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ObjectiveTo explore potential reasons for differences in preterm neonatal mortality in neonatal intensive care units (NICUs) in India and Pakistan.DesignA prospective observational study, the Project to Understand and Research Stillbirth and Preterms in Southeast Asia (PURPOSe) was conducted July 2018 to February 2020.SettingThree hospitals in Davangere, India, and a large public hospital in Karachi, Pakistan.PopulationOf a total of 3,202 preterm infants enrolled, 1,512 were admitted to a study NICU.MethodsWe collected data for neonates, including length of stay, diagnoses, and diagnostic tests.Main outcome measuresNeonatal mortality, tests performed, diagnoses ascertained.ResultsFor infants of equivalent weights and gestational ages, neonatal mortality in Pakistan was twice that in the Indian NICU. The mean newborn length of stay in Pakistan was 2 days compared with 10 days for India. Fewer diagnostics and other investigations were used to determine neonatal condition or guide treatment in the Pakistani NICU. Because of limited information from testing in Pakistan concerning clinical respiratory distress, respiratory distress syndrome appeared to be over‐diagnosed, whereas other conditions including pneumonia, sepsis, necrotising entercolitis and intraventricular haemorrhage were rarely diagnosed.ConclusionIn the Pakistani site, the limited resources available to the NICU appeared related to a shorter length of stay and decreased diagnostic testing, likely explaining the higher mortality. With improved care, reduction in mortality among preterm neonates should be achievable.

ObjectiveGlobally, early and optimal feeding practices and strategies for small and vulnerable infants are limited. We aim to share the challenges faced and implementation lessons learned from a complex, mixed methods research study on infant feeding.DesignA formative, multi‐site, observational cohort study using convergent parallel, mixed‐methods design.SettingTwelve tertiary/secondary, public/private hospitals in India, Malawi and Tanzania.Population or SampleModerately low birthweight infants (MLBW; 1.50–2.49 kg).MethodsWe assessed infant feeding and care practices through: (1) assessment of in‐facility documentation of 603 MLBW patient charts; (2) intensive observation of 148 MLBW infants during facility admission; and (3) prospective 1‐year follow‐up of 1114 MLBW infants. Focus group discussions and in‐depth interviews gathered perspectives on infant feeding among clinicians, families, and key stakeholders.Main Outcome MeasuresThe outcomes of the primary study were: (1) To understand the current practices and standard of care for feeding LBW infants; (2) To define and document the key outcomes (including growth, morbidity, and lack of success on mother's own milk) for LBW infants under current practices; (3) To assess the acceptability and feasibility of a system‐level Infant and Young Child Feeding (IYCF) intervention and the proposed infant feeding options for LBW infants.ResultsHospital‐level guidelines and provision of care for MLBW infants varied across and within countries. In all, 89% of charts had missing data on time to first feed and 56% lacked discharge weights. Among 148 infants observed in‐facility, 18.5% were discharged prior to meeting stated weight goals. Despite challenges during COVID, 90% of the prospective cohort was followed until 12 months of age.ConclusionsEnrolment and follow‐up of this vulnerable population required additional effort from researchers and the community. Using a mixed‐methods exploratory study allowed for a comprehensive understanding of MLBW health and evidence‐based planning of targeted large‐scale interventions. Multi‐site partnerships in global health research, which require active and equal engagement, are instrumental in avoiding duplication and building a stronger, generalisable evidence base.