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Background  South Asian studies, including those from Nepal, have documented increased risk of neonatal mortality among girls, despite their early biologic survival advantage. We examined sex differences in neonatal morbidity and care-seeking behavior to determine whether such differences could help explain previously observed excess late neonatal mortality among girls in Nepal.    Methods  A secondary analysis of data from a trial of chlorhexidine use among neonates in rural Nepal was conducted. The objective was to examine sex differences in neonatal morbidity and care-seeking behavior for ill newborns. Girls were used as the reference group.    Results  Referral for care was higher during the early neonatal period (ENP: 0–7 days old) (50.7 %) than the late neonatal period (LNP: 8–28 days old) (31.3 %), but was comparable by sex. There were some significant differences in reasons for referral by sex. Boys were significantly more often referred for convulsions/stiffness, having yellow body/eyes, severe skin infection, and having at least two of the following: difficulty breathing, difficulty feeding, fever, or vomiting during the ENP. Girls were more often referred for hypothermia. During the LNP, boys were significantly more often referred for having yellow body/eyes, persistent watery stool, and severe skin infection. There were no referral types in the LNP for which girls were more often referred. Less than half of those referred at any point were taken for care (47.0 %) and referred boys were more often taken than girls (Neonatal Period OR: 1.77, 95 % CI: 1.64 - 1.91). Family composition differentially impacted the relationship between care-seeking and sex. The greatest differences were in families with only prior living girls (Pahadi - ENP OR: 1.78, 95 % CI: 1.29 - 2.45 and LNP OR: 1.51, 95 % CI: 1.03 - 2.21; Madeshi - ENP OR: 2.86, 95 % CI: 2.28 – 3.59 and LNP OR: 2.45, 95 % CI: 1.84 – 3.26).    Conclusions  Care-seeking was inadequate for both sexes, but ill boys were consistently more often taken for care than girls, despite comparable referral. Behavioral interventions to improve care-seeking, especially in the early neonatal period, are needed to improve neonatal survival. Addressing gender bias in care-seeking, explicitly and within interventions, is essential to reducing neonatal mortality differentials between boys and girls.

Sex differences in morbidity and care-seeking during the neonatal period in rural southern Nepal