Awareness of prematurity as a significant problem was brought to the forefront by parent groups in Europe. These groups have played a key role in motivating policy makers and health care providers in their countries and at a global level to improve the quality of preterm care. Since 2011, the World Prematurity Day has been observed on the 17th November every year.
Most babies are born after 37 weeks of pregnancy. A baby born alive before 37 weeks may suffer from the consequences of preterm birth. Complications of prematurity are now the leading cause of death among children under-five globally. Worldwide 15 million babies are born preterm and of these approximately one million die, whilst survivors often suffer from a number of disabilities including learning difficulties, cerebral palsy, hearing and visual impairments (Gladstone M, Oliver C and van den Broek N (2015) 'Survival, morbidity, growth and developmental delay for babies born preterm in low and middle income countries - a systematic review of outcomes measured', PLoS ONE).
Sub-Saharan Africa bears the brunt of this problem, where nine of the eleven countries with the highest preterm birth rates are found. In addition, although WHO has published recommendations to improve outcomes of preterm births, preterms born in sub-Saharan Africa and South Asia are nine times more likely to die than those born in well-resourced countries. A key reason for this difference in survival relates to the timely access to quality and often specialised newborn care that many public health systems in sub-Saharan Africa and other low resource settings are unable to implement and/or sustain.
The majority of preterm births occur spontaneously and known causes include multifetal pregnancies, bleeding, preterm prelabour rupture of membranes, maternal infections and/or non-communicable diseases such as high blood pressure (van den Broek N, Jean-Baptiste R and Neilson JP (2014) 'Factors associated with preterm, early preterm and late preterm birth in Malawi', PLoS ONE). However, the causes are often unknown and this has therefore hampered the development of prevention strategies.
Prevention of preterm birth through medical interventions such as the provision of maternal oral antibiotics in pregnancy to prevent infections to the mother and baby (van den Broek NR, White SA, Goodall M, Ntonya C, Kayira E, Kafulafula G and Neilson JP (2009) 'The APPLe study: a randomized, community-based, placebo-controlled trial of azithromycin for the prevention of preterm birth, with meta-analysis', PLoS Medicine) have not been very successful. Various health and research groups worldwide continue to explore how and why preterm births occur, matched with the development of new strategies.
There is a growing recognition that maternal poverty and exposure to inequity at all levels in society contribute significantly to the causes and poor outcomes of preterm births. Mothers often bear the brunt of these adverse outcomes either through exposure to undignified treatment due to inability to pay for specialised services or the financial and psychological effects of prolonged hospital stay and poor outcomes.
CMNH, a WHO Collaborative Centre for Maternal and Newborn Health, works with partners to develop, evaluate and implement prevention and treatment strategies for preterm birth. It also works with policy makers and health care providers in low income settings to enhance universal and timely access to quality maternal and neonatal care. Going forward, it will be key for us as health researchers and providers to engage with policy makers, advocacy groups and funders to explore innovative funding schemes that could promote equitable access to quality maternal and neonatal care, particularly targeting the poor and marginalised communities. This would also help empower parents in these settings to become key stakeholders in driving improvements in preterm birth survival and long-term outcomes therefore “promoting health through the life course” that is a key WHO theme. As Mahatma Gandhi said, “The true measure of any society can be found in how it treats its most vulnerable members".
About the author:
Dr Helen Nabwera is a Senior Clinical Research Associate in Paediatrics. Helen's interests are in newborn health, nutrition and infectious diseases and she has clinical and research experience from sub-Saharan Africa and the UK.