Edith Nafula, 38, had been waiting for three years to get pregnant. When she did in 2015, she had no idea that it would mark the genesis of her struggles. Her excitement was cut short, when the baby was born prematurely (one week before term) and died.
Doctors at the Webuye County Hospital said it was because of high blood pressure.
Back home, her husband and his relatives became hostile. She got pregnant again last year, but at 26 weeks, she developed complications. At 27 weeks (on November 9), she went into labour early, due to high blood pressure, and delivered through C-section at the Moi Teaching and Referral Hospital in Eldoret.
Her baby weighed 600grammes and was placed in an incubator in the neonatal intensive care unit. She named her Testimony, a reminder that anyone can overcome the harrowing experience.
It took another one-and-half months for her baby to attain 1.6 kilogrammes, before she was discharged on December 29. Her husband visited her once when she was admitted at the health facility and didn’t show up again till she was discharged.
In her community, a preterm baby is considered a bad omen, that should be exterminated. Her in-laws advised the couple to get rid of the baby, but she opted to keep it. Six months later, she separated from her husband.
“I don’t know why they think she is a curse. She is a blessing. The government should sensitise people to understand that preterm babies are normal children,” she says.
While husband wanted nothing to do with their preterm baby, in Migori, 20-year-old Joel Moseti took a different approach. He cuts an odd figure at the nursery of the Kuria West Sub-County Hospital, in Kehancha, Migori, sitting comfortably, next to his wife, who lies in bed, with his bundle of joy tied to his chest. It has been three weeks since his daughter Dalvin Peninah was born (October 12), and her arrival came with mixed feelings.
“She was very tiny. Grossly underweight and fragile. I could barely look at her, let alone hold her,” he says.
At 1.4 kilogrammes, this was the first time Moseti had seen such a tiny, helpless baby. And if he thought he had seen tiny, he wasn’t ready for when her weight dropped to 600grammes.
“The only consolation was the doctor’s reassurance that she would get better,” he recalls. But for this to happen, the parents had to share their warmth, to stand in for lack of an incubator, by providing skin-to-skin contact, or what is known as kangaroo mother care.
The technique helps stabilise the body temperature of low birth weight (below 2.5 kilogrammes) and preterm babies, shielding them from the cold, and leading to faster improvement and development of vital body organs such as the heart and lungs and reflex action among other things.
It borrows from kangaroos – the Australian mammals that naturally give birth to underdeveloped young, then carries them in its pouch under the belly, nourishing them with milk and warmth.
In the first two weeks after starting on kangaroo care, Dalvin gained 400grammes.
Another young parent whose preterm baby was saved by kangaroo mother care, is Naomi Kerambo, whose daughter was born too soon (at seven months gestation) in 2014. She weighed 1.6 kilogrammes. Back then before she was given the option of kangaroo mother care, in the absence of an incubator, she swaddled the tot in warm clothing to keep her alive.
Last year, her second-born, a boy, was also born before term, at 28 weeks, weighing 1.7 kilogrammes. This time round she had kangaroo mother care and breastfeeding on her side. As a result, he gained 1.2 kilogrammes in a month, saving him from the vulnerability to death that comes with being born before term.
According to the World Health Organisation, one in every 10 newborns (or 15 million babies) is born before term, and approximately one million die each year due to complications of being born before term. Many survivors face a lifetime of disability, including learning disabilities and visual and hearing problems.
Kenya is among 15 countries with a high number of preterm births, with more than 180,000 babies born premature every year. Nearly 15,000 die.
Preterm babies (born before 37 weeks of gestation) have a high likelihood of dying if they don’t receive extra care. They usually need specialist skills, good nutrition and equipment such as incubators to ensure optimum body temperature and respirators to moderate oxygen, because their lungs are not well-developed. They need special support to attain at least 1.6 kilogrammes and boost their chances of survival.
Given that preterm births are a major contributor of neonatal mortality (death within the first 28 days of life), efforts are in place to reduce the burden and improve survival and quality of life for preemies.
Martina Nzyoka, the senior assistant director at the nursing department of the Mother and Baby facility at the Moi Teaching and Referral Hospital in Eldoret, says that the health facility records between 20 and 40 premature babies a day.
“In hospital, where the environment is sterile, the vulnerable newborns are protected from infections and contamination. And with minimal handling, the baby will grow into a healthy person,” she says.
Last December, the facility, which has incubators, introduced kangaroo mother care to boost chances of survival for preterm babies. Moreover, mothers are encouraged to continue with the technique, at home, after discharge from hospital, to give their preemies a fighting chance.
“The mother or father places the baby on their chest to give them warmth. But since we don’t have a family room, we only allow mothers to stay day and night with their babies which also boosts the bond between mother and baby,” she adds.
Since last year, 173 mothers have gone through the programme. The hospital follows up the progress of the babies after discharge, up to two years of age, and mothers who have gone through the programme are advised to return with their babies for regular check-ups.
“Some face the challenge of distance, so they don’t come back, so we follow up by calling them to check on the status of the baby. We also encourage them to visit the hospitals and clinics near where they live for regular check-ups," she adds.
Francis Ogaro, the deputy chief executive in-charge of clinical services at MTRH, says the facility last year adopted kangaroo mother care, an old science concept, to help decongest the facility.
He says that although the hospital has 56 incubators, there was need to adopt the programme to ensure that more babies born preterm, than the incubators available, are assisted.
“We are under pressure of space. This unit was built to accommodate 56 babies and at any given time, we can have more than 100 babies in that unit. With kangaroo care, we are able to teach mothers how to give their babies that crucial warmth, and discharge them earlier, to decongest the unit and give newer babies a fighting chance,” he says, adding that the referral hospital is also teaching counties in the north-rift region to adopt kangaroo care, so that they can support mothers who deliver before term, and their babies, and reduce referrals.
“We are going to health facilities in places like Kapsabet and Iten to establish and train their staff on kangaroo care, so that babies born there they don’t have to be referred to MTRH, unless it is necessary. Moreover, when lower-level facilities have this capacity, we can send the preterm babies who are improving back to them, with the assurance that it is safe for them to support mothers to continue offering kangaroo care,” adds Dr Ogaro, noting that beyond kangaroo care and focusing on survival, preterm babies also need regular eye checks.
Sometimes the hospital receives preterm babies from other counties and during the inter-county transfers to the health facility, may result to deaths.
For mothers, he says antenatal care, and even pre-conception care, is important to reduce some of the risk factors associated with premature births.
“Poor maternal nutrition (if the mother doesn’t feed on quality food), strenuous activities, and diseases like diabetes and hypertension, raise the likelihood that a woman will have a preterm birth,” explains Dr Ogaro.
Other risk factors are multiple pregnancies (carrying more than one baby, especially due to in vitro fertilisation (IVF).
“When you are carrying triplets or quadruplets, the uterus can expand to a point beyond which it can not expand further and the placenta may struggle to support multiple babies. As more women with fertility issues access IVF technology, which raises the likelihood of getting multiples due to enhanced fertility, we are likely to see more preterm babies.
“These women need support in face of the risks of preterm birth that they face, so that their excitement is not cut short, by not carrying the babies to term, or even losing them after birth."
Since kangaroo mother care was introduced to boost the chances of survival for preterm babies, especially in facilities with few or no incubators, 55 per cent of public health facilities in Kenya have set aside space for kangaroo mother care.
Beyond that, the World Health Organisation also recommends 10 elements of care for improved preterm birth outcomes, but Kenya has only included a few -- antenatal corticosteroids, tocolytics, magnesium sulfate, kangaroo mother care, and surfactant -- in its clinical standards of preterm care at the hospital level.
Nearly 85 percent of preterm babies are born between 32 and 37 weeks gestation and most of them babies do not need intensive care to survive, but they, and low birthweight babies, need the recommended solutions for survival and health because they are vulnerable and infections and breathing difficulties can mean the difference between life and death.
Interventions include essential newborn care (drying, warming, immediate and exclusive breastfeeding, hygiene and cord care) and basic care for feeding support. Moreover, to boost their chances, more effort is needed to identify women at risk of preterm labour and support them to give birth in a health facility that can offer extra care to keep their babies alive.
Scientists try to crack puzzle of preterm births in Migori
The Kenya Medical Research Institute (KEMRI) is researching preterm births in Migori, one of five counties with the highest preterm births, to decrease the burden of preterm births and improve survival and quality of life for preterm babies.
Between January and June 2018, Migori County Referral Hospital recorded 250 preterm births out of 1,200 total births, or a prematurity rate of 13 per cent. From June 2016 to September, 2018, a total of 30, 811 deliveries have been recorded out of which 3,729 were preterm and low birthweight babies.
More than 2,000 preemies have been enrolled for day 28 follow-up in the research project. Kemri researchers have completed follow up of 2,013 (82 per cent) out of which 143 (seven per cent) deaths were recorded.
“Interventions have to start right from conception, throughout pregnancy, during labour and after delivery. Mothers have to be taught the danger signs and things that contribute to preterm birth,” says Migori County Director of Health Elizabeth Mgumb.
Besides collecting data, the Pre Term Birth Initiative (PTBi) Kenya is also training health workers, seeking to improve quality of care in health facilities to manage labour, delivery and post-delivery care for mothers and babies, and implementing a modified WHO Safe Childbirth Checklist.
The project covers 17 high-volume health facilities. Besides establishing the actual burden of preterm births, the project will also help identify gaps and weaknesses and data to help in decision making.
“When you improve on documentation of gestation of age. The person will know to handle possibilities of preterm cases based on the history of the patient,” says principal investigator Phelgona Otieno.
“Recording a video during deliveries, analysis of the faults, successes and what needs to be improved at the maternity facilities, can help boost outcomes,” explains Dr Otieno, adding that quality improvement involves identifying the challenge that hinders the provision of quality care during birth. Some of the challenges could be lack of sufficient lighting in the delivery room, or insufficient warmth.
The project has also provided 50 incublankets for warmth during referral, giving babies warmth up to eight hours to decrease deaths.
Beatrice Olack a nutritionist at PTBi is conducting Verbal Autopsy Social Autopsy (VASA) to identify and understanding causes of, and circumstances preceding preterm deaths.
Migori CEC for Health Iscar Oluoch says that having a preterm birth is not curse and it can happen to anybody, regardless of social status.
“It is important for counties to invest in interventions that would support survival of preterm babies and mothers,” says Dr Oluoch.
She adds moving forward, counties should consider livelihood approaches for mothers who might take long nursing preterm babies in health facilities.
“No mother ever prepares to have a preterm birth, but anything can happen. We need to look into livelihood for mothers who take up to three months in hospital,” she said.
In another study, scientists are investigating the link between (indoor and outdoor) pollution and preterm births in 400 households Migori.
“We are looking at how the structure of the kitchen and ventilation might contribute to preterm births,” says Lydia Olaka, a lecturer at University of Nairobi department of Geology. “We are also trying to map the hotspots. It could be an issue of high mercury levels in soil, because of gold mining. We have collected soil and water samples for testing,” added Dr Olaka. - by Elizabeth Ojina