Over the past decade, birth and the first month of life has gained visibility as a critical time to intervene to continue momentum for child survival given that almost half of child deaths are now in the neonatal period (0–28 days after birth) (1). Investment in a healthy birth gives a triple return as this is the moment of greatest risk for women, stillbirths, and newborns and also crucial for child development and human capital (1). Yet despite great potential for mortality reduction, progress remains slow, with neonatal mortality reducing at about half the speed of maternal mortality or child mortality after the first month (1). The slowest progress has been in sub-Saharan Africa: at current rates of change it will be over a century before an African newborn has the same chance of survival as a baby born in Europe or North America (1). This gap reflects ongoing low visibility in comparison to the massive burden to families, to the health system, and to future development potential. Furthermore, this gap reflects the pervasive myth that newborn deaths are inevitable, a lack of visible successes for programmes at scale and a lack of leadership (2, 3).

The results of the Uganda Newborn Study (UNEST) as described by Waiswa et al. (4) and the other papers in this supplement are important for Uganda with implications for the rest of the continent, encapsulating many of the evidence shifts from the last decade, and giving clear messages to accelerate progress (4). UNEST was influenced by the 2005 Lancet neonatal survival series which identified highly cost-effective packages of interventions that could avert more than two-thirds of all neonatal deaths (5). At that time the majority of births in Africa and Asia were at home and an important message was that an estimated one third of neonatal deaths, especially in high mortality settings, could be prevented at community level (5). All of the well-known community-based trials at the time were from South Asia, and most were smaller scale efficacy trials, highlighting the need for contextual adaptation and a focus on effectiveness. In response to the 2005 Lancet neonatal series, Uganda held the first national stakeholder meeting on newborn survival, and undertook a situation analysis. A priority gap identified was the lack of locally relevant evidence regarding use of existing community and facility systems to address the main causes of neonatal deaths. With funding from The Bill & Melinda Gates Foundation through Save the Children's Saving Newborn Lives programme, researchers in Uganda partnered with national policymakers and district leaders to conduct UNEST as a two-arm cluster randomised trial evaluating a package of home visits during pregnancy and the postnatal period, with improved facility-based care effecting both the intervention and control arms (4).