Unveiling neonatal mortality inequities in Ghana: A geospatial and temporal analysis of regional disparities, healthcare accessibility, and institutional gaps to drive targeted interventions.

Background: Neonatal mortality remains a significant public health challenge in Ghana, with regional disparities and systemic inequities affecting progress toward achieving Sustainable Development Goal (SDG) 3. Previous studies show about three-fourths of these deaths occur in the early neonatal period (i.e., the first week of life). Despite national efforts to improve neonatal survival, limited data exist on spatial, motorized accessibility, and temporal trends. The aim of the study is to analyze neonatal mortality trends and burden across Ghana from 2019 to 2023, identify regional disparities, high risk regions and districts, and to examine the impact of healthcare accessibility on neonatal outcomes using geospatial and statistical modelling.

Methods: Using a retrospective analysis of neonatal mortality data from the District Health Information Management System 2 (DHIMS-2), we conducted a cross-sectional descriptive survey assessing early, late, and institutional neonatal mortality rates at national and regional levels. Geospatial mapping and poisson regression models were employed to identify high-risk areas and associated factors. A p-value <0.05 was used to declare statistical significance.

Results: Neonatal mortality in Ghana declined significantly between 2019 and 2023: early neonatal deaths decreased by 28.6% (4,645 to 3,317), and late neonatal deaths by 20.9% (912 to 721). Early and late neonatal mortality rates fell by 35.2% (6.51 to 4.22 per 1,000 live births) and 30.3% (1.32 to 0.92 per 1,000), respectively, with institutional neonatal mortality declining by 34.2% (7.79 to 5.13 per 1,000). However, stark regional disparities persisted. Greater Accra (5,626 deaths, 22.4%), Ashanti (4,234 deaths, 16.9%), and Northern (2,512 deaths, 10.0%) bore the highest burdens, while Savannah (259 deaths, 1.0%) and North-East (361 deaths, 1.4%) recorded the lowest. Poisson regression confirmed significant subnational heterogeneity: Oti (IRR = 0.24; CI = 0.13, 0.45), Western North (IRR = 0.28; CI = 0.15, 0.50), and North-East (IRR = 0.37; CI = 0.21, 0.62) exhibited mortality rates substantially lower than Greater Accra's baseline (IRR = 1). Conversely, Bono (IRR = 0.73; CI = 0.48, 1.12) and the Northern Region (IRR = 0.74; CI = 0.49, 1.13) showed no significant differences. Rural areas faced critical access barriers, with over 60% requiring >60 min to reach hospitals, likely exacerbating delays in care. These findings underscore progress in national mortality trends but highlight persistent inequities demanding region-specific interventions.

Conclusion: Neonatal mortality in Ghana has declined over time, yet significant regional disparities and access inequities remain. Targeted interventions, such as improving rural healthcare infrastructure, expanding neonatal intensive care units, and strengthening ante/postnatal care, are crucial to address these gaps, and to improve healthcare access and outcomes for newborns. Future research should explore quality-of-care determinants and community-level interventions to improve in neonatal survival. The study highlights the importance of robust surveillance systems for monitoring neonatal health trends and guiding resource allocation.