A Lost Decade: Zero Progress in Reducing Premature Births Since 2010, UN finds
Nurses working in Neonatal intensive care unit, Yekatit Hospital Medical College, Ethiopia.

Zero gains have been made in any region of the world in reducing premature births in the past decade, a major UN report found. In a perfect storm of flatlining progress in maternal and newborn health, preterm birth has become to the leading cause of child mortality worldwide, responsible for the deaths of over one in five children who die before their fifth birthday. 

The report, which includes the first updated estimates from the UN on preterm births since 2012, estimates 13.4 million babies were born prematurely in 2020, with nearly one million dying from complications related to their premature birth. Since 2010, a total of 152 million babies – one in 10 worldwide – were born too soon.

The consequences of preterm birth, where a baby is born in the first 37 weeks of pregnancy, can be lifelong, leaving millions of children facing serious physical and developmental disabilities and health complications that will shape their lives and that of their families.

“Every two seconds, a baby is born too soon,” the report by the World Health Organization (WHO), UNICEF, and the Partnership for Maternal, Newborn and Child Health (PMNCH) said. “Every 40 seconds, one of those babies dies.” 

Efforts to expand investments in the health of pregnant women, mothers and newborns remain chronically underfunded, the report found, adding that climate change, the cost of living crisis, conflicts and COVID-19 have added to the risks for women and babies around the world.

“Every woman must be able to access quality health services before and during pregnancy to identify and manage risks,” said Dr Anshu Banerjee, WHO’s Director of Maternal, Newborn, Child and Adolescent Health. “Ensuring quality care for these tiniest, most vulnerable babies and their families is absolutely imperative for improving child health and survival.”

“Where babies are born determines if they survive” 

Preterm birth by gestational age and region in 2020. Source: UNICEF, WHO.

Most preterm deaths and disabilities are preventable, but inequalities in access to quality and timely care can create staggering differences in a preterm baby’s odds of survival. In analysing the new data set out in the report, its authors are blunt: “Where babies are born determines if they survive.”

Fewer than one in 10 babies born before the 28-week mark survive in low-income countries, compared to nine out of 10 in high-income countries. Sub-Saharan Africa and South Asia have the highest premature birth rates and highest mortality risk. Together, they account for over 65% of preterm births globally. Overall, almost half of all preterm babies born in 2020 were from just five countries: China, India, Nigeria, Ethiopia and Pakistan.

“The single biggest gap that we see around the world is the chance of survival for a preterm baby,” Joy Lawn, a professor at the London School of Hygiene and Tropical Medicine and co-author of the report told BBC Africa. “So this is the loudest cry in this report, that these babies should have an equal chance.” 

Sister Munaye Esmael holds her four-day-old son Umar Abdul Shafri at the UNICEF-supported Neonatal Intensive Care Unit in Ethiopia.

A broader crisis in maternal health

But premature births are just one part of the larger story of maternal health inequalities

In 2020, nearly 95% of maternal deaths occurred in low- and lower-middle-income countries. Over 200,000 of those deaths – 70% – took place in sub-Saharan Africa, where girls who reach the age of 15 face a one in 40 chance of dying from pregnancy-related causes. 

Meanwhile, an estimated 2.3 million newborns died within their first 28 days of life in 2022. Of the 6400 infants dying every day, 98% were in low- and middle-income countries, and 78% were in sub-Saharan Africa and Asia.

“Pregnant women and newborns continue to die at unacceptably high rates worldwide, and the Covid-19 pandemic has created further setbacks to providing them with the healthcare they need,” Banerjee said. “More and smarter investments in primary healthcare are needed now so that every woman and baby – no matter where they live – has the best chance of health and survival.” 

More staff, more equipment, more support

As premature births claim the top spot on the ladder of causes of child mortality, less than a third of countries report having enough care units to treat vulnerable newborns, a new UN report launched at a major maternal and newborn health conference in Cape Town, South Africa, this week found. 

Around two-thirds of emergency childbirth facilities in sub-Saharan Africa are not fully functional due to a lack of vital resources like water, electricity, medicines, equipment, or staff for round-the-clock care, the report added. 

Miriam Asembo, a nurse and mother of two premature babies, shared her experience of what it is like to be on both sides of an underfunded maternal care system in her home country of Kenya. 

“There is a lack of incubators per number of premature babies born, we find babies sharing incubators in public hospitals, which is ridiculous,” she said, adding that sharing incubators can increase infant mortality due to infection risks. “It boils down to access to oxygen cylinders and medical air, which is something that we should not be talking about in 2023.” 

There is also a chronic lack of trained midwives, nurses and hospital staff. In 2022, nearly a third of women did not receive even half of the WHO’s recommended antenatal checkups during the pregnancy or have access to any postnatal care.

“We need to address the human resource shortages and training of personnel in these low-income countries, right from the traditional midwives to the nurses to the doctors,” Asembo said.

The saddest bit is as much as [people] give birth to babies prematurely, nobody follows up with you to find out what you are doing to keep the child alive,” she said of her experience after the birth of her two children, Sifa and Teko.

Lost years, lost potential 

Estimated national preterm birth rates and numbers in 2020. Source: UNICEF, WHO.

Poor neonatal conditions have been the leading cause of lost disability-adjusted life years (DALYs) since 1990. This high burden of DALYs – each representing the loss of one full year of health compared to life expectancy –  is due to how early babies who lose their lives to preterm-related complications die, effectively leaving their entire lives, and economic potential, ahead of them. 

“Investment in the right care during this sensitive period can unlock more human capital than at any other time in the life-course, bolstering the case for investing now to gain significant human and economic returns,” the report said. 

Lawn, who has worked in neonatal care across Africa for her entire career, echoed the report’s findings, highlighting the role Africa’s youthful demographics are already playing in the continent’s growth, and can play in its future. 

“We continue to accept that more than one million newborns die every year in Africa, more than on any other continent,” she said. “This is really critical for Africa … Those newborns, they don’t have a voice. Often the women who it happened to don’t have a voice. And politicians are not rising up and saying that this is not just charity, it is investing in the future of your country.

“You want your newborns not just to survive, but to thrive,” Joy concluded. “The investment may not be small, but the return is huge for the next generation.”

Image Credits: UNICEF.

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