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In this interview with SADE OGUNTOLA, the immediate past president of the Nigerian Society of Neonatal Medicine, Dr. Oluwakemi Tongo, discusses the difficulties in ensuring preterm babies survive and are free of issues while also outlining the causes behind Nigeria’s rising rate of premature births.
EVERY year, on November 17, the world observes World Prematurity Day to increase awareness of preterm births and the issues that preterm newborns and their families face globally. Why is this important?
This concern for pre-term babies is because they are born too soon, and they have some challenges that we all need to support them to overcome, but despite these, they are normal human beings like the rest of us. Typically, when the mother is pregnant, she’s looking forward to having a baby at nine months and carrying on with life. However, the challenge comes when they are born too soon and families are unprepared, and we therefore need to support the baby, the parents, and family members to cope with the pressure of caring for these babies till they are out of the woods. Preterm babies are normal people like you and I with potential for full growth and development. But we just need to provide a little extra support so that they can overcome and live their full life potentials with proper care and support.
Occasionally, some of them, after survival, may have some complications to deal with for the rest of their lives. Therefore, we must continue to help them at this time and raise awareness about preterm newborns and the need for our love and care, as well as for their families, so that everyone in society can appreciate the need to support and participate in their care.
What are the consequences of preterm babies on their families?
Well, the first one is that emotional shock. A woman is expecting to be put to bed at nine months, and suddenly the baby comes two months earlier when they are not ready. And then, the same baby now has extra needs, other than the regular love, feeding, and keeping warm that you provide for a full-term baby.
The mothers are required to be available constantly to breastfeed and provide skin-to-skin care, but most of our hospitals are not exactly designed for the comfort that those mothers require. This puts a lot of strain on the mother. The cost of care is high because they require extra care with one gadget or another. The parents would not have anticipated this, but they have to live with it.
Families are severely impacted financially, physically, and emotionally, especially if they are in a government-owned institution where the cost of care is often out of pocket and they pay at the point of care. The fathers are usually under tremendous pressure to care for the baby and mother, who may also have ongoing medical issues apart from having just been put to bed.
What is the contribution of prematurity to neonatal death rates in Nigeria?
A baby is preterm, irrespective of the size, if the baby did not complete 37 weeks inside the womb. One of the three major causes of neonatal deaths is complications arising from preterm births; the other two are infections and asphyxia. Prematurity also underlies a significant percentage of mortality among children under five years because of increased predisposition to various diseases after surviving the newborn period.
For example, the most frequent cause of death in children under five is pneumonia, and preterm babies are more likely to get pneumonia than their full-term peers. Preterm newborns are therefore over-represented in those groups of babies who die within their first five years of life due to various causes.
Why, in the opinion of experts, is preterm birth best avoided in the light of Nigeria’s medical circumstances?
All around the world, preventing preterm delivery is preferable to dealing with it since caring for premature babies can be costly. In Nigeria, the financial burden of caring for these infants can result in families spending as much as 5,000% of their total income. This is in addition to the financial burden to the hospital, as well as the psychological and physical toll it takes on the parents and medical staff. We are unable to adequately quantify these expenses.
Also, some of the survivors have some long-term effects or consequences from their premature birth, which may affect their quality of life. These complications can arise due to their immaturity or as complications of the care received.
Why are babies born prematurely in Nigeria?
The common conditions associated with prematurity are multiple pregnancies, pregnancy-induced hypertension (preeclampsia), and eclampsia, as well as ill health in the mothers generally. In some of these conditions, the babies have to be born prematurely to safeguard the mother’s health so that the mother doesn’t die in pregnancy. Also, infections in the mother’s genital tract or urinary tract could contribute to premature birth. Other obstetric conditions, include cervical incompetence. Not accessing antenatal care early is a major factor that can increase the chances of a preterm birth because the women would have missed the opportunity of early identification and management of the conditions.
Some nutritional issues also predispose to prematurity. Women who are deficient in vitamin D are more predisposed to having preterm babies. Their babies, too, are more prone to complications than those whose mothers do not have vitamin D deficiency. Thus, it highlights how crucial healthy eating is for expectant mothers.
Do you foresee more babies being born prematurely in Nigeria due to the current economic challenges?
At this time, the number of premature births is starting to rise. We now purposefully set aside more space in our special care baby ward for preterm infants and look for other methods to care for full-time newborns who need attention and have problems. This is due to the fact that many mothers now suffer from illnesses like anaemia, malnutrition, and hypertensive disorders, which raise the risk of giving birth to preterm babies.
Also, more women are now undergoing vitro fertilisation (IVF), and they frequently have a high number of babies implanted in their wombs. But the more babies the mother is carrying in her womb, the more likely it is that she will deliver earlier than full term.
Previously, it was believed that a lot of high-tech was needed to care for preterm babies, but new research has shown that we can care for these babies with just a few basic pieces of equipment. However, these pieces of equipment are frequently absent, so hospitals are unable to adequately provide these services.
There are some drugs like surfactant and caffeine essential to prevent them from having problems with breathing and bleeding into the brain. These drugs are scarce and very expensive. For instance, a one-kilogramme baby would require surfactant, which costs between N165, 000 and N185, 000 for a single dose. The surfactant is required to help their immature lungs to breathe effortlessly. This is beyond the reach of average families.
In the meantime, a woman who has experienced this issue once carries a higher risk of experiencing it in future pregnancies. In order for the woman to at least have that child and be content, and perhaps not even attempt to get pregnant again if she has one that has survived well, we must all make concerted efforts to assist these infants to survive.
Some of the evidence-based care that these babies need includes early and prolonged skin-to-skin care, and these babies need to receive breast milk as early as possible. It is therefore imperative to have newborn intensive care units where mothers too can be cared for; however, our present hospital designs require modifications to accommodate that. For the availability of human breastmilk, if we had breastmilk banks, it would be easy to support the nutrition of babies while waiting for their own mother’s milk to come in adequate quantities.
Apart from finance and a reduced health workforce, there is inadequate infrastructure for their care in Nigeria. The WHO recommendation is that secondary facilities should at least have basic equipment like phototherapy and CPAP to provide care for some categories of preterm babies, but we are still very far from this. From the look of things, it doesn’t appear that will come from government very soon. We therefore require that philanthropists endow hospitals and provide equipment to provide at least a certain minimum level of care for preterm babies and their mothers. So, it would only be those extreme preterms and complicated ones that will go to specialists or tertiary facilities.
Are there medical practices or lifestyle changes that you would suggest to help us reduce the incidence of preterm births in our community?
Nutrition is a problem, so we hope people will engage in good nutrition. Whatever little amount of money you have to eat, eat good food. The money spent on carbonated drinks and pastries can be put into making healthy local foods rich in vegetables and fruits. Good health-seeking behaviour is important, and our mothers should register early for antenatal care in licensed facilities that are manned by an appropriately trained health are workforce rather than wait until the pregnancy is over seven months. If they are identified as carrying high-risk pregnancies, they will be referred to the next higher level of healthcare.
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What policies or investments are needed in our health system to improve the care and outcomes of premature babies?
The WHO has a set of guidelines for caring for pre-term babies. and there is also a national guideline. There are a set of minimum standards for every level of health care. So, we hope our government will adhere to those things and provide the needed materials and manpower. Preterm babies are not meant to be cared for at the primary care level but at the secondary and tertiary healthcare levels. For the secondary care level, they should have at least a phototherapy, provide CPAP (continuous positive airway pressure), and safe oxygen. That will ensure that not every single preterm baby will need to go to a tertiary hospital where things are more expensive and more high-tech, and it’s a bit more difficult for the families to cope. Facilities for screening the eyes and ears after newborn care also need to be made more widely available to detect early and manage complications that can significantly affect quality of life.
In order to have the necessary laboratory backup, antibiotics, and subsidised essential medications for preterm care on hand, we must have the right policies in place. The health insurance system should also be strengthened and structured to make the care of newborns not dependent on out-of-pocket expenditures.
The newborns’ bodies are incapable of producing heat and are considerably worse premature babies. Therefore, we must provide these newborns with more warmth. The additional warmth is supplied via warming blankets, radiant warmers, and incubators. Kangaroo mother care is a natural, inexpensive way to keep small babies warm, prevent them from catching germs, and maintain steady breathing. Breast milk is also stimulated by this. Even for preterm babies, breast milk is still the best option. However, they struggle to suck sufficiently; therefore, mothers express their breast milk, and the infant is fed using a cup or tube. Support for breastfeeding and milk storage should therefore be provided.
