Perinatal mortality fell across 17 low- and middle-income countries, but not evenly
Stillbirth, early neonatal death, and the combined burden of perinatal mortality all declined across 17 low- and middle-income countries examined in a large modeling study built from repeated Demographic and Health Surveys. The overall direction of travel was encouraging, yet the pattern was uneven, country by country and household by household. Some settings moved faster than others, and the social gradient in survival remained plainly visible.
The analysis drew on 93 surveys conducted between 1990 and 2023, covering 1,019,253 pregnancies reported by 733,181 women. That scale matters because perinatal outcomes are difficult to measure well in places where civil registration is incomplete and family surveys carry the main burden of estimation. Stillbirths are frequently underreported, early neonatal deaths are sometimes misclassified, and age-at-death heaping can distort neonatal mortality estimates, especially when deaths cluster artificially around 7 days instead of being distributed across the first week of life. A statistical correction was therefore central to the study design, not an academic embellishment.
The investigators used life-table methods and a modified Gompertz-Makeham model to adjust for common data-quality problems, including underreporting, misclassification between stillbirth and death on days 0 to 1, and age-at-death heaping. Pregnancies of at least 7 months’ gestation were included to align with the standard stillbirth definition. Survey-specific estimates were then used to assess time trends and to examine maternal and household correlates through pooled random-effects meta-regression.
One finding stood out immediately: mortality was falling, but the decline was not fast enough to erase inequality.
What the adjusted estimates showed over three decades
Across countries, the pooled annual decline was -0.60 deaths per 1,000 births for stillbirths (95% CI, -0.78 to -0.41), -0.50 for early neonatal mortality (95% CI, -0.66 to -0.35), and -1.08 for perinatal mortality (95% CI, -1.40 to -0.76). Those figures suggest broad improvement over time, but they also reveal how much mortality remained embedded in maternity and newborn care systems across several settings.
The combined perinatal metric is clinically useful because it captures the narrow window in which obstetric complications, intrapartum hypoxia, infection, prematurity, and newborn instability overlap. In practice, a stillbirth and an early neonatal death may stem from the same cascade of delayed access, poor intrapartum monitoring, limited emergency obstetric capacity, or weak immediate newborn care. When both endpoints improve in parallel, it often points to progress in the entire delivery continuum rather than a single isolated intervention.
The study did not treat every country as a carbon copy of the next. Trends varied substantially between settings, which is exactly what one would expect where health-system capacity, antenatal coverage, facility birth rates, and emergency referral networks differ so widely. A uniform global slope would have been convenient; it would also have been misleading.
Education, wealth, and urban residence tracked with lower risk
Lower perinatal mortality was associated with urban residence, higher maternal education, wealthier households, and higher national Human Development Index levels. Maternal age of 30 years or older was associated with higher risk.
These associations fit clinical reality. Urban residence often brings closer access to facilities capable of managing obstructed labor, fetal distress, premature delivery, and neonatal compromise. Maternal education may improve care-seeking, recognition of danger signs, and adherence to antenatal follow-up. Household wealth can reduce barriers that delay transport, diagnostics, and delivery care, while a higher national Human Development Index likely reflects broader system strength, including infrastructure and workforce capacity.
Maternal age is more complex. Older maternal age can cluster with chronic disease burden, placental complications, hypertensive disorders, diabetes, and higher obstetric risk overall. The study did not claim a causal mechanism for every association, but the direction is consistent with known perinatal biology and obstetric risk patterns.
Why the modeling approach mattered for survey-based mortality estimates
Household surveys remain indispensable in many countries, but perinatal outcomes are particularly vulnerable to measurement error. Families may not report pregnancy losses consistently, stillbirths may be mistaken for very early neonatal deaths or vice versa, and recall can be incomplete years after the event. Age-at-death heaping further muddies neonatal estimates because reported ages do not always reflect the clinical timeline of illness and death.
The modified Gompertz-Makeham approach was built to address exactly these problems. By adjusting for underreporting and misclassification, the model aimed to produce estimates that better match underlying mortality patterns than crude survey counts alone. A sensitivity analysis using alternate assumptions supported the robustness of the country-level findings, which strengthens confidence in the broad downward trend even if some uncertainty remains around absolute levels.
Residual underreporting of pregnancy losses remains possible, and the study had no cause-of-death data. Those limitations leave important questions unanswered about whether the gains came from better obstetric care, improved newborn resuscitation, changes in fertility patterns, or broader social development. The model also depends on assumptions that perinatal mortality metrics can be compared across settings, an assumption that is necessary for cross-country analysis but never entirely free of risk.
The gap between decline and equity still defines the problem
The central message is not just that mortality rates improved. It is that improvement remained stratified by social position.
Urban women, more educated mothers, and wealthier households had better outcomes, while national development level tracked with lower perinatal mortality. Those gradients point to persistent barriers in access, quality, and continuity of care. In settings where the burden of death still concentrates around labor, delivery, and the first day of life, the path to further progress runs through stronger maternal referral systems, better intrapartum monitoring, skilled newborn care, and earlier recognition of fetal compromise.
The study’s conclusion is practical: better data systems are needed alongside better services. Without more reliable measurement, stillbirths and early neonatal deaths remain easy to undercount and harder to prevent with precision. Without stronger maternity and newborn care, the downward trend will continue to be slow, uneven, and socially patterned in the same familiar way.