The Effect of Referral Processes and Complications on Survival among Low-Birth-Weight Neonates in the Neonatal Intensive Care Unit of Dr. Wahidin Sudirohusodo Hospital, Makassar, Indonesia: A Retrospective Cohort Study

Background: Low birth weight (LBW) neonates represent a high-risk group for neonatal mortality, particularly in resource-limited settings. Despite national efforts to strengthen referral systems in Indonesia, the impact of referral processes and clinical complications on LBW survival in tertiary NICUs inadequately studied. Methods: A retrospective cohort study was conducted at Dr. Wahidin Sudirohusodo Hospital, Makassar, Eastern Indonesia, involving 319 LBW neonates admitted to the NICU between 2020 and 2023. The primary outcome was 28-day survival. Cox proportional hazards regression was used to estimate crude and adjusted hazard ratios for referral status and clinical complications. Results: The overall 28-day survival proportion was 61.89%, with peak mortality occurring on days 1 and 3 of life. Extremely low birth weight neonates had the lowest survival (8%). In multivariable analysis, referred neonates had a significantly higher hazard of death compared to directly admitted neonates (HR=1.86; 95% CI: 1.21–2.85; p=0.005). Clinical complications showed a positive but statistically non-significant association after adjustment (HR=2.97; 95% CI: 0.94-9.38; p=0.063). Conclusion: Referral status was the strongest independent predictor of mortality among LBW neonates. Strengthening pre-referral stabilization, neonatal transport systems, and inter-facility communication is critical to reducing preventable neonatal deaths in Eastern Indonesia.