The rate of neonatal mortality due to infection in South Asia is alarming. India is ranked highest in the world for neonatal deaths, with 5 million babies dying in 2019 (World Health Organization [WHO], 2020). Nigeria, Pakistan, Ethiopia, and the Democratic Republic of Congo collectively account for almost 50% of neonatal deaths worldwide (WHO, 2022). There is concern that this will increase to 20 million deaths yearly by 2050 (Carvalho et al., 2022).

Scientists are trying to determine if high infant mortality rates are due to bacterial or viral infections, and what social determinants and health-related factors contribute to these deaths. In research conducted in India, Bangladesh, and Pakistan, Arvay et al. (2022) recently summarized what is currently known and what merits further study. They found over 32% of infections were bacterial including gram-negative, antibiotic-resistant bacteria such as Klebsiella pneumoniae, Escherichia coli, and Enterobacter cloacae. It is unclear "how," "when," or "where" the newborns contract infection. Some experts are worried there is a relationship between these infections and overuse of antibiotics around the world. Antibiotic resistance has been identified in mothers and neonates within hours of birth (Carvalho et al., 2022). Is sepsis related to scarce resources in low- and medium-income countries that can be used to adequately diagnose and treat newborn sepsis? Is it the lack of quality maternal and newborn care in clinical facilities? Mechanisms for maternal or neonate transfer of infection is very complex. Carvalho et al. (2022) believe that infection is colonized in newborns during birth or shortly thereafter, either by maternal contact or through the environment in the birthing facility. One hypothesis is the transition from birthing sites to home may be inadequate. Is sepsis due to lack of reliable hygiene practices when there is lack of quality available water, low sanitation standards, and inadequate hygiene practices (WASH)? Are mortality rates related to neonatal age? Why was there a high mortality rate identified in a recent study conducted in India (International Institute for Population Sciences, 2022; Ram & Ram, 2022)?

The Oxford University BARNARDS team has been working for nearly a decade to make a difference in increasing the evidence on what we currently know about neonatal sepsis in low-to middle-income countries. They have founded 12 clinical sites in Bangladesh, Ethiopia, India, Nigeria, Pakistan, Rwanda, and South America (Carvalho et al., 2022). Ongoing studies have included 35,040 mothers and 35,285 babies. One project includes a quality maternal newborn center with a microbiology lab onside in the Murtala Muhammad Specialist Hospital in Kana, Nigeria. The focus of this initiative is improved clinical care, quality outcome-focused research, and aggressive outreach to vulnerable mother-baby couplets. Addressing social determinants of health in vulnerable populations of childbearing women and babies in South Asia is critical. Researchers have documented multiple hypothesized causes of neonatal sepsis and the effectiveness of interventions based on rigorous clinical research studies. Additional research is needed, with evidence-based measures being taken to reduce neonatal mortality worldwide.

It is important for maternity and neonatal nurses to be aware of common causes of infant morbidity and mortality in low- to middle-income countries around the world as nurses are increasingly caring for families who have immigrated to the United States and who may have concerns about the health of their baby based on experiences with childbirth in their home country.

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