Reducing preterm births and stillbirths 

Reducing preterm births and stillbirths 

• Two global reports released on January 10, 2023 — on child mortality and on stillbirths — prod us to reflect on whether India is doing enough for ensuring the health and survival of every child.

Higher mortality in rural areas

• The report on child mortality — ‘Levels and Trends in Child Mortality’, by the United Nations Inter-Agency Group for Child Mortality Estimation (UNIGME) — estimates that globally, five million children died before their fifth birthday (under-five mortality) in 2021. 
• Over half of these (2.7 million) occurred among children aged 1-59 months, while the remainder (2.3 million) occurred in just the first month of life (neonatal deaths).
• India’s share in these child mortalities was estimated at 7,09,366 under-five deaths; 5,86,787 infant deaths (death before first birthday); and 4,41,801 neonatal deaths. Many of these are preventable. In addition, the Sample Registration System (SRS), released in September 2022, showed wide inter-State variations in child mortality in India. 
• For every 1,000 live births, the infant mortality rate in Madhya Pradesh was six-fold the rate in Kerala. 
• children in rural parts in any age subgroup have much higher mortality rates than their urban counterparts.

Preterm birth challenge

• At the root of many child deaths are two neglected challenges. The first challenge is children being ‘born too early’ (preterm births), which means they are born alive before 37 weeks of pregnancy are completed. 
• This is a challenge because these ‘preterm babies’ are two to four times at higher risk of death after birth in comparison to those born after 37 weeks of gestation. 
• Globally, one in every 10 births is preterm; in India, one in every six to seven births is preterm. India has a high burden of preterm births, which means newborns in the country are at greater risk of complications and mortality.
• Studies have shown that preterm births contribute to one in every six under-five child deaths. However, three out of every four deaths due to preterm birth-related complications are preventable.

Stillbirths challenge

• The second challenge is stillbirths, the subject of the second report titled ‘Never Forgotten’, also by the UNIQUE. A baby who dies any time after 22 weeks of pregnancy, but before or during the birth, is classified as a stillborn.
• Globally, an estimated 1.9 million stillbirths happened in 2021. In 2021, the absolute estimated number of stillbirths in India (2,86,482) was greater than the death amongst children 1-59 months of age (2,67,565). 
• The rates and number of both preterm births and stillbirths are unacceptably high and drive neonatal, infant and child mortalities upwards in India. Thus, they demand urgent interventions.

Little data

• One of the reasons preterm births and stillbirths do not get due attention is the lack of granular and reliable data. 
• Over decades, while countries have strengthened the mechanisms for tracking child mortality, the data on stillbirths and preterm births are scarce. Even at the global level, the first-ever report on stillbirths was released only in October 2020. 
• In India, the SRS report on stillbirths fails the ‘smell test’. Its stillbirth estimates are less than even the lower end of the confidence interval by all other reliable estimates, including a recent peer-reviewed analysis with the use of government data from the Health Management Information System.
• Experts believe that the problem is the lack of timely, granular data on stillbirths from the block, district, and State levels.

Preventing deaths

• The majority of stillbirths and preterm births can be prevented by scaling up known and proven interventions and improving the quality of health services. 
• For reducing both stillbirths and preterm births, the focus must be on: increasing access to family planning services; improving antepartum services such as health and nutrition, including the intake of iron folic acid by pregnant mothers, providing counseling on the importance of a healthy diet, and optimal nutrition; and identification and management of risk factors. 
• The measures to prevent, detect early and manage diseases that put mothers at high risks, such as diabetes, hypertension, obesity, and infections, will also help in reducing preterm births and stillbirths. And it is possible to reduce future neurological complications for preterm babies by ensuring the Kangaroo mother care and early initiation of exclusive breastfeeding, among others.
• Half the stillbirths happen before delivery due to antepartum causes and the remaining during delivery (intrapartum). Monitoring labor and functional referral linkages and improving the quality of healthcare services will prevent stillbirths.

Need of data

• However, the interventions can be best delivered if data on preterm births and stillbirths are better recorded and reported. The maternal and perinatal deaths surveillance guidelines need to be effectively implemented and the International Classification of Diseases’ definition for perinatal mortality must be adopted. 
• The use of this classification will help standardize the causes of stillbirth reporting. Alongside, India needs to identify the hot spot clusters of stillbirths and preterm births for local and targeted interventions.
• In mid-2022, a Delhi-based not-for-profit, the Foundation for People-Centric Health Systems, drafted a report, which was endorsed by seven other organizations and professional associations including the Federation of Obstetric and Gynecological Societies of India and the Indian Association of Preventive and Social Medicine.
• It underscored the need for multi-stakeholder collaboration and flagged the need for better data. It is time for all stakeholders to work together and for health policymakers to take note of these challenges and start interventions.

Policy solutions

• Three weeks from now, the Union Budget will be presented in Parliament. It is likely that the government will list its achievements in the health sector. While achievements should be celebrated, it is equally important that policymakers pause to reflect on the neglected challenges. 
• Stillbirths and preterm births are highly sensitive ‘tracer indicators’ of the quality of maternal and child health services in particular, and overall health services in general.
• In the National Health Policy of 2017, the government committed to investing 2.5% of the GDP in health by 2025. Six years since then, the government’s allocation for health has increased only marginally. Even by the best estimate, it is around 1.5% of the GDP. 
• The Indian government’s investment in health is among the lowest in the world. Yet, there does not seem any urgency on its part to increase funding for health.

Need for more funding

• There are multiple reasons why India’s health system needs more government funding: children continue to die from preventable causes; pregnant women do not receive good quality care; aggregate mortality hides the inequities in health outcomes and the brunt of those inequities is borne by the poorest and marginalized families; and the primary healthcare system is underfunded, and some cosmetic changes along are not enough to improve health outcomes; among others. 
• The two recent reports are reminders that it is time for the government to allocate more funds for health, starting with the upcoming Budget.