In-hospital mortality and associated factors among term neonates with documented perinatal asphyxia in eastern Democratic Republic of the Congo: a retrospective cohort study

Abstract Background Perinatal asphyxia remains an important contributor to neonatal mortality and neurodevelopmental impairment, particularly in resource-limited settings, yet contemporary evidence from eastern Democratic Republic of the Congo (DRC) is scarce. We assessed the hospital burden, clinical severity, and factors associated with in-hospital mortality among affected neonates admitted to a tertiary neonatal intensive care unit (NICU). Methods We conducted a retrospective cohort study at the Hôpital Provincial Général de Référence de Bukavu, eastern DRC, including neonates with documented perinatal asphyxia admitted between January 2021 and December 2025. Diagnosis was based on an integrated assessment of perinatal, clinical, neurological, and, when available, biochemical findings documented by the attending NICU pediatrician. Hospital-detected incidence was estimated among inborn neonates. Prognostic analyses were restricted to term neonates and used logistic regression, with Firth penalization for multivariable analysis because of the limited number of deaths. Results Among 2,333 NICU admissions, 257 neonates (11.0%) had documented perinatal asphyxia, of whom 60 (23.3%) died. Among 183 inborn cases, the hospital-detected incidence proportion was 20.9 per 1,000 livebirths (95% CI 18.0–24.2). The primary prognostic analysis included 153 term neonates, of whom 27 (17.6%) died. Among 121 neonates with documented Sarnat–Sarnat staging, mortality increased from 4.5% in stage I to 15.3% in stage II and 32.5% in stage III (global exact p=0.018). Lower birth weight and outborn status were associated with mortality in univariable analyses. In the Firth multivariable model (n=99; 16 deaths), Sarnat–Sarnat stage remained associated with mortality overall, although adjusted estimates were highly imprecise. Conclusions Documented perinatal asphyxia was associated with substantial in-hospital mortality in this tertiary NICU, with mortality increasing across recorded encephalopathy stages. Lower birth weight and outborn status emerged as additional prognostic signals in exploratory univariable analyses. Given the limited number of deaths and substantial imprecision of adjusted estimates, these findings should be considered hypothesis-generating and require confirmation in larger prospective studies.