Incidence and predictors of mortality among neonates with respiratory distress syndrome admitted to neonatal intensive care units in Ethiopia: a systematic review and meta-analysis of evidence from two regional states.

backgroundNeonatal respiratory distress syndrome (RDS) is a leading cause of neonatal morbidity and mortality, particularly in low-resource settings. In Ethiopia, evidence on the incidence of mortality and its predictors among neonates with RDS is limited and fragmented. Therefore, this systematic review and meta-analysis, based on data from two regional states, aimed to answer the following question: “What is the pooled incidence of mortality, and what are the key predictors of death among neonates with RDS in Ethiopia?”

methodsInternational databases, PubMed, HINARI, Google Scholar, Embase, Scopus, and Ethiopian university repositories were searched for studies published between January 1, 2000, and February 10, 2026. Studies reporting the incidence of mortality and/or predictors among neonates with RDS in Ethiopia were eligible. Both published and gray literature were included. Study quality was assessed using the Joanna Briggs Institute critical appraisal checklist. The pooled incidence of mortality was estimated using the DerSimonian–Laird random-effects model. Heterogeneity was assessed with I² statistics and Cochran’s Q test, and publication bias was evaluated using funnel plots and Egger’s test. Associations with mortality were summarized using pooled hazard ratios. Subgroup analyses and sensitivity analysis explored sources of variation.

resultsFrom 1,982 records, five retrospective cohort studies, including 2,121 neonates and 12,272 neonatal-days of follow-up, were included. The pooled incidence of mortality was 62 deaths per 1000 neonatal-days (95% CI: 56–69; I² = 51.25%), corresponding to a case fatality rate of 36% (95% CI: 32.5–40.1%) within 28 days of birth. Mortality predictors were a birth weight of 1500–2499 g (HR 1.85; 95% CI: 1.41–2.43), very low birth weight (HR = 4.24; 95% CI: 2.30–7.83), preterm birth (HR = 1.77; 95% CI: 1.27–2.48), perinatal asphyxia (HR = 2.11; 95% CI: 1.31–3.41), and multiple pregnancies (HR = 2.25; 95% CI: 1.63–3.10), whereas maternal antenatal corticosteroids reduced mortality (HR = 0.33; 95% CI: 0.09–0.56). Sensitivity analyses indicated robust results; no substantial publication bias was detected.

conclusionsNeonatal mortality due to respiratory distress syndrome in Ethiopia, based on evidence from two regional states (Amhara and Oromia), remains high. Preterm, asphyxiated, and low-birth-weight neonates are at increased risk of death, while antenatal corticosteroid use is protective. These findings highlight the importance of strengthening the timely administration of antenatal corticosteroids and improving the clinical management of high-risk neonates to reduce mortality and improve survival outcomes in low-resource settings. However, as the analysis is based on a limited number of studies from only two regions, the results should be interpreted with caution. PROSPERO REGISTRATION NUMBER: CRD420261291462