The Mystery of the Missing Preterm Babies

Coming into this trip, I expected to see lots of babies. For the most part, that's been true. I've been overwhelmed by the number of adorable infants I've gotten to "observe" (read: oggle over and wish I could adopt). However, Aaron and I have run into a perplexing problem. 

"We don't have preterm babies."

Nearly every facility has told us this, and we have only seen a handful of visibly premature babies in our eight site visits. This should be good news, but considering Nepal has the 20th highest rate of preterm deliveries in the world, with 14% of all babies born before 37 weeks gestation, we should be seeing much more of them. So where are they?

We have a few hypotheses, with each of them posing unique challenges. 

1) They have all been referred to other facilities. 

This is the most common explanation we receive. Lower-level facilities refer women in preterm labor to tertiary care facilities with neonatal intensive care capabilities. If a woman delivers a preterm baby and they do not have the necessary equipment (for example, and incubator or a ventilator), hospitals will also refer the newborn. 

There are a number of issues associated with this system:

a. Tertiary facilities are limited, and even the government facility with the second-highest delivery volume in the country refers babies to nearby private hospitals because they do not believe their facility has the proper equipment to handle premature infants. This leads to overcrowding in many facilities. One primary health facility said they once had a nearby hospital refuse to admit a 1 kg baby born in the primary facility because they did not have room. The baby soon died without intensive care. 

b. As we have discussed in previous posts, this means that women in labor or unstable babies may have to travel many hours over dangerous roads to reach quality care. Ambulances are rare, and they aren't equipped with special technology to stabilize babies in transport. 

c. Lack of equipment in all facilities is a serious problem. From the primary hospital in Waling to the regional hospital in Pokhara, nearly every place wished for more ventilators and more incubators. Equipping the lower-level facilities could limit some of referrals, but cost and maintenance are major issues. A low-cost technology that breaks, or one that can't withstand monsoons and variable power, will not make a difference in the long run. 

d. Interventions at the lowest level that could prevent the need for intensive care are lacking. For example, many babies can get all the warmth they need from skin-to-skin care, but instead, they are referred to hospitals with incubators. Early delivery of surfactant can prevent babies from needing to go on ventilators, but surfactant is expensive and rarely available. 

2) Preterm babies are not being properly identified. 

How do you spot a preterm baby? It's actually harder than you might think. 

a. Gestational age estimates can be unreliable. Ultrasound equipment is expensive, and the mother's own estimate can be off. The difference between a 34-week baby and a 37-week baby can be dramatic, requiring very different levels of care. 

b. Another marker of prematurity, low birthweight, is hard to measure when you do not have a scale. Female community health volunteers use their own estimates to tell if babies are small-but in a country where stunting is prevalent, there's a chance that many babies get overlooked as being "average" when they are actually small. 

c. Skilled birth attendants in lower-level facilities that do not see as many preterm babies might fail to notice the distinctive physical characteristics of preterm babies when they do arrive. 

3) Preterm births are happening away from where we can see them. 

We have seen eight different districts in Nepal, but there are still 67 we have not explored. In addition, the home birth rate is still high, for a number of reasons. 

a. Women live too far away. Would you want to trek several days through the mountains to reach a hospital?

b. Hospital births can be a negative experience. Facilities are crowded, care for complications can be expensive, and every delivery we have seen so far has looked extremely painful for the mother, with episiotomies happening under limited and diluted local anesthesia. 

As we have come to realize, this one simple question- Where are the preterm babies?- has revealed so many complex issues that I would have never even considered prior to this trip. It's a bit ironic that not being able to find what we set out to find provided some of the best insight, but one point of these trips is to turn all of our assumptions upside down-and this trip has definitely succeeded in that!