Premature labour or preterm labour means spontaneous labour onset after the gestation of viability (24-28 weeks, in India) and before the completion of 37 weeks of the labour cycle. According to the WHO estimate, 15 million babies are born prematurely every year. That is more than 1 in 10 babies. Furthermore, approximately 1 million children die each year due to complications of preterm birth. And for the survivors, it’s a lifetime of disabilities, including cognitive, visual and hearing issues. 

Given the situation, 17th November has been known to be celebrated as World Prematurity Day to raise awareness about the condition, its tumultuous consequences on newborn and maternal health and its impact on the family. A purple ribbon is the official symbol to represent sensitivity and exceptionality. Besides this, the socks line has become a popular symbol for World Prematurity Day. The small pair of purple socks, framed by nine full-size baby socks symbolises the 1 in 10 babies who are born preterm. In this blog, we discuss the factors that lead to premature birth, it’s indicative signs and steps to prevent premature labour. 

Before we get to its roots, let’s understand the two categories of premature birth. The classification is done on the basis of presumed lung maturity. The period of 28-34 weeks is called Early Preterm when the lungs aren’t mature while the births that take place between 24-37 weeks are Late Preterm when the lungs are presumed to be almost mature. The prognosis of late preterm is better than the early preterm and fortunately enough, most premature births occur in the late preterm stage.

Premature Birth Causes 

There are numerous factors that can lead to premature birth and we’ve listed almost all of them for you. However, please note that according to the Manual of Obstetrics by Holland and Brew, no plausible cause is found in around 30-50% of total preterm births making it an enigmatic complication. 

1. Pregnancy Factors 

a. Urinary Tract Infections

Nearly 30% of all premature labour is the result of maternal genital infection. Urinary tract infection and asymptomatic bacteriuria can cause preterm labour and thus urine is sent for culture and sensitivity routinely in many centres. This also means that deprived women of lower socioeconomic status are at a higher risk of delivering premature babies. 

b. Antepartum Haemorrhage

Antepartum haemorrhage (APH) is usually defined as bleeding from the birth canal after the 24th week of pregnancy. It can occur at any time until the second trimester is complete; bleeding following the birth of the baby is a postpartum haemorrhage.

(To understand this, recall how we refer to clock time, AM and PM where the former is Ante Meridian and PM is Post Meridian)

There are three practical options for management:

• Expectant: in the hope that the pregnancy will continue
• Immediate caesarean section
• Rupture the membranes and aim at vaginal delivery

However, all these options are to be weighed against a number of other concerning factors and only then should the decision be taken. 

c. Cervical Inefficiency

Cervical inefficiency also called an incompetent cervix, occurs when weak cervical tissues cause or contribute to premature birth. The structural weakness of the cervix causes the cervix to open prematurely and increases a woman’s risk of preterm delivery. 

d. Uterine Anomalies 

The risk of premature birth varies with the type of anomaly and the outcome is worse in cases of the unicornuate or bicornuate uterus as compared to the separate uterus. According to the Cleveland Clinic, “A unicornuate uterus is a rare condition wherein a  person has only half a uterus. A female with a unicornuate uterus has one working fallopian tube (instead of two) and a smaller uterine cavity. It’s a congenital uterine anomaly, meaning one is born with it.  In the case of a bicornuate uterus, it’s the shape that causes the problem. A bicornuate uterus is described as heart-shaped, appearing to have two sides instead of one hollow cavity. This too being a congenital condition is a major contributor to premature births. According to research, the risk of preterm birth associated with uterine anomaly is high, especially with a history of preterm delivery or second-trimester loss. The risk remains high even in women with previous-term delivery.

e. PPROM

Premature Rupture Of Membranes (PROM) is a breaking open of the membranes (amniotic sac) before labour begins. If PROM occurs before 37 weeks of pregnancy, it is called Preterm Premature Rupture Of Membranes (PPROM). PROM occurs in about 8 to 10% of all pregnancies. Improper prenatal care, vaginal bleeding, STDS, history of premature birth and cigarette smoking are factors that increase the incidence of PPROM.

f. Fetal Growth Restrictions 

Fetal growth restriction (FGR) is a condition in which a fetus (unborn child) is smaller than the standard size for its corresponding gestational age. With this condition, a baby weighs less than 90% of other babies at the same gestational age.  Causes of FGR include high blood pressure in the mother, infections and smoking or alcohol abuse and issues with the placenta or the umbilical cord. The placenta is the tissue that brings nutrients and oxygen to the developing baby the blood flow in the umbilical cord, which connects the baby to the placenta.

g. Fetal Anomalies 

Fetal anomalies refer to malformations during the gestational period. There are two general categories of fetal anomalies:

• Structural anomalies affect the developing baby’s body parts, such as its heart, lungs, kidneys, limbs or facial features. Heart defects, missing toes, cleft lip and spina bifida are examples of structural birth defects.
• Functional anomalies affect how a body part or body system works, such as the brain, nervous system, or sensory perception. Examples of functional birth defects include seizures, blindness, developmental disabilities, muscular dystrophy and Down syndrome.

Some fetal anomalies may affect both the baby’s structure and function.

2. Maternal Age

Advanced maternal age has a higher risk of immaturity and fetal defects. In older women, the ova, which has been present in an immature state from birth, may have been affected by ageing or exposure to chemicals, drugs and other harmful agents. Thus, advanced age has an association with an increased risk of premature birth. Inversely, in young women (those below 18) the reproductive system may not be fully developed and thus face similar problems. 

3. Maternal Diet 

The mother is the only source of nutrition for the unborn child and thus a diet including all the five components of a balanced meal – protein, fibre, carbohydrates, vitamins and minerals and an ample quantity of water is of utmost importance. Maternal diet deficiency has a direct relation with premature birth as it is one of the biggest determinant factors of maternal weight. It has been seen that when maternal weight is below 45 kgs, the rate of premature labour is three times more than what it is when maternal weight is over 55 kgs.   

4. Maternal Medical Condition

German measles or rubella and cytomegalovirus diseases are among the most dangerous illnesses affecting pregnant mothers. These diseases also infect the child and thus cause significant developmental issues.  If the rubella virus crosses the placenta, it can cause devastating results like premature birth. Women who suffer from blood poisoning during pregnancy, most often than not, give birth to premature babies or ones smaller than the average babies. Finally, preterm labour is common in pregnancies complicated with chronic hypertension, heart illnesses, anaemia, renal disease, etc.

5. Drugs and Chemicals Use

It is absolutely necessary to avoid any kind of drugs or chemicals unless professionally prescribed by a certified doctor. Drugs and alcohol cause fetal anomalies as mentioned above which eventually lead to premature labour. Cigarette smoking is also very closely associated with prematurity and low birth weight. 

6. Chronic Stress 

Women who are stressed or depressed seem to be at higher risk of giving birth prematurely. And while scientists are yet to establish a conclusive link between the two, there exist a number of possible connections. Chronic stress causes long-term changes in the body’s vascular system, and hormone levels, and thus affects the body’s immunity that unleashes a different set of complications. The complications can potentially influence early labour (before 37 weeks gestation). Another reason can be that stressed mothers are less likely to lead healthy lifestyles. Mental well-being is difficult to assess – not least because we all have different stress thresholds – but some factors linked with psychological distress have been linked with premature birth too.

7. History Of Preterm Labour

A past history of preterm delivery is a strong predictor of a similar outcome. This risk increases with the number of past preterm deliveries and decreases with the occurrence of term delivery. The risk is also raised when there have been one or more second-trimester spontaneous or induced abortions. The risk with one preterm delivery is 17-40%. 

8. Coitus 

Frequent sexual intercourse during pregnancy is commonly believed to trigger contractions and, therefore, induce labour. However, in low-risk pregnancies, there is neither association with preterm birth, premature rupture of membranes, or low birth weight, nor with spontaneous onset of labour at term. 

Now that we understand the causes of premature birth, it will be easier to get a grasp of the preventive measures. 

Steps To Prevent Premature Birth 

While preventing preterm birth might not always be guaranteed but there are a number of simple ways you can support a full-term, healthy pregnancy that ensures holistic child development. 

1. Eat Right

While healthy pregnancy outcomes are generally associated with good nutrition, poor nutrition is known to predispose to preterm labour. Eat a balanced diet with foods rich in iron and folic acid as these keep a check on your haemoglobin levels. Women with haemoglobin less than 9g/dL are at a higher risk of going into premature labour. Overweight and underweight women have a higher chance of giving birth to preemies. Work with your nutritionist to achieve a healthy weight. Additionally, work with your healthcare provider to keep any chronic conditions under control. Read this article to know more about the basics of pregnancy diets. 

Apart from this, consuming unhealthy food on a regular basis will increase your stress levels and lead to anxiety. However, there are a few magic foods that can help relieve you from stress and also keep you and your baby hale and hearty. Here are the top 9 foods to help manage your stress. 

Here are some foods that you should include in your diet if you are looking for ways to relieve yourself from stress:

2. Stay Active 

Being physically active throughout pregnancy will boost your overall well-being and reduce your risk of conditions such as gestational diabetes which can lead to premature birth. Unless you’ve specifically been advised otherwise, it’s a good idea to do something that keeps your muscles active every day. This doesn’t have to involve organised exercise or something very elaborate, a routine evening walk can ward off the risk to a great extent.

Here’s a basic guide on the best exercises for pregnancy. 

3. Pregnancy Spacing 

According to a report by BBC News, mothers should wait at least a year between giving birth and getting pregnant again to reduce health risks to their health and that of their babies. Small gaps between pregnancies risk premature births, smaller babies and infant and mother mortality. The report is based on a study of nearly 150,000 births in Canada, by the University of British Columbia (UBC) and the Harvard TH Chan School of Public Health published in JAMA Internal Medicine. The study found 12-to-18 months was the ideal length of time between giving birth and becoming pregnant again. It also suggested that waiting 18 months between pregnancies reduced the risk to 0.5% (five cases per 1,000). Younger women who got pregnant six months after a previous birth had an 8.5% risk (85 cases per 1,000) of premature labour. This dropped to 3.7% (37 per 1,000) if they waited 18 months between pregnancies. 

4. Avoid Taking Stress

There are a few things that you can do to lower stress during pregnancy (and these are also excellent ideas if you’re not pregnant). More research needs to be done into exactly which relaxation strategies will help decrease the risk of preterm birth, but anything that reduces chronic stress could possibly increase your chances of having a term baby.

• Counselling

In one small study, researchers found that mothers with chronic stress who received psychological counselling during their pregnancies were less likely to deliver early.

• Exercise

Low-impact activities usually recommended during pregnancy include brisk walking, swimming, stationary cycling, and using an elliptical or stair climber. Yoga has been shown to improve pregnancy outcomes and reduce the risk of preterm birth. Talk to your physician about safe exercise during pregnancy and what to avoid (such as lying on your back or stomach). 

• Alternative therapies

Massage, aromatherapy, acupuncture, and hypnotherapy have been shown to help to reduce stress. (Note that no studies have shown whether they reduce the risk of preterm birth, specifically.)

• Eat Safe

Avoid consumption of alcohol, tobacco and illicit drugs in any form. Limit caffeine intake too. Do not take any medicines unless prescribed by your doctor. 

Warning Signs 

• Feeling of abdominal tightening (contractions) every 10 minutes or more often.
• A sensation of pelvic or lower abdominal pressure as if the baby is pushing down.
• Constant low, dull backache.
• Mild abdominal cramps.
• Any amount of vaginal spotting or bleeding.
• A change in the type of vaginal discharge — watery, mucus-like or bloody and an increase in its amount.
• Swelling in your face, hands or feet, or double vision, blurred vision or other eye disturbances. These are signs of pre-eclampsia, which is a common cause of pre-term deliveries.

If you observe any of the above-mentioned symptoms, contact your doctor as early as possible. Remember nothing is more important than you and your baby’s health. 

Healthifying The World For Premature Babies

Every baby is worth the wait. Be aware of the risks of prematurity and take proper precautions to save them. Remember, that even the smallest footprints can leave the deepest impressions. From a tiny spark will burst open a mighty flame. Save the little angels and protect them on this day and beyond. Premature birth is a real problem, we can’t afford to not talk about it. Spread awareness about the issues and let’s join hands to form a loving cradle for every child that comes into this world.