The Global Action Report on Preterm Birth Born Too Soon BORN TOO SOON THE GLOBAL ACTION REPORT ON PRETERM BIRTH Born Too Soon: The Global Action Report on Preterm Birth features the rst-ever estimates of preterm birth rates by country and is authored by a broad group of 45 international multi-disciplinary experts from 11 countries, with almost 50 organizations in support. This report is written in support of all families who have been touched by preterm birth. This report is written in support of the Global Strategy for Women’s and Children’s Health and the efforts of Every Woman Every Child, led by UN Secretary-General Ban Ki-moon. Cover photo: Colin Crowley/Save the Children The Global Action Report on Preterm Birth 2012 Born Too Soon The Global Action Report on Preterm Birth iv WHO Library Cataloguing-in-Publication Data: Born too soon: the global action report on preterm birth. 1.Premature birth – prevention and control. 2.Infant, premature. 3.Infant mortality – trends. 4.Prenatal care. 5.Infant care. I.World Health Organization. ISBN 978 92 4 150343 3 (NLM classication: WQ 330) @ World Health Organization 2012 All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). 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Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The named authors alone are responsible for the views expressed in this publication. Request for copies North America: globalprograms@marchofdimes.com Rest of the world: pmnch@who.int Recommended citation: March of Dimes, PMNCH, Save the Children, WHO. Born Too Soon: The Global Action Report on Preterm Birth. Eds CP Howson, MV Kinney, JE Lawn. World Health Organization. Geneva, 2012. vi Main abbreviations vi Country groups used in the report vii Foreword viii Commitments to preterm birth 1 Executive summary 8 Chapter 1. Preterm birth matters 16 Chapter 2. 15 million preterm births: priorities for action based on national, regional and global estimates 32 Chapter 3. Care before and between pregnancy 46 Chapter 4. Care during pregnancy and childbirth 60 Chapter 5. Care for the preterm baby 78 Chapter 6. Actions: everyone has a role to play 102 References 112 Acknowledgements Contents Photo: March of Dimes Photo: © Name The Global Action Report on Preterm Birth Main Abbreviations Country groups used in the report ANC Antenatal Care BMI Body Mass Index CHERG Child Health Epidemiology Research Group CPAP Continuous positive airway pressure DHS Demographic and Health Surveys EFCNI European Foundation for the Care of Newborn Infants GAPPS Global Alliance to Prevent Prematurity and Stillbirth GNI Gross National Income HIV Human Immunodeciency Virus IMCI Integrated Management of Childhood Illnesses IPTp Intermittent presumptive treatment during pregnancy for malaria IUGR Intrauterine growth restriction IVH Intraventricular hemorrhage KMC Kangaroo Mother Care LAMP Late and moderate preterm LBW Low birthweight LiST Lives Saved Tool LMP Last menstrual period MDG Millennium Development Goal MMR Maternal mortality ratio MOD March of Dimes Foundation NCD Non-communicable disease NGO Non-governmental organization NICU Neonatal intensive care unit NIH National Institutes of Health, USA NMR Neonatal mortality rate PMNCH Partnership for Maternal, Newborn & Child Health PREBIC International PREterm BIrth Collaborative pPROM Prelabor premature rupture of membranes RCT Randomized controlled trials RDS Respiratory distress syndrome RMNCH Reproductive, maternal, newborn and child health SNL Saving Newborn Lives, Save the Children STI Sexually transmitted infection UN United Nations UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund WHO World Health Organization Millennium Development Goal regions: Central & Eastern Asia, Developed, Latin America & the Caribbean, Northern Africa & Western Asia, Southeastern Asia & Oceania, Southern Asia, sub-Saharan Africa. For countries see http://mdgs.un.org World Bank country income classification: High-, middle- and low-income countries (details in Chapter 1) Countdown to 2015 priority countries: 75 countries where more than 95% of all maternal and child deaths occur (full list in Chapter 6) vii Photo: © Name Foreword The response to the 2010 launch of the Every Woman Every Child effort has been very encour- aging. Government leaders, philanthropic organizations, businesses and civil society groups around the world have made far-reaching commitments and contributions that are catalyzing action behind the Global Strategy for Women’s and Children’s Health and the health-related Millennium Development Goals (MDGs). Born Too Soon is yet another timely answer by partners that showcases how a multi-stakeholder approach can use evidence-based solutions to ensure the survival, health and well-being of some of the human family’s most defenseless members. Every year, about 15 million babies are born prematurely — more than one in 10 of all babies born around the world. All newborns are vulnerable, but preterm babies are acutely so. Many require special care simply to remain alive. Newborn deaths — those in the first month of life — account for 40 per cent of all deaths among children under five years of age. Prematurity is the world’s single biggest cause of newborn death, and the second leading cause of all child deaths, after pneumonia. Many of the preterm babies who survive face a lifetime of disability. These facts should be a call to action. Fortunately, solutions exist. Born Too Soon, produced by a global team of leading international organizations, academic institutions and United Nations agencies, highlights scientifically proven solutions to save preterm lives, provide care for preterm babies and reduce the high rates of death and disability. Ensuring the survival of preterm babies and their mothers requires sustained and significant financial and practical support. The Commission on Information and Accountability for Women’s and Children’s Health, established as part of the Every Woman Every Child effort, has given us new tools with which to ensure that resources and results can be tracked. I hope this mechanism will instill confidence and lead even more donors and other partners to join in advancing this cause and accelerating this crucial aspect of our work to achieve the MDGs by the agreed deadline of 2015. I launched the Global Strategy for Women’s and Children’s Health to draw attention to the urgency of saving the lives of the world’s most vulnerable people. I was driven not only by my concern, but 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. Let us act on the findings and recommendations of this report. Let us change the future for millions of babies born too soon, for their mothers and families, and indeed for entire countries. Enabling infants to survive and thrive is an imperative for building the future we want. Ban Ki-moon The United Nations Secretary-General The Global Action Report on Preterm Birth viii The Association of Women’s Health, Obstetric and Neonatal Nurses’ Late Preterm Infant (LPI) Research- Based Practice Project, supported by Johnson & Johnson, will raise awareness of risks associated with late preterm birth, help reduce complications and improve care. Outcomes include expanding the body of knowledge about LPI morbidity and increasing nurses’ ability to provide appropriate care. An Implementation Tool Kit will include strategies for effective nursing care as pivotal to eliminating preventable late preterm infant complications. The Bill & Melinda Gates Foundation commits to reducing preterm birth through its Family Health agenda with grants of $1.5 billion from 2010 to 2014 to support three core areas: coverage of interventions that work (e.g. Kangaroo Mother Care, antenatal corticosteroids); research and development of new interventions; and tools to better understand the burden and reduce the incidence of preterm birth, such as the Lives Saved Tool and MANDATE Project. CORE Group will increase awareness about practical steps to prevent and treat preterm complications to the CORE Group’s Community Health Network, a community of practice of over 70 member and associate organizations, by disseminating this report and other state-of-the-art information through its working groups, listservs, and social media channels that reach 3,000 health practitioners around the world. The Council of International Neonatal Nurses, Inc. is strongly committed to increasing awareness of the dan- gers of premature birth and in supporting the actions in this report, Born Too Soon, and to the prevention and care of babies not only because of the key role that neonatal nurses play in their early lives but also because of the urgent action needed in reducing the rates of preterm birth and related mortality and disability. DFID has set out clear plans to help improve the health of women and young children in many of the poorest countries and help save the lives of at least 250,000 newborn babies and 50,000 women during pregnancy and childbirth by 2015. The UK’s commitments to improve the lives of women and children can be found in “UK AID: Changing lives, delivering results”, on DFID’s website. The European Foundation for the Care of Newborn Infants in partnership with the Global Alliances, March of Dimes and other organizations, looks forward to reducing the severe toll of prematurity in all countries. As prematurity poses a serious and growing threat to the health and well- being of the future European population, EFCNI commits to making maternal and newborn health a policy priority in Europe by the year 2020. The Flour Fortication Initiative joins efforts to see babies delivered at full term through communication, advocacy and technical support for increased fortication of foods in developing countries. Studies indicate a link between maternal iron deciency anemia in early pregnancy and a greater risk of preterm delivery, and insufcient maternal folic acid can lead to neural tube defects, one cause of preterm deliveries. Projects include campaigns in Nigeria and Ethiopia and support to Uganda, Mozambique and elsewhere. The GAVI Alliance will help developing countries advance the control and elimination of rubella and congenital rubella syndrome through immunisation. Each year, 110,000 babies are born with severe birth defects from congenital rubella syndrome because their mothers were infected with rubella virus early in pregnancy. About 80% of those babies are born in GAVI-eligible countries. By 2015, over 700 million children will be immunised through campaigns and routine immunisation with combined measles-rubella vaccine. Commitments to preterm birth In support of the Every Woman Every Child effort to advance the Global Strategy on Women’s and Children’s Health, more than 30 organizations have provided commitments to advance the prevention and care of preterm birth. These statements will now become part of the overall set of commitments to the Global Strategy, and will be monitored annually through 2015 by the independent Expert Review Group established by the Commission on Information and Accountability for Women’s and Children’s Health. For the complete text of each commitment, please visit: http:// everywomaneverychild.org/borntoosoon commitments ix The Global Alliance for Clean Cookstoves at the UN Foundation will fund up to US$ 800,000 over the next two years for research on the link between the use of traditional cookstoves and child survival. It will focus on adverse pregnancy outcomes, including low birth weight, pre-term birth, and birth defects; and/or severe respiratory illness including pneumonia in children under-ve years of age. This research will hopefully identify new interventions to reduce premature births worldwide. Global Alliance to Prevent Prematurity and Stillbirth (GAPPS) commits to leading global efforts to discover the causes and mechanisms of preterm birth through the Preventing Preterm Birth initiative and operating the GAPPS Repository. GAPPS commits to expanding collaborative efforts for a global advocacy campaign to promote the critical need for strategic investment in research and catalyze fund- ing for it. GAPPS will work to make every birth a healthy birth. The Home for Premature Babies (HPB) is China’s largest association of those affected by preterm birth. We unite 400,000 families and work to raise awareness and provide rehabilitation service for preterm infants. Within 3 to 5 years we plan to double our membership; publish a monthly magazine on premature infants; establish a medical tele- consultation system; develop and implement a continuing education program for paediatricians; and establish a branch of HPB in every province in China. The International Confederation of Midwives will maintain its commitment to working towards enhancing the reproductive health of women, and the health of their newborn, including preventing preterm birth and care for premature babies, by promoting autonomous midwives as the most appropriate caregivers for childbearing women and their newborn and midwifery services as the most effective means of achieving MDGs 4&5 for child survival and maternal health. The International Pediatric Association’s (IPA) 177 pediatric societies support neonatal, child, adolescent and maternal health through policy advocacy, planning, expanded health services, pregnancies that are supported by the entire community and safe delivery for mother and baby. IPA will feature Born Too Soon on its website and in the organizational newsletter, encouraging national pediatric societies to feature this fundamental topic in educational meetings and policy discussions. The Japan International Cooperation Agency supports partner countries in building and strengthening systems for a “Continuum of Care for Maternal and Child Health” through technical cooperation US$ 25 million and grant aid projects of around US$ 13 million annually, and initiat- ing concessional loans to support partner countries to achieve MNCH-related MDGs. Japan’s Global Health Policy 2011-2015 commits to saving approximately 11.3 million children’s lives and 430,000 maternal lives in cooperation with other donors. The Johns Hopkins Bloomberg School of Public Health is committed to strengthening evidence on the extent and causes of preterm births globally and to developing cultur- ally and economically appropriate interventions to reduce the burden of premature birth around the world. We also commit to working with governments and their partners on the translation of evidence into effective policies and programs. We aim to achieve measurable results of our efforts by 2015. The Kinshasa School of Public Health in the Democratic Republic of the Congo, with its partner the University of North Carolina, has joined the Global Alliance to Prevent Prematurity and Stillbirth (GAPPS) and submitted a proposal aimed at preventing preterm birth. The goal of this initiative is to encourage scientic studies that will lead to or rene preventive interventions for preterm birth and still birth related to preterm birth, primarily in developing world settings. E v e r y W o m a n E v e r y C h i l d P h o t o : © M a r c h o f D i m e s The Global Action Report on Preterm Birth x The London School of Hygiene & Tropical Medicine (LSHTM) has a strategic long-term commitment to research through the MARCH Centre for Maternal, Reproductive and Child Health and will continue to improve the data and evidence base and to advance and evaluate innovative solutions for the poorest women and babies. LSHTM will work with partners to increase the numbers and capacity of scientists and institutions in the most affected countries. The March of Dimes commits to its Prematurity Campaign through 2020, devoting approximately $20 million annually to research into the causes of premature birth; collaboration with key stakeholders to enhance quality and accessibility of prenatal and newborn care; education and awareness cam- paigns to identify and reduce risk of prematurity. March of Dimes has worked with parent groups to create and promote World Prematurity Day, November 17, to advocate for further action, including the recommendations in this publication. Paediatrics and Child Health, College of Medicine, University of Malawi is committed to improving the care of newborns in Malawi. Specic efforts are being made to help premature babies with respiratory distress by introduc- ing appropriate technologies and enhancing the Kangaroo Mother Care through teaching and outreach. The Partnership for Maternal, Newborn & Child Health commits to developing a companion knowledge summary to this report; supporting preterm private sector commitments linked to the Commission on Life-saving Commodities for Women and Children; promoting World Prematurity Day, November 17; and tracking yearly progress of these com- mitments for the annual report of the independent Expert Review Group related to the Global Strategy and the recommendations of the Commission on Information and Accountability for Women’s and Children’s Health. Preterm Birth International Collaborative (PREBIC) supports prematurity prevention programs by organizing workshops for scientists and clinicians around the globe aimed to build consortiums of investigators. These consor- tiums identify knowledge gaps in various areas of preterm birth research and develop protocols to fill these gaps. PREBIC organizes scientic symposiums in association with major Obstetrics Congresses to educate health care professionals regarding ongoing preterm birth research. PREBIC’s research core supports investigators in high throughput research. The Preterm Clinical Research Consortium of Peking University Center of Medical Genetics (PUCMG) will work closely with global, regional and national communi- ties and organizations to raise public awareness of the toll of preterm birth in China, and continue existing programs directed at reducing the rate of preterm birth and associated mortality and disability. Within three years, PUCMG will have completed a prospective cohort study identifying major risk factors for preterm birth in the Chinese population. Save the Children commits to working with partners to make preventable newborn deaths unacceptable and to advance implementation of maternal and newborn services, enabling frontline health workers and empowering families to provide the care every newborn needs. By 2015, Save the Children will promote increases in equitable access for high-impact interventions for preterm babies including: antenatal corticosteroids to strengthen premature babies’ lungs; Kangaroo Mother Care; neonatal resuscitation; improved cord care; breastfeeding support; and effective treatment of neonatal infections. E v e r y W o m a n E v e r y C h i l d COMMITMENTS TO PRETERM BIRTH [...]... Stanton (unpublished Master’s thesis) 15 Million Preterm Births: Priorities for Action Based on National, Regional and Glo bal Esti mates While birthweight is closely linked with gestational age, 24 The Global Action Report on Preterm Birth Box 2.1: Overview of estimation methods for national, regional and global preterm birth rates World Health Organization estimates of preterm birth rates Preterm Birth. .. Prevention.” from http://www.iom.edu/Reports/2006 /Preterm- Birth- Causes-Consequences-and-Prevention.aspx 15 Million Preterm Births: Prioriti es for Action Ba sed on National, Regional and Global Estimat es — Hannah Blencowe, Simon Cousens, Doris Chou, Mikkel Z Oestergaard, Lale Say, Ann-Beth Moller, Mary Kinney, Joy Lawn 2 Chapter 2 15 million preterm births: priorities for action based on national, regional... provider-initiated in 2000, 15 Million Preterm Births: Priorities for Action Based on National, Regional and Glo bal Esti mates addition, other conditions have more recently been shown The Global Action Report on Preterm Birth compared to just over 20% in Scotland and the Netherlands ideally in the first trimester Gestational assessment based The levels of provider-initiated preterm births are increasing on. .. and newborns, in addition to reducing the rate of preterm birth and the mortality and disability associated with prematurity Preterm Birth Matters causes of neonatal mortality like preterm birth (the single 12 The Global Action Report on Preterm Birth non-health sectors such as education In addition, they Context for this report must be firmly embedded in existing frameworks for action With the establishment... broad coalition of organiza- ing for increased international attention to the problem tions and individuals that contributed importantly to the of preterm birth ( The global burden of preterm birth, ” review and the strengthening of the report s findings and actions The continuum of care for mothers, newborns and children Figure 1.3: Continuum of Care Neonatal p erio d Birth 28 d ay an The report has... lower gestational age cut-off is specified for DEFINITION OF PRETERM BIRTH RATE All live births before 37 completed weeks (whether singleton or multiple) Per 100 live births 15 Million Preterm Births: Priorities for Action Based on National, Regional and Glo bal Esti mates for 65 countries with sufficient data (Blencowe et al., 2012) 20 The Global Action Report on Preterm Birth Preterm birth – why... gestation) (Figure 2.2) Moderate countries are born preterm, accounting for 5% of all preterm preterm birth may be further split to focus on late preterm births Counting only live births underestimates the true burden birth (34 - . The Global Action Report on Preterm Birth Born Too Soon BORN TOO SOON THE GLOBAL ACTION REPORT ON PRETERM BIRTH Born Too Soon: The Global Action Report on Preterm Birth features the rst-ever. Crowley/Save the Children The Global Action Report on Preterm Birth 2012 Born Too Soon The Global Action Report on Preterm Birth iv WHO Library Cataloguing-in-Publication Data: Born too soon: the global. building the future we want. Ban Ki-moon The United Nations Secretary-General The Global Action Report on Preterm Birth viii The Association of Women’s Health, Obstetric and Neonatal Nurses’ Late Preterm