DOI: 10.12688/f1000research.187210.1 ISSN: 2046-1402

Documented Health System and Clinician-related Challenges among Neonatal Deaths at a Rural District Hospital, Eastern Cape, South Africa: A Retrospective Descriptive Study (2019–2025)

Babalwa Ntshalintshali, Guillermo Alfredo Pulido Estrada, Ntiyiso Vinny Khosa, Laston Gonah, Mirabel Nanjoh, Siyonela Mlonyeni
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Background Neonatal mortality remains a major public health challenge in low- and middle-income countries. Although the clinical causes of neonatal deaths are well documented, less is known about the health system and clinician-related challenges associated with neonatal deaths in rural South African hospitals. Aim To describe the documented health system and clinician- related challenges among neonatal deaths at a rural district hospital in the Eastern Cape between 2019 and 2025. Methods A retrospective descriptive study was conducted using routinely documented data from neonatal and maternal records, as well as Perinatal Problem Identification Programme (PPIP) audits for neonatal deaths between 2019 and 2025. All in-hospital neonatal deaths of patients who died in the labour ward and those admitted to the nursery were included. Data were extracted and analysed using IBM SPSS version 30. Denominators varied due to missing or incomplete records; only valid cases were analysed for each variable. Results Among 28,107 live births, 252 neonatal deaths were recorded. The identified documentation challenges form a backdrop against which these patterns should be interpreted. Incorrect maternal management (29.7%), incorrect emergency management (22.3%), delayed clinician response (17.9%), and failure to act on clinical findings (16.4%) were the most frequently documented clinician-related issues. Health system weaknesses included insufficient doctors (18.5%), insufficient nurses (13.3%), limited theatre capacity, equipment shortages, and documentation failures. Hypothermia was significantly more common among neonates born outside the facility (p < 0.001) in the neonates who died. Conclusion Frequently documented clinician-related issues and health system weaknesses were staffing shortages, equipment limitations, and delayed clinician responses. These findings highlight areas for quality improvement initiatives in routine care processes and health system support in similar resource-limited settings. Ethics Approved by Walter Sisulu University (WSU HREC 110/2025) and the Eastern Cape Health Research Committee (EC_202507_061).

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