Children are not born equal in their likelihood of survival. The risk of mortality is highest during and shortly after
birth. In the immediate postnatal period and beyond, perinatal events, nutrition, infections, family and environmental
exposures, and health services largely determine the risk of death. We argue that current public health programmes
do not fully acknowledge this spectrum of risk or respond accordingly. As a result, opportunities to improve the care,
survival, and development of children in resource-poor settings are overlooked. Children at high risk of mortality are
underidentified and commonly treated using guidelines that do not differentiate care according to the magnitude or
drivers of those risks. Children at low risk of mortality are often provided with more intensive care than needed,
disproportionately using limited health-care resources with minimal or no benefits. Declines in newborn, infant, and
child mortality rates globally are slowing, and further reductions are likely to be incrementally more difficult to
achieve once simple, high impact interventions have been universally implemented. Currently, 63 countries have
rates of neonatal mortality that are off track to meet the Sustainable Development Goal 2030 target
of 12 deaths per 1000 livebirths or less, and 54 countries have rates of mortality in children younger than 5 years that
are off track to meet the target of 25 deaths per 1000 livebirths or less. If these targets are to be met, a change of
approach is needed to address infant and child mortality and for health-care systems to more efficiently address
residual mortality.
