{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,24]],"date-time":"2026-08-24T18:21:59Z","timestamp":1787595719178,"version":"build-2736575974"},"reference-count":32,"publisher":"Public Library of Science (PLoS)","issue":"8","license":[{"start":{"date-parts":[[2026,8,24]],"date-time":"2026-08-24T00:00:00Z","timestamp":1787529600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosmedicine.org"],"crossmark-restriction":false},"short-container-title":["PLoS Med"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Stillbirths and early neonatal deaths account for a substantial proportion of global child mortality. Reliable measurement of these outcomes remains challenging in settings where civil registration systems are incomplete and household surveys are the primary data source. However, survey-based estimates are often affected by underreporting and misclassification between stillbirths and early neonatal deaths. We aimed to apply a statistical adjustment approach to improve estimates of stillbirth, early neonatal, and perinatal mortality trends and to assess socioeconomic inequalities in countries with repeated Demographic and Health Surveys (DHS).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods and findings<\/jats:title>\n                    <jats:p>We analyzed 93 DHS surveys with reproductive calendar data from 17 LMICs conducted between 1990 and 2023, covering 1,019,253 pregnancies reported by 733,181 women. Pregnancies of at least 7 months\u2019 gestation were included to align with the standard definition of stillbirth. Age-specific risks of stillbirth and early neonatal death were estimated using life-table methods and a modified Gompertz\u2013Makeham (mGM) model that adjusts for common survey data quality issues, including underreporting, misclassification between stillbirths and deaths on days 0\u20131, and age-at-death heaping, i.e., the tendency to systematically misreport age of neonatal death often at 7 days at the expenses of neighboring days. Survey-specific estimates were used to evaluate trends over time and to examine associations with maternal and household characteristics through mGM models and the pooled etimates random-effects meta-regression; all covariates were used for adjusting the perinatal mortality rates and also taking the survey sampling design into consideration. A sensitivity analysis using alternate assumptions confirmed the robustness of the findings at country level.<\/jats:p>\n                    <jats:p>Across countries, stillbirth, early neonatal, and perinatal mortality rates generally declined over time, although trends varied substantially between settings. The pooled annual decline was \u22120.60 deaths per 1,000 births for stillbirths (95% CI [\u22120.78,\u2009\u22120.41]), \u22120.50 for early neonatal mortality (95% CI [\u22120.66,\u2009\u22120.35]), and \u22121.08 for perinatal mortality (95% CI [\u22121.40,\u2009\u22120.76]). Lower perinatal mortality was associated with urban residence, higher maternal education, wealthier households, and higher national Human Development Index levels, whereas maternal age\u2009\u226530 years was associated with higher risk. Limitations include potential residual underreporting of pregnancy losses and lack of information on causes of death, in addition to our model assumptions relying on constant perinatal mortality metrics across different settings.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Adjusting for survey data quality issues may potentially improve the use of household survey data for estimating stillbirth and early neonatal mortality. Although most countries experienced declines in perinatal mortality, progress remains uneven and significant socioeconomic disparities persist. Strengthening maternal and newborn health services and improving data systems will be essential to accelerate progress toward global targets for reducing perinatal mortality.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pmed.1004791","type":"journal-article","created":{"date-parts":[[2026,8,24]],"date-time":"2026-08-24T17:23:35Z","timestamp":1787592215000},"page":"e1004791","update-policy":"https:\/\/doi.org\/10.1371\/journal.pmed.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["Trends of stillbirth, early neonatal and perinatal mortality rates and sociodemographic differentials of perinatal mortality rates in 17 low- and middle-income countries: A modeling study"],"prefix":"10.1371","volume":"23","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0242-9241","authenticated-orcid":true,"given":"Mohamed M.","family":"Ali","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Luca","family":"Cegolon","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4119-0803","authenticated-orcid":true,"given":"Saverio","family":"Bellizzi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,8,24]]},"reference":[{"key":"pmed.1004791.ref001","volume-title":"Stillbirth","author":"World Health Organization.","year":"2026"},{"issue":"1","key":"pmed.1004791.ref002","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2021-053049","article-title":"Association between prelabour caesarean section and perinatal outcomes: analysis of demographic and health surveys from 26 low-income and middle-income countries","volume":"12","author":"N Opiyo","year":"2022","journal-title":"BMJ Open"},{"key":"pmed.1004791.ref003","volume-title":"Standing up for stillbirths: current estimates and key interventions","author":"United Nations Inter-Agency Group for Child Mortality Estimation (UN IGME)","year":"2025"},{"key":"pmed.1004791.ref004","unstructured":"UNICEF. Levels and trends in child mortality. New York: UNICEF; 2024. Available from: https:\/\/data.unicef.org"},{"issue":"20","key":"pmed.1004791.ref005","doi-asserted-by":"crossref","first-page":"2047","DOI":"10.1056\/NEJMp058032","article-title":"Perinatal mortality in developing countries","volume":"352","author":"J Zupan","year":"2005","journal-title":"N Engl J Med"},{"issue":"1","key":"pmed.1004791.ref006","doi-asserted-by":"crossref","first-page":"321","DOI":"10.1215\/00703370-9709538","article-title":"Modeling age patterns of under-5 mortality: results from a log-quadratic model applied to high-quality vital registration data","volume":"59","author":"M Guillot","year":"2022","journal-title":"Demography"},{"issue":"6","key":"pmed.1004791.ref007","article-title":"Measuring stillbirth and perinatal mortality rates through household surveys: a population-based analysis using an integrated approach to data quality assessment and adjustment with 157 surveys from 53 countries","volume":"11","author":"MM Ali","year":"2023","journal-title":"Lancet Glob Health"},{"key":"pmed.1004791.ref008","volume-title":"Demographic and Health Surveys (various) [datasets]","author":"ICF","year":"2004"},{"key":"pmed.1004791.ref009","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2022-011411","article-title":"Making the health system work for over 25 million births annually: drivers of the notable decline in maternal and newborn mortality in India","volume":"9","author":"H Bhushan","year":"2024","journal-title":"BMJ Glob Health"},{"issue":"10018","key":"pmed.1004791.ref010","doi-asserted-by":"crossref","first-page":"587","DOI":"10.1016\/S0140-6736(15)00837-5","article-title":"Stillbirths: rates, risk factors, and acceleration towards 2030","volume":"387","author":"JE Lawn","year":"2016","journal-title":"Lancet"},{"issue":"10","key":"pmed.1004791.ref011","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.1002151","article-title":"Obstetric facility quality and newborn mortality in malawi: a cross-sectional study","volume":"13","author":"HH Leslie","year":"2016","journal-title":"PLoS Med"},{"issue":"3","key":"pmed.1004791.ref012","doi-asserted-by":"crossref","first-page":"0","DOI":"10.9745\/GHSP-D-20-00031","article-title":"The all babies count initiative: impact of a health system improvement approach on neonatal care and outcomes in Rwanda","volume":"8","author":"H Magge","year":"2020","journal-title":"Glob Health Sci Pract"},{"key":"pmed.1004791.ref013","doi-asserted-by":"crossref","first-page":"595379","DOI":"10.3389\/fpubh.2020.595379","article-title":"Rate, risk factors, and causes of neonatal deaths in jordan: analysis of data from Jordan Stillbirth and Neonatal Surveillance System (JSANDS)","volume":"8","author":"NA Al-Sheyab","year":"2020","journal-title":"Front Public Health"},{"key":"pmed.1004791.ref014","doi-asserted-by":"crossref","first-page":"04027","DOI":"10.7189\/jogh.14.04027","article-title":"Stagnation of maternal mortality decline in Bangladesh between 2010 and 2016 despite increased health service utilization: evidence from three cross-sectional surveys","volume":"14","author":"KZ Ahsan","year":"2024","journal-title":"J Glob Health"},{"issue":"4","key":"pmed.1004791.ref015","doi-asserted-by":"crossref","first-page":"334","DOI":"10.1093\/inthealth\/ihaa070","article-title":"Trends, patterns and cause-specific neonatal mortality in Tanzania: a hospital-based retrospective survey","volume":"13","author":"CD Mangu","year":"2021","journal-title":"Int Health"},{"key":"pmed.1004791.ref016","first-page":"1653076","article-title":"Antenatal care attendance and factors influencing birth weight in Ghana","volume":"2020","author":"PK Appiah","year":"2020","journal-title":"Int J Reprod Med"},{"issue":"1","key":"pmed.1004791.ref017","doi-asserted-by":"crossref","first-page":"981","DOI":"10.1186\/s12884-022-05282-x","article-title":"Antenatal and delivery practices and neonatal mortality among women with institutional and non-institutional deliveries in rural Zimbabwe","volume":"22","author":"C Noble","year":"2022","journal-title":"BMC Pregnancy Childbirth"},{"key":"pmed.1004791.ref018","article-title":"Use of data from various sources to evaluate and improve the prevention of mother-to-child transmission of HIV programme in Zimbabwe: a data integration exercise","author":"EL Sibanda","year":"2020","journal-title":"J Int AIDS Soc"},{"key":"pmed.1004791.ref019","volume-title":"Zimbabwe multiple indicator cluster survey 2019: survey findings report","author":"Zimbabwe National Statistics Agency (ZIMSTAT)","year":"2019"},{"key":"pmed.1004791.ref020","doi-asserted-by":"crossref","first-page":"134","DOI":"10.1186\/s13690-020-00516-w","article-title":"Correlates of antenatal care utilization among women in sub-Saharan Africa: evidence from demographic and health surveys","volume":"78","author":"ST Adedokun","year":"2020","journal-title":"Arch Public Health"},{"key":"pmed.1004791.ref021","unstructured":"UNICEF. Hidden tragedy: Nigeria accounts for one of the highest stillbirth rates in Africa. Available from: https:\/\/www.unicef.org\/nigeria"},{"key":"pmed.1004791.ref022","first-page":"318","article-title":"Rates and risk factors for antepartum and intrapartum stillbirths in Imo State, Nigeria: A hospital-based case-control study","volume":"19","author":"OB Nwosu","year":"2019","journal-title":"BMC Pregnancy Childbirth"},{"issue":"10","key":"pmed.1004791.ref023","article-title":"A reassessment of global antenatal care coverage for improving maternal health using sub-Saharan Africa as a case study","volume":"13","author":"JE-O Ataguba","year":"2018","journal-title":"PLoS One"},{"key":"pmed.1004791.ref024","article-title":"Independent and cumulative effects of risk factors associated with stillbirths in 50 low- and middle-income countries: a multi-country cross-sectional study","volume":"54","author":"Z Li","year":"2022","journal-title":"EClinicalMedicine"},{"issue":"10300","key":"pmed.1004791.ref025","doi-asserted-by":"crossref","first-page":"608","DOI":"10.1016\/S0140-6736(21)00534-1","article-title":"Parental education and inequalities in child mortality: a global systematic review and meta-analysis","volume":"398","author":"M Balaj","year":"2021","journal-title":"Lancet"},{"key":"pmed.1004791.ref026","doi-asserted-by":"crossref","first-page":"94","DOI":"10.11606\/S1518-8787.2017051007013","article-title":"Maternal education and age: inequalities in neonatal death","volume":"51","author":"SC Fonseca","year":"2017","journal-title":"Rev Saude Publica"},{"issue":"10018","key":"pmed.1004791.ref027","doi-asserted-by":"crossref","first-page":"587","DOI":"10.1016\/S0140-6736(15)00837-5","article-title":"Stillbirths: rates, risk factors, and acceleration towards 2030","volume":"387","author":"JE Lawn","year":"2016","journal-title":"Lancet"},{"issue":"2","key":"pmed.1004791.ref028","doi-asserted-by":"crossref","DOI":"10.1016\/S2214-109X(23)00468-0","article-title":"A global analysis of the determinants of maternal health and transitions in maternal mortality","volume":"12","author":"JP Souza","year":"2024","journal-title":"Lancet Glob Health"},{"key":"pmed.1004791.ref029","first-page":"16","article-title":"National chlorhexidine coverage and newborn umbilical cord care in Bangladesh and Nepal","volume":"3","author":"AC Moran","year":"2017","journal-title":"Matern Health Neonatol Perinatol"},{"issue":"7","key":"pmed.1004791.ref030","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0304841","article-title":"Adapting the log quadratic model to estimate age- and cause-specific mortality among neonates","volume":"19","author":"J Perin","year":"2024","journal-title":"PLoS One"},{"key":"pmed.1004791.ref031","article-title":"Learning from success: drivers of the maternal and newborn health transition in seven positive-outlier countries","volume":"9","author":"OMR Campbell","year":"2024","journal-title":"BMJ Global Health"},{"key":"pmed.1004791.ref032","unstructured":"World Health Organization. WHO pushes to revive stalled progress on maternal and child health. 2024. Available from: https:\/\/healthpolicy-watch.news"}],"container-title":["PLOS Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pmed.1004791","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,24]],"date-time":"2026-08-24T17:23:45Z","timestamp":1787592225000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pmed.1004791"}},"subtitle":[],"editor":[{"given":"Margaret E","family":"Kruk","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,8,24]]},"references-count":32,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2026,8,24]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pmed.1004791","relation":{},"ISSN":["1549-1676"],"issn-type":[{"value":"1549-1676","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,24]]}}}