World Prematurity Day
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Dr. Sayed Rubayet, Project Director, Saving Newborn Lives, Save the Children
I would like to start with the recent breakthrough news regarding child mortality and definitely that is not good news. In 2014, Lancet published that preterm is the number one cause for child mortality. Earlier it was number two. So, from that publication we came to know that globally 138 million babies are born and 11% (around 15.1 million) of them are born too soon that means before 37 weeks of pregnancy. Among them 1 million child die before their 5th birthday. If we count data of 10 countries, 60% of total premature birth happens in 10 countries among which Bangladesh stands at seven.
The main challenge is the survival gap. In western countries, survival rate of extreme preterm baby is more than 90% while in our country it is less than 10%. So the real challenge is for countries like Bangladesh where more than 50% preterm babies are born in the households. And even when babies are born in facility care, the quality of the facility is questionable.
According to WHO, 14% pregnancy are resulting with preterm deliveries in Bangladesh while the global average is 11%. In 2013, four lakh thirty five thousand premature babies were born in Bangladesh. If we estimate the causes of neonatal mortality, 45% of the deaths happening in the first month of life are due to preterm birth complication. This is not an encouraging situation. We need to do something.
In 2013, Bangladesh ranked 6th in the list of premature baby's death. As per the recent Lancet publication, the number of neonatal mortality in 2013 was 26,100. In 2012, a global initiative was taken to identify what the major challenges and what are the solutions regarding preterm birth. On behalf of UN secretary general, they published a report titled 'Born Too Soon: The Global Action Report on Preterm Birth'. They identified cost effective proven interventions to prevent and treat preterm birth complications. The report emphasizes on better healthcare for women and babies, increasing access to family planning, improving health before pregnancies, ensuring newborn cares as basics.
The World Prematurity Day was first observed in 2011. In Bangladesh we started it in 2012. The aim of the day is to update global evidence on prevention and treatment solutions, to highlight support for affected families, to strengthen high level national commitment and to create awareness through campaign.
Since the first observation of World Prematurity Day, a lot of progresses have happened. In April, 2013 the first ever new born global conference was held; Lancet published their 'Every New Born' series; every new born action plan was endorsed by world health assembly; every new born action plan was incorporated in some countries and so on. Bangladesh is one of the countries who have developed their every new born action plan. Now, it is at the final stage of preparation. The government has included some effective intervention programmes in their priority. Now we have a very comprehensive plan.
Now, the major challenge is to convert the policy into action, incorporate it in the programme, and effective coverage of these interventions. Against this background, I hope we would be able to work together and create a nice future for our newborns.
National Professor M.R. Khan, President, Bangladesh Perinatal Society
Adolescent pregnancy is a major problem. Adolescent girls and their family members should be made aware about the risks of being pregnant at adolescent age.
Another important point is initiation of early breast feeding. Usually milking starts on the third day. But during the first and second day, family members particularly grand parents becomes worried and put something, specially honey, into the mouth of newborn. It causes diarrhea. So we have inform parents that whatever milk the baby gets that is more than enough for the first day . That is the first vaccination for the new born babies. Even we should not give water to newborns.
Keeping newborn safe from infection is another important issue because it is difficult to diagnose their infection. In village, newborn get the worst room while they should be given the best one.
Professor T A Chowdhury, Founder President, Bangladesh Perinatal Society
There is a general consensus that if we increase institutional delivery it will automatically improve the situation of maternal and neo-natal mortality. Is it true? I don't think so. Because, newborns need different type of care than delivery. In many cases we find that the birth attendant does not have the necessary knowledge of newborn care, particularly preterm birth care. So we should emphasise on immediate care of newborns after birth. That's why we need to train midwifes on newborn care, particularly care for preterm babies. Premature birth is going to stay but what we have to find out that what are the simplest ways and effective measures to take care of premature babies.
There is another question. Should we resuscitate babies who are only 22-24 weeks of old. Many of these babies are not going to survive in any case. Those who will survive, half of them will survive at least with neurological problems. Should we have a cut off point where we should go to resuscitate premature babies? It is an ethical issue.
Other than natural pre-maturity we have got a group called hydrogenic prematurity that means the baby is get delivered before time due to mother's complication. If we can control pre-aclampsia, aclampsia, diabetes like complications before hand we can reduce this type of premature birth.
Extreme dietary deprivation may have a role in causing premature birth but ordinary malnutrition has very little relationship with premature labour. So we should not think that only dietary intervention can change the situation radically.
It will take a long time to be able to achieve cent percent institutional delivery so we should emphasize on simple means of delivery so that community can take care of it.
We can take the example of neo-natal intensive care unit. It is a drop in the ocean. We must be realistic in setting our aim. We find that our human resources are capable of delivering baby but not taking care of the baby, especially pre-term baby. So one of our priority areas should be ensuring that whoever is entrusted with delivery has to has basic knowledge of newborn care. In case of pre-mature baby it is more important. We need continuous training of the birth attendants.
Another important point is that at the home or lower community level, we can also administer the package of effective interventions. It only requires some degree of training and good to provide the care.
Dr. Hosne Ara Begum, Professor of Pediatrics and President, Bangladesh Neonatal Forum
There are several components of essential newborn care like resuscitation, warmth, breastfeeding, drying and wrapping, special care for the preterm and so on. These have already been listed in government programmes. The government has already formulated low cost strategies. Now the challenge is to implement those strategies at the grass root level. We have to increase number of nurses to ensure good anti-natal and pre-natal care. We also need good monitoring system.
Dr. Shams El Arifeen, Director CCAH, and Senior Scientist, icddr,b
Can we imagine of handling premature birth in a non-institutional setting? If not, we have to talk about how we can accelerate existing institutional facilities that we are using.
We do not have a good measure of pre-term delivery in Bangladesh. We can start with a programme where mothers would record length of pregnancy.
Globally, there is an emerging sort of research on how to reduce pre-term birth. These types of researches are also happening in Bangladesh. We are trying to find areas of biological intervention which can reduce likelihood of pre-term delivery. We are hopeful about it. In the meantime we have to find ways of saving premature babies.
Dr. M A Mannan, Professor of Neonatology BSMMU and Organizing Secretary, Bangladesh Perinatal Society
In our facilities, nurses mainly provide care. But all the nurses are not very much trained. The government with the assistance of UNICEF is now giving training to both doctor and nurses on sick newborn care in BSMMU and DMCH. We have already trained a good number of nurses across the country.
One of the most important causes of death of premature babies is infection. Premature babies have very little immunity. So they cannot survive against infection. To prevent this we have very simple methods. One is hand washing. There are evidences that if the care givers take proper hand washing, 70-80% infection cases can be reduced.
Professor Dr. Md. Mahbubul Haque, Secretary General, Bangladesh Neonatal Forum
Data shows that 84% of pre-term babies are late pre-terms. That means they are more than 2 kg. So they are easily manageable in delivery places. But people get feared and the doctor refers the case to higher centre. In the meantime of going to higher centre the baby gets sick. So we should train our manpower at the primary level about care of late pre-term baby.
Last year we conducted a study on KMC (Kangaroo Mother Care) in Dhaka Shishu Hospital with the help of WHO. We found that KMC was working excellently. We should scale up the KMC programme throughout the country and train our health workers on KMC.
Dr. Tapas Ranjan Das, Deputy Director & Programme Manager, MHS, DGFP
If we can train our service providers on prematurity complications we will be able to successfully address the issue. Knowing about which service is available where is also very important. We need to campaign at the community level to disseminate these information.
Professor Rowshan Ara Begum, Head, Obstetrics and Gynecology, Holy Family Red Crescent Medical College & Hospital and President, OGSB
We have to emphasize on contraception use by adolescents and newly married couples. Media can play a great role here to make people aware about this issue.
We need to strengthen the management of our district hospitals and equip them properly so that they can provide proper care to pre-term babies.
Sabiha Alam, Journalist, Prothom Alo
We are talking about institutional facilities but what is the status of these institutions? Whether they have enough manpower and facilities to provide proper care?
Dr. Allyson P. Bear, Deputy Director, OPHNE, USAID Bangladesh
High quality anti-natal care and delivery services are very important to address maternal and child mortality. In order to address the specific needs of premature babies we need to refer them to the proper institution at the earliest possible moment.
An important research shows that multi-vitamin supplementation during pregnancy actually reduce premature birth. We should explore the potential of this finding. It may play a good role in Bangladesh.
Dr. Riad Mahmud, Health Specialist (Maternal and Newborn Health), UNICEF Bangladesh
Some key data will help us understand the role of different sectors in reducing premature birth. 39% of women between 20-49 years got married by 15 years. One-third of the adolescent girls get married and adolescent birth rate in Bangladesh is 118 which is one of the highest in the world. MMR is double among adolescent girls. A recent study, conducted in 10 districts of Bangladesh, shows that 42% newborn die within six hours and most of them are born at home. Unless they are born in an institutional facility their survival remains at stake. With this I will emphasise on three domains: enabling policy environment, supply side and some demand parts. In terms of policy we are doing fine. We have a nice neonatal strategy. Even to establish special care we have scan strategy as well. To the policy matter, Unicef want to urge all the stakeholders to take multi-sectoral approach to eliminate child marriage from the country. We need to reduce teen pregnancy and delay the first pregnancy.
On supply side, I would quote form a recently published Lancet report "we need to ensure and scale up full supportive care of sick new born at facility for pre-term, sepsis and other conditions. So we need to ensure quality care of sick newborn at facility. I am very happy to say that Ministry of Health has recently endorsed the special care newborn strategy. Government would scale up special care newborn unit at all medical colleges and district hospitals.
We would like to recommend that newborn care, specially sick newborn care, and pre-term management should be included in the curriculum of midwife because they are the coming generation to save mother and newborn.
Dr. Farhana Dewan, Professor, Obstetrics and Gynecology, Shaheed Suhrawardy Medical College and Secretary General, OGSB
We still have to depend on the home delivery. Service of CSBS is complementary to the services we are giving in facilities. In terms of pre-term birth we have to look after both mother and newborn. We are providing training on both of these two issues to our skill birth attendants. These are included in their curriculum.
I want to highlight the point of referral system. The golden one minute of birth is very important for both pre-term and term baby. So in case of complication we must know how to refer a baby and where to refer.
Michael Foley, Director, Health & Nutrition, Save the Children
We have talked about several interventions like KMC, anti-sepsis management and so on. But we have to ensure that these interventions can deliver. So if we are going to effective scale up of these interventions we have to look at the whole health system. We have to continue our effort from boardroom to birth room. We have to ensure that every Bangladeshis have access to these services.
Save the Children through its new born mileage programme is looking at delivering the package of interventions in a pilot district , Kushtia. We are working intensively there. We are looking at how these interventions can be delivered effectively. So we are looking forward to the results and partnership of all the stakeholders to find effective interventions packages.
Uzma Syed, Advisor, Newborn Health, Save the Children USA
Every hour in Bangladesh we are loosing three babies from complications of prematurity. In 2013, we lost over 26,000 babies from pre-maturity complications. These data help us realize the burden.
I want to reiterate about stopping adolescent pregnancy, continuous maternal malnutrition, maternal anemia and so on. We should stop scaling up equipments and start scaling up interventions. We can save thousands of new borns without having newborn intensive care by initiation of early breastfeeding, skin to skin care, and appropriate cord care.
Dr. Rabeya Khatoon, National Professional Officer, MNCAH, WHO Bangladesh
We are generating evidences and helping countries use those evidences. One of the evidences is KMC for saving newborn lives specially for pre-mature babies. WHO has provided technical assistance to Dhaka Shishu Hospital on these types of low cost interventions.
I would urge media to help in disseminating information about these kinds of interventions.
We can use life-cycle approach to reduce pre-term birth complications in our country.
Dr. Soofia Khatoon, Professor of Pediatrics and President, Elect, Bangladesh Neonatal Forum
There should be two persons at delivery. One person should be for the mother and another one for the baby.
Initiation of breastfeeding within one hour of birth reduces 31% of neo-natal mortality if it continues as exclusive. It also addresses the hypothermia because it provides skin to skin care, hypoglycemia and infection. In case of taking care of pre-term babies, breast feeding can work tremendously because it contains high amount of proteins and anti-bodies. In our country there is a bad practice of giving preterm baby artificial milk. We should immediately stop this. Breastfeeding is enough for necessary growth, survival and infection prevention of pre-term babies.
Dr. Syed Abu Jafar Md. Musa, Director Primary Health Care and Line Director Maternal Newborn Child and Adolescent Health, DGHS, MOH&FW
I want to talk about some government initiatives. We started from the inception period. We are encouraging delay marriage and prevention of adolescent pregnancy. We are trying to increase our institutional delivery rate from 30% to 50%. The government is working for producing a good number of skill birth attendants. According to the commitment of the PM, 3000 posts for midwives have been created. 1225 students have already been enrolled in first two batches of training midwives. We are encouraging implementation of comprehensive newborn care package (CNCP). In our operation plan effective low cost interventions like KMC, Helping Babies Breathe have been reflected with proper importance. We are simultaneously establishing essential newborn care unit at the different level of hospitals. By 2016 we hope to cover all the medical college hospitals and district level hospitals. We have also initiated identification of pre-eclampsia, treatment of pre-eclampsia and management of PPH, management of birth asphyxia and so on. We have been working with all our stakeholders for the same goal of survival of the child, reducing pre-term birth and management of pre-term babies.
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