The World Health Organization has released a report - the first of its kind - on preterm birth worldwide: the risks, consequences, and what can be done to reduce the number of deaths and troubles associated with being born too soon. The data reveal a truly global problem, but most disturbing is the evidence that three-quarters of these deaths could be avoided with simple, low-cost medical care that just needs to reach the most in-need.
Every year, 15 million babies are born premature, the World Health Organization (WHO) has found. “Born Too Soon: The Global Action Report on Preterm Births”, a publication issued May 2, 2012 with partner agencies March of Dimes, Save the Children and The Partnership for Maternal, Newborn & Child Health, reveals some dramatic data on this significant, and growing, public health problem. While a full-term pregnancy, generally defined as 37 to 41 weeks, is necessary for proper development of the child, 10% of babies are now born too early. One million of those infants will die soon after birth. Preterm birth is, in fact, the leading direct cause of newborn deaths, and is the second cause of death in children under five, after pneumonia. Premature babies, more fragile than those carried full term, are also more likely to die from other causes, infections, in particular. Even for babies who survive this difficult beginning, the effects of being born too soon may linger. Preterm birth has been linked to neurodevelopmental problems leading to increased risk of cerebral palsy, learning impairment and visual disorders, in addition to higher rates of non-communicable disease later in life. Together, this means a significant and lasting impact on families, already burdened health systems, and society in general.
A truly global problem
Although premature birth is significantly more deadly in low-income regions, the survey of 64 countries reporting data revealed the global nature of the problem: the Top 10 in total number of early births includes India, Nigeria, Brazil and the United States. Despite the extent of the phenomenon and the significant risks associated with early deliveries, preterm birth has not, until now, received the attention it deserves. That fact is especially striking knowing that 75% of these children could be saved with nothing more than basic medical care and better hygiene practices, during delivery and soon thereafter, the report says.
While preterm birth is not a problem restricted to developing countries, its severity and outcome do vary by region. Eleven countries in the report have a preterm birth rate greater than 15%; nine of them are in sub-Saharan Africa. Together, the same region of Africa and South Asia account for 60% of total premature births. The survival gap between low- and high-income countries is also dramatic: in poor regions, extremely preterm babies, born before 28 weeks gestation, have a 90% chance of dying. In wealthy countries, where preterm babies may be looked after in neonatal intensive care units, this risk is only 10%.
Numerous reasons for preterm births, both spontaneous and elective
The factors contributing to preterm birth are multiple, and the causes are not well understood. Family history of premature birth is an indicator of high risk, suggesting genetic, epigenetic, and environmental factors at work, according to the WHO report. Infections, such as malaria, HIV, syphilis and even urinary tract infections, can lead to early deliveries. Short intervals between pregnancies can have an effect, as can the age of the mother: adolescent mothers and older women alike are more likely to give birth early. The latter case is more and more common in high-income countries, as fertility treatments allow women to have children later. These also impact the number of multiple births, a risk factor in itself.
Some pre-terms births, especially in developed countries, are provider-initiated, defined as induction of labor or elective caesarian birth before 37 weeks of gestation. This route may be chosen, for example, if the fetus’ health is in danger (due to problems like uterine rupture or fetal growth restriction). Underlying health problems of the mother, like diabetes, obesity, or hypertension, also increase the chance of complications and, therefore, the need for an elective preterm birth. As the WHO points out, “the worldwide epidemic of obesity and diabetes is, thus, likely to become an increasingly important contributor to global preterm birth.”
A recent study in the US, cited in the report, found that “more than half of all provider-initiated preterm births at 34 to 36 weeks gestation were carried out in the absence of a strong medical indication.” This fact is reflected in the $40 million initiative to reduce preterm births, called Strong Start, launched in February by the Department of Health and Human Services. The March of Dimes campaign “Healthy Babies are Worth the Wait” aims to eliminate non-medically necessary deliveries before 39 weeks, even, emphasizing that a full-term pregnancy gives vital organs time to develop and reduces the risk of a host of other problems for mother and baby.
Continued efforts of all kinds to reduce the number of preterm births are important: over the last twenty years, the rate has increased in 62 of the 65 countries covered in the WHO report. The risks are known and yet the large majority of deaths and disabling consequences could be avoided with basic medical intervention and hygiene awareness in less-served areas. Research and innovation for prevention is urgent, the WHO states, noting that although 92% of premature babies are born in low- and middle-income countries, while the vast majority of research concerns high-income nations.
Basic medical care & hygiene: Simple solutions save young lives
Even without necessarily pinning down the cause of preterm birth in every case, strategies exist to save newborn lives and reduce disabilities – some very simple, and very effective – but need to be implemented more widely. One such solution, known as “kangaroo mother care” has the mother, or a helper, carry the newborn against her skin, as soon as possible after birth. This simple method has been shown to reduce mortality by 51% compared to incubators, decrease infections by 60% and hypothermia by 80%. It is baby-, parent-, and health-system-friendly, saving costs by reducing hospital stays and nursing demands, and yet kangaroo care is used on a large scale in only a few countries. In an effort to promote its use, the WHO has published a guide to the method and how to adapt it to local culture and customs.
Respiratory distress is a common problem for babies born too early. The “Born Too Soon” report notes that an existing treatment to keep airways dry could be improved and scaled up for more widespread use if a synthetic generic version were available, as well as a better method of administering the drug, such as an aerosol form. These are challenges that should be possible to meet, but a commitment to the research will have to be made. In the meantime, an inexpensive, existing solution needs to be made provided in a more equitable manner. Corticosteroids administered before birth are known to reduce the risk of breathing problems in preterm infants. The WHO believes that this simple, inexpensive intervention, could alone save 370,000 lives annually.
Numerous examples illustrate that a combination of basic medical care, low-tech solutions, and fundamental hygiene practices would go a long way towards saving the lives of preterm babies. Perhaps the biggest hurdle, then, to be overcome is the lack of medical staff trained. “For newborns,” the report says, “people are as important as equipment or commodities. A shortage of people and inadequate training are the major reason for poor progress” in the effort to reduce newborn deaths. In the entire region of sub-Saharan African, no neonatal nurse training courses could be identified by the report.
Many of the world’s problems seem as though they might be improved if only someone would spearhead the effort and inject the necessary funding. In the case of preterm births, though, it is clear that many efforts to save lives and reduce associated disabilities are both affordable and relatively easy to implement. These steps have already worked in several countries, like Ecuador, Turkey and Sri Lanka, who have halved the number of infant deaths from preterm birth by improving care of infections and respiratory distress. It is partly for this reason that the Global Strategy for Women’s and Children’s Health was launched. United Nations Secretary-General Ban Ki-moon writes in the foreword to the WHO report that he was driven to promote this campaign by the “fundamental reality that what has been lacking in this effort is the will, not the techniques, technologies or science. We know what to do. And we all have a role to play. ... Enabling infants to survive and thrive is imperative for building the future we want.”
To find out more: Interactive map of preterm births, March of Dimes http://www.marchofdimes.com/mission/globalpreterm.html "Premature Birth", Centers for Disease Control and Prevention http://www.cdc.gov/Features/PrematureBirth/ Prematurity Campaign, March of Dimes http://www.marchofdimes.com/mission/prematurity.html "Preterm Labor and Birth", National Institute of Child Health & Human Development, NIH http://www.nichd.nih.gov/health/topics/preterm_labor_and_birth.cfm