Abstract
<title>Abstract</title> <p>Background This study aimed to quantify regional variation in perinatal mortality across seven tertiary referral maternity hospitals in Niger and identify modifiable maternal, clinical, and health-system determinants associated with perinatal mortality. Methods We conducted a retrospective multicenter hospital-based study including all births occurring at ≥ 28 weeks of gestation in seven tertiary referral maternity hospitals in Niger between January 1, 2023, and December 31, 2024. Perinatal death was defined as stillbirth or early neonatal death within the first seven days of life. Maternal, obstetric, and neonatal characteristics were extracted from standardized hospital records. Factors associated with perinatal mortality were identified using modified Poisson regression with robust variance estimation, accounting for clustering at the hospital level. Adjusted risk ratios (aRRs) with 95% confidence intervals (CIs) were estimated. Results Among 46,215 births, 7,819 perinatal deaths occurred, corresponding to a perinatal mortality rate of 169.2 per 1,000 births. Stillbirths accounted for 68.8% of all perinatal deaths. After multivariable adjustment, lack of formal maternal education (aRR 1.65; 95% CI 1.58–1.72), inadequate antenatal care attendance (aRR 2.78; 95% CI 2.71–2.84), prematurity (aRR 4.80; 95% CI: 4.27–5.33), low birth weight (aRR 4.13 ; 95% CI 3.87–4.39), rural residence (aRR 1.47; 95% CI 1.41–1.53), and referral to a tertiary hospital (aRR 2.16; 95% CI 2.01–2.31) were independently associated with an increased risk of perinatal mortality. The crude association between cesarean delivery and perinatal mortality was no longer statistically significant after adjustment. Conclusion Perinatal mortality remains a major public health challenge in tertiary referral maternity hospitals in Niger. Strengthening the quality of antenatal care, improving referral systems, expanding access to comprehensive emergency obstetric and newborn care, and optimizing the management of preterm and low-birth-weight infants are essential to reduce preventable perinatal deaths. This large multicenter study provides robust contemporary evidence to inform maternal and newborn health policies in Niger and similar low-resource settings.</p>