IMPORTANCE: There are wide disparities in neonatal mortality rates (NMRs, deaths <28 days of life after live birth per 1000 live births) between countries in Europe, indicating potential for improvement. Comparing country-specific patterns of births and deaths with countries with low mortality rates can facilitate the development of effective intervention strategies. OBJECTIVE: To investigate how these disparities are associated with the distribution of gestational age (GA) and GA-specific mortality rates. DESIGN, SETTING, AND PARTICIPANTS: This was a cross-sectional study of all live births in 14 participating European countries using routine data compiled by the Euro-Peristat Network. Live births with a GA of 22 weeks or higher from 2015 to 2020 were included. Data were analyzed from May to October 2023. EXPOSURES: GA at birth. MAIN OUTCOMES AND MEASURES: The study investigated excess neonatal mortality, defined as a rate difference relative to the pooled rate in the 3 countries with the lowest NMRs (Norway, Sweden, and Finland; hereafter termed the top 3). The Kitagawa method was used to divide this excess into the proportion explained by the GA distribution of births and by GA-specific mortality rates. A sensitivity analysis was conducted among births 24 weeks' GA or greater. RESULTS: There were 35 094 neonatal deaths among 15 123 428 live births for an overall NMR of 2.32 per 1000. The pooled NMR in the top 3 was 1.44 per 1000 (1937 of 1 342 528). Excess neonatal mortality compared with the top 3 ranged from 0.17 per 1000 in the Czech Republic to 1.82 per 1000 in Romania. Excess deaths were predominantly concentrated among births less than 28 weeks' GA (57.6% overall). Full-term births represented 22.7% of the excess deaths in Belgium, 17.8% in France, 40.6% in Romania and 17.3% in the United Kingdom. Heterogeneous patterns were observed when partitioning excess mortality into the proportion associated with the GA distribution vs GA-specific mortality. For example, these proportions were 9.2% and 90.8% in France, 58.4% and 41.6% in the United Kingdom, and 92.9% and 7.1% in Austria, respectively. These associations remained stable after removing births under 24 weeks' GA in most, but not all, countries. CONCLUSIONS AND RELEVANCE: This cohort study of 14 European countries found wide NMR disparities with varying patterns by GA. This knowledge is important for developing effective strategies to reduce neonatal mortality.

CRESS Obstetrical Perinatal and Paediatric Epidemiology Research Team EPOPe INSERM INRA Université Paris Cité Paris France

Department of Epidemiology and Biostatistics Institute of Mother and Child Warsaw Poland

Department of Global Public Health and Primary Care University of Bergen Bergen Norway

Department of Knowledge Brokers Finnish Institute for Health and Welfare Helsinki Finland

Department of Neonatal Intensive Care AP HP Hôpital Necker Enfants Malades Paris France

Department of Obstetrics and Gynecology 3rd Faculty of Medicine Charles University Prague Czech Republic

Department of Obstetrics and Gynecology Institute for the Care of Mother and Child Prague Czech Republic

Department of Obstetrics and Gynecology Maastricht University Medical Centre MUMC Maastricht the Netherlands

Department of Population Health Sciences College of Life Sciences University of Leicester Leicester United Kingdom

Direction de la Recherche des Etudes de l'Evaluation et des Statistiques Paris France

Division of Mental and Physical Health Norwegian Institute of Public Health Bergen Norway

Division of Public Health Croatian Institute of Public Health Zagreb Croatia

Faculty of Medicine East European Institute for Reproductive Health Academy of Romanian Scientists University 'Ovidius' Constanţa Constanța Romania

Federal Statistical Office Neuchâtel Switzerland

International Centre for Reproductive Health Department of Public Health and Primary Care Faculty of Medicine and Health Sciences Ghent University Ghent Belgium

Karolinska Institutet Department of Molecular Medicine and Surgery Stockholm Sweden

Region Stockholm Academic Primary Health Care Centre Stockholm Sweden

Section for Epidemiology Department of Public Health University of Copenhagen Copenhagen Denmark

Swedish National Board of Health and Welfare Department of Analysis Stockholm Sweden

Unit Demography and Health Directorate Social Statistics Statistics Austria Vienna Austria

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