Background: Studies in South Asia have documented increased risk of neonatal mortality among girls, despite evidence of a biological survival advantage.
Associations between gender preference and mortality are cited as reasons for excess mortality among girls. This has not, however, been tested in statistical models. Methods: A secondary analysis of data from a population-based randomised controlled trial of newborn infection prevention conducted in rural southern Nepal was used to estimate sex differences in early and late neonatal mortality, with girls as the reference group.
Biological factors, primarily respiratory depression and unconsciousness at birth, explained excess early neonatal mortality among boys. Increased late neonatal mortality among girls was explained by a three-way environmental interaction between ethnicity, sex and prior sibling composition categorised as primiparous newborns, infants born to families with prior living boys or boys and girls, and infants born to families with only prior living girls. Conclusions: Risk of neonatal mortality inverted between the early and late neonatal periods.
Excess risk of early neonatal death among boys was consistent with biological expectations. Excess risk for late neonatal death among girls was not explained by overarching gender preference or preferential care-seeking for boys as hypothesised, but was driven by increased risk among Madeshi girls born to families with only prior girls.
Trial registration: ClinicalTrials. Abstract Background: Studies in South Asia have documented increased risk of neonatal mortality among girls, despite evidence of a biological survival advantage. Gov't Research Support, U.
