Background Perinatal asphyxia (PNA) remains a leading, yet preventable, cause of neonatal death, disproportionately affecting low-resource settings like Ethiopia. Despite its significance, data on the burden and factors influencing survival among asphyxiated neonates in this region are scarce. This study aims to address this gap by investigating the time to death and its associated predictors in this vulnerable population.

Methods A retrospective cohort study was conducted at Wolaita Sodo University Comprehensive Specialized Hospital’s Neonatal Intensive Care Unit (NICU) in southern Ethiopia. Medical records of 404 neonates diagnosed with PNA between January 2019 and December 2023 were reviewed. The study followed these neonates for a total of 2889 person-days to assess their survival outcomes. Kaplan-Meier analysis estimated the median time to death, and a Weibull regression model identified independent predictors of mortality.

Results The findings revealed the incidence density of PNA-related mortality of 30.8 per 1,000 person-days (95% CI: 25.0-37.9). Notably, nearly 72% of deaths occurred within the first critical week of life, with a median survival time of 20 days. The multivariable Weibull regression analysis identified several factors significantly associated with shorter time to death at p 0.05. These are presence of meconium-stained amniotic fluid (MSAF), low fifth-minute Apgar score (less than 7), birth weight greater than 4000gm, low admission oxygen saturation level, treatment with anticonvulsant, the use of Continuous Positive Airway Pressure (CPAP) for oxygen administration, and need for resuscitation with chest compression.

Conclusion This study highlights the significant burden of PNA-related mortality, particularly during the first week of life, in a resource-limited setting. The findings underscore the urgent need for improved PNA management strategies. Furthermore, specific treatment decisions, including the use of anticonvulsants, oxygen therapy methods, and resuscitation techniques, emerged as crucial factors influencing survival outcomes. These results call for further investigation into these specific interventions and potentially revising PNA management protocols to optimize the chances of survival for asphyxiated neonates in low-resource settings like Ethiopia.

The authors have declared no competing interest.

The authors received no specific funding for this work.

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