Association of birth interval, delivery place, and distance to facility with neonatal mortality in southern Ethiopia: a cross-sectional study

Neonatal mortality remains a major public health concern in Ethiopia, particularly in rural areas where access to healthcare is limited. This study investigated the association between birth interval, place of delivery, and distance to health facilities and neonatal mortality among mothers in the Hawela Lida district in Southern Ethiopia. A cross-sectional study was conducted between February and March 2025, enrolling 3526 mothers who had delivered at least one live-born infant within the previous 5 years. We included only the most recent live birth for each mother, resulting in 3526 mother–most recent live birth pairs for analysis. Neonatal death was defined as death of a live-born infant within the first 28 completed days of life. Multistage sampling was used to select participants across ten kebeles in the Hawela Lida district. Multilevel modified Poisson regression models with robust error variance were fitted to assess the associations of birth interval, place of delivery, and distance to health facilities with the prevalence of reported neonatal death, while adjusting for individual- and community-level covariates. Among 3526 mother–most recent live birth pairs, there were 133 neonatal deaths reported, resulting in a prevalence of reported neonatal death of 3.8% (95% CI 2.6–5.9). The prevalence was slightly higher among mothers living in rural areas than among those living in urban areas (4.0% vs 2.7%). In multilevel modified Poisson regression analysis, short birth interval (< 24 months) was associated with a higher prevalence of reported neonatal death (adjusted prevalence ratio (aPR) = 2.71; 95% CI 1.70–4.18). Home delivery of the index live birth was associated with more than twice the prevalence of reported neonatal death compared with facility delivery (aPR = 2.56; 95% CI 1.52–3.69). At the community level, residing far from the nearest health facility was associated with a higher prevalence of reported neonatal death (aPR = 5.48; 95% CI 2.99–12.17). Prevalence of neonatal death was notable in the Hawela Lida district of Southern Ethiopia, particularly among mothers living in rural communities. Short birth intervals, home delivery, and greater distance from health facilities were associated with a higher prevalence of reported neonatal death. These findings suggest the need to strengthen access to maternal and newborn health services and support further longitudinal research to better understand factors associated with neonatal death and inform effective interventions.