What it takes to take a breath

In a rural health clinic, a baby tries to take her first breath.

But her lungs aren’t ready. Because she was born too early, they haven’t developed the slick, soap-like substance that keeps her air sacs from collapsing. Without that substance—called lung surfactant—breathing becomes a desperate, exhausting act.

She’s suffering from respiratory distress syndrome, or RDS, a life-threatening condition that appears within hours of birth in premature babies. Unless she gets treatment, her oxygen levels will plummet and her organs will begin to shut down. In one study from India, every baby born with RDS outside of a hospital setting died. In Ethiopia and Nigeria, RDS is responsible for almost half of all neonatal deaths.

At hospitals in higher-income countries, there’s a way to save her: a liquid form of organically-derived surfactant delivered directly into the lungs. But the procedure requires a highly-trained specialist to guide a breathing tube down the newborn’s windpipe—avoiding the stomach and placing it just right—at a cost of up to $20,000. In many parts of the world, that kind of care simply doesn’t exist.

But what if any healthcare worker anywhere in the world could simply hold a small nebulizer to the baby's face and deliver surfactant as an easy-to-administer inhalant?

This breakthrough—a synthetic surfactant that’s stable enough to be delivered through a nebulizer—is still in development, driven in part by Gates Foundation-supported research at Virginia Commonwealth University and UCLA’s Lundquist Institute for Biomedical Innovation. But its promise is extraordinary: an RDS treatment that costs less to make, doesn’t require a specialist to administer, and eliminates the need for intubation.

In other words, a therapy currently limited to the most advanced hospitals could become accessible in rural clinics and community settings around the world. Even in places with top-tier care, it could make treatment gentler, faster, and easier to deliver. In the United States—where RDS still affects 24,000 newborns a year—it could reduce the risks that come with intubating babies who might weigh only two or three pounds.

It’s the kind of innovation that could help solve one of the most persistent problems in global health: delivering intensive care without an intensive care unit, and helping millions more babies survive their first, most fragile moments.

Since 1990, the mortality rate for children under five has been cut by more than half—an amazing mark of global progress. But another statistic hasn’t fallen as fast: the number of babies who die in their first month of life.

Each year, 2.3 million newborns don’t survive past their first 28 days. And the day a baby is born is the most dangerous day of their life. The single biggest cause of these deaths is prematurity. Nearly 900,000 babies a year die from complications related to being born too soon, including infection, underdeveloped organs, and RDS.

Lower cost, easier-to-deliver surfactant is one way to give newborns a fighting chance, but it’s not the only way. Around the world, simple, affordable interventions already exist to identify at-risk pregnancies earlier, prevent more preterm births, and ensure a healthy birthing experience for mothers. Not only are these tools designed to work in the hardest-to-reach places—many of them start working even before a baby takes that first breath.

One of these innovations is a new type of ultrasound that’s changing who can catch the risks of preterm birth—and where.

Around the world, two thirds of women never get an ultrasound screening during pregnancy. Traditional machines are bulky and expensive, with specialized training required to operate them and interpret their results. In places where medical resources are already stretched thin, these types of ultrasounds are rarely an option.

But now, we have ultrasound devices about the size of a phone that can be operated by a nurse or midwife—no on-site specialist required. They weigh less than a pound. They process scans instantly. Their AI interface automatically detects high-risk conditions, like a shortened cervix or signs of early labor, so patients are referred for further care. And they have built-in telehealth functions to share images with remote specialists when needed.

By finding and flagging risks early, these AI-enabled ultrasounds are giving healthcare workers more time to act. In some cases, that means transferring the mother to a higher-level facility. In others, it means providing her with antenatal steroids—an inexpensive, underused treatment that speeds up fetal lung development—and, when needed, medications that delay labor just long enough for those steroids to take effect.

Early warning is essential, but we can save even more lives by going further upstream, starting with the health of pregnant women themselves.

In many low-income countries, undernutrition isn’t an exception. It’s the norm. And the intense demands of pregnancy make nutritional deficiencies even worse—putting mothers at increased risk of complications or death in childbirth, and raising the odds of early labor, low birth weight, and developmental delays for their babies.

But there’s a surprisingly simple fix: a daily supplement called MMS, or multiple-micronutrient supplementation, developed by the United Nations. It contains 15 essential vitamins and minerals for pregnancy—like zinc to reduce the risk of early labor, folic acid to help prevent birth defects, iron and vitamin D for healthy birth weight, and iodine for brain development. For an entire pregnancy, it costs just $2.60.

If MMS became the standard prenatal supplement in every low- and middle-income country, it could save nearly half a million newborn lives each year—and prevent serious complications in 25 million births by 2040.

The innovations above focus on treating, detecting, and preventing premature birth, a huge threat to newborn survival. But one of the most powerful ways to protect babies, preterm or full-term, is by ensuring their mothers stay healthy through pregnancy and childbirth.

When a woman dies during delivery, her baby is 46 times more likely to die in that first month of life. That’s why any serious effort to tackle infant mortality must also address postpartum hemorrhage—which tragically kills 70,000 women a year and is the leading cause of maternal mortality. Fortunately, two innovations are already helping healthcare workers catch and treat it before it becomes fatal.

The first is a calibrated drape—a simple plastic sheet placed under a woman during delivery that collects blood and shows, through printed measurement lines, exactly how much she’s losing. It gives healthcare workers a fast, accurate way to spot dangerous bleeding before it becomes life-threatening. The second is a one-time, 15-minute iron infusion during pregnancy that treats severe anemia—so if a woman does hemorrhage during childbirth, she’s less likely to experience catastrophic blood loss and more likely to survive.

Neither of these tools is complicated or expensive. But in combination, they can make a life-or-death difference for mothers and the babies who depend on them.

Taken together, these innovations form a chain of survival. They help mothers stay healthy through pregnancy. They detect problems before they become emergencies. They give fragile newborns a fighting chance. And they make it possible for families to celebrate a baby’s birth rather than mourning a loss.

Some of these tools are already saving lives. Others are on the verge of doing so. But their impact will be limited unless we prioritize and fund their delivery, not just their development. The world needs to make sure these innovations don’t get stuck in labs or warehouses—so they can reach the mothers and babies who need them most.