Post-discharge survival and incomplete postnatal care continuum among newborns discharged from hospital-based newborn care in Ethiopia: a prospective cohort study

Abstract Background The period after discharge from hospital-based newborn care is a critical but often under-documented phase in the continuum of care for newborns, particularly for preterm, low-birth-weight, and sick newborns. In Ethiopia, previous studies from the same broader implementation research project documented health system readiness, referral linkage, and quality-of-care challenges affecting newborn care. However, less is known about survival and postnatal care utilization after newborns are discharged from basic or advanced newborn care. This study assessed post-discharge survival and postnatal care utilization among newborns discharged from selected hospitals in Addis Ababa and Oromia Region, Ethiopia. Methods We conducted a prospective cohort study among 896 postpartum mother-newborn pairs discharged from four hospitals in Ethiopia between December 2017 and March 2019. The cohort included newborns discharged from advanced newborn care units, defined as neonatal intensive care units, kangaroo mother care units, or special newborn care units, and newborns discharged from basic newborn care units without admission to advanced care. Data were collected through medical record abstraction and maternal interviews at enrollment, followed by post-discharge contacts at approximately 7, 29, and 59 days after discharge. The primary outcomes were post-discharge mortality during 60 days of follow-up and utilization of postnatal care, including at least one postnatal care visit and completion of all three recommended postnatal care contacts. Modified Poisson regression with robust variance was used to identify factors associated with postnatal care utilization. Results Among 896 newborns included in the final analysis, three verified deaths occurred during 60 days of post-discharge follow-up, corresponding to a post-discharge mortality rate of 3.3 deaths per 1,000 followed newborns. One additional infant was recorded as having died before or at discharge and was not included in the post-discharge mortality numerator. Because mortality events were rare, multivariable analysis of mortality predictors was not feasible. Overall, 68.1% of newborns had at least one postnatal care visit after discharge, but only 16.1% completed all three recommended postnatal care contacts. Newborns enrolled in Oromia Region had lower utilization of at least one postnatal care visit and all three postnatal care contacts compared with those enrolled in Addis Ababa. Completion of all three postnatal care contacts was associated with facility stay of at least 24 hours after birth (aRR 1.92, 95% CI 1.21–3.05), maternal awareness of newborn danger signs at discharge (aRR 1.66, 95% CI 1.21–2.28), and maternal awareness of the timing of newborn follow-up visits (aRR 1.39, 95% CI 1.01–1.92). Conclusions Post-discharge survival was very high among newborns discharged from the study hospitals, including those who had received advanced newborn care. However, completion of the full postnatal care continuum remained low, and rural-urban differences in follow-up care were substantial. The findings suggest that survival after discharge can be favorable when newborns reach and are discharged from hospital-based care, but continuity of care after discharge remains incomplete. Strengthening discharge counseling, ensuring at least 24 hours of facility observation after birth, reinforcing maternal awareness of newborn danger signs and follow-up timing, and improving community-based postnatal follow-up may help sustain survival gains and improve post-discharge newborn care.