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World Prematurity Day
"Gone to the temple"

Anthony Costello, Director of the WHO Department for Maternal, Newborn, Child and Adolescent Health

Commentary
17 November 2015

She was only 2 hours old. Bright scarlet from the blush below her thin, porous, premature skin, she weighed in at well under 4 pounds. A fine down of moist hair covered her back and, though tiny, she was lively, kicking out with a lusty squeaky cry. A ‘32 weeker’ I guessed, about 2 months premature. Back in London she would have been transferred to a warm special care baby unit under the care of an experienced newborn nurse who would watch like a hawk for worrying signs like coldness, breathing problems, a change in colour, vomiting, a flick in temperature or any other hint of infection. Her blood sugar would be monitored and her fluid intake recorded. A thin feeding tube would be threaded through her nose to provide expressed breastmilk. Any sign of deterioration and a specialist paediatrician would be called.

Anthony Costello, Director of the WHO Department for Maternal, Newborn, Child and Adolescent Health

But in rural Nepal, in a small run-down district hospital in the western hills, 2 days walk from a road, the staff rarely saw newborns, let alone premmies. At that time, 25 years ago, 9 out of 10 mothers delivered at home. The nurse on duty that night wasn’t trained. The ward was cold with just 2 postnatal beds. Old ladies in heart failure, young men with fractures, a woman unconscious with meningitis, and knots of relatives shared the space. There were no feeding tubes, thermometers, blood tests or baby monitors to spot shallow breathing. No electricity for an incubator. The doctor was away and I’d been called in from a neighbouring Save the Children project.

I spent 3 hours with her mother, Laxmi, and the ward nurse. We went through skin-to-skin nursing (or kangaroo mother care) to keep her baby warm, how they could monitor the baby’s temperature by touch, and how to use a silver paladay (a shallow cup with a narrow lip) to help Laxmi drip feed the baby with her expressed breastmilk. I was optimistic. There were no signs of infection and Laxmi’s waters had broken only an hour before she delivered. She was only here because she’d come to the market. Being her second baby Laxmi was confident about breastfeeding and baby care. As a precaution I left some antibiotic drops with the nurse. At 10pm I walked home by moonlight and set my alarm.

"We need the political will, finance, advocacy and skills to ensure that every woman and every child have the best chance for a safe delivery."

Anthony Costello, Director of the WHO Department for Maternal, Newborn, Child and Adolescent Health

I rose at dawn and hurried back to the hospital. When I got to the ward the nurse shrugged. Laxmi had disappeared. Her daughter had died after midnight and she had had to walk the 6 hours home to feed her buffalo and her other child. She had wrapped her dead baby in a sheet and gone to the temple in the holy forest to find a Brahmin priest. I was shocked into silence. In London the baby’s chances of survival would have been better than 98%. With basic newborn nursing, nothing high tech, she would have stabilised and thrived. No rocket science, just attention to detail - skilled monitoring of warmth, breathing, hygiene, early breastfeeding, prompt treatment for any signs of infection, and keeping the baby close to mum. The cause of her death was uncertain. Perhaps she got cold, or her blood sugar dropped precipitously, or her breathing had stopped briefly and she hadn’t been stimulated. We won’t know for sure.

This tragic case happened long ago when I worked in the magical mountain villages of the Himalaya, when 1 in 10 infants and 1 in a hundred mothers died after childbirth. Those figures have since halved, but survival of preterm infants in Nepal and about 70 other resource-poor countries remains low. On 17 November, World Prematurity Day, we advocate for systems of care that will prevent up to a million needless deaths of preterm babies each year. We’re not talking about the most extreme cases, really tiny babies that can only be saved with high-tech neonatal intensive care units and months of support from ventilators and drips. We mean instead the basic nursing care and simple equipment that will save the lives of most babies born too soon, things like kangaroo mother care, inexpensive medicines and access to oxygen, as recommended in WHO’s guidelines to improve survival of preterm babies.

Based on this scientific evidence from WHO, the United Nations has a clear strategy to cut newborn deaths: to invest in care during labour, birth and the first days of life; to improve the quality of maternal and newborn care; to reach every woman and every newborn including the poorest; to harness the power of parents, families and communities; and to count every newborn so we can track births and deaths and monitor what we do. And all of these efforts must be backed up by strong health systems that can provide quality services to all people, whenever and wherever they need them.

More than half of under-five deaths happen in the newborn period. If we want to achieve our development goals, we need the political will, finance, advocacy and skills to ensure that every woman and every child have the best chance for a safe delivery. We can do it.