In 2015 just under 6 million children under the age of five died across the globe. Of these, about 2.6 million died within the first month of being born. And more than 60% of these deaths took place in Africa and South Asia. Just over a third of these babies died as a result of complications because they were born premature.
Prematurity is the most common cause of neonatal deaths globally. Babies are considered premature if they are born before the mother reaches 37 weeks of pregnancy.
In developed countries, the main causes of preterm deaths are well known and studied. Some babies develop infections, others have breathing problems such as birth asphyxia or lung immaturity. They also have feeding problems or experience metabolic and electrolyte disturbances and congenital malformations.
But in low resource countries, the causes of preterm deaths is much less understood. Anecdotal evidence from experts and clinicians in neonatal intensive care units is that infections such as neonatal sepsis and asphyxia are common. But there is no data to back this up.
It is therefore critical to identify the most “treatable and preventable” causes of death in low resource settings. These findings would help inform the tools and interventions that must be developed and included in national programmes to reduce neonatal mortality in the developing world.
Approaches that work
Reducing the high rates of children under the age of five who die has been a global health priority since the early 1990s. At the time diarrhoea, pneumonia and malaria were the three leading killers of children under the age of five.
To tackle these several interventions were rolled out and since deaths of children under five has more than halved. The interventions were simple: oral rehydration solutions and zinc for diarrhoea, a pneumococcal vaccine and antibiotics for pneumonia and antimalarial medicines and long-lasting insecticide treated nets for malaria.
But these reductions has meant that the proportion of deaths in the neonatal age group has increased. Just under half of all the under-five deaths are due to neonatal mortality.
The thinking behind these interventions is based on the principles of precision medicine where the right solution is delivered to the right population at the right time.
The same approach can be used to deal with neonatal mortality. And these interventions can then be deployed based on the number and type of preterm birth risk factors in particular women.
There are four groups of factors that increase the likelihood of a woman having a preterm baby:
Age: women who fall pregnant under the age of 20 when their bodies are physiologically unable to handle a baby or over the age of 35 when their bodies’ fertility functions start to decline are at risk of having a preterm baby.
Illness: women who develop diabetes during pregnancy or suffer from chronic illnesses such as hypertension, asthma or heart disease have a higher risk of delivering a preterm baby. In addition, women with tuberculosis, HIV/AIDS, persistent malaria, urinary tract infections and vaginal infections are also at risk.
Bad habits: smoking and alcohol drinking also contribute.
Socio-economic conditions: being single, having a low income and low levels of education also have an effect on a baby being born prematurely. This is mainly due to them having a lack of proper nutrition or being overworked.
Old and new interventions
For these risks to be dealt with, health authorities make the best use of existing tools. But in addition to this, they must remain receptive to new approaches.
There are several existing interventions that could reduce preterm deliveries and prevent poor pregnancy outcomes. Some are based on improving the access to preconception packages while others include enhanced care packages for women at higher risk of preterm birth. Women with hypertensive disease, for example, could be identified and treated.
Similarly, teenage girls could be given family planning lessons and all women receive regular antenatal care during pregnancy. Those with infections such as tuberculosis, HIV, syphilis, and urinary tract infections could be treated promptly.
But there are also new interventions that should be explored. For a pregnant young woman working long hours in a remote agricultural area, the intervention package could include prepaid transport to a facility for delivery, decreased working hours as pregnancy progresses as well as nutritional supplements.
For an urban woman with a sedentary desk job in an area where there is a high prevalence of sexually transmitted infections, the intervention package might focus on treating the infection and recommendations for gentle exercise. But in this case transport would not be a priority.
Defining concrete interventions
Preterm mortality is a major contributor to overall child mortality.
The challenge is that there is a lack of research to define and prioritise the specific causes of mortality of preterm infants. There is also no research defining concrete interventions that can be scaled up.
The lens of precision thinking can help with this challenge as it can help develop a more focused and targeted intervention package that can be implemented.