Need to Focus Beyond the Medical Causes: a Systematic Review of the Social Factors Affecting Neonatal Deaths Ravi Prakash Upadhyay, a Anand Krishnan, b Sanjay K. Rai, b Palanivel Chinnakali, c Oluwakemi Odukoya d a Department of Community Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital b Center for Community Medicine, All India Institute of Medical Sciences, New Delhi, India c Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India d Department of Community Health and Primary Care, College of Medicine, University of Lagos, Lagos, Nigeria Abstract Background: Reducing the global total of 3.3 million neonatal deaths is crucial to meeting the fourth Millennium Development Goal. Until recently, attention has been on the medical causes of the neonatal deaths, while the social factors contextualising these deaths have largely remained unaddressed. The current review aimed to quantify the role of these factors in neonatal deaths. Methods: A systematic search was performed through PubMed, Google scholar, Cochrane library, Medline, IndMed, Embase, World Health Organization and Biomed central databases. Studies published from 1995 to 2011 were included. Random effects meta-analysis was performed to derive at an estimate of the burden of delays, as defined by the ‘three delays model’ by Thadeus and Maine. Results: A total of 17 studies were reviewed. The majority of them (n = 10) were from the African continent. Level 3 delay, i.e. delay in receiving appropriate treatment upon reaching a health facility (38.7%, 95% CI, 21.7%–57.3%) and delay in deciding to seek care for the illness (Level 1 delay) (28%, 95% CI, 16%–43%) were the major contributors to neonatal deaths. Level 2 delay, i.e. delay in reaching a health facility (18.3%, 95% CI, 2.6–43.8%) contributed least to the neonatal deaths. Conclusion: Creating awareness among caregivers regarding early recognition and treatment seeking for neonatal illness along with improving the quality of neonatal care provided at the health facilities is essential to reduce neonatal mortality. Keywords: neonatal deaths, social factors, three delays model, systematic review. Globally around 3.3 million neonatal deaths occur every year, with majority of them occurring in low and middle-income countries, reflecting the wide variation in neonatal mortality rates between devel- oped and developing countries. 1–3 Within developing countries, there is also a social gradient and neonatal mortality rates differ by area of residence, wealth index, education and access to health care services. 1,4 The World Health Organization (WHO) suggests that the inequality in health within and between countries exists due to social determinants that influence health. 5,6 Promotion of neonatal health could be seen as a result of effective interventions in two broad domains: the biomedical domain that addresses diseases; and the social, economic and political domain that addresses the structural determinants of health. Social factors have an impact on mortality rate as they influ- ence the interaction between the health system and the patient. Neonatal mortality is not solely influenced by specific medical conditions (such as low birthweight, sepsis/infection, birth asphyxia, etc.) but also affected by socio-economic status, parental education, aware- ness of caregivers regarding severity of illness, avail- ability of funds and transport, ethnic traditions or beliefs and other cultural factors. These factors impact on the reasons for not availing medical care, delay in seeking care, delay in reaching a health facility and the quality of treatment received at the hospital. Thus, to bring down the neonatal Correspondence: Ravi Prakash Upadhyay, Department of Community Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi 110029, India. E-mail: ravi.p.upadhyay@gmail.com 127 doi: 10.1111/ppe.12098 © 2013 John Wiley & Sons Ltd Paediatric and Perinatal Epidemiology, 2014, 28, 127–137