24 per 1000
live births (95%CI 22 to 26) and early neonatal mortality rate was 16 per 1000 live births (95% CI 14 to 17). Neonatal
mortality rates decreased over the period from 26 per 1000 live births in 2003 to 19 per 1000 live births in 2009. In all,
32%(137) of the neonatal deaths were from infections, 21%(88) from birth injury and asphyxia and 18%(76) from
prematurity, making these three the leading causes of neonatal deaths in the area. Birth injury and asphyxia (31%) and
prematurity (26%) were the leading causes of early neonatal deaths, while infection accounted for 59% of late neonatal
deaths. Nearly 46% of all neonatal deaths occurred during the first three postnatal days. In multivariate analysis, multiple
births, gestational age ,32 weeks and first pregnancies conferred the highest odds of neonatal deaths.
Conclusions: Neonatal mortality rates are declining in rural northern Ghana, with majority of deaths occurring within the
first week of life. This has major policy, programmatic and research implications. Further research is needed to better
understand the social, cultural, and logistical factors that drive high mortality in the early days following delivery.
Citation: Welaga P, Moyer CA, Aborigo R, Adongo P, Williams J, et al. (2013) Why Are Babies Dying in the First Month after Birth? A 7-Year Study of Neonatal
Mortality in Northern Ghana. PLoS ONE 8(3): e58924. doi:10.1371/journal.pone.0058924
Editor: Ann M. Moormann, University of Massachusetts Medical School, United States of America
Received October 12, 2012; Accepted February 8, 2013; Published March 19, 2013
Copyright: ? 2013 Welaga et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: Funding was provided by grants and in-kind contributions from the Navrongo Health Research Center and the Universities of North Carolina and
Michigan. The data used for the analysis is part of an ongoing project activities of the Navrongo Health and Demographic Surveillance System which monitors the
population dynamics of the study area. The universities of North Carolina and Michigan supported the travel expenses of Cyril Engmann and Cheryl Moyer
respectively in this collaborative work. The funders had no role in study design, and analysis, decision to publish, or preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: email@example.com
Although child mortality is declining worldwide, an estimated
8.8 million children still die every year before their fifth birthday
. More than 40% of these children die within 28 days after birth
(considered the ‘‘neonatal period’’),  a burden borne dispro-
portionately by low- and middle-income countries .
Sub-Saharan Africa has among the highest neonatal mortality
rates in the world, yet some of the weakest health and vital
registration systems[3–6]. Neonatal mortality rates are typically
estimated using complex statistical modelling, small hospital-based
studies, or nationally representative demographic and health
surveys that use cluster-level sampling of live births . As a result,
neonatal mortality rates are often underestimated in developing
country settings [4,8,9].
In Ghana, published neonatal mortality rates have ranged from
fewer than 15 per 1000 live births  to more than 30 per 1000
live births . Without a clear sense of the true burden of
neonatal deaths and the aetiology of those deaths, planning
appropriate interventions is extremely difficult.
This research sought to address these challenges by relying upon
a well-established demographic surveillance system to collect
primary data on all neonatal deaths in the Kassena-Nankana
District of the Upper East Region in northern Ghana between
2003 and 2009. The Navrongo Health and Demographic
Surveillance System (NHDSS) was instituted and managed by
the Navrongo Health Research Centre (NHRC) to collect
longitudinal data on births, deaths, pregnancies, marriages and
migration using trained field workers who visit all households in
the area three times a year to update both individual and
PLOS ONE | www.plosone.org1 March 2013 | Volume 8 | Issue 3 | e58924
household information[12–14]. Using data from the NHDSS, this
study aimed to determine not only the neonatal mortality rate for
the study area, but also to determine the leading causes of death
and to examine the timing of deaths within the first month after
This study was reviewed and approved by the institutional
ethics review committees of the Navrongo Health Research
Centre, the University of North Carolina at Chapel Hill and the
University of Michigan.
We sought verbal consent from household heads or any other
elderly member of the household to update the health and
demographic information of household members every four
months including verbal autopsies for the dead as part of the
operations of the Navrongo Health and Demographic Surveillance
System (NHDSS). As a health and demographic surveillance
system with frequent visits to households to update health and
demographic information, verbal consent was deemed appropriate
for monitoring of the demographic events which requires routine
frequent visits to households. From 2011, written consent is
required before the conduct of verbal autopsies for the dead. The
information given out to respondents during the consent process is
documented and field workers have been adequately trained to
administer the consent. The consent process was approved by the
Institutional Review Board of the Navrongo Health Research
We conducted this study in the Kassena-Nankana District
(KND) of the Upper East region of northern Ghana. The KND
includes a population of approximately 152,000 residents who live
within the catchment area of the NHDSS. The study area is
typical of many rural areas in sub-Saharan Africa with the
majority of inhabitants being subsistence farmers who live in small,
scattered settlements. There are two main ethnic groups, the
Kassenas and the Nankanis with a combined fertility rate of 3.8.
One district hospital in the KND draws from six smaller health
centres and one private clinic in the study area. In addition, there
are more than 30 Community Health Compounds (CHCs) which
provide basic health care services in the area.
Registration of Pregnancies, Deliveries and Deaths
Fieldworkers with a minimum of a high school education are
trained for at least three weeks by NHRC in community entry and
data collection procedures. Fieldworkers identified and registered
all pregnancies, deliveries and deaths in the study area during their
routine household visits, conducted once every four months.
Community key informants, who are selected members of the
community and trained by NHRC, complement the efforts of
fieldworkers by registering all pregnancies, births and child deaths
that occur in their communities. This is to ensure the timely
capture of all demographic events, especially neonatal deaths.
Each registered pregnancy was monitored until completion and
categorized as resulting in a live birth or stillbirth, a miscarriage,
an abortion, or a migration if the pregnant woman moved out of
the study area. We determined gestational age using the mother’s
last menstrual period which was established at the time of
registering the pregnancy. Our operational definition of stillbirth
at the population level is fetal death at 28 weeks gestation or more
with no signs of life at birth, i.e. no breathing, no heart rate and no
movement. Unique identifiers linked maternal health and
demographic data to infant data. Eighty-five percent of all
pregnancies were registered by week 28. Verbal autopsies (VA)
were conducted on all infant deaths that were identified by the
Determining Cause of Death
We used validated VA tools to assess cause of death among
neonates[15–17]. The VA instruments include a battery of
questions as well as a section for verbatim narrations of the
circumstances leading to the death. Experienced field supervisors
trained by the NHRC conducted the interviews with the neonate’s
immediate caregiver. VA interviews were typically conducted
approximately 3 months after deaths occurred. This interval was
chosen to minimize the risk of additional emotional trauma for
respondents by interviewing them too soon after a neonatal death,
and to decrease the likelihood of recall bias [18,19].
Data collection was rigorously supervised, and 5% of interviews
were repeated for quality assurance. When discrepancies were
detected, interviews were repeated.
Three physicians each reviewed the VA forms and assigned an
underlying cause of death (COD) corresponding to the 3-digit
code of the international statistical classification of diseases and
health-related problems . If at least two agreed on the
underlying COD, a diagnosis was established. Where there was
disagreement among all three, the form was submitted to two
additional physicians for review. Where there was VA information
but no consensus could be reached regarding underlying COD,
the case was declared undetermined. Where little or no
information was available to enable an assignment of COD, the
diagnosis was declared unknown.
We used STATA 11.2 for all analysis. Frequencies and
descriptive statistics were calculated for both maternal and
neonate characteristics. A wealth index was computed using
principal component analysis (PCA) from household assets as an
estimate of household socioeconomic status. The household assets
in the analysis included more than 25 separate items, from large
assets (e.g., land and car ownership) to smaller household items
(e.g., radio, fan ownership). Factors potentially associated with
neonatal mortality rates were grouped into three domains:
maternal characteristics; delivery location; and infant character-
istics. Unadjusted and adjusted odds ratios with 95% confidence
intervals were computed to assess the relationship between
neonatal mortality and selected variables. Reference categories
were defined as those usually associated with the lowest neonatal
mortality rates. All variables found to be significant in bivariate
analysis were then included in a multivariate logistic regression
model, and adjusted odds ratios with 95% confidence intervals
Between January 2003 and 2009, there were 18,237 pregnant
women enrolled. In total, 429 mothers moved out of the study area
before delivery, and there were 106 miscarriages and 248
stillbirths. The analysis was limited to children whose pregnancies
were previously registered and monitored until completion.
Among the pregnancy outcomes recorded, there were 17,751 live
births including 297 multiple births. (See Figure 1.).
There were 424 neonatal deaths, 275 (64.8%) of which occurred
in the first week of life. The neonatal mortality rate for the period
was 24 per 1000 live births (95% CI 22 to 26) and the early
neonatal mortality (ENM) rate was 16 per 1000 live births (95%
Neonatal Mortality in Northern Ghana
PLOS ONE | www.plosone.org2 March 2013 | Volume 8 | Issue 3 | e58924
CI 14 to 17). Neonatal mortality rates decreased over the 7-year
period from 26 per 1000 live births in 2003 to 19 per 1000 live
births in 2009 (See Table 1).
Approximately 68% of all deliveries were full term (.36
weeks gestation) and 59% of deliveries occurred at home over
the 7-year period. Slightly less than 10% of deliveries occurred
to teenagers, and 26% of mothers were older than 35 at the
time of delivery. More than 90% of mothers had either no
formal education or education that ended after primary or
junior secondary school, and 89% were either married or
cohabitating. More than 70% of women had at least one
antenatal care visit at the time of registering the pregnancy, and
96.5% of deliveries were singleton births. The mortality rate for
singletons was 22 per 1000 compared to 72.4 per 1000 live
births for multiple births (p,0.0001). About 21% of births
occurred to mothers delivering from their first pregnancy and
77% had one or more children before this delivery.
In all, 32% (137) of the neonatal deaths were from infections,
21% (88) from birth injury and asphyxia and 18% (76) from
prematurity, making these three the leading causes of neonatal
deaths in this region of northern Ghana. Birth injury and asphyxia
are put under the same classification in this study and it includes
babies who die as a result of damages to the tissues and organs of
the child including intracranial injury (brain injury) during
delivery. These babies do not cry or cannot breathe, or have a
shrill cry or seizures shortly after birth and this is often a result of
difficulties during childbirth.
Birth injury and asphyxia (31%) and prematurity (26%) were
the leading causes of early neonatal deaths, while infection
accounted for 59% of late neonatal deaths (See Figure 2). The
main causes of death showed a decline in cause specific mortality
rates over the period with increases for infections in 2008 and 2009
(See Figure 3). There was no neonatal death attributed to
infanticide after 2007.
Figure 4 shows neonatal mortality rates by day of life. More
than 28% of all neonatal deaths (119) occurred on the first day of
life, 13% on the second day and approximately 5% on the third
day. Nearly 46% of all neonatal deaths occurred during the first
three postnatal days. There was a flattening of the cumulative
proportion of neonatal deaths curve after the fourth day.
In bivariate analysis, maternal age younger than 20, being
single, primiparity, prematurity, and multiple births were
significant predictors of neonatal deaths (Table 2). Maternal
age younger than 20 was associated with a 1.8-fold increased
Figure 1. Study population of pregnancies registered in Navrongo HDSS: 2003–2009.
Table 1. Neonatal Mortality Rates and Leading Causes of Deaths in Kassena-Nankana District, Ghana (2003–2009).
200320042005 2006 20072008 2009Total
Live Births2,9352,8242,577 2,4652,605 2,4211,924 17,751
Number of Deaths(NMR/1000)77 (26.2) 66 (23.4)74 (28.7)49 (19.9)55(21.1) 66(27.3) 37 (19.2) 424(23.9)
Infective causes (CSNMR)33 (11.2)22 (7.8)22 (8.5) 21 (8.5)10(3.8) 15(6.2)14 (7.3)137(7.7)
Birth injury (CSNMR)13 (4.4)15 (5.3)11 (4.3)11 (4.5) 17(6.5)13(5.4) 8 (4.2)88(5.0)
Prematurity (CSNMR)18 (6.1) 13 (4.6)14 (5.4)7 (2.8) 10(3.8)12(5.0)2 (1.0) 76(4.3)
Other disorders related to perinatal period (CSNMR) 0 1 (0.4)0 5 (2.0)14(5.4) 19(7.8)6 (3.1) 4 (2.5)
Infanticide (CSNMR)2 (0.7) 3 (1.1)2 (0.8)2 (0.8)0009 (0.5)
Undetermined/incomplete coding11 (3.7) 12 (4.2)25 (9.7) 3 (1.2)4(1.9) 7(2.9)7 (3.6)69 (3.9)
CSNMR – Cause-Specific Neonatal Mortality Rate.
Neonatal Mortality in Northern Ghana
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odds of neonatal death compared with mothers aged 20 to 34
years. Children delivered from first pregnancies had nearly
twofold increased odds of death in the first 28 days compared
with children from second or more pregnancies. Even though
not statistically significant, male sex was associated with a 1.2-
fold increased odds of death compared to females [OR=1.19,
95% CI (0.98–1.45)].
In multivariate analysis, multiple births, gestational age ,32
weeks and first pregnancies conferred the highest odds of neonatal
deaths. Infants from first pregnancies had a 1.5-fold increased odds
of death. Multiple gestation was associated with a nearly fourfold
increased odds of neonatal death and prematurity (gestational age
,32 weeks) was associated with a threefold increase in the odds of
Figure 2. Causes of Early and Late Neonatal Deaths in Navrongo HDSS from 2003 to 2009*. *shown as a percent of early, late, all neonatal
Figure 3. Trends in overall and cause-specific neonatal mortality rates in the Kassena-Nankana districts: 2003–2009 (n=424).
Neonatal Mortality in Northern Ghana
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In this study we found that nearly two-thirds (64.8%) of the 424
neonatal deaths in the KND in northern Ghana occurred in the
first week of life. Nearly half of all neonatal deaths (46%) occurred
in the first three postnatal days. Leading causes of all neonatal
deaths in this region were infections, birth injury and asphyxia,
and prematurity, with early neonatal deaths most likely to result
from birth injury and asphyxia and prematurity, and late neonatal
deaths most likely to result from infections. In multivariate
analysis, we found that multiple births, prematurity and first
pregnancies conferred the highest odds of neonatal deaths.
Overall, we found a neonatal mortality rate in this region of 24
per 1000 live births (95% CI 22 to 26) during the study period.
The rate fell from 26.2 neonatal deaths per 1000 live births in
2003 to 19 per 1000 live births in 2009. We also found an overall
early neonatal mortality rate of 16 per 1000 live births (95% CI 14
to 17), a rate that had dropped from 17 per 1000 in 2003 to 11 per
1000 in 2009 (data not shown). Our study’s neonatal mortality rate
for the period is higher than what was found in the 2008 Ghana
Demographic Health Survey, which reported an overall neonatal
death rate of 17 per 1000 live births from the Upper East region of
Ghana  and the Child Health Epidemiology Reference Group
(CHERG), which suggested Ghana had fewer than 15 neonatal
deaths per 1000 live births . However, a 2010 estimate by Lui
et al suggested that Ghana had 28.1 neonatal deaths per 1000 live
births across the country (uncertainty interval of 20.3 to 37.1) .
It is important to remember that the Ghana DHS analysis was
based upon an unweighted random sample that included 500
infant deaths while the CHERG analysis was based upon a
combination of civil registration data and sampled DHS data. Our
findings include all neonatal deaths enrolled in NHDSS which
were monitored from pregnancy until death between 2003 and
2009 and do not reflect sampling or statistical modelling.
Neonatal mortality rates have dropped in the KND since 2003,
 a finding consistent with other literature . However, the
rate of drop in neonatal mortality is considerably less than that of
under five mortality, both worldwide and in Ghana, resulting in
the percentage of under five deaths that are attributable to
neonatal mortality rising. . Thus improvements in both under
five and neonatal mortality are masking the disproportionate
impact of deaths during the first 28 days of life in the developing
Our study showed that approximately 28% of all neonatal
deaths occurred during the first day of life, 53% during the first
three days of life, and 65% during the first week of life. These
findings are consistent with other studies reported in the literature
including those from Guatemala, India, Pakistan, Zambia and the
Democratic Republic of Congo  [23–25]. It is clear that policies
and programs that specifically target neonates during the first week
of life are urgently needed to improve both neonatal and child
Our study identified prematurity, multiple births and first births
to be significantly associated with increased odds of deaths after
controlling for other factors in our multivariable model (see
Table 2). Our findings are consistent with a similar study in
Burkina Faso  as well as elsewhere in Ghana, Pakistan, and
Democratic Republic of Congo [11,24,27]. Multiple births
accounted for 3.3% of all births and 10% of all neonatal deaths
in the study area. This may be due to the increased likelihood of
multiple births being delivered preterm , thus increasing the
odds of neonatal death. We also found that neonates born to
primiparous women had increased odds of neonatal death even
after controlling for maternal age and other confounding variables.
Similar findings were observed in Central Africa  and in
In our study, lower socioeconomic status (SES) did not confer
increased odds for neonatal death. This is contrary to much of the
existing literature that links neonatal mortality to slum residence,
lower SES, or other indicators of poverty [30–32]. Our findings
may in part be explained by the improvement in the health system
in the KND during the study period, including the widespread
implementation of Community-based Health Planning and
Services (CHPS) which assigns nurses to regional community
Figure 4. Timing of neonatal deaths in Navrongo HDSS: 2003–2009.
Neonatal Mortality in Northern Ghana
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Table 2. Demographic and health characteristics of mothers and neonates, as associated with neonatal deaths.
Live born births Neonatal deathsOdds ratio Adjusted OR
n (%) (NMR/1000 live births)(95% CI) (95% CI)
,20 1,734 (9.8)68 (39.2) 1.82 (1.38–2.39)*NS
20–34 11,386 (64.1)250 (22.0)1
4,631 (26.1)106 (22.9) 1.04 (0.83–1.31)
No formal education7,209 (40.6)170 (23.6) 0.99 (0.68–1.43)
Primary/JSS9,051 (50.8)215 (23.8) 1.00 (0.70–1.44)
Secondary/tertiary1,469 (8.3)35 (23.8)1
Missing58 (0.3)4 (6.9) 3.03 (1.04–8.84)*
Presence of partner
Single2,024 (11.4) 67 (33.1) 1.47 (1.13–1.92)* NS
Married/cohabiting 15,727 (88.6)357 (22.7)1
Yes 3,721 (21.0)140 (37.6) 1.89 (1.54–2.32)*1.52 (1.07–2.14)*
No 14,030 (79.0)284 (20.2)11
Number of children
1 4,019 (22.6)144 (35.8) 1.93 (1.54–2.42)* NS
2–4 9,057 (51.0) 171 (18.9)1
4,675 (26.4) 109 (23.3) 1.24 (0.97–1.58)
No perinatal care5,291 (29.8)123 (23.2)1
One visit or more12,460 (70.2)301 (24.2) 1.04 (0.84–1.29)
Home/other 10,523 (59.3)236 (22.4)1
Clinic/hospital 6,777 (38.2)175 (25.8)1.16 (0.95–1.41)
Missing451 (2.5) 13 (28.8)1.29 (0.73–2.28)
Male8,994 (50.7) 233 (25.9) 1.19 (0.98–1.45) NS
Female8,757 (49.3) 191 (21.8)1
,32 weeks1,596 (9.0) 99 (62.0)3.39 (2.66–4.32)* 3.10 (2.43–3.96)*
32 to 36 weeks4,079 (23.0)94 (23.0) 1.21 (0.95–1.54)1.11 (0.87–1.42)
.36 weeks 12,076 (68.0)231 (19.1)11
Yes594 (3.3) 43 (72.4)3.46 (2.50–4.80)* 3.91 (2.79–5.49)*
No 16,703 (94.1) 368 (22.0)11
Missing454 (2.6) 13 (28.6) 1.30 (0.75–2.29) 1.18 (0.67–2.08)
Poor3,831 (21.6) 99 (25.8) 1.23 (0.90–1.67)
Next poor3,323 (18.7)67 (20.2) 0.95 (0.68–1.33)
Average 3,399 (19.1)72 (21.2)1
Next rich3,425 (19.3)81 (23.6) 1.12 (0.81–1.45)
Rich 1,875 (10.6)53 (28.3) 1.34 (0.94–1.54)
Missing1,898 (10.7) 52 (27.4) 1.30(0.91–1.87)
Total17751 (100) 424 (23.9)
*Indicates significance at 95% CI. Abbreviations: NS, not significant.
Neonatal Mortality in Northern Ghana
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health centres to provide basic curative and preventive health care
We also found that young maternal age (delivery before age 20)
was not significantly associated with neonatal death rates in
multivariate analysis, which is also contrary to existing literature
. Taken together, our data suggests that improving a region’s
health system has the potential to offset the detrimental effect of
poverty and teenage pregnancy on neonatal health.
We found the main causes of neonatal death in our study to be
infections (32%), birth asphyxia and birth injuries (21%) and
prematurity (18%). Most of the neonatal deaths from infections
were due to septicaemia (86.9%), followed by acute lower
respiratory infections (5.8%), meningitis (5.1%), anaemia (1.5%)
and diarrhoea diseases (0.7%). Based on the detailed causes of
death from infections, most of the deaths could be deduced to be
from bacterial infections but a few of the gastro-enteritis cases
could be viral infections.
Our findings are consistent with Black et al.’s systematic analysis
which showed that in sub-Saharan Africa, infections, pre-term
birth complications and birth asphyxia were the leading causes of
neonatal death . However, our results conflict with a study
similar to ours conducted in neighboring Burkina Faso, which
reported pre-term birth (42%) and infections (18%) to be the
dominant causes of neonatal deaths . In our study, neonatal
deaths from infections as well as birth asphyxia and birth injuries
appeared to decrease over the period, a finding we attribute to
improvements in the health system and community’s access to
health care between 2003 and 2009. Note however that neonatal
deaths from prematurity appear to have stalled over the period.
We believe the results of our study have several important
implications for research and practice. First, we found that
neonatal mortality rates are improving in rural northern Ghana, a
sparsely populated region with widespread poverty. While such a
finding is encouraging, and may be attributable to increased
community health services and a concerted effort to provide better
healthcare for rural residents [13,14,29], our findings also suggest
that a critical intervention period in this region is being missed: the
first few days after birth. Further research is needed that explores
what occurs in those first few days. Are women delivering at home
and failing to seek post-partum care for their newborns? Are
women delivering in facilities that are ill-equipped to handle
complicated or premature deliveries, or are healthcare personnel
insufficiently trained to resuscitate infants in need? Are women
delivering in well-equipped facilities with well-trained personnel
but returning home and failing to recognize danger signs in their
infants? Poor infant feeding have also been shown to be associated
with neonatal mortality especially in the first seven days of life in
the study area . Further research is warranted to address these
and other causal questions.
Interestingly, the practice of infanticide appears to have
stopped. Researchers have described the phenomenon of the
‘‘spirit child’’  and how such infants, imbued with malevolent
intent, brought deep misfortune to the family. These infants were
perceived to be spirits ‘‘from the bush’’ and once labelled were
taken ‘‘back to the bush’’ and left alone. In a 2006 analysis from
the same region, 2% of neonatal deaths were reported to be due to
such infanticide . However our data suggests that since 2007
this practice has stopped. We speculate that widespread education
may have resulted in this practice ceasing.
From a practice standpoint, our research suggests that
healthcare providers in this region of Ghana – including
traditional birth attendants and local midwives who operate
outside the facility setting – may benefit from additional training
surrounding safe delivery, infant resuscitation, and clean delivery
practices. This latter point is consistent with other research
conducted by our group that found clean delivery practices were
not always followed, especially outside formal healthcare settings
. Our results also emphasize the importance of educating
women and other infant care providers, such as grandmothers,
about the danger signs to watch for in the first few days following
In addition to the significant implications of our findings, we
believe that this research has several important methodological
strengths. The first is that this study is a prospective study which
documented all pregnancies occurring over a 7-year period and
followed them through to delivery, thereby reducing the chances
of missing any neonatal death. This study includes data collected
every four months on nearly 18,000 participants, as well as
rigorous study oversight and the use of experienced study
personnel to collect and analyse the data .
Nonetheless, this study has several limitations worthy of
discussion. First, birth weight data was not available for the
neonatal deaths recorded in this study. Frequently, birth weight is
used as a proxy for gestational age, and both demonstrate similar
interactions with neonatal deaths [4,24,25,29,36]. In this study, we
used gestational age calculated based on the last menstrual period
(LMP) and delivery date. This method is widely used in
environments with limited technological resources, so even though
recall of exact date of LMP may not be precise, we do not think
this significantly biases the results. Second, as with any epidemi-
ologic study, causality cannot be established from cross-sectional
data. However, we found a strong association between prematu-
rity, multiple births and first births and neonatal deaths. This
relationship – while not definitively causal – provides valuable
insight into risk factors for neonatal mortality among pregnant
women in rural West Africa.
Another possible limitation of our study is the use of VA to
determine the probable COD. Even though several studies have
found VA to be a viable method to determine most COD[11,37–
41], it is not the gold standard. However, our rural West African
setting did not allow for independent validation of verbal autopsy
findings through laboratory, radiologic, microbiologic or post-
In summary, we found neonatal mortality rates are declining in
the KND of rural northern Ghana, yet the majority of neonatal
deaths occur during the first week of life. We found prematurity,
multiple births and first births to be significantly associated with
neonatal death, and our study found infections, prematurity, birth
asphyxia and birth injuries to be the leading causes of neonatal
deaths. Most of the deaths from infections were from septicaemia.
Socioeconomic status and births from teenage mothers were not
significant predictors of neonatal mortality in the study area, which
may be attributable to improvements in health systems in this
region of Ghana. Our study has important implications for
research and practice, suggesting that mothers delivering for the
first time and mothers of multiple births may require additional
attention during the neonatal period, and providers may need
additional training and resources to handle complicated and
premature deliveries. Measure should also be put in place in health
facilities to reduce neonatal sepsis by preventing and treating
infections in mothers and providing a clean birth environment for
save delivery in order to lower the chances of neonates contracting
bacterial infections. Further research is needed to better under-
stand the social, cultural, and logistical factors that are driving high
mortality in the early days following delivery.
Neonatal Mortality in Northern Ghana
PLOS ONE | www.plosone.org7 March 2013 | Volume 8 | Issue 3 | e58924
Author Contributions Download full-text
Approved final manuscript: PW CAM RAA PA JW AH AO CE.
Conceived and designed the experiments: PW CAM RA PA JW AH AO
CE. Performed the experiments: PW CAM CE. Analyzed the data: PW
CAM RA PA JW AH AO CE. Wrote the paper: PW CAM RA PA JW AH
1. Black RE, Cousens S, Johnson HL, Lawn JE, Rudan I, et al. (2010) Child Health
Epidemiology Reference Group of WHO and UNICEF: Global, regional, and
national causes of child mortality in 2008: a systematic analysis. Lancet
2. World Health Organization (2006) Neonatal and Perinatal Mortality: Country,
Regional, and Global Estimates.
3. Baiden F, Hodgson A, Adjuik M, Adongo P, Ayaga B, et al. (2006) Trend and
causes of neonatal mortality in the Kassena-Nankana district of northern Ghana,
1995–2002. Trop Med Int Health 11(4): 532–539.
4. Engmann C, Jehan I, Ditekemena J, Garces A, Phiri M, et al. (2009) Using
verbal autopsy to ascertain perinatal cause of death: are trained non-physicians
adequate? Trop Med Int Health 14(12): 1496–1504.
5. Zaidi AK, Huskins WC, Thaver D, Bhutta ZA, Abbas Z, et al. (2005) Hospital-
acquired neonatal infections in developing countries. Lancet 365(9465): 1175–
6. Bryce J, Boschi-Pinto C, Shibuya K, Black RE (2005) WHO Child Health
Epidemiology Reference Group: WHO estimates of the causes of death in
children. Lancet 365(9465): 1147–1152.
7. Stanton C, Lawn JE, Rahman H, Wilczynska-Ketende K, Hill K (2006)
Stillbirth rates: delivering estimates in 190 countries. Lancet 367(9521): 1487–
8. Anonymous Stumbling around in the dark (2005) Lancet 365(9476): 1983.
9. Lawn J, Shibuya K, Stein C (2005) No cry at birth: global estimates of
intrapartum stillbirths and intrapartum-related neonatal deaths. Bull World
Health Organ 83(6): 409–417.
10. Oestergaard MZ, Inoue M, Yoshida S, Mahanani WR, Gore FM, et al. (2011)
United Nations Inter-Agency Group for Child Mortality Estimation and the
Child Health Epidemiology Reference Group: Neonatal mortality levels for 193
countries in 2009 with trends since 1990: a systematic analysis of progress,
projections, and priorities. PLoS Med 8(8): e1001080.
11. Edmond KM, Quigley MA, Zandoh C, Danso S, Hurt C, et al. (2008) Aetiology
of stillbirths and neonatal deaths in rural Ghana: implications for health
programming in developing countries. Paediatr Perinat Epidemiol 22(5): 430–
12. Binka FN, Nazzar A, Phillips JF (1995) The Navrongo Community Health and
Family Planning Project. Stud Fam Plann 26(3): 121–139.
13. Binka FN, Bawah AA, Phillips JF, Hodgson A, Adjuik M, et al. (2007) Rapid
achievement of the child survival millennium development goal: evidence from
the Navrongo experiment in Northern Ghana. Trop Med Int Health 12(5): 578–
14. Phillips JF, Bawah AA, Binka FN (2006) Accelerating reproductive and child
health programme impact with community-based services: the Navrongo
experiment in Ghana. Bull World Health Organ 84(12): 949–955.
15. Chandramohan D, Shibuya K, Setel P, Cairncross S, Lopez AD (2008) Should
data from demographic surveillance systems be made more widely available to
researchers? PLoS Med 5(2): e57.
16. Setel PW, Whiting DR, Hemed Y, Chandramohan D, Wolfson LJ, et al. (2006)
Validity of verbal autopsy procedures for determining cause of death in
Tanzania. Trop Med Int Health 11(5): 681–696.
17. Setel PW, Macfarlane SB, Szreter S, Mikkelsen L, Jha P, et al. (2007)
Monitoring of Vital Events: A scandal of invisibility: making everyone count by
counting everyone. Lancet 370(9598): 1569–1577.
18. Engmann C, Ditekemena J, Jehan I, Garces A, Phiri M, et al. (2011) Classifying
perinatal mortality using verbal autopsy: is there a role for nonphysicians? Popul
Health Metr 9: 42.
19. Garenne M, Fontaine O (2006) Assessing probable causes of death using a
standardized questionnaire: a study in rural Senegal. Bull World Health Organ
20. World Health Organization (2005) World Health Organization International Statistical
Classification of Diseases: 10th Revision, 2nd Edition ed. Geneva: World Health
21. Ghana Statistical Service (2009) Ghana Demographic and Health Survey, 2008: Accra:
Ghana: Ghana Health Services (GHS) and ICF Macro.
22. Liu L, Johnson HL, Cousens S, Perin J, Scott S, et al. (2012) Child Health
Epidemiology Reference Group of WHO and UNICEF: Global, regional, and
national causes of child mortality: an updated systematic analysis for 2010 with
time trends since 2000. Lancet 379(9832): 2151–2161.
23. Baqui AH, Darmstadt GL, Williams EK, Kumar V, Kiran TU, et al. (2006)
Rates, timing and causes of neonatal deaths in rural India: implications for
neonatal health programmes. Bull World Health Organ 84(9): 706–713.
24. Jehan I, Harris H, Salat S, Zeb A, Mobeen N, et al. (2009) Neonatal mortality,
risk factors and causes: a prospective population-based cohort study in urban
Pakistan. Bull World Health Organ 87(2): 130–138.
25. Engmann C, Garces A, Jehan I, Ditekemena J, Phiri M, et al. (2012) Causes of
community stillbirths and early neonatal deaths in low-income countries using
verbal autopsy: an International, Multicenter Study. J Perinatol 32(8): 585–592.
26. Diallo AH, Meda N, Ouedraogo WT, Cousens S, Tylleskar T, et al. (2011) A
prospective study on neonatal mortality and its predictors in a rural area in
Burkina Faso: can MDG-4 be met by 2015? J Perinatol 31(10): 656–663.
27. Engmann C, Matendo R, Kinoshita R, Ditekemena J, Moore J, et al. (2009)
Stillbirth and early neonatal mortality in rural Central Africa. Int J Gynaecol
Obstet 105(2): 112–117.
28. Petterson B, Blair E, Watson L, Stanley F (1998) Adverse outcome after multiple
pregnancy. Baillieres Clin Obstet Gynaecol 12(1): 1–17.
29. Engmann C, Walega P, Aborigo RA, Adongo P, Moyer CA, et al. (2012)
Stillbirths and early neonatal mortality in rural Northern Ghana. Trop Med Int
Health 17(3): 272–282.
30. de Almeida MF, Alencar GP, Schoeps D, Novaes HM, Campbell O, et al. (2011)
Survival and risk factors for neonatal mortality in a cohort of very low birth
weight infants in the southern region of Sao Paulo city, Brazil. Cad Saude
Publica 27(6): 1088–1098.
31. Rahman S, Salameh K, Bener A, El Ansari W (2010) Socioeconomic
associations of improved maternal, neonatal, and perinatal survival in Qatar.
Int J Womens Health 2: 311–318.
32. Upadhyay RP, Dwivedi PR, Rai SK, Misra P, Kalaivani M, et al. (2012)
Determinants of neonatal mortality in rural Haryana: a retrospective population
based study. Indian Pediatr 49(4): 291–294.
33. Aborigo R, Moyer CA, Rominski S, Adongo P, Williams J, et al. (2012) Infant
nutrition in the first seven days of life in rural northern Ghana. BMC Preg Child
34. Denham AR, Adongo PB, Freydberg N, Hodgson A (2010) Chasing spirits:
Clarifying the spirit child phenomenon and infanticide in Northern Ghana. Soc
Sci Med 71(3): 608–615.
35. Moyer CA, Aborigo RA, Logonia G, Affah G, Rominski S, et al. (2012) Clean
delivery practices in rural northern Ghana: A qualitative study of community
and provider knowledge, attitudes, and beliefs systems. BMC Pregnancy
Childbirth 12(1): 50.
36. McClure EM, Wright LL, Goldenberg RL, Goudar SS, Parida SN, et al.
(2007)The global network: a prospective study of stillbirths in developing
countries. Am J Obstet Gynecol 197(3): 247.e1–247.e5.
37. Edmond KM, Quigley MA, Zandoh C, Danso S, Hurt C, et al. (2008)
Diagnostic accuracy of verbal autopsies in ascertaining the causes of stillbirths
and neonatal deaths in rural Ghana. Paediatr Perinat Epidemiol, 22(5): 417–
38. Setel PW, Sankoh O, Rao C, Velkoff VA, Mathers C, et al. (2005) Sample
registration of vital events with verbal autopsy: a renewed commitment to
measuring and monitoring vital statistics. Bull World Health Organ 83(8): 611–
39. Lawn JE, Osrin D, Adler A, Cousens S (2008) Four million neonatal deaths:
counting and attribution of cause of death. Paediatr Perinat Epidemiol 22(5):
40. Soleman N, Chandramohan D, Shibuya K (2006) Verbal autopsy: current
practices and challenges. Bull World Health Organ 84(3): 239–245.
41. Fottrell E, Byass P (2010) Verbal autopsy: methods in transition. Epidemiol Rev
Neonatal Mortality in Northern Ghana
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