Although survival data on very low birth weight (VLBW) infants from developing countries indicates that mortality rates are high, there is considerable disagreement on the relative contribution of respiratory distress syndrome to neonatal morbidity and mortality. With improving facilities for newborn care, it is now possible to provide basic respiratory support to some babies with RDS in selected centres. We prospectively evaluated the profile and outcome of newborn infants with respiratory distress admitted to the newborn services at Aga Khan University Hospital in Karachi. The overall mortality for newborns with documented RDS was 81/200 (41 per cent), and was highest (70 per cent) for babies weighing < 1000 g at birth. Univariate and logistic regression analysis of factors significantly associated with high risk of dying despite respiratory support, included low apgar score at one minute (P = 0.003), admission AaDO2 value > 400 (P = 0.001), development of acute renal failure (Relative risk 6.2, 95 per cent confidence interval 1.0-40.0), intraventricular haemorrhage (RR 2.6, 95 per cent CI 1.3-5.2) and pneumothorax (RR 3.7, 95 per cent CI 1.8-7.7). Our data highlight the importance of the immediate postnatal period in infants with RDS and suggest that close attention to early stabilization of VLBW infants with RDS, may further reduce the mortality associated with this disorder.