Multisectoral Factors Associated with Global National Trends in Neonatal Mortality Rates: A Call for Targeted Public Health Intervention, Particularly in Countries Impacted Most by COVID-19

Background: The United Nations’ 2030 Sustainable Development Goals (SDGs) target an end to preventable newborn deaths and a reduction in neonatal mortality rate ( < 28 d, NMR) to 12/1,000 live births for all countries. Understanding concurrent trends in country-level, multisectoral factors associated with NMR trends may illuminate opportunities for intervention strategies. Our objective was to explore country-specific trends in NMR from 1990-2019 and identify those countries which contribute to the largest percentage of neonatal deaths in order to focus efforts on reducing NMRs in those specific countries. Unfortunately, due to the COVID-19 pandemic, the 2030 SDGs have been severely impacted.

Methods: We created a comprehensive global database of NMR and associated variables that were selected based on literature review and categorized into Population Health, Health Systems, Maternal, Neonatal, and Social factors from 1990 to 2019. Data were compiled from publicly available sources including UNICEF, World Bank, WHO, and OECD. Data were collected and analyzed for 195 countries. NMR trends were analyzed from 1990 to 2019 with more targeted analysis of trends in the last 2 decades from 2000 to 2019. We then performed statistical analyses using the selected variables to compare variable means using t-tests, identify bivariate associations, and generate multivariable regression models.

Results: In terms of total deaths, 20 countries contributed 75% of the total 2.5 million neonatal deaths. All of these 20 countries showed decreases in NMR since 1990 (Figure 1). However, only China and Egypt accomplished the UN goal of reducing NMR to 12/1,000 live births. We compared variables associated with NMR in our 20 target countries to the remaining countries and found significant differences between the means for most variables (Table 1). Bivariate regression analyses showed statistically significant associations between NMR trends and changes over time in median income, health care spending, literacy level, maternal mortality ratio, and low birthweight rate. Ultimately the variables maternal mortality ratio change and median income change were selected for multivariable analysis based on collinearity. The multivariate regression model generated using NMR, maternal mortality ratio change, median income change resulted in an r-squared value of 0.54, explaining 54% of the variance in NMR trends.

Conclusion: Since 20 countries contribute 75% of the neonatal deaths worldwide, we propose that targeting these 20 countries would have the greatest impact on global neonatal deaths. Future research will focus on identification of country specific barriers and evaluating the countries with greatest NMR improvements to propose effective focused strategies for reducing NMRs in high burden countries. The disparate impact that COVID-19 has had on countries with the highest neonatal mortality burden should be a primary focus of continued public health invention efforts, and is a specific focus of our ongoing research.