According to the WHO, 295,000 women and 2.5 million newborns die every year during childbirth from preventable causes. In addition, 2.6 million stillbirths occur every year. Around 98% of these deaths occur in low-resource countries [1] - [4] . In sub-Saharan Africa, including Côte d’Ivoire, various demographic and health surveys show that neonatal mortality accounts for 40% of infant deaths [5] and is higher in absolute terms than in the rest of the world. The challenge for this country is to ensure a high quality of care [6] . This involves identifying care problems and adopting good practices. The WHO recommends carrying out an audit of morbidity and neonatal deaths to identify and implement ways of improving the quality of maternal and neonatal care [7] . Through this process, hospital staff can learn from the audited cases and improve care. The Ministry of Health of Côte d’Ivoire has included in its action plan for the survival of newborns, a decentralization of the care of newborns in regional hospitals as one of the interventions to be implemented. The Ministry of Health of Côte d’Ivoire has included in its action plan for newborn survival, a decentralization of the care of newborns in regional hospitals as one of the high-impact interventions for the reduction of neonatal mortality [8] .

This is how a neonatal unit has been opened in a regional hospital (CHR), which is a second-level hospital in the Ivorian health pyramid. To firmly anchor this decentralization policy, it is important to put in place a strategy for large-scale implementation. To facilitate this transition, an audit of neonatal deaths was carried out in this unit. The aim of this study was to provide teams with tools enabling them to understand the causes and factors leading to neonatal deaths.

This study enabled us to carry out an audit of neonatal deaths, the aim of which is to improve patient care. The audit can be carried out in several ways [11] . The three delays model designed by Thaddéus and Maine in 1994 [10] initially to audit maternal deaths has been little used in audits of neonatal deaths [12] . Its use in our study enabled us to determine the main direct causes of newborn death and to analyze the factors contributing to the three delays. The mortality rate was 14%, and the main causes of death were neonatal asphyxia (34%), neonatal infection (24%) and prematurity (14%). Our data are in line with those of several other authors, but in a different order [13] - [18] neonatal asphyxia has immediate repercussions on the morbidity and mortality of the newborn, as well as sometimes serious consequences for the child’s development [19] . There is a need to reinforce guidelines aimed at transferring high-risk pregnancies in utero to specialized centers where the mother and newborn can be properly cared for, with a view to reducing maternal and infant mortality [12] . Similarly, emergency obstetric and neonatal care, and resuscitation of the newborn in the delivery room, must be taught in all centers that deliver babies. In addition, proper monitoring of labor with a partogram would prevent many cases of perinatal asphyxia [12] . Neonatal infection was the second leading cause of death. Several factors could explain infections in newborns. On the one hand, factors linked to the mother’s urogenital infections, which accounted for 22.9% of untreated or poorly treated infections during pregnancy, and on the other, poor hygiene conditions during hospitalization. According to Nyenga’s study, obstetrical history was a factor in neonatal infections [20] . Reinforcing the prevention of urogenital infections in mothers is necessary [12] [21] . The audit process enabled us to note that the third delay (78.6%) was the most frequent, followed by the first delay (63%), then the second delay (40%). In the study by Mbaruku et al. in Tanzania, the third delay (72.5%) was the most frequent, followed by the second delay (21.5%) and the first delay (19%) [12] .

On the other hand, for Fla Koueta et al, the second delay (77%) was the most frequent, followed by the third delay (66.9%) and finally the first delay (64.4%) [22] . The overall analysis of these results authorizes us to say that the delay in deciding to go to a health service causes the greatest number of deaths. In fact, the first delay was noted in 62.9% of deaths, and significantly increased the risk of death, with an odds ratio of 1.27. This underlines the importance of pregnancy monitoring, whose parameters and interventions are crucial to the harmonious growth of the newborn, as well as mothers’ lack of awareness of danger signs [23] . Pregnancy monitoring needs to be strengthened by improving ANC for early detection of high-risk pregnancies [24] . The second delay was observed in 40% of deaths.

The contributing factors were origin from a peripheral maternity hospital and low socio-economic status, but we found no statistical link between these factors and death. For Mbaruku et al. and Hinderaker et al. in Tanzania, this delay is not only linked to the remoteness of the health center and poverty, but also and above all to the poor organization of the referral system [12] [25] [26] . Emergency obstetric and neonatal care (EmONC) should emphasize essential care at birth and emergency gestures to be performed in the event of vital distress before any transfer, which should be medicalized. The third delay (79%) was encountered in hospital. This was mainly due to a delay in the start of treatment because the paraclinical work-up had not been carried out urgently. For Kedy Koumet et al., the factors influencing in-hospital mortality are the socio-economic environment, access to care, patient type, technical facilities and human resources [15] .

Neonatal mortality remains high and results from a delay in consultation and monitoring of pregnancy. Measures must be taken to reduce this delay.

Kouakou Cyprien: conception, data collection, data entry, data analysis, and drafting of the manuscript

Djivohessoun Augustine: participation in study design and manuscript writing.

Djoman Isabelle, Gro Bi Andre, Mansou Komenan: participation in drafting the manuscript.

Folquet A. Designing and carrying out the work of collecting the results, Reading and revising the manuscript. All authors have read and approved the final version of the manuscript.