by In a pristine, organised room a repeating beeping sound is suddenly masked by high-pitched crying, followed by sighs of relief as a baby is born. Right on time and at a healthy weight, the baby has already avoided a whole range of risk factors that would stand in the way of a healthy development. But the same cannot be said for about one in every four of their fellow newborns, who are born too small or too early; a “Small Vulnerable Newborn”.
This new term was introduced in a series of papers published in the Lancet by an international collaboration of researchers spanning countries from Finland and the USA to Kenya and South Africa. The research sketches the scale of the issue, particularly in Low and Middle-Income Countries (LMICs), bringing together findings on the context, causes, and consequences of being born too small or too early, and grouping these cases under the umbrella term “Small Vulnerable Newborns” (SVNs). In doing so, they provide “a better framework on how to address this group unitedly; one giant group coming from the same pile of risks and having some of the same associations later in life”, explains Dr. Nanna Maaløe, assistant professor at the University of Copenhagen, whose research focuses on global health during pregnancy and childbirth.
“We know much of this already”, she continues. “We know we have a major stillbirth issue globally. We know we have a major preterm birth issue. We know that we have a major issue with intrauterine growth restriction. And we already know that stillbirths and neonatal deaths – both groups are associated with what you can call an ‘epidemic of grief’”.
The Small Vulnerable Newborns Series
Over half of the newborn deaths in 2020, as well as the majority of the 1.9 million stillbirths each year, are associated with being SVN. But the issues extend beyond birth: “If you are born vulnerable and you survive your newborn period, then you are at increased risk of morbidity and too early mortality throughout life”, adds Nanna.
But what causes the birth of an SVN? The causes and complications that lead to being born prematurely may differ from those leading to being born too small, but undernourishment, psychological stress, and environmental exposure are examples of factors affecting both. A mother who is constantly under stress, or does not have access to proper nutrition, is more likely to give birth to a newborn that is vulnerable. Thankfully, at each stage of the pregnancy where things may go astray, there are interventions that can reduce that risk. Protection against infections, supporting better nutrition, and healthier living conditions can be positive changes to the life of an at-risk mother, making it more likely that she will give birth to a healthy baby. “These risks for the babies are closely related to the woman’s risks during pregnancy and childbirth; working on these risks is a way to improve the health of both the woman and her baby”, adds Dr. Maaløe, emphasising the dimension of women’s health, a facet of the issue that is arguably underexplored in the series.
The researchers list proven interventions that can help with the prevention of SVN births, including nutrient supplements, low-dose aspirin, and psychosocial interventions for smokers. Some of the interventions, such as insecticide-treated bednets are better suited for specific subgroups of at-risk mothers, while others, like screening and treatment for syphilis, work positively for all cases. In addition to these, potential interventions such as omega-3 supplements appear promising but are in need of further research.
Carrying the Burden
While being born an SVN is a danger globally, not all parts of the world suffer equally. “The burden of SVN and stillbirth is highest in South Asia, Sub-Saharan Africa, and in humanitarian contexts”, state the authors, “hence activities need to focus especially on these settings”.
Global commitments have been made to tackle the issue, yet progress has been stagnant in the past decade. The authors trace the lack of progress to “inadequate response” and close the series with a call for all countries to reduce the number of SVNs and stillbirths through action based on three pillars: problem recognition, intervention implementation, and increased accountability.
Particularly for the first and last pillars they place importance on routine health data, which has been inconsistent or lacking, making it harder to understand the issue. This is part of why the series introduces the new term of SVNs, grouping three types of vulnerable babies. Their aim is to streamline and refine data collection, the central role of which is underlined by Dr. Maaløe’s assertion that “what is measured, will most likely change, and what we see with stillbirth, preterm birth, and low birthweight, is that overall, it is largely underestimated, undervalued in statistics and in global progress reports”.
The death of a newborn is in itself a tragedy. However, SVNs are not a problem confined to the morbidity of mortality. It is indicative of, and contributes to, a wider issue in the plagued communities which run the risk of being locked in a vicious cycle where (surviving) SVNs live vulnerable lives, leading to a ‘vulnerable society’ perpetuating the conditions that make future mothers vulnerable. And so the cycle continues, making this an issue of sustainable development disproportionately affecting less affluent countries.
This sentiment is echoed by Nanna Maaløe who, in her experience working with some of the most congested hospitals in countries like Tanzania, has seen this discrepancy. Referring to the Lancet series, she states: “At the current speed, it will take 160 years before a woman in Sub-Saharan Africa has the same chance of giving birth to a live baby as a woman in Denmark has now”. She poignantly adds, “The progress is so slow, and we know what to do about this”.
Bridging the Gap
We can no longer evade the question that is looming since Dr. Maaløe’s “we know much of this already”; what are we doing about it? The intention appears to be there: as the authors of the series state, “Embedded in the UN’s Sustainable Development Goals is a roadmap to break the cycle of poverty and disadvantage perpetuated by poor health in childhood and adolescence, giving rise to vulnerable pregnancy and infancy”. And yet, the results are falling short of expectations.
The World Health Organization (WHO) provides clinical guidelines for contacts throughout the period of pregnancy. However, both the Lancet series and Nanna agree that often in LMICs, the guidelines do not lead to the predicted outcomes; “There persists such a crucial gap between clinical guidelines from, for example, the WHO, and reality”, Nanna comments, further reinforcing the importance of a focus on implementation, the second pillar in the series’ call-to-action. Pointing at the series, she highlights the main point: “What is very much the message here, is the ‘evidence-practice gap’; how come we know, but we don’t do”.
Both appear to promote the need for a ‘horizontal approach’, with a broader focus on the health system and the context within which it operates; a context which in many LMICs is characterised by inadequate infrastructure, over-congested facilities and poverty, all within rapidly expanding urban settings. A case exemplifying these structural factors is Dar es Salaam, Tanzania’s largest city, the world’s second fastest growing metropole, and one of the foci of Nanna’s work within the PartoMa Project for creating guidelines that account for the realities of the setting and of those who work within it.
She paints a powerful picture, describing real situations from overwhelmed clinics, with up to six women in labour at the same time sharing just one inexperienced and overworked attendant, whose only guidelines “show them an ideal reality that they can never live up to in the current clinical setting”. “One of the root causes of these major issues of evidence-practice gaps are dysfunctional, sick health systems”, Nanna concludes. In a manner analogous to the health of the mother determining the health of the baby, such challenges are ‘birthed’ from the afflictions of the health sector; an unhealthy baby from an unhealthy mother.
It is necessary then for any guidelines to be contextualised, taking into consideration the conditions under which the healthcare providers work, or as Dr. Maaløe puts it: “That gap shouldn’t be there; we should understand that we develop clinical guidelines for the front line, with the front line. We are serving them”.
Perhaps then the solution lies in strengthening the respective health systems with due consideration for specific circumstances, rather than in detached research approaches. “In Tanzania, many governmental people say that they are so tired of ‘pilotism’, pilot studies, at a time when we have so many things that have never been implemented”, recounts Nanna, who has been focusing on co-creation of clinical guidelines; collaborating with frontline healthcare providers and local women, relying on their tacit knowledge and experiences of the issues faced in these settings to develop guidelines “localised to their reality”. Whether that entails adapting the current WHO guidelines to be applicable to specific circumstances or adding ones that address the issues faced in this context, the objective is a pragmatic one: “As long as some women are sharing one birth attendant with five other women, there must be guidance for that overwhelmed birth attendant to prioritise between them”. A cooperative approach, which appears both the most effective and most equitable avenue for accelerating progress in this field.
Thinking Global
The new Lancet series, as well as Dr. Nanna Maaløe, operate within a similar paradigm, one of “thinking global”, rejecting the demarcation of this type of research as ‘low resource health system research’. Rather, viewing these challenges and those working on them as they are: global health challenges tackled by global health providers. A horizontal and dialogue oriented approach, an outlook on research where one can say that “in a way, this is ‘research activism’; this is making research matter”, as Nanna said of the series. Where research is mobilised in service to those at the front line of healthcare, arming them so that they can, in turn, serve the women who need them the most.
In examining the issue of Small Vulnerable Newborns, we find it tethered, as if by an umbilical cord, to a larger systemic issue we are called upon to collaboratively resolve. Hence in addressing the issue of babies born too small or too early, we are confronted with an issue neither too small, nor too early to prioritise.
