Authorisation from the departmental authorities, health districts and department heads were obtained prior to data collection. Anonymity and confidentiality were guaranteed at all stages concerning the identity of newborns and their parents on the one hand, and on the other hand for the healthcare staff involved in the care of the mother and newborn.

From 1^st January to 31 May 2020, 74 newborns died out of 588 admissions, representing an in-hospital mortality rate of 12.58%. Of these, 57 (77.03%) deaths occurred during the first week of life, representing an early neonatal in-hospital mortality rate of 9.69%, and 17 (22.97%) occurred after the first week, representing a late neonatal in-hospital mortality rate of 2.89%. The direct causes of death were infection (47.30%), prematurity (33.78%), hyaline membrane disease (28.38%), perinatal asphyxia (27.03%), respiratory distress (12.16%), congenital malformations (9.46%), neonatal jaundice (6.76%), hypoglycaemia and disseminated intravascular coagulation (DIVC) (5.41%), neonatal anaemia (4.05%), hypothermia (2.70%), hypotrophy, heart disease, septicaemia and haemorrhagic syndrome in 1.35% of cases each.

Male newborns accounted for 47% and female newborns for 52.30%, giving a sex ratio of 0.89. Among the latter, 59.46% were born outside the hospital and 40.54% in the hospital’s maternity ward. Referred newborns were transported by motorbike (51.62%), non-medical vehicle (12.90%) and ambulance (35.48%). Referrals were made by general practitioners (44.83%), midwives (31.03%), nurses (9%), nursing assistants, paediatricians and others in 3.45% of cases.

The main dysfunctions identified in the community were delayed access to care (45.95%), poorly monitored pregnancies (35.14%) and home births (13.51%). The distribution of newborns according to community dysfunctions is presented in Table 1 .

The main dysfunctions noted in peripheral centers were delays in referral (35.14%), inadequate pre-referral care (13.51%), and non-medical referral (12.16%). The distribution of newborns according to dysfunctions at the peripheral center is shown in Table 2 .

The main dysfunctions noted at the referral hospital were inadequate emergency treatment (47.30%), poorly completed medical records (37.84%), and inadequate treatment of complications (27.03%). The distribution of newborns according to dysfunctions at the referral center is shown in Table 3 .

In the community, awareness-raising was mainly recommended as a corrective measure. At the peripheral center, this involved feedback meetings (50%) and working sessions (10.81%). At the referral center, the proposed actions were feedback (63.51%), advocacy with the hospital administration (27.03%), and feedback to the neonatology team (27.03%). The distribution of corrective actions formulated for the referral center is shown in Table 4 .

After completing the first phase of the audit, it became necessary to organize the response at the departmental level in order to extend the systematic review of newborn deaths in the health districts of the Borgou department. The terms of reference were developed with a view to seeking funding to train the neonatal death surveillance committees of the four health districts of the Borgou Departmental Health Directorate in the different methods of neonatal death audit. This training took place from June 1^st to 30, 2020. This enabled the capacity building of 55 members of neonatal death surveillance committees throughout the Borgou department. These committees were responsible for conducting maternal and neonatal death audits at the operational level. Starting in 1^st July 2020, these committees regularly conducted neonatal death audits under the supervision of the Borgou Departmental Health Directorate authorities. The distribution of committee members trained from June 1^st to 30, 2020, is presented in Table 5 . In view of the extent of the dysfunctions related to the referral of mothers and newborn and under the aegis of the authorities of the Borgou Departmental Health Directorate, a reorganization of referrals and counter-referrals was carried out: in May 2025, a forum for the management of referrals and counter-referrals of mother-child pairs was created. A monthly schedule of pediatricians and obstetrician-gynecologists is drawn up at the beginning of each month. Referrals are reviewed by both experts, according to their field, as they are made. Feedback is provided to the health workers involved in the referral. A referral and counter-referral committee has also been set up in the referral hospital to manage counter-referrals to peripheral health centers.

After reviewing the work of the audit committees of the four health districts from July 1^st, 2020, to June 30, 2025, we arrived at the following results: of the 1,427 neonatal deaths recorded in the Borgou Departmental Health Directorate, 895 were audited, representing an audit completion rate of 62.71%.

The distribution of death audit completion rates in the Borgou Departmental Health Directorate from July 1^st 2020, to June 30, 2025, by health district is presented in Table 6 .

In-hospital mortality according to this study was 12.58%. A hospital study conducted in a leading university hospital in the Somali region of Ethiopia found a mortality rate of 130 per thousand live births; birth asphyxia, prematurity, sepsis and congenital anomalies were the main causes of admission and death [6] . Another study conducted in 35 hospitals in Tanzania noted a neonatal mortality rate of 11.3%. The main causes of early neonatal death were birth asphyxia (22.3%) and respiratory distress (20.8%), while those of late neonatal death were sepsis (29.1%) and respiratory distress (20.0%) [7] . In a provincial hospital in Botswana, neonatal mortality was 227 per 1000 live births. Univariate analysis revealed that sepsis, extremely low birth weight, hypoxic ischemic encephalopathy, critical illness, and infants born at home were associated with an increased risk of all-cause mortality [8] . This rate is below the 20.3% found in Douala hospital at Cameroon [9] . In a study conducted in a university hospital in Burkina Faso, the neonatal mortality rate was 19.72%. The main causes of death were neonatal infections 37.68%, prematurity 22%, asphyxia 53.62%, respiratory distress 68% [10] . Another study in another university hospital in the same country noted that the main causes of death were prematurity (42.84%), neonatal infection (NNI) (25.42%), neonatal distress (NNS) (20.81%) and malformation (3.80%) [11] . In Ghana, the same causes were found in two different health and demographic surveillance systems [12] .

Neonatal mortality remains high despite efforts to positively impact this indicator. This slows down the reduction of infant and child mortality. The direct causes of neonatal deaths are known and preventable in most cases. However, many factors contribute to their occurrence. These factors are linked to risky behaviors in the community with regard to healthcare, healthcare professionals, and the organization of care. Other African authors have also noted similar dysfunctions in studies conducted on the audit. According to a study conducted in Côte d’Ivoire in 2016, the three delays identified were: delayed decision-making (84.2%), delayed access to health services (20.2%), and delayed receipt of appropriate care (15.7%) [13] .

In another study in Somalia, those whose mothers did not attend prenatal care visits were at greater risk of death [14] . In Papua New Guinea, patient-related factors included failure to respond to reduced fetal movements and delays in seeking care during labor. Factors associated with healthcare personnel included poor intrapartum care, late diagnosis of breech presentation, and a prolonged second stage without intervention [5] . In a study conducted in Haiti and the United States, infant mortality rates were generally higher for births outside hospitals than for births in hospitals [15] [16] .

Systematic audits of neonatal deaths are a strategy for improving the quality of care [17] . Indeed, systematic death audits and clinical mentoring have led to a downward trajectory in all perinatal mortality indicators in Bangladesh, Ghana, and Tanzania through improved quality of care [18] . The 100% completion rate set by the ministerial decree that institutionalized neonatal death audits has not been achieved. Some authors have cited the availability of resources to support audits as a factor that either promotes or hinders the regularity of audits [19] [20] .