Babies born in Cuba, Malaysia, Portugal, and the United Kingdom have a better chance of surviving the first month compared to those born in the United States, according to researchers at the World Health Organization and Save the Children.

In a 20 year analysis of newborn death rates around the world, the study published in PLoS Medicine revealed the number of infants who die before they are 4 weeks old account for 41% of child deaths worldwide. Newborn deaths in the United States ranked 41 out of 45 among industrialized countries, on par with Qatar and Croatia.

America's low ranking among modern nations may come as surprise to many who regard the U.S. health care system as the best in the world. Researchers say preterm delivery (delivering before 37 weeks) plays a role in the United State's lower ranking.

“Prenatal care is not all created equal. There are areas of the United States where access to prenatal and preventive care is a real problem. It puts the mother at a disadvantage and contributes to premature births and death rate,” says the study’s author Dr. Joy Lawn of the non-government organization Save the Children.

The study says the leading causes of newborn death worldwide are preterm delivery, asphyxia and severe infections. More than a half million babies in the United States—1 in every 8—are born premature each year.

The United States has seen a 26% reduction in newborn deaths since 1990, but that number is lower than the global average.

“We have seen the numbers come down in the U.S. but at a notably slower rate than other countries,” says Lawn. “We actually found 50 countries, including China, have dropped their newborn death rate by more than 50% in the last 20 years.”

Half of the 3.3 million newborn deaths around the world occur in just five countries: Pakistan, China, Democratic Republic of Congo, India, and Nigeria. But researchers say the newborn death rates in these regions can be decreased by utilizing known interventions: Improving hygiene when a baby is born, breastfeeding and keeping babies warm after birth.

“Society often thinks people won’t change their behaviors, but that’s not true. These mothers want their babies to survive, too. They just don’t know better right now,” says Lawn.

Health experts say simply teaching midwives and community workers in Africa and South Asia proper hygiene care and how to properly wrap the baby can limit infections and have a profound impact on death rates. Also teaching “kangaroo mother care,” which is when a mother ties the newborn baby to their chest, can cut the number of deaths in half, according to Save the Children.