BackgroundIn Ethiopia, the trend of neonatal mortality showed slow pace of reduction from 2000–2016 compared to the reduction in infant and under-five mortality over the same period. This study aimed at unpacking the trends of admission, specific causes and rate of neonatal mortality as well as predictors of neonatal mortality at a general hospital in Somali region of Ethiopia.MethodsA hospital based retrospective cohort study was conducted from 25th of May 2017to 10th of June, 2017. All the new-borns admitted in the neonatal Intensive Care Unit of the hospital were reviewed over three years period (Aug2014-May2017). Data were cleaned and exported to SPSS version 20 and both descriptive and analytical analysis were executed. The level of significance was set at P<0.05. Binary logistic regression was used to produce summary of statistics including crude and adjusted odds ratio and 95% confidence intervals.ResultsThis study reviewed a total of 792 new-borns below the age of 28 days admitted in the NICU of Karamara hospital over a period of three years (August, 2014 to May, 2017). The mean birth weight was 2733 ± 740 g and neonates with normal birth weight stood at 64%. Seven hundred forty seven new-borns (94.3%) were discharged alive while 45 (5.7%) new-borns died in the course of hospitalization making a Neonatal Mortality Rate (NMR) of 5.7% (57 per 1000 live births), and 96 percent of these deaths were early neonatal deaths that occurred in the first one week of life (i.e. <7 days).After all variables which had an association with neonatal mortality (P <0.05) were entered in to a multivariate logistic model to control the effect of confounders: prematurity (AOR = 0.492(0.253, 0.957), P = 0.037) and average length of stay below two days (AOR = 0.418(0.186, 0.936), P = 0.034) were independently associated with neonatal mortality showing protective effect.ConclusionThe causes of neonatal death reported in this study are preventable, the neonatal mortality rate is high compared to the national and regional figures. Prematurity and shorter length of stay in the NICU of less than two days showed independent association with neonatal mortality. This calls for more work along the continuum of care, improving the quality of care, early transfer of sick neonates to the NICU along with scaling up establishment of the NICUs in other hospitals of the region.