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Importance: In resource-constrained settings where the neonatal mortality rate (NMR) is high due to preventable causes and health systems are underused, community-based interventions can increase newborn survival by improving health care practices., Objectives: To develop and evaluate the effectiveness of a community-based maternal and newborn care services package to reduce perinatal and neonatal mortality in rural Pakistan., Design, Setting, and Participants: This cluster randomized clinical trial was conducted between November 1, 2012, and December 31, 2013, in district Rahim Yar Khan in the province of Punjab. A cluster was defined as an administrative union council. Any consenting pregnant resident of the study area, regardless of gestational age, was enrolled. An ongoing pregnancy surveillance system identified 12 529 and 12 333 pregnancies in the intervention and control clusters, respectively; 9410 pregnancies were excluded from analysis due to continuation of pregnancy at the end of the study, loss to follow-up, or miscarriage. Participants were followed up until the 40th postpartum day. Statistical analysis was performed from January to May 2014., Intervention: A maternal and newborn health pack, training for community- and facility-based health care professionals, and community mobilization through counseling and education sessions., Main Outcomes and Measures: The primary outcome was perinatal mortality, defined as stillbirths per 1000 births and neonatal death within 7 days per 1000 live births. The secondary outcome was neonatal mortality, defined as death within 28 days of life per 1000 live births. Systematic random sampling was used to allocate 10 clusters each to intervention and control groups. Analysis was conducted on a modified intention-to-treat basis., Results: For the control group vs the intervention group, the total number of households was 33 188 vs 34 315, the median number of households per cluster was 3092 (IQR, 3018-3467) vs 3469 (IQR, 3019-4075), the total population was 229 155 vs 234 674, the mean (SD) number of residents per household was 6.9 (9.5) vs 6.8 (9.6), the number of males per 100 females (ie, the sex ratio) was 104.2 vs 103.7, and the mean (SD) number of children younger than 5 years per household was 1.0 (4.2) vs 1.0 (4.3). Altogether, 7598 births from conrol clusters and 8017 births from intervention clusters were analyzed. There was no significant difference in perinatal mortality between the intervention and control clusters (rate ratio, 0.86; 95% CI, 0.69-1.08; P = .19). The NMR was lower among the intervention than the control clusters (39.2/1000 live births vs 52.2/1000 live births; rate ratio, 0.75; 95% CI, 0.58-0.95; P = .02). The frequencies of antenatal visits and facility births were similar between the 2 groups. However, clean delivery practices were higher among intervention clusters than control clusters (63.2% [2284 of 3616] vs 13.2% [455 of 3458]; P < .001). Chlorhexidine use was also more common among intervention clusters than control clusters (55.9% [4271 of 7642] vs 0.3% [19 of 7203]; P < .001)., Conclusions and Relevance: This pragmatic cluster randomized clinical trial demonstrated a reduction in NMR that occurred in the background of improved household intrapartum and newborn care practices. However, the effect of the intervention on antenatal visits, facility births, and perinatal mortality rates was inconclusive, highlighting areas requiring further research. Nevertheless, the improvement in NMR underscores the effectiveness of community-based programs in low-resource settings., Trial Registration: ClinicalTrials.gov Identifier: NCT01751945.

Background: COVID-19 vaccines have been shown to protect pregnant individuals against mild and severe COVID-19 outcomes. However, limited safety data are available for inactivated (CoronaVac) and mRNA (BNT162b2) vaccines during pregnancy regarding their effect on birth outcomes and neonatal mortality, especially in low- and middle-income countries., Methods: We conducted a retrospective population-based cohort study in Rio de Janeiro, Brazil, with 17 513 singleton live births conceived between 15 May 2021 and 23 October 2021. The primary exposure was maternal vaccination with CoronaVac or mRNA BNT162b2 vaccines and sub-analyses were performed by the gestational trimester of the first dose and the number of doses given during pregnancy. The outcomes were pre-term birth (PTB), small for gestational age (SGA), low birthweight (LBW), low Apgar 5 and neonatal death. We used the Cox model to estimate the hazard ratio (HR) with a 95% CI and applied the inverse probability of treatment weights to generate adjusted HRs., Results: We found no significant increase in the risk of PTB (HR: 0.98; 95% CI 0.88, 1.10), SGA (HR: 1.09; 95% CI 0.96, 1.27), LBW (HR: 1.00; 95% CI 0.88, 1.14), low Apgar 5 (HR: 0.81; 95% CI 0.55, 1.22) or neonatal death (HR: 0.88; 95% CI 0.56, 1.48) in women vaccinated with CoronaVac or BNT162b2 vaccines. These findings were consistent across sub-analyses stratified by the gestational trimester of the first dose and the number of doses given during pregnancy. We found mild yet consistent protection against PTB in women who received different vaccine platforms during the third trimester of pregnancy (any vaccines, HR: 0.78; 95% CI 0.63, 0.98; BNT162b2, HR: 0.75; 95% CI 0.59, 0.99)., Conclusions: This study provides evidence that COVID-19 vaccination in all trimesters of pregnancy, irrespective of the vaccine type, is safe and does not increase the risk of adverse birth outcomes or neonatal deaths., (© The Author(s) 2023. Published by Oxford University Press on behalf of the International Epidemiological Association.)

Background: Ongoing high neonatal mortality rates (NMRs) represent a global challenge. In 2021, of the 5 million deaths reported worldwide for children under five years of age, 47% were newborns. Pakistan has one of the five highest national NMRs in the world, with an estimated 39 neonatal deaths per 1,000 live births. Reducing newborn deaths requires sustainable, evidence-based, and cost-effective interventions that can be integrated within existing community healthcare infrastructure across regions with high NMR., Methods: This pragmatic, community-based, parallel-arm, open-label, cluster randomized controlled trial aims to estimate the effect of Lady Health Workers (LHWs) providing an integrated newborn care kit (iNCK) with educational instructions to pregnant women in their third trimester, compared to the local standard of care in Gilgit-Baltistan, Pakistan, on neonatal mortality and other newborn and maternal health outcomes. The iNCK contains a clean birth kit, 4% chlorhexidine topical gel, sunflower oil emollient, a ThermoSpot™ temperature monitoring sticker, a fleece blanket, a click-to-heat reusable warmer, three 200 μg misoprostol tablets, and a pictorial instruction guide and diary. LHWs are also provided with a handheld scale to weigh the newborn. The primary study outcome is neonatal mortality, defined as a newborn death in the first 28 days of life., Discussion: This study will generate policy-relevant knowledge on the effectiveness of integrating evidence-based maternal and newborn interventions and delivering them directly to pregnant women via existing community health infrastructure, for reducing neonatal mortality and morbidity, in a remote, mountainous area with a high NMR., Trial Registration: NCT04798833, March 15, 2021., (© 2023. The Author(s).)

Introduction: Infant and neonatal mortality estimates are typically derived from retrospective birth histories collected through surveys in countries with unreliable civil registration and vital statistics systems. Yet such data are subject to biases, including under-reporting of deaths and age misreporting, which impact mortality estimates. Prospective population-based cohort studies are an underutilized data source for mortality estimation that may offer strengths that avoid biases., Methods: We conducted a secondary analysis of data from the Child Health Epidemiology Reference Group, including 11 population-based pregnancy or birth cohort studies, to evaluate the appropriateness of vital event data for mortality estimation. Analyses were descriptive, summarizing study designs, populations, protocols, and internal checks to assess their impact on data quality. We calculated infant and neonatal morality rates and compared patterns with Demographic and Health Survey (DHS) data., Results: Studies yielded 71,760 pregnant women and 85,095 live births. Specific field protocols, especially pregnancy enrollment, limited exclusion criteria, and frequent follow-up visits after delivery, led to higher birth outcome ascertainment and fewer missing deaths. Most studies had low follow-up loss in pregnancy and the first month with little evidence of date heaping. Among studies in Asia and Latin America, neonatal mortality rates (NMR) were similar to DHS, while several studies in Sub-Saharan Africa had lower NMRs than DHS. Infant mortality varied by study and region between sources., Conclusions: Prospective, population-based cohort studies following rigorous protocols can yield high-quality vital event data to improve characterization of detailed mortality patterns of infants in low- and middle-income countries, especially in the early neonatal period where mortality risk is highest and changes rapidly., (© 2023. The Author(s).)

Introduction: The global neonatal death (NND) rate has been declining in recent decades, but there are no comprehensive data concerning the characteristics of NNDs in Hong Kong. This study investigated the trends and aetiologies of NNDs among singleton pregnancies in Hong Kong., Methods: This study included all cases of NND from singleton pregnancies in a tertiary hospital in Hong Kong between 2000 and 2019. The rates, clinical characteristics, and aetiologies of NND were compared between the first (2000-2009) and the second (2010-2019) decades., Results: The NND rate decreased from 1.66/1000 livebirths (97 cases) in the first decade to 1.32/1000 livebirths (87 cases) in the second decade. Congenital or genetic abnormalities (82 cases) caused 44.6% of all NNDs. There was a significant reduction from 0.82/1000 livebirths in the first decade to 0.52/1000 livebirths in the second decade (P=0.037). Other causes of NND were prematurity (69 cases; 37.5%), sepsis (16 cases; 8.7%), hypoxic-ischaemic encephalopathy (15 cases; 8.2%), and sudden infant death syndrome (2 cases; 1.1%). Gestational age-specific neonatal mortality for moderately preterm neonates (31-33 weeks of gestation) significantly decreased from 34.73/1000 in 2000-2009 to 8.63/1000 in 2010-2019 (P=0.001), but there were no significant changes in neonatal mortality for other gestations., Conclusion: The NND rate in Hong Kong is among the lowest worldwide. Neonatal deaths in our centre declined over the past two decades, mainly because of improvements in the prenatal diagnosis and treatment of congenital or genetic abnormalities, as well as an improved survival rate among moderately preterm neonates., Competing Interests: All authors have disclosed no conflicts of interest.

Neonatal mortality is the death of a live-born baby within the first 28 days of birth. For the selected households, neonatal mortality was collected from children aged 0-28 days and women aged 15-49. The neonatal period is a significant 4-week period in human life because it carries a greater mortality risk. To identify the determinant factors of neonatal mortality in Ethiopia based on EDHS 2016 data with the application of count regression models. In this study, all neonates in Ethiopia were born within the 5 years preceding EDHS 2016 of the source population in the selected EAs from September to December 2015. Count regression models were used to analyze the data. A total of 10,641 live-born neonates within the previous 5 years of EDHS 2016 had neonatal mortality of women aged 15-49, which was considered in the study to be 7193. The data were found to have excess zeros (96.6%), and the variance (0.052) was higher than its mean (0.04). The count regression model (ZINB) was best fitted to the data with maximum likelihood parameter estimation methods. The average neonatal mortality difference in multiple births was increased by IRR = 8.53 times compared with a single birth. The average number of neonatal deaths experienced during breastfeeding was lower (IRR = 0.38) than that experienced by mothers who did not experience breastfeeding their child. The average neonatal mortality difference in rural residences was increased by IRR = 3.99 times compared to urban mothers' residences. In this study, the prevalence of Neonatal mortality in Ethiopia was higher. For selected ZINB count regression models of explanatory variables, such as multiple birth types, having rural residence factors of neonatal mortality increased the risk of death. However, having early breastfeeding, a female household head, and antenatal visits (1-4) and (5-10) during pregnancy decrease the risk of neonatal death., (© 2022. The Author(s).)

Objective: A large proportion of neonatal deaths in India are attributable to low birth weight (LBW). We report population-based distribution and determinants of birth weight in Bihar state, and on the perceptions about birth weight among carers., Design: A cross-sectional household survey in a state representative sample of 6007 live births born in 2018-2019. Mothers provided detailed interviews on sociodemographic characteristics and birth weight, and their perceptions on LBW (birth weight <2500 g). We report on birth weight availability, LBW prevalence, neonatal mortality rate (NMR) by birth weight and perceptions of mothers on LBW implications., Setting: Bihar state, India., Participants: Women with live birth between October 2018 and September 2019., Results: A total of 5021 (83.5%) live births participated, and 3939 (78.4%) were weighed at birth. LBW prevalence among those with available birth weight was 18.4% (95% CI 17.1 to 19.7). Majority (87.5%) of the live births born at home were not weighed at birth. LBW prevalence decreased and birth weight ≥2500 g increased significantly with increasing wealth index quartile. NMR was significantly higher in live births weighing <1500 g (11.3%; 95% CI 5.1 to 23.1) and 1500-1999 g (8.0%; 95% CI 4.6 to 13.6) than those weighing ≥2500 g (1.3%, 95% CI 0.9 to 1.7). Assuming proportional correspondence of LBW and NMR in live births with and without birth weight, the estimated LBW among those without birth weight was 35.5% (95% CI 33.0 to 38.0) and among all live births irrespective of birth weight availability was 23.0% (95% CI 21.9 to 24.2). 70% of mothers considered LBW to be a sign of sickness, 59.5% perceived it as a risk of developing other illnesses and 8.6% as having an increased probability of death., Conclusions: Missing birth weight is substantially compromising the planning of interventions to address LBW at the population-level. Variations of LBW by place of delivery and sociodemographic indicators, and the perceptions of carers about LBW can facilitate appropriate actions to address LBW and the associated neonatal mortality., Competing Interests: Competing interests: PN and DB are employees of Bill & Melinda Gates Foundation. Other authors declare no completing interests., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Early identification of high-risk pregnancies can reduce global neonatal mortality rate. Using the most recent Demographic and Health Surveys from 56 low- and middle-income countries, we examined the proportion of mothers with history of neonatal deaths. Logistic regression models were used to assess the association between maternal history of neonatal death and subsequent neonatal mortality. The adjusted models controlled for socioeconomic, child, and pregnancy-related factors. Country-specific analyses were performed to assess heterogeneity in this association across countries. Among the 437,049 live births included in the study, 6910 resulted in neonatal deaths. In general, 22.4% (1549) occurred to mothers with previous history of neonatal death; at the country-level, this proportion ranged from 1.2% (95% confidence interval [CI] 0.0, 2.6) in Dominican Republic to 38.1% (95% CI 26.0, 50.1) in Niger. Maternal history of neonatal death was significantly associated with subsequent neonatal death in both the pooled and the subgroup analyses. In the fully adjusted model, history of neonatal death was associated with 2.1 (95% CI 1.9, 2.4) times higher odds of subsequent neonatal mortality in the pooled analysis. We observed large variation in the associations across countries ranging from fully adjusted odds ratio (FAOR) of 0.4 (95% CI 0.0, 4.0) in Dominican Republic to 16.1 (95% CI 3.6, 42.0) in South Africa. Our study suggests that maternal history of neonatal death could be an effective early identifier of high-risk pregnancies in resource-poor countries. However, country-specific contexts must be considered in national policy discussions., (© 2021. The Author(s).)

Objectives　The proportion of Japanese women who maintain their employment during pregnancy and after delivery has been increasing. Previous studies from Western countries showed an association between the mother's occupation and birth outcomes; however, to the best of our knowledge, no epidemiological study has analyzed this association in Japan. Therefore, data from the national Vital Statistics: Occupational and Industrial Aspects were used to examine the association between the mother's occupation and (1) the risk of stillbirth at or after 12 weeks of gestation, and (2) the risk of infant death under 1 year of age after livebirth.Methods　Data from the Vital Statistics: Occupational and Industrial Aspects (Live Birth Form, and Foetal Death Form) for fiscal years (FYs) 1995, 2000, 2005, 2010, and 2015 and Vital Statistics data files (Death Form) from FYs 1995-96, 2000-01, 2005-06, 2010-11, and 2015-16 were analyzed. The study population consisted of (1) 5,355,881 infants who were born during the survey period, with (2) 5,290,808 live birth excluding still birth during the same period. The odds ratios (ORs) were estimated for (1) stillbirth (without stillbirth = livebirth) and (2) infant death (without infant death = alive at 1 year of age) by mother's occupation (managers/specialist/technical workers, clerical workers, sales workers, service workers, blue collar workers, and not employed) using logistic regression. Blue collar workers included workers in security, agriculture/forestry/fishing, manufacturing process, transport, and machine operation. The population attributable risk (PAR) for stillbirth attributed to mother's occupation among employed mothers was also calculated.Results　There were 61,179 (1.1%) stillbirths in the study population and 12,789 (0.2%) infant deaths among 5,290,808 live birth. Compared to managers/specialist/technical workers, the adjusted ORs (95% confidence interval) for stillbirth among clerical workers, sales workers, service workers, blue collar workers and not employed women were 1.24 (1.20-1.29), 1.48 (1.41-1.56), 1.76 (1.69-1.83), 1.54 (1.46-1.61), and 0.95 (0.92-0.98), respectively. There was no association between the mother's occupation and infant deaths. The PAR values for stillbirth among mothers employed as clerical workers and service workers were 7.4% and 12.3%.Conclusion　The risk of stillbirth differed according to the mother's occupation in our study. The OR and PAR of stillbirth were the highest for service workers. Mother's occupation was not associated with the risk of infant death; therefore, the mothers' occupation is likely to affect the children's condition only during pregnancy. Our study suggests the importance of understanding the causal linkage between pregnant women's occupation and birth outcomes.

Background: Obesity prevalence is increasing in many countries in the world, including Asia. Maternal obesity is highly associated with fetal and neonatal deaths. This study investigated whether maternal obesity is a risk factor of fetal death (measured in terms of miscarriage and stillbirth) and neonatal mortality in South and South-East Asian countries., Methods: This cross-sectional study pooled the most recent Demographic and Health Surveys (DHS) from eight South and South-East Asian countries (2014-2018). Multivariate logistic regression was deployed to check the relationships between maternal obesity with fetal and neonatal deaths. Finally, multilevel logistic regression model was employed since the DHS data has a hierarchical structure., Results: The pooled logistic regression model illustrated that maternal obesity is associated with higher odds of miscarriage (adjusted odds ratio [aOR]: 1.26, 95% CI: 1.20-1.33) and stillbirths (aOR: 1.46, 95% CI: 1.27-1.67) after adjustment of confounders. Children of obese mothers were at 1.18 (aOR: 1.18, 95% CI: 1.08-1.28) times greater risk of dying during the early neonatal period than mothers with a healthy weight. However, whether maternal obesity is statistically a significant risk factor for the offspring's late neonatal deaths was not confirmed. The significant association between maternal obesity with miscarriage, stillbirth and early neonatal mortality was further confirmed by multilevel logistic regression results., Conclusion: Maternal obesity in South and South-East Asian countries is associated with a greater risk of fetal and early neonatal deaths. This finding has substantial public health implications. Strategies to prevent and reduce obesity should be developed before planning pregnancy to reduce the fetal and neonatal death burden. Obese women need to deliver at the institutional facility centre that can offer obstetrics and early neonatal care., Competing Interests: The authors have declared that no competing interests exist.

Background: Recent decreases in neonatal mortality have been slower than expected for most countries. This study aims to predict the risk of neonatal mortality using only data routinely available from birth records in the largest city of the Americas., Methods: A probabilistic linkage of every birth record occurring in the municipality of São Paulo, Brazil, between 2012 e 2017 was performed with the death records from 2012 to 2018 (1,202,843 births and 447,687 deaths), and a total of 7282 neonatal deaths were identified (a neonatal mortality rate of 6.46 per 1000 live births). Births from 2012 and 2016 (N = 941,308; or 83.44% of the total) were used to train five different machine learning algorithms, while births occurring in 2017 (N = 186,854; or 16.56% of the total) were used to test their predictive performance on new unseen data., Results: The best performance was obtained by the extreme gradient boosting trees (XGBoost) algorithm, with a very high AUC of 0.97 and F1-score of 0.55. The 5% births with the highest predicted risk of neonatal death included more than 90% of the actual neonatal deaths. On the other hand, there were no deaths among the 5% births with the lowest predicted risk. There were no significant differences in predictive performance for vulnerable subgroups. The use of a smaller number of variables (WHO's five minimum perinatal indicators) decreased overall performance but the results still remained high (AUC of 0.91). With the addition of only three more variables, we achieved the same predictive performance (AUC of 0.97) as using all the 23 variables originally available from the Brazilian birth records., Conclusion: Machine learning algorithms were able to identify with very high predictive performance the neonatal mortality risk of newborns using only routinely collected data., (© 2021. The Author(s).)

Objective: To explore any apparent trends in maternal or neonatal outcomes during the Covid-19 pandemic by comparing the maternity outcomes before, during and after the pandemic., Study Design: A retrospective review was performed of maternity statistics recorded on the hospital database of a large tertiary referral centre in Dublin with over 8000 deliveries per annum from 1st January to 31st July 2020. This time period represented the months prior to, during the peak and following the pandemic in Ireland., Results: There was no correlation between the monthly number of Covid deaths and the monthly number of perinatal deaths (r = 0.465, NS), preterm births (r = 0.339, NS) or hypertensive pregnancies (r = 0.48, NS). Compared to the combined numbers for the same month in 2018 and 2019, there were no significant changes in perinatal deaths or preterm births in the months when Covid deaths were at their height. The rate of preterm birth was significantly less common in January-July 2020 compared to January-July in 2018/2019 (7.4 % v 8.6 %, chi-sq 4.53, P = 0.03)., Conclusion: The was no evidence of a negative impact of the Covid-19 pandemic on maternity services, as demonstrated by maternal and neonatal outcomes., Competing Interests: Declaration of Competing Interest The authors report no declarations of interest., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Babies born weighing ≥ 2500 g account for more than 80% of the births in most resource-limited locations and for nearly 50% of the 28-day neonatal deaths. In contrast, in high-resource settings, 28-day neonatal mortality among this group represents only a small fraction of the neonatal deaths. Yet mortality risks for birth weight of ≥ 2500 g is limited. Knowledge regarding the factors associated with mortality in these babies will help in identifying interventions that can reduce mortality., Methods: The Global Network's Maternal Newborn Health Registry (MNHR) is a prospective, population-based observational study that includes all pregnant women and their pregnancy outcomes in defined geographic communities that has been conducted in research sites in six low-middle income countries (India, Pakistan, Democratic Republic of Congo, Guatemala, Kenya and Zambia). Study staff enroll all pregnant women as early as possible during pregnancy and conduct follow-up visits to ascertain delivery and 28-day neonatal outcomes. We analyzed the neonatal mortality rates (NMR) and risk factors for deaths by 28 days among all live-born babies with a birthweight ≥ 2500 g from 2010 to 2018 across the Global Network sites., Results: Babies born in the Global Network sites from 2010 to 2018 with a birthweight ≥ 2500 g accounted for 84.8% of the births and 45.4% of the 28-day neonatal deaths. Among this group, the overall NMR was 13.1/1000 live births. The overall 28-day NMR for ongoing clusters was highest in Pakistan (29.7/1000 live births) and lowest in the Zambian/Kenyan sites (9.3/1000) for ≥ 2500 g infants. ≥ 2500 g NMRs declined for Zambia/Kenya and India. For Pakistan and Guatemala, the NMR remained almost unchanged over the period. The ≥ 2500 g risks related to maternal, delivery and newborn characteristics varied by site. Maternal factors that increased risk and were common for all sites included nulliparity, hypertensive disease, previous stillbirth, maternal death, obstructed labor, severe postpartum hemorrhage, and abnormal fetal presentation. Neonatal characteristics including resuscitation, hospitalization, congenital anomalies and male sex, as well as lower gestational ages and birthweights were also associated with increased mortality., Conclusions: Nearly half of neonatal deaths in the Global Network sites occurred in infants born weighing ≥ 2500 g. The NMR for those infants was 13.1 per 1000 live births, much higher than rates usually seen in high-income countries. The changes in NMR over time varied across the sites. Even among babies born ≥ 2500 g, lower gestational age and birthweight were largely associated with increased risk of mortality. Since many of these deaths should be preventable, attention to preventing mortality in these infants should have an important impact on overall NMR., Trial Registration: https://ClinicalTrials.gov Identifier: NCT01073475.

Background: The current maternal mortality ratio in Uganda is 336 maternal deaths per 100,000 live births. Infant mortality is 43 deaths per 1000 live births, with 42% of the mortality occurring during the neonatal period. This might be related to a weak health system in the country. This study aimed at assessing the uptake of lifesaving services during pregnancy and childbirth in Hoima District, Uganda., Methods: The study used a cross-sectional quantitative design among 691 women with a child under 5 years. Households were randomly sampled from a list of all the villages in the district with the ENA for SMART software using the EPI methodology. Pre-coded questionnaires uploaded in the Open Data Kit were used for data collection. The data was cleaned and analysed using MS Excel and SPSS software. Descriptive results are presented., Results: Of the 55.1% women attending at least four antenatal care (ANC) visits, only 24.3% had the first ANC within the first trimester. Moreover, ANC services generally was of poor quality, with only 0.4% meeting all the requirements for quality of ANC service. The highest contributors to this poor quality included poor uptake of iron-folic acid (adherence 28.8%), the six-required birth preparedness and complication readiness items (13.2%), and recognition of the seven danger signs of pregnancy (3.0%). Adherence to the seven essential newborn care actions was very low (0.5%), mainly caused by three practices: initiating breastfeeding within 1 h (59.9%), lack of postnatal care within 24 h (20.1%), and failure to recognize the 6 danger signs of the newborn (2.4%). Only 11.1% of the males participated in all maternal and newborn care requirements, by encouraging women to seek healthcare (39.9%), accompanying them to healthcare (36.9%), and HIV counselling and support services (26.2%)., Conclusion: The study reveals poor maternal and newborn practices throughout the continuum of care, from ANC and skilled birth attendance to newborn care during childbirth. With such poor results, it is not surprising that Hoima is sixth of 10 districts that have the highest numbers of deaths due to maternal mortality in Uganda.

Background: Globally, every year greater than twenty million newborns are born weighing less than 2500grams, of which over 96% of them were in developing countries. It contributes to sixty to eighty percent of all neonatal deaths, annually. These infants weighing less than 2500gram will have a poor immune system and are at risk of morbidity and mortality. This study was aimed to investigate the survival status and predictors of mortality among neonates admitted with low birth weight at public hospitals in Ethiopia., Method: A prospective cohort study was conducted among selected 216 newborns admitted with low birth weight who were admitted in neonatal intensive care unit at Arba Minch General hospital, Sawla General Hospital and Chencha district hospital from 1st March 2018 to 28st February 2019. Data were entered into Epi data version 3.02 and exported to STATA V 14 for analysis. The Kaplan Meier survival curve together with log rank test was used to estimate the survival time of the newborns. Variables which had p-value <0.05 in multivariable analysis using the cox proportional hazard model were declared as statistically significant., Result: The cumulative proportion of surviving at the end of third days was 99.01% (95%CI: 96.11, 99.75). Similarly it was 97.81% (95%CI: 94.25, 99.18), 96.27% (95%CI: 91.76, 98.33) and 94.33% (95%CI: 88.72, 97.19) at the end of fourth, fifth and sixth day respectively. The overall mean survival time was 17.13 days (95%CI: 12.76, 21.49). The incidence of mortality among neonates admitted with low birth weight was 83 per 1000 live births. Mothers with DM (AHR:4.79; 95%CI:1.15, 19.8), maternal HIV infection(AHR:6.47;95%CI:1.43,29.3), not keeping the newborn under KMC(AHR:13.0;95%CI:3.42, 49.5) and initiating exclusive breast feeding within one hour(AHR:0.19;95%CI:0.04, 0.95) were statistically significant in multivariable cox regression analysis., Conclusion: The risk of mortality among neonates admitted with low birth weight was high at the early admission period and the incidence of mortality was high. Maternal history of diabetes mellitus, HIV/AIDS infection, keeping the newborn under kangaroo mother care and exclusive breast feeding initiation were statistically significant predictors of mortality. Special emphasis should be given for neonates with low birth weight at the early follow up periods and Kangaroo mother care practice should be a usual practice., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Hargeisa Group Hospital, Somaliland, opened a neonatal unit in 2013. We aimed to study causes of admission, risk factors for neonatal death and post-discharge care to address modifiable factors., Methods: we analysed hospital records from June-October 2013 (n=164). In addition, we reached primary caregivers of 94 patients for further information after discharge., Results: of the 164 patients, 65% were male, 31% weighed <2500 grams, 16% were premature, 43% were exposed to meconium and 29% had premature rupture of membranes (PROM). Twenty-seven percent were admitted after caesarean section and 36% had been bag-mask ventilated. The most common diagnoses for admission were asphyxia (34%), respiratory distress (27%), sepsis (16%) and prematurity (15%). The mortality before discharge was 15%, 23/1430 (1.6%) of live-born at the hospital. Half of the admitted preterm babies died (RR for death for preterm vs term born 4.6, 95% CI 2.3-9.0) as well as 28% of the patients with birth weight <2500 grams (RR 2.1, 95% CI 1.0-4.2). The mortality rate with or without PROM was 29% vs 15% (RR 2.0, 95% CI 1.0-3.9). At 28 days of age, 34% of the patients were exclusively breastfed and 44% had not yet been vaccinated. Diarrhoea, vomiting and/or respiratory distress after discharge were reported for 44%., Conclusion: prematurity and low birth weight were important risk factors for neonatal death in this cohort, contributing to the high mortality rate. Low numbers of exclusively breastfed and vaccinated infants are also issues of concern to be targeted in the peri- and postnatal care., Competing Interests: The authors declare no competing interests., (Copyright: Karen Marie Lundeby et al.)

Introduction: Nepal has made considerable progress on improving child survival during the Millennium Development Goal period, however, further progress will require accelerated reduction in neonatal mortality. Neonatal survival is one of the priorities for Sustainable Development Goals 2030. This paper examines the trends, equity gaps and factors associated with neonatal mortality between 2001 and 2016 to assess the likelihood of Every Newborn Action Plan (ENAP) target being reached in Nepal by 2030., Methods: This study used data from the 2001, 2006, 2011 and 2016 Nepal Demographic and Health Surveys. We examined neonatal mortality rate (NMR) across the socioeconomic strata and the annual rate of reduction (ARR) between 2001 and 2016. We assessed association of socio-demographic, maternal, obstetric and neonatal factors associated with neonatal mortality. Based on the ARR among the wealth quintile between 2001 and 2016, we made projection of NMR to achieve the ENAP target. Using the Lorenz curve, we calculated the inequity distribution among the wealth quintiles between 2001 and 2016., Results: In NDHS of 2001, 2006, 2011 and 2016, a total of 8400, 8600, 13,485 and 13,089 women were interviewed respectively. There were significant disparities between wealth quintiles that widened over the 15 years. The ARR for NMR declined with an average of 4.0% between 2001 and 2016. Multivariate analysis of the 2016 data showed that women who had not been vaccinated against tetanus had the highest risk of neonatal mortality (adjusted odds ratio [AOR] 3.38; 95% confidence interval [CI] 1.20-9.55), followed by women who had no education (AOR 1.87; 95% CI 1.62-2.16). Further factors significantly associated with neonatal mortality were the mother giving birth before the age of 20 (AOR 1.76; CI 95% 1.17-2.59), household air pollution (AOR 1.37; CI 95% 1.59-1.62), belonging to a poorest quintile (AOR 1.37; CI 95% 1.21-1.54), residing in a rural area (AOR 1.28; CI 95% 1.13-1.44), and having no toilet at home (AOR 1.21; CI 95% 1.06-1.40). If the trend of neonatal mortality rate of 2016 continues, it is projected that the poorest family will reach the ENAP target in 2067., Conclusions: Although neonatal mortality is declining in Nepal, if the current trend continues it will take another 50 years for families in the poorest group to attain the 2030 ENAP target. There are different factors associated with neonatal mortality, reducing the disparities for maternal and neonatal care will reduce mortality among the poorest families.

Background: Perinatal and neonatal mortality rates have been described as sensitive indices of the quality of health care services. Regular audits of perinatal and neonatal mortalities are desirable to evaluate the various global interventions., Objective: To describe the current pattern of perinatal and neonatal mortality in a Nigerian tertiary health facility., Methods: Using a prospective audit method, the socio-demographic parameters of all perinatal and neonatal deaths recorded in a Nigerian tertiary facility between February 2017 and January 2018 were studied., Results: There were 1,019 deliveries with stillbirth rate of 27.5/1000 total births and early neonatal death (END) rate among in-born babies of 27.2/1000 live births. The overall perinatal mortality rate for in-facility deliveries was 53.9/1000 total births and neonatal mortality (till the end of 28 days) rate of 27.2/1000 live births. Severe perinatal asphyxia and prematurity were the leading causes of neonatal deaths while obstructed labour and intra-partum eclampsia were the two leading maternal conditions related to stillbirths (25.0% and 21.4% respectively).Gestational age < 32 weeks, age < 24 hours and inborn status were significantly associated with END (p = 0.002, p <0.001 and p = 0.002 respectively)., Conclusion: The in-facility perinatal mortality rate was high though stillbirth rate was relatively low. There is a need to improve the quality of emergency obstetric and neonatal services prior to referral to tertiary facilities., (© 2019 Ogunlesi et al.)

Maternal, fetal, and neonatal health outcomes are interdependent. Designing public health strategies that link fetal and neonatal outcomes with maternal outcomes is necessary in order to successfully reduce perinatal and neonatal mortality, particularly in low- and middle- income countries. However, to date, there has been no standardized method for documenting, reporting, and reviewing facility-based stillbirths and neonatal deaths that links to maternal health outcomes would enable a more comprehensive understanding of the burden and determinants of poor fetal and neonatal outcomes. We developed and pilot-tested an adapted RAPID tool, Perinatal-Neonatal Rapid Ascertainment Process for Institutional Deaths (PN RAPID), to systematically identify and quantify facility-based stillbirths and neonatal deaths and link them to maternal health factors in two countries: Liberia and Nepal. This study found an absence of stillbirth timing documented in records, a high proportion of neonatal deaths occurring within the first 24 hours, and an absence of documentation of pregnancy-related and maternal factors that might be associated with fetal and neonatal outcomes. The use of an adapted RAPID methodology and tools was limited by these data gaps, highlighting the need for concurrent strengthening of death documentation through training and standardized record templates., Competing Interests: The authors have read the journal’s policy and the authors of this manuscript have the following competing interests: ATB, ET, DRA, EKD, and E. Handzel are paid employees of the CDC. BGC, SR, and E. Hulland were paid employees of the CDC during the writing of this paper; however, they are no longer employed by the CDC. There are no patents, products in development or marketed products associated with this research to declare. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Georgia has one of the highest perinatal mortality rates (i.e., stillbirths and early neonatal deaths combined) in Europe. The Georgian Birth Registry was started in 2016 to provide data for preventive measures of maternal and child health. In this study, we aim to determine the incidence of perinatal mortality, assess the distribution of stillbirths and early neonatal deaths, and to determine the major causes of perinatal mortality in Georgia. Data sources were the Georgian Birth Registry and the vital registration system for the year 2017. Causes of early neonatal deaths were assigned into five categories, using the Wigglesworth classification with the Neonatal and Intrauterine deaths Classification according to Etiology modification. The study used descriptive statistics only, specifically counts, means, proportions, and rates, using the statistical software STATA version 15.0. (StataCorp, College Station, TX, USA). In 2017, 489 stillbirths and 238 early neonatal deaths were recorded, resulting in a perinatal mortality rate of 13.6 per 1000 births. About 80% of stillbirths had an unknown cause of death. The majority of stillbirths occurred before the start of labor (85%), and almost one-third were delivered by caesarean section (28%). Prematurity (58%) and congenital malformations (23%) were the main causes of early neonatal deaths, and 70% of early neonatal deaths occurred after the first day of life. The perinatal mortality rate in Georgia remained high in 2017. The major causes of early neonatal deaths were comparable to those of many high-income countries. Contrary to global data, most early neonatal deaths occurred after the first day of life., Competing Interests: The authors declare they have no conflicts of interest., (© 2019 Atlantis Press International B.V.)

Background: The objectives of this study were to understand the differences in mortality rate, risk factors for mortality, and cause of death distribution in three neonatal age sub-groups (0-2, 3-7, and 8-27 days) and assess the change in mortality rate with previous assessments to inform programmatic decision-making in the Indian state of Bihar, a large state with a high burden of newborn deaths., Methods: Detailed interviews were conducted in a representative sample of 23,602 live births between January and December 2016 (96.2% participation) in Bihar state. We estimated the neonatal mortality rate (NMR) for the three age sub-groups and explored the association of these deaths with a variety of risk factors using a hierarchical logistic regression model approach. Verbal autopsies were conducted using the PHMRC questionnaire and the cause of death assigned using the SmartVA automated algorithm. Change in NMR from 2011 to 2016 was estimated by comparing it with a previous assessment., Results: The NMR 0-2-day, 3-7-day, and 8-27-day mortality estimates in 2016 were 24.7 (95% CI 21.8-28.0), 13.2 (11.1 to 15.7), 5.8 (4.4 to 7.5), and 5.8 (4.5 to 7.5) per 1000 live births, respectively. A statistically significant reduction of 23.3% (95% CI 9.2% to 37.3) was seen in NMR from 2011 to 2016, driven by a reduction of 35.3% (95% CI 18.4% to 52.2) in 0-2-day mortality. In the final regression model, the highest odds for mortality in 0-2 days were related to the gestation period of ≤ 8 months (OR 16.5, 95% CI 11.9-22.9) followed by obstetric complications, no antiseptic cord care, and delivery at a private health facility or home. The 3-7- and 8-27-day mortality was driven by illness in the neonatal period (OR 10.33, 95% CI 6.31-16.90, and OR 4.88, 95% CI 3.13-7.61, respectively) and pregnancy with multiple foetuses (OR 5.15, 95% CI 2.39-11.10, and OR 11.77, 95% CI 6.43-21.53, respectively). Birth asphyxia (61.1%) and preterm delivery (22.1%) accounted for most of 0-2-day deaths; pneumonia (34.5%), preterm delivery (33.7%), and meningitis/sepsis (20.1%) accounted for the majority of 3-7-day deaths; meningitis/sepsis (30.6%), pneumonia (29.1%), and preterm delivery (26.2%) were the leading causes of death at 8-27 days., Conclusions: To our knowledge, this is the first study to report a detailed neonatal epidemiology by age sub-groups for a major Indian state, which has highlighted the distinctly different mortality rate, risk factors, and causes of death at 0-2 days versus the rest of the neonatal period. Monitoring mortality at 0-2 and 3-7 days separately in the traditional early neonatal period of 0-7 days would enable more effective programming to reduce neonatal mortality.

Introduction: Perinatal mortality indicates quality of maternal and neonatal care and is high in Nepal. This study was conducted to find out the prevalence of perinatal deaths in a tertiary care center., Methods: This descriptive cross-sectional study was conducted from July 2017 to June 2018 at KIST Medical College and Teaching Hospital. Details of each perinatal death were filled in predesigned proforma from hospital in-patient records within 24 hours of perinatal death. The total of 1088 cases were selected for the study and convenience sampling was done. Statistical analysis was done with Statistical Package for Social Sciences version 17.0., Results: Prevalence of perinatal death is 16 (1.46%) out of 1095 births. In the same way, perinatal mortality rate, stillbirth rate and early neonatal mortality rate were calculated and found to be 14.61 per 1000 births, 8.21 per 1000 births and 6.44 per 1000 live births respectively. Preterm neonates constituted of 71.4% of early neonatal deaths., Conclusions: Perinatal mortality rate was 50% lower than that of national survey, however comparable with study at another tertiary care center at Kathmandu. Stillbirth and prematurity contributed significantly to perinatal mortality. Provision of good antenatal surveillance, identification of high risk pregnancies and good neonatal care to preterm neonates would be required to reduce perinatal mortality.

Background: Benshangul Gumuze region is one of the regional states in Ethiopia, with highest rate of neonatal mortality rate. The trend increased at alarming rate from 42/1000 live birth in 2005 to 62/ 1000 live birth in 2011. Hence, identifying predictors of neonatal death and implement evidence based interventions at community level is crucial to reduce the mortality. Therefore, the purpose of this study was to identify predictors of neonatal mortality in Assosa zone, Western Ethiopia., Methods: A community based matched case control study was conducted from February 1, until December 30, 2013. The study included 114 cases who died during the first 28 completed days after birth from September 1, 2010 till September 1, 2013. For each case, one alive control matched approximately by the same date of birth (-/+ 2 days) was identified from the preliminary data collected. Finally, multivariate conditional logistic regression analysis was performed; and goodness of fit of the final model was tested using likely hood ratio test. All analysis was done using EPI Info version 7 and SPSS version 16 statistical softwares., Results: Model households in health extension packages [AmOR = 0.32; 95%CI:0.12-0.86], age at first pregnancy < 20 years old [AmOR = 4.3;95%CI: 1.13-16.27],pregnancy complication [AmOR = 4.59; 95%CI: 1.53-13.78], delivery complication [AmOR = 2.80; 95%CI: 1.06-7.39], antenatal care visit [AmOR = 0.34;95%CI: 0.12-0.94], primipara mothers [AmOR = 3.37; 95%CI:1.05-10.78], small size neonate at birth [AmOR = 3.40: 95%CI: 1.05-11.55], gestational age < 37 weeks [AmOR = 4.35;95%CI:1.16-16.28], and home delivery [AmOR = 2.84; 95%CI:1.07-7.55] were found statistically significantly associated with neonatal mortality., Conclusions: Model households in health extension package and antenatal care visit were associated with reducing risk of neonatal mortality. However, age at first pregnancy < 20 years old, primipara mothers, pregnancy complication, delivery complication, small size neonates, gestational age < 37 weeks, and home delivery were associated with increasing risk of neonatal death. Therefore, promotion of model household in health extension package, anti natal care visit, institutional delivery, family planning to prevent early age pregnancy; and improve access to basic emergency obstetric care and intensive newborn care centers are effective interventions to reduce risk of neonatal mortality at community level.

Objectives An enhanced surveillance system that integrated health information systems and extended surveillance to previously uncovered areas to capture all births, perinatal and maternal deaths in a rural district of Pakistan was established in 2015, and this study uses capture-recapture methodology to assess completeness. Methods Births and deaths collected by the survey were matched with the data captured by the enhanced surveillance system. Capture-recapture methodology was used to estimate the total number of births and deaths, measure the degree of underestimation, and adjust mortality rates. Results Of all births, 99% were captured by the enhanced surveillance system. Ninety percent of neonatal deaths and 86% of early neonatal deaths were recorded. The recorded neonatal mortality rate was 40 per 1000 live births (95% CI 35-44), and after adjustment for under-enumeration was 42 per 1000 live births (95% CI 37-46). Recorded rates underestimated neonatal mortality by 5% and perinatal mortality by 7%. Five stillbirths were recorded by the survey and all were matched to recorded stillbirths. The one maternal death recorded by the survey was matched with the maternal death captured by the enhanced surveillance system. The maternal mortality ratio prior to adjustment for under-enumeration was 247 per 100,000 live births (95% CI 147-391), whereas after adjustment it was 246 per 100,000 live births (95% CI 146-389). Conclusion Application of capture-recapture methods to the enhanced surveillance system indicated a high completeness of birth and death recording by the surveillance system.

Objective: to evaluate the completeness of perinatal death investigation sheets, stratified by age components., Method: descriptive study carried out in Recife, PE, in 2014. Among 308 perinatal deaths, 46 were excluded from this study due to association with congenital malformations, and 7 due to missing investigation sheets. Analysis included 255 deaths (160 fetal deaths, and 95 preterm neonatal deaths). The degree of completeness of 98 variables was calculated. They were aggregated into six blocks: identification, prenatal care, birth care, family characteristics, occurrence of death and conclusions and recommendations., Results: the median rate of completeness for perinatal death investigation sheets was 85.7% (82.8% for records of fetal deaths and 89.5% for records of preterm neonatal deaths). The best-filled information block was "identification" (96.1%), as well as its components: fetal (94.7%) and preterm neonatal (97.9%). The worst was "prenatal care" (69.8%), along with its components: fetal (73.8%) and preterm neonatal (67.4%)., Conclusion: investigation sheets had good completeness; there were differences between variables and components of perinatal death.

Introduction Nigeria contributes more obstetric, postpartum and neonatal deaths and stillbirths globally than any other country. The Clinton Health Access Initiative in partnership with the Nigerian Federal Ministry of Health and the state Governments of Kano, Katsina, and Kaduna implemented an integrated Maternal and Neonatal Health program from July 2014. Up to 90% women deliver at home in Northern Nigeria, where maternal mortality ratio and neonatal mortality rates (MMR and NMR) are high and severe challenges to improving survival exist. Methods Community-based leaders ("key informants") reported monthly vital events. Pre-post comparisons of later (months 16-18) with conservative baseline (months 7-9) rates were used to assess change in MMR, NMR, perinatal mortality (PMR) and stillbirth. Two-tailed cross-tabulations and unadjusted and adjusted logistic regression analyses were conducted. Results Data on 147,455 births (144,641 livebirths and 4275 stillbirths) were analyzed. At endline (months 16-18), MMR declined 37% (OR 0.629, 95% CI 0.490-0.806, p ≤ 0.0003) vs. baseline 440/100,000 births (months 7-9). NMR declined 43% (OR 0.574, 95% CI 0.503-0.655, p < 0.0001 vs. baseline 15.2/1000 livebirths. Stillbirth rates declined 15% (OR 0.850, 95% CI 0.768-0.941, p = 0.0018) vs. baseline 21.1/1000 births. PMR declined 27% (OR 0.733, 95% CI 0.676-0.795, p < 0.0001) vs. baseline 36.0/1000 births. Adjusted results were similar. Discussion The findings are similar to the Cochrane Review effects of community-based interventions and indicate large survival improvements compared to much slower global and flat national trends. Key informant data have limitations, however, their limitations would have little effect on the results magnitude or significance.

Background: Infections cause about one fifth of the estimated 2.7 million annual neonatal deaths worldwide. Population-based data on burden and risk factors of neonatal infections are lacking in developing countries, which are required for the appropriate design of effective preventive and therapeutic interventions in resource-poor settings., Methods: We used data from a community-based cluster-randomized trial conducted to evaluate the impact of two umbilical cord cleansing regimens with chlorhexidine solution on neonatal mortality and morbidity in a rural area of Sylhet District in Bangladesh. Newborns were assessed four times in the first 9 days of life by trained community health workers (CHWs) using a WHO IMCI-like clinical algorithm. Cumulative incidence of the first episode of infections in the first 9 days of life was estimated using survival analysis technique accounting for survival bias and competing risk of death before the occurrence of infection. A multivariable generalized estimating equation log-binomial regression model was used to identify factors independently associated with infections., Results: Between 2007 and 2009, 30,267 newborns who received at least one postnatal assessment visit by a CHW within the first 9 days of life were included in this study. Cumulative incidence of infections in the first 9 days of life was 14.5% (95% CI 14.1-14.9%). Significant risk factors included previous child death in the family [RR 1.10 (95% CI 1.02-1.19)]; overcrowding [RR 1.14 (95% CI 1.04-1.25)]; home delivery [RR 1.86 (95% CI 1.58-2.19)]; unclean cord care [RR 1.15 (95% CI 1.03-1.28)]; multiple births [RR 1.34 (95% CI 1.15-1.56)]; low birth weight [reference: ≥ 2500 g, RR (95% CI) for < 1500, 1500-1999, and 2000-2499 g were 4.69 (4.01-5.48), 2.15 (1.92-2.42), and 1.15 (1.07-1.25) respectively]; and birth asphyxia [RR 1.65 (1.51-1.81)]. Higher pregnancy order lowered the risk of infections in the study population [compared to first pregnancy, RR (95% CI) for second, third, and ≥ fourth pregnancy babies were 0.93 (0.85-1.02), 0.88 (0.79-0.97), and 0.79 (0.71-0.87), respectively]., Conclusion: Neonatal infections and associated deaths can be reduced by identifying and following up high-risk mothers and newborns and promoting facility delivery and clean cord care in resource-poor countries like Bangladesh where the burden of clinically ascertained neonatal infections is high. Further research is needed to measure the burden of infections in the entire neonatal period, particularly in the second fortnight and its association with essential newborn care., Trial Registration: NCT00434408 . Registered February 9, 2007.

Objective: This study was conducted to determine the maternal and neonatal characteristics that influence very early neonatal mortality using 811 delivery records at the Eastern Regional Hospital of Ghana., Results: The very early neonatal mortality rate was 9 per 1000 live births. Multi-parity reduced the odds of very early neonatal death by 30%. Mothers with a previous neonatal death had about 8 times the odds of having a very early neonatal death as compared to those without a history of neonatal death.

Objective: The objective of this study was to test the validity of the pragmatic criteria of the definitions of neonatal near miss, extending them throughout the infant period, and to estimate the indicators of perinatal care in public maternity hospitals., Methods: A cohort of live births from six maternity hospitals in the municipalities of São Paulo, Niterói, and Rio de Janeiro, Brazil, was carried out in 2011. We carried out interviews and checked prenatal cards and medical records. We compared the pragmatic criteria (birth weight, gestational age, and 5' Apgar score) of the definitions of near miss of Pileggi et al., Pileggi-Castro et al., Souza et al., and Silva et al. We calculated sensitivity, specificity (gold standard: infant mortality), percentage of deaths among newborns with life-threatening conditions, and rates of near miss, mortality, and severe outcomes per 1,000 live births., Results: A total 7,315 newborns were analyzed (completeness of information > 99%). The sensitivity of the definition of Pileggi-Castro et al. was higher, resulting in a higher number of cases of near miss, Souza et al. presented lower value, and Pileggi et al. and de Silva et al. presented intermediate values. There is an increase in sensitivity when the period goes from 0-6 to 0-27 days, and there is a decrease when it goes to 0-364 days. Specificities were high (≥ 97%) and above sensitivities (54% to 77%). One maternity hospital in São Paulo and one in Niterói presented, respectively, the lowest and highest rates of infant mortality, near miss, and frequency of births with life-threatening conditions, regardless of the definition., Conclusions: The definitions of near miss based exclusively on pragmatic criteria are valid and can be used for monitoring purposes. Based on the perinatal literature, the cutoff points adopted by Silva et al. were more appropriate. Periodic studies could apply a more complete definition, incorporating clinical, laboratory, and management criteria, including congenital anomalies predictive of infant mortality.

We aimed to evaluate factors associated with cases of neonatal near miss and neonatal deaths at six public maternity hospitals in São Paulo and Rio de Janeiro States, Brazil, in 2011. A prospective hospital-based birth cohort investigated these outcomes among live births with life-threatening conditions. Associations were tested using multinomial logistic regression models with hierarchical levels. High rates of near miss were observed for maternal syphilis (52.2‰ live births) and lack of prenatal care (80.8‰ live births). Maternal black skin color (OR = 1.9; 95%CI: 1.2-3.2), hemorrhage (OR = 2.2; 95%CI: 1.3-3.9), hypertension (OR = 3.0; 95%CI: 2.0-4.4), syphilis (OR = 3.3; 95%CI: 1.5-7.2), lack of prenatal care (OR = 5.6; 95%CI: 2.6-11.7), cesarean section and hospital, were associated with near miss; while hemorrhage (OR = 4.6; 95%CI: 1,8-11.3), lack of prenatal care (OR = 17.4; 95%CI: 6.5-46.8) and hospital, with death. Improvements in access to qualified care for pregnant women and newborns are necessary to reduce neonatal life-threatening conditions.

Objectives: To assess trends in early neonatal mortality (ENM) and population-attributable risk (PAR) estimates for predictors of ENM in Nigeria., Design, Setting and Participants: A cross-sectional data on 63 844 singleton live births within the preceding 5 years from the 2003, 2008 and 2013 Nigeria Demographic and Health Surveys were used. Adjusted PARs were used to estimate the number of early neonatal deaths attributable to each predictor in the final multivariable Cox regression model., Main Outcome Measures: ENM, defined as the death of a live-born singleton between birth and 6 days of life., Results: The ENM rate slightly declined from 30.5 (95% CI 26.1 to 34.9) to 26.1 (CI 24.3 to 27.9) during the study period. Approximately 36 746 (CI 14 656 to 56 920) and 37 752 (CI 23 433 to 51 126) early neonatal deaths were attributable to rural residence and male sex, respectively. Other significant predictors of ENM included small neonates (attributable number: 25 884, CI 19 172 to 31 953), maternal age <20 years (11 708, CI 8521 to 17 042), caesarean section (6312, CI 4260 to 8521) and birth order ≥4 with a short birth interval (≤2 years) (18 929, CI 12 781 to 25 563))., Conclusions: To improve early neonatal survival in Nigeria, community-based interventions are needed for small neonates, and to promote delayed first pregnancy, child spacing and timely referral for sick male neonates and caesarean delivery., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objective  The primary aim of this study was to determine if there is an association between maternal obesity and cerebral palsy or death in children. Study Design  This is a retrospective cohort analysis of a randomized controlled clinical trial previously performed by the Maternal-Fetal Medicine Units Network. Women in the original trial were included if at high risk for preterm delivery. The present study included singletons enrolled in the original study with complete data. Obese and nonobese women were compared. A secondary analysis comparing class 3 obese or classes 1 to 2 obese women to nonobese women was performed. The primary outcome was a composite of cerebral palsy or perinatal death. Results  In this study, 1,261 nonobese, 339 obese, and 69 morbidly obese women were included. When adjusted for gestational age at delivery and magnesium exposure, there was no association between maternal obesity and child cerebral palsy or death. In the analysis using obesity severity categories, excess risk for adverse outcome appeared confined to the class 3 obese group. Conclusion  In women at high risk of delivering preterm, maternal obesity was not independently associated with child cerebral palsy or death. The association in unadjusted analysis appears to be mediated by preterm birth among obese patients., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Introduction: In low income and middle income countries, neonatal mortality remains high despite the gradual reduction in under five mortality. Newborn death contributes for about 38% of all under five deaths. This study has identified the magnitude and independent predictors of neonatal mortality in rural Ethiopia., Methods: This population based nested case control study was conducted in rural West Gojam zone, Northern Ethiopia, among a cohort of pregnant women who gave birth between March 2011 and Feb 2012. The cohort was established by Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) project in 2010 by recruiting mothers in their third trimester, as identified by trained community volunteers. Once identified, women stayed in the cohort throughout their pregnancy period receiving Community Maternal and Newborn Health (CMNH) training by health extension workers and community volunteers till the end of the first 48 hours postpartum. Cases were 75 mothers who lost their newborns to neonatal death and controls were 150 randomly selected mothers with neonates who survived the neonatal period. Data to identify cause of death were collected using the WHO standard verbal autopsy questionnaire after the culturally appropriate 40 days of bereavement period. Binomial logistic regression model was used to identify independent contributors to neonatal mortality., Result: The neonatal mortality rate was AOR(95%CI) = 18.6 (14.8, 23.2) per 1000 live births. Neonatal mortality declined with an increase in family size, neonates who were born among a family of more than two had lesser odds of death in the neonatal period than those who were born in a family of two AOR (95% CI) = 0.13 (0.02, 0.71). Mothers who gave birth to 2-4 AOR(95%CI) = 0.15 (0.05, 0.48) and 5+ children AOR(95%CI) = 0.08 (0.02, 0.26) had lesser odds of losing their newborns to neonatal mortality. Previous history of losing a newborn to neonatal death also increased the odds of neonatal mortality during the last birth AOR (95%CI) = 0.25 (0.11, 0.53)., Conclusion: The neonatal mortality rate in our study was three times lower than the regional neonatal mortality rate estimate, indicating community based interventions could significantly decrease neonatal mortality. The identified determinants, which are amenable for change, emphasize the need to improve quality of care during pregnancy, labour and delivery to improve pregnancy outcome.

Researchers and policymakers often rely on the infant mortality rate as an indicator of a country's health. Despite arguments about its relevance, uniform measurement of infant mortality is necessary to guarantee its use as a valid measure of population health. Using important socioeconomic indicators, we develop a novel method to adjust country-specific reported infant mortality figures. We conclude that an augmented measure of mortality that includes both infant and late fetal deaths should be considered when assessing levels of social welfare in a country. In addition, mortality statistics that exhibit a substantially high ratio of late fetal to early neonatal deaths should be more closely scrutinized.

Background: Neonatal and maternal health services have a bearing on neonatal mortality. Direct and indirect factors affecting neonatal health outcomes therefore require understanding to enable well-targeted interventions. This study, therefore, assessed the interrelationship between newborn health outcomes and maternal service utilization factors., Methods: We investigated maternal health utilization factors using health facility delivery and at least four Antenatal Care (ANC) visits; and newborn health outcomes using newborn death and low birth weight (LBW). We used data from a household cross-sectional survey that was conducted in 2015 in Kamuli, Pallisa and Kibuku districts. We interviewed 1946 women who had delivered in the last 12 months. The four interrelated (Endogenous) outcomes were ANC attendance, health facility delivery, newborn death, and LBW. We performed analysis using a structural equation modeling technique., Results: A history of newborn death (aOR = 12.64, 95% CI 5.31-30.10) and birth of a LBW baby (aOR = 3.51, 95% CI 1.48-8.37) were directly related to increased odds of newborn death. Factors that reduced the odds of LBW as a mediating factor for newborn death were ANC fourth time attendance (aOR = 0.62, 95% CI 0.45-0.85), having post-primary level education (aOR = 0.68, 95% CI 0.46-0.98) compared to none and being gravida three (aOR = 0.49, 95% CI 0.26-0.94) compared to being gravida one. Mother's age group, 20-24 (aOR = 0.24, 95% CI 0.08-0.75) and 25-29 years (aOR = 0.20, 95% CI 0.05-0.86) compared to 15-19 years was also associated with reduced odds of LBW. Additionally, ANC visits during the first trimester (aOR = 2.04, 95% CI 1.79-2.34), and village health teams (VHTs) visits while pregnant (aOR = 1.14, 95% CI 1.01-1.30) were associated with increased odds of at least four ANC visits, which is a mediating factor for health facility delivery, LBW and newborn death. Surprisingly, newborn death was not significantly different between health facility and community deliveries., Conclusions: Attending ANC at least four times was a mediating factor for reduced newborn death and low birth weight. Interventions in maternal health and newborn health should focus on factors that increase ANC fourth time attendance and those that reduce LBW especially in resource-limited settings. Targeting women with high-risk pregnancies is also crucial for reducing newborn deaths.

Objective: To examine rates of unexplained intrauterine fetal demise (IUFD) and neonatal morbidity in uncomplicated term pregnancies to identify the optimal gestational age for delivery., Methods: A retrospective case control study was performed with singleton pregnancies delivered between 37 0/7 weeks and 42 6/7 weeks. Exclusion criteria were "complicated pregnancies": emergency deliveries, maternal hypertension, diabetes, infection, fetal disease/malformations and placental abnormalities., Results: Nineteen thousand two hundred and sixty-four maternal/infant pairs were examined. The overall rate of NICU admission was 2.7% and the rate of unexplained IUFD was 2.02 per 1000 births. The lowest rate of IUFD was found at 39 weeks (1.40 per 1000 births). Odds ratios adjusted for maternal smoking, ethnicity, age and mode of delivery showed 2.74 (95% CI 0.35-21.83) risk of IUFD at 42 versus 39 weeks, 2.09 (1.47-2.98) risk of NICU admission at 37 versus 38 weeks, 2.54 (1.62-3.97) risk of respiratory morbidity at 37 versus 38 weeks and 3.38 (1.84-6.18) risk of transient tachypnea of the newborn or respiratory distress syndrome at 37 versus 38 weeks., Conclusions: Neonatal respiratory morbidity was lowest for deliveries at 38-39 weeks. IUFD was 2.74 times more likely at 42 weeks versus 39 weeks. Our findings support current guidelines advising clinicians when to deliver term pregnancies.

Objectives: To identify mortality trends and risk factors associated with stillbirths and neonatal deaths 1982-2011., Methods: Population-based cross-sectional study based on reported pregnancy history in Iganga-Mayuge Health and Demographic Surveillance Site (HDSS) in Uganda. A pregnancy history survey was conducted among women aged 15-49 years living in the HDSS during May-July 2011 (n = 10 540). Time trends were analysed with cubic splines and linear regression. Potential risk factors were examined with multilevel logistic regression with adjusted odds ratios (AOR) and 95% confidence intervals (CI)., Results: 34 073 births from 1982 to 2011 were analysed. The annual rate of decrease was 0.9% for stillbirths and 1.8% for neonatal mortality. Stillbirths were associated with several risk factors: multiple births (AOR 2.57, CI 1.66-3.99), previous adverse outcome (AOR 6.16, CI 4.26-8.88) and grand multiparity among 35- to 49-year-olds (AOR 1.97, CI 1.32-2.89). Neonatal deaths were associated with multiple births (AOR 6.16, CI 4.80-7.92) and advanced maternal age linked with parity of 1-4 (AOR 2.34, CI 1.28-4.25) and grand multiparity (AOR 1.44, CI 1.09-1.90). Education, marital status and household wealth were not associated with the outcomes., Conclusions: The slow decline in mortality rates and easily identifiable risk factors calls for improving quality of care at birth and a rethinking of how to address obstetric risks, potentially a revival of the risk approach in antenatal care., (© 2016 John Wiley & Sons Ltd.)

Background: Factors contributing to perinatal mortality (PM) in Northwest Russia remain unclear. This study investigated possible associations between selected maternal and fetal characteristics and PM based on data from the population-based Murmansk County Birth Registry., Objective: This study investigated possible associations between selected maternal and fetal characteristics and PM based on data from the population-based Murmansk County Birth Registry., Methods: The study population consisted of all live- and stillbirths registered in the Murmansk County Birth Registry during 2006-2011 (n = 52,806). We excluded multiple births, births prior to 22 and after 45 completed weeks of gestation, infants with congenital malformations, and births with missing information regarding gestational age (a total of n = 3,666) and/or the studied characteristics (n = 2,356). Possible associations between maternal socio-demographic and lifestyle characteristics, maternal pre-pregnancy characteristics, pregnancy characteristics, and PM were studied by multivariable logistic regression. Crude and adjusted odds ratios with 95% confidence intervals were calculated., Results: Of the 49,140 births eligible for prevalence analysis, 338 were identified as perinatal deaths (6.9 per 1,000 births). After adjustment for other factors, maternal low education level, prior preterm delivery, spontaneous or induced abortions, antepartum hemorrhage, antenatally detected or suspected fetal growth retardation, and alcohol abuse during pregnancy all significantly increased the risk of PM. We observed a higher risk of PM in unmarried women, as well as overweight or obese mothers. Maternal underweight reduced the risk of PM., Conclusions: Our results suggest that both social and medical factors are important correlates of perinatal mortality in Northwest Russia.

More than 40% of all deaths in children under 5 years of age occur during the neonatal period: the first month of life. Immunization of pregnant women has proven beneficial to both mother and infant by decreasing morbidity and mortality. With an increasing number of immunization trials being conducted in pregnant women, as well as roll-out of recommended vaccines to pregnant women, there is a need to clarify details of a neonatal death. This manuscript defines levels of certainty of a neonatal death, related to the viability of the neonate, who confirmed the death, and the timing of the death during the neonatal period and in relation to immunization of the mother., (Copyright © 2016. Published by Elsevier Ltd.)

Background: Globally, the proportion of child deaths that occur in the neonatal period remains a high level of 37-41%. Differences of cause in neonate death exist in different regions as well as in different economic development countries. The specific aim of this study was to investigate the causes, characteristics, and differences of death in neonates during hospitalization in the tertiary Neonatal Intensive Care Unit (NICU) of China., Methods: All the dead neonates admitted to 26 NICUs were included between January l, 2011, and December 31, 2011. All the data were collected retrospectively from clinical records by a designed questionnaire. Data collected from each NICU were delivered to the leading institution where the results were analyzed., Results: A total of 744 newborns died during the 1-year survey, accounting for 1.2% of all the neonates admitted to 26 NICUs and 37.6% of all the deaths in children under 5 years of age in these hospitals. Preterm neonate death accounted for 59.3% of all the death. The leading causes of death in preterm and term infants were pulmonary disease and infection, respectively. In early neonate period, pulmonary diseases (56.5%) occupied the largest proportion of preterm deaths while infection (27%) and neurologic diseases (22%) were the two main causes of term deaths. In late neonate period, infection was the leading cause of both preterm and term neonate deaths. About two-thirds of neonate death occurred after medical care withdrawal. Of the cases who might survive if receiving continuing treatment, parents' concern about the long-term outcomes was the main reason of medical care withdrawal., Conclusions: Neonate death still accounts for a high proportion of all the deaths in children under 5 years of age. Our study showed the majority of neonate death occurred in preterm infants. Cause of death varied with the age of death and gestational age. Accurate and prompt evaluation of the long-term outcomes should be carried out to guide the critical decision.

Objective: We explore preterm-related neonatal deaths using the WHO application of the International Classification of Disease (ICD-10) to deaths during the perinatal period: ICD-PM as an informative case study, where ICD-PM can improve data use to guide clinical practice and programmatic decision-making., Design: Retrospective application of ICD-PM., Setting: South Africa, and the UK., Population: Perinatal death databases., Methods: Descriptive analysis of neonatal deaths and maternal conditions present., Main Outcome Measures: Causes of preterm neonatal mortality and associated maternal conditions., Results: We included 98 term and 173 preterm early neonatal deaths from South Africa, and 956 term and 3248 preterm neonatal deaths from the UK. In the South African data set, the main causes of death were respiratory/cardiovascular disorders (34.7%), low birthweight/prematurity (29.2%), and disorders of cerebral status (25.5%). Amongst preterm deaths, low birthweight/prematurity (43.9%) and respiratory/cardiovascular disorders (32.4%) were the leading causes. In the data set from the UK, the leading causes of death were low birthweight/prematurity (31.6%), congenital abnormalities (27.4%), and deaths of unspecified cause (26.1%). In the preterm deaths, the leading causes were low birthweight/prematurity (40.9%) and deaths of unspecified cause (29.6%). In South Africa, 61% of preterm deaths resulted from the maternal condition of preterm spontaneous labour. Among the preterm deaths in the data set from the UK, no maternal condition was present in 36%, followed by complications of placenta, cord, and membranes (23%), and other complications of labour and delivery (22%)., Conclusions: ICD-PM can be used to appraise the maternal and newborn conditions contributing to preterm deaths, and can inform practice., Tweetable Abstract: ICD-PM can be used to appraise maternal and newborn contributors to preterm deaths to improve quality of care., (© 2016 Royal College of Obstetricians and Gynaecologists The World Health Organization retains copyright and all other rights in the manuscript of this article as submitted for publication.)

Objective: To apply the World Health Organization (WHO) Application of the International Classification of Diseases, tenth revision (ICD-10) to deaths during the perinatal period: ICD-Perinatal Mortality (ICD-PM) to existing perinatal death databases., Design: Retrospective application of ICD-PM., Setting: South Africa, UK., Population: Perinatal death databases., Methods: Deaths were grouped according to timing of death and then by the ICD-PM cause of death. The main maternal condition at the time of perinatal death was assigned to each case., Main Outcome Measures: Causes of perinatal mortality, associated maternal conditions., Results: In South Africa 344/689 (50%) deaths occurred antepartum, 11% (n = 74) intrapartum and 39% (n = 271) in the early neonatal period. In the UK 4377/9067 (48.3%) deaths occurred antepartum, with 457 (5%) intrapartum and 4233 (46.7%) in the neonatal period. Antepartum deaths were due to unspecified causes (59%), chromosomal abnormalities (21%) or problems related to fetal growth (14%). Intrapartum deaths followed acute intrapartum events (69%); neonatal deaths followed consequences of low birthweight/ prematurity (31%), chromosomal abnormalities (26%), or unspecified causes in healthy mothers (25%). Mothers were often healthy; 53%, 38% and 45% in the antepartum, intrapartum and neonatal death groups, respectively. Where there was a maternal condition, it was most often maternal medical conditions, and complications of placenta, cord and membranes., Conclusions: The ICD-PM can be a globally applicable perinatal death classification system that emphasises the need for a focus on the mother-baby dyad as we move beyond 2015., Tweetable Abstract: ICD-PM is a global system that classifies perinatal deaths and links them to maternal conditions., (© 2016 Royal College of Obstetricians and Gynaecologists The World Health Organization retains copyright and all other rights in the manuscript of this article as submitted for publication.)

Background: The Democratic Republic of Congo (DRC) has suffered from war and lingering conflicts in East DRC and has one of the highest infant mortality rates in the world. Prior research has documented increases in infant and child mortality associated with war, but the empirical evidence is limited in several respects. Measures of conflict are quite crude or conflict is not tightly linked to periods of exposure to infant death. Few studies have distinguished between the effects of war on neonatal versus post-neonatal infants. No study has considered possible differences between women who give birth during wartime and those who do not that may be related to greater infant mortality., Methods: The analysis used the nationally representative sample of 15,103 mothers and 53,768 children from the 2007 and 2013/2014 Demographic Health Survey in the DRC and indicators of conflict events and conflict deaths from the 2013 Uppsala Conflict Data. To account for unobserved heterogeneity across women, a multi-level modeling approach was followed by grouping all births for each woman and estimating random intercepts in discrete time event history models., Results: Post-neonatal mortality increased during the Congolese wars, and was highest where conflict events and deaths were extreme. Neonatal mortality was not associated with conflict levels. Infant mortality was not higher in East DRC, where conflicts continued during the post Congolese war period. Models specifying unobserved differences between mothers who give birth during war and those who have children in peacetime did not reduce the estimated effect of war, i.e., no support was found for selectivity in the sample of births during war., Conclusion: Differences in effects of the Congolese war on neonatal versus post-neonatal mortality suggest that conflict influences the conditions of infants' lives more than the aspects of mothers' pregnancy conditions and delivery that are relevant for infant mortality. These differences may, however, be specific to the nature of conflict and prior conditions in the DRC. Because of continued political instability, violent conflict may be expected to continue in contexts such as the DRC; we must therefore continue to document, analyze and monitor the mechanisms through which war influences infant mortality.

Background: Adult immigrants in Canada have a survival advantage over their Canadian-born counterparts. It is unknown whether migrants are able to transmit their survival advantage to their Canadian-born children., Methods: Neonatal and postneonatal mortality between the Canadian-born population and 12 immigrant subgroups were compared using 1990-2005 linked birth-infant death records. Age-at-death specific mortality rates and rate differences were calculated by nativity status and maternal birthplace. A chi-square statistic was used to compare group differences in maternal sociodemographic characteristics. Multivariate survival analysis was used to estimate the effect of maternal birthplace on neonatal and postneonatal mortality, net of maternal sociodemographic and infant characteristics., Results: Overall, immigrants had lower rates of neonatal and postneonatal mortality than the Canadian-born population. But the adjusted risk of neonatal mortality was higher for Sub-Saharan African (hazard ratio [HR] = 1.32; 95 % confidence interval [CI] = 1.05, 1.66), Haitian (HR = 2.29, 95 % CI = 1.90, 2.76), non-Spanish Caribbean (HR = 1.38; 95 % CI = 1.01, 1.89), and Pakistani (HR = 1.87; 95 % CI = 1.31, 2.68) migrants relative to Canadian-born women. There were fewer significant disparities in postneonatal death, with higher adjusted risks of mortality observed for Pakistani (HR = 2.67, 95 % CI = 1.77, 4.02) and Haitian (HR = 1.41, 95 % CI = 1.02, 1.97) migrants only., Conclusion: Inequalities in infant mortality are more concentrated in the neonatal period. Contingent on surviving the first 27 days after birth, the infants of most immigrants (except those from Haiti and Pakistan) have the same chances of survival as the infants of Canadian-born women. Improvements in prenatal care and access to postpartum care may reduce disparities in infant mortality.

Accurately defining and reporting perinatal deaths (ie, fetal and infant deaths) is a critical first step in understanding the magnitude and causes of these important events. In addition to obstetric health care providers, neonatologists and pediatricians should have easy access to current and updated resources that clearly provide US definitions and reporting requirements for live births, fetal deaths, and infant deaths. Correct identification of these vital events will improve local, state, and national data so that these deaths can be better addressed and prevented., (Copyright © 2016 by the American Academy of Pediatrics.)

Within relatively small areas, there exist high spatial variations of mortality between villages. In rural Burkina Faso, with data from 1993 to 1998, clusters of particularly high child mortality were identified in the population of the Nouna Health and Demographic Surveillance System (HDSS), a member of the INDEPTH Network. In this paper, we report child mortality with respect to temporal trends, spatial clustering and disparity in this HDSS from 1993 to 2012. Poisson regression was used to describe village-specific child mortality rates and time trends in mortality. The spatial scan statistic was used to identify villages or village clusters with higher child mortality. Clustering of mortality in the area is still present, but not as strong as before. The disparity of child mortality between villages has decreased. The decrease occurred in the context of an overall halving of child mortality in the rural area of Nouna HDSS between 1993 and 2012. Extrapolated to the Millennium Development Goals target period 1990-2015, this yields an estimated reduction of 54%, which is not too far off the aim of a two-thirds reduction., (© 2016 John Wiley & Sons Ltd.)

Introduction: To elucidate possible mechanisms behind the increased risk of stillbirth and infant mortality among migrants in Denmark, this study aimed to analyse characteristics of perinatal deaths at Hvidovre Hospital 2006-2010 - -according to maternal country of origin., Methods: We identified children born at Hvidovre Hospital who died perinatally and included the patient files in a series of case studies. Our data were linked to data from population-covering registries in Statistics Denmark. Timing, causes of death as well as social, medical and obstetric characteristics of the parents were described according to maternal country of origin., Results: This study included 125 perinatal deaths. The data indicated that intrapartum death, death caused by maternal disease, lethal malformation and preterm birth may be more frequent among non-Western than among Danish-born women. Obesity and disposition to diabetes may also be more prevalent among the non-Western women., Conclusions: The role of obesity, gestational diabetes, preeclampsia and severe congenital anomalies should be a main focus in improving our understanding the increased risk of perinatal death among non-Western migrant women in Denmark. Six of 28 perinatal deaths in the non-Western group were intrapartum deaths and warrants further concern., Funding: This project was funded by the Danish Council for Strategic Research as part of the SULIM project., Trial Registration: The linkage of data from patient files to data from Statistics Denmark was approved by the Danish Data Protection Agency. Only anonymised data were used.