Preterm or premature births pertain to births earlier than 38 weeks of gestation. The WHO (2013) estimates that each year around 15 million infants are born before 37 weeks. The preterm birth rate varies across 184 countries but range from 5-18% of all live births. On one hand, estimates show that approximately 75% of preterm mortality can be prevented even without intensive care interventions (WHO, 2013). On the other, prematurity has become the top cause of newborn mortality with over a million deaths every year which accounts for 35% of total newborn mortality (Lawn et al., 2012). Third world or low-income countries in Africa and Asia have disproportionately higher rates of preterm births and associated deaths. To better understand the disparity, it is necessary to investigate and compare survival rates and the standards of care across third world and developed or high-income countries.
Preterm Deaths and Survival Rates in the Third World
There are three categories of preterm deliveries. Extremely preterm babies are born less than 28 weeks gestation while very preterm babies are born between 28 and 32 weeks (March of Dimes et al., 2012). Moderate to late preterm are babies born between 32 to 37 weeks. As shown in Table 1, more than 80% of preterm infants in the third world are delivered between 32-37 weeks, 10% are very preterm, and just 5% are extremely preterm (Lawn et al., 2012). The latter requires neonatal intensive care in order to survive, but many deaths in very preterm and especially in moderate to late preterm can be effectively prevented by using simple and cost-effective interventions outside of intensive care units.
Recent reports state that 90% of extremely premature babies or those born before 28 weeks gestation die within the first days of life in low-income countries reflecting a 10% survival rate (Blencowe et al., 2012). In contrast, the proportion of babies of the same gestational age dying in high-income countries is 10% or a 90% survival rate. Hence, the survival gap is 10:90. In babies delivered at 24 weeks gestation, a time when the neonate has just reached the age of viability, the disparity is much more glaring. The survival rate of such neonates in developed countries is 50% (March of Dimes et al., 2012). On the other hand, most of similar cases die in low-income countries. Meanwhile, in moderate to late preterm babies born at 32 weeks in third world countries, only about 50% survive (Lawn et al., 2012).
A major factor contributing to the disparity especially among very preterm and extremely preterm infants is the lack of adequate neonatal intensive care in the third world compared to the availability of such services in the developed world (Althabe et al., 2014). For instance, these babies often require ventilator support. At the same time, the quality of newborn care is also insufficient. The most common causes of death in these patients are respiratory distress syndrome, neonatal sepsis, jaundice, brain injury, necrotizing enterocolitis, and anemia. Most of these conditions arise from the immaturity of the involved organs and aggravated by the ineffective management of feeding difficulties, hypothermia, infections of the cord and skin, hypoglycemia, and hypoxia (Lawn et al., 2012). These physiologic events and their negative outcomes in the preterm newborn are preventable with improvements in both facilities and clinical practice.
Care of Preterm Infants in Third World Countries
In response to the alarming trend in premature infant mortality and survival, the World Health Organization (WHO) developed and promoted the essential newborn care guidelines in developing countries as a cost-effective strategy in preventing deaths in preterm as well as term babies. The guidelines address the deficiencies in neonatal care as described above. In the Philippines, a low-income country in Asia, the WHO guidelines are integrated in the Unang Yakap (First Embrace) Protocol for New Life applicable in community and hospital settings (DOH, 2010). The practice was institutionalized through Administrative Order 2009-005.
The protocol consists of four steps (see Appendix 1). First, immediate and thorough drying of the newborn is done with a clean, warm, and dry cloth. Second, uninterrupted skin-to-skin contact between neonate and mother is ensured to promote breastfeeding and prevent infection and hypoglycemia (DOH, 2010). This is done by placing the neonate on the mother’s bare chest and covering with a blanket. Third, the umbilical cord is clamped and cut three minutes after delivery or when pulsations cease to reduce the likelihood of anemia. Fourth, the newborn is not separated from the mother to promote early feeding, thermoregulation, and colonization by the normal bacterial flora on the mother’s skin (DOH, 2010). Interventions such as vitamin K administration and eye care are performed only after the first feeding. The newborn’s first bath must be at least six hours post birth to optimize the benefits from the baby’s vernix caseosa.
The Unang Yakap Protocol for New Life is similar to what is known as kangaroo mother care in other countries. In a meta-analysis of 15 clinical trials and observational studies conducted largely in hospital settings in low income and middle income countries, there is evidence suggesting a significant reduction in serious morbidity and preterm neonatal deaths especially those attributed to infection (Lawn et al., 2010). The authors note, however, that the wide-scale implementation of kangaroo mother care guidelines in hospitals and community care settings is absent contributing to the continued prevalence of preterm infant deaths in these countries. While the protocol may address the needs of late preterm infants who are more physiologically mature, the steps seem to be too simplistic with no separate guidance for extremely preterm, very preterm, and moderately preterm neonates who may have other needs.
Comparison to Care Given in the United States
A major difference between the care of premature infants in third world and developed countries is that in the latter antenatal interventions are widely employed. Part of antenatal care involves an evaluation of the risk to preterm delivery (Lim, Butt & Crane, 2011). In women determined to be at risk or are in preterm labor, corticosteroids such as dexamethasone are administered as a preventive measure against respiratory distress in the newborn. About 80% of such women in developed countries receive antenatal dexamethasone compared to 10% of the same population of women in third world countries (Althabe et al., 2014). A systematic review of clinical trials on this intervention in high- and middle-income countries found a 31% decline in neonatal mortality as well as a significant reduction in serious neonatal illness.
The above trials were conducted in tertiary hospital settings providing NICU support. Whereas almost all term and preterm births in developed countries occur in these settings, fewer than 50% of births in the third world take place in hospitals (Althabe et al., 2014). At the same time, the low quality of prenatal care in the latter may preclude the determination of pregnant women at risk for preterm delivery so that measures to improve neonate survival can be implemented. Even if this intervention can be administered in the home or community setting, the skill level of lay or community health workers may be inadequate to ensure safety and effectiveness (Lawn et al., 2012). Thus, access to corticosteroid therapy is limited in low-income countries and contributes to the high incidence of preterm deaths.
Compared with the Unang Yakap protocol, the management of preterm infants in high income countries such as the United States following delivery is more specific to the needs of these neonates, involves multiple disciplines, led by experts, and encourages mother or support person participation. This is illustrated in the Academy of Breastfeeding Medicine (ABM)’s Protocol #10 addressing the risk for inadequate nutrition among preterm infants. It does so by recommending the development of a written feeding plan that incorporates the baby’s gestational age, risk factors, and needs as well as breastfeeding issues related to the mother (ABM, 2011).
The ABM Protocol further promotes the use of multiple standardized assessment tools, e.g. LATCH Score and the Infant Breastfeeding Assessment Tool (IBFAT), as appropriate to obtain data in formulating the plan (ABM, 2011). It also includes monitoring the neonate for signs of common problems such as RDS, jaundice, and infection to allow for early management. As such, there is flexibility that permits the accommodation of varying needs as well as concrete steps that nurses can follow in providing care. The plan is informed by evidence from the literature and communicated to the health care team. Mother and support person education is further provided to facilitate their involvement and ensure the effectiveness of the plan.
Conclusion
Preterm birth is a global phenomenon. However, there is disparity in the incidence of such births and the mortality and survival of preterm infants between third world and developed countries. More than the effect of resource constraints, preterm deaths in the former are due to preventable causes. The WHO’s essential new born care guidelines, also known as kangaroo mother care, represent practice changes that have been shown to be effective in reducing preterm deaths. However, related protocols are not widely adopted. In addition, protocols incorporating the WHO guidelines fail to provide more specific guidance for the care of preterm infants and their mother who may have varying needs.
References
Academy of Breastfeeding Medicine (2011). ABM Clinical Protocol #10: Breastfeeding the late preterm infant (34 to 36 weeks gestation). Breastfeeding Medicine, 6(3), 151- 156. doi: 10.1089/bfm.2011.9990
Althabe, F., Belizan, J.M., McClure, E.M., Hemingway-Foday, J., Berrueta, M., Mazzoni, A., Buekens, P.M. (2014). A population-based, multifaceted strategy to implement antenatal corticosteroid treatment versus standard care for the reduction of neonatal mortality due to preterm birth in low-income and middle-income countries: The ACT cluster-randomised trial. The Lancet, in press. doi:10.1016/S0140- 6736(14)61651-2.
Blencowe, H., Cousens, S., Oestergaard, M.Z., Chou, D., Moller, A., Narwal, R., Lawn, J.E. (2012). National, regional, and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: A systematic analysis and implications. The Lancet, 379(9832), 2162-2172. doi:10.1016/S0140- 6736(12)60820-4.
Lawn, J.E., Mwansa-Kambafwile, J., Horta, B.L., Barros, F.C., & Cousens, S. (2010). ‘Kangaroo mother care’ to prevent neonatal deaths due to preterm birth complications. International Journal of Epidemiology, 39(1), i144-i154. doi:10.1093/ije/dyq031.
Lawn, J.E., Davidge, R., Paul, V., von Xylander, S., de Graft Johnson, J., Costello, A., Molyneux, L. (2012). Chapter 5. Care for the preterm baby. Retrieved from http://www.who.int/pmnch/media/news/2012/borntoosoon_chapter5.pdf
Lim, K., Butt, K., & Crane, J.M. (2011). SOGC clinical practice guideline: Ultrasonographic cervical length assessment in predicting preterm birth in singleton pregnancies. Journal of Obstetrics and Gynaecology Canada, 33(5), 486-499. Retrieved from http://www.guideline.gov/content.aspx?id=33545
March of Dimes, PMNCH, Save the Children, & World Health Organization (2012). Born too soon: The global action report on preterm birth. Geneva, Switzerland: World Health Organization.
World Health Organization (2013). Preterm birth: Fact sheet N 363. Retrieved from http://www.who.int/mediacentre/factsheets/fs363/en/
Appendix 1
Unang Yakap Essential Newborn Care Protocol for New Life
