Geneva — Each year, some 15 million babies in the world, more than one in 10 births, are born too early, according to the just released report Born Too Soon: The Global Action Report on Preterm Birth.
More than one 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.
An estimated three-quarters of those preterm babies who die could survive without expensive care if a few proven and inexpensive treatments and preventions were available worldwide, according to more than 100 experts who contributed to the report, representing almost 40 UN agencies, universities, and organizations.
The report explains what is known about preterm birth, its causes, and the kinds of care that are needed.
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 Organization, offer a detailed plan for the actions needed to reduce both the death toll and the numbers of preterm births.
First-ever country figures for a large, but neglected problem
Preterm births have been an overlooked and neglected problem, world health leaders say.
"All newborns are vulnerable, but preterm babies are acutely so," says UN 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 unrecognized killer," says Joy Lawn, M.D., PhD, co-editor of the report and Director, Global Evidence and Policy for Save the Children. "Preterm births account for almost half of all newborn deaths worldwide and are now the second leading cause of death in children under 5, 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 rates over 15 percent, all but 2 are in sub-Saharan Africa. Preterm births account for 11.1 percent of the world's live births, sixty 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.
The problem of preterm births is not confined to low-income countries.
The United States and Brazil both rank among the top 10 countries with the highest number of preterm births. In the United States, for example, about 12 percent, or more than one in nine of all births, are preterm.
The countries with the greatest numbers of preterm births are India - 3,519,100; China - 1,172,300; Nigeria - 773,600; Pakistan - 748,100; Indonesia - 675,700; United States - 517,400; Bangladesh - 424,100; Philippines - 348,900; Democratic Republic of the Congo - 341,400; and Brazil - 279,300.
The 10 countries with the highest rates of preterm births for every 100 births are: Malawi-18.1 per 100; Comoros and Congo-16.7; Zimbabwe-16.6; Equatorial Guinea-16.5; Mozambique-16.4; Gabon-16.3; Pakistan-15.8; Indonesia-15.5; and Mauritania-15.4.
Those contrast with the 11 countries with the lowest rates of preterm births: Belarus-4.1; Ecuador-5.1; Latvia-5.3; Finland, Croatia, and Samoa-5.5; Lithuania and Estonia-5.7; Antigua/Barbuda -5.8; Japan and Sweden-5.9.
"The numbers of preterm births are increasing. In all but 3 countries, preterm birth rates increased in the last 20 years," says Dr. Lawn.
"Worldwide, 50 million births still happen at home and many babies die without birth or death certificates," says Dr. Lawn.
In high-income countries, the increases in the number of preterm births are linked to the number of older women having babies, increased use of fertility drugs and resulting multiple pregnancies. In some developed countries, medically unnecessary inductions and Cesarean deliveries before full-term have also increased preterm births. In many low-income countries, the main causes of preterm births include infections, malaria, HIV, and high adolescent pregnancy rates. In rich and poor countries, many preterm births remain unexplained.
"The report also focuses on the dramatic survival gap between low-income and high-income countries for babies born before 28 weeks," says Christopher Howson, PhD., co-editor of the report, an epidemiologist and head of Global Programs for the 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," says Dr. Howson. "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 U.S., the preterm birth rate for women aged 20 to 35 was between 11-12 percent; it was more than 15 percent for women under 17 and over 40.
Spotlighting preterm births may help many low-income countries, mainly in sub-Saharan Africa, achieve UN 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.
All preterm births are not the same
For the report, preterm was defined as 37 weeks of completed gestation or less, which is the standard WHO definition.
Preterm babies are defined in 3 categories:
- Late preterm - those born between 32 and 37 weeks - account for 84 percent of total preterm births, or 12.5 million. Most survive with supportive care.
- Very preterm - those born between 28 and 32 weeks. These babies require extra supportive care. Most will survive.
- Extremely preterm - those born before 28 weeks. These babies require the most intensive, expensive care to survive. In developed countries, these babies have a 90 percent chance of survival, though they may suffer lifelong physical, neurological, and learning disabilities. In low-income countries, only 10 percent survive.
A recent March of Dimes analysis shows that, even though numbers are low, the risk of death of babies born between 37 and 39 weeks of gestation is twice as high as full term babies, or 39 weeks.
"It is important to ensure that babies get at least 39 weeks of gestation when medically possible, and to deliver this message to both providers and mothers," says Dr. Howson. "A healthy baby is worth the wait."
Inexpensive and simple techniques save lives
"People tend to associate preterm with high-cost intensive care services which would be challenging to poor countries, but a whole menu of effective, inexpensive services are available and work to save most of these lives," says Carole Presern, PhD, a midwife who has delivered babies in remote areas of Asia and is the Director of The Partnership for Maternal, Newborn & Child Health.
Experts at the UN, medical institutions and field organizations say that inexpensive, proven forms of care for premature babies could save at least three quarters of these babies in the developing world. These include:
- Antenatal steroid injections for mothers in premature labor, which cost $1 an injection. This helps develop immature fetal lungs and prevent respiratory problems; yet, in low-income countries, they are only available and provided for 10 percent of those in need. This alone could save almost 400,000 lives of babies a year.
- "Kangaroo care" where the infant is held skin-to-skin on the mother's chest to keep warm. The warmth is very important for premature infants. Kangaroo care makes frequent breastfeeding easy and provides constant maternal supervision for the infant. This could save 450,000 lives a year.
- Antiseptic cream to prevent birth cord infection.
- Antibiotics to prevent and fight infection, an important cause of neonatal death.
All health care providers, including physicians, nurses, and midwives, need training in basic preterm care, notes Dr. Presern who says she has seen too many situations where even the doctor doesn't seem to know what to do with a tiny infant.
Two types of preterm birth
Preterm births are divided into two categories: Those that are spontaneous from early onset of labor or premature rupture of the membranes and those that are provider- induced.
Provider-induced early deliveries may occur when the health of the mother or fetus is in jeopardy, such as in pre-eclampsia (dangerously high blood pressure in pregnancy), for convenience of the doctor, midwife or mother, or by an error in due dates. Even babies born a few weeks too soon are more likely to be re-hospitalized or to have breathing problems or other illnesses.
Prevention key to reducing premature births
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, says Elizabeth Mason, M.D., Director of Maternal, Newborn, Child and Adolescent Health at the World Health Organization 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," says Dr. Mason. "We know that poverty, women's education, malaria and HIV all have an impact on the pregnancy and the health of the baby."
A number of risk factors for preterm birth have been identified, including a prior history of preterm birth, underweight, obesity, diabetes, hypertension, smoking, infection, maternal age (either under 17 or over 40), genetics, multi-fetal pregnancy (twins, triplets, and higher), and pregnancies spaced too closely together.
However, little is known about the interplay of these and other environmental and social factors.
The report calls for a strong research program to identify risk factors clearly and understand how their interactions may lead to preterm birth so that more definitive ways can be found to screen and treat women at risk to prevent the problem from occurring.
Until research provides better answers, though, 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, and making sure that all women have access to good preconception and prenatal health care and receive the recommended number of visits during pregnancy.
An agenda for action
In addition to detailed recommendations about needed research, the report offers 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 to global philanthropic institutions and civil society.
Some 30 groups have already committed to take part in the overall effort to reduce both the absolute numbers of preterm births and the mortality rate and to support the research agenda. 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 includes specific actions such as addressing the missing essential medicines and equipment, training existing health staff in how to look after women in preterm labor 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," says 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."