The PNMR among the rural population of northwest Ethiopia was very high, and the finding is in agreement with previous national reports by WHO, 2007 , and EDHS, 2011 for the Amhara Regional State of Ethiopia . A recent community-level study conducted in Burkina Faso reported a PNMR of 79.0 per 1000 total births which was greater than the findings of this study . The possible reason for the difference might be the fact that the Ethiopian Government has initiated a community based health service package (Health Extension Package) that intensified the availability of maternal and child health services through the Health Extension Program . The health extension workers provide family planning and immunization services; they promote preparedness for birth and readiness for complications, and active management of the third stage of labor among others .
The risk factors identified in this study, namely low educational status of mothers, maternal ownership of business as occupation, history of still birth, short birth interval of less than two years, mother’s being unimmunized for at least two doses of TT Vaccine during pregnancy are in agreement with findings of previous studies done in other developing and middle income countries [11, 18, 21].
In this study, the highest perinatal mortality was observed among illiterate mothers, and the finding is similar to those of other studies in developing countries [19, 20]. Evidences from other developing countries also indicated that increased levels of mother’s education were observed to be associated with improved chances of infant survival . Our findings emphasize the need for encouraging female literacy which by itself is expected to provide multiple benefits and better chances for alleviating poverty and poverty-related health problems . Education can improve economic status, access to health care, and birth spacing which are known to reduce the risk of perinatal mortality .
The results of this study also specified that twin are more likely to die during the perinatal period compared to children born singletons, as has been reported by a similar study in rural Burkina Faso . Intrauterine growth restrictions and birth defects and/or disabilities that are common in multiple pregnancy increase vulnerability to perinatal death [12, 28]. These multiple pregnancies require special and expensive medical care  which is not accessible and available in our study area.
In our study, women who had experienced previous still birth had an increased risk of losing their children in the consecutive perinatal period, and this finding is consistent with findings of a previous study . Moreover, genetic and environmental factors can lead to repeated occurrences of small-for-gestational age [SGA], birth/intrauterine growth restriction, preeclampsia, and placental abruption which can eventually cause untreated perinatal death [29, 30].
A short birth spacing of less than 24 months was associated with an increased risk of perinatal mortality because of the well known phenomena related to sibling competitions recognized as the maternal depletion syndrome [15–17]. The syndrome is also associated with premature rupture of membranes and puerperal endometritis [31, 32] which can cause perinatal deaths. As reported by previous studies, mothers who received at least two doses of maternal tetanus toxoid vaccinations could significantly reduce perinatal mortality [14, 33].
Even though every effort was made to maintain the quality of the data, the study has limitations that should be noted when interpreting the results. First of all, readers should be cautious since the study findings show a wide confidence interval because of the small sample size of the deaths. Secondly, although the study design was prospective, it was not able to measure birth weight of the neonates and other clinical conditions which are important predicators of perinatal mortality because most deliveries took place at home and the researchers could not manage to secure resources to do anthropometric and clinical assessments immediately after birth.