The rise in the number of babies born too soon has become a public health issue in many countries including Sri Lanka despite the country’s record of having the lowest maternal and infant mortality rates in South Asia. Numerous studies have endorsed the fact that pre-term birth puts the infant at increased risk of several life threatening medical complications .
With World Prematurity Day being observed a few days ago on November 17 , The Sunday Observer spoke to Senior Consultant Neonatologist, University Unit, De Soysa Hospital for Women, Colombo, and Senior Lecturer, Department of Paediatrics, University of Colombo, Dr Nishani Lucas to find out more about this emerging health concern and how it could be resolved.
Excerpts
 Dr Nishani Lucas |
Q: World Prematurity Day which was observed on November 17, was a day where global attention was focussed on what is widely believed to be the leading cause of child deaths under five years . As a Consultant Neonatologist familiar with health issues of new born babies , can you tell our readers who is considered a premature baby?
A. A baby that has not reached full maturity at the time of birth and is born before completion of 37 weeks is identified as a premature baby.
Q: So , how long does a full term pregnancy last for?
A. A full-term pregnancy lasts an average of 40 weeks (38 – 42 weeks) from the day of the last menstrual period to the day that the baby is born. The word “term” is used to denote “maturity.”
Q: What does a premature baby weigh normally?
A. The weight of the baby will change with the degree of prematurity. Babies who are born earlier around 24 weeks gestation can weigh as little as 500g.
Q: What are the physical characteristics to look out for in a premature baby
A. Babies who are born very early appear red due to thin, fragile, transparent skin, where blood vessels can be seen visualised through the skin. They are covered with body hair called lanugo. Their breast tissue is not developed, ear lobes are very soft and will stick together if folded on itself, eyelids are fused, and underside of feet is very smooth without any creases. They have immature genitalia with undescended testis in boys.
Q:Many people are confused by the terms Pre-term and Premature- are they the same thing? Or do they have a different meaning?
A. The action of a baby being born before completing “term”, i.e. The full duration of the pregnancy is known as a “preterm birth”. The baby itself is described as a “premature baby “. Although these words are used interchangeably, “preterm” is an adverb that describes when the baby was born whereas “premature” is a noun that describes the baby.
Q. What is the percentage of Sri Lankan women who have pre-term babies , and what categories of women are more at risk to having pre-term babies?
A. Preterm labour i.e. the mother going into labour before completing term accounts for about 40% of preterm births. The risk of preterm labour is increased in women who have had a preterm birth in the past, multiple pregnancy (twins, triplets), problem with the uterus or cervix, overweight, underweight, getting pregnant soon after having a baby, a family history of preterm birth, diabetes, high blood pressure, infections in the uterus, urinary tract or vagina, sexually transmitted infections, liver disease during pregnancy, conditions making abnormal blood clots, delay in getting prenatal care, inadequate weight gain during pregnancy, in vitro fertilisation, birth defects in the baby.
Smoking, drinking alcohol, use of street drugs, working long hours or having to stand a lot and exposure to air pollution, lead, radiation, paint, smoke from someone else’s cigarettes and domestic violence are also risk factors for pre term births.
Q: Is prematurity hereditary?
A. Yes, there is a genetic component in prematurity. A woman who is born prematurely is more likely to have a preterm birth, with the risk increasing with the degree of prematurity of the woman herself.
Q: Is having a baby at a late age after 35 a risk for premature births?
A. Yes, it is. Maternal age over 35 years is a risk factors that increases prematurity.
Q: Ideally how old should a mother be to give birth to her first baby?
A. Ages younger than 17 years or older than 35 years increase the risk of preterm birth. Therefore, the ideal age to give birth is between the ages of 17-35 years.
Q: I understand that premature babies face short term and long term health complications. What are the short term complications?
A. The most common short-term problem faced by premature babies is difficulty in breathing due to immature lungs. Immature blood vessels inside the brain resulting in bleeding inside the brain (intraventricular haemorrhage), low blood sugar, inability to maintain body temperature, increased risk of infection, and yellowish discoloration (jaundice) are some of the other short-term problems faced by premature babies.
Q: What are the Long term complications ?
A. Long term respiratory support especially increases the risk of bronchopulmonary dysplasia which is a chronic lung disease in premature babies. Other long-term complications include retinopathy of prematurity, where Immature retina inside the eye can be easily damaged by oxygen, osteopenia of prematurity, where bones can be easily damaged due to loss of minerals through the immature kidneys, anemia of prematurity where baby is at high risk of anemia due to being born before the iron transfer takes place from the mother as well as blood loss due to frequent blood tests, neurological deficit, developmental delay, and poor growth.
Q: I read that such children face problems of brain damage ? Do you agree?
A. Premature babies are at a higher risk of brain damage due to higher risk of bleeds inside the brain (intraventricular hemorrhage) and due to higher risk of constriction of the blood vessels inside the brain (periventricular leukomalacia) due to overventilation. Infections as well as episodes of hypoxia increase the risk of brain damage.
Q: Psychological effects of a baby separated from its mother and kept in an Neonatal intensive care unit right after birth?
A. The presence of the parents, ability to provide breast milk and kangaroo mother care, play an important role in supporting the premature baby in overcoming the many challenges faced.
The baby is admitted to the neonatal unit only if the baby is sick or less than 32-weeks gestation or less than 1500g birth weight. The mother can visit the baby at any time of day and spend any amount of time with the baby. In fact, the mother is encouraged to visit the baby even in a wheelchair, as it is important for both mother and baby to be in contact to improve lactation so that mother can produce enough breast milk for the baby and give kangaroo mother care both of which increase the baby’s immunity and improve the baby’s outcome. Both parents are encouraged to touch and talk to their premature babies even those who are on mechanical ventilators.
Q: Where are most premature babies born in Sri Lanka?
A. According to our health indicators Sri Lanka holds one of the highest places in births at health care facilities. Around 99.9% of all births occur at a health care facility with 99.9% skilled attendance i.e., equipped with health care personnel who are trained to handle emergency situations for both mother and baby.
Q:What if the mother is unable to reach a hospital in time if she lives in a remote area?
A. Every pregnancy should be notified to public health midwife (PHM), which in turn will be assessed by the medical officer of health (MOH) in each area and refer women at risk of preterm delivery to a tertiary care hospital which has facilities to care for both mother and baby in case of preterm delivery.
Mothers are educated by the PHM and the MOH about seeking care early, so that they have a plan of how to get transport in an emergency. In case a woman is delivers while on the way to hospital or at home, both mother and baby should be taken to the nearest hospital.
Q: It is said that ideally a premature child should be born in a hospital with neonatal intensive care units (NICUs). Do we have enough of these units in our hospitals islandwide? If not how many do we need per live birth?
A. Hospitals that provide neonatal care are graded according to their facilities and expertise. Every province has at least one level-3 hospital (usually a teaching hospital with neonatal intensive care facilities capable of looking after babies below ( 1250g). Women at risk of preterm labour are referred by the MOH to the nearest hospital with the required expertise. Better quality neonatal care has resulted in intact survival of babies born at 24 weeks gestation who need intensive care for 3-4 months.
Q: Recent global studies have revealed that 15 million babies are born prematurely in the world, that means one in ten babies are born prematurely in the world every year. What are the figures like in Sri Lanka according to its live birth population annually?
A. Sri Lanka had similar figures with a documented a preterm rate of 11 per 100 live births in 2014.
Q: According to data from UNICEF complications from preterm birth accounts for nearly one million deaths globally each year. Are the figures similar in Sri Lanka as well?
A. Sri Lanka reported a neonatal mortality rate of 7 per 1000 live births in 2019, which accounted for about 2300 neonatal deaths per year of which prematurity accounted for 26%.
Q: Gaps in optimal care of premature babies which you think need to be filled?
A. The increase in assisted reproductive techniques leading to increase in multiple premature births as well as increase in the survival of premature babies have led to an increase in the need of intensive care cots, intensive care equipment, as well as nurses and doctors who are trained and experienced in caring for premature babies. Parents need to visit the baby as much as possible while providing breast milk and kangaroo mother care.
Q: Your message to all mothers out there ?
A. Avoid smoking, alcohol, street drugs, optimize your health, register early, and get regular antenatal care to prevent a preterm birth. However, if you have a preterm birth, spending time with your baby, providing breastmilk and kangaroo mother care will help your baby to overcome the challenges of prematurity.