Neonatal mortality following referral from peripheral facilities to Kanifing General Hospital, The Gambia (2022–2024): a survival analysis approach

BACKGROUND: Neonatal mortality remains a critical public health challenge in Sub-Saharan Africa, with The Gambia reporting one of the highest rates in the region. Despite global progress, the neonatal mortality rate has shown limited decline, and context-specific data on delivery setting-related risk factors remain needed to inform health system strengthening in The Gambia. We aimed to identify risk factors for neonatal mortality at Kanifing General Hospital (KGH), and examine the association between place of delivery and survival outcomes. METHODS: We conducted a retrospective cohort study of 1,354 neonates admitted to KGH between January 2022 and December 2024. The primary outcome was neonatal death during admission. Kaplan-Meier survival analysis and Cox proportional hazards regression with robust standard errors clustered by facility were used to identify risk factors. RESULTS: During the study period, 137 deaths occurred (10.1% mortality; 95% CI: 8.6-11.9). Median follow-up was 96 h. Overall, survival at 7 days was 87.8%, but differed substantially between neonates delivered at KGH Labour Ward (91.3%) versus peripheral facilities (78.9%; log-rank p < 0.001). In multivariable analysis, delivery at KGH Labour Ward was strongly protective (adjusted hazard ratio [aHR] 0.41; 95% CI: 0.28-0.58; p < 0.001), representing a 59% reduction in mortality risk. Higher birth weight was protective (aHR 0.58 per kg; 95% CI: 0.37-0.90; p = 0.016), while birth asphyxia increased mortality risk (aHR 1.30; 95% CI: 1.11-1.53; p = 0.001). The model demonstrated acceptable discrimination (C-statistic = 0.713). E-value sensitivity analysis indicated robustness to unmeasured confounding (E-value = 4.36 for facility effect). Study limitations include the retrospective design and single-center setting. CONCLUSIONS: Neonates referred from peripheral facilities experienced substantially higher mortality compared to those delivered at the referral hospital. Birth weight and birth asphyxia were independently associated with survival. These findings highlight the critical importance of strengthening referral hospital capacity and improving quality of care at peripheral facilities to reduce neonatal mortality in The Gambia.