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
Photo: @ckarema via Twitter
“Today as we mark World Prematurity Day, we officially open the International Kangaroo Mother Care Conference by reflecting on preterm babies everywhere and the care they deserve to receive.” – Dr. Agnes Binagwaho, Rwanda Minister of Health
The Ministry of Health in Rwanda welcomed over 200 experts, researchers, policy makers and stakeholders to the 10th International Conference on Kangaroo Mother Care (KMC). The 3-day conference, organized in collaboration with Rwanda Paediatric Association, seeks to encourage research and exchange experiences and knowledge among countries across Africa, Asia, Europe and the Americas. Delegates from the 28 countries represented at this meeting will have an opportunity to consult with colleagues from around the world on next steps that can be taken to accelerate the uptake of this life-saving intervention.
“India hosted the previous KMC conference in 2012, and we have come today to the ‘Land of One Thousand Hills’ from the land of one thousand challenges to say: Kangaroo Care saves lives, and the commitment evidenced by countries in this room is encouraging” commented Dr. Sashi Vani, Professor of Pediatrics and KMC champion from India.
As reported in recent estimates, for the first time in history complications of preterm birth outrank all other causes as the world's number one killer of young children. Of the estimated 6.3 million deaths of children under the age of five in 2013 around the world, complications from preterm births accounted for nearly 1.1 million deaths.
KMC is not only a proven solution to save the lives of preterm babies by regulating temperature, preventing infections and promoting breastfeeding; it will improve the health and development of babies. Throughout the conference, researchers will present the latest evidence around the benefits of KMC that extend beyond survival, including improved breathing and brain activity. Participants will also discuss issues around implementing, planning and running a local KMC program, with experiences from Bangladesh, Indonesia, the Philippines, Malawi, and Zambia among others.
Photo: Laerdal Global Health
To kick off the meeting, a group of global health experts, KMC champions, practitioners and institutional donors came together to identify the catalytic strategies necessary to remove the barriers that have prevented the uptake of KMC, and chart a road map to accelerate its effective implementation. Known as the KMC Acceleration Partnership, this multi-partner stakeholder group was established in 2013 to address the barriers to effective implementation of KMC globally, and accelerate uptake of KMC as part of a package of reproductive, maternal, newborn and child health (RMNCH) services.
Dr. Binagwaho stressed, “Globally, we have a lot to do. We’ve come together to learn from each other and go faster. We cannot do it alone. And by coming together, we will also go farther.”
The partnership calls for increased and concentrated action at global and national levels to achieve a 50% increase in coverage of KMC by 2020 among stable preterm newborns or babies weighing less than 2,000 grams. These ambitious coverage targets set out in the global Every Newborn Action Plan position KMC as a key component of an integrated RMNCH package of care.
This blog was originally published by the London School of Hygiene & Tropical Medicine's IDEAS project. Written by Dr. Yashua Alkai Hamza.
It was a cold night in December when the twins came into the world. Born too early to a young mother by C-section they were tiny, cold and barely alive. I was on call attending to what was perhaps my 18th delivery of the day. Exhausted and inexperienced, I received them with anxiety: there were already too many sick babies in the hospital without enough staff to look after them. There was a power cut so even if there were any incubators available – there weren’t - they wouldn’t work. As the family scrambled to get blood for the anaemic mum, no one paid attention to the babies. I was left with the tiny newborns, who were considered too small to survive. I did the only thing I could: I strapped them to my chest and listened to their shallow breathing and weak cries. After a few minutes one of them stopped crying, and I knew she was dead.
On World Prematurity Day, let us count every newborn, including those born too soon.
Death from prematurity can become a self-fulfilling prophesy
Traditional beliefs add to Nigeria’s complex problems of “everyday diseases”, natural disasters and political instability. In rural villages of Northeastern Nigeria, many believe that babies born small or too soon do not survive no matter what is done. Villagers call premature babies “ bakwaini”, which means “born on the seventh month”. This belief of non-survivability makes it easy to ignore interventions that can save some premature babies and, just like the twins born that night I was on duty, no one gives them a chance. But solutions can be low tech, easily accessible and affordable. For the twins, kangaroo mother care may have provided at least part of the answer.
A simple solution?
Kangaroo mother care, which involves strapping a premature newborn to a mother’s chest “skin to skin” for warmth and to promote exclusive breastfeeding, has been slow to catch on. As a health worker it is easy to see its importance. But for many, the benefits are not clear. Mothers may complain about the restrictions of having a baby strapped in front of them. Not only is it is strange for those who traditionally put their babies on their backs, it also interferes with daily household chores and, as many have told me, “ it looks funny”. Kangaroo mother care requires motivation, patience and time. Many mothers simply do not have that luxury. There are other children to tend to, house chores to do as well as the time consuming rituals of having a new baby.
Making the link, changing behaviours
How can mothers be persuaded that premature newborns can survive? Interventions such as Kangaroo mother care mean families need to adopt and continue with new, unfamiliar, behaviours. More research is needed to understand what influences families’ adoption of behaviours critical to newborn and maternal survival. For example, families may not want to adopt interventions like Kangaroo mother care because healthcare providers are not convinced about the benefits and therefore families and communities are also not convinced.
The IDEAS team and I will spend the next nine months conducting qualitative research with families in Northeastern Nigeria, Ethiopia and Uttar Pradesh, India to gain deeper insights into what could lead to sustained behaviour change. Our evidence may help to find out how the development community and Nigerian government can help families and communities adopt and continue with new behaviours that can save babies born too soon. The Nigerian government’s recent call to action to save newborn lives gives me hope that our evidence can be turned into action and preterm deaths will no longer be seen as inevitable.
Thinking back to a hopeful future
Many times my mind has wandered back to that cold night in December when I strapped those twins to my chest. I have often thought about my actions. Although one tiny baby died, her sister survived and is now in her teens. I, too, was a preterm baby. My mother strapped me to her chest and saved my life. Just as my mother saved me, I was able to save the little baby girl. Thanks to the warmth she received at birth she got a chance to survive. I have had many calls from her grateful parents. Who knows what she might grow up to be?
Above Photos: (1) Twins in the Demogratic Republic of the Congo © Jon Warren, World Vision. (2) Kangaroo Mother Care with twins © Isabel Pinto.
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