The A-B-C of Premature Delivery and Perinatal Mortality

Pregnancy Prematurity

A perinatal death is the death of a foetus or an early neonate i.e. within the first 7 days of life, while perinatal mortality rate is defined as the number of perinatal deaths per 1000 total births in a given population. Globally, perinatal conditions represent one of the top ten leading causes of disease burden. And this burden is even higher in developing countries like Nigeria where together with HIV/AIDS, malaria, undernutrition, maternal and infective conditions, perinatal conditions constitute the leading cause of disease burden. The associated burden is not only in terms of disability or death but also in terms of emotional and financial strain on the families involved. There is also the huge health care cost (with associated direct and indirect economic losses) to the society in general. Sadly, this dismal outcome will continue to worsen unless something is done to halt the trend. Global epidemiologic transitions are not favourable either, with the steepest rise in non-communicable diseases now also occurring in the less developed countries. Fortunately though, majority of the causes of prematurity and perinatal mortality can be prevented. It therefore becomes imperative that we continue to elucidate ways –tested, tried and even novel- to tackle this scourge.

Contributory to perinatal mortality is premature delivery, the definition of which varies by country and depends on the level of sophistication of health care delivery system in any given setting. In the United Kingdom, premature delivery is one occurring after 24 weeks of intra-uterine life (life in the womb) but before the attainment of full term status i.e. 37 completed weeks. This is however different from what is obtained in the United States of America where delivery occurring after 20 weeks of gestation but before full term is considered premature. In Nigeria, the definition is also different, and is in line with the internationally accepted definition which considers any delivery occurring after 28 weeks but before full term as premature. It is instructive to note however that, most of these definitions are actually based on evidence showing the survivability of a premature foetus on life support measures. Thus, one would be forced to wonder what evidence there is to suggest the applicability of the 28 weeks mark in the Nigerian setting. As it stands today, we are largely unaware of the probability of a foetus surviving outside of the uterus after 20, 24, 28, or even 32 weeks gestation in Nigeria. Having said that, and regardless of the definition, it is important to do all that is humanly possible to ensure that no life is lost in the process of procreation (either for mothers or their babies) and that when premature deliveries occur mechanisms are in place to cushion the burden (emotional and financial) on the families involved. This is even more imperative in our setting where “out of pocket” expenditure accounts for over 70% of health care spending thereby signifying the enormous burden that individuals and families are faced with in the unfortunate event of disability or disease — any disease for that matter.

The causes of premature delivery range from foetal causes (those that are due to reasons associated with the baby) to maternal causes (those that are due to factors related to the mother). It would however appear that maternal causes seem to play a bigger role in the aetiology of prematurity in comparison to foetal causes. The common causes that we need to be aware of in an attempt to prevent premature delivery include:

– Maternal stress; even though it is difficult to convince anybody to take things easy in an atmosphere of constant strife like we have in Nigeria but stress surely does play a role in predisposing to premature delivery thus it is important that efforts are made to either eliminate or diminish sources of stress in pregnancy. These sources can range from difficult work schedules to prolonged working hours, financial worries or bereavement. Whatever the stressor, relaxation techniques and exercise have however been proven to be potent stress busters.

– Maternal infections; including malaria, urinary tract infections and bacterial vaginosis; It is therefore important to be aware of the symptoms of some of these conditions or better still, when not feeling well, expectant mothers should not hesitate to go see their doctor.

– Other maternal conditions such as high blood pressure and diabetes. It is important to note that some of these conditions can present for the first time in pregnancy as such, it is not advisable to be dismissive of them simply because they weren’t present before pregnancy. Regular monitoring during antenatal care (ANC) is recommended and as a matter of fact part of routine ANC.

– Maternal cigarette smoking; thus, it is important to quit smoking before (and even after) conception.

– Maternal alcohol intake; alcohol is known to cause very serious syndromes in the unborn baby including the foetal alcohol syndrome as such it is important to abstain from alcohol before and during pregnancy.

– Previous uterine and cervical procedures such as cone biopsy of the cervix (this is a procedure performed on women who have shown early signs of cervical cancer). Cervical incompetence can however occur even without any readily discernible cause. Recognising this early would allow for the institution of measures that would prevent premature delivery.

– Previous history of premature delivery is also a predisposing factor to future premature deliveries thus it is important that such a history is volunteered at ANC.

– Multiple pregnancies: twins, triplets and other forms of multiple pregnancies predispose to premature delivery and it is expected that this possibility be detected and discussed during regular antenatal care.

– Heavy workloads; it is also important to avoid heavy work or lifting heavy objects during the later stages of pregnancy. Here, it is important to state that “pounding yam” during later stages of pregnancy could predispose to premature delivery. As such no matter how much husbands or relatives like “pounded-yam” the expectant mother should not be saddled with the responsibility of preparing it.

– Nutritional inadequacies; it is important to ensure adequate intake of nutritious diet before, during and after pregnancy. This is important not just in preventing premature delivery but also in preventing certain congenital malformations in the baby and other problems like anaemia in pregnancy.

– Drugs; certain drugs are known to be uterotonic and increase uterine contractions. It is therefore important that expectant women refrain from using drugs that have not been prescribed by a doctor. If in doubt about the potential effects of a drug it is always safe to seek an expert opinion.

– Idiopathic; we don’t know the cause and cannot explain why it has occurred!

This list is by no means exhaustive. It is however important to note that key to most health care interventions is health education and early detection. It is therefore imperative that the message on premature delivery is continually spread to every nook and cranny of our society; to those who probably need the information even more than the rest of us; and to those who are not fortunate enough to access social media. Additionally, it is important that the message emphasizes the importance of early registration at the antenatal clinic and regular attendance at these clinics. For those who eventually suffer from premature delivery, it is also important that we do all that is possible to not only save the life of the baby but to also ameliorate the sufferings of the parents. It is in this regard that the effort by Petra Akinti Onyegbule in setting up the Tiny Beating Hearts Initiative (TBHI) comes highly applauded. There is the need for advocacy is this regard and it would appear that TBHI being a non-governmental organization is poised to face the challenge head-on. To do this, it will need all the support it can get, in whatever guise. The goal, I am sure, is to touch one beating heart at a time. “No matter how tiny”.

Editor’s Note: November 17th has been designated as the World Prematurity Day. A day set aside to honour the about 15 million babies born prematurely yearly around the world. Join Tiny Beating Hearts Initiative in this year’s commemoration of the WPD on Saturday, November 16 by 7 am. We shall walk the short distance from OPIC Plaza (by Sheraton Hotel) Ikeja to LASUTH where there shall be a media parley immediately afterwards.

-By Mustapha Abubakar

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