Bill & Melinda Gates Foundation

Can We Cross the Last Ten Feet to Save Newborn Lives from Preterm Birth?

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November 14, 2012

In global health, we often talk about the "last mile problem" – a metaphor for the challenges of getting information, services, and products to the people we are trying to reach. But what if the challenge is mostly about the last ten feet? In other words, the connection of the end-user with a solution is literally around the corner, in the next room, or perhaps in another cabinet in the same room. The solution may be literally within ten feet of reach but still fails to reach those who need it. This may be especially true as it relates to premature ("preterm") birth.

Take antenatal corticosteroids for example. These drugs are routinely given to mothers in preterm labor—before 37 weeks of pregnancy are completed—in high income settings to improve their baby’s chance of survival. The lungs of these babies who are born too early are missing a critical substance called surfactant that would allow them to breathe more easily. Antenatal corticosteroids help the premature baby’s lungs mature more quickly, essentially letting them know that they are about to start breathing air and need to start producing surfactant immediately.

In low-income countries, where premature infants (or preemies) have a particularly heightened risk of dying, antenatal corticosteroids can save the lives and prevent adverse effects of hundreds of thousands of babies annually. In fact, it is estimated that about 400,000 lives would be saved if we could traverse the last 10 feet to get this medication to preterm infants the world over who need it.

In fact, it is estimated that about 400,000 lives would be saved if we could traverse the last 10 feet to get this medication to preterm infants the world over who need it.


Preemies treated with corticosteroids are less likely to be surfactant deficient, less likely to develop respiratory distress syndrome, less likely to need ventilator support (which often is not available in these settings anyway), and are less likely to die.

Smart investments - such as these proven interventions - have the ability to save and dramatically improve the lives of countless mothers and babies, further making the case that international development aid works.

Dexamethasone is a corticosteroid drug proven to be effective in these preterm birth situations and is already listed on the WHO Essential Medicine list to treat allergic reactions and nausea, among other things. Over 90 countries have added it to their essential medicines lists as well, and at about a dollar per course of treatment, it is very affordable as an antenatal corticosteroid.

All of this means that dexamethasone should be available in most health facilities. However, when it is in those health facilities, it’s rarely in the maternity ward. It is kept in other wards for those other indications and other ailments. It’s just ten feet away, but those ten feet can be challenging to cross.

There are a number of theories as to why dexamethasone doesn’t move from one shelf to another at a health center. Perhaps caregivers are not aware that the drug can be used in this way? Perhaps they know, but do not believe it is effective? Perhaps they know it is effective but aren’t sure what dose to give when? But we need to figure this out and address these reasons systematically.

Sometimes caregivers cross those last ten feet after a presentation at a conference that gives them the confidence to administer the drug. Sometimes it takes the Minister of Health mandating its use for preterm births, implementing a check list, and/or training all health personnel. Or maybe what is needed is someone at all the health facilities reminding caregivers daily to use antenatal corticosteroids for moms who are in premature labor.

What is the best way to move this life saving drug the last ten feet? What has been your experience solving the last ten feet problem? Are there other ten-feet problems that you have experienced?

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