With proper care, preterm babies can survive

On November 17, the world celebrates world Prematurity Day to raise awareness of premature birth and the devastating impact it can have on families. 
Premature birth is a growing global health concern and according to the World Health Organisation (WHO), about 13.4 million babies were born preterm in 2020. Worldwide, complications of preterm births are the single largest cause of neonatal deaths and the second leading cause of deaths among children less than five years.

Unfortunately, there is scarcity of literature on the current trend of preterm births in Uganda. According to Dr Jessica Nakibuuka, a neonatal consultant and head of the neonatal unit at Mulago Specialised Women and Neonatal Hospital, each hospital has customised statistics about preterm births and many of them remain unrecorded since they occur in communities that are hard to reach.
Since there are few health facilities that have neonatal intensive care units and many of them are concentrated in urban areas, the existing infrastructure is unable to support such children.
“Our health care system is already overwhelmed by the number of mature patients. We do not have the infrastructure or trained personnel to handle pre-term children, especially in the rural and hard to reach areas,” says Dr Nakibuuka.

In many government hospitals where these facilities are available, preterm babies are congested because private facilities are expensive. The babies have to share the resources in order to survive. However, this comes with a risk of infection, which reduces their survival rate.
The causes of preterm births are categorised depending on the mother, the foetus or structural conditions. Causes related to the mother can include infections such as malaria, Urinary Tract infections, diabetes, hypertension, anaemia, extremes of age, alcohol and drug use, kidney and heart problems, stress, trauma.

Multiple babies and some syndromes such as down syndrome babies are likely to be born before term. Structural conditions such as uterine fibroids, leaking of amniotic fluid and a cervix that is very small usually opens before term.
When, after assessment the doctor realises that they can only save both lives by birthing the baby, he will recommend a C-section as soon as possible. 
“The midwife and the nurses should ensure that the baby breathes within the first hour. Before the mother gives birth to the baby, she is usually injected with dexamethasone and betamethasone to speed up the baby’s lung development. The baby is also given magnesium sulfate injection to prevent cerebral palsy,” Dr Nakibuuka says.

Different needs
According to Marion Kyomugisa, a midwife specialising in the NICU (a nursery in a hospital that provides around-the-clock care to sick or preterm babies) at Nakasero Hospital in Kampala, preterm babies are categorised according to their gestation at the time they are born and their chances of survival increase with older gestation.  Those born less than 28 weeks are extreme preterm, between 28 and 32 weeks are very preterm while 32 to 37 weeks are moderate to late preterm.
“Counselling at this point is critical. The doctor usually draws a plan with the mother on how to manage the baby, depending on their gestation age. Those below 32 weeks usually have not developed the skill of feeding and breathing so they require to be fed through a tube,” Kyomugisa says.

When a baby develops an infection, the doctor may assess and recommend that it temporarily stops taking the mother’s breast milk and instead feed the baby on glucose that is delivered through a cannula.
When the baby stabilises, the doctors will encourage skin to skin contact in what is commonly referred to as Kangaroo mother care. This will help to keep the baby warm and help the mother gain confidence that she can take care of her baby.
Kyomugisa emphasises thorough hygiene even before the mother is allowed into the NICU. The mother should have taken a bath, wash their hands with soap, cover her head, wear a sterile gown, shoes and a mask.
Nakasero Hospital registers between seven to 12 preterm births a month, considering all the categories.

Dr Nakibuuka says about 42 to 45 percent of the births at the hospital are preterm, although they also get referrals from outside the hospital. The cost of having a baby in the NICU at Mulago Specialised Women and Neonatal Hospital is between Shs150,000 to Shs250,000 per day, depending on the baby’s gestation age and condition.
Nakasero Hospital on the other hand charges between Shs600,000 to Shs700,000 for mild cases and Shs1m to Shs1.5m for extremes.
“The greatest challenge with those from other facilities is transportation. They are usually brought here when they are cold with breathing problems. Sometimes, we cannot do much, the reason why we advise early referrals to bring the baby in utero (before the mother delivers),” Kyomugisa says.

Nakayaga’s experience
Rose Nakayaga delivered her baby at 33 weeks. Everything seemed okay until one night in November 2022 when she suffered a leak while sleeping.
“I realised it was not urine so I padded myself and waited for the day to break. In the morning, I made my way to hospital and upon examination, the midwife said the cervix was still closed. The doctor asked that I get admitted so that the baby’s heart is monitored,” she says.

However, the leak became more frequent and the subsequent scans showed the amount of amniotic fluid was reducing and the baby’s heart rate was becoming weaker. 
She was then injected with drugs to fasten the development of the baby’s organs while a counsellor prepared her for a C-section delivery.
“My baby weighed 1.9 kilogrammes at birth and was immediately taken to the nursery. As a first time mother, this was terrifying. I have worked in the hospital for a while and had calmed several mothers in such situations but I could not do anything for myself. I would cry all the time,” she recalls.

Since her baby seemed fine, she hoped to be discharged in a few days but this did not happen. Her baby developed jaundice a week after being in the nursery and was treated under phototherapy. When she was finally discharged, she was excited but also worried since she unsure of how to take care of the baby at home.
“We were readmitted as the doctors monitored how the baby was adjusting out of the incubator. For two days, the doctors and nurses taught me how to feed the baby. Although the cost was high and I had already used all the money on my insurance cover, I had to reach an agreement with hospital administration for the money to be deducted from my salary once I resumed work,” she recalls.

Discharging the baby
Dr Shamim Namugerwa, a paediatrician at Nakasero Hospital, says in developed countries, a preterm baby can only be discharged when they weigh 1.8kgs. However, in Uganda, a child can be discharged at 1.5kgs as long as they do not have other complications.                                                                       
“Other parameters are often considered before the baby is discharged include ability to feed, ability to breathe on their own without any oxygen support as well as ability to regulate their temperature without an incubator,” she says.
Techniques that work
There are strategies, according to Dr Nakibuuka, that are not expensive but have been proved to increase the quality of life for preterm children. They include comprehensive and exclusive breastfeeding, kangaroo mother care, practicing hand washing and minimal handling as well as restricting visitors. 

“These techniques, when applied correctly, reduce hospitalisation, risk of infection and sepsis, boost the immune system of the baby and keep the baby warm,” she says.
Proper management at birth, coupled with routine immunisation and a weekly review, especially in the first month after being discharged minimises the risk of complications for preterm babies in their infancy or adulthood.

Reducing risk
To reduce the magnitude of problems associated with preterm births, Marion Kyomugisa, a midwife specialising in the NICU at Nakasero Hospital, advises mothers to undergo comprehensive preconception care so that risk factors such as anaemia, low body weight (below 50kg), blood pressure and glucose levels, heart and kidney problems, HIV and viral load test, hepatitis, urinary tract infections are managed.

“Mothers should not conceive unless all these parameters are checked. When they are found to have a problem with these, they should have them treated before conception. As soon as a mother conceives, it is important that she goes for antenatal care for proper monitoring,” Kyomugisa says.

WHO recommends about eight antenatal visits before a mother gives birth, especially if she has no complications but can always go to hospital whenever there is need, sometimes more than the recommended times.

During the antenatal visits, doctors advise mothers to sleep under a treated mosquito net and are given fansidar, an antimalaria drug to prevent premature births caused by malaria.