Photo: Loulou d'Aki/Save the Children
As the world recognizes World Prematurity Day today, the Maternal Health Task Force is ever mindful of the key role a woman’s and mother’s health plays in the prevention of premature birth. While improving neonatal care and promoting interventions—such as kangaroo care are important—the rising rate of preterm births suggests prevention is key for decreasing neonatal mortality rates. And what would prevention be without ensuring the health of the woman before and during pregnancy?
The health of a pregnant woman is paramount, not only for her own survival and health, but also to prevent the number one killer of neonates: prematurity. While it is true that a large percentage of preterm births are iatrogenic, meaning the cause is unknown, there are several preventable factors that increase a woman’s risk of delivering prematurely. Ensuring women’s rights; preventing and treating infectious and non-communicable diseases; providing quality preconception and antenatal care; and promoting facility delivery to prevent maternal death will not only improve the lives of mothers, but also aid in preventing prematurity and neonatal death.
Respecting a women’s right to live a violence-free life and plan her family is basic and essential, yet women around the world still suffer violence, often in their own homes, and many are not given the choice to plan their families. Domestic violence plays a significant role at putting a woman at risk for delivering prematurely. Family planning also plays a key role in decreasing premature birth; meeting the unmet need for family planning is estimated to decrease the number of premature births and neonatal mortality. In addition, appropriate birth spacing decreases a woman’s odds of giving birth prematurely by 16 percent.
Preventing and treating infectious and chronic disease
While the prevention and treatment of infectious diseases has long been a focus of antenatal care, more recently the importance of mitigating the effects of non-communicable diseases (NCDs) through preconception care has been realized as key for decreasing prematurity and birth complications.
Providing a women with the education and means to prevent sexually transmitted infections (STIs) and treatment if needed is not only key for her health, but can significantly decrease birth complications and prematurity. In addition to STIs, rubella—a vaccine-preventable disease—and malaria significantly increase the risk of preterm birth. Providing methods of prevention and appropriate treatment for these infections will have a significant impact on the rate of prematurity and the health of women and their children.
A life course approach to preventing prematurity necessitates the need for ensuring the overall health of women prior to pregnancy. Non-communicable diseases—such as low BMI, high BMI, high blood pressure, asthma, diabetes, and thyroid and heart disease—are significant contributors to prematurity. Providing regular care before conception and antenatal care during pregnancy to address chronic health problems will improve the chances for a healthy pregnancy for both the mother and her newborn.
Antenatal Care and Facility Births
Skilled care is a key intervention for the health of the mother and the prevention of birth complications, including prematurity. Regular antenatal care visits allow complications to be addressed, familiarization with the health sector, and increased chance of delivering in a facility. Since not all preterm births can be prevented, a facility birth, which has an incredible positive impact on maternal mortality, also situates the premature infant in a setting where emergency services may be provided. The majority of premature newborns die in the first hour of life, which indicates the need for the immediate emergency and supportive facility-based care, such as resuscitation, treatment of sepsis, and thermoregulation.
The rate of preterm birth—the number one cause of death in children under-five—can be reduced through integrated maternal and neonatal health. By addressing the health of both the mother and the newborn, complications can be mitigated and lives saved.
When you see pictures of tiny preterm babies, you likely marvel at how they fit in the palm of a hand, or how a wedding ring can slide up their arm and reach their elbow. What you may not consider is the lifelong toll premature birth can have on a person – if they survive it at all.
New research shows that for the first time ever, preterm birth is now the leading cause of death for all children under age 5 around the world.
More than 15 million babies are born too soon every year, and nearly one million of them don’t survive infancy. Those who do survive are often faced with lasting health issues such as cerebral palsy, developmental delays, or respiratory, vision and hearing problems. The burden is magnified in many developing countries, where world-class neonatal intensive care units, let alone a basic level of healthcare, are not available.
Dr. Craig Rubens, executive director of the Global Alliance to Prevent Prematurity and Stillbirth (GAPPS), an initiative of Seattle Children’s, says a larger, coordinated research effort is critical to lowering the number of babies born preterm.
“It’s easy to look at preterm birth and view it as a single endpoint,” Rubens said. “In reality, preterm birth can have many causes and pathways. Although the end result is the same, we need more research to understand the different pathways so we can develop ways to prevent them.”
In conjunction with World Prematurity Day today, Rubens and his team have published a state-of-the-art review in Science Translational Medicine, providing a central analysis of preterm birth research. The findings, Rubens said, leave a lot to be desired.
“There are not enough resources dedicated to researching the complex problem of preterm birth and its prevention,” he said. “Our paper is a clarion call to the scientific community, that investing in preterm birth research will pay dividends with millions of lives saved and also save billions of dollars in healthcare expenses associated with preterm birth.”
In 2007, the Institute of Medicine estimated the annual costs associated with preterm birth to be $26 billion in the U.S. alone, and those numbers have surely increased since.
In the paper, Rubens and his co-authors note that there are many factors that can increase a woman’s likelihood of preterm birth – including genetics, stress and poor pregnancy weight gain – however, there is very little known about why those factors increase risk and what can be done to prevent them.
There are also discrepancies in preterm birth rates that are poorly understood. For example, in the United States, babies of non-Hispanic black women have preterm birth rates that are 40% greater than those of Hispanic and non-Hispanic white women, and this difference persists even after adjustment for maternal socioeconomic status and education. Unfortunately, even less is understood about the risk factors, disparities and causes of preterm birth in high-burden, low-resource countries.
Despite the sobering statistics, Rubens is optimistic that preterm birth will be recognized as a global issue that needs to be prioritized.
“As more people learn that preterm birth is the leading cause of death for children under age 5 around the world – and that it happens to moms and babies from the U.S. to Uganda – we are hopeful that scientists, policymakers and funders will prioritize preterm birth research so that every birth can be a healthy birth.”
- Science Translational Medicine paper
- World Prematurity Day
- Global Alliance to Prevent Prematurity and Stillbirth
Above photo courtesy of Paul Joseph Brown/GAPPS
15 million babies are born too soon every year, making premature birth the leading cause of newborn death around the world. Most preterm births and deaths occur in low-income countries, where 5.6 million babies are born in homes and another 4.4 million are born in primary care facilities with limited capacity for special care. The majority of deaths in preterm babies could be prevented with feasible, low-cost interventions, such as kangaroo mother care and early recognition and treatment of complications of prematurity, including infections and jaundice.
But in low-income settings, how do we know which babies are premature in the first place? In high-income countries, most women recall their last menstrual period and have an ultrasound, which provides accurate pregnancy dating. However, in many low-income countries, the percentage of women who have access to ultrasound is in the single digits.
With this in mind, for Saving Lives at Birth Round 1 and with support from the World Health Organization, we have been testing the accuracy of a range of different methods to help community health workers (CHWs) easily identify preterm infants. We’ve been conducting our analysis in the Projahnmo field site in Sylhet, Bangladesh as part of a collaboration between Johns Hopkins Bloomberg School of Public Health, International Center for Diarrheal Disease Research – Bangladesh, Shimantik NGO, and the Bangladeshi Ministry of Health and Family Welfare. We assess each newborn by measuring various physical characteristics, including the flexibility of the baby’s ear and length of the baby’s foot. We then compare these measurements to previously captured ultrasounds, which allows us to evaluate the accuracy of each method at discerning prematurity.
A community health worker measures a newborn's foot.
Once preterm babies are identified, providing these high-risk newborns with specialized, life-saving care is the next step in preventing preterm birth complications and deaths. With our new Saving Lives at Birth Round 4 grant, we plan to develop a toolkit to help CHWs better identify and manage small babies. The first part of the toolkit will be a mobile phone application to help the CHW identify premature infants using our simple and rapid preterm assessment. The mobile application will also guide the CHW through managing the preterm baby at home, with modules for early referral to the hospital for the very premature baby as well as modules for home-based management of common complications and illnesses, such as possible severe bacterial infection, jaundice, feeding difficulties, and hypothermia. The mobileapplication will support clinical decision-making to ensure that each essential step in the care pathway is followed every time for every baby.
The second essential piece of our small baby toolkit will be a simple, low-cost plastic jaundice ruler to improve the ability of CHWs to assess newborns for jaundice. Jaundice is perhaps the most common neonatal illness, affecting 50% of full term and 80% of preterm babies, but which in severe cases can lead to permanent brain damage or death. Neonatal jaundice occurs when the liver cannot process old red blood cells fast enough and a pigment called bilirubin builds up in the blood, turning the baby’s skin and eyes yellow. The more yellow the skin, the more bilirubin in the blood, and the more severe the disease.
To this end, we are creating a ruler that uses colors instead of numbers as its units of measurement. This jaundice ruler will be developed and validated in Bangladesh. After pressing the ruler into the baby’s skin, the CHW will be able to match the yellow tones in the skin to the yellow tones in the ruler to determine the severity of disease.
Together, these tools will empower community health workers to more accurately recognize, refer and manage premature and jaundiced newborns. In turn, this will improve access to effective treatment for mothers and their babies, an important step in reducjng neonatal morbidity and mortality in the highest burden and lowest resource settings.
Baby Nga was born at home in her mother's bed. They weren't sure exactly what day she was due to arrive, but they knew that this day was too early; the midwife shook her head with fading hope that the infant would make it.
She was too small. She was too early. Medical skills in Vietnam were not advanced enough in the early 1940s to save many of the babies who were born prematurely. Nga's mother gently wrapped her in tiny blankets and kept her close to the oven; both of them sleeping where it was warm, their own version of a modern-day incubator. Her birthdate was not recorded.
Just over twenty years later, Nga was pregnant with her first child and living in the United States. "You will need a c-section," the doctors told her, "You are too small to give birth." It didn't make any difference how she planned to have her baby, because like Nga, her newborn decided to enter the world weeks ahead of schedule. At 5 pounds, she was small, but the doctors in Memphis knew how to care for a baby born at this stage of development.
My mother named me Joy to mark the arrival of 5 pounds of happiness into our new family.
I knew the story of my mother's birth. Her "real" birthday was a running joke in the family because the day on her birth certificate was chosen as a lucky day, not because it was the actual day that she was born. Even my grandmother wasn't sure what the actual calendar day was. I also knew that I was premature. As I grew, my mother, Nga, would remark on how such a small baby could be such a tall adult. I didn't know that this medical history could lead to my own daughter being born early.
My beautiful daughter Kendall was born at 35 weeks. Baby shower gifts were not assembled, supplies for a newborn had yet to be acquired, and a dresser drawer was briefly considered as a temporary bassinet. Like many late preterm newborns, Kendall appeared as a full-sized baby. She had some digestive issues in the first months, but she was healthy and strong. We were lucky. Prematurity remains the top cause of newborn mortality in the United States.
November marks Prematurity Awareness Month. Although we've seen a growth in research about babies born early over the course of my family's three generations of preterm births, nearly 1 in 8 babies in the United States are still born too soon. However, while some preterm births are not preventable, we know now that there are modifiable behaviors that moms can adopt to reduce their risk of preterm birth :
- Cessation of smoking and avoidance of alcohol or drugs.
- Prenatal care from a health care provider (HCP) as soon as you think you may be pregnant, and throughout pregnancy
- Informing your HCP if you've had a previous preterm labor or birth.
- Controlling diseases like high blood pressure or diabetes through your HCP.
- Eating a healthy diet and taking prenatal vitamins.
- Learning the warning signs or symptoms of preterm labor.
Staying healthy during pregnancy and reducing the risk factors of preterm birth are the focus of Healthy Babies are Worth the Wait (HBWW). The HBWW partnership between the March of Dimes and Johnson & Johnson reduced singleton preterm birth rates by 12 percent during a pilot program in Kentucky, and is now implemented in 8 states. Linking the medical community, the Department of Health, the community at large and families, the HBWW program educates and supports pregnant women to help ensure that a mom has a full 39 weeks of pregnancy.
My family's story is not unique, but we have been fortunate Many others who could avoid preterm birth are not as lucky, simply because they're unaware of how to reduce their own risk. During Prematurity Awareness Month, join me in spreading this message. Together, we can save babies' lives by reducing preterm birth. Together, we can ensure that anyone who might be pregnant understands the risk factors for preterm birth and has access to services to help prevent it.
Follow Joy Marini, MS, PA-C on Twitter: www.twitter.com/@joymarini
Every major killer of children under five years of age has a well-defined and resourced prevention agenda that engages the public and private sectors in partnership, except the #1 killer of children under 5 - preterm birth. If this doesn't change within the next five years, the world will struggle to achieve the
Pneumonia and diarrhea have vaccines, the Hib, pneumococcal and rotavirus, which are currently being introduced in low-income countries by GAVI, The Vaccine Alliance, , in partnership with Vestergaard Frandsen and Sumitomo Chemical and many other partners.
But when it comes to preventing prematurity, the leading cause of child mortality and the cause of an estimated 965,000 ’t have highly effective interventions like vaccines or bed nets; we dont have a public-private partnership focused on prevention; and we don’t have a robust, evidence-based understanding of the causes of preterm birth and how to prevent it.
What the world needs to do now is to take a bold step forward and commit to developing a Public-Private Partnership to Prevent Preterm Birth. The partnership should set an ambitious goal - to halve preterm birth rates - with an initial strategic geographic focus on the countries with the largest numbers of preterm deaths, including India (253,000 deaths), Nigeria (88,000 deaths) and Pakistan (71,000 deaths). Together, these three countries account for an estimated one-third of all preterm births globally and an astounding 44% of all deaths from preterm birth complications.
The Partnership would target the leading risk factors for preterm birth based on the landmark 2012 Born Too Soon
The Public-Private Partnership to Prevent Preterm Birth would target four areas we call the LINC factors (a) Lifestyle, (b) Infection, (c) Nutrition and (d) Contraception, and work in close partnership with governments, non-government organizations, the private sector, the research community and parent groups to reduce the risk factors among the target populations in India, Pakistan and Nigeria. Through working alliances, the Partnership would improve access to preterm prevention programs where at-risk girls and women before, during and between pregnancy could receive lifestyle education, testing and treatment of infections and non-communicable diseases; nutrition support; and access to modern contraception. Interventions would preferably be provided at one location and fully integrated with mainstream maternal and child health services.
Lifestyle services will need to focus on the prevention, diagnosis and treatment of risk factors like tobacco smoking, alcohol use and exposure to indoor air pollution. At the very minimum, pregnant women in the target populations should be tested for syphilis, urinary-tract infections, malaria, and HIV-AIDS. Nutrition interventions need to target both underweight and overweight, addressing iron, calcium, protein and energy deficiencies. Modern contraception that is easily accessible, especially to adolescent girls to delay pregnancy and to women who have just had babies to delay subsequent pregnancies and improve birth spacing, is absolutely critical.
Not all risk factors will apply equally to all populations. A recent study on risk factors for preterm birth in twenty-two countries found that the greatest risk factors in Asia were maternal malnutrition, preeclampsia, urinary tract infections, and diabetes, while diabetes, malaria, preeclampsia, malnutrition and HIV-AIDS played a more important role in increasing risk in sub-Saharan populations. It will be very important that the Partnership tailor program interventions to address the leading preterm birth risk factors by target populations.
To be effective, the Partnership should actively engage priority stakeholders in a number of key sectors, including relevant government agencies active in the target populations; non-government organizations with a major track record in adolescent, maternal and newborn health, survival and development; and major manufacturers of relevant services and products, including diagnostic tests and medicines for diabetes, high blood pressure, urinary tract infections, syphilis, malaria and HIV-AIDS; macro- and micronutrient supplements and fortified foods; and contraception. Supply-side private sector expertise will not be enough. We need the expertise of the leading private sector experts in behavior change, social media and telecommunications to design and deliver programs that inspire women and girls to take the actions necessary to reduce their risk of preterm birth.
Critically, we need research and development experts working alongside the Partnership to improve our knowledge and understanding of how to prevent preterm birth. The Every Newborn Action Plan argues strongly that “”much more knowledge is needed to address the solution and reach a point where preterm birth is prevented,and it calls for more research to discover new ways of preventing preterm birth by providing a better ing of the biological bases and causal pathways of preterm labour and for the development of new treatments, including tocolytics to delay preterm birth.
Child deaths have been halved since 1990 and the contribution of prevention technologies like vaccines and bed nets to this dramatic reduction cannot be underestimated. While care for any mother or baby struggling to survive and thrive is an imperative, prevention is the most critical tool in our arsenal to fight the leading threats to maternal and child health and development. With just 400 days until we usher in the new era of the Sustainable Development Goals, it is more important than ever that we have a robust global strategy to fight the leading cause of child death - preterm birth. To do so, it will be essential that the strategy includes a powerful prevention agenda. Prevention is an absolutely urgent priority for the mothers and families of the almost one million preterm babies who will lose their lives in 2015 and for the many millions more preterm babies who survive birth but who continue to struggle with life-long disabilities as a result.
Leith Greenslade is Vice-Chair at the MDG Health Alliance , an unprecedented movement spearheaded by the United Nations Secretary-General to advance the health of women and children. Dr. Christopher Howson is Vice-President for Global Programs at the , a global leader in the fight to prevent preterm birth.United Nations Special Envoy for Financing the Health Millennium Development Goals in support of
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