Women who battled complications in pregnancy and were forced by life-threatening conditions to deliver before 37 weeks narrate how their preterm babies had brushes with death following a lack of facilities to provide accessible and affordable neonatal care. CHIJIOKE IREMEKA reports
The survival and developmental trajectories of preterm babies in Africa, especially in Nigeria are nothing near heart-warming.
Preterm babies are those born too early, less than 37 weeks gestation, according to the World Health Organisation.
The WHO states that premature birth is the leading cause of death among children under five around the world, and a leading cause of disability and ill health later in life in Sub-Saharan Africa and South Asia, accounting for over 60 per cent of preterm births worldwide.
According to a report by United Nations agencies and partners, every two seconds, a baby is born too soon and every 40 seconds, one of those babies dies.
This has been attributed to a myriad of factors, among them a lack of equipment and skilled health workers to manage the complexities associated with their care.
These factors were what Mrs. Felicia Jimi was confronted with when her baby came a little too early.
Felicia’s desire after her colourful wedding in 2022, was to become pregnant and feel the joy of motherhood.
As soon as she was confirmed to be pregnant in January 2023, the new bride looked forward to having a healthy baby that would weigh as much as 3.8kg at birth.
However, the expectation of the soft-spoken woman was cut short by heavy bleeding, which prevented her from carrying her pregnancy to full term and was forced to deliver at 32 weeks.
The bleeding, she told our correspondent, almost took her life and that of the unborn baby, despite all the extra precautions she took to take good care of herself.
According to Felicia, the bleeding started at home and she was rushed to the hospital by her husband and some neighbours.
The Ondo-born hairstylist said she never liked the idea of giving birth to a small baby and so, jettisoned the idea of using certain herbal concoctions to reduce the size and weight of her unborn child as some women do as part of measures to lessen their travails during labour
She said, unfortunately, what she feared most in terms of having a small baby, became her lot when she had an emergency Caesarean Section at 32 weeks in a private hospital, along the Old Ojo Road in the Amuwo Odofin Local Government Area of Lagos State.
Born prematurely and weighing 1.5kg, the baby required specialised care in a Neonatal Intensive Care Unit.
Since the hospital had no such functional facility, the baby, a boy, was referred to the Amuwo Odofin Maternal and Child Centre, Festac and kept in an incubator, while Felicia was left to recuperate in a different hospital entirely.
She recalled that it took five agonising days to be reunited with her son, noting that it was not a pleasurable experience.
The woman narrated, “After my child’s delivery, while I was in a separate hospital for the first six days, my baby was in an incubator at MCC. They were feeding him with glucose intravenously before my breast milk started flowing.
“A day after, my breast milk started flowing, the nurses at the hospital where I gave birth helped me to massage and extract my breast milk and it was taken to my son at MCC. This was how my baby was being fed until I reunited with him.
“On getting to the MCC, I was still kept in a separate ward and I wasn’t permitted to visit him at will. Again, the nurses at MCC were the ones helping to extract my breast milk. They used a syringe to give him glucose and to pass the milk into his mouth. Initially, they used tubes.
“My baby was kept in the incubator for two weeks and four days before he was stabilised. We were discharged and asked to come every week for continuous preterm care and monitoring. Meanwhile, I was discharged before him and had to visit him from home daily. The nurses were quite helpful and understanding.”
WHO’s standard for preterm care
The WHO’s recommendation for improving preterm birth outcomes, for unstable newborns weighing 2000g or less at birth is that they be cared for in a thermoneutral environment either under radiant warmers or in incubators.
Available data show that Nigeria needs approximately 9, 000 incubators to cater for its 773,600 premature babies born annually.
According to the global health body, subcategories of preterm births based on gestational age include extremely preterm (less than 28 weeks); very preterm (28 to less than 32 weeks) and moderate to late preterm (32 to 37 weeks).
Nursing preterm babies tough
Felicia, who stated that nursing a preterm is a tough venture, recounts her challenges, disclosing that she had to put up with post-surgery pains and the emotional pain of not having her newborn nestling beside her.
“I started lactating heavily, but I couldn’t breastfeed him because he was not with me. It wasn’t easy for me then,” she recalled in an emotion-laden voice.
“I wasn’t sleeping well. A lot of thoughts kept running through my mind like; is he okay? Was he still alive? Would he be hungry? Are they giving him food? Initially, I wasn’t allowed to touch him and I felt really bad. But I thank God because it was for the newborn’s sake.
“When he eventually stabilised that I could breastfeed him, the nurses wouldn’t allow me to breastfeed him, instead, it was done through a feeding bottle. This was because my son wasn’t latching to my nipples very well and the milk was always pouring out of his mouth. Also, the nurses wanted to know the quantity of milk he was fed.
“As a mother of a preterm, you hardly can sleep because you have to be giving the baby food at short intervals. Initially, you might have to feed him every five minutes and it will gradually increase to 10 minutes, to 20 minutes and from there, it becomes an hourly thing.”
“In most cases, he will suck and sleep and I will have to wake him up to continue. If the baby is not being fed within short intervals, he won’t get enough milk and will not develop optimally. I couldn’t go anywhere within the period I was trying to ensure he developed well and I couldn’t carry him on my back like a full-term baby.”
Death by choking
Felicia, who is thankful to God that her baby later gained weight, said she can now go out briefly and come back, and revealed that her baby would be 10 months soon.
She, however, added that she discussed the feeding concerns with her physician, who told her to continue feeding and observing him to ensure that the baby does not get choked as that is one of the reasons for preterm death.
According to the International Breastfeeding Journal, mothers face challenges when breastfeeding their preterm, stating that there is a need for public health nurses to guide them through this experience.
“Families with a late preterm need to be informed about the challenges associated with breastfeeding a preterm. All health care professionals must receive proper training on safe and effective breastfeeding of preterm infants and be able to proffer strategies to resolve any breastfeeding problems,” the journal stated.
In the WHO report released on October 5, 2023, an estimated 13.4 million babies were born early in 2020 with nearly one million dying from preterm complications.
The data is equivalent to one in 10 babies born early, before 37 weeks of pregnancy worldwide.
Meanwhile, on June 15, 2023, WHO said of every 10 babies born, one is preterm and every 40 seconds, one of those babies dies.
It noted that preterm birth rates have not changed in the past decade in any region of the world with 152 million vulnerable babies born too soon from 2010 to 2020.
The global health body said that the impacts of conflict, climate change and COVID-19, among others, are increasing risks for women and babies everywhere.
High blood pressure-induced preterm birth
Another mother whose son survived after he was delivered prematurely amid lack of a neonatal facility is a 26-year-old woman who simply identified herself as Rose.
The businesswoman, who recalled being so excited when she became pregnant with her second baby, also expected to carry the pregnancy to a full term like her first but that never came to be as she was diagnosed with severe high blood pressure which threatened her life and the survival of her unborn baby.
Felicia had to undergo an emergency CS at 34 weeks.
She recounted, “When I went for my antenatal care that very day, I was having a headache even though I was taking my drugs regularly as instructed by the doctor. I never knew that I would be booked for an emergency CS that day. My doctor had expressed concern about my condition and on several occasions said I might not carry the pregnancy to full term.
“So, when my doctor checked my blood pressure repeatedly that day and it was still very high, he immediately scheduled me for an emergency CS. He told me to call my husband to come and sign the consent form. Thankfully, the CS was successful.”
However, at birth, her son weighed just 2kg and he was very fragile.
Felicia said, unfortunately, taking care of a premature baby was a problem at the private facility where she delivered as they had no functional incubator.
The woman told our correspondent that her baby survived by a stroke of luck as the private hospital, which they were referred to and noted to have neonatal facilities, had only one incubator that was not functional.
“I was excited when my baby survived and was discharged because I saw a lot of preterm babies that died in the hospital even before they were kept inside the incubators”, Rose told nigeriacurrently.com Healthwise.
According to paediatric experts, an incubator is set to a certain temperature to help the baby maintain the required body temperature, while the baby is fed with breast milk and given a drip right inside the medical device.
They said the number of days that a baby stays in the incubator depends on its weight and activeness.
The WHO also said preterm birth is now the leading cause of child deaths, accounting for more than one in five of all deaths of children occurring before their fifth birthday, insisting that urgent action is needed to improve and prevent preterm birth.
Killed by jaundice
Amid the happy story of preterm survival abound sad ones, among them being that of 27-year-old Chikamsi Udeora, whose premature baby died less than a week after birth.
The Anambra indigene, who got pregnant in late November 2022, was presented with eclampsia at 27 weeks.
She revealed having two seizures; one at home and the other, on the hospital bed, while being attended to by a medical team, noting that this prompted the
doctors to opt for an operation to save her life and that of the child
“The doctor told me that I have pregnancy-induced hypertension coupled with high blood sugar. He assured me that having a CS to save my life and that of the baby was the ideal thing to do.
“The CS was successful and it was done in July 2023. When I woke up from the effects of the anaesthesia, I was told that my baby was in the incubator. I was taken to the neonatal unit to see her and I was excited she was alive”, Chikamsi recounted.
Sadly, Chikamsi and her husband’s happiness was short-lived as the baby died days after from complications arising from jaundice.
“I had a successful CS delivery and four days later, while I was still on admission, it was discovered that my baby had serious jaundice, which had started showing on her body and in her eyes. The hospital couldn’t remedy it and still didn’t refer us to another hospital with better facilities.
“The nurses were always putting my daughter in a bathing bowl and placing her under the sun. They assured me that she would be fine. Unfortunately, after all the stress I went through, the baby still died.” She cried.
Complications leading to preterm
A Consultant Gynaecologist and Obstetrician at the Havana Specialist Hospital, Lagos, Dr. Ngozi Obiora, said babies may be born preterm due to spontaneous labour or because there is a medical indication to plan an induction or caesarean birth early.
She said preterm birth occurs for a variety of reasons including eclampsia, infections, ruptured amniotic fluid and antepartum haemorrhage among others.
According to her, the earlier a baby arrives, the smaller it will be, and with a head larger than the rest of its body.
According to the Royal College of Obstetricians and Gynaecologists, Antepartum haemorrhage is bleeding from or into the genital tract, adding that it occurs from 24 plus weeks of pregnancy and before the birth of the baby.
The most important causes of APH are placenta previa and placental abruption.
On the structure of a preterm, Obiora said that with little fat, the baby’s skin will be thinner and more transparent to the point that one could see the blood vessels beneath it.
She said the newborn may have lanugo, which is fine hair on her back and shoulders.
“Preterm features will appear sharper and less rounded than they would be at term, and probably won’t have any of the white, cheesy vernix, which is a greasy deposit that covers the skin at birth, and which protects babies at birth. This is because the vernix is never produced until late in pregnancy,” she said.
Obiora said preterm babies will get cold in normal room temperatures due to lack of fat, which explains why they are placed in incubators immediately after birth to keep warm.
According to her, “You may also notice that the baby will cry softly, if at all, and may have trouble breathing. This is because the baby’s respiratory system is still immature. If the preterm is more than two months early, breathing difficulties can cause serious health issues because other immature organs in the body may not get enough oxygen supply.
“And to ensure that this doesn’t happen, doctors will keep the baby under close observation, watching its breathing and heart rate with a cardio-respiratory monitor. If it needs help, it might be placed on extra oxygen or special equipment such as a ventilator; or Continued Positive Airway Pressure to support its breathing.”
Another, a Consultant Paediatrician at the Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Dr. Sylvia Echendu said complications that lead to the deaths of preterm are known and are primarily due to a lack of skilled workers and equipment to handle their cases.
The consultant at the Life International Hospital, Awka, Anambra State, said several preterm patients die in remote villages where there are no skilled professionals.
The paediatrician added, “There is no appropriate equipment to handle these cases. Some hospitals in the country don’t have the necessary equipment to handle such cases.
“Some of them don’t have oxygen, incubators, and phototherapy units, and what they do is to place the preterm in the sun when they suspect jaundice. Though there are some cases you can break through with such but not when it’s serious jaundice. What is required for serious jaundice is a good phototherapy unit that can handle cases like that.
“Also, in the whole Anambra, only one centre has a ventilator. Of course, power supply is essential because all this equipment won’t work without electricity. The majority of hospitals where these preterm are born don’t have equipment.”
‘Investment in equipment, neonate care will reduce preterm death’
She noted that with investment in equipment and education of professionals on neonate care, the preterm mortality rate in Nigeria will be reduced.
“These local facilities where these preterm are born don’t refer them to us and if they do, it would have been late.
“You don’t have any business being in a facility that does not have the required equipment to save your child when there is likelihood of preterm birth. Above all, we need to educate our mothers because they believe in certain practices that if you don’t know your onus, they would confuse you.
“A woman after giving birth will tell you, ‘Nurse I have my coconut water.’ She believes that coconut water, if given to the baby immediately after birth will remove chances of having abdominal aches,” she lamented.
Director of Maternal, Newborn, Child and Adolescent Health and Ageing, WHO, Dr. Anshu Banerjee, said, “Preterm babies are especially vulnerable to life-threatening health complications, and they need special care and attention.
“These numbers show an urgent need for serious investment in services available to support them and their families, as well as a greater focus on prevention – in particular, ensuring access to quality health care before and during every pregnancy.”
Low-tech and cost-effective interventions will save lives
Meanwhile, a Consultant Paediatrician at Holy Cross Hospital, Festac, Lagos, Dr. Esther Christian said reducing the burden of preterm birth has two main elements – prevention and care, adding that interventions that are proven to help prevent preterm birth are clustered in the preconception, between pregnancy, and pregnancy periods, as well as during preterm labour.
She said spreading the uptake of low-tech and cost-effective interventions can save thousands of lives and raise awareness about how to reduce preterm birth, which is the leading cause of neonatal deaths worldwide.
“Antenatal steroid injections are helpful. When given to mothers in preterm labour, dexamethasone helps speed up the development of the baby’s lungs. Two shots can stop premature babies from going into respiratory distress when they are born,” she added.
Christian noted that the use of these injections can prevent nearly 400,000 deaths a year, saying that Kangaroo Mother Care, which involves placing the newborn skin-to-skin on the mother’s chest will help regulate the newborn’s body temperature, facilitate breastfeeding, and help in brain growth and development. KMC can prevent up to 450,000 deaths annually.”
Saving power of breast milk
Speaking on the need for the preterm to be fed with the mother’s first breast milk that runs for the first four days after birth (colostrums) as a way of improving preterm nutrition and immunity, a Nutritionist and a Professor at the Department of Nursing Science, University of Calabar, Cross River State, Mary Mgbekem said colostrums is the first and the best food a child eats after birth.
She noted that the colostrum contains the best nutrition a child needs in life, adding, “Nutritionists are the advocates of exclusive breastfeeding.”
Also, a lactation expert at the University of Western Australia, Professor Peter Hartmann, said, “White blood cells contained in the colostrums, which babies are fed within the first few days of their lives, are important as far as immune responses are concerned. They provide protection and challenge pathogens.”
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