Preterm Birth: The Next Great Frontier in Global Health

Photo: © Paul Joseph Brown/GAPPS

We depart the crowded, noisy, bustling capital city of Dhaka, first by road and then we board a small outboard motorboat. We move downriver, the noisy motorboat cutting through the warm, boggy air of the Bangladesh delta. We pass the quiet work of fishermen casting nets from canoes, low flat barges of coal and cattle, small villages of corrugated tin, women washing clothes, tall spires of kilns making handmade brick. We arrive at our destination, stepping out of the boat and walking the short path from the river to the hospital. We pass through a dark hallway that opens to a sunny courtyard. 

And there we see the icons of public health history. Lining the hallway is a row of vinyl cots in bright blue, red, and yellow, each with a hole in the center and a bucket beneath. The bright primary colors of the cots belie their purpose. Cholera beds. These are the cots that have been used to manage the disease that once left a wake of death from populations struck by severe watery diarrhea and dehydration. We have arrived at the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) in Matlab. Originally born from a barge that traveled the river treating cholera patients, this site became a pillar of public health research, where, in the 1960s, the first cholera vaccine trials were conducted, and soon after, the landmark studies of oral rehydration therapy that revolutionized treatment of one of the leading causes of mortality worldwide.

From these beginnings decades ago, icddr,b has grown into a large research institute, investigating a broad repertoire of public health challenges. The project is based on a community cohort of 225,000 people who are visited regularly at their homes to monitor for morbidity, mortality, and health behaviors, linked to a technically-sophisticated laboratory in Dhaka that conducts studies in microbiology, immunology, pathology, nutrition, environmental health, maternal-child health, and climate change.  

And today we have come to help support the work of icddr,b to address the next frontier – the one area of child survival that has seen the most limited gains: the relentless burden of death of newborns. We arrive to help support the development of research studies of pregnant women, to establish ways to monitor women throughout their pregnancies, and start to unravel the complex and elusive systems that regulate pregnancy and cause preterm birth. These efforts are aimed at discovering ways to identify women at risk and find new solutions to prevent preterm birth, the leading cause of newborn deaths worldwide. I have confronted supposedly quixotic issues already many times in my career. I’ve worked on malaria in the days of emerging drug resistance and studies of insecticide-treated bednets, and I’ve worked to get AIDS treatment to Africa in the earliest days of antiretroviral therapy. Remarkably, I’ve seen dramatic accomplishment in these fields. But we don’t have answers on how to prevent preterm birth. I don’t know if this can be accomplished in my lifetime. But here we are. We are all here together – these experienced icddr,b epidemiologists, doctors, nurses, laboratory technicians, and data managers. 

We have all come to roll up our sleeves and start. Start somewhere.

Photo: © Paul Joseph Brown / GAPPS

The team of midwives that we are working with is a formidable group. Between them, they have decades of experience with pregnant women. You can feel their presence and collective experience, their clear command of managing complex medical situations in the most difficult conditions. We gather together in a small room for ultrasound training. They are already experienced practitioners in ultrasound. We’re now building rigorous systems to accurately assess gestational age. The information to be collected by the midwives forms the cornerstone for the complex array of biological investigations on preterm birth. The decade of bench research that will follow relies on the precision of the work of these women.

Photo: © Eve Lackritz / GAPPS

We gather around our first pregnant patient. The room is dimmed so we can all see the screen. The light of the ultrasound machine glows in the middle of our clinical huddle, the inner circle of pregnant woman and practitioner. Our role as trainers quickly fades; the midwives emerge as a cohesive group talking and guiding each other. With constant, quiet chatter in Bangla, the group guides each midwife as she moves to capture the perfect image and measurements. We move through the week with more ultrasound training, and standardizing ways to collect specimens and samples from placentas. Each time, the pattern is the same – our brief introductory session quickly moves to these proficient practitioners guiding each other to build this research project.

We’re facing a large and complex study – with a projected sample size of 4,000 pregnant women in Bangladesh alone, collecting specimens four times in pregnancy, attending deliveries at all hospitals in the area. The specimens will be shared with a consortium of the top preterm birth researchers in the world, as part of the Preventing Preterm Birth initiative. If it can be done, this group can do it. And if we do it right, we hope even more investigators will join this endeavor, all with the hope to find new answers to the complex problem of preterm birth.

We finally depart our visit. The next frontier has been set in their sights. We leave this ambitious group undaunted by the mission.

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November is Prematurity Awareness Month, and Nov. 17 is World Prematurity Day. Find out more about preterm birth and how you can help at www.worldprematurityday.org or www.gapps.org.