The postponement of neonatal deaths into the postneonatal period: evidence from Massachusetts

Part of the slow decline in the postneonatal mortality rate and the rapid decline in the neonatal mortality rate during the 1970s may have been due to a postponement of some neonatal deaths into the postneonatal period. The authors hypothesized that any such postponement should be accompanied by a lack of decline, or even an increase, in late neonatal and postneonatal mortality rates among low birth weight babies and babies dying of conditions originating in the perinatal period. To examine this theory, the authors used vital records data to compare infant mortality rates in Massachusetts during 1970-1972 with rates during 1978-1980. Log-linear hazard models were used to calculate death rates, while controlling for changes in maternal age, race, education, and prior reproductive history. The authors found that babies of birth weight under 1,500 g had no decline in late neonatal mortality rates and babies of birth weight under 2,500 g had no decline in postneonatal mortality rates. Babies of birth weight 500-999 g had an increased postneonatal mortality rate (rate ratio = 2.4; 95% confidence limits = 1.0-5.4). These unimproved or increased death rates were due in part to conditions originating in the perinatal period. The authors conclude that, although infant mortality rates have declined, this postponement was real, and that efforts to monitor infant mortality will benefit from its routine quantification.     

Levels and determinants of early neonatal mortality in Natal, northeastern Brazil: results of a surveillance and case-control study

An institution-based surveillance and nested case-control study was conducted in Natal, Northeastern Brazil to estimate the level and determinants of early neonatal mortality. The early neonatal mortality rate was 25.5 per 1000 live-birth, 75% of early neonatal deaths were premature low birthweight infants, and the mortality rates were 591 and 318 per 1000 respectively, for preterm small for gestational age (PT-SGA) and preterm appropriate for gestational age (PT-AGA) infants. Mortality was 50 per 1000 for term low birthweight, and 8.6 for term normal birthweight AGA infants. In addition to prematurity and low birthweight, the main risk factors associated with early neonatal death were maternal smoking, complications during pregnancy or intrapartum, and inadequate antenatal care. The associations were weaker for prepregnancy factors such as single marital status or low maternal body weight, and no significant associations were observed with socioeconomic status. These findings suggest that in this population, efforts to reduce early neonatal death should focus on improved maternal care and the prevention of prematurity.     

Perinatal mortality in southern Brazil: a population-based study of 7392 births

Perinatal, fetal and early neonatal mortality rates were determined in a population of 7392 babies born in hospitals in Pelotas (total population, 260 000) during 1982. These babies represented over 99% of all births in the city in that year. The perinatal mortality rate for singletons was 31.9 per 1000 total births, the fetal mortality rate being 16.2 and the early neonatal mortality rate 15.9 per 1000 total births.     

Intra-urban variations of neonatal and post-neonatal mortality in a developing city

Numerous surveys at the national and regional level have demonstrated that large inequalities in infant health status exist in Southern Africa. Few studies have assessed infant mortality at the intra-urban scale of geographic analysis. Comparisons between infant mortality rates from different areas are made even more meaningful if the data are divided into two primary categories based on period-of-death; these being the neonatal and post-neonatal components. This study presents the results of a survey undertaken in Metropolitan Cape Town (population 1.6 million) during 1982. The aim was to determine the spatial variation of neonatal and post-neonatal mortality at the suburb (or community) level within the city. Overall, a total of 36,789 live births and 928 infant deaths were recorded; 53.4% in the neonatal period and 46.6% in the post-neonatal period. The mean infant mortality rate was 25.2 per 1000 live births; the neonatal mortality rate and post-neonatal mortality rate being 13.5/1000 and 11.7/1000, respectively. A marked range in death rates was evident for both components. For the neonatal category it was 0.0-49.9/1000 and 0.0-40.0/1000 for the post-neonatal period. The generally low post-neonatal mortality rate among the 69 suburbs studied has made the neonatal component the dominant contributor to the infant mortality rate. However, in the lowest socio-economic areas the post-neonatal mortality rate was responsible for over 60% of infant deaths.(ABSTRACT TRUNCATED AT 250 WORDS)     

Level,Causes and Risk Factors of Neonatal Mortality,in Jordan: Results of a National Prospective Study

Objective The present study aimed at assessment of the magnitude of neonatal mortality in Jordan, and its causes and associated factors. Methods Through a multistage sampling technique, a total of 21,928 deliveries with a gestational period ≥20 weeks from 18 hospitals were included in the study. The status of their babies 28 days after birth, whether dead or alive, was ascertained. Extensive data were collected about mothers and their newborns at admission and after 28 days of birth. Causes of death were classified according to the neonatal and intrauterine death classification according to etiology. Preventability of death was classified according to Herman’s classification into preventable, partially preventable, and not preventable. Results Neonatal mortality rate, overall and for subgroups of the study was obtained. Risk factors for neonatal mortality were first examined in bivariate analyses and finally by multivariate logistic regression models to account for potential confounders. A total of 327 babies ≥20 weeks of gestation died in the neonatal period (14.9/1000 LB). Excluding babies <1000 g and <28 weeks of gestation to be consistent with the WHO and UNICEF’s annual neonatal mortality reports, the NNMR decreased to 10.5/1000 LB. About 79 % of all neonatal deaths occurred in the first week after birth with over 42 % occurring in the first day after birth. According to NICE hierarchical classification, most neonatal deaths were due to congenital anomalies (27.2 %), multiple births (26.0 %), or unexplained immaturity (21.7 %). Other important causes included maternal disease (6.7 %), specific infant conditions (6.4 %), and unexplained asphyxia (4.9 %). According to Herman’s classification, 37 % of neonatal deaths were preventable and 59 % possibly preventable. An experts’ panel determined that 37.3 % of neonatal deaths received optimal medical care while the medical care provided to the rest was less than optimal. After adjusting for socio-demographic characteristics, type of the hospital, and clinical and medical history of women, the following variables were significantly associated with neonatal mortality: male gender, congenital defects, inadequate antenatal visits, multiple pregnancy, presentation at delivery, and gestational age. Conclusion The present study showed the level, causes, and risk factors of NNM in Jordan. It showed also that a large proportion of NNDs are preventable or possibly preventable. Providing optimal intrapartum, and immediate postpartum care is likely to result in avoidance of a large proportion of NNDs.     

Impact of increased neonatal survival on postneonatal mortality in the United States

Summary. Neonatal intensive care has increased neonatal survival, but has also led to postponement of some of the neonatal deaths to the postneonatal period, particularly in very low birthweight (<1.5kg) infants. Our report assesses the impact of the increased neonatal survival and the accompanying delayed deaths on the crude postneonatal mortality rate oi the US, using the national livebirth cohort data of 1960,1980, and 1986. With increased neonatal survival, very low birthweight infants comprised 0.68% of all neonatal survivors in 1986, compared with only 0.31% in 1960. However, postneonatal mortality was increased in infants with birth weights < 1.0 kg from 69 per 1000 neonatal survivors in 1960 to 116 per 1000 in 1986. All other birthweight groups (> 1.0 kg) showed significant reductions in their postneonatal mortality, although the 1.0–1.5 kg group showed the least improvement. Thus, in 1986, 12.1% of all postneonatal deaths were from the very low birthweight neonatal survivors, as compared with 2.7% in 1960. If there had been no improvement in neonatal survival of very low birthweight infants since 1960, the crude postneonatal mortality rate of the US would have been 5.5% and 7.9% less than the actual rates of 3.65 and 3.45 per 1000 neonatal survivors in 1980 and 1986, respectively. However, the impact of these delayed deaths in very low birthweight infants was far less than the increase in their neonatal survival: an additional 416 per 1000 very low birthweight infants survived to 1 year of age in 1986 as compared with 1960. Delayed deaths in the 1.5-2.5 kg birthweight group had a very small effect on postneonatal mortality and there was no such effect of delayed deaths in the > 2.5 kg birthweight group.     

Investigating variations in infant mortality in England and Wales by mother's country of birth, 1983-2001

The aim of this study was to investigate variations in infant mortality from 1983 to 2001 by birthweight, registration status, father's social class, age of mother at birth and cause of death, among babies of mothers born in countries that represent the largest ethnic minority groups in England and Wales. A total of 70,208 infant death registration records linked to their corresponding birth registration records were used. The study focused on infant deaths of babies of mothers born in the UK, Republic of Ireland, Caribbean, West Africa, East Africa, India, Pakistan and Bangladesh. From 1983 to 2001 infant mortality rates decreased overall, and this was also apparent in the rates by mother's country of birth. Overall, babies of mothers born in Pakistan consistently had the highest infant mortality rates. Low-birthweight babies of mothers born in West Africa had the highest infant, neonatal and postneonatal death rates. Differences were also seen by registration status, mother's age and between manual and non-manual occupations for all countries from 1983 to 2001. For babies of mothers born in the UK, Caribbean and West Africa, immaturity-related conditions were the most common cause of infant deaths. The leading cause of infant death among babies of mothers born in Pakistan and Bangladesh was congenital anomalies.     

Ethnic determinants of perinatal statistics of Chinese: demography of China, Hong Kong and Singapore

Despite limited health resources, the Chinese have achieved reasonably good perinatal and neonatal mortality rates comparable to those of many developed countries. China, Hong Kong and Singapore, areas with different socioeconomic structures, have shared the same favourable ethnic determinants of perinatal mortality. The Chinese have much lower incidence of very low birthweight babies (less than 1000 g) and lethal congenital anomalies. The former is probably related to the rarity of teenage pregnancy, maternal smoking and alcohol consumption. Asphyxia remains a major contributor to perinatal deaths. The perinatal mortality rate in mainland China has remained relatively unchanged in contrast to the dramatic falling trend in Hong Kong and Singapore in the past two decades. This may be accounted for by differences in socioeconomic conditions despite their identical ethnic origin. Studying the Chinese sociocultural pattern may have a great impact on perinatal mortality by preventing low birthweight babies.     

A prospective survey of the outcome of pregnancy in a rural area of the Gambia

Pregnancy outcome was studied in 672 women over a 1-year period in a rural area of Gambia where medical resources were very limited, prior to the introduction of a primary health care program. Maternal mortality was quite high (22/1000), primarily the result of postpartum hemorrhage and infections. Stillbirth and neonatal death rates were also very high (35 and 65/1000); prematurity and infections were the primary causes of neonatal deaths. First or late pregnancies, either prior to age 20 or after age 40, and multiple pregnancies were all associated with a poor pregnancy outcome. Women in these groups should therefore be encouraged by traditional birth attendants and by the staff of rural antenatal clinics to deliver at a health center or hospital.     

Causes of perinatal mortality in Pelotas, RS (Brazil). Use of a simplified classification

The causes of perinatal mortality among 7392 hospital births which occurred in Pelotas, RS, Brazil during 1982, were analyzed using the simplified classification described by Wigglesworth. The main advantage of this classification is that it can be used even in places where postmortems are seldom performed. The perinatal deaths were classified into 5 groups: a) macerated fetuses without malformations; b) congenital malformations; c) immaturity; d) asphyxia, and e) other causes of death. The perinatal mortality rate was 33.7/1000 births, nearly equally divided between fetal and early neonatal deaths, and 8.8% of the babies were of low birthweight. 36% of the perinatal deaths were antepartum stillbirths, and 60% of these weighed 2000 g or more. The 2nd most important cause was immaturity, which accounted for 31% of the deaths. In this latter group, 21% weighed 2000 g or more at birth. These findings, as well as the high birthweight-specific perinatal mortality rates, strongly suggest that there are deficiencies in the antenatal and delivery care in Pelotas that must be corrected promptly. Policies that should be implemented by health planners include: decentralization of antenatal care clinics; utilization in these clinics of the "at-risk" concept to identify women at high risk of delivering low birthweight babies, efforts to increase community participation and home visits in order to attract those pregnant women who do not attend clinics. In addition, it is mandatory that well-trained doctors (obstetricians and pediatricians) should be available 24 hours/day at the maternity hospitals to assist mothers and babies identified as being at high risk. (author's)     

Outcome of hospitalised out-born preterm babies

187 babies born elsewhere and referred to the Pediatric Department of the Christian Medical College and Hospital, Ludhiana, for management of prematurity over a period of 6 years were studied. Babies with hypothermia and those below 1200 g were given iv fluids. Preterm babies delivered in the institution and managed in the neonatal special care nursery over 1 year were also studied for comparison. The preterm babies were evenly distributed in the different gestation age groups between 28 and 36 weeks. About half the babies were appropriate for gestational age, while 47% were small for gestational age. The weight ranged from 760 to 2260 g. Males (166) outnumbered females (21) by a ratio of 8:1. There was a high incidence of hypothermia (54%) at the time of admission, more so in babies with gross prematurity. In babies less than 30 weeks old, 80% had become hypothermic during transit to the hospital. A fatal outcome was seen in 69% of babies with hypothermia as compared to 38% of babies admitted without hypothermia. 85% of babies were born in circumstances of potential infection in the form of prolonged rupture of membranes, multiple unsterile vaginal examinations, foul smelling liquor, fever of the mother, or a combination of these. Septicemia, purulent meningitis, bronchopneumonia, and diarrhea were the common infections. Other common morbidities were hyaline membrane disease, necrotizing enterocolitis, and metabolic disturbances. The overall mortality was 54% and it was inversely proportional to the gestational age, increasing from 36% at 35-36 weeks to 82% at 28-30 weeks. On the other hand, there was only a 21% mortality rate among preterm babies delivered at the hospital and managed in the neonatal nursery. Mortality was 9% in babies at 35-36 weeks. Intracranial hemorrhage was the most common cause of death in the study group, accounting for 42% of total deaths (59% of deaths at 28-30 weeks gestation, decreasing to only 4% at 35-36 weeks), followed by septicemia in 31%. On the other hand, septicemia caused about one-third of deaths at 35-36 weeks.     

四川省2001-2009年婴儿死亡率变化趋势及死因分析

目的 了解2001-2009年四川省婴儿年龄别和主要死因别死亡率的变化趋势.方法 采用四川省5岁以下儿童死亡监测收集的2001-2009年监测点儿童死亡资料,计算城乡新生儿、婴儿死亡率及婴儿死因别死亡率.结果 2009年四川省新生儿、婴儿死亡率分别为7.6‰和12.1‰,较2001年(18.6‰和25.5‰)分别下降了...     

Infant mortality rate at a selected urban, semi-urban and rural areas of Egypt, 1992: a retrospective study

A study of infant mortality rate (IMR) in Egypt in 1992 was conducted at three randomly selected areas representing different social classes. IMR per 1000 live births was ranged between 27.1 to 33.5. The differences between male and female IMR were markedly observed with no consensus amongst study areas. Neonatal mortality rate ranged between 4.7 to 11.1 while the post neonatal mortality rate ranged between 18.4 to 23.0. Diarrheal diseases were the most common cause of death amongst infants at all study areas, followed by respiratory illnesses. Inaccurate and under registration were noticed clearly in this work as observed from absence of neonatal deaths in rural areas. Also, in rural areas, prematurity was not recorded as a cause of death. Similarly, neonatal tetanus was not recorded as a cause of death at all study areas.     

The effect of surfactant on birthweight-specific neonatal mortality rate, New York City

PURPOSE: Surfactant has been shown to cause decreased neonatal mortality rate (NMR) in randomized studies of preterm infants. It is not clear whether the introduction of surfactant caused a decrease in neonatal mortality in a community. This study explores the hypothesis that the introduction of surfactant in 1990 to 1991 explains a decrease in neonatal mortality in New York City (NYC) among infants with birthweight of 500 to 1499 g. METHODS: For each of the 20 hospitals in New York City that began using surfactant in 1990 or 1991, we compared the NMR in the 2 years before the introduction of surfactant with the NMR in the 2 years after its introduction. Poisson regression models were fit to the death rates, adjusting for birthweight and other determinants of neonatal mortality. RESULTS: NMR in the 20 hospitals decreased by 13.7% (from 231.3 to 199.6 neonatal deaths per 1000 live births). This decrease remained significant after adjusting for birthweight and other risk factors. Infants with birthweight 1000 to 1249 grams benefited most from the introduction of surfactant; their NMR decreased by 19.6%. After adjusting for birthweight, those born before the introduction of surfactant were 1.18 times as likely to die in the first 27 days as those born after the introduction of surfactant (95% CI 1.04, 1.33). CONCLUSION: It appears that surfactant had a significant impact on NMR in NYC among very low birthweight babies.     

Structured review of neonatal deaths in a managed care organisation

We sought to quantify neonatal mortality (< 28 days) in a 10-hospital system, determine what proportion was associated with suboptimal neonatal care and make recommendations on how neonatal mortality rates (NMRs) could be used in quality improvement efforts. Deaths were identified using electronic linkage to the State of California Death Certificate Tapes. Individual fatalities were reviewed by a minimum of two physicians who did not care for the infant. Deaths were classified as either being associated with suboptimal care or not. For deaths where suboptimal care was an issue, emphasis was on delineating the process involved in the death. Subjects were all neonatal deaths among 64 469 babies born in 1990–91 in the 10 birth facilities of the Kaiser Permanente Medical Care Program, Northern California Region. A total of 241 neonatal deaths were identified. Adjusting for prematurity by increasing the follow-up period in preterm babies (included as neonatal deaths if they died up to 40 weeks corrected gestational age + 27.9 days) increased overall mortality rates by 5%. Birthweight-specific NMRs in Kaiser Permanente are similar to those of other published reports. Among the 198 deaths in babies weighing  500 g at birth, only 14 (7%) were possibly associated with suboptimal care. In populations with access to health insurance, reporting only aggregate NMRs is of limited use. The number of deaths that could be ascribed to suboptimal neonatal care is very small and measuring variations in rates of such deaths is difficult. Future measurements of quality of care will require more sophisticated measures, database systems, review strategies and dissemination methods.     

Causes of Neonatal Deaths in a Rural Subdistrict of Bangladesh: Implications for Intervention

The study assessed the timing and causes of neonatal deaths in a rural area of Bangladesh. A population-based demographic surveillance system, run by the International Centre for Diarrhoeal Disease Research, Bangladesh, recorded livebirths and neonatal deaths during 2003-2004 among a population of 224,000 living in Matlab, a rural subdistrict of eastern Bangladesh. Deaths were investigated using the INDEPTH/World Health Organization verbal autopsy. Three physicians independently reviewed data from verbal autopsy interview to assign the cause of death. There were 11,291 livebirths and 365 neonatal deaths during the two-year period. The neonatal mortality rate was 32.3 per 1,000 livebirths. Thirty-seven percent of the neonatal deaths occurred within 24 hours, 76% within 0-3 days, 84% within 0-7 days, and the remaining 16% within 8-28 days. Birth asphyxia (45%), prematurity/low birthweight (15%), sepsis/meningitis (12%), respiratory distress syndrome (7%), and pneumonia (6%) were the major direct causes of death. Birth asphyxia (52.8%) was the single largest category of cause of death in the early neonatal period while meningitis/sepsis (48.3%) was the single largest category in the late neonatal period. The high proportion of deaths during the early neonatal period and the far-higher proportion of neonatal deaths caused by birth asphyxia compared to the global average (45% vs 23-29%) indicate the lack of skilled birth attendance and newborn care for the large majority of births that occur in the home in rural Bangladesh. Resuscitation of newborns and management of low-birthweight/premature babies need to be at the core of neonatal interventional packages in rural Bangladesh.Key words: Causes of death, Interventions, Neonatal mortality, Verbal autopsy, Bangladesh     

Perinatal mortality in the St. Louis metropolitan area

Statistical data in fetal, neonatal, perinatal, and infant mortality were collected from various sources for the St. Louis metropolitan area (St. Louis City and St. Louis County). The overall perinatal mortality rate of 25.8 for the St. Louis metropolitan area in 1973 compares favorably with the national rate of 25.5 in 1973. The prematurity rate at St. Louis City Hospital (SLCH) is almost three times that of St. Mary's Health Center (SMHC), 12.7 in contrast to 4.8. Both the neonatal and perinatal mortality rates at SLCH are about twice the rate of SMHC, neonatal 19.5 versus 7.4 and perinatal 31.7 in contrast to 19.6. Prematurity and its complications still seem to be the leading cause of neonatal mortality. With modern obstetrical and intensive neonatal care, the survival rates for low birth weight infants has improved markedly. The combined survival rates at SLCH and SMHC, 1972 through 1974 for infants weighing 501-1,000 gms 28 percent; 1,001-1,500 gms, 74 percent; 1,501-2,5000 gms, 95.5 percent; and greater than 2,500 gms. 99.7 percent. Recent studies have shown that the long-term prognosis for these low birth weight infants, in terms of neurological or intellectual sequelae is good. Thus, a more aggressive approach to the management of perinatal problems can be expected to yield excellent results.     

High Rates of Mortality and Morbidity Occur in Infants With Parenteral Nutrition–Associated Cholestasis

Background: Extremely few data are available about the natural history of parenteral nutrition (PN)–associated cholestasis. The authors evaluated a cohort of infants at a large center to determine the outcome of PN‐associated cholestasis in infants with some gastrointestinal function. Methods: The authors reviewed the records of all infants admitted to a level 3 neonatal intensive care unit over a 16‐month period who had the diagnosis of PN‐associated cholestasis. Records were reviewed in these infants for course of cholestasis, laboratory values, outcome, and infection rate. Results: Sixty‐six patients were admitted who met the study criteria. There were 10 deaths and 1 referral for liver transplant (Death/TPlant) (17%) in the first year of life. All Death/TPlant infants had at least 1 positive blood culture after the onset of cholestasis. Maximum conjugated bilirubin (MaxCB) in Death/TPlant infants was 15.7 ± 2.2 (SEM) compared to 8.4± 1.0 mg/dL in babies who recovered. Of 21 infants with a MaxCB≥ 10.0, Death/TPlant occurred in 8/21 (38%). Of 40 babies with positive blood cultures, 11 were in the Death/TPlant group vs no deaths among the 25 without positive blood cultures. Average time to resolution from the MaxCB to a CB <2.0 mg/dL was 66 ± 7 days (n = 49). Conclusions: Infants with PN‐associated cholestasis have high rates of mortality despite the presence of some gastrointestinal function. These data support further evaluation and the development of novel forms of therapy for babies with parenteral‐associated CB ≥2 mg/dL with emphasis on interventions for infants with a CB >10 mg/dL.     

Identifying high‐risk babies born in the community using foot length measurement at birth in Uganda

Background Low birthweight and prematurity are risk factors for neonatal mortality. Identifying low birthweight and premature babies at birth and giving them appropriate care could increase their chances of survival. This study aimed at assessing the use of foot length as a surrogate for low birthweight and prematurity, and recommending an operational cut‐off for identifying high‐risk babies at the community level in low resource settings. Methods A hospital‐based cross‐sectional study was carried out between 1 September and 17 December 2009 in Uganda. Foot length of 711 newborns was measured using three different methods and their weight taken using a digital salter scale within 24 h of life. Gestational age of the newborns was also estimated using the Eregie method. Non‐parametric receiver operating characteristic curve analysis was carried out to determine the foot length method with the highest predictive value to predict low birthweight and premature newborns. Sensitivity, specificity and predictive values for a range of foot lengths were estimated to determine the optimal cut‐off to predict low birthweight and prematurity in this setting. Results Of the 711 babies recruited on day 1, 85 (12%) babies were low birthweight (<2500 g) and 29 (4%) premature (<37 weeks). The operational cut‐off for foot length to detect small babies was defined as 7.6 cm, with sensitivity 85% [95% confidence interval (CI) 75–92] and specificity 81% (95% CI 78–84) for low birthweight, and sensitivity 96% (95% CI 82–100) and specificity 76% (95% CI 73–79) for premature babies. Conclusion Foot length in the first days of life can predict low birthweight and prematurity among newborn babies in this setting. Further evaluation is needed to assess the feasibility of its use by community health workers to identify babies that need extra care.     

Neonatal mortality due to preterm birth at 28-36 weeks' gestation in China, 2003-2008

Almost all (99%) neonatal deaths occur in developing countries, where the progress in reducing neonatal mortality rates (NMR) has been small; the Millennium Development Goal for child survival cannot be met if this situation continues. China is among the 10 countries that have the largest numbers of neonatal deaths. In order to provide effective interventions to reduce the national NMR for government policy makers, we analyse the trends, causes and characteristics of the neonatal deaths of preterm babies in different regions of China during the period 2003-2008. The data for this retrospective study were retrieved from the population-based Maternal and Child Health Surveillance System of China. The Cochran-Armitage trend test was used to analyse the trend of NMRs due to immaturity. The national NMR due to immaturity has decreased by 38.7% in 6 years. However, the proportion of preterm births among the causes of neonatal death has increased significantly from 33.6% in 2003 to 40.9% in 2008. The relative risk of neonatal death among preterm babies has shown significant regional disparity. In 2008, the adjusted relative risk was 1.30 [95% confidence interval (CI) 0.95, 1.78] in the inland regions and 2.37 [95% CI 1.56, 3.60] in the remote regions, both compared with the coastal regions. The proportion of neonatal deaths with a gestational age <32 weeks or a birthweight <1500 g was highest among the coastal regions. Most neonatal deaths of preterm babies in remote areas were born at home and were not treated before death. Our study suggests that preterm birth is the leading cause of neonatal death in China and neonatal mortality due to immaturity displayed regional differences. The Chinese government should implement major effective strategies for reducing the mortality of preterm infants to further decrease the total NMR. Priority interventions should be region-specific, depending on the availability of economic and health care resources.