Table 1 Main Constraints to Scaling Up Preterm Birth and Stillbirth Interventions in LMICs

Community and

• Insufficient demand for effective and available interventions

Household Level

• Barriers to use of effective interventions (e.g., physical, financial, and sociocultural)

Health Services Delivery Level

• Shortage and distribution of appropriately qualified healthcare providers

• Weak technical guidance, program management and supervision

• Inadequate pharmaceutical products and medical supplies

• Lack of equipment and infrastructure

• Poor accessibility of health services

Health Sector Policy and

• Weak and overly centralized systems for planning and management

Strategic Management Level

• Lack of competent district health management teams

• Weak drug policies and supply system

• Inadequate regulation of pharmaceutical and private sectors

• Improper industry practices

• Poorly functioning health information systems

• Lack of intersectoral action and partnership for health between government, industry and civil society

• Weak incentives to use inputs (e.g., medicines and laboratory tests) efficiently and respond to user needs and preferences

• Difficulty in scaling up successful interventions to the national level

• Monitoring and evaluating programs

• Reliance on donor funding that reduces flexibility and ownership

• Donor practices that damage country policies

Public Policies Cutting

• Government bureaucracy (civil service rules and remuneration, centralized management system, civil service reforms)

Across Sectors

• Poor availability of communication and transport infrastructure

Visibility of the Problem

• Lack of data on the magnitude of preterm birth and stillbirth

   - broad measurement issues (e.g., sources of data)

   - need for better operational definition of stillbirth

   - need to distinguish antepartum and intrapartum deaths

   - need for better measurement of preterm birth (i.e., not based on birth weight)

   - better identification of preterm birth and low birth weight

• Lack of political visibility of the problem of preterm birth and stillbirth at country and international levels

Environmental and

• Governance and overall policy framework

Contextual Characteristics

   - corruption, weak government, weak rule of law and enforceability of contracts

   - political instability and insecurity

   - weak ministry of health

   - low priority attached to social sectors

   - weak structures for public-sector accountability

   - lack of free press

• Physical environment

   - climatic and geographic predisposition to disease

   - physical environment unfavorable to service delivery