OBJECTIVE: To describe the cause-specific morbidity and mortality, and referral patterns of all neonates admitted to a tertiary referral hospital in the northern provinces of Vietnam. DESIGN: A prospective hospital based observational study. SETTING: The Neonatal Department, National Hospital of Pediatrics, Hanoi, Vietnam. PATIENTS: All admissions to the Neonatal Department over a 12 month period. MAIN OUTCOME MEASURES: Cause-specific morbidity and mortality; deaths. RESULTS: There were 5064 admissions with the commonest discharge diagnoses being infection (32%) and prematurity (29%). The case fatality ratio (CFR) was 13.9% (n = 703). Infection (38%), cardio/respiratory disorders (27%), congenital abnormalities (20%) and neurological conditions (10%) were the main causes of death. Of all the deaths, 38% had an admission weight ≥2500g. Higher CFR were associated with lower admission weights. Very few deaths (3%) occurred in the first 24 hours of life. Most referrals and deaths came from Hanoi and neighbouring provincial hospitals, with few from the most distant provinces. Two distant referral provinces had the highest CFR. CONCLUSIONS: The CFR was high and few deaths occurred in neonates <24 hours old. The high rates of infection call for an improvement in infection control practices and peripartum antibiotic use at provincial and tertiary level. Understanding provincial hospital capacity and referral pathways is crucial to improving the outcomes at tertiary centres. A quality of care audit tool would enable more targeted interventions and monitoring of health outcomes.