title: Examining national and district-level trends in neonatal health in Peru through an equity lens: a success story driven by political will and societal advocacy.
abstract: Peru has impressively reduced its neonatal mortality rate (NMR). We aimed, for the period 2000-2013, to: (a) describe national and district NMR variations over time; (b) assess NMR trends by wealth quintile and place of residence; (c) describe evolution of mortality causes; (d) assess completeness of registered mortality; (e) assess coverage and equity of NMR-related interventions; and (f) explore underlying driving factors.
  
  
  
  We compared national NMR time trends from different sources. To describe NMR trends by wealth quintiles, place of residence and districts, we pooled data on births and deaths by calendar year for neonates born to women interviewed in multiple surveys. We disaggregated coverage of NMR-related interventions by wealth quintiles and place of residence. To identify success factors, we ran regression analyses and combined desk reviews with qualitative interviews and group discussions.
  
  
  
  NMR fell by 51 % from 2000 to 2013, second only to Brazil in Latin America. Reduction was higher in rural and poorest segments (52 and 58 %). District NMR change varied by source. Regarding cause-specific NMRs, prematurity decreased from 7.0 to 3.2 per 1,000 live births, intra-partum related events from 2.9 to 1.2, congenital abnormalities from 2.4 to 1.8, sepsis from 1.9 to 0.8, pneumonia from 0.9 to 0.4, and other conditions from 1.2 to 0.7. Under-registration of neonatal deaths decreased recently, more in districts with higher development index and lower rural population. Coverage of family planning, antenatal care and skilled birth attendance increased more in rural areas and in the poorest quintile. Regressions did not show consistent associations between mortality and predictors. During the study period social determinants improved substantially, and dramatic out-of-health-sector and health-sector changes occurred. Rural areas and the poorest quintile experienced greater NMR reduction. This progress was driven, within a context of economic growth and poverty reduction, by a combination of strong societal advocacy and political will, which translated into pro-poor implementation of evidence-based interventions with a rights-based approach.
  
  
  
  Although progress in Peru for reducing NMR has been remarkable, future challenges include closing remaining gaps for urban and rural populations and improving newborn health with qualified staff and intermediate- and intensive-level health facilities.
authors.affiliation: Centro de Investigación para el Desarrollo Integral y Sostenible (CIDIS), Universidad Peruana Cayetano Heredia, Lima, Peru. lhuicho@gmail.com.|School of Medicine, Universidad Peruana Cayetano Heredia and Universidad Nacional Mayor de San Marcos, Lima, Peru. lhuicho@gmail.com.|Instituto Nacional de Salud del Niño, Lima, Peru. lhuicho@gmail.com.
authors.forename: Luis
authors.initials: L
authors.lastname: Huicho
authors.affiliation: Centro de Investigación para el Desarrollo Integral y Sostenible (CIDIS), Universidad Peruana Cayetano Heredia, Lima, Peru.
authors.forename: Carlos A
authors.initials: CA
authors.lastname: Huayanay-Espinoza
authors.affiliation: Centro de Investigación para el Desarrollo Integral y Sostenible (CIDIS), Universidad Peruana Cayetano Heredia, Lima, Peru.|Instituto Nacional de Salud del Niño, Lima, Peru.
authors.forename: Eder
authors.initials: E
authors.lastname: Herrera-Perez
authors.affiliation: Ministerio de Economía y Finanzas, Lima, Peru.
authors.forename: Jessica
authors.initials: J
authors.lastname: Niño de Guzman
authors.affiliation: Centro de Investigación para el Desarrollo Integral y Sostenible (CIDIS), Universidad Peruana Cayetano Heredia, Lima, Peru.
authors.forename: Maria
authors.initials: M
authors.lastname: Rivera-Ch
authors.affiliation: International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil.
authors.forename: Maria Clara
authors.initials: MC
authors.lastname: Restrepo-Méndez
authors.affiliation: International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil.
authors.forename: Aluisio J D
authors.initials: AJ
authors.lastname: Barros
mesh_terms: D000328:Adult; D005193:Family Planning Services / Q000706:statistics & numerical data; D005260:Female; D006798:Housing; D006801:Humans; D007223:Infant; D000068104:Infant Health / Q000706:statistics & numerical data*; D007226:Infant Mortality / Q000639:trends; D007231:Infant, Newborn; D007234:Infant, Premature; D010568:Peru / Q000453:epidemiology; D011247:Pregnancy; D011295:Prenatal Care / Q000706:statistics & numerical data; D012111:Residence Characteristics / Q000706:statistics & numerical data*; D012424:Rural Population
keywords: Advocacy; Equity; Evidence-based interventions; Neonatal mortality; Policy and system analysis; Success factors