Best practices on caring, reducing preterm babies’ deaths

• 60 Per Cent Die Yearly In Nigeria

Worried by the increase in cases of preterm babies, paediatricians have noted that while the average pregnancy lasts for approximately 37 to 42 weeks, every baby born before the completion of 37 weeks of pregnancy is considered a premature baby.

A preterm baby in an incubator

Statistics have it that in Nigeria, premature babies account for 40 to 60 per cent of all perinatal deaths. In low-income countries like Nigeria, half of the premature babies born die due to a lack of feasible, cost-effective primary care. Many survivors face a lifetime of disability, including learning disability and visual hearing problems.

Consultant Paediatrician at Newborn Unit Lagos University Teaching Hospital (LUTH), Idi-Araba, Lagos, Dr. Beatrice Ezenwa, said unless a medical reason exists, healthy mothers and babies should not be separated after birth and during the early days following birth. Interrupting, delaying, or limiting the time that a mother and her baby spend together may have a harmful effect on their relationship and on breastfeeding success.

She noted that with the advent of the COVID-19 pandemic, the separation and restrictions became worse, limiting or prohibiting access of parents to neonatal care units. Even though evidence shows that separation at this crucial stage of life can result in long-term health and developmental issues in newborns and may impact the mental health of parents.

She explained what obtains after delivery: the mother goes to the lying-in ward, while her baby is cared for in the neonatal wards. Mothers wait long hours to see their babies. Their babies’ visits are often only during feeding times.

She disclosed that because of the increase in preterm cases, Global Alliance for Newborn Care (GLANCE) launched a campaign to raise awareness for the benefits of zero separation of preterm and sick babies and their parents.

She said: “They also felt that the separation restrictions were introduced with no evidence and in conflict with World Health Organization (WHO) recommendations.

The WHO states that: “Mother and infant should be enabled to remain together while rooming-in throughout the day and night and practice skin-to-skin contact, including continuous mother care, especially immediately after birth and during the establishment of breastfeeding, whether they or their infants have suspected or confirmed COVID-19 virus infection.”

It noted that continuous skin-to-skin contact of the infant with the chest of the mother or another caregiver when not possible with the mother and feeding exclusively with breast milk is among the most effective interventions for preventing death in infants with low birth weight.

WHO guidelines currently recommend the initiation of short, intermittent sessions of kangaroo mother care when the infant’s condition begins to stabilise and continuous kangaroo mother care when the infant’s condition has stabilised.

Ezenwa stated that babies placed skin-to-skin on their mothers adjust easily to life outside the womb. They stay warm more easily, cry less, have lower levels of stress hormones, and breastfeed sooner than newborns who are separated from their mothers.

“The benefits of skin-to-skin contact continue beyond the first hour. The longer and more often mothers and babies are skin-to-skin in the hours and days after the birth, the greater the benefit. When a mother and her baby are skin-to-skin, the baby is exposed to the normal bacteria on the mother’s skin, which may protect the baby from becoming sick due to harmful germs. Mothers who hold their babies skin-to-skin after birth are more likely to make greater amounts of breast milk, breastfeed longer, and breastfeed without offering formula.” 

She stated that when skin-to-skin mother care starts as soon as preterm or low birth weight (LBW) baby is born, it significantly reduces mortality by 40 per cent among hospitalised infants. She added that new evidence shows a further 25 per cent reduction when it is initiated immediately after birth, either with the mother or a surrogate.

She said starting continuous mother care immediately after birth has the potential to save up to 150,000 more lives each year, compared with the current recommendation of starting it only once a baby is stable. Immediate skin-to-skin mother care for preterm and low birth weight babies requires dedicated support of the mother, or a surrogate, in providing this immediate, ongoing skin-to-skin contact from birth.

Ezenwa noted that WPD is a global event to raise awareness on the challenges and burden of preterm birth, adding that complications of preterm birth are now the leading cause of neonatal and Under 5 mortalities. “

Public Health Physician and Health Promotion Specialist, 2016 Fellow of Mandela Washington Fellowship for Young African Leaders, Dr. Obinna Ebirim, said government at all levels must make health a priority and strengthen health systems if we must drastically reduce deaths resulting from premature births. He hinted that the emphasis must be on primary health care as over 60 per cent of premature births require services that can be properly managed in standard and functional primary health care facilities.

Ebirim explained that various roles of government in strengthening the health system could be approached from the World Health Organization (WHO)’s six building blocks, namely; leadership and governance, healthcare financing, health workforce, medical products and technology, information and research, and service delivery. The primary health care under one roof (PHCUOR) reform of the current administration that mandates states and the FCT to set up state Primary Health Care Development Agencies (SPHCDA) must be encouraged to improve governance and coordination of primary health care services in Nigeria.

To ensure that poor mothers and newborn babies have unhindered access to care at a cost they can afford, the National Health Insurance Scheme (NHIS) must strive to cover more Nigerians, especially those in the informal sector, with quality healthcare and the government of Nigeria should implement the National Health Act provides that not less than 1 per cent of the consolidated revenue of the federation should be set aside for the basic health care provision fund that caters for basic health care for newborn babies, pregnant women, and the poorest of the society.

Ebirim explained that pregnant mothers must register and regularly attend their antenatal care visits to avoid cases of preterm births. Also, they should adhere strictly to medical instructions, be vigilant and approach the health facility when in doubt or worried about their health with support from their spouses and family. Upon delivery, mothers must ensure that their children are vaccinated at birth, 6 weeks, 10 weeks, 14 weeks, 9 months and during supplementary immunization days as these will reduce the complications of premature babies.

Head Newborn Unit, LUTH, Prof. Chinyere Ezeaka, stated that the challenges of preterm babies are based on fact that they are technically born before they are physically ready to face the world and as such require special care and face a greater risk of serious health problems.

She said because they are not ready for the challenges of survival outside the womb, they require assistance to cope, adding that some of the challenges they face include the inability to maintain temperature, feeding difficulties, breathing difficulties and need for respiratory support equipment, and inability to fight the invasion of their body systems by germs. They may also have exaggerated jaundice, which their liver cannot manage efficiently and their brains cannot tolerate. They can bleed into the brain due to immaturity. In addition, they cannot cope adequately with some of the interventions they require such as medication.

Ezeaka further noted that preterm babies face long term challenges such as complications of being born too soon extending beyond the newborn period throughout the life cycle. After surviving the challenges of the immediate newborn period, they have chronic breathing problems and lung disease, cerebral palsy, intellectual impairment, learning and behavioral problems throughout childhood, vision and hearing impediment, recurrent hospitalization, increase risk of non-communicable diseases like hypertension and diabetes, reduced life attainment with major impact on the society and business. In addition female, preterm babies have a greater risk of having preterm and LBW babies later in life. Thus, prematurity not only affects a newborn directly but can also result in a vicious intergenerational cycle of risk.

She said that preterm babies have challenges to the family and society such as most of these babies are often immediately transferred to the newborn unit for specialized care thereby creating emotional stress for the family especially the mothers. The economic burden and the physical demand on parents are often unquantifiable. In families where there are other children at home, they are often neglected during the period of care. Apart from the care families, the healthcare system is often overburdened, as their care is usually very intensive, requiring more staff than older children and adults.

She said: ”As we countdown to 2030, all countries must accelerate their collective efforts to reduce preventable newborn deaths. There is a great need for intensive advocacy and awareness creation for all stakeholders, government, healthcare workers, non-governmental organizations (NGO), communities and families to take steps to prevent preterm births where possible and support the care of such babies, improve health systems and save lives of the leaders of tomorrow.”