Perinatal Mortality Rate (PNMR) is known to be one of the key health status and socio-economic indicators of the community [1]. It is specifically a sensitive index of the quality of prenatal, obstetric, and early neonatal care available to women and newborns in any setting [2, 3]. There are an estimated ten perinatal deaths for each maternal death [4]. At least 75% of the perinatal deaths that occur in developing countries are caused by problems that also kill women. These include prolonged/obstructed labour, puerperal sepsis, eclampsia, women’s nutrition, infection and hemorrhage [5].

Global estimates show that the PNMR in developed regions of the world is about 10 per 1000 total births compared to 50 per 1000 total births in less developed regions [1]. Sub-Saharan Africa has the highest rate of perinatal deaths, 56 per 1000 births [1]. According to the Ethiopian Demographic and Health Survey (EDHS) 2011, PNMR in Ethiopia was estimated at 46 per 1000 births [6], however, the rate varies by regions ranging from 20 to 58 deaths per 1000 births. The PNMR was 55 per 1000 births in the Amhara Regional State, where this study was conducted [6].

Although the country has intensified efforts to provide basic maternal and child health services through the Health Extension Program [7, 8], reducing perinatal deaths remains a formidable challenge to achieving Millennium Development Goal 4 in rural Ethiopia [9, 10], where only 4.1% of deliveries are attended by skilled birth attendants [6].

The causes of perinatal morality are multiple and include previous still births [11], twin births [12, 13], being unimmunized for two doses of tetanus during pregnancy [14], birth interval of less than 24 months for the index child [15–17], illiteracy [18–20] mother’s being farmer by occupation [21].

In a country like Ethiopia, where only 10% of the births are delivered at a health facility, documenting the rate and causes of perinatal mortality through a community based prospective study is an important input for planning effective interventions. Previous estimates in Ethiopia are either largely hospital-based [22, 23] or retrospective household surveys [6] which have obvious limitations associated with recall and selection bias. In addition, the risk factors for the perinatal mortality are poorly documented and understood in northwest Ethiopia. Thus, the objective of this prospective follow up community-based study was to estimate PNMR and to identify the potential risk factors in rural communities of northwest Ethiopia.

In the multivariate logistic regression, the following factors were associated with increased risk of perinatal mortality. Among the socio-demographic factors, maternal illiteracy [AOR = 4.83, 95% CI (1.45, 16.05)], and working on own business [AOR = 5.40, CI (1.40, 27.96)]; among child factors being a female child [AOR = 1.61, 95% CI (1.04, 2.67)] and multiple/twin birth [AOR = 7.09, 95% CI, (3.22, 15.61] were significantly associated with perinatal death.

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 [1], and EDHS, 2011 for the Amhara Regional State of Ethiopia [6]. 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 [13]. 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 [7]. 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 [8].

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 [26]. 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 [26]. Education can improve economic status, access to health care, and birth spacing which are known to reduce the risk of perinatal mortality [27].

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 [13]. 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 [28] 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 [29]. 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.

In summary, perinatal death in the study area was largely due to preventable conditions for which existing maternal health programs have been proven interventions. Therefore, urgent actions are required to expand the existing maternal and newborn health services in the short term to rapidly and significantly reduce perinatal mortality in rural settings of Ethiopia as the country is making progress to achieving its long term vision of making poverty history.

GA is a Public Health expert specializing on child health research at the University of Gondar. He is an active member of the Dabat Demographic Surveillance and Health research team.

YB is a senior professor of epidemiology and public health at Addis Continental Institute of Public Health. He has extensively published on maternal and child health issues.

AW is an Associate Professor at the Department of Epidemiology and Biostatistics of Addis Ababa University, Ethiopia. He has been teaching Biostatistics and research Methods for many years and has participated in many field/clinical trials.

YK is a senior professor of public health at the Institute of Public Health, the University of Gondar. He has been teaching several courses in public health, epidemiology, and research methods in Ethiopian universities for more than ten years. He has collaborated with national and international colleagues in different research projects. He has advised doctoral and MPH students in Ethiopia.