Born Too Soon: Preterm births a global concern

South Africa’s progress on reducing preterm births has stagnated over the past decade. In 2020, 1.2 million babies were born in South Africa. Thirteen percent (154 800) were preterm or born too soon. South Africa is among the top five for preterm birth rates in the world. 

“That’s completely a flat line. The really shocking thing that South Africa needs to pay attention to is that there’s been no change in the last decade,” says Joy Lawn, a professor of maternal and child health at the London School of Hygiene and Tropical Medicine. 

She’s also the editor of a new report, Born Too Soon, that details the impact of preterm births over the past decade. The report found that preterm birth rates have not changed in any region in the world in the past decade, with 152 million vulnerable babies born too soon from 2010 to 2020.

It cites preterm birth as the leading cause of child deaths in children under the age of 5.

Preterm survivors can face lifelong health consequences, with an increased likelihood of disability and developmental delays.

Preterm babies are born before 37 weeks of pregnancy. In South Africa, the neonatal mortality rate from 2019 to 2020 was 12 per 1 000 live births in South Africa. Preterm birth was the cause of almost 50% of neonatal deaths, according to the South African Maternal, Perinatal and Neonatal Health Policy published in 2021. 

Why are there so many preterm births?

The Born Too Soon report says failure to invest in health care for pregnant women and newborns is partially to blame for the stagnation in progress, while conflict, climate change, and COVID-19 have added to the risks.

The World Health Organisation (WHO) says most preterm births happen spontaneously. Some are due to medical reasons such as infections that require early induction of labour, others due to a caesarean birth or other chronic conditions such as diabetes and high blood pressure. 

Adding to this are the multiple burdens of diseases in South Africa, says Lawn. An estimated 30% of pregnant women live with HIV in South Africa, according to the National Institute for Communicable Disease (NICD). Several studies show an increased risk of preterm births for mothers with HIV. The use of antiretroviral therapy (ART) is also associated with preterm deliveries.

There is reason for hope though. “South Africa has a good data tracking system of birth outcomes”, says Professor Justus Hofmeyr, a consultant in the Department of Obstetrics and Gynaecology, East London Hospital Complex. 

Established in the early 1990s, the Perinatal Problem Identification Programme (PPIP) captures perinatal mortality data and identifies factors to stimulate actions of better maternal and neonatal care. 

Both Lawn and Hofmeyr say South Africa has a good antenatal care policy on paper in its National Health Policy, but it needs to ensure equitability and quality implementation.

“There are big inequalities between the private sector and public sector and between provinces such as the Western Cape compared to Eastern Cape,” says Lawn. 

How to reduce the number of preterm birth complications

“Two measures that are not expensive and could quickly make a difference are delayed cord clamping and the use of antenatal corticosteroids for women at risk of preterm delivery”, says Lawn. 

Hofmyer echoes that the delayed cord clamping for newborn preterm babies needs awareness-raising. “There’s a natural tendency for health providers to clamp the cord quickly in order to move the preterm baby to a resuscitation area, but there is now strong evidence that delaying clamping the cord for up to one minute significantly reduces complications of prematurity and mortality.”

Delaying clamping the umbilical cord that connects the newborn to the mother allows extra time for the blood in the cord and placenta to flow to the baby. If the cord is clamped instantly after birth, it could potentially reduce the baby’s blood volume and haemoglobin, a protein found in the red blood cells that carries oxygen. “It especially has a consequential impact on preterm babies who are more likely to be anaemic” says Lawn. 

Another “low-hanging fruit” is antenatal corticosteroid treatment. Lawn says it would ‘accelerate the lung maturation of the newborn and it’s effective in reducing neonatal respiratory morbidity.’

In 2021, the WHO recommended antenatal corticosteroid therapy for women with a high likelihood of preterm birth from 24 weeks to 34 weeks of pregnancy. 

“This can half the deaths from respiratory distress. It’s low cost. But the thing is to remember to do it and to do it early enough,” says Lawn. 

A silent pandemic

Compared to other communicable or non-communicable diseases, says Lawn, preterm birth remains a silent pandemic because 80% of neonatal deaths are in sub-Saharan Africa and South Asia and babies and mothers often don’t have a voice.

“For HIV we have a very loud voice which is so important, but these babies don’t have a voice. And often the women who are affected don’t (have a voice.) So it makes media coverage even more important,” she says.

Stillbirth, especially, remains a taboo subject worldwide, even in high-income countries. According to UNICEF, a stillbirth occurs every 16 seconds. It causes profound psychological suffering as well as stigma from communities towards women and their families. 

“Somehow the blame ends up being put back on women instead of on the system or on science.” Lawn says the focus should be on systemically bettering care before and during labour. – Health-e News

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