Regional disparities and factors associated with perinatal mortality in seven tertiary referral maternity hospitals in Niger: a multicenter hospital-based study

Perinatal mortality remains a major public health challenge in sub-Saharan Africa, but contemporary multicenter evidence from Niger is limited. This study aimed to describe variation in facility-based perinatal mortality across seven tertiary referral maternity hospitals and identify maternal, obstetric, and neonatal factors associated with perinatal mortality. We conducted a retrospective multicenter hospital-based study including births occurring at ≥ 28 weeks of gestation in seven tertiary referral maternity hospitals in Niger between January 1, 2023, and December 31, 2024. Perinatal death comprised stillbirth and early neonatal death during the first seven completed days of life. Early neonatal deaths were ascertained from hospital records during the initial hospitalization or following readmission within the first seven days; systematic post-discharge follow-up was not available. Factors associated with perinatal mortality were examined using modified Poisson regression with robust variance estimation, accounting for clustering within hospitals. Adjusted risk ratios (aRRs) with 95% confidence intervals (CIs) were estimated. Among 46,215 births, 7,819 perinatal deaths were recorded, corresponding to a facility-based perinatal mortality rate of 169.2 per 1,000 births. Stillbirths accounted for 68.8% of perinatal deaths. In multivariable analysis, no formal maternal education (aRR 1.65; 95% CI 1.58–1.72), no antenatal care visits (aRR 2.78; 95% CI 2.71–2.84), rural residence (aRR 1.47; 95% CI 1.41–1.53), referral to a tertiary hospital (aRR 2.16; 95% CI 2.01–2.31), gestational age 28–32 weeks (aRR 4.80; 95% CI 4.27–5.33), and birth weight < 1,500 g (aRR 4.13; 95% CI 3.87–4.39) were associated with higher perinatal mortality. The crude association with cesarean delivery was no longer statistically significant after adjustment. Facility-based perinatal mortality was high across the participating tertiary referral hospitals and varied substantially between facilities. Maternal education, antenatal care attendance, residence, referral status, prematurity, and low birth weight were associated with perinatal mortality. Strengthening antenatal and referral care, improving care for preterm and low-birth-weight newborns, addressing broader social determinants including maternal education, and strengthening systematic perinatal death review within the Maternal and Perinatal Death Surveillance and Response framework should be considered priorities.