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OP-ED: Born too early: Preterm births in Bangladesh

  • Published at 03:25 am November 17th, 2021

Identifying the appropriate approaches to preterm birth prevention and care

Imagine you are an extremely important person. You are supposed to go somewhere, be somewhere. Everyone is eagerly expecting you and wants to give you special treatment with an exclusive hospitality experience. But unfortunately, you arrive at your destination early -- perhaps too early -- and have caught your hosts in the middle of their preparations. 

You feel awkward and the hosts feel embarrassed. From there, everything will be rushed. The initial chaos of your early arrival results in a domino effect and tarnishes the hospitality that the hosts have been planning for months.

Babies born too soon, ie, preterm births, create this exact chaotic situation. The World Health Organization (WHO) defines preterm birth as babies born before 37 weeks of pregnancy.

While there are many instances of spontaneous preterm births that occur without any discernible reason, some common causes are intrauterine infections, multiple pregnancies, chronic conditions like maternal diabetes or high blood pressure, environmental factors such as indoor air pollution, and lifestyle factors like smoking.

Annually, nearly 15 million babies are born prematurely around the world. This equates to more than one in 10 babies. Nearly a million of these premature births die before completing their first month of life due to complications like respiratory distress syndrome, apnea, jaundice, and intraventricular hemorrhage. 

Prematurity is the leading cause of death among children under five years of age globally, but even more so in low- and middle-income countries. Among these, Bangladesh ranks seventh on the global list of preterm deaths with an estimated 15,000 deaths per year. 

Even if a premature baby survives the neonatal period, WHO cites that they are at increased risk of lifelong disability. They are more likely to suffer from attention deficit hyperactivity disorder (ADHD), anxiety, cerebral palsy, asthma, pneumonia, vision loss, hearing impairment, intestinal anomalies, and meningitis.

So, what is the way out? WHO recommends focusing on three areas through a life course approach, starting with caring for pregnant women to prevention and management of preterm birth complications:

Midwife-led continuity of care (MLCC) 

The WHO recommends midwife-led continuity of care (MLCC) models, where one midwife or a group of midwives works together to provide care to a woman, newborn, and her family throughout the pregnancy, birth, and after birth.

This midwifery-led care adopts a philosophy that is missing in the over-medicalized childbirth in a clinical care practice. In resource-poor settings, MLCC can reduce the risk of a premature birth by around 24%. 

However, this model requires a well-functioning midwifery program and should only be provided by educated, trained, licensed, and well-supervised midwives. In addition, access to emergency obstetric and neonatal care is a precondition for this model. 

Kangaroo Mother Care (KMC) 

Kangaroo Mother Care is a widely used method of caring for preterm and low birth weight babies -- usually those weighing less than 2,000 grams at birth. KMC includes continuous skin-to-skin contact between the mother and the baby for an extended period of time -- usually weeks -- coupled with exclusive and frequent breastfeeding. 

In several studies conducted in low and middle-income country settings, KMC substantially reduced child mortality over the traditional incubator-based approach, which is more expensive and adds additional risks of hospital-acquired infections. 

Specific clinical interventions 

The WHO also provides specific recommendations for interventions during pregnancy, birth, and the neonatal period to improve outcomes for preterm infants. 

These can include interventions provided to the mother such as steroid injections before birth in case of premature rupture of the membrane and antibiotics before labor when there are signs of intrauterine infections. Recommended interventions for newborns include thermal care, feeding support, safe oxygen use, and other treatments to help babies breathe more easily.

The government of Bangladesh initiated its current health sector program (January 2017 - June 2022) with an aim to reduce the newborn mortality rate to under 12 per 1,000 live births by 2030. Recognizing premature birth as a major concern, the Ministry of Health and Family Welfare has established around 42 Special Care Newborn Units (SCANU) in tertiary and district level hospitals around the country.

Following the WHO recommendation, KMC services were introduced in 132 tertiary, district, and upazila government hospitals. Some private hospitals have also introduced KMC services and established special care units for newborns with illness and other complications.

Despite many initiatives, ample challenges remain. The current utilization of newborn services is dismal. Nationally, there is little awareness raising and promotion among health workers and mothers regarding the importance of receiving care for babies born prematurely or with a low birth weight.

The number of KMC corners is less than adequate according to the Bangladesh Health Facility Survey 2017, considering the number of newborns born prematurely in the country. In addition, the ANC counselling package does not include any special orientation regarding caring for preterm births. There is also an acute shortage of trained healthcare providers and logistics across the country for providing care to newborns.

Another challenge is that, oddly, there is often a stigma attached to preterm babies which can act as a barrier to appropriate care-seeking practices. One of the most common stigmas is “fatalism,” a misconception that preterm babies are not as valuable as other babies and that they will not survive even after receiving treatment and care. 

In resource-poor locations, this could limit the impact of interventions aimed at prematurity. Another not-so spoken challenge is the lack of respectful care during and after pregnancy and childbirth. Respectful care is every woman’s right and the health workers are obliged to treat women in accordance with that at all times, especially during birth and caring for small and sick newborns. 

Also, whereas KMC is a low-cost intervention, it is not an easy one. Holding a baby skin-to-skin for long hours during Bangladesh’s hot and humid days is challenging. Mothers need counselling and continuous support to stay motivated.

Prioritizing investment in preterm birth prevention and care is necessary to achieve sustainable development goals. It requires a comprehensive approach and a change in the mindset of healthcare providers and policy makers to prioritize the prevention of and care for preterm births with respect, dignity, and quality. 

Shusmita Khan is Research Associate, Data for Impact (D4I), Carolina Population Center. This article was produced with the support of the United States Agency for International Development (USAID) under the terms of USAID's Research for Decision Makers (RDM) Activity. Views expressed herein do not necessarily reflect the views of the US Government or USAID. To learn more, please email Shusmita Khan at [email protected]

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