Global report on preterm birth and stillbirth (5 of 7): advocacy barriers and opportunities

Background

According to an old Swiss proverb, "a new mother lazing in childbed is a blessing to her family". Today mothers rarely enjoy restful days after birth, but enter directly into the challenge of combining baby- and self-care. They often face a combination of infant crying and personal tiredness. Yet, routine postnatal care often lacks effective strategies to alleviate these challenges which can adversely affect family health. We explored how new mothers experience and handle postnatal infant crying and their own tiredness in the context of changing hospital care practices in Switzerland.

Methods

Purposeful sampling was used to enroll 15 mothers of diverse parity and educational backgrounds, all of who had given birth to a full term healthy neonate. Using interpretive phenomenology, we analyzed interview and participant observation data collected during the postnatal hospital stay and at 6 and 12 weeks post birth. This paper reports on the postnatal hospital experience.

Results

Women's personal beliefs about beneficial childcare practices shaped how they cared for their newborn's and their own needs during the early postnatal period in the hospital. These beliefs ranged from an infant-centered approach focused on the infant's development of a basic sense of trust to an approach that balanced the infants' demands with the mother's personal needs. Getting adequate rest was particularly difficult for mothers striving to provide infant-centered care for an unsettled neonate. These mothers suffered from sleep deprivation and severe tiredness unless they were able to leave the baby with health professionals for several hours during the night.

Conclusion

New mothers often need permission to attend to their own needs, as well as practical support with childcare to recover from birth especially when neonates are fussy. To strengthen family health from the earliest stage, postnatal care should establish conditions which enable new mothers to balance the care of their infant with their own needs.     

Global report on preterm birth and stillbirth (5 of 7): advocacy barriers and opportunities

Background

Efforts to achieve the Millennium Development Goals (MDGs) to improve maternal and child health can be accelerated by addressing preterm birth and stillbirth. However, most global health stakeholders are unaware of the inextricable connections of these adverse pregnancy outcomes to maternal, newborn and child health (MNCH). Improved visibility of preterm births and stillbirths will help fuel investments and strengthen commitments in the discovery, development and delivery of low-cost solutions globally. This article addresses potential barriers and opportunities to increasing global awareness and understanding.

Methods

Qualitative research was conducted to analyze current knowledge, attitudes and commitments toward preterm birth and stillbirth; identify advocacy challenges; and learn more about examples of programs that successfully advocate for research and appropriate interventions. Forty-one individuals from 14 countries on six continents were interviewed. They included maternal, newborn, and child health advocates and implementers, United Nations agency representatives, policymakers, researchers, and private and government donors.

Results

A common recognition of three advocacy challenges with regard to preterm birth and stillbirth emerged from these interviews: (1) lack of data about the magnitude and impact; (2) lack of awareness and understanding; and (3) lack of low-cost, effective and scalable interventions. Participants also identified advocacy opportunities. The first of these opportunities involves linking preterm birth and stillbirth to the MDGs, adding these outcomes to broader global health discussions and advocacy efforts, and presenting a united voice among advocates in the context of broader MNCH issues when addressing preterm birth and stillbirth. Another key opportunity is putting a human face to these tragedies—such as a parent who can speak to the personal impact on the family. Lastly, several interviewees suggested identifying and engaging champions to garner additional visibility and strengthen efforts. Ideal champions will work collaboratively with these and other maternal, newborn and child health issues. Conclusion: Advocacy efforts to add preterm births and stillbirths to broader MNCH goals, such as the MDGs, and to identify champions for these issues, will accelerate interdisciplinary efforts to reduce these adverse outcomes. The next article in this report presents an overview of related ethical considerations.

     

Global report on preterm birth and stillbirth (6 of 7): ethical considerations

Introduction

Despite the substantial global burden of preterm and stillbirth, little attention has been given to the ethical considerations related to research and interventions in the global context. Ethical dilemmas surrounding reproductive decisions and the care of preterm newborns impact the delivery of interventions, and are not well understood in low-resource settings. Issues such as how to address the moral and cultural attitudes surrounding stillbirths, have cross-cutting implications for global visibility of the disease burden. This analysis identifies ethical issues impacting definitions, discovery, development, and delivery of effective interventions to decrease the global burden of preterm birth and stillbirth.

Methods

This review is based on a comprehensive literature review; an ethical analysis of other articles within this global report; and discussions with GAPPS's Scientific Advisory Council, team of international investigators, and a community of international experts on maternal, newborn, and child health and bioethics from the 2009 International Conference on Prematurity and Stillbirth. The literature review includes articles in PubMed, Academic Search Complete (EBSCO), and Philosopher's Index with a range of 1995-2008.

Results

Advancements in discovery science relating to preterm birth and stillbirth require careful consideration in the design and use of repositories containing maternal specimens and data. Equally important is the need to improve clinical translation from basic science research to delivery of interventions, and to ensure global needs inform discovery science agenda-setting. Ethical issues in the development of interventions include a need to balance immediate versus long-term impacts—such as caring for preterm newborns rather than preventing preterm births. The delivery of interventions must address: women's health disparities as determinants of preterm birth and stillbirth; improving measurements of impact on equity in coverage; balancing maternal and newborn outcomes in choosing interventions; and understanding the personal and cross-cultural experiences of preterm birth and stillbirth among women, families and communities.

Conclusion

Efforts to improve visibility, funding, research and the successful delivery of interventions for preterm birth and stillbirth face a number of ethical concerns. Thoughtful input from those in health policy, bioethics and international research ethics helped shape an interdisciplinary global action agenda to prevent preterm birth and stillbirth.

     

Global report on preterm birth and stillbirth (2 of 7): discovery science

Background

Normal and abnormal processes of pregnancy and childbirth are poorly understood. This second article in a global report explains what is known about the etiologies of preterm births and stillbirths and identifies critical gaps in knowledge. Two important concepts emerge: the continuum of pregnancy, beginning at implantation and ending with uterine involution following birth; and the multifactorial etiologies of preterm birth and stillbirth. Improved tools and data will enable discovery scientists to identify causal pathways and cost-effective interventions.

Pregnancy and parturition continuum

The biological process of pregnancy and childbirth begins with implantation and, after birth, ends with the return of the uterus to its previous state. The majority of pregnancy is characterized by rapid uterine and fetal growth without contractions. Yet most research has addressed only uterine stimulation (labor) that accounts for <0.5% of pregnancy.

Etiologies

The etiologies of preterm birth and stillbirth differ by gestational age, genetics, and environmental factors. Approximately 30% of all preterm births are indicated for either maternal or fetal complications, such as maternal illness or fetal growth restriction. Commonly recognized pathways leading to preterm birth occur most often during the gestational ages indicated: (1) inflammation caused by infection (22-32 weeks); (2) decidual hemorrhage caused by uteroplacental thrombosis (early or late preterm birth); (3) stress (32-36 weeks); and (4) uterine overdistention, often caused by multiple fetuses (32-36 weeks). Other contributors include cervical insufficiency, smoking, and systemic infections. Many stillbirths have similar causes and mechanisms. About two-thirds of late fetal deaths occur during the antepartum period; the other third occur during childbirth. Intrapartum asphyxia is a leading cause of stillbirths in low- and middle-income countries.

Recommendations

Utilizing new systems biology tools, opportunities now exist for researchers to investigate various pathways important to normal and abnormal pregnancies. Improved access to quality data and biological specimens are critical to advancing discovery science. Phenotypes, standardized definitions, and uniform criteria for assessing preterm birth and stillbirth outcomes are other immediate research needs.

Conclusion

Preterm birth and stillbirth have multifactorial etiologies. More resources must be directed toward accelerating our understanding of these complex processes, and identifying upstream and cost-effective solutions that will improve these pregnancy outcomes.

     

Global report on preterm birth and stillbirth (4 of 7): delivery of interventions

Background

The efficacious interventions identified in the previous article of this report will fail unless they are delivered at high and equitable coverage. This article discusses critical delivery constraints and strategies.

Barriers to scaling up interventions

Achieving universal coverage entails addressing major barriers at many levels. An overarching constraint is the lack of political will, resulting from the dearth of preterm birth and stillbirth data and the lack of visibility. Other barriers exist at the household and community levels, such as insufficient demand for interventions or sociocultural barriers; at the health services level, such as a lack of resources and trained healthcare providers; and at the health sector policy and management level, such as poorly functioning, centralized systems. Additional constraints involve weak governance and accountability, political instability, and challenges in the physical environment.

Strategies and examples

Scaling up maternal, newborn and child health interventions requires strengthening health systems, but there is also a role for focused, targeted interventions. Choosing a strategy involves identifying appropriate channels for reaching high coverage, which depends on many factors such as access to and attendance at healthcare facilities. Delivery channels vary, and may include facility- and community-based healthcare providers, mass media campaigns, and community-based approaches and marketing strategies. Issues related to scaling up are discussed in the context of four interventions that may be given to mothers at different stages throughout pregnancy or to newborns: (1) detection and treatment of syphilis; (2) emergency Cesarean section; (3) newborn resuscitation; and (4) kangaroo mother care. Systematic reviews of the literature and large-scale implementation studies are analyzed for each intervention.

Conclusion

Equitable and successful scale-up of preterm birth and stillbirth interventions will require addressing multiple barriers, and utilizing multiple delivery approaches and channels. Another important need is developing strategies to discontinue ineffective or harmful interventions. Preterm birth and stillbirth interventions must also be placed in the broader maternal, newborn and child health context to identify and prioritize those that will help improve several outcomes at the same time. The next article discusses advocacy challenges and opportunities.

     

Global report on preterm birth and stillbirth (7 of 7): mobilizing resources to accelerate innovative solutions (Global Action Agenda)

Background

Preterm birth and stillbirth are complex local and global health problems requiring an interdisciplinary approach and an international commitment. Stakeholders developed recommendations for a Global Action Agenda (GAA) at the 2009 International Conference on Prematurity and Stillbirth. The primary goal of this GAA is to forge a collaborative effort toward achieving common goals to prevent preterm birth and stillbirth, and to improve related maternal, newborn, and child health outcomes.

Conference participants

GAPPS co-convened this four-day conference with the Bill & Melinda Gates Foundation, March of Dimes, PATH, Save the Children, UNICEF and the World Health Organization. Participants included about 200 leading international researchers, policymakers, health care practitioners and philanthropists. A near-final draft of this report was sent three weeks in advance to help co-chairs and participants prepare for workgroup discussions.

Global Action Agenda

Twelve thematic workgroups, composed of interdisciplinary experts, made recommendations on short-, intermediate-, and long-term milestones, and success metrics. Recommendations are based on the following themes: (1) advance discovery of the magnitude, causes and innovative solutions; (2) promote development and delivery of low-cost, proven interventions; (3) improve advocacy efforts to increase awareness that preterm birth and stillbirth are leading contributors to the global health burden; (4) increase resources for research and implementation; and (5) consider ethical and social justice implications throughout all efforts.

Summary

The conference provided an unprecedented opportunity for maternal, newborn and child health stakeholders to create a collaborative strategy for addressing preterm birth and stillbirth globally. Participants and others have already completed or launched work on key milestones identified in the GAA. Updates will be provided at www.gapps.org.

     

Global report on preterm birth and stillbirth (3 of 7): evidence for effectiveness of interventions

Introduction

Interventions directed toward mothers before and during pregnancy and childbirth may help reduce preterm births and stillbirths. Survival of preterm newborns may also be improved with interventions given during these times or soon after birth. This comprehensive review assesses existing interventions for low- and middle-income countries (LMICs).

Methods

Approximately 2,000 intervention studies were systematically evaluated through December 31, 2008. They addressed preterm birth or low birth weight; stillbirth or perinatal mortality; and management of preterm newborns. Out of 82 identified interventions, 49 were relevant to LMICs and had reasonable amounts of evidence, and therefore selected for in-depth reviews. Each was classified and assessed by the quality of available evidence and its potential to treat or prevent preterm birth and stillbirth. Impacts on other maternal, fetal, newborn or child health outcomes were also considered. Assessments were based on an adaptation of the Grades of Recommendation Assessment, Development and Evaluation criteria.

Results

Most interventions require additional research to improve the quality of evidence. Others had little evidence of benefit and should be discontinued. The following are supported by moderate- to high-quality evidence and strongly recommended for LMICs:? Two interventions prevent preterm births—smoking cessation and progesterone? Eight interventions prevent stillbirths—balanced protein energy supplementation, screening and treatment of syphilis, intermittant presumptive treatment for malaria during pregnancy, insecticide-treated mosquito nets, birth preparedness, emergency obstetric care, cesarean section for breech presentation, and elective induction for post-term delivery? Eleven interventions improve survival of preterm newborns—prophylactic steroids in preterm labor, antibiotics for PROM, vitamin K supplementation at delivery, case management of neonatal sepsis and pneumonia, delayed cord clamping, room air (vs. 100% oxygen) for resuscitation, hospital-based kangaroo mother care, early breastfeeding, thermal care, and surfactant therapy and application of continued distending pressure to the lungs for respiratory distress syndrome

Conclusion

The research paradigm for discovery science and intervention development must be balanced to address prevention as well as improve morbidity and mortality in all settings. This review also reveals significant gaps in current knowledge of interventions spanning the continuum of maternal and fetal outcomes, and the critical need to generate further high-quality evidence for promising interventions.

     

Disparities in perinatal medicine: preterm birth, stillbirth, and infant mortality

Infant mortality, stillbirths, and preterm births are major public health priorities with significant disparities based on race and ethnicity. Interestingly, when evaluating the rates over the past 30 to 50 years, the disparity persists in all three and is remarkably consistent. In the United States, the infant mortality rate is 6.7 deaths per 1,000 live births, the stillbirth rate is 6.2 per 1,000 deliveries, and the preterm birth rate is 12.8% of live births. The rates among non-Hispanic African Americans are dramatically higher, nearly double the infant mortality at 13.4 infant deaths per 1,000 live births, nearly double the stillbirth rate at 11.1 stillbirths per 1,000 deliveries, and one third higher with preterm births at 18.4% of live births. Despite numerous conferences, workshops, articles, and investigators focusing on this line of work, the disparities persist and, in some cases, are growing. In this article, we summarize a Eunice Kennedy Shriver National Institute of Child Health and Human Development workshop that focused on these disparities to identify the associated factors to determine their relative contributions, identify gaps in knowledge, and develop specific strategies to address the disparities in the short-term and long-term.     

The role of stillbirth prevention and late preterm (near-term) births

Stillbirth remains an important cause of fetal loss in both the term and late-preterm (near-term) pregnancy. As ongoing research further elucidates the causes of intrauterine fetal demise (IUFD), strategies can be tested to reduce its occurrence. Currently, reduction of IUFD in the term and late preterm infants should focus on reduction or elimination of risk factors (eg, smoking and control of medical conditions) and enhanced fetal surveillance in those pregnancies identified to be at increased risk.     

Diabetes mellitus and the risk of preterm birth with regard to the risk of spontaneous preterm birth

Introduction.?It is internationally agreed that diabetes mellitus (DM) is associated with increased maternal and fetal morbidity and long-term complications. To avoid these complications, it is often necessary to induce birth before term. The impact of DM on spontaneous preterm birth (spontaneous labor, preterm premature rupture of membranes and/or cervical incompetence resulting in delivery before the completion of 37 gestation weeks) is still unexplained. Preterm birth accounts for the most neonatal deaths and infant morbidities, and therefore it still remains one of the biggest challenges in obstetrics.

Objective.?Our study determined if there is an increasing tendency towards spontaneous preterm birth in mothers with gestational and preexisting DM.

Methods.?In this retrospective cohort study, 187 pregnant women with gestational DM and preexisting DM were compared to a randomized control group consisting of 192 normoglycemic women concerning gestational age and perinatal outcome. Data were collected by the Medical University of Vienna. Multiple pregnancies and women with severe maternal diseases, such as preeclampsia, were excluded.

Results.?Women with DM tended significantly more often to preterm births (P?=?0.002). A significant difference in the incidence of spontaneous preterm birth was found (P?=?0.047).

Conclusion.?DM affects the length of gestation and incidence of spontaneous preterm birth.     

Nursing's contribution to the literature on preterm labor and birth

Although preterm labor and birth continues to plague us as an unsolved mystery in maternal/child health, much has actually been learned over the past few decades. Most reviews of the preterm labor literature examine the research in an interdisciplinary manner; this article instead looks at the active role that nurses have taken in the research concerning preterm labor and birth. This article will categorize research conducted by nurses over the past 30 years on preterm labor and birth, emphasizing some of the changes in nursing practice engendered by nursing's important research effort.     

Genetic associations in preterm birth: a primer of marker selection, study design, and data analysis

Spontaneous preterm birth (PTB; delivery before 37 weeks gestation) is a primary risk factor for infant morbidity and mortality. The etiology is unclear, but there is evidence that there is a genetic predisposition to PTB. Armed with the suggestion of genetic risk factors and the failure to identify useful biomarkers, investigators are starting to actively pursue the role of genetic predisposition in PTB. Several studies have been done to date assessing the role of single gene variants. However, positive findings have failed to replicate. We argue that heterogeneity in study designs, definition of phenotype, single-nucleotide polymorphism (SNP) selection, population selection, and sample size makes data interpretation difficult in complex phenotypes such as PTB. In this review, we introduce general concepts of study designs in genetic epidemiology, selection of candidate genes and markers for analysis, and analytical methodologies. We also introduce how the concept of gene-gene interactions (biologic epistasis) and gene-environment interactions may affect the predisposition to PTB.     

Weight gain and spontaneous preterm birth: the role of race or ethnicity and previous preterm birth

OBJECTIVE: To study how the relationship between gestational weight gain and spontaneous preterm birth interacts with maternal race or ethnicity and previous preterm birth status. METHODS: This was a retrospective cohort study of singleton births to women of normal or low prepregnancy body mass index. Gestational weight gain was measured as total weight gain divided by weeks of gestation at delivery, and weight gain was categorized as low (less than 0.27 kg/wk,), normal (0.27-0.52 kg/wk), or high (more than 0.52 kg/wk). Univariable and multivariable analyses were performed on the relationship between weight gain categories and spontaneous preterm birth, stratified by maternal race or ethnicity and history of previous preterm birth. RESULTS: Overall, low weight gain was associated with spontaneous preterm birth (adjusted odds ratio [AOR] 2.5, 95% confidence interval [CI] 2.0-3.1). Although low gain was consistently associated with increased spontaneous preterm birth, some differences were found in subgroup analysis. Among African Americans with a previous preterm birth, both low and high weight gain were associated with increased odds of spontaneous preterm birth (AOR for low weight gain 4.3, 95% CI 1.2-15.5; AOR for high weight gain 6.1, 95% CI 1.8-20.2). For all other groups, high weight gain was not associated with spontaneous preterm birth. Among Asians with a previous preterm birth, low weight gain was not statistically significantly associated with spontaneous preterm birth (AOR 1.9, 95% CI 0.5-7.7). Among Asians there was also a non-statistically significant inverse relationship between high weight gain and spontaneous preterm birth (AOR 0.5, 95% CI 0.3-1.1). CONCLUSION: These results confirm an association between low maternal weight gain and spontaneous preterm birth. The effect modification of maternal race or ethnicity and history of previous preterm birth on this association deserves further study. LEVEL OF EVIDENCE: II-2.     

The impact of interpregnancy interval and previous preterm birth on the subsequent risk of preterm birth

OBJECTIVE: To examine the impact of the interpregnancy interval and a previous preterm birth on the subsequent risk of a preterm birth. METHODS: A retrospective analysis was conducted on a group of 4072 women who had at least two consecutive births, excluding multiple gestation, fetal anomalies, cervical incompetence, and stillbirth. Multivariate logistic regression was used to investigate the association between interpregnancy interval, preterm birth of the first child in the pair (index pregnancy), and the risk of a preterm birth of the second child in the pair (outcome pregnancy). RESULTS: Women with interpregnancy intervals of less than 12 months (odds ratio [OR] 1.3; 95% confidence interval [CI] 1.0-1.7) were at increased risks of preterm birth with the outcome pregnancy. Furthermore, there was an increased risk for a subsequent preterm birth in women who had a preterm birth in the index pregnancy (OR 4.2; 95% CI 3.0-6.0). The risk decreased as the interpregnancy interval increased, with a relatively low risk at 18 to 48 months; subsequently, it increased sharply. In contrast, women who had delivered their previous infants at term carried an increased risk of preterm birth with the outcome pregnancy only if the interval was less than 6 months. CONCLUSION: A difference was found in the impact of the interpregnancy interval on the subsequent risk of preterm birth between women with a prior preterm birth and those who previously delivered an infant at term.