The effects of cash transfers on adult and child mortality in low- and middle-income countries.

Poverty is an important social determinant of health that is associated with increased risk of death1-5. Cash transfer programmes provide non-contributory monetary transfers to individuals or households, with or without behavioural conditions such as children's school attendance6,7. Over recent decades, cash transfer programmes have emerged as central components of poverty reduction strategies of many governments in low- and middle-income countries6,7. The effects of these programmes on adult and child mortality rates remains an important gap in the literature, however, with existing evidence limited to a few specific conditional cash transfer programmes, primarily in Latin America8-14. Here we evaluated the effects of large-scale, government-led cash transfer programmes on all-cause adult and child mortality using individual-level longitudinal mortality datasets from many low- and middle-income countries. We found that cash transfer programmes were associated with significant reductions in mortality among children under five years of age and women. Secondary heterogeneity analyses suggested similar effects for conditional and unconditional programmes, and larger effects for programmes that covered a larger share of the population and provided larger transfer amounts, and in countries with lower health expenditures, lower baseline life expectancy, and higher perceived regulatory quality. Our findings support the use of anti-poverty programmes such as cash transfers, which many countries have introduced or expanded during the COVID-19 pandemic, to improve population health.

Case Report: Molecular autopsy underlie COVID-19-associated sudden, unexplained child mortality.

Herein, we report a child with COVID-19 and seemingly no underlying disease, who died suddenly. The autopsy revealed severe anemia and thrombocytopenia, splenomegaly, hypercytokinemia, and a rare ectopic congenital coronary origin. Immunohistochemical analysis demonstrated that the patient had acute lymphoblastic leukemia of the B-cell precursor phenotype (BCP-ALL). The complex cardiac and hematological abnormalities suggested the presence of an underlying disease; therefore, we performed whole-exome sequencing (WES). WES revealed a leucine-zipper-like transcription regulator 1 (LZTR1) variant, indicating Noonan syndrome (NS). Therefore, we concluded that the patient had underlying NS along with coronary artery malformation and that COVID-19 infection may have triggered the sudden cardiac death due to increased cardiac load caused by high fever and dehydration. In addition, multiple organ failure due to hypercytokinemia probably contributed to the patient's death. This case would be of interest to pathologists and pediatricians because of the limited number of NS patients with LZTR1 variants; the complex combination of an LZTR1 variant, BCP-ALL, and COVID-19; and a rare pattern of the anomalous origin of the coronary artery. Thus, we highlight the significance of molecular autopsy and the application of WES with conventional diagnostic methods.

The New Crisis of Increasing All-Cause Mortality in US Children and Adolescents.

This Viewpoint discusses increased rates in pediatric mortality by age and cause between 1999 and 2021.

Child Mortality in England During the First 2 Years of the COVID-19 Pandemic.

Importance: During the first year of the COVID-19 pandemic, child mortality in England was the lowest on record, but if this trend will continue, or if unrecognized morbidity during the first year of the pandemic will manifest as increased deaths over the next few years is unclear. Objective: To examine the risks and patterns of childhood deaths before and during the COVID-19 pandemic. Design, Setting, and Participants: This population-based cohort study includes all child deaths in England from April 1, 2019, to March 31, 2022. Exposures: The year of death. Main Outcomes and Measures: The primary outcome measure is risk of death. Results: Of the 9983 child deaths reported during the study period, 9872 (98.8%) were linked to demographic and population data with 3409 deaths (34.5%) between April 2019 and March 2020, 3035 (30.7%) between April 2020 and March 2021, and 3428 (34.7%) between April 2021 and March 2022. Most deaths occurred in children who were younger than 1 year (6257 of 9872 [62.7%]), the majority were male (5534 of 9760 [56.7%]), and lived in an urban area (8766 of 9872 [88.8%]). The risk of death was lower between April 2020 and March 2021 (relative risk [RR], 0.89 [95% CI, 0.84-0.93]), but not between April 2021 and March 2022 (RR, 1.00 [95% CI, 0.95-1.05]) when compared with April 2019 to March 2020. A population attributable risk (PAF) of 4.0% (95% CI, 0.1%-6.8%) suggested fewer deaths occurred during the whole 3-year period than expected. Reductions were seen in risk of dying by infection (PAF, 22.8% [95% CI, 8.2%-37.0%]) and underlying disease (PAF, 13.3% [95% CI, 8.1%-18.8%]), but there was evidence of an increasing risk of death by trauma (PAF, 14.7% [95% CI, 2.9%-25.2%]). Any reduction in the risk of death was greater in rural areas than in urban areas (RR, 0.73 [95% CI, 0.63-0.85] vs RR, 0.91 [95% CI, 0.86-0.95]) and was not seen in children older than 9 years. Conclusions and Relevance: In this cohort study, there was a significant reduction in all-cause child mortality during the first year of the COVID-19 pandemic (2020-2021), which returned to close to prepandemic levels the following year (2021-2022). However, there was a net reduction in deaths despite this, with 4% fewer deaths during the 3-year period than would have been expected from the 2019 to 2020 risks. The reductions were largest in rural areas and in children younger than 10 years.

Healthcare utilization and maternal and child mortality during the COVID-19 pandemic in 18 low- and middle-income countries: An interrupted time-series analysis with mathematical modeling of administrative data.

BACKGROUND: The Coronavirus Disease 2019 (COVID-19) pandemic has had wide-reaching direct and indirect impacts on population health. In low- and middle-income countries, these impacts can halt progress toward reducing maternal and child mortality. This study estimates changes in health services utilization during the pandemic and the associated consequences for maternal, neonatal, and child mortality. METHODS AND FINDINGS: Data on service utilization from January 2018 to June 2021 were extracted from health management information systems of 18 low- and lower-middle-income countries (Afghanistan, Bangladesh, Cameroon, Democratic Republic of the Congo (DRC), Ethiopia, Ghana, Guinea, Haiti, Kenya, Liberia, Madagascar, Malawi, Mali, Nigeria, Senegal, Sierra Leone, Somalia, and Uganda). An interrupted time-series design was used to estimate the percent change in the volumes of outpatient consultations and maternal and child health services delivered during the pandemic compared to projected volumes based on prepandemic trends. The Lives Saved Tool mathematical model was used to project the impact of the service utilization disruptions on child and maternal mortality. In addition, the estimated monthly disruptions were also correlated to the monthly number of COVID-19 deaths officially reported, time since the start of the pandemic, and relative severity of mobility restrictions. Across the 18 countries, we estimate an average decline in OPD volume of 13.1% and average declines of 2.6% to 4.6% for maternal and child services. We projected that decreases in essential health service utilization between March 2020 and June 2021 were associated with 113,962 excess deaths (110,686 children under 5, and 3,276 mothers), representing 3.6% and 1.5% increases in child and maternal mortality, respectively. This excess mortality is associated with the decline in utilization of the essential health services included in the analysis, but the utilization shortfalls vary substantially between countries, health services, and over time. The largest disruptions, associated with 27.5% of the excess deaths, occurred during the second quarter of 2020, regardless of whether countries reported the highest rate of COVID-19-related mortality during the same months. There is a significant relationship between the magnitude of service disruptions and the stringency of mobility restrictions. The study is limited by the extent to which administrative data, which varies in quality across countries, can accurately capture the changes in service coverage in the population. CONCLUSIONS: Declines in healthcare utilization during the COVID-19 pandemic amplified the pandemic's harmful impacts on health outcomes and threaten to reverse gains in reducing maternal and child mortality. As efforts and resource allocation toward prevention and treatment of COVID-19 continue, essential health services must be maintained, particularly in low- and middle-income countries.

What can work and how? An overview of evidence-based interventions and delivery strategies to support health and human development from before conception to 20 years.

Progress has been made globally in improving the coverage of key maternal, newborn, and early childhood interventions in low-income and middle-income countries, which has contributed to a decrease in child mortality and morbidity. However, inequities remain, and many children and adolescents are still not covered by life-saving and nurturing care interventions, despite their relatively low costs and high cost-effectiveness. This Series paper builds on a large body of work from the past two decades on evidence-based interventions and packages of care for survival, strategies for delivery, and platforms to reach the most vulnerable. We review the current evidence base on the effectiveness of a variety of essential and emerging interventions that can be delivered from before conception until age 20 years to help children and adolescents not only survive into adulthood, but also to grow and develop optimally, support their wellbeing, and help them reach their full developmental potential. Although scaling up evidence-based interventions in children younger than 5 years might have the greatest effect on reducing child mortality rates, we highlight interventions and evidence gaps for school-age children (5-9 years) and the transition from childhood to adolescence (10-19 years), including interventions to support mental health and positive development, and address unintentional injuries, neglected tropical diseases, and non-communicable diseases.

Parental education and inequalities in child mortality: a global systematic review and meta-analysis.

BACKGROUND: The educational attainment of parents, particularly mothers, has been associated with lower levels of child mortality, yet there is no consensus on the magnitude of this relationship globally. We aimed to estimate the total reductions in under-5 mortality that are associated with increased maternal and paternal education, during distinct age intervals. METHODS: This study is a comprehensive global systematic review and meta-analysis of all existing studies of the effects of parental education on neonatal, infant, and under-5 child mortality, combined with primary analyses of Demographic and Health Survey (DHS) data. The literature search of seven databases (CINAHL, Embase, MEDLINE, PsycINFO, PubMed, Scopus, and Web of Science) was done between Jan 23 and Feb 8, 2019, and updated on Jan 7, 2021, with no language or publication date restrictions. Teams of independent reviewers assessed each record for its inclusion of individual-level data on parental education and child mortality and excluded articles on the basis of study design and availability of relevant statistics. Full-text screening was done in 15 languages. Data extracted from these studies were combined with primary microdata from the DHS for meta-analyses relating maternal or paternal education with mortality at six age intervals: 0-27 days, 1-11 months, 1-4 years, 0-4 years, 0-11 months, and 1 month to 4 years. Novel mixed-effects meta-regression models were implemented to address heterogeneity in referent and exposure measures among the studies and to adjust for study-level covariates (wealth or income, partner's years of schooling, and sex of the child). This study was registered with PROSPERO (CRD42020141731). FINDINGS: The systematic review returned 5339 unique records, yielding 186 included studies after exclusions. DHS data were compiled from 114 unique surveys, capturing 3 112 474 livebirths. Data extracted from the systematic review were synthesized together with primary DHS data, for meta-analysis on a total of 300 studies from 92 countries. Both increased maternal and paternal education showed a dose-response relationship linked to reduced under-5 mortality, with maternal education emerging as a stronger predictor. We observed a reduction in under-5 mortality of 31·0% (95% CI 29·0-32·6) for children born to mothers with 12 years of education (ie, completed secondary education) and 17·3% (15·0-18·8) for children born to fathers with 12 years of education, compared with those born to a parent with no education. We also showed that a single additional year of schooling was, on average, associated with a reduction in under-5 mortality of 3·04% (2·82-3·23) for maternal education and 1·57% (1·35-1·72) for paternal education. The association between higher parental education and lower child mortality was significant for both parents at all ages studied and was largest after the first month of life. The meta-analysis framework incorporated uncertainty associated with each individual effect size into the model fitting process, in an effort to decrease the risk of bias introduced by study design and quality. INTERPRETATION: To our knowledge, this study is the first effort to systematically quantify the transgenerational importance of education for child survival at the global level. The results showed that lower maternal and paternal education are both risk factors for child mortality, even after controlling for other markers of family socioeconomic status. This study provides robust evidence for universal quality education as a mechanism to achieve the Sustainable Development Goal target 3.2 of reducing neonatal and child mortality. FUNDING: Research Council of Norway, Bill & Melinda Gates Foundation, and Rockefeller Foundation-Boston University Commission on Social Determinants, Data, and Decision Making (3-D Commission).

Estimating Child Mortality at the Sub-national Level in Papua New Guinea: Evidence From the Integrated Health and Demographic Surveillance System.

BACKGROUND: Child mortality is an important indication of an effective public health system. Data sources available for the estimation of child mortality in Papua New Guinea (PNG) are limited. OBJECTIVE: The objective of this study was to provide child mortality estimates at the sub-national level in PNG using new data from the integrated Health and Demographic Surveillance System (iHDSS). METHOD: Using direct estimation and indirect estimation methods, household vital statistics and maternal birth history data were analysed to estimate three key child health indicators: Under 5 Mortality Rate (U5MR), Infant Mortality Rate (IMR) and Neonatal Mortality Rate (NMR) for the period 2014-2017. Differentials of estimates were evaluated by comparing the mean relative differences between the two methods. RESULTS: The direct estimations showed U5MR of 93, IMR of 51 and NMR of 34 per 1000 live births for all the sites in the period 2014-2017. The indirect estimations reported an U5MR of 105 and IMR of 67 per 1000 live births for all the sites in 2014. The mean relative differences in U5MR and IMR estimates between the two methods were 3 and 24 percentage points, respectively. U5MR estimates varied across the surveillance sites, with the highest level observed in Hela Province (136), and followed by Eastern Highlands (122), Madang (105), and Central (42). DISCUSSION: The indirect estimations showed higher estimates for U5MR and IMR than the direct estimations. The differentials between IMR estimates were larger than between U5MR estimates, implying the U5MR estimates are more reliable than IMR estimates. The variations in child mortality estimates between provinces highlight the impact of contextual factors on child mortality. The high U5MR estimates were likely associated with inequality in socioeconomic development, limited access to healthcare services, and a result of the measles outbreaks that occurred in the highlands region from 2014-2017. CONCLUSION: The iHDSS has provided reliable data for the direct and indirect estimations of child mortality at the sub-national level. This data source is complementary to the existing national data sources for monitoring and reporting child mortality in PNG.

Adopting population-based interventions towards sustaining child health services in the midst of COVID-19 in sub-Saharan Africa: application of the socio-ecological model.

Child health services remain one of the most cost-effective strategies in reducing child mortality which is still disturbingly high in sub-Saharan Africa (SSA). Efforts by governments and other stakeholders in response to the COVID-19 pandemic have inadvertently disrupted the provision of other essential health services including those focusing on children. This comes at the backdrop of the World Health Organization´s guidelines for countries to sustain priority services while fighting the COVID-19 pandemic. Underpinned by the Socio-Ecological Model (SEM), we propose population-based interventions which could help in sustaining child health services in the midst of COVID-19 in SSA. At the intrapersonal and interpersonal levels, educating mothers during routine community outreach services, during child welfare clinics, and in church/mosques could be useful. Education and sensitization of male partners could also be an important intervention. At the institutional and community levels, we recommend the allocation of more funds to other essential health services including child health services. The training and deployment of more general nurses, community health nurses/officers, and public health officers is imperative. The provision and adherence to COVID-19 preventive protocols at health facilities are also recommended at these levels. At the public policy level, insurance and tax relief packages for frontline professionals providing child health services and micro-credit facilities at reduced interest rates for women could be implemented towards sustaining the utilisation of child health services.

Neonatal and child mortality - are they different in developing and developed countries?

Aim is to present the neonatal and child mortality in high-(HIC) and low-income (LIC) countries and possible influence of COVID-19 pandemic. In recently published sustainable development goals (SDGs) report and other sources the data on infant and under-five mortality (U-5MR) in HIC and LIC are presented. SDG 3.2 has targeted elimination of preventable child mortality, reduction of neonatal mortality rate (NMR) to less than 12 per 1,000 live births, and reduction of U-5MR to less than 25 per 1,000 live births by 2030. Negative influence of COVID-19 pandemic on performance of SDG 3.2 has been discussed. The lowest NMR was in HIC, almost 10 times lower than in LIC and sub-Saharan Africa (SSA). Data on the U-5MR between HIC and LIC are even worse because the difference was between 13 and 15 times lower in HIC. More children are dying after the neonatal period in LIC. In HIC, NMR comprises 56.3% of U-5MR, while in LIC it is 40.3%, and in SSA, it is 36.8%. Births attended by skilled birth personnel in HIC was 99.0% and in LIC it was only 58.6%, which might affect early NMR. The COVID-19 pandemic is affecting the delivery of perinatal health, with possible negative effects on stillbirth rates, NMR, U-5MR, maternal mortality rates, and many other indicators. The gap of the NMR and U-5MR between HIC and LIC has increasing tendency regardless of COVID-19 pandemic, affecting adversely perinatal health indicators in HIC and LIC.

Estimated impact of the 2020 economic downturn on under-5 mortality for 129 countries.

In low- and middle-income countries (LMICs), economic downturns can lead to increased child mortality by affecting dietary, environmental, and care-seeking factors. This study estimates the potential loss of life in children under five years old attributable to economic downturns in 2020. We used a multi-level, mixed effects model to estimate the relationship between gross domestic product (GDP) per capita and under-5 mortality rates (U5MRs) specific to each of 129 LMICs. Public data were retrieved from the World Bank World Development Indicators database and the United Nations World Populations Prospects estimates for the years 1990-2020. Country-specific regression coefficients on the relationship between child mortality and GDP were used to estimate the impact on U5MR of reductions in GDP per capita of 5%, 10%, and 15%. A 5% reduction in GDP per capita in 2020 was estimated to cause an additional 282,996 deaths in children under 5 in 2020. At 10% and 15%, recessions led to higher losses of under-5 lives, increasing to 585,802 and 911,026 additional deaths, respectively. Nearly half of all the potential under-5 lives lost in LMICs were estimated to occur in Sub-Saharan Africa. Because most of these deaths will likely be due to nutrition and environmental factors amenable to intervention, countries should ensure continued investments in food supplementation, growth monitoring, and comprehensive primary health care to mitigate potential burdens.

Child, maternal, and adult mortality in Sierra Leone: nationally representative mortality survey 2018-20.

BACKGROUND: Sierra Leone's child and maternal mortality rates are among the highest in the world. However, little is known about the causes of premature mortality in the country. To rectify this, the Ministry of Health and Sanitation of Sierra Leone launched the Sierra Leone Sample Registration System (SL-SRS) of births and deaths. Here, we report cause-specific mortality from the first SL-SRS round, representing deaths from 2018 to 2020. METHODS: The Countrywide Mortality Surveillance for Action platform established the SL-SRS, which involved conducting electronic verbal autopsies in 678 randomly selected villages and urban blocks throughout the country. 61 surveyors, in teams of four or five, enrolled people and ascertained deaths of individuals younger than 70 years in 2019-20, capturing verbal autopsies on deaths from 2018 to 2020. Centrally, two trained physicians independently assigned causes of death according to the International Classification of Diseases (tenth edition). SL-SRS death proportions were applied to 5-year mortality averages from the UN World Population Prospects (2019) to derive cause-specific death totals and risks of death nationally and in four Sierra Leone regions, with comparisons made with the Western region where Freetown, the capital, is located. We compared SL-SRS results with the cause-specific mortality estimates for Sierra Leone in the 2019 WHO Global Health Estimates. FINDINGS: Between Sept 1, 2019, and Dec 15, 2020, we enrolled 343 000 people and ascertained 8374 deaths of individuals younger than 70 years. Malaria was the leading cause of death in children and adults, nationally and in each region, representing 22% of deaths under age 70 years in 2020. Other infectious diseases accounted for an additional 16% of deaths. Overall maternal mortality ratio was 510 deaths per 100 000 livebirths (95% CI 483-538), and neonatal mortality rate was 31·1 deaths per 1000 livebirths (95% CI 30·4-31·8), both among the highest rates in the world. Haemorrhage was the major cause of maternal mortality and birth asphyxia or trauma was the major cause of neonatal mortality. Excess deaths were not detected in the months of 2020 corresponding to the peak of the COVID-19 pandemic. Half of the deaths occurred in rural areas and at home. If the Northern, Eastern, and Southern regions of Sierra Leone had the lower death rates observed in the Western region, about 20 000 deaths (just over a quarter of national total deaths in people younger than 70 years) would have been avoided. WHO model-based data vastly underestimated malaria deaths and some specific causes of injury deaths, and substantially overestimated maternal mortality. INTERPRETATION: Over 60% of individuals in Sierra Leone die prematurely, before age 70 years, most from preventable or treatable causes. Nationally representative mortality surveys such as the SL-SRS are of high value in providing reliable cause-of-death information to set public health priorities and target interventions in low-income countries. FUNDING: Bill & Melinda Gates Foundation, Canadian Institutes of Health Research, Queen Elizabeth Scholarship Program.

Child mortality in England during the first year of the COVID-19 pandemic.

OBJECTIVES: To quantify the relative risk (RR) of childhood deaths across the whole of England during the first year of the COVID-19 pandemic, compared with a similar period of 2019. DESIGN: This work is based on data collected by the National Child Mortality Database (NCMD). Deaths from 1 April 2020 until 31 March 2021 (2020-2021) were compared with those from the same period of 2019-2020. RR and excess mortality were derived for deaths in 2020-2021 vs 2019-2020. SETTING: All deaths reported to NCMD in England of children under 18 years of age, between April 2019 and March 2021. PARTICIPANTS: 6490 deaths of children, under the age of 18 years, reported to the NCMD over the study period. RESULTS: Children had similar demographics in the 2 years. There were 356 (198-514) fewer deaths in 2020-2021 than in 2019-2020 (RR 0.90 (0.85 to 0.94), p<0.001). Deaths from infection (RR 0.49 (0.38 to 0.64)) and from other underlying medical conditions (RR 0.75 (0.68 to 0.82)) were lower in 2020-2021 than 2019-2020, and weak evidence (RR 0.50 (0.23 to 1.07), p=0.074) that this was also true of deaths from substance abuse. CONCLUSIONS: Childhood mortality in England during the first year of the SARS-CoV-2 pandemic was lower than expected, with over 300 fewer deaths than the preceding 12 months. The greatest reduction was in children less than 10 years old. It is important that we learn from this effect that potentially offers alternative ways to improve the outcome for the most vulnerable children in our society.

Indirect effects of the SARS CoV-2 pandemic on the prevalence of breastfeeding: Modeling its impact. / Efectos indirectos de la pandemia por SARS CoV-2 en la prevalencia de lactancia materna: modelación de su impacto

INTRODUCTION: Breastfeeding has a protective effect against acute respiratory and diarrheal infections. There are psychological and social effects due to physical isolation in the population in the mother-child group. OBJECTIVE: To assess the impact on infant mortality due to a decrease in the prevalence of breastfeeding during 2020 due to the physical isolation against the SARS CoV-2 (COVID-19) pandemic in Colombia. MATERIALS AND METHODS: We used the population attributable risk approach taking into account the prevalence of breastfeeding and its potential decrease associated with the measures of physical isolation and the relative risk (RR) of the association between exclusive breastfeeding and the occurrence of acute infection consequences in the growth (weight for height) of children under the age of five through a mathematical modeling program. RESULTS: We found an increase of 11.39% in the number of cases of growth arrest in the age group of 6 to 11 months with a 50% decrease in breastfeeding prevalence, as well as an increase in the number of diarrhea cases in children between 1 and 5 months of age from 5% (5.67%) on, and an increased number of deaths in children under 5 years (9.04%) with a 50% decrease in the prevalence of exclusive breastfeeding. CONCLUSIONS: A lower prevalence of breastfeeding has an impact on infant morbidity and mortality in the short and medium-term. As a public health policy, current maternal and childcare strategies must be kept in order to reduce risks in the pediatric population.

Introducción. La lactancia materna tiene un efecto protector frente a infecciones respiratorias y diarreicas agudas. Hay efectos psicológicos y sociales por el aislamiento físico en la población en el grupo materno-infantil. Objetivo. Evaluar el eventual impacto en la mortalidad infantil de la disminución en la prevalencia de la lactancia materna durante el 2020 a causa del aislamiento físico por la pandemia del SARS CoV-2 (COVID-19) en Colombia. Materiales y métodos. Se utilizó el enfoque de riesgo atribuible poblacional, teniendo en cuenta la prevalencia de la lactancia materna y su potencial disminución asociada con las medidas de aislamiento físico y el riesgo relativo (RR) de la asociación entre la lactancia materna exclusiva y el efecto de la aparición de infecciones agudas en el crecimiento (peso para la altura) de niños menores de cinco años mediante un programa de modelamiento matemático. Resultados. Se registró un aumento del número casos de detención del crecimiento en el grupo etario de 6 a 11 meses de 11,39 % al disminuir en 50 % la prevalencia de la lactancia materna, así como un mayor número de casos por diarrea en los cinco primeros meses a partir del 5 % (5,67 %), y un incremento en el número de muertes en menores de 5 años (9,04 %) al disminuirse en 50 % la prevalencia de la lactancia materna. Conclusiones. Se registró un impacto en la morbilidad y la mortalidad infantil a corto y mediano plazo al disminuir la prevalencia en la lactancia materna. Como política pública en salud, deben mantenerse las estrategias actuales de atención materno-infantil para disminuir riesgos en la población infantil.

Effectiveness of neonatal "near miss" audits in reducing perinatal morbidity and mortality: a systematic review protocol.

OBJECTIVE: This review will assess the effectiveness of neonatal near-miss audits in reducing perinatal mortality and morbidity, as implemented in health care facilities. INTRODUCTION: Every year, 2.5 million newborns die and 2.6 million more are stillborn worldwide. While many perinatal deaths are preventable, their reduction has been markedly slower than the decline of maternal or child mortality rates. It is hypothesized that neonatal near miss is part of the spectrum of stillbirth-neonatal death and that auditing these cases might reduce perinatal mortality and morbidity. INCLUSION CRITERIA: This review will consider neonatal near-miss audits implemented in health care facilities worldwide. Randomized controlled trials, cluster-randomized trials, quasi-randomized controlled trials, controlled before-and-after studies, interrupted time series, case-control, cohort studies, cross-sectional studies, and case series will be included. Conference abstracts, letters, studies duplicating validation data from previous studies, gray literature, and unpublished studies will be excluded. METHODS: Using the JBI guidelines for conducting systematic reviews of effectiveness, the review will search the following electronic bibliographic databases: MEDLINE, Embase, Scopus, CINAHL, LILACS, and SciELO. No publication date or language limits will be imposed. Two independent reviewers will screen titles, abstracts, and full-text studies, assessing methodological quality with the JBI critical appraisal tools. GRADE will be used to assess the confidence in the findings. Covidence will be used for data extraction and management. A meta-analysis will be performed if the selected studies are sufficiently homogeneous. If not, the results will be discussed as a narrative synthesis. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO (CRD42021224090).