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

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.

• 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 stake holders

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. Th ey included researchers, healthcare practitioners, UN and government agencies, nonprofi ts, policymakers, and funders. Two dozen co-chairs led an intensive four-day eff ort 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. Th is 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.
Th e 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 specifi c expertise in the given topic.

Summary of workgroup recommendations for the Global Action Agenda
Workgroups identifi ed overarching goals and several key outputs for the GAA. In addition, they identifi ed specifi c milestones, set to a uniform timeline, and metrics of evaluation that corresponded with each output. (See Tables 1-12.) 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 refl ect the consensus reached at the meeting. Additional recommendations received from individuals post-confer ence 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). Th is 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 identifi ed by the twelve thematic workgroups.

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 identifi ed by this workgroup
• Defi ne phenotype of normal pregnancy • Develop animal and in-silico models of normal parturition • Defi ne regulators and mechanisms governing stages of parturition

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 identifi ed by this workgroup
• Determine causes and diff erential susceptibility to infection, and maternal:fetal immune response associated with preterm birth and stillbirth utilizing highdimensional 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 micronutrient exposure contributes to preterm birth and stillbirth

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 identifi ed by this workgroup
• Characterize genetic risks for preterm birth and stillbirth, and identify potentially modifi able environmental infl uences, especially for LMICs • Intensively characterize the "envirome" (xenobiotics, microbiomes, environmental infl uences) relative to the global risks for preterm birth and stillbirth

Epidemiology of preterm delivery Overarching goal
To improve collection, analysis, interpretation, and applica tion of epidemiological data as a basis for interventions to reduce preterm birth

Key outputs identifi ed by this workgroup
• Improve descriptive epidemiology of preterm birth • Improve analytical (risk factor identifi cation) epidemiology • Strengthen data collection and analysis capacity to inform health care policy

Stillbirth epidemiology Overarching goal
Stillbirths are an important indicator of women's health, and accurate collection of data will help infl uence health care providers and policymakers to improve maternal and child health

Key outputs identifi ed by this workgroup
• Ensure the collection of comparable data of highquality, and build capacity • Develop uniform classifi cation for stillbirths • Develop targeted and in-depth population based studies • Inform evidence-based policies and interventions

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

Key outputs identifi ed by this workgroup
• Set and disseminate research priorities • Complete prioritized research and share results • Strengthen research capacity

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 evidencebased and context-specifi c interventions, delivered with high coverage and equity

Key outputs identifi ed 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

Overarching goal
To achieve the maximum reduction in stillbirths and neonatal deaths due to preterm births by implementing eff ective 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 identifi ed 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

Facility-based strategies and constraints Overarching Goal
By 2015 all community members will have timely access to eff ective, aff ordable 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 identifi ed 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 fi rst and referral levels-quality facility-based care is accessible to all mothers, newborns and children in a timely manner • 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 fi nancial and political support for scaling-up a core set of evidence-based, eff ective interventions for preventing and managing preterm birth and stillbirth, and integrate into national policies and guidelines

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 identifi ed by this workgroup
• Identify the range of ethical or social justice considerations that arise along the research pathway, from defi nitions to discovery, development and delivery • Engage scientists and key stakeholders regarding the ethical and social justice considerations identifi ed 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

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 identifi ed by this workgroup
• Eff ective international MNCH leadership to infl uence global health initiatives • Catalyze, facilitate, leverage and provide targeted support to engage national governments to test and/or scale up eff ective interventions • Accelerate progress in the discovery, development, and delivery of low-cost solutions that may be used in all settings

Post-conference momentum
Th is 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: 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. Identifi cation of lead agencies and core team members responsible for implementation must also be identifi ed for each output. Examples of new and ongoing activities identifi ed in the GAA will be posted at www.gapps.org.

A GLOBAL ACTION AGENDA ON PRETERM BIRTH AND STILLBIRTH
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

Success Metrics
A. Defi ne phenotype of normal pregnancy

A GLOBAL ACTION AGENDA ON PRETERM BIRTH AND STILLBIRTH
Overarching Goal: To achieve the maximum reduction in stillbirths and neonatal deaths due to preterm births by implementing eff ective 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

Success Metrics
A. Deploy, strengthen and sustain community health workers (CHWs) at scale 1. Endorse community-based intervention packages as essential to addressing these problems at scale 2. Strengthen the Global report on preterm birth and stillbirth with evidence-based community mechanisms http://www.biomedcentral.com/1471-2393/10/S1/S7 Table 9. Facility-Based Strategies and Constraints

A GLOBAL ACTION AGENDA ON PRETERM BIRTH AND STILLBIRTH
Overarching Goal: By 2015 all community members will have timely access to eff ective, aff ordable and high-quality facility-based MNCH care provided by informed and responsive HWs as part of an integrated and equitable system to reduce perinatal mortality and morbidity

Success Metrics
A. Obtain funding dedicated to a prioritized research agenda