Smart thinking is needed in developing countries to cut premature births

Preterm infant deaths contribute greatly to child mortality rates, which is why focused research and intervention plans are urgently needed.


In 2015, just under six 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, and 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 poorer countries, the causes of preterm deaths are 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 programs to reduce neonatal mortality in the developing world.

Reducing the high rate of children under the age of five who die has been a global health priority since the early 1990s. At the time diarrhea, pneumonia and malaria were the three leading killers of preschoolers.

To tackle these, several interventions were rolled out and, since then, deaths of children under five have more than halved. The interventions were simple: oral re-hydration solutions and zinc for diarrhea, a pneumococcal vaccine and antibiotics for pneumonia, and antimalarial medicines and long-lasting insecticide-treated nets for malaria.

But these reductions have meant the proportion of deaths in the neonatal age group has increased. Just under half of all the under-five deaths are now owed to neonatal mortality.

The thinking behind these interventions is based on the principles of precision medicine, which delivers the right solution 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 certain women.

There are three 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 having a baby, or over the age of 35, when their fertility starts 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. Women with tuberculosis, HIV, malaria or persistent urinary tract infections and vaginal infections are also at risk; and
  • Socioeconomic conditions: Being single, and having a low income and a low level of education, also increases a mother’s risk of her baby being born prematurely. This is mainly because such women lack proper nutrition or are overworked.

For these risks to be dealt with, health authorities make the best use of their 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.

Women with hypertensive disease, for example, could be identified and treated. Similarly, teenage girls could be given family planning advice and all women could receive regular antenatal care during pregnancy. Those with 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 health facility for delivery, and decreased working hours as her 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.

Preterm mortality is a major contributor to overall child mortality. The challenge is that there is a lack of research to define and prioritize 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 in developing a more focused and targeted intervention package that can be implemented. — The Conversation Africa

Lulu Mussa Muhe is a professor of paediatrics at Addis Ababa University.

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