1. Implementing Interventions to Reduce
the Burden of Preterm and Stillbirth:
How do we do it?
Courtney Gravett, MPH
Research Associate II
Global Alliance to Prevent Prematurity
and Stillbirth (GAPPS)
Seattle Children’s
courtney.gravett@seattlechildrens.org

2. Preterm deaths and Stillbirths can
be prevented now
• Effective implementation of current, known
interventions can reduce preterm deaths by 75%
and stillbirths by 45%
• Many preterm deaths and stillbirths are due to
lack of action, or an inability to act
• Prevention and intervention is possible all along
the continuum of care

3. Many premature babies can be saved before intensive
becomes available...
Public health
approaches
Improved individual neonatal care eg
feeding, warmth, hygiene, antibiotics,
resuscitation
Neonatal intensive care
introduction and scale up
Over 60% reduction can be achieved before neonatal intensive care
and history shows the impact would be huge
Data sources for UK and US historical data: (CDC, 2012, Office for National Statistics, 2012, NIH, 1985, Smith et al., 1983, Jamison et al., 2006, Lissauer and Fanaroff, 2006, Baker,
2000, Philip, 2005, Wegman, 2001). With thanks to Boston Consulting Group

4. Continuum of Care
Kerber K, et al. Continuum of care for maternal, newborn and child health: from slogan to delivery. Lancet 2007; 370:1358=69

5. Interventions for preterm birth and stillbirth
along the continuum of care
PRE- PREGNANCY BIRTH POSTNATAL/ CHILDHOOD
PREGNANCY NEWBORN
•Family planning/ •Prevent & treat •Antenatal •Essential & Extra care
birth spacing sexually steroids • Kangaroo Mother Care
PTB •Prevent & treat transmitted •Tocolytics to •Management of sick
sexually transmitted infections slow labor newborns
infections •Nutrition •Identify preterm •Neonatal resuscitation
•Nutrition babies
•Prevent & treat •Screen& treat •Active management of •Postnatal
sexually for syphilis labor follow-up
transmitted •Nutrition •Emergency obstetric
infections care, including c-section
SB •Magnesium sulfate
•Nutrition
•Antibiotics
•Induction of labor after
41 weeks

6. Prevention of preterm birth and stillbirth
must be accelerated
Care before and between pregnancy
Implement:
• Family planning strategies, including birth
spacing and provision of adolescent-friendly
services
• Prevention and management of STIs and
NCDs
• Education and health promotion for girls and
women of childbearing age
• Promotion of healthy nutrition and addressing
life-style risks like smoking

7. Prevention of preterm birth and stillbirth
Care during pregnancy and childbirth
Implement:
• Antenatal care for all pregnant women
• Screening & treatment of sexually transmitted
infections, especially syphilis
• Management of pregnant women at higher risk
of preterm labor
• Management of preterm labor with provision of
essential equipment and drugs
• Reduce non-medically indicated early
induction of labor and cesarean
• Promotion of healthy behaviors and life-style
risks during pregnancy
• Active management of the third stage of labor
• Comprehensive emergency obstetric care

8. Care of the premature newborn
COMMUNITY LEVEL/HOME
Home and low levels of health system
• Essential newborn care (warmth, cleanliness, feeding)
• Support for early breastfeeding and cup feeding if needed
• Facilitated referral, transport schemes
Hospital
• Kangaroo Mother Care
FACILITY LEVEL/OUTREACH
• Neonatal resuscitation with bag and mask if needed
• Supportive care for RDS eg safe oxygen therapy
• Other supportive care eg NG tube feeding, IV fluids
• Treatment of infections with antibiotics
Referral hospital
• Increased nursing and medical support
• Phased introduction of intensive care eg ventilation REFERRAL LEVEL/DISTRICT
• Surfactant (cost issues)

9. Moving Forward to Reduce
Preterm Deaths and
Stillbirths

10. Examples of Barriers to Scaling Up
Interventions
• Community/Household level
– Sociocultural barriers (eg stigma), financial constraints
• Health service level
– Lack of resources and trained providers
• Health sector and management level
– Weak supply management
– Lack of competent district health management teams
• Lack of political will

11. Prevention and management of
preterm birth and stillbirth must be
included in the wider agenda
• Functional health systems are a prerequisite for
comprehensive antenatal and childbirth care
• Implementation research is needed
• Must integrate with other RMNC health programs
– Antenatal corticosteroids
• The steps for scaling up interventions are highly
context specific

12. Start where you are

13. 8 Countries have reduced preterm
death in the last decade
• Sri Lanka Contributing factors:
• Turkey • National commitment to improved obstetric and
• Belarus
neonatal care
• Croatia
• Systematic referral systems for neonatal care
• Ecuador
• El Salvador • Strengthened equipment and personnel
• Oman • Re-invigorated community-based healthcare
• China • Promotion and training of skilled birth attendants

14. Some middle income countries have
halved deaths due to preterm birth in a
decade Sri Lanka
• Lower middle-income country
Turkey that reduced NMR from 13 to
10 and halved preterm
• Upper middle-income country that reduced specific mortality
NMR from 21 to 10 • Long term investment in
primary care with free health
• Implemented demand and supply strategies, care at government facilities
including cash incentives for expectant women • Reinvigorated community-
based care, including referral
• Invested in quality care improvements, such as networks for women in
focusing on nursing staff skills, resuscitation, preterm labor
basic care of preterm babies • Recent introduction of
advanced care at tertiary
centers
Source: Analysis conducted using data from Liu et al., 2012. Credit: Boston Consulting Group with the Global Preterm Birth Mortality Reduction Analysis Group

15. Factors contributing to successful
implementation of interventions
• Buy-in by key stakeholders
• Intervention is context specific i.e., culturally
sensitive, locally adapted to staffing levels,
burden of disease, causes of mortality, etc.
• Intervention builds on/ complements existing
programs
• Intervention is supported by national policies,
service guidelines, training materials, job aids,
supervisory systems and indicators to track
outcomes
• Robust supply chain

16. Who is involved?
• Government and policy makers at local, national
and global levels
• United Nations and other multilateral
organizations
• Donors
• Private Sector
• Academic and research institutions
• Healthcare workers and professional
associations
Coordination, collaboration, and commitment among all the
players is crucial to success

17. Conclusion: Advance a Coordinated Agenda
for Preterm and Stillbirth Prevention and
Care
• Scale up what works – practical and feasible
interventions for care
• Improve integration with existing programs
• Address common challenges in the wider
reproductive, maternal, newborn and child
health agenda:
• Access and utilization of quality healthcare

18. Important Resources
Global report on preterm birth & stillbirth: the foundation
for innovative solutions and improved outcomes
www.biomedcentral.com/bmcpregnancychildbirth/supplements/
Born Too soon: The Global Action Report on Preterm Birth
www.who.int/pmnch/media/news/2012/preterm_birth_report/en/index.html
Essential Interventions, Commodities and Guidelines for
Reproductive, Maternal, Newborn and Child Health
www.who.int/pmnch/topics/part_publications/201112_essential_interv
entions/en/index.html

19. Increase Awareness and Visibility of
the Problem
November 17th is World Prematurity Day
For more information visit the March of Dimes
website:
http://www.marchofdimes.com/mission/prematurity_wpd.html

20. Quality vs Coverage gap
• Get from Jim