Four million newborn deaths: Is the global research agenda evidence-based? Joy E. Lawn a,b, ⁎, Igor Rudan c,d,e , Craig Rubens f a Senior Research and Policy Advisor, Saving Newborn Lives, Save the Children-US, South Africa b Health Systems Research Unit, Medical Research Council, Cape Town, South Africa c Croatian Centre for Global Health, University of Split Medical School, Split, Croatia d Department of Public Health Sciences, University of Edinburgh Medical School, Scotland, UK e Consultant to the Child Health and Nutrition Research Initiative, Dhaka, Bangladesh f Executive Director of Global Alliance for Prevention of Prematurity and Stillbirths (GAPPS), Seattle Children's Hospital, Seattle, WA, United Sates abstract article info Keywords: Neonatal Newborn Research Priority-setting Neonatal infections Preterm birth Birth asphyxia Inequity Epidemiology Millennium Development Goals Four million neonates die each year. These deaths are mostly in low-income countries, but neonatal mortality and morbidity are also a priority burden in high-income countries. Epidemiological evidence suggests newborn research would prioritise the poorest families; birth and the first days of life; major causes particularly infections, preterm birth and asphyxia; and include preventive strategies as well as improved care. However research investment is not commensurate to burden, and there is a mismatch with current research priorities. South Asia and sub Saharan Africa, with 75% of the burden, expend around US$20 million per year on newborn research, a fraction of what is spent on a smaller proportion of health problem in rich countries. We propose a research pipeline of description, discovery, development of solutions and delivery of research with scale-up to reach the poorest families. Listing research options and applying quantitative scoring enables systematic, transparent research prioritisation. As well as a research pipeline, a “people pipeline” is required to generate research capacity in low-income countries. © 2008 Elsevier Ireland Ltd. All rights reserved. 1. Introduction Each year, four million babies die in their first four weeks of life (the neonatal period). This equates to more than 10,000 deaths a day. Many die at home without contact with formal healthcare [1]. Most of these deaths are unrecorded and remain invisible to all but their families. The fourth global Millennium Development Goal (MDG 4) calls for a two-thirds reduction in the death rate of children under the age of 5 by 2015. Accelerating progress in reducing neonatal deaths is crucial because while progress is being made in reducing postneonatal mor- tality, fewer countries are achieving rapid reductions in neonatal mortality. In addition at least 3.2 million babies are stillborn each year [2], with one third dying in labour [3]. Ninety-nine percent of newborn deaths occur in low and middle- income countries [1] but almost all the research information available in the public domain focuses on the one percent of deaths occurring in the richest countries. In rich countries, neonates account for at least two-thirds of deaths among children under five years. If research investments were aligned with the burden of neonatal health problems and based on the potential global impact of the research, what would this agenda look like? 2. Evidence to inform a global newborn health research agenda 2.1. Where? Almost three-quarters of neonatal deaths occur in South Asia and Sub Saharan Africa. India alone experiences over 1 million neonatal deaths each year. Of the 20 countries with the highest neonatal mortality rates, three-quarters are in Africa and many are experiencing conflict or have seen recent conflict [4]. Ironically data may be weakest from transitional countries and large countries such as China where registration is still too low to be representative and large population- based surveys are not undertaken [5]. However national averages can hide populations at greater risk, requiring targeted programmes and research. Within countries there may be marked variation. For example in India, Kerala State has a neonatal mortality rate (NMR) of around 10, but in some northern Indian states this is six-fold higher. In both industrialised and developing countries, NMR and neonatal morbidity are higher for the poorest families. In the USA the infant mortality rate for African Americans is almost double that for white Early Human Development 84 (2008) 809–814 ⁎ Corresponding author. 11 South Way, Pinelands, Cape Town 7405, South Africa. Tel.: +27 21 532 3494; fax: +27 21 531 5140. E-mail address: joylawn@yahoo.co.uk (J.E. Lawn). 0378-3782/$ – see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.earlhumdev.2008.09.009 Contents lists available at ScienceDirect Early Human Development journal homepage: www.elsevier.com/locate/earlhumdev