Neonatal mortality risk of vulnerable newborns: A descriptive analysis of subnational, population-based birth cohorts for 238 143 live births in low- and middle-income settings from 2000 to 2017

the Subnational Vulnerable Newborn Prevalence Collaborative Group and Vulnerable Newborn Measurement Core Group, Elizabeth A. Hazel, Daniel J. Erchick, Joanne Katz, Anne C.C. Lee, Michael Diaz, Lee S.F. Wu, Keith P. West, Abu Ahmed Shamim, Parul Christian, Hasmot Ali, Abdullah H. Baqui, Samir K. Saha, Salahuddin Ahmed, Arunangshu Dutta Roy, Mariângela F. Silveira, Romina Buffarini, Roger Shapiro, Rebecca Zash, Patrick KolsterenCarl Lachat, Lieven Huybregts, Dominique Roberfroid, Zhonghai Zhu, Lingxia Zeng, Seifu H. Gebreyesus, Kokeb Tesfamariam, Seth Adu-Afarwuah, Kathryn G. Dewey, Stephaney Gyaase, Kwaku Poku-Asante, Ellen Boamah Kaali, Darby Jack, Thulasiraj Ravilla, James Tielsch, Sunita Taneja, Ranadip Chowdhury, Per Ashorn, Kenneth Maleta, Ulla Ashorn, Charles Mangani, Luke C. Mullany, Subarna K. Khatry, Vundli Ramokolo, Wanga Zembe-Mkabile, Wafaie W. Fawzi, Dongqing Wang, Christentze Schmiegelow, Daniel Minja, Omari Abdul Msemo, John P.A. Lusingu, Emily R. Smith, Honorati Masanja, Aroonsri Mongkolchati, Paniya Keentupthai, Abel Kakuru, Richard Kajubi, Katherine E.A. Semrau, Davidson H. Hamer, Albert Manasyan, Jake M. Pry, Bernard Chasekwa, Jean H Humphrey, Robert E Black

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Objective: We aimed to understand the mortality risks of vulnerable newborns (defined as preterm and/or born weighing smaller or larger compared to a standard population), in low- and middle-income countries (LMICs). Design: Descriptive multi-country, secondary analysis of individual-level study data of babies born since 2000. Setting: Sixteen subnational, population-based studies from nine LMICs in sub-Saharan Africa, Southern and Eastern Asia, and Latin America. Population: Live birth neonates. Methods: We categorically defined five vulnerable newborn types based on size (large- or appropriate- or small-for-gestational age [LGA, AGA, SGA]), and term (T) and preterm (PT): T + LGA, T + SGA, PT + LGA, PT + AGA, and PT + SGA, with T + AGA (reference). A 10-type definition included low birthweight (LBW) and non-LBW, and a four-type definition collapsed AGA/LGA into one category. We performed imputation for missing birthweights in 13 of the studies. Main Outcome Measures: Median and interquartile ranges by study for the prevalence, mortality rates and relative mortality risks for the four, six and ten type classification. Results: There were 238 143 live births with known neonatal status. Four of the six types had higher mortality risk: T + SGA (median relative risk [RR] 2.8, interquartile range [IQR] 2.0–3.2), PT + LGA (median RR 7.3, IQR 2.3–10.4), PT + AGA (median RR 6.0, IQR 4.4–13.2) and PT + SGA (median RR 10.4, IQR 8.6–13.9). T + SGA, PT + LGA and PT + AGA babies who were LBW, had higher risk compared with non-LBW babies. Conclusions: Small and/or preterm babies in LIMCs have a considerably increased mortality risk compared with babies born at term and larger. This classification system may advance the understanding of the social determinants and biomedical risk factors along with improved treatment that is critical for newborn health.

Original languageEnglish
JournalBJOG: An International Journal of Obstetrics and Gynaecology
Publication statusE-pub ahead of print - 2023
Publication typeA1 Journal article-refereed


  • low-and middle-income countries, obstetrics and gynaecology
  • paediatrics: neonatal
  • preterm
  • small-for-gestational age

Publication forum classification

  • Publication forum level 2

ASJC Scopus subject areas

  • Obstetrics and Gynaecology


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