Survival, Mortality Predictors, and Morbidity in Extremely Low Birth Weight Neonates: A Retrospective Cohort Study at a Tertiary Hospital in the Eastern Cape, South Africa

<b>Background</b>: Extremely low birth weight (ELBW) neonates (<1000 g) contribute significantly to global neonatal and under-five mortality, with heightened vulnerability in resource-limited settings. <b>Objectives</b>: The overall aim of this manuscript is to evaluate the survival outcomes and associated factors among ELBW infants in a resource-limited tertiary care setting in South Africa. <b>Methods</b>: This retrospective cohort study examined survival outcomes, causes of death, and associated morbidities among 192 ELBW infants admitted to Frere Hospital, South Africa (SA), between January 2020 and February 2025. Kaplan-Meier survival analysis and multivariable Poisson regression were used to identify predictors of mortality. <b>Results</b>: Overall, 42% of neonates survived to discharge. Common morbidities included respiratory distress syndrome (78%) and extreme prematurity (30%). Extreme prematurity (<28 weeks) was associated with a markedly increased risk of mortality (adjusted IRR = 0.20; 95% CI: 0.08-0.53; <i>p</i> < 0.001), while caesarean section conferred a protective effect compared to vaginal delivery (adjusted IRR = 0.38; 95% CI: 0.23-0.64; <i>p</i> < 0.001). <b>Conclusions</b>: The findings highlight that strengthened antenatal care, consistent neonatal resuscitation, and equitable intensive care remain essential. Policy-driven investment in surfactant therapy, CPAP, and infection control is critical; without such measures, ELBW infants' mortality will continue to be disproportionately high in resource-limited settings.