Each year, some 15 million babies in the world are born too early. More than 1 million of those babies die shortly after birth; countless others suffer some type of lifelong physical, neurological or educational disability, often at great cost to families and society; and Pakistan is eighth in the top 10 countries with the highest rate of preterm births, disclosed a detailed report titled ‘Born Too Soon: The Global Action Report on Preterm Birth’ issued on Wednesday.
Authored by a broad group of 45 international multidisciplinary experts from 26 organisations – including Pakistan’s reputable Aga Khan University – and 11 countries with over 40 organisations in support, the report estimated that three-quarters of those preterm babies who die could survive without expensive care if a few proven and inexpensive prevention and treatment strategies are implemented worldwide.
The lead authors of the report from the March of Dimes Foundation, The Partnership for Maternal, Newborn & Child Health, Save the Children and the World Health Organisation offered a detailed plan for the actions needed to reduce both the death toll and the number of preterm births.
“All newborns are vulnerable, but preterm babies are acutely so,” said United Nations Secretary General Ban Ki-moon, who wrote the foreword to the report and considers the effort to reduce preterm births and deaths an integral part of his Global Strategy for Women’s and Children’s Health. “Being born too soon is an unrecognised killer,” said Dr Joy Lawn, co-editor of the report and Director of Global Evidence and Policy for Save the Children’s Saving Newborn Lives programme. “Preterm births account for almost half of all newborn deaths worldwide and are now the second leading cause of death in children under five, after pneumonia.”
New figures in the report show both the magnitude of the problem and the disparities between countries. Of the 11 countries with preterm birth rate over 15 percent, all but two are in Sub-Saharan Africa. Preterm births account for 11.1 percent of the world’s live births, 60 percent of them in South Asia and Sub-Saharan Africa. In the poorest countries, on average, 12 percent of babies are born too soon, compared to 9 percent in higher income countries. Preterm births account for more than one in 10 of the world’s live births, and 60 percent of them occur in South Asia and Sub-Saharan Africa.
Pakistan, with 748,100 preterm births annually, has the fourth highest number after India at 3,519,100, China at 1,172,300 and Nigeria at 773,600. Not too far behind is Tanzania – number 12 on the list – followed by Uganda at 14 and Kenya at 15.
Pakistan is eighth in the top 10 countries with the highest rate of preterm births at 15.8 for every 100 births along with countries from Sub-Saharan Africa. Malawi is at 18.1 per 100, Comoros and Congo at 16.7, Zimbabwe at 16.6, Equatorial Guinea at 16.5, Mozambique at 16.4, Gabon at 16.3, Indonesia at 15.5 and Mauritania at 15.4.
The rate for the East African countries of Uganda, Kenya and Tanzania are at 13.6, 12.3 and 11.4, respectively. Those contrast with the 11 countries with the lowest rate of preterm births. They are Belarus at 4.1 per 100; Ecuador at 5.1; Latvia at 5.3; Finland, Croatia and Samoa at 5.5; Lithuania and Estonia at 5.7; Antigua and Barbuda at 5.8; and Japan and Sweden at 5.9. “The number of preterm births is increasing. In all but three countries, preterm birth rate increased in the last 20 years,” said Dr Lawn. “Worldwide, 50 million births still happen at home and many babies die without birth or death certificates.”
In high income countries, the increase in the number of preterm births is linked to the number of older women having babies, increased use of fertility drugs and the resulting multiple pregnancies. In some developed countries, medically unnecessary inductions and Caesarean deliveries before full term have also increased preterm births. In many low income countries, the main causes of preterm births include infections, malaria, human immunodeficiency virus and high adolescent pregnancy rates. In rich and poor countries, many preterm births remain unexplained.
“For too long, prematurity has been regarded as synonymous with a limited chance of survival. Our studies suggest that several low cost solutions are possible for the care of women before and during pregnancy and importantly after preterm birth. These have a huge potential to save lives and improve pregnancy outcomes,” said Dr Zulfiqar Bhutta, the founding chair of Women and Child Health at the Aga Khan University and one of the authors of the report.
Basic measures such as antenatal steroid injections for mothers in premature labour, ‘kangaroo care’ where the infant is held skin-to-skin on the mother’s chest for warmth and ease of breastfeeding, antiseptic cream to prevent birth cord infection, and antibiotics to prevent and fight infection – an important cause of neonatal death – are all inexpensive, proven forms of care for premature babies that could dramatically improve the chances of survival. The report stated that a key way to reduce the number of preterm birth is to ensure that all pregnancies go to full term, or 39 weeks.
Until research provides better answers, the report advises taking effective measures now, such as screening women for known medical conditions that could put them at risk during pregnancy, assuring good nutrition before and during pregnancy, making sure that all women have access to good preconception and prenatal healthcare, and that they are able to visit their doctor regularly during pregnancy. The lead authors of the report offered a detailed action plan to reduce the number of global preterm births as well as the associated fatalities.
“The report also focuses on the dramatic survival gap between low income and high income countries for babies born before 28 weeks,” said Dr Christopher Howson, co-editor of the report and the head of Global Programmes at March of Dimes. “In low income countries, more than 90 percent of extremely preterm babies die within the first few days of life, while less than 10 percent die in high-income countries.”
“However, this is a solvable problem. A number of countries, for example, Ecuador, Botswana, Turkey, Oman and Sri Lanka have halved their neonatal deaths from preterm birth through improving care of serious complications like infections and respiratory distress.” “These interventions are particularly effective in preventing death in moderately preterm babies, which account for more than 80 percent of all preterm births.”
Wide differences within countries were found. For example, in the United States, the preterm birth rate in 2009 for black Americans was as high as 17.5 percent, compared with 10.9 percent for white Americans. The age of the mother made a significant difference. In the United States, the preterm birth rate for women aged 20 to 35 was between 11 percent and 12 percent; it was more than 15 percent for women under 17 and over 40. Spotlighting preterm births might help many low income countries, mainly in Sub-Saharan Africa, achieve the United Nations Millennium Development Goal 4 (a two-thirds reduction in young child deaths) and Goal 5 (improved maternal health) by 2015.
These goals were set by the United Nations General Assembly in 2000. Nearly all high income developed countries have already met these goals. A key way to reduce preterm numbers is to find ways to help all pregnancies go to full term, or 39 weeks.
“Prevention will be the key,” said Dr Elizabeth Mason, Director of Maternal, Newborn, Child and Adolescent Health at the World Health Organisation and a major contributor to the report. “We are now looking closely at what can be done before a woman gets pregnant to help her have an optimal outcome.” “We know that poverty, women’s education, malaria and human immunodeficiency virus have an impact on the pregnancy and the health of the baby.”
A number of risk factors for preterm births have been identified, including a prior history of preterm birth, being underweight, obesity, diabetes, hypertension, smoking, infection, maternal age (either under 17 or over 40), genetics, multi-foetal pregnancy (twins, triplets or higher) and pregnancies spaced too close together.
However, little is known about the interplay of these and other environmental as well as social factors.
The report called for a strong research programme to identify the risk factors clearly and understand how their interactions night lead to preterm birth so that more definitive ways could be found to screen and treat women at risk to prevent the problem from occurring.
In addition to detailed recommendations about needed research, the report offered an agenda and action plan for all groups concerned with preterm birth and child health, ranging from the United Nations and governments at all levels to donor countries, global philanthropic institutions and civil society.
Some 30 groups have already committed to take part in the overall effort to reduce both the absolute number of preterm births and the mortality rate.These commitments are posted on www.everywomaneverychild.org, supporting the Every Woman Every Child effort to advance the Global Strategy for Women’s and Children’s Health.
The extensive list of recommendations in the report included specific actions such as addressing the missing essential medicines and equipment, training existing health staff in how to look after women in preterm labour and these vulnerable babies, increased funding for research to find new prevention solutions, and better data for accurate future counts. Efforts to increase awareness of the preterm birth issue are essential.
“This report is not the last word, but an important next step,” said Dr Howson. “Both the report and the broad international constituency behind it offer a framework and set of clear actions to help accelerate global progress on preterm birth.”