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This article is part of the supplement: Global report on preterm birth & stillbirth: the foundation for innovative solutions and improved outcomes

Open Access Review

Global report on preterm birth and stillbirth (7 of 7): mobilizing resources to accelerate innovative solutions (Global Action Agenda)

Craig E Rubens12*, Michael G Gravett3, Cesar G Victora4, Toni M Nunes1 and the GAPPS Review Group

Author Affiliations

1 Global Alliance to Prevent Prematurity and Stillbirth, an initiative of Seattle Children's, Seattle, Washington, USA

2 Department of Pediatrics at University of Washington School of Medicine, Seattle, Washington, USA

3 Department of Obstetrics and Gynecology, University of Washington, Seattle, WA USA

4 Universidade Federal de Pelotas, Pelotas 96001-970, Brazil

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BMC Pregnancy and Childbirth 2010, 10(Suppl 1):S7  doi:10.1186/1471-2393-10-S1-S7

The electronic version of this article is the complete one and can be found online at: http://www.biomedcentral.com/1471-2393/10?issue=S1


Published:23 February 2010

© 2010 Rubens et al; licensee BioMed Central Ltd.

This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background

Preterm birth and stillbirth are complex local and global health problems requiring an interdisciplinary approach and an international commitment. Stakeholders developed recommendations for a Global Action Agenda (GAA) at the 2009 International Conference on Prematurity and Stillbirth. The primary goal of this GAA is to forge a collaborative effort toward achieving common goals to prevent preterm birth and stillbirth, and to improve related maternal, newborn, and child health outcomes.

Conference participants

GAPPS co-convened this four-day conference with the Bill & Melinda Gates Foundation, March of Dimes, PATH, Save the Children, UNICEF and the World Health Organization. Participants included about 200 leading international researchers, policymakers, health care practitioners and philanthropists. A near-final draft of this report was sent three weeks in advance to help co-chairs and participants prepare for workgroup discussions.

Global Action Agenda

Twelve thematic workgroups, composed of interdisciplinary experts, made recommendations on short-, intermediate-, and long-term milestones, and success metrics. Recommendations are based on the following themes: (1) advance discovery of the magnitude, causes and innovative solutions; (2) promote development and delivery of low-cost, proven interventions; (3) improve advocacy efforts to increase awareness that preterm birth and stillbirth are leading contributors to the global health burden; (4) increase resources for research and implementation; and (5) consider ethical and social justice implications throughout all efforts.

Summary

The conference provided an unprecedented opportunity for maternal, newborn and child health stakeholders to create a collaborative strategy for addressing preterm birth and stillbirth globally. Participants and others have already completed or launched work on key milestones identified in the GAA. Updates will be provided at www.gapps.org.

Background

Despite the significant global burden of preterm birth and stillbirth, these issues have attracted remarkably little attention and investment. Some of this void can be attributed to a shortage of adequate data. As multiple causes and pathways contribute to preterm birth and stillbirth, a comprehensive, interdisciplinary approach is needed to prevent these outcomes.

The Global Action Agenda (GAA) highlights the need for a collaborative, international commitment for the discovery, development, and delivery of cost-effective interventions. Global advocacy efforts are critical to increase visibility and resources for these issues. All efforts must be guided by ethical and social justice principles. These issues are discussed in the first six articles of this global report [1-6].

In May 2009, the Global Alliance to Prevent Prematurity and Stillbirth (GAPPS), an initiative of Seattle Children's, co-convened the 2009 International Conference on Prematurity and Stillbirth with the Bill & Melinda Gates Foundation, March of Dimes, PATH, Save the Children, UNICEF and the World Health Organization. All participants shared a common goal: to improve maternal, newborn and child health globally.

Goals of the International Conference in Seattle, WA, USA

The three primary goals set for workgroups during the conference are outlined below:

• Develop a roadmap of short-term, intermediate, and long-term milestones, including an international research agenda that would lead to new interventions

• Identify the most successful current interventions to improve maternal, fetal, newborn and child health outcomes

• Set the stage for policy action among global stakeholders

Overview of participants

An interdisciplinary group of 185 experts participated in this invitation-only meeting. Participants represented 35 countries, with diverse participation from low-, middle-, and high-income countries. They included researchers, healthcare practitioners, UN and government agencies, nonprofits, policymakers, and funders. Two dozen co-chairs led an intensive four-day effort to develop a comprehensive and coordinated action strategy to improve pregnancy outcomes.

Format of working conference

All participants received a nearly completed draft of articles 1 through 6 of this report three weeks prior to the conference, as well as summary presentations at the beginning of the meeting by the GAPPS team of investigators. This information provided a solid foundation that helped make workgroup discussions highly productive and accelerated the creation of these recommendations for a Global Action Agenda (GAA). Many participants also provided invaluable feedback on the report.

The conference program was composed of an opening session, plenary sessions, and workgroup meetings and presentations. A dozen thematic workgroups included an average of 15 interdisciplinary stakeholders to ensure vigorous discussion and foster continued collaboration beyond the conference. An archived Webcast of the conference is available at www.gapps.org.

Each workgroup was led by two co-chairs with specific expertise in the given topic.

Summary of workgroup recommendations for the Global Action Agenda

Workgroups identified overarching goals and several key outputs for the GAA. In addition, they identified specific milestones, set to a uniform timeline, and metrics of evaluation that corresponded with each output. (See Tables 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12.)

Table 1. Normal Gestational Biology A GLOBAL ACTION AGENDA ON PRETERM BIRTH AND STILLBIRTH

Table 2. Abnormal Gestational Biology A GLOBAL ACTION AGENDA ON PRETERM BIRTH AND STILLBIRTH

Table 3. Genetic and Environmental Factors A GLOBAL ACTION AGENDA ON PRETERM BIRTH AND STILLBIRTH

Table 4. Epidemiology of Preterm Delivery A GLOBAL ACTION AGENDA ON PRETERM BIRTH AND STILLBIRTH

Table 5. Stillbirth Epidemiology A GLOBAL ACTION AGENDA ON PRETERM BIRTH AND STILLBIRTH

Table 6. Intervention Development A GLOBAL ACTION AGENDA ON PRETERM BIRTH AND STILLBIRTH

Table 7. Prioritization of Interventions for Scaling Up A GLOBAL ACTION AGENDA ON PRETERM BIRTH AND STILLBIRTH

Table 8. Community-Based Strategies and Constraints A GLOBAL ACTION AGENDA ON PRETERM BIRTH AND STILLBIRTH

Table 9. Facility-Based Strategies and Constraints A GLOBAL ACTION AGENDA ON PRETERM BIRTH AND STILLBIRTH

Table 10. Advocacy and Policy A GLOBAL ACTION AGENDA ON PRETERM BIRTH AND STILLBIRTH

Table 11. Ethics and Social Justice A GLOBAL ACTION AGENDA ON PRETERM BIRTH AND STILLBIRTH

Table 12. Resource and Development Funding A GLOBAL ACTION AGENDA ON PRETERM BIRTH AND STILLBIRTH

Post-conference, co-chairs and other participants were encouraged to review a draft of the GAA to ensure all salient points were included and provide additional suggestions, including lead agencies and core team members. Recommendations included in the GAA reflect the consensus reached at the meeting. Additional recommendations received from individuals post-conference have not been included unless vetted by the workgroup.

Most milestones are set to be achieved by 2012, and the latest by 2015 to correspond with the United Nations Millennium Development Goals (MDGs). This is a living document that will be updated at least once annually. It will also be available at www.gapps.org. Below is a summary of the overarching goals and outputs identified by the twelve thematic workgroups.

1. Normal gestational biology

Overarching goal

To gain comprehensive knowledge of the biology and regulation of human gestational biology in order to identify pathways and critical junctures to facilitate prediction and prevention of preterm birth and stillbirth

Key outputs identified by this workgroup

• Define phenotype of normal pregnancy

• Develop animal and in-silico models of normal parturition

• Define regulators and mechanisms governing stages of parturition

2. Abnormal gestational biology

Overarching goal

To understand the mechanisms contributing to preterm birth and stillbirth, with emphasis upon infectious, genetic, and environmental factors, abnormal placental vascular development, and early gestational events

Key outputs identified by this workgroup

• Determine causes and differential susceptibility to infection, and maternal:fetal immune response associated with preterm birth and stillbirth utilizing high-dimensional systems biology approaches

• Determine causes of vascular mal-adaptation resulting in abnormal uteroplacental perfusion, fetal growth restriction and abruption associated with preterm birth and stillbirth utilizing high-dimensional systems biology approaches

• Determine if preconceptual and/or antenatal micro-nutrient exposure contributes to preterm birth and stillbirth

3. Genetic and environmental factors

Overarching goal

To determine and reduce the role of genetics, the environment, and their interactions on the burden of preterm birth and stillbirth

Key outputs identified by this workgroup

• Characterize genetic risks for preterm birth and stillbirth, and identify potentially modifiable environmental influences, especially for LMICs

• Intensively characterize the "envirome" (xenobiotics, microbiomes, environmental influences) relative to the global risks for preterm birth and stillbirth

4. Epidemiology of preterm delivery

Overarching goal

To improve collection, analysis, interpretation, and application of epidemiological data as a basis for interventions to reduce preterm birth

Key outputs identified by this workgroup

• Improve descriptive epidemiology of preterm birth

• Improve analytical (risk factor identification) epidemiology

• Strengthen data collection and analysis capacity to inform health care policy

5. Stillbirth epidemiology

Overarching goal

Stillbirths are an important indicator of women's health, and accurate collection of data will help influence health care providers and policymakers to improve maternal and child health

Key outputs identified by this workgroup

• Ensure the collection of comparable data of high-quality, and build capacity

• Develop uniform classification for stillbirths

• Develop targeted and in-depth population based studies

• Inform evidence-based policies and interventions

6. Intervention development

Overarching goal

Generate knowledge to develop new capacities and strengthen existing capacities to improve birth outcomes

Key outputs identified by this workgroup

• Set and disseminate research priorities

• Complete prioritized research and share results

• Strengthen research capacity

7. Prioritization of interventions for scaling up

Overarching goal

Reduce stillbirths and mortality due to preterm birth through development and application of dynamic processes that engages stakeholders for prioritization of evidence-based and context-specific interventions, delivered with high coverage and equity

Key outputs identified by this workgroup

• Advocate use of evidence in prioritization among stakeholders

• Ensure inclusion of preterm birth and stillbirth interventions into existing prioritization processes

• Select best intervention candidates for scale-up in health facilities

• Select best intervention candidates for scale-up in communities and homes

8. Community-based strategies and constraints

Overarching goal

To achieve the maximum reduction in stillbirths and neonatal deaths due to preterm births by implementing effective community-based approaches at high coverage within the continuum of maternal and newborn care. (We aim to achieve by 2020, a one-third reduction in stillbirths and two-thirds reduction in neonatal mortality due to preterm birth in 68 high mortality countries)

Key outputs identified by this workgroup

• Deploy, strengthen and sustain community health workers (CHWs) at scale

• Build capacity of community to identify, promote and monitor actions

• Promote and enhance support structures for CHWs and communities

9. Facility-based strategies and constraints

Overarching Goal

By 2015 all community members will have timely access to effective, affordable and high quality facility-based maternal, newborn and child health (MNCH) care provided by informed and responsive CHWs as part of an integrated and equitable system to reduce perinatal mortality and morbidity

Key outputs identified by this workgroup

• Obtain funding dedicated to a prioritized research agenda

• Provide quality care for all community members attending health facilities

• All facilities provide core packages of MNCH services at first and referral levels—quality facility-based care is accessible to all mothers, newborns and children in a timely manner

10. Advocacy and policy

Overarching Goal

Key actors allocate sufficient resources and support policies, programs, and actions at the global, regional, national, and community levels to ensure safe full-term pregnancies and healthy newborns

Key outputs identified by this workgroup

• Increase funding for research on the scope, causes, consequences, interventions, and scaling-up of interventions for preterm birth and stillbirth

• Increase awareness of the magnitude, impact, and opportunities to reduce and prevent preterm birth and stillbirth, as they relate to the accomplishments of the MDGs

• Build financial and political support for scaling-up a core set of evidence-based, effective interventions for preventing and managing preterm birth and stillbirth, and integrate into national policies and guidelines

11. Ethics and social justice

Overarching goal

To help inform an ethically responsible and culturally appropriate response to the global burden of preterm birth and stillbirth

Key outputs identified by this workgroup

• Identify the range of ethical or social justice considerations that arise along the research pathway, from definitions to discovery, development and delivery

• Engage scientists and key stakeholders regarding the ethical and social justice considerations identified above

• Set a research agenda to address gaps in ethical guidance, policy, and cross-cultural understanding of the ethical issues surrounding the global burden of preterm birth and stillbirth

12. Resources and funding

Overarching goal

Improve coordination and increase global and national funding for preterm birth and stillbirth within the Reproductive, Maternal, Newborn and Child Health (RMNCH) context

Key outputs identified by this workgroup

• Effective international MNCH leadership to influence global health initiatives

• Catalyze, facilitate, leverage and provide targeted support to engage national governments to test and/or scale up effective interventions

• Accelerate progress in the discovery, development, and delivery of low-cost solutions that may be used in all settings

Post-conference momentum

This collaborative strategy to address preterm birth and stillbirth will also help accelerate improvements in maternal, newborn and child health. Progress on these inseparable outcomes depends on a more coordinated and interdisciplinary approach. GAPPS, participants, and other stakeholders have already begun to work on the following four sets of initiatives:

Tell the story

• Within the global health community at the highest levels

• Within the broader community, increase awareness and understanding for the magnitude of the problem

Close the research gaps

• Standardize definitions, classification systems, and data collection

• Accelerate research and alleviate obstacles through increased collaboration

• Accelerate translation of discoveries to interventions

• Improve coordination between intervention development and delivery

• Build in-country research capacity

Support the discovery, development, and delivery of interventions globally

• Scientists, advocates and funders must work together with countries that have the greatest health burden

Collaborate to unlock resources

• Includes resources needed for the discovery of what does and does not work, and for the development and delivery of effective interventions

• Inform advocates and funders with a collective, unified voice

• Improve coordination between funders and opportunities

• Increase funding at global and national levels

Ongoing, interdisciplinary dialogue will continue to be fostered by GAPPS. It is important to note that much of the feedback was to move up the deadline for milestones, as much of the work has recently been initiated or is already in progress. Identification of lead agencies and core team members responsible for implementation must also be identified for each output. Examples of new and ongoing activities identified in the GAA will be posted at http://www.gapps.org. webcite

Authors' contributions

The article was written and reviewed by all authors. The summary section of the Global Action Agenda was based on workgroup recommendations developed by participants during the 2009 International Conference on Prematurity and Stillbirth.

Competing interests

The authors declare they have no competing interests

Acknowledgements

This report was supported by the Global Alliance to Prevent Prematurity and Stillbirth, an initiative of Seattle Children's, through a grant from the Bill & Melinda Gates Foundation. We are especially grateful to the GAPPS Scientific Advisory Council, workgroup co-chairs, and participants at the International Conference on Prematurity and Stillbirth (see Additional File for full report). We also thank Catherine Waszak and Terri Dumala for their superb administrative support.

This article has been published as part of BMC Pregnancy and Childbirth Volume 10 Supplement 1, 2010. The full contents of this report are available online at http://www.biomedcentral.com/1471-2393/10?issue=S1. We thank all members of the GAPPS Review Group for their contributions and review of the seven articles in this report, and list them here in alphabetical order: Fernando C Barros, Maneesh Batra, Zulfiqar Ahmed Bhutta, Anne-Véronique Fajon, Michael G Gravett, Thomas N Hansen, Maureen Kelley, Joy E Lawn, Toni M Nunes, Craig E Rubens, Megan Sather, Cynthia Stanton, Cesar G Victora, and Rachel Zaentz.

References

  1. Lawn JE, Gravett MG, Nunes TM, Rubens CE, Stanton C, and GAPPS Review Group: Global report on preterm birth and stillbirth (1 of 7): Definitions, description of the burden and opportunities to improve data.

    BMC Pregnancy and Childbirth 2010, 10(Suppl 1):S1. OpenURL

  2. Gravett MG, Rubens CE, Nunes TM, and GAPPS Review Group: Global report on preterm birth and stillbirth (2 of 7): discovery science.

    BMC Pregnancy and Childbirth 2010, 10(Suppl 1):S2. OpenURL

  3. Barros FC, Bhutta ZA, Batra M, Hansen TN, Victora CG, Rubens CE, and GAPPS Review Group: Global report on preterm birth and stillbirth (3 of 7): evidence for effectiveness of interventions.

    BMC Pregnancy and Childbirth 2010, 10(Suppl 1):S3. OpenURL

  4. Victora CG, Rubens CE, and the GAPPS Review Group: Global report on preterm birth and stillbirth (4 of 7): delivery of interventions.

    BMC Pregnancy and Childbirth 2010, 10(Suppl 1):S4. OpenURL

  5. Sather M, Fajon AV, Zaentz R, Rubens CE, and the GAPPS Review Group: Global report on preterm birth and stillbirth (5 of 7): advocacy barriers and opportunities.

    BMC Pregnancy and Childbirth 2010, 10(Suppl 1):S5. OpenURL

  6. Kelley MK, Rubens CE, and the GAPPS Review Group: Global report on preterm birth and stillbirth (6 of 7): ethical considerations.

    BMC Pregnancy and Childbirth 2010, 10(Suppl 1):S6. OpenURL