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Every birth a healthy birth

      Progress in understanding and combating pneumonia, diarrhea, and other childhood illnesses has substantially reduced the percentage of children who die worldwide <5 years of age.
      UNICEF
      State of the world's children.
      But child mortality will remain unacceptably high without major research and implementation advances against what has increasingly become a leading cause of death among children: premature birth.
      See related article, page 368
      Each year, 15 million babies are born preterm around the world, accounting for about one-third of the >3 million neonatal deaths.
      • Liu L.
      • Johnson H.L.
      • Cousens S.
      • et al.
      Child Health Epidemiology Reference Group of WHO and UNICEF
      Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000.
      In addition, >2.5 million stillbirths occur each year,
      • Cousens S.
      • Blencowe H.
      • Stanton C.
      • et al.
      National, regional, and worldwide estimates of stillbirth rates in 2009 with trends since 1995: a systematic analysis.
      many of them also preterm. November 17 has been designated as World Prematurity Day, helping draw worldwide attention to the magnitude and impact of the problem and to the millions of babies and families affected each year. As useful as that is in highlighting the importance of preterm birth as a global health and social issue, it will take increased, and more coordinated, action by researchers, funders, and governments to reduce the prevalence of preterm birth worldwide.
      Differing rates of preterm birth and stillbirth among countries and population groups suggest that the incidence of these conditions can be dramatically reduced. But, to achieve wanted reductions requires that we ask, and answer, fundamental questions about both “normal” and “abnormal” pregnancies. In this issue of the American Journal of Obstetrics and Gynecology, Gravett and Rubens
      • Gravett M.G.
      • Rubens C.E.
      Global Alliance to Prevent Prematurity and Stillbirth Technical Team
      A framework for strategic investments in research to reduce the global burden of preterm birth.
      provide a valuable framework to bring together investigators and funders to help pose and answer these fundamental questions. Preterm birth and stillbirth are complex disorders with multiple causes and pathways, and will require complex approaches to tackle them effectively. Much research has focused on the initiation of labor and childbirth; however, while important, these processes constitute just a small part of pregnancy. Understanding the determinants of a healthy pregnancy is one of the most difficult, and literally one of the most vital, issues in biomedical research today.
      Paucity of knowledge about pregnancy and childbirth has, inevitably, led to a paucity of effective interventions to improve pregnancy outcomes. Paradoxically, this creates a tremendous current opportunity to improve the lives of women and their children. The good news is that novel tools and research approaches are now available that can help unravel the formidable complexity of pregnancy and childbirth. Today, researchers can investigate everything from the genome (of mother, fetus, and vaginal and other relevant microbes) to environmental exposures to identify the complex interplay of biology, behavior, and environmental factors that determine the health of a pregnancy. Epigenomics even opens the possibility of understanding how transgenerational effects influence pregnancy and parturition. Integrated investigations of the mother, fetus, and newborn in different contexts and among different population groups can reveal the biological pathways and interactions that result in adverse outcomes and suggest how to prevent or ameliorate those outcomes. Social networking offers the new possibility of linking large numbers of pregnant women in a coordinated effort to use their unique perspectives to better define and understand the parameters of “normal” pregnancy. Other research can help better identify factors that, in various settings, lead to nonmedically indicated early delivery. Implementation research can examine existing interventions–from nutritional modifications to decreasing toxic exposures to improved care during pregnancy to the identification and control of maternal infections–to determine their true efficacy and understand barriers to implementation of the most appropriate and effective ones.
      Major barriers to conducting such research today include global funding levels and insufficient coordination among funders and researchers. These factors, along with the relatively low priority accorded this field and insufficient recent scientific progress, have in turn led to a relative dearth of researchers focused on this critical area. No one funding agency, foundation, or government can marshal all the resources or create the scientific climate needed to prioritize, understand, and prevent complex disorders like prematurity and stillbirth. Models are needed that draw on networks of funders, researchers, and advocates to raise the profile of research on pregnancy and childbirth and to build the necessary human and scientific resources to understand their complexity and to fashion and validate better interventions.
      These new models will require increased awareness and coordination among funders. A key finding by Gravett and Rubens
      • Gravett M.G.
      • Rubens C.E.
      Global Alliance to Prevent Prematurity and Stillbirth Technical Team
      A framework for strategic investments in research to reduce the global burden of preterm birth.
      was that even funders concerned about the problem lack a guiding consensus regarding priority areas for research and the development of interventions. This presents another opportunity: a shared, clear vision of where the field is going would facilitate a systematic approach to prioritizing research investments. A lockstep approach is neither indicated nor optimal; however, a shared vision that allows and even encourages funders and researchers to employ–but coordinate–different emphases, strategies, and approaches would prove helpful to all.
      Coordinated approaches to research on pregnancy and childbirth will yield major advances. Panels of experts could identify critical issues, create innovative transdisciplinary approaches, and help generate calls for proposals. Researchers could apply the newest tools and advances from other fields, including human and microbial genomics, proteomics, immunology, cardiology, infectious disease, and behavioral and social sciences to the study of prematurity and stillbirth. Networks of groups then could investigate the broad and complex range of factors involved in pregnancy and childbirth. It is now reasonable to declare a goal of mapping the “gestome”–all of the factors involved in a healthy pregnancy–and to anticipate achieving it. A focused, coordinated approach could develop the new high-impact and low-cost interventions desperately needed to improve maternal and newborn health around the world. An ancillary benefit of a coordinated effort to this truly global problem in child health is that it will, by necessity, foster global scientific relationships and spur infrastructure development in less research-intensive regions–relationships and infrastructure that could also serve to tackle other important maternal and child health issues.
      The United Nations' Millennium Development Goal 4 calls on the world to reduce the <5-year mortality rate by two-thirds from the 1990s through 2015. This goal cannot be met without a much greater understanding of pregnancy and childbirth. A strengthened commitment to discovery and implementation research, and a global effort to fund and coordinate such investigations could help reach the unassailable global health, economic, and social justice goal that every birth be a healthy birth.

      Acknowledgment

      The author thanks Dr Catherine Spong for her thoughtful review of manuscript drafts.

      References

        • UNICEF
        State of the world's children.
        UNICEF, New York, NY2012
        • Liu L.
        • Johnson H.L.
        • Cousens S.
        • et al.
        • Child Health Epidemiology Reference Group of WHO and UNICEF
        Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000.
        Lancet. 2012; 379: 2151-2161
        • Cousens S.
        • Blencowe H.
        • Stanton C.
        • et al.
        National, regional, and worldwide estimates of stillbirth rates in 2009 with trends since 1995: a systematic analysis.
        Lancet. 2011; 16: 1319-1330
        • Gravett M.G.
        • Rubens C.E.
        • Global Alliance to Prevent Prematurity and Stillbirth Technical Team
        A framework for strategic investments in research to reduce the global burden of preterm birth.
        Am J Obstet Gynecol. 2012; 207: 368-373

      Linked Article

      • A framework for strategic investments in research to reduce the global burden of preterm birth
        American Journal of Obstetrics & GynecologyVol. 207Issue 5
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          Preterm birth and stillbirth are among the greatest health burdens associated with pregnancy and childbirth. Fifteen million babies are born preterm each year, causing about 1 million deaths annually and lifelong problems for many survivors; 3 million stillbirths also occur annually. Worldwide, the number of women and children who die during pregnancy and childbirth exceeds the total number of births in the United States. New approaches could provide a greater understanding of prematurity, stillbirth, and maternal complications of pregnancy and childbirth.
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      • Framework for preventing preterm birth must include contraception
        American Journal of Obstetrics & GynecologyVol. 208Issue 6
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          Thank you for providing the Journal's readership with a focused issue (November 2012) honoring World Prematurity Day and directing attention to novel efforts to reduce the incidence of preterm birth. As stated in the Framework1 and accompanying editorial,2 there are exciting opportunities ahead. Mapping the human Gestome may lead to the identification of effective preterm birth preventative strategies. However, the potential of this approach, or any other, to truly affect the rate of preterm birth will be unrealized unless it is accompanied by a comprehensive approach to improve family planning services.
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