Q. Globally, pre term maturity has been cited as the leading cause of morbidity and death in children under five years in many countries with Sri Lanka as one of the few exceptions in the region to have a very low if not the lowest incidence of infant mortality rates. However, persistent reports of pre-term births recorded in many hospitals ( said to range from 10–15 per 1000 live births with approximately 24,500 babies being recorded as born prematurely annually across the country) has raised concerns among health officials.
The Sunday Observer spoke to Community Physician, Epidemiology Unit, Ministry of Health Dr Dimuth Peiris to find out what or who a preterm baby is, what caused its mother to give birth too early and health impacts to the child, the period of gestation when most mothers were vulnerable to risks of having a preterm baby - and most importantly how such births could be prevented or minimised.
Our first question to him was to define what pre term baby means. In reply he said,
“A preterm birth is defined by WHO as babies born before completing 37 weeks or 259 days of gestation.”
Asked if there were sub categories of preterm birth, based on gestational age he replied in the positive .
“Yes, they are further categorised into extremely preterm (i.e. below 28 weeks), very preterm (28 to below 32 weeks), moderate (32 to below 34 weeks), and late preterm (34 to below 37 weeks).
To a further query to elaborate on each of these sub categories he explained , ” When babies are born too early, ,they are often at risk of death as well as health complications . However when the delivery is closer to the expected date or near to the completion of 40 weeks these risks are low”
We also asked about the veracity of a report saying that there is a dramatic difference in survival of premature babies depending on where they are born- (more than 90 percent of extremely preterm babies (less than 28 weeks) born in low-income countries die within the first few days of life; yet less than 10 percent of extremely preterm babies die in high-income settings.)
His reply was in the affirmative. “Yes it is true. To manage babies who are extremely preterm and sometimes very preterm needs specialised care units with sophisticated equipment and trained staff. Low and middle income countries have issues in providing these facilities.”
Causes for upward drive in preterm babies
When MediSnips queried as to what had caused this upward drive in preterm babies and fatalities arising from complications on the global level, was it poverty and malnutrition? Infections during a pregnancy? ,he said, “ Actually, the reason for the rise is mainly due to increased reporting and due to correct dating of pregnancy by early ultrasound scans. The core reason however is prematurity itself, which is the main issue of preterms. As their body systems are not mature enough to face the external environment as they are born. Due to recent medical advances, and effective management most other causes of infant and neonatal mortality have come down , while preterm births have now surfaced as a main contributor of neonatal deaths.”
Asked if it was true that pre-existing chronic diseases such as Diabetes and Hypertension as well as heart problems were also a contributory factor to a mother giving birth too early, he replied in the affirmative: “Yes, there are studies that have identified these factors as risk factors”
What about the genetic factor? If a pregnant mother had a family history of premature births, was she more at risk than a pregnant woman without a family history of early births?.
“Yes “he said, ” There are evidence in medical literature that a family history of preterm births is a risk factor for preterm births”
Asked to comment on a further query with regard to the age of the mother at the time of getting pregnant his reply was, “Maternal age has been found to have a “U-shaped” effect on preterm birth. This means that the higher risk of delivering preterm is found in the following extreme age groups: teenagers and elderly mothers”
So what is the ideal age a woman should have her first baby ?
“ I would say before the age of 35 years.”
Healthy pregnancy
Citing UNICEF ‘s view that the first step towards reducing preterm births was to ensure that all mothers -to- be have a healthy pregnancy, and asked to define what a healthy pregnancy is, he said. “ A healthy pregnancy means that a mother should have a good nutritional and health status without any medical conditions that affect both the mother and the baby at the time she gets pregnant”,
Asked to comment on the country’s first ever antenatal care guidelines compiled by the WHO and its partners, to help prevent preterm birth, such as counselling on healthy diet and optimal nutrition, and tobacco and substance use; fetal measurements including use of ultrasound to help determine gestational age and detect multiple pregnancies; and better access to contraceptives and increased empowerment could also help reduce preterm births and whether he considered they were practical considering our limited resources, this is what he had to say:.,
“We have formulated a comprehensive national maternal care package which includes all of these strategies. In 2021, 81 percent of pregnant mothers registered before 8 weeks of gestation and 95% received antenatal care.
Serial measurement of fetal growth, Universal ultrasound scanning, early referral for specialised care are being carried out throughout the country and this has helped to identify preterm births accurately and had contributed to better care for them by early referral.”
He also fielded another question on the WHO statement that more than three quarters of premature babies can be saved with feasible, cost-effective care, such as essential care during childbirth and in the postnatal period for every mother and baby, provision of antenatal steroid injections (given to pregnant women at risk of preterm labour and under set criteria to strengthen the babies’ lungs), kangaroo mother care (the baby is carried by the mother with skin-to-skin contact and frequent breastfeeding) and antibiotics to treat newborn infections. His response to the Sunday Observer question was, “When considering the preterm deliveries majority falls to the categories of late and moderate preterms and they can be managed with less costly methods but those methods like kangaroo mother care need to be implemented properly to achieve this status”.
Role of midwives
Also commenting on a further question on the role of the midwife, a popular figure in rural Sri Lanka in reducing the risk of prematurity he said “Midwives should be empowered to identify the risk factors of preterm delivery and the care of the preterm baby after delivery. They can play a major role by referring them at the correct time before delivery as in-utero transfer. A slight drop in body temperature has been identified as a risk factor that leads to poor outcomes in preterm babies and thus in-utero transfer is advocated than transferring neonates. “
To our final questions requesting a message to all mothers to be and those planning to become pregnant , he gave the following advice: “If you have a healthy pregnancy the risk to your baby as well as to you is less. That said, a healthy pregnancy needs to be planned well before you get married.
Being knowledgeable on risk factors for preterm births and other conditions before conceiving will help you to avoid them. It is better for you to avoid extremes of age when conceiving and get proper antenatal care which is freely given by the government. It is also important that you adhere to the advice of the health professionals.”