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. 2023 Feb 21;18(2):e0278741. doi: 10.1371/journal.pone.0278741

Prevalence and determinants of neonatal near miss in Ethiopia: A systematic review and meta-analysis

Ababe Tamirat Deressa 1,*, Melese Siyoum Desta 2
Editor: Carla Betina Andreucci3
PMCID: PMC9942950  PMID: 36809252

Abstract

Introduction

Neonatal near miss is a condition of newborn infant characterized by severe morbidity (near miss), but survived these conditions within the first 27 days of life. It is considered as the first step to design management strategies that can contribute in reducing long term complication and mortality. The aim of this study was to assess prevalence and determinants of neonatal near miss in Ethiopia.

Methods

The protocol of this systematic review and meta-analysis was registered at the Prospero with a registration number of (PROSPERO 2020: CRD42020206235). International online databases such as PubMed, CINAHL, Google scholar, Global Health, Directory of open Access journal and African Index Medicus were used to search articles. Data extraction was undertaken with Microsoft Excel and STATA11 was used to conduct the Meta-Analysis. Random effect model analysis was considered when there was evidence of heterogeneity between the studies.

Results

The overall pooled prevalence of neonatal near miss was 35.51% (95%CI: 20.32–50.70, I2 = 97.0%, p = 0.000). Primiparity (OR = 2.52, 95%CI: 1.62, 3.42), referral linkage (OR = 3.92, 95%CI: 2.73, 5.12), premature rupture of membrane (OR = 5.05, 95%CI: 2.03, 8.08), Obstructed labor (OR = 4.27, 95%CI: 1.62, 6.91) and maternal medical complications during pregnancy (OR = 7.10, 95%CI: 1.23, 12.98) had shown significant statistical association with neonatal near miss.

Conclusion

The prevalence of neonatal near miss in Ethiopia is evidenced to be high. Primiparity, referral linkage, premature rupture of membrane, obstructed labor and maternal medical complications during pregnancy were found to be determinant factors of neonatal near miss.

Introduction

Neonatal near miss is defined as a condition of newborn infant characterized by severe morbidity (near miss) of pragmatic and management criteria, but survived these conditions within the first 27 days of life. The pragmatic criteria includes birth weight < 1750g, Apgar score <7 at 5 minute and gestational age <33 complete weeks. The management criteria involves parenteral antibiotic therapy, nasal CPAP, any intubation, phototherapy within 24 hours of life, cardiopulmonary resuscitation, use of vasoactive drugs, use of anticonvulsants, use of surfactant, use of blood products, surgery and use of steroids for the treatment of refractory hypoglycemia [1, 2]. For neonates with life threatening situations, neonatal near miss was proposed as a tool for assessing the quality of care. It is also considered as the first step to design management strategies that can contribute in reducing long term complication and mortality [3].

Wide range rates of neonatal miss was reported across the world. Almost finding of different studies agree that the rate and/or prevalence and/or incidence of neonatal near miss is higher than that of infant or neonatal mortality. For instance, WHO multicounty Survey on Maternal and Newborn Health reported 72.5 and 9.2 neonatal near miss and early neonatal death per 1000 livebirths respectively [4]. In Brazil survey, the rate of neonatal near miss and early neonatal mortality per 1000 live births were 39.2 vs 11.1 [5].

Studies in Brazil reported different prevalence or rates of neonatal near miss from different parts of the country. The stated findings were 21.4, 91.7, 39.2 and 33 neonatal near miss cases per 1,000 live births in Brazil. In all of these studies neonatal mortality was less prevalent than neonatal near miss [5–8]. The study in Nepal indicated the prevalence to be 7.9% [9]. The Fifth Perinatal Care Survey of South Africa reported the prevalence of neonatal near miss and neonatal mortality to be 2.47 and 0.63 respectively [10]. In tertiary hospitals of Southern Ghana the prevalence of neonatal near miss was 69.5% [11] and 12% incident in Obafemi Awolowo University teaching hospitals of Nigeria [12].

Various factors contribute to the development of neonatal miss. For example, delays in obstetric care, inadequate prenatal care, delayed access to health services [13]; advanced maternal age, multiparty, hypertensive disease, forceps-assisted vaginal delivery [7]; gestational age of less than 32 weeks, use of mechanical ventilation, congenital malformation [5]; gestational age < 33 weeks, neurologic dysfunction, respiratory dysfunction, hemoglobin < 10 g/dl [11], not being delivered with cesarean section, and severe maternal morbidity [9] are some of the stated factors from different studies.

In Ethiopia, the neonatal and infant mortality rate remain higher than the rate from some developing countries. The recent finding reported the neonatal mortality rate of 29.1 [14] and the infant mortality rate of 48 deaths [15] per 1,000 live births respectively.

As it has been evidenced in different findings, it can be understood that we can save the life many neonates from those who were diagnosed for neonatal near miss. Hence, Identifying the burden of neonatal near miss and its associated factors directly contribute to reduction of neonatal mortality since it help us to early diagnosis and treat the causes the mortality. However, different studies reported different prevalence and determinant factors of neonatal near miss in the country. Hence, it remained unclear to understand the burden and determinants of neonatal near miss at country level. Thus, this study aimed at generating single study that estimates the prevalence and determinants of neonatal near miss in Ethiopia.

Methods

PROSPERO registration

The protocol of this systematic review and meta-analysis was registered at the Prospero with a registration number of (PROSPERO 2020: CRD42020206235) that is available from https://www.crd.york.ac.uk/PROSPERO.

Search strategy

International online databases (such as PubMed, CINAHL, Google scholar, Global Health, Directory of open Access journal and African Index Medicus) and the Hawassa university library were used to search articles on prevalence and determinants of neonatal near miss from August 15–25, 2020. To access all important articles from the mentioned data bases, searching terms were based on adapted PICO questions. Different approaches were utilized to get comprehensive data on neonatal near miss. MeSH terms including “neonatal near miss” OR “perinatal asphyxia OR “birth asphyxia” OR “prematurity” OR “preterm birth” OR “neonatal jaundice” OR “neonatal hypoglycemia” OR “Neonatal organ failure” OR “Neonatal seizure” OR “severe congenital anomaly” AND related in Ethiopia were searched in the international online electronic database. These MeSH terms are generated based on the definition on neonatal near miss as stated in the introduction.

Inclusion and exclusion criteria

Cross-sectional, case-control and cohort studies were included (Table 1). Cross sectional studies were only considered to calculate the pooled prevalence of neonatal near miss. Research articles written in English language which reported the prevalence or magnitude and/or associated factors or predictors or determinants of neonatal near miss were included in this Systematic review and meta-analysis. On the other hand, articles without full text and abstract, duplicated studies and anonymous reports were excluded.

Table 1. Study characteristics included in the systematic review and meta-analysis.

S/No Author [year] Region Sample Size Study design Data collection techniques Study Setting
1. Belay HG et al [from Research square] Amhara 404 Cross sectional Checklist based Institution based (hospital)
2. Mersha A et al [2019] SNNPR* 484 Case-Control Interviewer administered Institution based (hospital)
3. Tekelab T et al [2020] SNNPR* 2,704 Cohort study Interviewer administered Institution based (hospital)
4. Woldeyes Y et al [unpublished] SNNPR* 380 Cross sectional Checklist based Institution based (hospital)
5. Tassew HA et al [2020] Amhara 422 Cross sectional Checklist based Institution based (hospital)
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*Southern Nation, Nationalities and People’s Region

Data extraction and quality assessment

After collecting findings from all databases and screening the eligible studies, the articles were extracted on Microsoft Excel spreadsheet. The two authors (ATD & MSD) independently extracted the data and reviewed all the screened and included articles. Any disagreement was handled by the third invited reviewer. After all, a consensus was reached through discussion between authors. Newcastle- Ottawa Quality Assessment Scale (NOS) for cross- sectional, case-control and cohort studies was used to assess the methodological quality of each study and to deter- mine the extent of addressing bias in its selection, comparability and outcome measurement. As per the NOS, fulfilling 3 or 4 criteria in selection domain and 1 or 2 in comparability domain and 2 or 3 in outcome/exposure domain guarantees the study to be categorized as good quality study. Accordingly, all included studies are with good quality.

Measurement of outcome

Two main outcome variables were considered in this study. The first is prevalence of neonatal near miss and the second is determinants of neonatal near miss. Standard error (SE) and Odds ratio (OR) were calculated as effect measure for the analysis of prevalence and determinant factors respectively.

Publication bias and heterogeneity

To check the heterogeneity of the studies, the analysis of Cochrane Q test and I2 with its corresponding p-value were used. A value of 0, 25, 50, and 75% was used to declare the het- erogeneity test as no, low, medium and high heterogeneity respectively. Analysis of random effect model computed when there is evidence of heterogeneity. Funnel plot and Egger regression asymmetry tests were employed to assess the existence of publication bias. A funnel plot showed that asymmetrical distribution and the Egger test value was 0.034. Hence, there is publication bias in the studies.

Data analysis

The data were extracted using Microsoft Excel. Then, meta-analysis were conducted using STATA 11 software. The estimated prevalence of each study was presented using forest plots with standard error as effect measure and 95% confidence interval (CI). Besides, the analysis of determinant factors from the studies were presented by using forest plots with effect measure of Odds ratio (OR) and its 95% confidence interval (CI).

Ethical consideration

Ethical clearance is not needed for this Systematic Review and Meta-Analysis.

Results

A total of 101 articles and one article were found with electronic and other approach of searching respectively. Twenty eight were duplication and 74 articles were screened. From these 74 articles, 69 of them were excluded due to irrelevance, absence of full text or Abstract. Finally, 5 articles were remained eligible for this systematic review and meta-analysis among which three articles were used to determine the pooled prevalence of neonatal near miss (Fig 1).

Fig 1. PRISMA flow chart of study selection for systematic review and meta-analysis of prevalence of neonatal near miss in Ethiopia.

Fig 1

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Epidemiology of neonatal near miss in Ethiopia

A wide-ranging prevalence of neonatal near miss was observed across different studies included in this review [16–18]. The overall pooled prevalence of neonatal near miss in Ethiopia was found to be 35.51% (95%CI: 20.32–50.70, I2 = 97.0%, p = 0.000) using a random effect model (Fig 2).

Fig 2. Pooled prevalence of neonatal near miss in Ethiopia.

Fig 2

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Determinants of neonatal near miss

Five studies were used to analyze determinant factors for neonatal near miss (Fig 3).

Fig 3. PRISMA flow chart of study selection for systematic review and meta-analysis of determinants of neonatal near miss in Ethiopia.

Fig 3

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Association between primiparity and neonatal near miss

Two studies were involved for meta-analysis of this category [16, 17]. The likelihood of developing neonatal near miss among neonates who were born to primipara mother was 2.52 times (OR = 2.52, 95%CI: 1.62, 3.42) more likely than their counter parts. Studies included in this meta-analysis were characterized by no heterogeneity (I2 = 0.0%, p = 0.829). Thus, the analysis was undertaken with fixed effect model (Fig 4).

Fig 4. Association between primiparity and neonatal near miss.

Fig 4

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Association between referral linkage and neonatal near miss

Two studies were involved in this category of meta-analysis [16, 19]. The likelihood of developing neonatal near miss among neonates who had history of referral linkage was almost 4 folds (OR = 3.92, 95%CI: 2.73, 5.12) higher than their counter parts. Studies included in this meta-analysis were characterized by no heterogeneity (I2 = 0.0%, p = 0.502). Thus, the analysis was conducted with fixed effect model (Fig 5).

Fig 5. Association between referral linkage and neonatal near miss.

Fig 5

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Association between premature rupture of membrane (PROM) and neonatal near miss

Three studies were involved for meta-analysis of this category [16, 17, 20]. Neonates who were born after premature rupture of membrane (PROM) had 5 times (OR = 5.05, 95%CI: 2.03, 8.08) more odds of developing neonatal near miss than their counter parts. Studies included in this meta-analysis were characterized by moderate heterogeneity (I2 = 49.1%, p = 0.140). Hence, the analysis was undertaken with random effect model (Fig 6).

Fig 6. Association between premature rupture of membrane (PROM) and neonatal near miss.

Fig 6

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Association between obstructed labor and neonatal near miss

Two studies were involved in this category of meta-analysis [16, 17]. Neonates who were born to mothers with history of obstructed labor had 4.27 times (OR = 4.27, 95%CI: 1.62, 6.91) more odds of developing neonatal near miss than their counter parts. Studies included in this meta-analysis were characterized by no heterogeneity (I2 = 0.0%, p = 0.908). Thus, analysis was undertaken with fixed effect model (Fig 7).

Fig 7. Association between obstructed labor and neonatal near miss.

Fig 7

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Association between history of maternal medical complications during pregnancy and neonatal near miss

Three studies were involved for meta-analysis of this category [17, 19, 20]. The likelihood of developing neonatal near miss among neonates who were born to mothers who had history of medical complications during pregnancy was 7 times (OR = 7.10, 95%CI: 1.23, 12.98) more likely than those neonates born to mothers who had no history of medical complications. Studies included in this meta-analysis were characterized by high heterogeneity (I2 = 82.7%, p = 0.001). Thus, the analysis was undertaken with random effect model (Fig 8).

Fig 8. Association between history of maternal medical complication and neonatal near miss.

Fig 8

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Discussion

In this Systematic review and Meta-analysis, the prevalence and determinants of neonatal near miss in Ethiopia were explored. Accordingly, the finding evidenced as neonatal near miss is significant public health problem in the country so that policy maker should design strategies to improve obstetric and neonatal care for its reduction. The pooled prevalence of neonatal near miss in this study is higher than that of reported prevalence from Brazil [5–8], Nepal [9], south Africa [10], Ghana [11] and Nigeria [12]. These stated countries might have better socio-economic status that may contribute for having better facility that gives quality obstetric and neonatal care. This care is directly linked with the status of neonatal near miss in a country. Thus, the variation of the prevalence can be due to this differences. Moreover, other reasons for this variation may include differences in study settings, study design and sample size.

Primiparity was found to be risk for neonatal near miss in this study and neonates of primipara mothers shall get close attention in neonatal care. This finding is supportable with finding from Nepal where neonates who born to multiparous women less likely develop neonatal near miss in Nepal [9]. Primipara mothers may not have adequate birth preparedness as multipara mothers which highly contributes to prevent maternal and neonatal complications during and after pregnancy. Hence, this may be the reason behind for association of primiparity and neonatal near miss.

In this study, neonates who had history of referral linkage showed more odds of developing neonatal near miss. This is may be due to delay of getting quality services that is evidenced to be the risk for developing neonatal near miss [12, 13]. In addition, the case/morbidity of the neonates may get aggravated till they reach the institutions to which they are referred. On the other hand, this study also evidenced as premature rupture of membrane (PROM) is one of the determinant factors for neonatal near miss. Different studies [21–24] stated as PROM is risk factor for neonatal sepsis. Neonatal sepsis is treated with parenteral antibiotic therapy which is one of the management criteria [1] to define neonatal near miss. Thus, this reason may justify the association between PROM and neonatal near miss. This association may imply as Ministry of health and Regional health bureau shall integrate Neonatal intensive care unit in each hospitals so as to reduce referral linkage.

Obstructed labor may be risk factor for prolonged labor which in turn can lead to meconium staining. Various studies [25–30] reported that meconium staining is determinants of perinatal asphyxia. Neonates with perinatal asphyxia might fulfill the criteria for definition of neonatal near miss [1] since their management may involve parenteral antibiotic therapy, nasal CPAP and intubation. These all may be the reason behind for the association between obstructed labor and neonatal near miss. This association implies as neonates born after obstructed labor should get close supervision and better care.

Maternal medical complication that was found to be determinant factor of neonatal near miss in this study is supported with finding from other studies [7, 9, 12]. So, health care professional shall pay better attention of for newborns of these mothers in unit of neonatal care. Evidences [31, 32] reported that complications like hypertension during pregnancy leads to preterm birth which is one of the criteria to define neonatal near miss [1] and this can be taken in to account for the current association.

Limitations

Neonatal near miss had no clear standard definition and this challenged the inclusion of the articles. In addition, it is not widely studied in the country and this resulted in finding of few published articles. On the other hand, variables were not uniformly studied across the studies and it was difficult to match the variables from different studies for the Meta-Analysis. Besides; though we have tried to minimize it, the risk of bias may have overestimated the prevalence of near miss. Moreover, we couldn’t review unpublished articles from universities in the country and this may result in very few missing.

Conclusion

From the Meta-Analysis, the prevalence of neonatal near miss in Ethiopia is evidenced to be high. Primiparity, referral linkage, premature rupture of membrane, obstructed labor and maternal medical complications during pregnancy were found to be determinant factors of neonatal near miss in this study.

Supporting information

S1 File

(DOCX)

Click here for additional data file. (15.4KB, docx)

Acknowledgments

We are grateful to Hawassa University for providing internet services which is vital for accomplishment of this systematic Review and Meta-Analysis. Again, we extend our thanks to Dr. Ayalew Astatkie for his support in reviewing. Moreover, our gratitude extends to Dr. Dereje Bayissa for his support in English edition.

Data Availability

All relevant data are within the paper and its Supporting Information files.

Funding Statement

The authors received no specific funding for this work

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15 Dec 2021

PONE-D-20-32942Prevalence and determinants of neonatal near miss in Ethiopia: A Systematic Review and Meta-AnalysisPLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Partly

Reviewer #4: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: I Don't Know

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This is a Systematic Review and Meta-Analysis on prevalence and determinants of neonatal near miss in Ethiopia. The subject is current and relevant, and overall, the methods are adequate. However, the manuscript could have more robustness.

See please some comments below.

There is need for an English revision.

Abstract: adequate.

Introduction: I suggest you explain near miss criteria in the methods section, and not in your first paragraph. I suggest you explain a little further the importance of considering neonatal near miss together with neonatal deaths to expand health surveillance. I suggest you develop the text a little further, making hypotheses about the meaning of different available data on the prevalence of neonatal near miss worldwide, rather than simply presenting numbers. I also suggest that you describe the situation regarding infant deaths in Ethiopia, therefore highlighting the relevance of your research.

Methods: Your exclusion criteria are not clear. Was English the only language included in your search? I think the table with included studies is misplaced within the manuscript, it should appear after the PRISMA chart. I would like you to detail further how you handled the risk of bias in meta-analysis with case-control and cohort studies. You have mentioned a third reviewer handling conflicts of article inclusion in your systematic review, but the manuscript has two authors only. I suggest you name the third reviewer in acknowledgement section.

Discussion: Please explain why better socio-economic status contribute for better obstetric and neonatal care (funding for health programmes and facilities? Availability of childbirth care providers? Etc). What do you think will consist in “adequate birth preparedness” for primipara women? I don´t agree with the assumption of meconium-stained liquor to be a reason for neonatal near miss after obstructed labour. Meconium may be the consequence of a protracted labour, so reasons for the prolonged second stage of labour should play a more important role in the matter. Please provide further examples of maternal complications found in included studies that lead to neonatal near miss (you have mentioned hypertension only).

The text in limitations section is unclear.

Reviewer #2: The discussion brought important reflections, which are in line with the objective.

The methodology was adequate, as well as the statistics were satisfactorily performed: statistics were rigorous for the type of analysis in question, especially because it is an extremely relevant subject and with few articles published in the area.

The language is intelligible. The references used are recent.

Reviewer #3: The manuscript needs extensive English revision.

Some parts are confusing, e.g, Figure 4 is the same as Figure 2. In Figure 2, 5 studies were included in the final analysys but only 3 studies were included in the meta analysis of near miss prevalence.

What are the reasons for the 69 exclusions? It is recommended by rhe PRISMA guideline that authors report the reasons for exclusion.

Where is Figure 1 with the funnel plot?

Discussion should be more elaborated as some findings are poorly explained such as the findings about primiparity.

The study has an evident risk of publication bias, and this is difficult to access with less than 10 studies. This risk of bias may have overestimated the prevalence of near miss and this must be discussed.

Reviewer #4: Relevant study. Appropriate title. In introduction, it is important to add prevalence studies in developed countries, outside the African continent, only Brazil was mentioned. In the method, record the period defined for searching the databases. I recommend keeping table 1 of the characterization of the studies in the results section. One of the 5 studies selected to make up the review was not published, so how did researchers gain access to the full text?

The authors show in the method that they applied statistic tests to verify the heterogeneity but they do not present the test results.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

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PLoS One. 2023 Feb 21;18(2):e0278741. doi: 10.1371/journal.pone.0278741.r002

Author response to Decision Letter 0

22 Jun 2022

Date: June, 2022

To: PLOS ONE

Author’s Point-by-point responses

I am so grateful for the constructive and teaching comments raised from the reviewers and I have given responses for comments and questions respectively. Besides, I have highlighted the correction in the main manuscript document with truck changes.

Reviewer’s comments Author’s responses

Reviewer 1

There is need for an English revision.

Introduction: I suggest you explain near miss criteria in the methods section, and not in your first paragraph. I suggest you explain a little further the importance of considering neonatal near miss together with neonatal deaths to expand health surveillance. I suggest you develop the text a little further, making hypotheses about the meaning of different available data on the prevalence of neonatal near miss worldwide, rather than simply presenting numbers. I also suggest that you describe the situation regarding infant deaths in Ethiopia, therefore highlighting the relevance of your research. I would like to express my gratitude for your constructive comments. My responses are elicited below.

� The English revision for the manuscript was undertaken with Open Grammarly software and one fluent speaker of the language whose name is stated under the Acknowledgement.

� I thought the background information including the scientific definition of the subject matter shall be in the introduction part as introductory phase. This write-up is recommended by many researchers. Now, I have also incorporated it in the Methods section.

� The findings of the literatures were also hypothesized in the last paragraph of the introduction.

� The importance of considering neonatal near miss together with neonatal deaths to expand health surveillance was also described.

� Neonatal and infant deaths in Ethiopia were also highlighted.

Methods: Your exclusion criteria are not clear. Was English the only language included in your search? I think the table with included studies is misplaced within the manuscript, it should appear after the PRISMA chart. I would like you to detail further how you handled the risk of bias in meta-analysis with case-control and cohort studies.

You have mentioned a third reviewer handling conflicts of article inclusion in your systematic review, but the manuscript has two authors only. I suggest you name the third reviewer in acknowledgement section.

� As it was stated in the Methods Section, after searching the articles, articles without full text or abstract, duplicated studies and anonymous reports were excluded. Also, articles or reports written in language different from English was also excluded on searching phase.

� Table of included studies is part of Methods section under sub-section of “Inclusion and exclusion Criteria”. But, PRISMA chart is part of the “Result” since it describes the included and excluded researches for the two objectives separately.

� One approach to avoid bias in Meta-Analysis, especially selection bias, is conducting rigorous systematic reviews. Thus tough reviews were undertaken. Again the quality assessment was performed for each study by paying attention for related issues.

� The third reviewer is already mentioned in the acknowledgment section.

Discussion: Please explain why better socio-economic status contribute for better obstetric and neonatal care (funding for health programmes and facilities? What do you think will consist in “adequate birth preparedness” for primipara women? I don´t agree with the assumption of meconium-stained liquor to be a reason for neonatal near miss after obstructed labour. Meconium may be the consequence of a protracted labour, so reasons for the prolonged second stage of labour should play a more important role in the matter. Please provide further examples of maternal complications found in included studies that lead to neonatal near miss (you have mentioned hypertension only).

The text in limitations section is unclear. � The discussion point was to justify that the country with better socio-economic status can have improved level of medical equipment that can directly contribute to provide better or quality obstetric and neonatal care.

� Adequate birth preparedness here is to intensify any readiness the pregnant mother can have to get timely use of skilled maternal and neonatal care, especially during childbirth

� In the definition of neonatal near miss, one pragmatic criteria is birth Asphyxia. Thus, the discussion here is to show that when there is Meconium staining or aspiration more likely there will be birth Asphyxia which fulfills the diagnosis of neonatal near miss. On the other hand, the perspective from which you rationalized is also correct.

Reviewer #2 � Thank you for your constructive review!

Reviewer #3

The manuscript needs extensive English revision.

Some parts are confusing, e.g, Figure 4 is the same as Figure 2. In Figure 2, 5 studies were included in the final analysys but only 3 studies were included in the meta analysis of near miss prevalence.

What are the reasons for the 69 exclusions? It is recommended by rhe PRISMA guideline that authors report the reasons for exclusion.

Where is Figure 1 with the funnel plot?

Discussion should be more elaborated as some findings are poorly explained such as the findings about primiparity.

The study has an evident risk of publication bias, and this is difficult to access with less than 10 studies. This risk of bias may have overestimated the prevalence of near miss and this must be discussed.

I would like to express my gratitude for your constructive comments. My responses are elicited below.

� The English revision for the manuscript was undertaken with Open Grammarly software and one fluent speaker of the language whose name is stated under the Acknowledgement.

� Figure 2, corrected to Figure 1, presents the studies that are selected to determine the prevalence of neonatal near miss. In this Figure, the case control and cohort studies are not included. On the other side, Figure 4, corrected to Figure 3, presents the studies that are selected to determine the predictors of neonatal near miss. In this figure studies (including case-control and cohort study) that conducted the analysis for associated factors, determinants or predictors of neonatal near miss were included.

� Thank you for your correcting comment! Now I have corrected that 3 studies were included in Figure 2 to determine the pooled prevalence on neonatal near miss.

� As it was stated in the Methods Section, after searching the articles, articles without full text or abstract, duplicated studies and anonymous reports were excluded. Also, articles or reports written in language different from English was also excluded on searching phase.

� Again, thank you for your exceptional look. I haven’t excluded Figure 1 for invisibility of its graphics and I have now removed it from the manuscript.

� Other discussions are well looked.

� I agree with your idea concerning publication bias. Here it is analyzed to look its presence and absence. But, it is presence is not pronounced as limitation since the selected studies are less than ten.

� The possible effect of risk of bias on the result is elaborated in the Limitation section in this revised Manuscript.

Reviewer #4

Relevant study. Appropriate title. In introduction, it is important to add prevalence studies in developed countries, outside the African continent, only Brazil was mentioned.

I recommend keeping table 1 of the characterization of the studies in the results section. One of the 5 studies selected to make up the review was not published, so how did researchers gain access to the full text?

The authors show in the method that they applied statistic tests to verify the heterogeneity but they do not present the test results.

� Thank you very much for your constructive Review!

� The comment is well incorporated and the literatures from developing countries are emphasized just to make sound and equivalent discussions with the current study.

� Since it summarizes the number of selected studies from the search, hat is the reason for presenting Table 1 in Methods section.

� As it recommended one approach of minimizing selection bias is searching and including unpublished articles. Thus; we, the authors, included the unpublished articles from the library of Hawassa University where we were working.

� The Figure of heterogeneity test is removed due to its graphics invisibility. However, the test result is written in text in the paragraph.

Attachment

Submitted filename: Response to Reviewers.docx

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Decision Letter 1

Carla Betina Andreucci

24 Aug 2022

PONE-D-20-32942R1Prevalence and determinants of neonatal near miss in Ethiopia: A Systematic Review and Meta-AnalysisPLOS ONE

Dear Dr. Deressa,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

The reviewers suggested further revision in your manuscript. The review comments can be found at the end of this email. Please note some minor clarifications needed and the suggested language revision.

Thank you for submitting your article to Plos One. We look forward to receiving your revision.

Please submit your revised manuscript by Oct 08 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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Academic Editor

PLOS ONE

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Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

Reviewer #3: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

Reviewer #3: No

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: The researchers accepted most of the suggestions, with a great improvement in the paper.

I believe that some topics of the "discussion" could have been discussed more comprehensively.

I reinforce the importance of the topic.

Reviewer #3: The manuscript has suffered many corrections, but English needs to be revised. Maybe there are texting problems (for example, from line 69-71 and from 126-127).

On line 89, is the period correct? from 15-25 august 2020 only?

On results, line 140-143, the sum does not match.

All figures need to be checked, for example, is figure 5 actually figure 4? is figure 6 actually figure 5?

On line 238-244, it must be emphasized that the bias of publication was a matter of concern.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

Reviewer #3: No

**********

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PLoS One. 2023 Feb 21;18(2):e0278741. doi: 10.1371/journal.pone.0278741.r004

Author response to Decision Letter 1

19 Oct 2022

Reviewer #2

The researchers accepted most of the suggestions, with a great improvement in the paper.

I believe that some topics of the "discussion" could have been discussed more comprehensively.

I reinforce the importance of the topic.

Author’s responses

I would like to express my gratitude for your constructive comments. Now, I have tried to address the concern and rearranged the paragraphs under discussion.

Reviewer #3

The manuscript has suffered many corrections, but English needs to be revised. Maybe there are texting problems (for example, from line 69-71 and from 126-127).

On line 89, is the period correct? from 15-25 august 2020 only?

On results, line 140-143, the sum does not match.

All figures need to be checked, for example, is figure 5 actually figure 4? is figure 6 actually figure 5?

On line 238-244, it must be emphasized that the bias of publication was a matter of concern.

Author’s responses

� Thank you for your deep looking and constructive comments. Now, the comments are well incorporated in the edited manuscript accordingly on their respective lines. Besides, number of articles under result section was edited and written in clear expression as follow.

“A total of 101 articles and one article were found with electronic and other approach of searching respectively. Twenty eight were duplication and 74 articles were screened. From these 74 articles, 69 of them were excluded due to irrelevance, absence of full text or Abstract”.

� August 15-25, 2020 was the period for on line data searching. Thus, it was correct.

Attachment

Submitted filename: Response to Reviewers.docx

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Decision Letter 2

Carla Betina Andreucci

23 Nov 2022

Prevalence and determinants of neonatal near miss in Ethiopia: A Systematic Review and Meta-Analysis

PONE-D-20-32942R2

Dear Dr. Deressa,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Carla Betina Andreucci, M.D., P.h.D.

Academic Editor

PLOS ONE

Acceptance letter

Carla Betina Andreucci

29 Nov 2022

PONE-D-20-32942R2

Prevalence and Determinants of Neonatal Near Miss in Ethiopia: A Systematic Review and Meta-Analysis

Dear Dr. Deressa:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Mrs. Carla Betina Andreucci

Academic Editor

PLOS ONE

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