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Neonatal outcomes in a level II regional neonatal intensive care unit. BACKGROUND: Improvement of neonatal mortality is a challenge in developing countries such as Iraq due to increased demand and overload of maternity services. The aim of this study was to document the number, disease patterns and outcome of admitted newborns and the improvement after implementation of clinical protocols, and to identify possible future target measures. METHOD: A descriptive study was conducted at the neonatal intensive care unit (NICU) of a regional hospital from 2011 to 2013. Of 72 320 deliveries, 4694 newborns were admitted and met selection criteria. Clinical guidelines, clinical skills training of nurses and resident doctors, and improvement of medical records were implemented during the study period. All patient demographics, causes of admission/death and mortality were analyzed. RESULTS: From a total of 4694 admitted newborns; 42% were delivered vaginally, 60% were male, 43% were <2500 g, and 31% were premature. The neonatal deaths consisted of 1076 newborns, 84% of whom died before 7 days of age, and 39% of whom weighed ≤1500 g. Respiratory distress syndrome was the main cause of death (62.2%). Due to the increased total number of deliveries, and hence the corresponding increased number of vaginal deliveries (R = 0.97), the number of NICU admissions was significantly increased (R = 0.569, P = 0.009). Notably, the mortality rate was significantly decreased (R = -0.487, P = 0.004). CONCLUSIONS: Maternity overload contributed to the high neonatal mortality, whereas implementation of clinical guidelines and of medical staff training improved neonatal outcomes. Future target interventions include optimized timing of cesarean section and the detection of potentially complicated deliveries.