Background

Although hemolytic disease of the fetus and newborn (HDFN) has become rare in high-income countries, it remains a significant cause of perinatal death in low-and middle-income countries. Nonetheless, true epidemiological data in Africa are lacking.

Objective

To obtain insight into the prevalence of anti-Rhesus D-mediated HDFN in Ethiopia, pregnancy outcomes were compared between RhD-negative and RhD-positive women.

Study design

A multicenter facility-based retrospective cohort study was performed on 6796 women who gave birth (≥28 weeks of gestation) in 13 Ethiopian Obstetric Surveillance System hospitals from January to March 2024. Data were retrospectively collected from maternal and neonatal medical records from antenatal care to birth and neonatal registry. The composite adverse perinatal outcomes (APO) included stillbirth, neonatal loss, or Neonatal Intensive Care Unit admission. The likelihood of HDFN was based on clinical review by 3 experts blinded to the maternal blood group.

Results

In 6141 of 6796 women with known RhD status, 327 (5.3%) were RhD-negative. APO was seen in 13.3% women, and occurred twice as often in RhD-negative, as compared to RhD-positive women (aOR=2.3; 95% CI: 1.7-2.9). Clinical signs were highly suggestive of HDFN in 5.8% of RhD-negative women, as compared to 0.2% in RhD-positive women (P<.0001).

Conclusion

Our study identifies that RhD-negative women experience a two-fold increased odds of APO, most likely due to HDFN. This highlights the need for strategies to address these maternal and child health inequities, including using anti-RhD immunoprophylaxis to prevent HDFN and screening for blood group antibodies to identify pregnancies at risk.

© 2026 The Authors.