Countdown 2030: Trends in neonatal mortality between 1990 and 2023 with projections towards sustainable development goal target 3.2 at the global, regional, and national levels

Abstract

Background:

In 2015, the UN General Assembly set Sustainable Development Goals (SDGs), in which SDG 3.2 called for all countries to reach a neonatal mortality to at least as low as 12 per 1000 live births by 2030. As the SDG era enters its final years, especially after the COVID-19 pandemic, it is time to take stock of worldwide trends in terms of neonatal mortality and progress towards SDG target 3.2. We aimed to evaluate the time trends in neonatal mortality from 1990 to 2023 with projections towards SDG target 3.2 at the global, regional, and national levels.

Materials and methods:

Annual neonatal deaths and neonatal mortality rate (NMR) between 1990 and 2023 at the global, regional, and national levels were collected from a dataset complied by the UN Inter-agency group for Child Mortality Estimation. The percentage changes in neonatal deaths and the estimated annual percentage changes (EAPCs) in NMRs at the global, regional, and national levels were calculated. The year in which the location with an NMR above 12 deaths per 1000 live births would achieve the SDG 3.2 NMR target was estimated using time-series analyses.

Results:

Globally, the number of neonatal deaths decreased by 56.42% from 5.24 million in 1990 to 2.28 million in 2023 and the NMR decreased by an average of 2.54% (95% CI: 2.44%, 2.63%) per year from 36.70 deaths per 1000 live births in 1990 to 17.33 deaths per 1000 live births in 2023. The global NMR is expected to achieve SDG target 3.2 by 2036. At the regional level, the NMR decreased significantly in all SDG regions between 1990 and 2023 but remained above SDG target 3.2 in Sub-Saharan Africa, Central and Southern Asia, and Western Asia and Northern Africa, with NMRs of 26.41, 20.74, and 12.80 deaths per 1000 live births in 2023, respectively. Sub-Saharan Africa and Central and Southern Asia are projected to reach the SDG 3.2 target by 2068 and 2041, respectively. At the national level, the NMR increased significantly in Dominica (EAPC = 3.95; 95% CI: 3.74, 4.17), Botswana (EAPC = 1.92; 95% CI: 1.14, 2.70), Grenada (EAPC = 1.06; 95% CI: 0.48, 1.63), and Eswatini (EAPC = 0.32; 95% CI: 0.19, 0.44) between 1990 and 2023. Among the 200 countries and territories worldwide, 125 have already met SDG target 3.2, and 7 are expected to do so by 2030. Of the remaining 68 countries that would not achieve SDG target 3.2 by 2030, 11 would meet it between 2031 and 2040, 12 would meet it between 2041 and 2050, and 37 would meet it after 2050, if the average rate of decline from 1990 to 2023 continues; however, the NMR would be deteriorating in Dominica, Botswana, Grenada, Venezuela (Bolivarian Republic of), Eswatini, Zimbabwe, Dominican Republic, and Fiji.

Conclusions:

Despite substantial progress in reducing the NMR worldwide since 1990, more than a quarter of countries and territories would miss SDG target 3.2 by 2030, and nearly half of those countries and territories would meet SDG target 3.2 after 2050. Urgent actions are needed in most regions and countries with high NMRs, particularly those in sub-Saharan Africa.

Introduction

Child mortality is an indicator of the health and social development of populations^[1]. The survival of children under 5 years of age has been the principal focus of the global child health agenda in recent decades. In 2000, Millennium Development Goal 4 (MDG4) was established to catalyze extraordinary political, financial, and social commitments to reduce the under-5 mortality rate (U5MR) by two-thirds between 1990 and 2015^[2]. In 2015, the MDGs were replaced by more all-encompassing, albeit less health-focused, Sustainable Development Goals (SDGs)^[3]. SDG 3.2 specifically calls to, “By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1000 live births and under-5 mortality to at least as low as 25 per 1000 live births.” With efforts across multiple platforms by an array of organizations and governments in the period of the MDGs, and in the subsequent period of the SDGs, an estimated 5.30 million children died before their fifth birthday in 2019, a substantial reduction from the estimated 9.92 million deaths of children younger than 5 years in 2000^[4].

As the U5MR decreases, the share of neonatal deaths, i.e., deaths occurring in the first month, which is among the most vulnerable periods of life, tends to increase. Globally, the estimated share of under-5 deaths that were neonatal in 2019 was 47%, a 7% increase from 1990^[5]. Indeed, in most SDG regions of the world, the majority of under-5 deaths are neonatal; for example, the share was more than 50% in 2019 in South Asia (62.73%), North America (59.26%), Western Europe (57.89%), the Middle East and North Africa (56.16%), Latin America and the Caribbean (55.62%), Europe and Central Asia (53.41%), Eastern Europe and Central Asia (51.43%), and East Asia and Pacific (50.11%). The share was still less than 50%, however, where the U5MR was relatively high; for instance, the share was only 33.55% in West and Central Africa, 37.24% in sub-Saharan Africa, and 43.90% in Eastern and Southern Africa. Over the past several decades, dramatic progress has been made in improving health and reducing the mortality rate of neonates globally. The global neonatal mortality rate (NMR) has been reduced by more than half from 36.6 deaths per 1000 live births in 1990 to 17.5 deaths per 1000 live births in 2019^[5]. However, despite such an extraordinary reduction, the global NMR is still well above the target of 12 deaths per 1000 live births as defined by SDG 3.2. In addition, substantive threats and inequities jeopardize child survival in many parts of the world, including increasing inequity and economic instability, new and protracted conflicts, the intensifying impact of climate change, and the fallout of COVID-19, which could lead to stagnation or even reversal of gains and the continued needless loss of children’s lives^[6–9]. The UN Department of Economic and Social Affairs reported that COVID-19 threatens to reverse the progress of SDG 3, including child mortality, as it continues to erode health systems, disrupt routine health services and constrain access to nutritious diets and essential nutrition services^[10]. Therefore, the increasing importance of neonatal deaths in terms of child mortality warrants increased efforts to reduce neonatal mortality in addition to under-5 mortality.

As the SDG era has entered its final years, especially after the COVID-19 pandemic, the global public health and development communities must take stock of progress over the past decades. There has not yet been a comprehensive assessment of NMRs in the SDG era, both before and after the COVID-19 pandemic. Selected publications have assessed progress towards 2030 before the COVID-19 pandemic or provided projections to 2030^[11–14], but none have analyzed the worldwide trends and progress towards the NMR target by 2030 in the context of COVID-19. Therefore, we used detailed data on neonatal mortality compiled by the UN Inter-agency group for Child Mortality Estimation (UN IGME) to determine the global, regional, and national trends in NMRs between 1990 and 2023, with projections towards the SDG target 3.2, to provide a more comprehensive perspective for making globally and regionally targeted interventions and health policies.

HIGHLIGHTS

• Globally, the neonatal mortality rate (NMR) decreased by an average of 2.54% per year from 36.70 deaths per 1000 live births in 1990 to 17.33 deaths per 1000 live births in 2023, with the Sustainable Development Goals (SDGs) target 3.2 of an NMR of at least as low as 12 per 1000 live births achieved by 2036.

• At the regional level, the NMRs in Sub-Saharan Africa, Central and Southern Asia, and Western Asia and Northern Africa remain above SDG target 3.2 in 2023, and are projected to reach the SDG 3.2 target by 2068, 2041, and 2030, respectively.

• At the national level, 125 countries and territories have already met SDG target 3.2 in 2023, and 7 are expected to do so by 2030, 11 by 2031–2040, 12 by 2041–2050, and 37 after 2050; however, the NMR would be deteriorating in Dominica, Botswana, Grenada, Venezuela (Bolivarian Republic of), Eswatini, Zimbabwe, Dominican Republic, and Fiji.

• Urgent actions are needed most in regions and countries with high NMRs, particularly those in sub-Saharan Africa.

Methods

Data source

This study utilized data compiled by the UN IGME on annual neonatal deaths and NMRs by location from 1990 to 2023 and by location and cause from 2000 to 2021. NMR is the probability of dying within the first 28 days of life, expressed per 1000 live births. The UN IGME formed in 2004 is led by the United Nations Children’s Fund and includes the World Health Organization, the World Bank Group, and the United Nations Population Division of the Department of Economic and Social Affairs as full members. Broadly, there are three main data sources for the NMR: vital registration systems, sample vital registration systems, and survey data^[13]. NMR estimation was performed via a Bayesian hierarchical penalized B-splines regression model^[15]. UN IGME estimates the ratio of NMR to other child mortality (i.e., [U5MR–NMR]) and obtains estimates of NMR by recombining the ratios with U5MR estimates. The ratio was modelled as the product of two components: the expected ratio and a country-year-specific multiplier. The technical details on the model specification, implementation, and validation are available elsewhere. The absolute number of neonatal deaths was calculated via a birth-week cohort method, which is based on the estimated NMR, as well as the estimates of population numbers by the UN Population Division^[13]. As of January 2024, the database for neonatal mortality was available in 200 countries and territories that were categorized into 7 SDG regions. Empirical databases and final estimates are updated annually and are available from the UN IGME web portal, Child Mortality Estimation Info, available at <https://childmortality.org>.

Statistical analysis

First, we presented the numbers of neonatal deaths and NMRs with 90% uncertainty intervals (UIs) in 1990 and 2023 at the global, regional, and national levels and additionally the global NMRs with 90% UIs by cause in 2000 and 2021. Second, we calculated the percentage changes in neonatal deaths and the estimated annual percentage changes (EAPCs) in NMRs at the global, regional, and national levels to quantify their temporal trends. The percentage changes in neonatal deaths from 1990 to 2023 were calculated via the following equation: percentage change = $\frac{\mathrm{D}\mathrm{e}\mathrm{a}\mathrm{t}\mathrm{h}\mathrm{s}\in 2023-\mathrm{D}\mathrm{e}\mathrm{a}\mathrm{t}\mathrm{h}\mathrm{s}\in 1990}{\mathrm{D}\mathrm{e}\mathrm{a}\mathrm{t}\mathrm{h}\mathrm{s}\in 1990}\times 100\mathrm{\%}$. The EAPC is a summary and widely used measure of the rate tend over a specified time interval^[16]. A regression line was fitted to the natural logarithm of the NMR, i.e., y = α + βx + ε, where y = ln (NMR) and x = calendar year, α represents the intercept, β coefficient represents a geometric mean ratio, and ε is the error term. The EAPC was calculated as $100\times (e^{\beta }-1)$, and its 95% confidence interval (CI) was calculated to reflect the temporal trend in rate. The trend in rate was reflected in the EAPC value and its 95% CI: rate is in an upward trend when the EAPC and the lower boundary of the 95% CI are positive; conversely, rate is in a downward trend when EAPC and the upper boundary of the 95% CI are negative. We calculated the EAPCs in the NMRs between 1990 and 2023 to reflect their temporal trends during this period. Third, time-series analyses were applied to estimate the year in which the location with an NMR above 12 deaths per 1000 live births in 2023 would achieve the SDG 3.2 NMR target on the basis of the EAPC in the NMR between 1990 and 2023 and the NMR in 2023. The study has been reported in line with the strengthening the reporting of cohort, cross-sectional, and case-control studies in surgery (STROCSS) criteria^[17]. Finally, we presented the NMRs by cause in 2021 for countries projected to fail to achieve the SDG 3.2 NMR target by 2030. All analyses were conducted with SAS 9.4 (SAS Institute, Inc., Cary, NC, USA). A two-tailed P-value <0.05 was considered statistically significant. Data visualization was created by ArcGIS Desktop 10.7 (Esri, Redlands, USA) and OriginPro 2022 (OriginLab, Northampton, USA).

Results

Global trends in neonatal mortality with projections towards SDG target 3.2

Globally, the number of neonatal deaths decreased by 56.42%, from 5.24 (90% UI: 5.08, 5.41) million in 1990 to 2.28 (90% UI: 2.14, 2.56) million in 2023 (Table 1 and Fig. 1). The global NMR decreased by an average of 2.54% (EAPC = −2.54, 95% CI: −2.63, −2.44) per year from 36.70 (90% UI: 35.61, 37.91) deaths per 1000 live births in 1990 to 17.33 (90% UI: 16.25, 19.41) deaths per 1000 live births in 2023 (Table 1 and Fig. 1). From 2000 to 2021, NMRs from all causes declined (Fig. 2). The two leading causes of neonatal deaths were both prematurity and birth asphyxia/trauma from 2000 to 2021. In terms of NMRs by specific causes, congenital anomalies ranked third in 2021, second only to prematurity and birth asphyxia/trauma, while they ranked fifth after prematurity, birth asphyxia/trauma, lower respiratory infections, and sepsis in 2000. The global NMR is projected to reach the SDG 3.2 target of fewer than 12 deaths per 1000 live births by 2036 (Supplementary Digital Content eTable 1, available at: http://links.lww.com/JS9/E877).

Table 1.

Global neonatal mortality in 1990 and 2023 and their trends from 1990 to 2023

Characteristics	1990		2023		1990–2023
	Deaths in thousand No. (90% UI)	NMR per 1000 live births No. (90% UI)	Deaths in thousand No. (90% UI)	NMR per 1000 live births No. (90% UI)	Percentage change in deaths (%) No.	EAPC in NMR No. (95% CI)
Global	5240.46 (5083.91, 5413.12)	36.70 (35.61, 37.91)	2284.02 (2142.09, 2557.10)	17.33 (16.25, 19.41)	−56.42	−2.54 (−2.63, −2.44)
SDG region
Sub-Saharan Africa	1010.69 (971.69, 1056.75)	45.54 (43.78, 47.62)	1058.67 (945.80, 1278.58)	26.41 (23.59, 31.90)	4.75	−1.74 (−1.79, −1.69)
Western Asia and Northern Africa	292.25 (282.07, 303.50)	30.82 (29.74, 32.01)	150.43 (130.47, 181.74)	12.80 (11.10, 15.47)	−48.53	−2.78 (−2.88, −2.69)
Central and Southern Asia	2375.79 (2280.04, 2474.95)	56.12 (53.86, 58.46)	810.41 (734.33, 904.44)	20.74 (18.79, 23.15)	−65.89	−3.02 (−3.12, −2.92)
Eastern and South-Eastern Asia	1183.82 (1088.64, 1289.41)	27.89 (25.65, 30.38)	148.74 (130.44, 176.15)	7.24 (6.35, 8.57)	−87.44	−4.73 (−4.97, −4.50)
Latin America and Caribbean	268.28 (254.79, 283.04)	22.54 (21.41, 23.78)	80.66 (73.60, 91.38)	8.66 (7.90, 9.81)	−69.93	−2.90 (−3.09, −2.71)
Oceania	7.02 (6.41, 7.66)	13.36 (12.19, 14.57)	6.77 (4.78, 9.97)	9.94 (7.01, 14.63)	−3.55	−0.99 (−1.13, −0.85)
North America and Europe	102.61 (96.82, 109.40)	7.37 (6.96, 7.86)	28.33 (27.19, 29.56)	2.74 (2.63, 2.85)	−72.40	−2.96 (−3.05, −2.87)

CI: confidence interval; EAPC: estimated annual percentage change; NMR: neonatal mortality rate; SDG: Sustainable Development Goals; UI: uncertainty interval.

Figure 1.

Global neonatal deaths and NMR, 1990-2023.

Note: NMR: neonatal mortality rate.

Figure 2.

Leading causes of global neonatal deaths and NMR per 1000 live births in 2000 and 2021.

Note: NMR: neonatal mortality rate, HIV/AIDs: human immunodeficiency virus or acquired immunodeficiency syndrome.

Regional trends in neonatal mortality with projections towards SDG target 3.2

Across seven SDG regions, most of the global neonatal deaths (81.83%) were concentrated in Sub-Saharan Africa (1.06 million) and Central and Southern Asia (0.81 million) in 2023 (Table 1). The number of neonatal deaths decreased in all SDG regions from 1990 to 2023, with the largest decrease in Eastern and South-Eastern Asia (−87.44%), followed by North America and Europe (−72.40%). All the SDG regions experienced a significant decreasing trend in NMRs between 1990 and 2023, with the largest decrease in Eastern and South-Eastern Asia (EAPC = −4.73; 95% CI: −4.97, −4.50), followed by Central and Southern Asia (EAPC = −3.02; 95% CI: −3.12, −2.92) (Table 1 and Fig. 3). In 2023, the NMR ranged from 2.74 to 26.41 deaths per 1000 live births across SDG regions, with Eastern and South-Eastern Asia, Latin America and Caribbean, Oceania, and North America and Europe already achieving the NMR target in SDG 3.2. Western Asia and Northern Africa are projected to reach an NMR of at least 12 deaths per 1000 live births by 2026 (Supplementary Digital Content eTable 1, available at: http://links.lww.com/JS9/E877). The NMR in Sub-Saharan Africa and Central and Southern Asia is projected to reach the SDG 3.2 target by 2068 and 2041, respectively.

Figure 3.

NMR in SDG regions, 1990-2023.

Note: NMR: neonatal mortality rate; SDG: Sustainable Development Goals.

National trends in neonatal mortality with projections towards SDG target 3.2

Across the 200 countries and territories worldwide, the absolute number of neonatal deaths in India (401 499) and Nigeria (258 588) accounted for approximately one-third of the global number of neonatal deaths (2.31 million) in 2023 (Fig. 4A and Supplementary Digital Content eTable 2, available at: http://links.lww.com/JS9/E877). A total of 173 countries and territories experienced a decrease in the number of neonatal deaths from 1990 to 2023, with the most pronounced decrease in Anguilla (−100.00%), Montserrat (−100.00%), Niue (−100.00%), and San Marino (−100.00%), followed by China (−96.97%) (Fig. 4B and Supplementary Digital Content eTable 2, available at: http://links.lww.com/JS9/E877). Neonatal deaths increased from 1990 to 2023 in the remaining 27 countries, with the most pronounced increases in Somalia (69.54%), the Democratic Republic of the Congo (58,42%), and Chad (57.76%).

Figure 4.

Neonatal deaths in 2023 (A) and the percentage change in neonatal deaths from 1990 to 2023 (B) at the national level.

The NMR varied considerably across the world, with the highest NMR in 2023 in South Sudan (40.24 deaths per 1000 live births), followed by Pakistan (37.60 deaths per 1000 live births) and Somalia (34.90 deaths per 1000 live births) (Fig. 5A and Supplementary Digital Content eTable 2, available at: http://links.lww.com/JS9/E877). There were 125 countries and territories (63%) worldwide that achieved the SDG 3.2 NMR target by 2023, such as Sweden, Singapore, and China (Fig. 5B and Supplementary Digital Content eTable 2, available at: http://links.lww.com/JS9/E877). The remaining 75 countries and territories have NMRs higher than 12.00 deaths per 1000 live births in 2023, 47 of which are 12.00 to 24.00 deaths per 1000 live births and 28 of which are higher than 24.00 deaths per 1000 live births (Fig. 5A and Supplementary Digital Content eTable 2, available at: http://links.lww.com/JS9/E877). The NMRs were deemed to be in a decreasing trend in 188 countries and territories between 1990 and 2023, with the largest decrease in Belarus (EAPC = −8.17; 95% CI: −8.57, −7.75), followed by Estonia (EAPC = −7.66; 95% CI: −7.49, −7.38) and China (EAPC = −7.62; 95% CI: −8.00, −7.24) (Fig. 5B and Supplementary Digital Content eTable 2, available at: http://links.lww.com/JS9/E877). The NMRs were deemed to be in an increasing trend in Dominica (EAPC = 3.95; 95% CI: 3.74, 4.17), Botswana (EAPC = 1.92; 95% CI: 1.14, 2.70), Grenada (EAPC = 1.06; 95% CI: 0.48, 1.63), and Eswatini (EAPC = 0.32; 95% CI: 0.19, 0.44) between 1990 and 2023. The NMRs remained stable in Bahamas, Niue, Namibia, Saint Lucia, Fiji, Dominican Republic, Zimbabwe, and Venezuela (Bolivarian Republic of) between 1990 and 2023.

Figure 5.

NMR in 2023 (A) and the EAPC in the NMR between 1990 and 2023 (B) at the national level.

Note: EAPC: estimated annual percentage change; NMR: neonatal mortality rate.

Among the 75 countries and territories with an NMR higher than 12 deaths per 1000 live births in 2023, 68 could not achieve the SDG 3.2 NMR target by 2030, and 7 countries, such as Bhutan, Tajikistan, and Iraq, were expected to reduce the NMR to at least as low as 12 deaths per 1000 live births by 2030 if the average rate of decline from 1990 to 2023 continues (Fig. 6 and Supplementary Digital Content eTable 3, available at: http://links.lww.com/JS9/E877). Three-quarters of the 68 that would not achieve the SDG 3.2 NMR target by 2030 are in sub-Saharan Africa. 11 countries and territories, such as Nepal, Bangladesh, and India, were projected to meet the 2030 target in the subsequent decade (i.e., y 2040). Another 12 countries, such as Jamaica, Yemen, and Mozambique, were projected to achieve the SDG 3.2 NMR target between 2041 and 2050. In particular, 37 countries and territories, such as Burkina Faso, Ethiopia, and Zambia, were projected to achieve the SDG 3.2 NMR target after 2050 and the NMR is expected to deteriorate in Dominica, Botswana, Grenada, Venezuela (Bolivarian Republic of), Eswatini, Zimbabwe, Dominican Republic, and Fiji.

Figure 6.

Years in which the NMR reduction target is expected to be achieved at the national level.

Note: NMR: neonatal mortality rate.

Among countries projected to miss the SDG 3.2 NMR target by 2030, the leading cause of neonatal deaths in 2021 in Dominica, Nigeria, and Niger was birth asphyxia/trauma, while that in other countries was prematurity (Fig. 7). In more than half of these countries, congenital anomalies were the third leading cause of neonatal deaths in 2021, second only to prematurity and birth asphyxia/trauma. Lower respiratory infections were the third leading cause of neonatal deaths in 2021 in almost all remaining countries. In addition to prematurity, birth asphyxia/trauma, congenital anomalies, and lower respiratory infections, injuries were still relatively important in Afghanistan compared with countries where injuries contributed to a very low proportion of NMR.

Figure 7.

NMRs by cause in 2021 for countries projected to miss the SDG 3.2 NMR target by 2030.

Note: NMR: neonatal mortality rate; SDG: Sustainable Development Goals. Data on NMRs by causes in 2021 in Niue were not available.

Discussion

This study used data on neonatal mortality compiled by the UN IGME to comprehensively assess the global, regional, and national trends in neonatal mortality between 1990 and 2023 and the progress towards SDG target 3.2. We found remarkable progress in improving child survival worldwide over the past three decades, with the global NMR decreasing from 36.70 deaths per 1000 live births in 1990 to 17.33 deaths per 1000 live births in 2023. At the regional level, the NMR decreased significantly in all SDG regions between 1990 and 2023, with 4 out of 7 of the SDG regions already meeting the NMR target by 2030 in 2023. At the national level, the NMR decreased significantly in 188 countries and territories between 1990 and 2023 but increased significantly in Dominica, Botswana, Grenada, and Eswatini and remained stable in the remaining 8 countries and territories during this period. Among the 200 countries and territories worldwide, 125 countries and territories have already met the NMR target by 2030 in 2023, and 7 countries and territories would meet the target by 2030, 11 countries and territories by 2031-2040, 12 countries and territories by 2041-2050, and 37 countries and territories after 2050; however, the NMR would deteriorate in Dominica, Botswana, Grenada, Venezuela (Bolivarian Republic of), Eswatini, Zimbabwe, Dominican Republic, and Fiji. In addition to prematurity and birth asphyxia/trauma, congenital anomalies, and lower respiratory infections are still critical among countries projected to miss the SDG 3.2 NMR target by 2030.

The survival of a newborn is a sensitive marker of a health system’s response to its most vulnerable citizens and requires all stakeholders to improve access to, and quality of, health care for women and newborns within the continuum of care that spans pre-conception, pregnancy, childhood and adolescence. The global NMR decreased by an average of 2.54% per year between 1990 and 2023, undeniably attributed to the scale-up of high-impact interventions, such as skilled health personnel at birth, care for small and sick newborns, care and antenatal and postnatal care^[18–27]. Despite substantial gains in reducing the global NMR, progress has been insufficient to achieve SDG target 3.2 by 2030. If trends between 1990 and 2023 continue, SDG target 3.2 worldwide would be reached by 2036–6 years behind schedule. In addition, a large number of neonatal deaths remain, and neonates face widespread geographical disparities in their chances of survival. In 2023, more than four-fifths of the global neonatal deaths occurred in Sub-Saharan Africa and Central and Southern Asia, with NMRs of 26.41 and 20.74 deaths per 1000 live births, respectively. The NMR is projected to be lower than 12 deaths per 1000 live births in Sub-Saharan Africa by 2068 and in Central and Southern Asia by 2041. Western Asia and Northern Africa are projected to meet the NMR target in SDG 3.2 by 2026. The other four SDG regions, Eastern and South-Eastern Asia, Latin America and the Caribbean, Oceania, and North America and Europe, have already achieved the NMR target in SDG 3.2 by 2023. Thus, reducing the global NMR to 12 deaths per 1000 live births would primarily require an acceleration of progress for Sub-Saharan Africa.

Globally, 66% of the world’s countries and territories would achieve SDG target 3.2 with an NMR of 12 or fewer deaths per 1000 live births before 2030. Among the countries and territories projected to meet the SDG 3.2 NMR target by 2030, 125 have already met by 2023, and 7 would meet by 2030. However, the remaining 68 countries and territories would miss the neonatal mortality target by 2030, specifically in Sub-Saharan Africa. If trends between 1990 and 2023 continue, 11 countries and territories are projected to meet the NMR SDG target in 2031–2040, 12 countries by 2041–2050, and 37 after 2050. Notably, Dominica, Botswana, Grenada, Venezuela (Bolivarian Republic of), Eswatini, Zimbabwe, Dominican Republic, and Fiji could not achieve SDG target 3.2 if the average rate of increase from 1990 to 2023 continues. Our estimates show that globally, not only is the decline in NMRs too slow in 60 countries and territories, but NMRs have exhibited stable or upward trends in 8 countries, thereby making it impossible to achieve the SDG 3.2 NMR target by 2030. This means that there is still work to be done in improving child survival in these countries and territories to accelerate progress to achieve the NMR SDG target. Globally, about one-third of neonatal deaths occur on the day of birth, and nearly three-fourths occur during the first week of life^[18,28]. Therefore, health care interventions must focus on births. Enhancing data on the timing and location of neonatal deaths, as well as the factors causing delays, is crucial for designing context-specific community and health system strategies.

In this study, we found that on a global scale, the leading causes of neonatal deaths are prematurity, birth asphyxia/trauma, and congenital anomalies. Among countries projected to meet the SDG 3.2 NMR target after 2030, congenital anomalies or lower respiratory infections are the main causes of neonatal deaths after prematurity and birth asphyxia/trauma. Notably, injuries constitute a relatively significant cause of neonatal deaths in Afghanistan compared to countries where injuries accounted for a very low proportion of neonatal deaths. We found that prematurity is the leading cause of neonatal deaths in Botswana, Grenada, Venezuela (Bolivarian Republic of), Eswatini, Zimbabwe, Dominican Republic, and Fiji, whereas birth asphyxia/trauma in Dominica. This aligns with a previous study showing that intrapartum complications were almost exclusively responsible for the rise in neonatal mortality in Dominica from 2000 to 2016^[29]. Thus, despite heterogeneous neonatal death cause profiles at the national level, prioritizing essential interventions around the time of birth and care for small and sick newborns will save the most lives. Investing in care around the time of birth provided by skilled health personnel, essential newborn care, and care for small and sick newborns is the priority activity for reversing trends in NMRs in these countries. For example, interventions targeting newborns such as neonatal resuscitation (institutional), kangaroo mother care, management of newborn sepsis with injectable antibiotics, and antibiotics for preterm pre-labour rupture of membrane were the most cost-effective interventions with incremental cost-effectiveness ratios of US$7, US$8, US$17, and US$69 per disability-adjusted life years averted in Ethiopia, respectively^[30]. Additionally, reducing neonatal deaths from congenital anomalies will require better detection of some conditions and surgical interventions for many cases. Injuries in conflict and humanitarian crisis settings, such as Afghanistan, should be a priority for both global assistance and pediatric surgical training. Future research is needed to identify the barriers to implementing neonatal mortality reduction interventions and to elucidate the mechanisms behind disparities between countries, and within countries.

Limitations

The current study comprehensively assessed the global, regional, and national trends in NMRs between 1990 and 2023 and their progress towards SDG target 3.2 using data compiled by the UN IGME. However, several limitations should be noted. First, the UN IGME estimates are the most comprehensive, transparent, and up-to-date information on child survival, providing the basis for assessing progress towards survival goals and for evidence-based policy. However, despite the expansion of data availability and advances in analytical methods, the lack of timely, high-quality data on child mortality for many countries is one of the limitations of this study. Second, the EAPCs in the NMRs and the relative changes in number of neonatal deaths were used to assess the long-term trends from 1990 to 2023, which might mask the recent short-term trends that reflected the effectiveness of recent prevention interventions. Third, although this study aims to provide an exhaustive description of trends in NMR at the global, regional, and national levels and their progress towards SDG target 3.2, it does not directly address the underlying causes of death for neonates or specific interventions that might be directly associated with neonatal deaths.

Conclusions

In summary, despite dramatic reductions in the NMR over the past three decades, the global NMR would miss the NMR SDG target on time mainly due to some countries with high NMRs in Sub-Saharan Africa. Urgent actions are needed in most regions and countries with high NMRs, particularly those in Sub-Saharan Africa. Reducing neonatal mortality requires investing in care around the time of birth provided by skilled health personnel, essential newborn care and care for small and sick newborns.

Ethical approval

Ethical approval was not required for analysis of these deidentified open-source data.

Consent

No informed consent was required since our research is a secondary analysis of public data.

Sources of funding

This work was supported by the Nationally Funded Postdoctoral Researcher Program (GZB20240035), the National Natural Science Foundation of China (72 441 022), and the National Key Research and Development Program of China (2021ZD0114104). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Author contributions

M.L.: conceived the study, designed the study, collected the data, supervised the study, interpreted the results and revised the letter. G.C.: searched the literature and wrote the manuscript. G.C., J.L., and M.L.: revised the manuscript. G.C.: analyzed the data and drew the figures. All authors contributed to the writing of the report. All authors contributed to writing the manuscript, and approved the final version for publication.

Conflicts of interest disclosure

The authors have no conflicts of interest to declare.

Guarantor

Min Liu.

Research registration unique identifying number (UIN)

None.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Data availability statement

All data used in this study can be freely accessed at the UN Inter-agency group for Child Mortality Estimation (https://childmortality.org/).