Prognosis of neonates receiving invasive mechanical ventilation in low-resource settings: a systematic review and prognostic meta-analysis

Provision of invasive mechanical ventilation (IMV) in the neonatal intensive care has seen a steady rise in low-esource settings (LRS). However, outcomes among those exposed to IMV remain under-reported, with the current evidence base being restricted to single-centre observational studies, thus limiting comparative analyses and effective healthcare planning. This study aims to estimate the pooled proportion of mortality and morbidity among neonates exposed to IMV in low-resource settings. Medline, Embase, and CENTRAL were searched until 22 August 2025. Randomised and non-randomised studies were included. Two reviewers, blinded to each other, extracted data independently. Proportion-based meta-analyses using random-effects model were performed. Risk of bias was assessed using ROBINS-E, and evidence-certainty was evaluated using the GRADE approach. One hundred of 117 studies were included, with most conducted in South Asia. In-hospital mortality was reported in 68 studies (7193 neonates), with a pooled estimate of 45% (39%–50%), evidence-certainty being very low. Among the secondary outcomes, the pooled rates were as follows: bronchopulmonary dysplasia, 10% (5%–18%); intraventricular haemorrhage (any grade), 10% (5%–19%); necrotising enterocolitis (any stage), 14% (6%–31%); retinopathy of prematurity (any stage), 33% (22%–46%); ventilator-associated pneumonia, 21% (14%–29%); sepsis, 32% (25%–40%) and pulmonary haemorrhage, 9% (6%–14%). Evidence-certainty for all the secondary outcomes was also very low. Subgroup analysis comparing two distinct time epochs revealed a significant difference in mortality, 43% (36%–50%) (I2 = 93.5%) in the post-2010 epoch compared to 55% (48%–63%) (I2 = 82.9%) in the pre-2010 epoch (p = 0.004). Heterogeneous outcome definitions and predominance of unadjusted analyses across studies limit the existing evidence. Conclusions: In LRS, the mortality and morbidity rates among neonates receiving IMV remain substantially high with a modest improvement in survival in the past decade. Improving outcomes mandates moving beyond access to the provision of IMV to investing in comprehensive training and scaling up critical auxiliary resources. Future research must adopt standardised outcome definitions and adjusted analyses to precisely quantify the impact of IMV in LRS.