L ITERATURE R EVIEW
2.4 Challenges Experienced by Midwives Managing Preterm Birth and Preterm Babies
2.3.2.3 Poor Feeding
Feeding intolerance is a common problem of preterm neonates. Feeding is ideal for optimum growth and development and prevention of infection in a preterm infant and early initiation of feeding is beneficial to all infants (Joseph, 2015:63). Preterm babies face feeding difficulties because the suck and swallow process only starts at 34 weeks gestation and they need help to feed and are more likely to aspirate (WHO, 2012:64).
2.3.2.4 Sepsis
Newborns are at high risk of acquiring infection; this is due to their immature immune system. They are usually protected from infection through exclusive breastfeeding, and limited contact with other individuals (Essential Newborn Care, 2012:26). Most
challenges may vary according to the gestational age, the condition of the foetus and will be classified under health care provider-related, patient-related and administrative-related challenges.
2.4.1 Health Care Provider-Related Challenges as Perceived by Midwives Globally
McNamara (2003:81) stressed that most challenges in the management of PTB relative to obstetrical practice occur during the antepartum period. The source continues to show that there is a challenge in the management at the limit of viability (gestational age or estimated foetal weight) which requires joint management amongst health care providers and the parents of the baby (Table 2.2).
Table 2.2: Limits of viability in premature neonates
≤ 22 Weeks Not Viable
23-24 Completed Weeks Varied Outcomes
25-26 Completed Weeks Most Survive 1. Compassionate care
2. No active treatment 3. No Caesarean section
1. Consider expected results at resuscitation 2. Limited benefit of
Caesarean section for infant
3. Potential harm of Caesarean section to the mother
1. Any required neonatal care
2. Caesarean section if indicated
McNamara (2003:81)
In this case, information is given to the mother about the condition of the foetus, cause of preterm labour and the possible outcomes for the baby, and parents make therapeutic choices for the required management. The prevention of preterm labour is one of the greatest challenges for obstetricians and much of it also depends on social and economic factors (Goswani & Rhoda, 2014:2042). Midwives just like other nurses, face a challenge of staff shortage when working at the state hospitals. This was evidenced in a study conducted in Cape Town, entitled ‘Occupational challenges faced by nursing personnel at a state hospital in Cape Town, South Africa.’ (Brophy,
2015:93). Thommesen (2014:73) found the midwives’ challenges in providing quality maternal and neonatal care are poor working conditions, feeling of insecurity and frustration at work. Thommesen (2014) revealed that most midwives in Ethiopia started in midwifery without A passion and they do not show urgency in emergency situations.
In a study entitled ‘Prolonged mechanical ventilation: challenges for nurses and outcome in extremely preterm babies,’ Joseph (2015:61) identified some challenges that nurses face when providing care to babies who are on mechanical ventilation;
these include thermoregulation caused by minimal brown fat, body positioning and maintaining patent airways which may be caused by minimal change in position;
stable heamodynamics; maintenance of growth and development; prevention of infections; accidental removing of endotracheal tubes for intubation; long-term complications that are due to prolonged ventilation; communication with the family of the baby; and ethical issues.
2.4.2 Patient-Related Challenges as Perceived by Midwives Globally
In a study conducted in Europe about ‘Ethical decision making for extremely preterm deliveries,’ parents appeared to be rarely involved in the decisions about their infants in the context of the very preterm births, both before and after delivery (Garel, Seguret, Kaminski & Cuttini, 2004:398). Not involving the parents in decision making for care of their infants/neonates may cause problems for the health care providers and may affect quality of care provided to the neonate.And for the mothers to understand the diagnosis and comply with the treatment, they need to be part of decision making team. According to Lasiuk, Corneau & Newburn- Cook (2013:8), parents with preterm babies experience psychological trauma due to being unable to help, hold or care for their babies; protect them from pain, or share them with other family members. Lasiuk et al. (2013) further explained that
breastfeeding, KMC and family-centred practices are meaningful to parents with preterm babies in NICU as it helps them with constructing their role as parents and moderating their sense of helplessness.
Pattinson (2003:453) conducted a study entitled ‘Challenges in saving babies- Avoidable factors, missed opportunities and substandard care in prenatal deaths in South Africa.’ The results showed that delays in seeking medical attention during labour which is most common in rural areas, poor reporting of reduced foetal movement and women who do not attend ANC frequently and those who attend late are at higher risk of developing complications in pregnancy and during labour.
The Demographic and Health Survey of 1998 indicated that 95% of women attend ANC during pregnancy. It appears that the issue is not about encouraging women to attend ANC, but to persuade them to attend early because most women have their pregnancies confirmed within three months of missing their periods, but they do not book immediately—they initiate ANC months later (Pattinson, 2003:453).
2.4.3 Administrative/System-Related Challenges as Perceived by Midwives Globally
There are financial and operational issues that can be challenges in providing care for preterm babies. Brophy (2015:93) reflected on a challenge of lack of resources. It was found that if a hospital’s resources are not well managed, the service delivery to patients will be negatively affected. The use of open multi-patient rooms poses a challenge in a manner that it increases the costs of care for preterm babies who are kept in NICU. Prolonged length of hospital stay is one factor that attributes to this increased NICU costs. Complications that increase the length of stay adversely affect costs. However, therapies that reduce the intensity of illness decrease the costs of care. Reduction of length of hospital stay can be achieved by minimising hospital- acquired infections which usually occurs during close contact between patients,
preterm babies in this case and accidentally using the same equipment in infants. The use of private and semi-private rooms for neonates allows for improved care will result in reduced hospital stay and lower costs for NICU. Shortage of nurses in neonatal care is also a challenge (Floyd, 2005:64). Perinatal deaths from spontaneous preterm labour is sometimes caused by lack of adequate neonatal facilities in rural areas wherein the woman arrives to the institution in advanced labour and the baby is delivered shortly thereafter, the opportunity for interventions by suppressing labour and giving corticosteroids is therefore low (Pattinson, 2003:454).
2.4.4 Challenges Experienced By Midwives When Providing Care To Preterm Babies In South Africa
A study conducted in two academic hospitals in Gauteng found that most participants working in neonatal units did not have knowledge on the management of pain to neonates and there were also no clear guidelines on this item. This was evidenced when sixty-four percent of respondants reported the absence of a written guideline in the wards they worked in, whilst only 36% had a written pain management guideline (Khoza & Tjale, 2014:5).
The increasing rate of babies born preterm poses a greater challenge for midwives and other health professionals who are directly providing care to these babies. A significant factor that increases PTB is advanced maternal age, advanced maternal age leads to many complications with PTB being the most common; this was found in a study conducted in Dr. George Mukhari Hospital from 1st September to 30th September 2010 (Hoque, 2012:284).