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

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 problem1, 2, 3, 4 and contains a call for action with recommended international and national interventions.⁵ 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%).⁶ 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.^7,8

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 1.

Proposed high-level, short- and medium-term SVN roadmap.^a

Pillars	National action	What (the problem)	How	Who
1. Problem recognition: make SVN prevention a health priority	1.1. 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 local
2. Intervention implementation: scale-up quality care for women, particularly during pregnancy and at birth	2.1. 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 academia
	2.2. 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 agents
3. Increased accountability: improved measurement and monitoring	3.1. 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 staff
	3.2. 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 sectors

^aDiscussed and agreed on during the Lima meeting, in November 2023.

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.^9,10 Key drivers of progress included strong civil society advocacy and the equitable implementation of multisectoral interventions, within the context of sustained economic growth.⁹

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.

Contributors

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.

Declaration of interests

None to declare.