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The COVID-19 pandemic is not just a health crisis - it is a full-blown economic and social crisis that is impacting the lives and livelihoods of billions of people. This commentary examines the mutually dependent relationship between health security and universal health coverage (UHC), and how the longstanding underinvestment in both renders us all vulnerable. It also discusses the vulnerability of services for sexual and reproductive health and rights (SRHR) in times of crisis, which is compounded when these services are not included and well integrated into national UHC packages. It concludes with a call for stronger political leadership for UHC and SRHR as the global community strives to \"build back better\" after COVID-19.

Progress There has been no measurable change in global preterm birth rates in the past decade, in any region. A handful of countries have reduced their preterm birth rates, but only marginally (0.5 percentage points annually), and there has been little progress in availability of preterm birth data globally. An estimated 13.4 million (95% credible interval (CrI): [12.3, 15.2 million]) newborns were preterm or “born too soon” in 2020, 9.9% (95% CrI: [9.1, 11.2%]) of births worldwide. Preterm birth complications remained the top cause of under-5 child mortality globally in 2022, accounting for about 1 million neonatal deaths, similar to figures a decade ago. More encouragingly, some countries have improved data systems to better capture preterm birth information and advancements have been made in gestational age measurement, highlighting targeted efforts towards improving data for action. This paper is part of a series based on the report “Born too soon: decade of action on preterm birth”. Programmatic priorities Preventing preterm birth is a critical priority and could be accelerated by focusing on context-specific risk factors, and addressing spontaneous and provider-initiated preterm births, including non-medically indicated caesarean sections. Effective care can prevent 900 000 deaths from complications of preterm birth, particularly among those born before 32 weeks’ gestation. Stillbirths should be included in data, policies and programmes relating to preterm birth. Most stillbirths occur preterm (an estimated 74.3%) and have a profound, long-lasting impact on families. Addressing stillbirths is essential for reducing the overall burden of preterm birth and minimising loss of human capital. Pivots It is important that the data are available and of high quality, plus are used to drive action. We focus on three pivots to improve in the next decade: (1) counting every baby everywhere, including those stillborn, and accurately recording gestational age and birthweight; (2) strengthening national data systems to improve the availability of individual-level data for action, including quality improvement in maternity wards and small and sick newborn care units, plus follow-up for long-term health outcomes including disabilities; and (3) using data to strengthen shared accountability at all levels, from the community to global levels. Plain language summary While improved data and increased global focus on newborn survival are positive steps, the number of preterm births remains high at approximately 13.4 million worldwide in 2020. An estimated 1 in 10 babies were born too soon in 2020, and complications related to preterm birth remain the top cause of death in children under 5 based on latest United Nations estimates. Advancing data collection in a unified way (e.g. a core dataset for preterm births) and data use is foundational for change, counting all newborns, both live and stillborn, and with timely and gold-standard assessment of gestational age. Together we can tackle this challenge affecting every family through data-driven decision making, action and transparency at all levels; from local to national to global. Key findings • Rates: There has been no change in the preterm rate in the past decade. Globally, 1 in 10 babies is born preterm (<37 weeks’ gestation) (13.4 million (95% credible interval (CrI): [12.3, 15.2 million]) newborns were preterm or “born too soon” in 2020, 9.9% (95% CrI: [9.1, 11.2%])). • Deaths: In high-income countries, 9 in 10 extremely preterm babies (<28 weeks) survive; whereas fewer than 1 in 10 survive in low-income countries. Preterm birth accounts for 1 million neonatal deaths worldwide, and was the top cause of under-5 mortality in 2022. • Risk factors: Focusing on known risk factors for preventing preterm birth, and using and improving routine data for the care of preterm babies should be key programmatic priorities. • Data: Counting every baby, including stillbirths, and tracking the care of vulnerable newborns will ensure that all babies are accounted for in future research, providing data for action and accountability.

[...]progress remains insufficient to achieve the necessary reductions in newborn and child mortality to meet the SDG targets by 2030. [...]we place additional emphasis on the follow-up care and support that is needed for survivors of preterm birth and their families. Poverty often limits access to essential services such as prenatal care, proper nutrition, and safe living conditions, which are critical for preventing preterm births and managing complications. Yet, investment in preterm birth prevention and care can unlock more human capital than at any other time across the life course, impacting futures for millions of families and resulting in significant human and economic returns [11, 12]. [See PDF for image] Fig. 1 Navigating Born Too Soon 2012 and 2023 We present updated data and evidence from the 2012 report [6], now examined through a broader lens, including new data on preterm birth rates, trends, risk factors, and advances in measurement globally; maternal health and care relevant to preterm prevention, with an emphasis on sexual and reproductive health and rights; care for small and sick newborns; and implementation learning for systems change, extending beyond preterm care alone.

Progress This paper is a narrative review that takes stock of the progress in addressing preterm birth over the past decade – notably on policies, national plans, innovation, evidence, social mobilisation, and community engagement – to inform future progress on preterm birth. At the global policy level, many countries have strongly supported collective initiatives and resolutions on maternal and newborn health relevant to preterm birth in multilateral fora, most recently through a World Health Assembly resolution calling for a revival amongst the global community on stalled progress for maternal, newborn and child health. Following the adoption of other global plans, like the Every Newborn Action Plan and Strategies for Ending Preventable Maternal Mortality, most countries set corresponding national mortality and coverage targets, and many have national and subnational policies and plans for integrated maternal and newborn health. Adequate financing remains a challenge, and sexual and reproductive health and rights of women and girls are being challenged globally. There have been significant advances in evidence-based interventions for preterm birth prevention and care, reflected in updated World Health Organization guidelines on antenatal, intrapartum and postpartum care, and care for small and sick newborns. The past decade has also seen progress in social mobilisation and community engagement, particularly parent groups and healthcare professional organisations advocating on issues surrounding preterm birth. Polycrisis and vulnerability There are, however, significant challenges that continue to hamper progress on preterm birth. Polycrisis – the interplay of overlapping economic, geopolitical, and environmental crises – compounds existing inequities, especially in places where health systems are already weak. Distinct and overlapping threats from conflict, climate change and the cost-of-living crisis present life-or-death challenges to those already facing extreme vulnerability, particularly women and girls, and small and sick newborns. Preterm birth: a marker of maternal and neonatal health progress in the coming decade The detrimental impacts of preterm birth are felt along the life course and across generations. The success of countries and the global community in preventing preterm births and ensuring high-quality care for mothers and preterm babies serves as a critical measure of progress – or failure – in advancing global efforts to improve maternal and newborn health. Plain language summary Countries have agreed on global plans and resolutions to improve maternal and newborn health. The World Health Assembly recently emphasized the need for renewed efforts in this area. Many countries have set national goals, but implementation remains a challenge as does funding. There have been advances in evidence-based interventions for preterm birth prevention and care, reflected in updated World Health Organization guidelines. Progress has also been made in community engagement, with parent groups and healthcare organisations as leading advocates. However, overlapping crises hinder progress, including conflicts, climate change, pandemics, and the cost-of-living crisis. These crises increase inequities and pose serious risks to women and newborns, especially where health systems are weak. Preterm birth is an important indicator of progress on maternal and neonatal health. How well countries and the global community address preterm birth and provide care for mothers and babies will show their overall success or failure in improving maternal and newborn health more broadly. Key findings • Over the past decade, global and national policy frameworks, targets and plans relevant to preterm birth have been adopted, though significant funding gaps remain. •  Knowledge of ‘what works’ to prevent and delay preterm birth and to care for babies who are born preterm has improved and is reflected in updated World Health Organization technical guidelines. •  The world has flatlined on preterm birth prevention resulting in renewed urgency to learn from and fully leverage knowledge gained over the past decade to accelerate progress in the next decade. •  Overlapping and compounding challenges of climate change, conflict, pandemics and the cost-of-living crisis pose significant direct and indirect risks for pregnant women and preterm babies and must be mitigated. •  Addressing preterm birth is a key component of integrated maternal and newborn health across the continuum of care and along the life course, and a key marker of progress.

Progress needed Preterm birth rates have “flatlined” for a decade with major loss of human capital, hindering progress for many Sustainable Development Goals. Progress on the reduction of maternal, newborn and child mortality needs to accelerate by between 3 and 11-fold to reach national and global targets by 2030. Priorities Actions are required on two tracks: (1) prevention of preterm birth, including better management for women in preterm labour, and (2) provision of high-quality care to vulnerable newborns, including those born into fragile and conflict-affected settings. Together these tracks have potential for high impact in terms of millions of lives saved, and socioeconomic returns on investment. We can and must do more to provide quality and respectful reproductive, antenatal and birth care for all adolescent girls and women, everywhere, and close unacceptable survival gaps for small and sick newborns. New focus is essential on threats beyond the health sector, notably conflict and the climate crisis. Pivots The cost of inaction is too high in every country. Four pivots are central to accelerating action: invest, implement, integrate, and innovate. More specifically these pivots include investments in systems including more skilled human resources; implementation of high-impact interventions with data used for quality improvement and accountability; innovations including new health technologies and also systems and social innovations; plus, integration with levels of the health sector and across sectors and the life-course, with families at the centre. Everyone has a role to play. Increasing speed now, and sustaining progress, requires multi-level leadership including from grassroots movements led by parents and affected people through to heads of state. Some countries provide examples of such change: The United States of America in data identified inequalities by state and ethnicity for preterm birth. Importantly noting drops in donor aid, India has made ambitious investment in the health sector and beyond, and United Republic of Tanzania in multi-level leadership. Changing gears requires the ambition and energy witnessed a generation ago for HIV/AIDS. We have the ability now to ensure that every baby born too soon – and their mothers – can survive and thrive. Our next generation depends on us acting now for more healthy starts and hopeful futures.

Progress The past ten years have seen uneven developments in women's and adolescents' health and reproductive rights. Globally, reductions of maternal and neonatal mortality rates and adolescent birth rates have been achieved along with improvements in coverage of key reproductive and maternal health services. However, preterm birth rates have not changed significantly. There is still large variation in these rates across the world, with the highest rates occurring in South Asia and sub-Saharan Africa. Programmatic priorities Effective interventions based on current clinical guidelines are available that can prevent preterm birth or reduce its negative impacts on newborns. These recommended interventions can be delivered as part of essential health service packages during the preconception, antenatal, intrapartum, and postnatal phases. They encompass comprehensive family planning services that enable women and adolescent girls to determine the timing and number of children they have, and the provision of prevention and treatment-related interventions during pregnancy, childbirth, and the postnatal period that improve maternal and newborn health including reducing preterm births as well as stillbirths. Health system improvements are needed so that all women are reached with these services and that they are provided respectfully and according to standards. Pivots To better prevent and manage preterm births as part of broader goals of improving maternal and newborn health, health systems need to be strengthened so that all women are reached with essential packages of care before, during, and after pregnancy and childbirth. Achieving this and integrating these service packages into universal health coverage strategies requires collaboration across government leaders, civil society members, private sector actors, and development partners. Increasing coverage of antenatal care, institutional delivery, and postnatal care represents an opportunity to improve the quality of care provided during those service contacts including through the provision of interventions that address modifiable risk factors for preterm birth such as prevention and treatment of infections, poor nutritional status, and substance use. Other pivots to enhance the quality of care include using existing tools to optimize the management of preterm birth, such as appropriate use of antenatal corticosteroids, and providing respectful person-centred care for women, adolescents, and families. Plain language summary Over the past decade, progress in women's and adolescents' health and reproductive rights has been uneven. Significant advancements have been made in family planning, antenatal care, skilled birth attendance, postnatal care, and the provision of sexual and reproductive health services. Maternal and neonatal mortality rates have dropped, although the pace of decline has slowed in recent years. Preterm birth rates, however, have remained relatively unchanged across regions, with most preterm births occurring in low- and middle-income countries. Programmatic priorities focus on the health sector's ability to offer evidence-based services to all women that can prevent preterm birth or mitigate the effects on newborns. This can be achieved through the implementation of high-quality service packages during the preconception, antenatal, intrapartum, and postnatal stages, based on current clinical guidelines. Also, well-coordinated intersectoral interventions are needed for countries to achieve substantial preterm birth reductions. Health systems must be strengthened so that they are ready to provide high quality services for the prevention and management of preterm birth, most of which are also effective at improving other aspects of maternal and newborn health including prevention of stillbirths. This requires collaboration among government leaders, civil society, the private sector, and development partners. Integrating sexual, reproductive, and maternal health services into primary health care systems and working towards universal health coverage are critical steps in achieving these goals. To reduce preterm births, service packages that improve women's nutrition, prevent infections and reduce stress and substance use during pregnancy should be scaled up. Additionally, enhancing the quality of care for women and adolescents before, during, and after childbirth is crucial. This includes optimizing preterm birth management with antenatal corticosteroids and providing respectful, person-centered care that values women's voices in the health care context.

[...]the Every Woman Every Child movement attracted more than US$60 billion dollars to women's and children's health between 2010 and 2015, with commitments from over 300 partners.6 The movement has spurred partnership mechanisms to support country-led implementation of the global strategy (2016-2030) - including the Global Financing Facility in support of Every Woman Every Child, the Innovation Marketplace, Unified Accountability Framework and the UN system's health agencies' H6 partnership.1 The global strategy (2016-2030) recognizes that human rights and other fundamental development principles - such as equity, community ownership and development effectiveness - are drivers of transformative change.1 In Peru, principles of equity underpinned a programme of poverty mapping to identify and prioritize reaching poor, rural and indigenous populations with social protection programmes and culturally appropriate, affordable care.7 In Kenya, the institutionalization of human rights principles is benefiting women's health following complaints alleging systematic violation of women's reproductive health rights in health facilities.

The COVID-19 pandemic is not just a health crisis – it is a full-blown economic and social crisis that is impacting the lives and livelihoods of billions of people. This commentary examines the mutually dependent relationship between health security and universal health coverage (UHC), and how the longstanding underinvestment in both renders us all vulnerable. It also discusses the vulnerability of services for sexual and reproductive health and rights (SRHR) in times of crisis, which is compounded when these services are not included and well integrated into national UHC packages. It concludes with a call for stronger political leadership for UHC and SRHR as the global community strives to “build back better” after COVID-19. La pandémie de COVID-19 n’est pas seulement une crise sanitaire, c’est une véritable crise économique et sociale qui a des conséquences sur la vie et les moyens d’existence de milliards de personnes. Ce commentaire examine la relation mutuellement dépendante entre sécurité sanitaire et couverture santé universelle (CSU) et de quelle manière le sous-investissement chronique dans ces deux domaines nous rend tous vulnérables. Il aborde aussi la vulnérabilité des services de santé et droits sexuels et reproductifs en temps de crise, une vulnérabilité qui est aggravée quand ces services ne sont pas inclus et bien intégrés dans les paniers nationaux de la CSU. Il se termine par un appel pour un leadership politique plus énergique autour de la CSU ainsi que de la santé et des droits sexuels et reproductifs, tandis que la communauté internationale s’efforce de « se reconstruire en mieux » après le COVID-19. La pandemia de COVID-19 no es solo una crisis de salud, sino también una crisis económica y social generalizada, que está impactando la vida y el sustento de miles de millones de personas. Este comentario examina la relación mutuamente dependiente entre la seguridad de salud y la cobertura universal de salud (CUS), y cómo la subinversión de larga data en ambas hace vulnerables a todas las personas. Además, discute la vulnerabilidad de los servicios de salud y derechos sexuales y reproductivos (SDSR) en tiempos de crisis, que es agravada cuando estos servicios no son incluidos y bien integrados en los paquetes nacionales de CUS. Concluye con un llamado a mejor liderazgo político para la CUS y SDSR, a medida que la comunidad mundial lucha por ’reconstruir mejor’ después de COVID-19.