In this interview with Sade Oguntola, Dr Kemi Tongo, a physician who specialises in the health care of newborns at the University College Hospital (UCH), Ibadan, explains why babies born too soon in Nigeria require increased support and care.
Millions of babies around the world are born prematurely each year. Why are preterm babies of concern?
About 15 million babies are born too soon every year. These are babies born before 37 completed weeks of pregnancy if we count from the first day of the mothers’ last menstrual period. Now, about 871,000 of them are born in Nigeria and it translates to about 11 per cent of our annual deliveries. November 17 is a day set aside globally to remember preterm babies and to create awareness about their plight. These babies have special needs. Families of preterm babies also require support to provide the necessary care for these babies. The health care system requires support to provide care for them. That is the whole essence of the world prematurity day.
Preterm babies are more likely to die when compared with full term babies. For this reason, they require special attention. If the care they need at the time of birth and subsequently are provided, they grow and develop to achieve their full potentials. If this necessary care eludes them during this period, they could end up with lifelong challenges like blindness, hearing defects, impaired neurodevelopmental outcomes, poor growth or even problems with their lungs.
Why are these babies born too soon?
They’re born too soon because of problems either with the mothers’ health, mothers’ womb or even the babies themselves. Some result from stressful situations, including domestic abuse, that the mothers go through. Maternal health problems like hypertensive disorders in pregnancy, diabetes or even malaria may result in premature delivery. Doctors sometimes have to bring out the baby earlier to save the mother’s life or to even save the baby from dying inside the womb due to some pregnancy complications. Also, where the placenta cannot sustain the pregnancy any longer, the fetus stands a risk of dying if it stays longer in the womb. Infections in some instances can make a woman go into premature labour. Multiple pregnancies are also associated with a higher risk of premature delivery. Prematurity has different categories, depending on the gestational age but the younger the gestation, the higher the risk of morbidity and mortality.
What should expecting parents know about babies born too soon?
Babies born too soon are normal human beings with potential to become anything in life if supported to survive and thrive. But because they have come too soon, their organs are not yet well suited for life outside the womb. So, they need extra support. The most basic of these needs is warmth. They cannot keep warm. When they are in a cold environment, they get cold easily and that can kill them. Likewise, an environment that is too hot also has its own problems. So, we need an environment with a normal temperature for their age and size.
Nutrition is another area. Breast milk is the best for them too. Everything should be done to support the mother to get her breast milk. Depending on how preterm they are, they may not be able to suck adequately from their mothers. Even if they can suck adequately, the size of their stomachs cannot take enough milk that they need or cannot digest the breast milk well enough. So, for that reason, we have to do something about how we feed them. They cannot take all they need at once, yet they need more to grow. So, you must gradually introduce the mom’s milk to their guts; small volumes increasing gradually every day. The condition necessitating preterm delivery too may still be contending with the mother so she requires support to breastfeed or express her breast milk without making her feel too stressed.
They have problems with breathing, depending on how preterm they are, so they often need respiratory support either by way of giving oxygen or by what we call continuous positive airway pressure so that they don’t get tired. They are particularly prone to infections because they cannot fight off infections. So, we need to shield them from germs.
Since the brain is not fully developed, they can bleed into the brain. That becomes a problem for the future. The liver cannot handle bilirubin, so they are more prone to jaundice. The bilirubin more readily crosses their brain-blood barrier causing brain damage. The ears are not well developed; so the drugs we give to save their lives can also damage them. The eyes can be damaged also by too much oxygen, although they often need oxygen supplementation.
Since these preterm babies have extra needs, parents must cooperate with health caregivers to ensure they survive. When health care workers ask that they wash their hands before touching the baby, provide breast milk promptly, and continue kangaroo mother care at home, they must appreciate why it has to be done. It is closeness from kangaroo mother care that helps the baby to keep warm, helps the mother’s flow of breast milk protect the baby from germs, prevents some breathing problems and brings about faster growth and earlier hospital discharge.
At home, the parents should not give them unprescribed medications; they should recognise that these babies are preterm and can still develop problems even at home. They should not just leave these children in the care of anybody. We teach them about danger signs they should watch out for when they are at home and they should immediately present to the hospital if those signs are observed.
What are these danger signs?
These include, inability to feed/poor feeding, fast breathing than what it was before they left hospital, difficulty in breathing, high or low body temperature, only moving when stimulated, lethargy, umbilicus redness or draining pus, skin boils, and vomiting. Others include whiteness or yellowness of baby’s palms and soles, dark or blue lips, bleeding from any site on the body, and abnormal movements like jerking of the hands or the legs or when baby keeps bringing up the food. Throwing up food is not unusual if it is once a day but if it becomes more than once a day, they should quickly come to the hospital.
Is our health system doing enough for these babies?
These babies do not have enough in terms of the infrastructure, equipment, manpower, hands-on-ground care for them, among many other things. The facilities are not really there, talking in terms of infrastructure for KMC, equipment like incubators, CPAP machine, ventilators and laboratory support. In the few places where some of these are available, adequate funding and support for their maintenance are not there. Where they are available, they are beyond the reach of the middle and lower class. The adequate manpower is also lacking because they require more hands per baby. These are really challenging. Howbeit, they are human beings too and they have the right to a quality life. It is our collective responsibility to ensure that we provide everything needed for their care. Some peculiar drugs needed for their care are costly, and most times beyond the reach of the average parents, that is if they are available. Some support is needed to ensure these are provided and in the appropriate newborn formulation for the care of these babies.
Are there cultural practices that should be done away with?
All those traditional things that we do, like stretching of the hands and legs, throwing of the baby up, and rubbing the baby’s skin with different local or homemade ointments should be done away with for preterm babies. Also, scarifications, hot fomentation and compress on the skin should also not be done. Hot fomentation and compress will dry the skin, cause invisible cracks that allow germs to easily enter into the body. Preterm babies should not be separated from their mothers. Mothers must exclusively breastfeed them. They need to feed both day and night; there is nothing like the baby has slept. The baby must feed every three hours minimum and if they are much smaller, we say every two hours. And when the baby has fed directly from the breast, they should still express whatever is left and top up with a cup and/or spoon. It’s not safe to light a fire in the room with babies and lock windows. It’s important to just shut the windows so that breeze does not enter and then put the baby in kangaroo mother care position, strapped to the mother’s bare chest. That’s sufficient to keep the baby warm. Electric room heaters that allow you set the room temperature may be helpful. But certainly not an open or a kerosine stove due to carbon monoxide that gets released into the room.
Q: Are there things that can be done to prevent prematurity in babies?
A: Prevention of prematurity is always better. In some situations, it is preventable. Pregnant women need to register promptly for antenatal care so that those with multiple pregnancies or with conditions that can cause premature delivery are identified early and appropriate care is provided to prevent premature delivery. In fact, women with multiple pregnancies need doctors to monitor them and should not be in the PHC. Also, pregnant women with complaints should report promptly to the hospital. For example, if the woman is draining liquor, she should not sit at home for days till the amniotic fluid would have finished and the baby is in trouble and has to be brought out.
Caring for these preterm babies is really capital-intensive both in the hospital and at home. So, philanthropists should look their way. Our hospitals are old; for instance, they do not have spaces for kangaroo mother care. The wards of old hospitals are not designed to support mothers of preterm babies. So, philanthropists can help to build new wards or refurbish existing ones to accommodate this. Family-centred care on the part of health workers has been shown to improve outcomes in these babies. Support is also needed for the supply of basic equipment like incubators CPAP machines, phototherapy, monitoring devices and ventilators to provide care for babies in the newborn units.