In 2012, the World Health Organization published a global action report on preterm birth and invited experts and stakeholders from over 50 organisations to produce evidence-based solutions that could ensure the survival of the most vulnerable infants.1

However, a decade later, evidence-based life-saving interventions are still not being given sufficient priority and they are not equitably distributed across the globe. Respiratory distress syndrome (RDS) is still the major killer of preterm infants, and access to adequate respiratory support could prevent 42% of RDS-related deaths in sub-Saharan Africa.2

In this issue of Acta Paediatrica, Tooke et al. provide a brief overview of the availability of newborn respiratory care in 49 countries in the African continent.3 Supplemental oxygen, continuous positive airway pressure (CPAP), surfactant replacement therapy and oxygen monitoring are often lacking in this region. So are paediatricians, neonatologists and countries where neonatal nursing is recognised as a specialty. The data were collected by an informal survey of neonatal experts who worked in the most well-equipped public hospital and private facilities but had a knowledge of the wider health provision in their country. CPAP was used in 63% of the government units but more than 50% lacked heated and humidified oxygen. Surfactant was available in 39% of the units. However, preterm infants with RDS would not be provided with CPAP or surfactant in 90% of the major cities with a population above 100,000. No data were available from rural areas. Surprisingly, the availability of CPAP and surfactant replacement therapy was not significantly higher in private facilities. In many centres, one vial of surfactant cost more than the annual earning in sub-Saharan Africa.

The lack of specialised neonatal staff is still an overwhelming problem. According to the expert group, 35 of the 54 African countries in Africa had fewer neonatologists for an entire country than a single western neonatal unit. More than 15 countries reported that the country had one neonatologist or less. Neonatal nursing was only a recognised specialty in 10 countries.

There has been a scarcity of data on neonatal care in Africa. This survey is an important step in understanding the current situations in resource-limited settings. The data were mostly collected from single respondents, which limited the reliability of the results, and a majority of preterm infants were cared for by neonatal services not included in the survey. This underlines the importance of national surveillance so that we can understand the critical gaps in health systems. Future surveys should collect data on average length of stay and estimated medical costs for preterm infants with RDS.

Africa still has the highest perinatal mortality in the world. The rate of preterm birth in Africa is twice as high as in western countries, causing a disproportionally higher burden on health systems. Respiratory support is an essential component in managing preterm infants and calls for robust, cost-effective equipment, proper maintenance and sustained staff training. This survey did not provide any information on the quality of care delivered by the centres that had implemented more advanced respiratory support. CPAP and surfactant replacement therapy are standard treatment in high-resource settings and study sites with highly motivated well-trained staff. In contrast, a nurse working in a resource-limited African setting could care for up to 20 preterm infants. This means that CPAP prongs can hang loosely on the infant's face, single oxygen cylinders deliver inadequate flows to dozens of devices, and families have to buy high-cost surfactant at pharmacies with poor storage routines and limited supplies.

Healthcare disparities cannot remain at these current levels. Americans account for more than 50% of global healthcare expenditures and spend 10600 USD per head of population each year. Sub-Saharan Africa account for less than 1% of global expenditures despite similar sized populations and spend 83 USD per person per year.4 This gap is unacceptably large. High-quality care for preterm infants is a cost-effective but expensive investment in all societies. Data from India, which have pioneered low-cost healthcare innovations, showed that the average cost of caring for infants born at weight 1250−1499 g is 1240 USD. This far exceeds the funding allocated for preterm care in most African settings.5 Low-cost essential health packages have been identified, including antenatal steroids, CPAP, Kangaroo mother care, promoting breastfeeding, preventing cord infections and antibiotics.6 However, there are still knowledge gaps about cost-effective interventions in specific contexts, and less than a quarter of births in Sub-Saharan Africa take place in health centres and hospitals.7 Reduced stillbirth and improved preterm birth survival rates can only be achieved if these countries provide universal health coverage and high-quality delivery services.8

The United Nations Sustainable Development Goals include a target to end preventable death of newborn infants and children by 2030. Due to improved global vaccination rates, preterm birth before 37 weeks of pregnancy is now the most common cause of death and disability among the 135 million infants born each year. One million preterm babies die each year across the globe, and preterm birth is now the leading cause of death for children under 5 years. Time is running out. We urgently need to prioritise the highest impact interventions, and we also need to remain optimistic.

A multicentre trial in four African countries, published in 2021, evaluated the impact of continuous Kangaroo mother care on preterm infants weighing 1000–1799 g.9 Providing this intervention soon after birth improved neonatal survival by 25%. Such interventions should be prioritised in the poorest regions of the world instead of costly therapies such as surfactant replacement therapies. The effectiveness of CPAP in low-resource settings is yet not clear,10 and safety concerns still exist, in particular, because of lack of supervision by physician and frequent staff rotation. Cost-effective and safe practices such as Kangaroo mother care should be higher on the list of priorities. The Helping Babies Breathe curriculum has improved neonatal resuscitation outcomes and could easily be adapted to include a low-cost preterm simulator. Much work remains to be done. Skilled health workers, informed parents, innovative technologies and governments willing to make the necessary investments are inextricably linked with the survival of preterm infants. The time to act is now.

No potential conflict of interest relevant to this article was reported.