Representative image. Photo: Christian Bowen/Unsplash
New Delhi: India has not shown any improvement in reducing preterm or premature births in the previous decade, reveals a new analysis published in The Lancet on Friday, October 6. This is in contrast with the improvements that the country has made in other maternal and child mortality indicators over the same time period.
The paper analysed preterm births in 2020 across 194 countries and compared them with trends from 2010. It found that the preterm birth rate – i.e., the number of births that took place prematurely every 1000 live births – was 13.0 in 2020, almost identical to the rate of 13.1 in 2010. A preterm birth is defined as a baby who is born before the 37th week of gestation, as opposed to the normal term of 40 weeks.
India contributed 20% of all preterm births (3·02 million) – the highest in the world. It was followed by Pakistan, Nigeria, China, Ethiopia, Bangladesh, the Democratic Republic of the Congo, and the US.
However, these absolute numbers must be interpreted with few caveats, two being the reflection of large population sizes and the high number of total births happening in these countries. The authors of the paper add that these high numbers of preterm births were also reflective of “weaker health systems that are unable to deliver high-quality family planning, antenatal care, and childbirth services to all individuals who need them”.
Preterm births have a higher chance of neonatal mortality (children dying within one month of birth). India has significantly reduced the neonatal mortality rate to 24.9 per 1000 live births according to the National Family Health Survey (NFHS)-5 data, down from 29.5 in the previous survey. Its share of the global newborn mortality burden came down from one-third in 1990 to below a quarter now. But the country still registers the highest number of neonatal deaths across the world. While preterm births are not the only reason for neonatal deaths, they remain one of the most significant causes.
T. Sundararaman, former head of the Union Ministry of Health and Family Welfare’s National Health Systems Resource Centre, told The Wire that preterm births strain a healthcare system. A child born before the full term will require special care, said Sundararaman, who was not associated with The Lancet paper.
“Some of these babies are born so small (underweight) that it is a real challenge to save them,” he said.
Dr Vipin Vashishtha, a Bijnor-based paediatrician also not associated with The Lancet paper, agreed. “They [preterm babies] may require resuscitation, ventilation to prevent asphyxia… these services may not be readily available at the periphery,” he said.
Besides these special services, the presence of a paediatrician is also of utmost importance. The ‘Rural Health Statistics (RHS) 2021-22’ show that there are thousands of community health centres (CHCs) across India that don’t even have a single paediatrician stationed. Take, for instance, Uttar Pradesh. More than 600 CHCs don’t have a child specialist. As many as 4,474 CHCs across India don’t have a paediatrician.
A neonate, who develops complications, may require treatment in a Special Newborn Care Unit (SNCU). It is a separate unit in close proximity to the labour room with 12 or more beds that is meant to be managed by adequately trained doctors, staff nurses and support staff to provide 24×7 services. It is usually established at district hospitals (DHs) or sub-divisional hospitals. Now, the same RHS 2021-22 says there is a shortage of more than 5,000 doctors and about 16,000 paramedical staff members across district hospitals in India.
In other words, while there is a high burden of preterm births in the country, there is inadequate healthcare service delivery to prevent the death of neonates born prematurely and who may go on to develop complications.
Not all prematurely born kids face the risk of neonatal mortality. But many may experience a delay in brain development, cognitive impairment or cerebral palsy, Dr Vashishtha said. If proper facilities for neonatal care are available, many of these complications can be avoided.
Besides, the World Health Organisation (WHO), in its report ‘Born Too Soon‘ released in May 2023 reckoned premature births as one of the two underlying causes of low birth weight.
“Low-birth-weight newborns are more likely to become children who are stunted or wasted, and to experience developmental delays, and more likely to become undernourished adolescents, and then undernourished adults,” it said.
Also Read: ‘In 2020, 13 Million Babies Were Born Too Early. India Is Among Top Five Nations Where It Happened’
Are preterm births avoidable?
Can preterm births be avoided? The answer to this question lies in the circumstances leading to them. The Lancet paper says, yes, they can be.
One of the underlying reasons that women deliver a child before the full term is the below-par care they receive during pregnancy, also known as antenatal care (ANC).
If proper antenatal care is provided, a preterm pregnancy may be projected beforehand, and plans can be made accordingly. Also, infections are one of the main causes of preterm births – which can be diagnosed and treated with proper ANC.
The authors of The Lancet paper say that an expectant mother must receive eight antenatal checkups at a healthcare facility. While Indian guidelines recommend a minimum of four, data shows that even that target is not met for a significant chunk of pregnant women. According to NFHS-5, a little more than half of pregnant women – 58.1% – received four ANC check-ups.
Moreover, these are merely the numbers. In other words, 58.1% of women went to a healthcare facility at least four times during pregnancy – but we do not know anything about the quality of ANC they received.
Some clues about the quality of ANC can be gleaned from a paper published in BJOG (a journal of the Royal College of Obstetricians and Gynaecologists) in July 2019. Three of the five authors of the paper were funded by the Indian Council of Medical Research. They used the NFHS-4 data, which said 51% of women received four ANC check-ups, to find that less than a quarter – 23.5% – of them got what they describe as “adequate ANC”. As many as 58.8% received “inadequate ANC”.
They used eight indicators to determine if ANC was adequate, such as weight measurement, urine testing, blood samples for investigating infections in expecting women, and consumption of iron and folic acid tablets.
The authors also found a rich-poor and rural-urban divide. About two out of five women belonging to the richest wealth quintile received adequate ANC, but this was 7.9% among the poorest women.
The second important factor, according to Sundararaman, is what are called social determinants of health. The WHO’s ‘Born Too Soon’ report also lays stress on factors like management of anaemia and proper diet. “Nutritional deficiencies, particularly iron deficiency anaemia, can lead to preterm delivery and low birth weight,” it said.
Now, NFHS-5 (conducted between 2019-21) revealed more than half, i.e., 52.2% of pregnant women aged 15-49 years were anaemic. The corresponding figure for NFHS-4 (conducted between 2015-16) was 50.4%.
“Merely a woman paying three or four visits to a nearby health facility [for ANC] won’t serve much purpose unless these social determinants of health – nutrition and anaemia – are not addressed,” Sundararaman said.
While Dr Vashishtha agreed that these lacunae in addressing preventable causes of preterm births, he also said a “large number of” such births are idiopathic – for which the cause could not be known. Although there is no nationwide study to say what percentage of preterm births are idiopathic, the paper published in The Lancet does not count it as one of the reasons.
A commentary published in the American Journal of Obstetrics and Gynecology in 1993 says idiopathic preterm births can also be avoided. “We suggest that an exhaustive evaluation plan can identify possible causes in the majority (96%) of cases of ‘idiopathic’ preterm labour that result in preterm delivery,” it read.
Multiple pregnancies, especially during the teenage years, are one of the driving factors of preterm births.
Global scenario
Meanwhile, the eight countries with the highest rate of preterm births (number of preterm births per 1000 live births) remained unchanged between 2010 and 2020 – although the order of some has interchanged. These are India, Pakistan, Bangladesh, China, Ethiopia, the US, the Democratic Republic of Congo and Nigeria. From the global point of view also, the scenario didn’t improve in 2020 as compared to 2010.
“Although most of the high preterm birth rates occur in low-income and middle-income countries and areas, rates of 10% or higher [preterm births] were also observed in high-income countries such as Greece and the USA,” the paper reads.
However, the authors make a significant observation. The survival of neonates born as early as 26 weeks of gestation in resource-rich settings are “more likely to survive than those born in contexts with poor access to care regardless of gestational age”. In other words, while some rich countries may also have a high number of preterm births, the chances of those babies surviving are much better there as compared to the ones where the healthcare facilities are poor.