Delivering India from preterm births

Every year almost three and half million babies are born premature in India which accounts almost for 13% of births in the country. A premature baby is defined as a baby born alive before 37 weeks of pregnancy. The duration of normal pregnancy is 40 weeks. The sub-categories of preterm birth, based on gestational age include, extremely preterm (<28 weeks); very preterm (28 to <32 weeks); moderate to late preterm (32 to <37 weeks).

Majority of countries show an increase in preterm birth rates over the past 20 years owing to increase in maternal age, underlying maternal health problems such as diabetes and high blood pressure, greater use of infertility treatments, increased rates of multiple pregnancies and changes in obstetric practices such as more Caesarean births before term.

Causes of prematurity

Pregnant women have an increased risk of preterm delivery if they are younger than 17 years or older than 35 years. The commonest causes of preterm delivery are:

• Previous preterm birth, poor nutrition of mother

• Weak cervix or abnormal uterus

• Pre-existing diseases in mother like diseases of heart, kidney, lung and liver

• Hypertensive or diabetic mothers

• Infections like urinary tract infection during pregnancy

• Premature rupture of membrane and multiple pregnancies

While many babies survive, some don’t even make it past their first day. In 2016, an estimated 2,600 children died within the first 24 hours of their birth. For almost two million newborns, their first week was also their last. In all, 2.6 million children died before the end of their first month.

The neonatal death rate due to premature birth stands at a staggering 43% owing to prematurity and low birth weight. Further, the rate of neonatal mortality in India is 6 to 35 per 1,000 live birth in different states with the first month varying from 6 out of 1,000 in Kerala to 20 out of 1,000 in Telangana and 35 out of 1,000 in Madhya Pradesh.

Furthermore, inequalities in survival rates around the world are stark. Half of the babies born at 24 weeks survive in high-income countries, but in low-income settings, half the babies born at 32 weeks continue to die due to a lack of feasible, cost-effective and basic care for infections and breathing difficulties.

However, a majority of neonates born after 32 weeks can be saved with simple interventions and support.

Pregnancy care

For a healthy baby, the care should start from a very early stage before pregnancy. Marriage at a proper age and first pregnancy play an important role in preventing the complications of pregnancy. Adolescent pregnancies have a higher risk of adverse birth outcomes, with a 50% increased risk of stillbirths and neonatal deaths for which balanced protein and energy supplements are required.

Good nutrition of mother and supplementing them especially with iron, calcium, folic acid is very important. Further, regular antenatal visit, screening of pregnant mother for anaemia, hypertension and diabetes and preventing infection is necessary for better outcome.

In cases of preterm delivery (34 weeks of gestation), the mother should be given steroids. Antenatal steroids help in reducing the incidence of breathing problems in preterm neonates after birth. Further, magnesium sulphate to prevent future neurologic impairment in the child should be administered to mother in case of preterm delivery.

Promoting hospital delivery and good care at the time of labour and child birth is crucial. Keeping cord clean and dry, vaccination and exclusive breast milk will improve the outcome of neonates.

Maintenance of temperature, treating respiratory distress, kangaroo mother care, safe oxygen use, prevention of infection and good nutrition will help in saving many preterm babies.

Checking preterm delivery

• Family planning, including birth spacing and provision of adolescent-friendly services

• Improved quality of care before, between and during pregnancy

• Increased empowerment, education and health promotion for women, especially adolescents

• Prevention and screening/management of sexually transmitted infections

• Promoting healthy nutrition including micronutrient fortification and addressing lifestyle risks, such as smoking, and environmental risks, like indoor air pollution

Care of premature baby

• Essential and extra newborn care, especially feeding support

• Neonatal resuscitation

• Kangaroo mother care

• Management of premature babies with complications, especially respiratory distress syndrome and infection

• Comprehensive neonatal intensive care

(The writer is Director Intensive Care Services, Rainbow Children’s Hospital)