[Comment] The rising burden of small vulnerable newborns in China: demanding targeted interventions

The rising burden of small vulnerable newborns in China: demanding targeted interventions Affiliations & Notes aSchool of Public Health, Xi'an Medical University, Xi'an, China bDepartment of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China cKey Laboratory of Environment and Gene-Related Diseases, Xi'an Jiaotong University, Ministry of Education, Xi'an, China Article Info Publication History: Published February 18, 2026 DOI: 10.1016/S2214-109X(25)00529-7 External LinkAlso available on ScienceDirect External Link Copyright: © 2025 The Author(s). Published by Elsevier Ltd. Linked Articles - Prevalence estimates of small vulnerable newborns in China (2012–22): a modelling studyThe Lancet Global HealthFebruary 18, 2026 Download started OkThe latest WHO report indicates that there were 4·5 million maternal and newborn deaths globally in 2022. Of these, 1·9 million were stillbirths and 2·3 million were neonatal deaths (age <28 days), with nearly 60% occurring in low-income and middle-income countries.1 Infants born preterm (<37 weeks of gestation), small for gestational age (SGA), or who have low birthweight (LBW; <2500 g) have a substantially higher risk of maternal and child mortality;2 these conditions are collectively responsible for up to 80% of all neonatal deaths worldwide.3 In addition to the mortality risk, such infants remain susceptible to health problems across their lifespan, a cycle that often perpetuates across generations. Societally, there are human capital losses and wider societal effects such as socioeconomic development and burden of long-term care to health system and families.2,4 Despite the availability of effective interventions for preterm birth, LBW, and SGA,2,5,6 challenges in routine antenatal care have resulted in suboptimal progress in neonatal mortality reduction. In China, neonatal mortality has substantially declined from approximately 33·1 per 1000 livebirths in 1990 to 3·1 per 1000 livebirths in 2022.7,8 Despite outstanding progress in child survival, approximately 65 700 children younger than 5 years died in China in 2022, of whom 45·1% died in the neonatal period.8 In the 2023 Lancet Series, the Small Vulnerable Newborn Consortium proposed a new framework bringing together preterm birth, LBW, and SGA under the category small vulnerable newborn (SVN).2 This framework is designed to accelerate progress towards Sustainable Development Goal (SDG) 3.2, with the aim of ending preventable deaths of newborns and children younger than 5 years by 2030. However, limited research has adopted the unified definition to assess the burden of neonatal vulnerability in China,9 potentially resulting in an underestimation. China's evolving fertility policies and rising use of assisted reproductive technologies have increased the occurrence of high-risk pregnancies, advanced maternal age, multiparity, and multiple births, which elevate the risk of adverse birth outcomes. Accurate assessment of the SVN burden is essential to guide perinatal interventions, establish child health monitoring, and inform policies aimed at reducing neonatal mortality. In The Lancet Global Health, Yanxia Xie and colleagues10 provide a comprehensive epidemiological analysis of SVNs in China, examining four mutually exclusive clinical subtypes (preterm non-SGA, preterm SGA, term SGA, and LBW only) nationwide and across 31 provinces between 2012 and 2022. The findings show that, in 2022, an estimated 13·2 per 100 liveborn newborns in mainland China were identified as SVNs. The national prevalence ratios (PRs) of SVNs remained stable overall between 2012 and 2022, with an observable turning point around 2018, when ratios began to increase after a previous decline. However, divergent trends emerged across subtypes. The PR of term SGA livebirths decreased, whereas the PRs of preterm non-SGA livebirths and LBW-only livebirths increased over the same period. Substantial geographical heterogeneity was also observed. In 2022, Qinghai had the highest PRs of SVN, preterm SGA, and term SGA livebirths, while Liaoning had the highest PR of preterm non-SGA livebirths and Chongqing had the highest PR of LBW-only livebirths. Temporally, Heilongjiang showed the most rapid increase in SVN prevalence, with Inner Mongolia showing the fastest growth in both preterm SGA and preterm non-SGA subtypes. Notably, SVNs accounted for more than 60% of in-hospital neonatal deaths and more than 80% of stillbirths, highlighting their severe public health burden. The substantial geographical heterogeneity in SVN prevalence and subtype distribution demands that prevention and resource allocation be calibrated to local epidemiological profiles. Three research priorities emerge to address the rising burden of SVN births in China. At the national level, the immediate task is to investigate the drivers (eg, social determinants and maternal healthcare service quality) of the post-2018 rise in national SVN burden. This understanding is crucial to inform the shift from surveillance to the design and implementation of precise interventions. Second, shifting the focus to the SVN subtype level, the observed divergent trends across SVN subtypes indicate potential fundamental differences in their causal pathways. Therefore, clarifying distinct aetiological networks is essential to develop targeted interventions. Given that multiple micronutrient supplementation has been shown to reduce risks for both preterm SGA and term SGA,11 it warrants evaluation as a promising intervention to mitigate the rising burden of preterm-onset SVN. Third, at the spatial level, geographical diversity of SVNs at the provincial levels necessitates identifying modifiable local drivers, spanning health-care capacity, environmental exposures, socioeconomic status, and genetic factors, to guide context-specific interventions. Xie and colleagues critically operationalise the 2023 Lancet SVN Series' global call to action within China by establishing the first national epidemiological profile of SVNs, thereby bridging a major knowledge gap and transitioning SVNs from a global priority to a national target. This study delivers a key policy message that the substantial provincial heterogeneity necessitates a shift to geographically tailored interventions, an imperative strategy for China to achieve SDG 3.2 and Healthy China 2030, thereby ending preventable under-5 deaths by 2030. Competing Interests We declare no competing interests. References 1. Thiruvengadam, R ∙ Ayushi ∙ Murugesan, DR ∙ et al. Incidence of and risk factors for small vulnerable newborns in north India: a secondary analysis of a prospective pregnancy cohort Lancet Glob Health. 2024; 12:e1261-e1277 2. Ashorn, P ∙ Ashorn, U ∙ Muthiani, Y ∙ et al. Small vulnerable newborns—big potential for impact Lancet. 2023; 401:1692-1706 3. Blencowe, H ∙ Krasevec, J ∙ de Onis, M ∙ et al. National, regional, and worldwide estimates of low birthweight in 2015, with trends from 2000: a systematic analysis Lancet Glob Health. 2019; 7:e849-e860 4. Lawn, JE ∙ Blencowe, H ∙ Oza, S ∙ et al. Every Newborn: progress, priorities, and potential beyond survival Lancet. 2014; 384:189-205 5. Hofmeyr, GJ ∙ Black, RE ∙ Rogozińska, E ∙ et al. Evidence-based antenatal interventions to reduce the incidence of small vulnerable newborns and their associated poor outcomes Lancet. 2023; 401:1733-1744 6. Zeng, LX ∙ Dibley, MJ ∙ Cheng, Y ∙ et al. Impact of micronutrient supplementation during pregnancy on birth weight, duration of gestation, and perinatal mortality in rural western China: double blind cluster randomised controlled trial Br Med J. 2008; 337, a2001 7. Qiao, J ∙ Wang, Y ∙ Li, X ∙ et al. A Lancet Commission on 70 years of women's reproductive, maternal, newborn, child, and adolescent health in China Lancet. 2021; 397:2497-2536 8. He, C ∙ Kang, L ∙ Liu, Y ∙ et al. Changes in the epidemiology of under-5 mortality in China from 2016 to 2022: an observational analysis of population-based surveillance data Lancet Public Health. 2024; 9:e1059-e1069 9. Zhao, Y ∙ Jia, Z ∙ Wang, L ∙ et al. Trends in the incidence of high-risk newborns based on a new conceptual framework - Beijing Municipality, China, 2013–2022 China CDC Wkly. 2024; 6:767-771 10. Xie, Y ∙ Liang, J ∙ Mu, Y ∙ et al. Prevalence estimates of small vulnerable newborns in China (2012–22): a modelling study Lancet Glob Health. 2026; published online Feb 18. https://doi.org/10.1016/S2214-109X(25)00498-X 11. Wang, D ∙ Liu, E ∙ Perumal, N ∙ et al. The effects of prenatal multiple micronutrient supplementation and small-quantity lipid-based nutrient supplementation on small vulnerable newborn types in low-income and middle-income countries: a meta-analysis of individual participant data Lancet Glob Health. 2025; 13:e298-e308