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Small vulnerable newborns: the urgent need of strong actions in Peru and the entire Latin America

2024; Elsevier BV; Volume: 34; Linguagem: Inglês

10.1016/j.lana.2024.100748

2667-193X

Luis Huicho, Elisa Vidal-Cárdenas, Tiia Haapaniemi, Per Ashorn, Lourdes Aguero, Erasmo Alayo, Wendy Albán, Laura C. Altobelli, Rosa Ambulay, Federico Arnillas, Carlos Arósquipa, Per Ashorn, Tiia Haapaniemi, Rossana Bautista, Sicilia Bellomo, Magaly M. Blas, Betzabé Butrón, Henry Cabrera Arredondo, María del Carmen Calle, Luis Cam, Amyela Carrasco, Enrique Castañeda, Elizabeth Castillo Espinoza, Marilú Chiang, Felipe Chu, Gabriela Conde, Luis Cordero, Carla Cortez, Lilian Cuba Diaz, Flor de María Pilar Curi Tito, Miguel Dávila, Carlos Delgado, Diego Fano-Sizgorich, MaríaFernandez, Carmen Fernández Sierra, Yenka Flores, Jorge Galdos, Gustavo F. Gonzáles, Carla Gonzales, Jaime Genaro Gonzalez Diaz, Eberth Javier Guzmán Alvarez, Haapaniemi, Cecilia Herbozo, Rosmery Hinojosa, Nelly Huamaní Huamaní, Carlos Huayanay, Lidya Huicho, Luis Huicho, Mirtha Elena Huertas Fuentes, Ofelia León Muñoz, Fabiola Lèon‐Velarde, Ariela Luna, Pilar Mazzetti, Nelly Mercado, Mauro Meza Olivera, Ronald Monasterio Huertas, Óscar J. Mújica, César V. Munayco, Jessica Niño de Guzman, Lucysancy Olivareas, Julio Nishikawa, Guillermo Oriundo, Magali Ortiz Panta, Mónica J. Pajuelo, Karim Pardo, Tania Pariona Tarqui, Ricardo Sánchez‐Peña, Silvia Pessah, Hugo Quezada, Sandra Rado, Ritva Repo, Mary F. Reyes, Rosa Rodriguez Toro, S. López, Celina Salcedo, José Luis Saly Rosas Solano, Teresa Samamé, Laura Sánchez, María Inés Sánchez Griñan, Julio César Sánchez Tonohuye, Roberto Shimabuku, Paul Soplin Alvarado, Mario Tavera Salazar, María Elena Ugaz, Florencia Amada Urtecho Vera, Rodrigo Valladares Morales, Constanza Vallenas Bejar, Jeannette Avila Vargas-Machuca, Sarah María Vega, Pablo Velásquez, José Enrique Velasquez, César G. Victora, Elisa Vidal, Taissa Vila, Marianela Villalta, Amelia Villar, Eugenio Villar Montesinos, Edith Villareal, Víctor Zamora, Brizza Zuazo,

Infant Development and Preterm Care

Each year, approximately 35 million babies—more than 25% of all newborns worldwide–are born too soon (before 37 completed gestation weeks) or too small (birth weight <2500 g or smaller than expected for gestational age and sex). These small vulnerable newborns (SVN) experienced adverse exposures during their intrauterine period, leading to fetal growth restriction, preterm birth, or both. After birth, they will have a markedly increased risk of neonatal death and later childhood mortality. Being born too soon or too small is also associated with stillbirth and multiple morbidities with short-term and long-term adverse consequences, for newborns and their families. For society, there is a major loss of human and economic capital. Therefore, prevention of SVN births is critical both for global child health and for societal development. We can and should devote our best efforts to prevent the birth of SVN, by preventing fetal growth restriction and preterm birth. There are effective and simple interventions that should be widely implemented, but progress is too slow all over the world. A recently published Lancet Series on Small Vulnerable Newborns provides supporting evidence to tackle the problem1Ashorn P. Ashorn U. Muthiani Y. et al.UNICEF–WHO Low Birthweight Estimates Group. Small vulnerable newborns-big potential for impact.Lancet. 2023; 401: 1692-1706https://doi.org/10.1016/S0140-6736(23)00354-9Summary Full Text Full Text PDF PubMed Scopus (31) Google Scholar, 2Lawn J.E. Ohuma E.O. Bradley E. et al.Small babies, big risks: global estimates of prevalence and mortality for vulnerable newborns to accelerate change and improve counting.Lancet. 2023; 401: 1707-1719https://doi.org/10.1016/S0140-6736(23)00522-6Summary Full Text Full Text PDF PubMed Scopus (57) Google Scholar, 3Hunter P.J. Awoyemi T. Ayede A.I. et al.Biological and pathological mechanisms leading to the birth of a small vulnerable newborn.Lancet. 2023; 401: 1720-1732https://doi.org/10.1016/S0140-6736(23)00573-1Summary Full Text Full Text PDF PubMed Scopus (13) Google Scholar, 4Hofmeyr G.J. Black R.E. Rogozińska E. et al.Evidence-based antenatal interventions to reduce the incidence of small vulnerable newborns and their associated poor outcomes.Lancet. 2023; 401: 1733-1744https://doi.org/10.1016/S0140-6736(23)00355-0Summary Full Text Full Text PDF PubMed Scopus (20) Google Scholar and contains a call for action with recommended international and national interventions.5Mohiddin A. Semrau K.E.A. Simon J. et al.The ethical, economic, and developmental imperative to prevent small vulnerable newborns and stillbirths: essential actions to improve the country and global response.Lancet. 2023; (published online May 8)https://doi.org/10.1016/S0140-6736(23)00721-3Summary Full Text Full Text PDF Scopus (3) Google Scholar Concrete actions at regional and national levels should follow. We need to speak loud and clear, so the SVN are included as a top priority in the global and national agendas. The 2023 Lancet Series on SVN was presented and discussed in Lima, Peru, on 30 November 2023, as part of a series of regional launches, with the participation of co-authors, members of the academia, other stakeholders of public and private sectors, and the civil society. There was a lively discussion about the current situation in the world, in Latin America and in Peru, and several valuable ideas were provided by the participants on the way forward. In Latin America and the Caribbean (LAC; represented in this reference by Argentina (2017–2018), Brazil (2010–2021), Chile (2000–2021), Mexico (2000–2021), Peru (2010–2021) and Uruguay (2010–2021)), of all reported live births between 2000 and 2021, 12.6% were SVN, representing over 6.7 million newborns, with Peru being on the top-three rank for all four types of SVN. At country level, from 2010 to 2021, over 11% of all Peruvian newborns were SVN, amounting to over 330,000 newborns, mostly due to preterm newborns adequate for gestational age (5.2%) and full-term babies small for gestational age (4.6%).6Suárez-Idueta L. Yargawa J. Blencowe H. et al.Vulnerable newborn types: analysis of population-based registries for 165 million births in 23 countries, 2000-2021.BJOG. 2023; ([published online ahead of print, 2023 May 8])https://doi.org/10.1111/1471-0528.17505Crossref Scopus (9) Google Scholar The SVN problem is surely concentrated among the poorest, in the most remote areas and indigenous communities, which will ultimately influence the response strategies, likely requiring a territorial approach. However, all segments of the population are affected, as the continued high caesarean section rates show in Peru and the whole region.7Quezada-Pinedo H.G. Cajachagua-Torres K.N. Guzman-Vilca W.C. Tarazona-Meza C. Carrillo-Larco R.M. Huicho L. Flat trend of high caesarean section rates in Peru: a pooled analysis of 3,376,062 births from the national birth registry, 2012 to 2020.Lancet Reg Health Am. 2022; 12: Nonehttps://doi.org/10.1016/j.lana.2022.100293Summary Full Text Full Text PDF Scopus (3) Google Scholar,8Betran A.P. Ye J. Moller A.B. Souza J.P. Zhang J. Trends and projections of caesarean section rates: global and regional estimates.BMJ Glob Health. 2021; 6e005671https://doi.org/10.1136/bmjgh-2021-005671Crossref PubMed Scopus (379) Google Scholar During the launch event in Lima, key recommendations for action proposed in the Lancet series were explored, further discussed, and consolidated in a proposed high-level National SVN Roadmap that takes into account the particular context of Peru (Table 1), whose salient aspects include the importance of: 1) integrating systems and ensuring data quality, 2) generating data and disseminating findings by the academia, 3) making the SVN part of the public agenda with close participation of the civil society to help ground the issue and help prioritize it, and 4) designing an "SVN Peru Plan" and promote for it to be included in the national plans along with the necessary investment.Table 1Proposed high-level, short- and medium-term SVN roadmap.aDiscussed and agreed on during the Lima meeting, in November 2023.PillarsNational actionWhat (the problem)HowWho1. Problem recognition: make SVN prevention a health priority1.1. Develop or integrate within other national plans•SVN not on the national agenda•Weak communication and leadership, political instability•Low budget execution, fiscal policy not aligned to health policy•Introduce SVN in the national agenda•Resume successful national experiences (e.g., childhood stunting)•Include SVN in country budget allocation•Multiple actors, regional and local2. Intervention implementation: scale-up quality care for women, particularly during pregnancy and at birth2.1. Ensure early start of high-quality antenatal and childbirth care for all pregnant women•Interventions focused on treatment•Community health agents not formally recognized.•Decentralization: a pending agenda•Reverse the curative approach strengthening the primary level•Work with other programs/sectors to face challenges, create synergies and amplify impact•Multiple actors•Incorporate community health agents•Work with the academia2.2. Scale up interventions; include them as part of Universal Health Coverage•Antenatal care not focused on quality•Ministry of Health's approach not linked with the community•Focus on quality antenatal care•Work with communities, supported by community health agents•Multiple actors; include community health agents3. Increased accountability: improved measurement and monitoring3.1. Date all pregnancies, weigh all newborns and stillbirths and collate data on preterm and SGA newborns•Low coverage of antenatal ultrasound•Registry of stillbirths insufficient•Deficient information systems, without budget allocation•Expand coverage of antenatal ultrasounds•Strengthen the vital events registration system•Integrate systems and ensure data quality•Healthcare professionals•Information systems staff3.2. Promote societal level action with a multi-sectoral approach•Lack of an equitable multisectoral approach•Weak governance and accountability•Lack of regional and local evidence•Strengthen equitable multi-sectoral actions and accountability mechanisms, building on previous experiences•Generation and dissemination of data by academia•All sectorsa Discussed and agreed on during the Lima meeting, in November 2023. Open table in a new tab Peru has a long tradition of successful efforts in the process of achieving substantial progress in reproductive, maternal and child health. It was able to reduce dramatically in the last two decades the under-five mortality rate, the under-five stunting prevalence and the neonatal mortality rate, although huge gaps remain, particularly between the rural and urban areas and between the richest and the poorest segments of the population.9Huicho L. Segura E.R. Huayanay-Espinoza C.A. et al.Child health and nutrition in Peru within an antipoverty political agenda: a Countdown to 2015 country case study.Lancet Glob Health. 2016; 4: e414-e426https://doi.org/10.1016/S2214-109X(16)00085-1Summary Full Text Full Text PDF PubMed Scopus (87) Google Scholar,10Huicho L. Vidal-Cárdenas E. Akseer N. et al.Drivers of stunting reduction in Peru: a country case study.Am J Clin Nutr. 2020; 112: 816S-829Shttps://doi.org/10.1093/ajcn/nqaa164Summary Full Text Full Text PDF PubMed Scopus (25) Google Scholar Key drivers of progress included strong civil society advocacy and the equitable implementation of multisectoral interventions, within the context of sustained economic growth.9Huicho L. Segura E.R. Huayanay-Espinoza C.A. et al.Child health and nutrition in Peru within an antipoverty political agenda: a Countdown to 2015 country case study.Lancet Glob Health. 2016; 4: e414-e426https://doi.org/10.1016/S2214-109X(16)00085-1Summary Full Text Full Text PDF PubMed Scopus (87) Google Scholar Building on this rich experience, Peru is in a unique position to tackle successfully the challenge posed by the SVN. But it needs to recognize the problem and define it clearly, to appropriately reorientate the strong advocacy role of the stakeholders earlier involved so effectively in the advancement of the Reproductive, Maternal, Newborn and Child Health (RMNCH) agenda, engage them in the SVN particular challenges, and to persuade technocrats to invest in the design and implementation of existing interventions for SVN. We acknowledge that while this proposed action plan is only a first step in the complex process to effectively tackle the problem, it is a necessary one. We are confident to boost with this appeal further discussion on the SVN in Peru and the entire LAC region. All authors conceived the paper. LH and EVC prepared the first draft of the manuscript. All authors provided critical scientific and editorial input to improve the manuscript. All authors approved the submitted version. None to declare. Download .xlsx (.02 MB) Help with xlsx files Supplementary File