Sub-Saharan Africa has one of the world’s highest neonatal mortality rates and neonatal mortality remains a big challenge in South Africa, despite government investment in healthcare.
The South Africa Demographic and Health Survey reports that the neonatal mortality rate in South Africa is at 21 deaths per 1 000 live births, figures that are of major concern to Dr Harishia Naidoo of the University of Pretoria’s (UP) Department of Paediatrics and Child Health.
“If the current trajectory continues, Every Newborn Action Plan’s target of reducing deaths to less than 10 per 1 000 live births will not be met by 2035,” she says referring to the global plan launched in 2014 with the aim of ending preventable newborn mortality and stillbirth and reducing maternal mortality and morbidity.
Prem baby at Tembisa Provincial Tertiary Hospital
Premature birth – that is, birth before 37 weeks’ gestation – is the most common cause of neonatal deaths in low- and middle-income countries (LMICs). Deaths are particularly high because of a lack of simple, effective measures – before and after birth, says Dr Naidoo, who also heads up the Neonatal Unit at Tembisa Hospital, which has the second-highest number of live births in Gauteng.
Dr Naidoo wants to improve neonatal mortality in the province. She says there are pre- and post-birth measures that can be taken to achieve this goal, despite overcrowding and a lack of staff in government hospitals. “About 2 million neonatal deaths could be prevented by utilising evidence-based interventions that are already at our disposal.”
Unplanned pregnancies, infection
For starters, preventing premature birth, and its complications, requires a healthy, planned pregnancy. A major problem in South Africa is that many pregnancies are unplanned – or girls are falling pregnant at a young age.
“Mothers younger than 18 years are at greater risk of preterm deliveries,” says Dr Naidoo. Family planning and contraception are essential – and are freely available in public health institutions. However, a lack of a preferred type of contraception and misconceptions regarding the use of contraception often result in unplanned pregnancy.
Infection is another common reason for preterm deliveries in LMICs. Dr Naidoo says: “Poor socio-economic background and a lack of access to amenities increase the risk of infection as well.”
Dr Naidoo says it is essential that pregnant women receive pre-conceptual counselling so that a mother’s mental and physical condition can be optimised. Antenatal intervention also means infections can be adequately screened and treated, before conception. “This will prevent premature deaths relating to congenital infections.”
Hypertension in mothers – another cause of preterm deliveries – can be monitored and treated during antenatal interventions.
According to the World Health Organisation, a premature baby is particularly vulnerable to impaired respiration, has difficulty feeding, poor body temperature regulation and is at a high risk of infection. Dr Naidoo identifies specific interventions for improving preterm survival despite these vulnerabilities.
Administering maternal antenatal corticosteroids can reduce respiratory distress syndrome (RDS) by 34% in preterm babies and reduce neonatal deaths by 31%. Dr Naidoo says: “Antenatal corticosteroids can reduce neonatal death within the first 24 hours of administration and should therefore be given even if delivery is imminent.”
There are a number of postnatal interventions that can also increase a preterm baby’s chance of survival: for example, says Dr Naidoo, if the need for the infant to be transported to a higher level of care for respiratory support is eliminated. However, in most provinces, the level of care in district hospitals is at a basic level, and infants need to be taken to secondary or tertiary hospitals.
Continuous positive airway pressure (CPAP) is a promising intervention to treat RDS and, if applied immediately after birth, can reduce the need for incubation and invasive ventilation by 50%. This can also prevent chronic lung disease.
Hypothermia is a major problem in premature births. Dr Naidoo says that a loss of just one degree in temperature results in a 28% increase in mortality. Wrapping babies in cling film or plastic bags immediately after birth can reduce hypothermia by 58%.
While these are all very effective affordable measures, they are not implemented in Gauteng district hospitals. “More training, staff and beds are required for these measures to be implemented,” says Dr Naidoo.
While she waits for these measures to be implemented, she says the fundamental importance of breastfeeding and a mother’s touch should not be forgotten. Breastmilk has countless nutritional and health benefits.
“Human milk contributes to the development of the preterm neonate’s immature host defence mechanisms, decreasing the risk of necrotizing enterocolitis (NEC) and sepsis, and thereby reducing neonatal morbidity and mortality.” NEC is a serious disease that affects the intestines of premature babies while sepsis is a disease caused by the presence of bacteria, a virus or fungus in the blood. Feeding premature babies with breastmilk is particularly important in LMIC homes where hygiene conditions are poor.
Another boost to a baby’s development is Kangaroo Mother Care (KMC) – when the infant is placed skin-to-skin in an upright position on the parent’s chest. “This simple method improves growth and development and improves oxygen saturation. It is also said to reduce neonatal mortality by 50%, making it an ideal tool in LMIC homes and clinics where other resources are limited,” says Dr Naidoo.