New Delhi: India’s apex health research agency is set to kick off a nationwide exercise to evaluate the efficacy and coverage of interventions currently under way to tackle the issue of preterm births in order to reduce the neonatal mortality rate.
Preterm birth, when babies are born alive before 37 weeks of pregnancy are completed, is the leading cause of neonatal mortality and is associated with long-term physical, neurodevelopmental and socioeconomic effects. Such babies, also called preemies, typically weigh less than 2.5 kg at birth.
According to a World Health Organisation (WHO) report of 2023, over 30 lakh pre-term babies are born in India annually—more than 20 percent of such babies born globally and the highest in the world. These births are a leading cause of neonatal mortality or death within 28 days of birth.
The Indian Council of Medical Research (ICMR) over the next few months will start research projects in several parts of the country to assess interventions to tackle preterm births, according to the recommended guidelines to reduce deaths in low-weight newborns.
The interventions to be studied include administration of antenatal corticosteroids (a type of steroid) in pregnant women likely to give birth to preterm babies, early enteral feeding or feeding through a tube and advancing it rapidly, and immediate kangaroo mother care in Mother Newborn Intensive Care Unit (MNICU).
Kangaroo mother care are tailored for low birth weight infants, and the process includes
early and prolonged skin-to-skin contact with the mother, or a substitute caregiver, and exclusive and frequent breastfeeding.
Another intervention that will be studied through the project is early use of continuous positive airway pressure for respiratory distress syndrome. Together these interventions are called PrECISE.
According to government statistics, India’s neonatal mortality rate (NMR) has declined from 26 per 1,000 live births in 2014 to 20 per 1,000 live births in 2020.
A senior official in the Union health ministry said the ICMR has undertaken a programme for strengthening, implementing and monitoring the target of achieving single-digit NMR in the country.
“As part of this project, ICMR researchers will develop and optimise implementation models of PrECISE interventions that can ensure higher coverage as well as better quality services for low-birth weight babies in hospitals,” said the official.
The researchers will also examine sustainability of the interventions, apart from estimating the incremental costs of the implementation model and studying the impact of these strategies on the survival of preterm newborns at discharge from the hospital.
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Huge crisis
There are sub-categories of preterm birth, based on gestational age and include extremely preterm (less than 28 weeks), very preterm (28 to less than 32 weeks) and moderate to late preterm (32 to 37 weeks).
Babies may be born preterm because of spontaneous preterm labour, multiple pregnancies, chronic medical conditions such as hypertension and diabetes in pregnant women, or because there is a medical indication to plan an induction of labour or caesarean birth early.
An estimated 13.4 million babies or more than 1 in 10 babies were born too early in 2020, according to WHO figures, while approximately 9 lakh children aged under five died of complications of preterm birth.
Experts say that many survivors face a lifetime of disability, including learning disabilities and visual and hearing problems, and inequalities in survival rates around the world are stark.
For example, in developing and low-income countries, half of the babies born at or below 32 weeks (two months early) die due to lack of feasible, cost-effective care such as warmth, breastfeeding support and basic care for infections and breathing difficulties.
In high-income countries, on the other hand, almost all these babies survive. Suboptimal use of technology in middle-income settings is causing an increased burden of disability among preterm babies who survive the neonatal period.
An ICMR document on the project, seen by ThePrint, says that preterm neonates account for about 20-70 percent of NICU admissions in the country. Apart from the heightened risk of dying early, these infants often battle long and short-term morbidities like respiratory-distress syndrome and related complications.
Those who survive often have a long struggle with lungs, systemic and pulmonary hypertension, chronic kidney disease, insulin resistance and metabolic syndrome apart from premature ischaemic heart disease and endocrine dysfunction, it states.
Dr Rakesh Tiwari, senior paediatrician from Paras Hospital in Gurugram, underlined that despite significant advances in neonatal care, mortality among preterm babies continues to remain high due to both biological vulnerability and systemic challenges.
“Preterm infants are born with underdeveloped lungs, immature immune systems, and fragile organ functions, making them highly susceptible to respiratory distress, severe infections, and feeding difficulties,” he told ThePrint.
These risks are further compounded by gaps in maternal care, limited access to timely interventions, and variable quality of neonatal services.
Many deliveries still take place in facilities without adequately staffed or equipped newborn units, and delays in referral or safe transport often reduce the chances of survival, said the paediatrician.
Inadequate implementation of effective strategies
The ICMR document says that antenatal corticosteroids when given to pregnant women between 24-34 weeks of gestation with threatened preterm birth are effective in improving neonatal outcomes, and have been found to reduce neonatal mortality by over 20 percent.
The government guidelines also emphasis the use of corticosteroids in preterm labour, emphasising administration under specific conditions. Yet, both underuse and overuse have been observed in practice, which is harmful, noted the apex health research agency.
In case of kangaroo mother care, while it improves survival of the neonate by 40 percent, when provided to clinically stable babies, lack of awareness and resistance to change among healthcare providers, cultural barriers, lack of maternal education have been found as factors hindering its adoption.
The ICMR said unpublished data from ongoing studies shows a very low coverage of kangaroo mother care in India’s special newborn care units.
Also, the document said, starting enteral feeding (intake of food via the gastrointestinal tract) early among preterm newborns and advancing it rapidly, improves micronutrient absorption, supports intestinal development and maturation, fosters microbiome growth, minimises inflammation and contributes to enhanced neurodevelopment.
But currently the coverage of early enteral feeding within 24 hours in newborn intensive care settings is very low, ranging from 14-43 percent across states.
The ICMR also highlighted that continuous positive airway pressure (CPAP) is a critical intervention for respiratory support in preterm infants and is recommended in preterm infants with clinical signs of respiratory distress syndrome.
Facility-based newborn care guidelines have now introduced the use of early CPAP as standard of care at secondary level of care, a survey on its usage in government hospitals across states revealed that just 68.3 percent of medical college hospitals (MCH) and 36.6 percent of district hospitals (DH) used it in neonates.
By identifying systemic obstacles and tailoring solutions to local contexts, the exercise can ensure that life-saving newborn care practices reach those who need them the most, says the agency.
Some specialists, meanwhile, stressed on improving antenatal care and infection control to tackle the issue.
“We need to focus on ensuring every pregnant woman has access to quality antenatal care, proper nutrition, and timely detection and management of health issues. When we empower communities and prioritise maternal health, we give our preemies the best possible start,” said Dr Poonam Chillar, assistant professor, paediatrics with ShardaCare.
Also, maintaining proper and strict asepsis while providing care and management to preterms is of utmost importance to prevent infections and complications in these vulnerable infants, she emphasised.
(Edited by Nida Fatima Siddiqui)
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