Maternal History of Neonatal Death as an Emerging Risk Factor of Subsequent Neonatal Mortality in Low- and Middle-Income Countries | Global Health | JAMA Network Open | JAMA Network
[Skip to Navigation]
Views 1,193
Citations 0
Invited Commentary
Global Health
April 16, 2020

Maternal History of Neonatal Death as an Emerging Risk Factor of Subsequent Neonatal Mortality in Low- and Middle-Income Countries

Author Affiliations
  • 1Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
  • 2Feinberg School of Medicine, Northwestern University, Chicago, Illinois
  • 3Epidemiology, Zilber School of Public Health, University of Wisconsin, Milwaukee
JAMA Netw Open. 2020;3(4):e202972. doi:10.1001/jamanetworkopen.2020.2972

Early neonatal death, defined as death occuring between birth to age 7 days, represents 60% to 73% of all postnatal deaths and remains a worldwide challenge.1 Enormous disparities in levels of neonatal mortality are reported across countries and regions depending on the level of industrialization and degree of development. The United Nations’ Sustainable Development Goal 3, released in 2015, aims to reduce neonatal mortality to 12 per 1000 live births by 2030. Low- and middle-income countries (LMICs) are seeking strategies to achieve this goal.

The study by Kapoor et al2 examined the association of maternal history of neonatal death with subsequent neonatal mortality using a cross-section of nationally representative data from the 2016 National Family Health Survey in India. The results reported by Kapoor et al2 are consistent with published evidence that suggest that past adverse obstetric history can be a risk factor of adverse perinatal outcomes and that maternal history of neonatal death is associated with subsequent neonatal mortality.2 The authors report that approximately one-quarter of subsequent neonatal deaths in their sample occurred among mothers with history of neonatal death. This association was even stronger when there was a history of multiple neonatal deaths or when a previous death occurred within 48 hours of birth. Maternal history of neonatal death warrants recognition as an important risk factor of the high neonatal mortality rate (NMR) in India, and Kapoor et al2 present a compelling argument for incorporating it in future strategies aimed at reducing NMR in this context, as it provides a low-cost, pragmatic course of action that can be seamlessly implemented by policy makers for early pregnancy-related risk assessment. However, additional studies are needed to validate the role of maternal history of neonatal death as a risk factor of subsequent neonatal mortality.

Between 1973 and 2013, there was a 56% reduction in childhood mortality, defined as death occuring between age 28 days to 5 years.3 However, the rate of reduction of early neonatal death has been slower than that observed in children younger than 5 years. In fact, early neonatal death has now emerged as a significant contributor of overall mortality in those younger than 5 years, and neonatal deaths constitute 44% of all deaths in this age group, with LMICs accounting for most of these deaths.4 The first week of life is the most critical period for a neonate, with most early neonatal deaths occurring within the first 12 hours of life,3 indicating the etiological importance of antenatal and perinatal events. While we recognize the need for an integrated intrapartum approach to maternal and neonatal care, antenatal management continues to play an important role in maternal and neonatal outcomes. We know that the type of prenatal care available affects NMR, such that areas with high-quality care have lower perinatal mortality rates. Residing in areas without consistent and appropriate obstetric and pediatric health care facilities is associated with as much as a 60% increase in the risk of perinatal death.5 The ability to identify mothers with a history of neonatal death early during a current pregnancy has been proposed as a simple and effective screening tool for identification of high-risk pregnancies that would benefit from intensive surveillance during the antenatal and intrapartum periods. This could enable timely referral and access to facilities with superior obstetric and neonatal care, thus ensuring health promotion and disease prevention by effective maternal counseling, diagnosis and treatment of specific maternal risk factors, and delivery interventions to mitigate adverse neonatal outcomes.

The World Health Organization’s Every Newborn Action Plan,6 launched in June 2014, was aimed at accelerating progress to end preventable neonatal deaths and stillbirths, as well as reduce maternal morbidity and mortality. The plan provides strategies for implementing effective cause-specific interventions. However, achieving the United Nations’ goal of reduction of neonatal mortality requires economically feasible implementation of targeted strategies based on community and national resources, especially with respect to LMICs. While data exist on maternal conditions associated with an elevated risk of neonatal mortality,7 awareness of specific causes of neonatal mortality is limited, but it is needed to adequately address high NMR in LMICs. In addition, allocating adequate resources for women with identified high-risk pregnancies to access appropriate obstetrics care in institutions with supporting pediatric and neonatal services will undoubtedly aid in reducing overall NMR.

It would seem intuitive that the consequence of identifying women with a history of perinatal death, especially early neonatal death, would signal increased surveillance in later pregnancies. In the future, it would also be useful to determine, as best as possible, the etiological factors associated with perinatal death, so that appropriate counseling could be provided to expectant parents and suitable interventions instituted in preventable circumstances, such as alleviating maternal risk factors associated with low birth weight and/or premature birth, hospital delivery instead of home birth, early screening and treatment of perinatal infection, appropriate vaccination of pregnant women, and suitable training for caregivers in neonatal resuscitation and early neonatal support, including detection and management of hyperbilirubinemia. To achieve this, many researchers have indicated the need for future studies designed to provide insight into the causes of neonatal death, as some causative factors (eg, inborn errors of metabolism and genetic anomalies, perinatal infection, and birth asphyxia) may recur in future pregnancies, as the antenatal milieu is likely to be similar.8

It is not surprising that adverse outcomes of previous pregnancies, including miscarriages and stillbirths, would be indicators of risk for future pregnancies. However, reporting causative diagnoses presents a unique challenge, as one-half of the world’s newborn infants do not get a birth certificate, and there is no death certificate for most neonatal deaths and almost all stillbirths.6 This is especially true in LMICs, where the need is greatest for high-quality data because they carry the highest burden of NMR; therefore, initiatives of systematic classification are warranted to improve our understanding of the regional causes of stillbirths and neonatal deaths. Future studies that focus on determination of causative factors associated with neonatal mortality will inform the direction of targeted public health policies and interventions for governments and policy makers in LMICs and accelerate progress in achieving effective strategies that result in optimal newborn health and survival.

Back to top
Article Information

Published: April 16, 2020. doi:10.1001/jamanetworkopen.2020.2972

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Khan JY et al. JAMA Network Open.

Corresponding Author: Janine Y. Khan, MD, MBA, Ann and Robert H Lurie Children’s Hospital of Chicago, 225 E Chicago Ave, Box 45, Chicago, IL 60611 (

Conflict of Interest Disclosures: None reported.

UNICEF.  Neonatal mortality. Revised September 2019. Accessed March 16, 2020.
Kapoor  M, Kim  R, Sahoo  T,  et al.  Association of maternal history of neonatal death with subsequent neonatal death in India.   JAMA Netw Open. 2020;3(4):e202887. doi:10.1001/jamanetworkopen.2020.2887Google Scholar
Lehtonen  L, Gimeno  A, Parra-Llorca  A, Vento  M.  Early neonatal death: a challenge worldwide.   Semin Fetal Neonatal Med. 2017;22(3):153-160. doi:10.1016/j.siny.2017.02.006 PubMedGoogle ScholarCrossref
You  D, Bastian  P, Wu  J, Wardlaw  T; UNICEF.  Levels and trends in child mortality: report 2013. Accessed March 16, 2020.
Greenwood  R, Golding  J, McCaw-Binns  A, Keeling  J, Ashley  D.  The epidemiology of perinatal death in Jamaica.   Paediatr Perinat Epidemiol. 1994;8(suppl 1):143-157. doi:10.1111/j.1365-3016.1994.tb00497.xPubMedGoogle ScholarCrossref
Lawn  JE, Blencowe  H, Oza  S,  et al; Lancet Every Newborn Study Group.  Every newborn: progress, priorities, and potential beyond survival.   Lancet. 2014;384(9938):189-205. doi:10.1016/S0140-6736(14)60496-7 PubMedGoogle ScholarCrossref
Singh  G, Sidhu  K.  Bad obstetric history: a prospective study.   Med J Armed Forces India. 2010;66(2):117-120. doi:10.1016/S0377-1237(10)80121-2 PubMedGoogle ScholarCrossref
Alfirevic  Z, Heazell  A.  Reducing the impact of perinatal death: the case for increased understanding of underlying causes to inform change to save babies’ lives.   Semin Fetal Neonatal Med. 2017;22(3):117. doi:10.1016/j.siny.2017.02.007 PubMedGoogle ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words