"I'm done giving birth. If I do not stop now, I may end up giving birth to a baby at two months of pregnancy," says 32-year-old Sophie Namwebe.
Namwebe, a resident of Spondee in Wakiso district, wants to stop giving birth because of her past three experiences of delivering premature babies.
She has four children, all boys, but only the firstborn was born full term at nine months. The rest were born prematurely at seven months or less.
Her youngest son was born weighing 0.8kg during the sixth month of the pregnancy at Naguru General Hospital in Kampala.
"I went into labour at six months and was rushed to Naguru General Hospital, where I gave birth through C-section. By the time my son was born, he weighed 0.8kg. He was very tiny, did not cry and nurses thought he would not survive. We spent a week in neonatal intensive care unit and we were discharged.
"Since then, my baby is progressing very well," says Namwebe.
"Premature babies are very delicate, and as a mother, you are anxious, stressed and physically drained as you live in fear of whether the baby will survive or die.
"I weighed him recently and he has gained some weight. He now weighs 1.2kg. Do you know what that means to me as a mother? It is an exciting milestone; it means my baby has a chance to survive," she adds.
Namwebe reveals that after delivering her third-born, she never went into her menstrual periods again for seven years. Instead, she would experience a lot of pain in the lower abdomen.
She went to the hospital to find out what the problem was, and after several scans, doctors told her that her fallopian tubes had closed and she would never have her periods again or have more children.
"After six months of being told I will never produce again, I fell sick. I went to the hospital to test for malaria, which turned out negative. Doctors recommended I do a scan, and to my shock, I found out that I was six months pregnant. I did not know I was pregnant, nor did I experience any signs or symptoms of pregnancy," she recalls while laughing.
Sr. Juliet Kyomugisha, who is in charge of the Special Care Unit at Naguru Genral Hospital, says Namwebe has a condition known as incompetent cervix.
She says an incompetent cervix, also known as a cervical insufficiency or weakened cervix, is a condition that occurs when weak cervical tissue causes or contributes to premature birth or the loss of an otherwise healthy pregnancy.
Before pregnancy, a woman's cervix is normally closed and rigid, but as pregnancy progresses and she prepares to give birth, the cervix gradually softens, decreases in length and opens.
"If a woman has an incompetent cervix condition, the cervix might begin to open too soon, causing her to give birth too early," Kyomugisha says.
She explains that during pregnancy, as the baby grows and gets heavier, they press against the cervix. This pressure may cause the cervix to start to open before the baby is ready to be born, which may lead to a miscarriage or preterm delivery.
Dr. Placid Mihayo, a gynecologist and obstetrician at the health ministry, says an incompetent cervix is caused by a number of factors. Genetic weakness of the cervix is one of them. Some women naturally have weak a cervix, which can easily dilate before a baby is full term.
Other causes inlude previous tears in the cervix during delivery, damage of the cervix during a difficult birth, previous trauma to the cervix, such as dilation and curettage from a termination or a miscarriage exposure, and a malformed cervix or uterus from a birth defect.
Worldwide, an incompetent or weakened cervix happens in about 1-2% of pregnancies. Almost 25% of babies miscarried in the second trimester are due to incompetent cervix.
Mihayo says the condition can be corrected through a cervical cerclage, which is also known as cervical stitch -- a procedure in which stitches are used to close the cervix during pregnancy to help prevent pregnancy loss or preterm birth.
"The stitch is placed in or around the cervix and the procedure is usually performed between week 14 and 16 of pregnancy. Stitching is done to try and prevent late miscarriage or premature birth in women who stand high chances of cervical insufficiency," he explains.
The stitch can be removed when the pregnancy reaches full term or she develops labour pains or rapture of membranes to avoid any damage in case someone is going to deliver.
These sutures will be removed between 36-38 weeks to prevent any problems when one goes into labour. However, removal of the cerclage does not result in spontaneous delivery of the baby.
This kind of treatment is planned for women at high risk of premature labour, which could be due to cervical incompetency.
Women that may have had three or more late miscarriages or three or more premature births may be advised to have a cervical suture inserted at about 12-14 weeks of pregnancy even if their cervix is not shortened.
Mihayo reveals that it is challenging to diagnose an incompetent cervix because it often does not show any symptoms. It can often occur without pain or contractions, but if symptoms are to present, they may be mild, and include cramping, backache and mild contractions.
Sr. Kyomugisha, too, agrees this condition can be difficult to diagnose and as a result, treat.
She advises women who have had this kind of problem to continuously seek medical attention for monitoring and in case of any challenge, they can be attended to immediately by health workers.
Dr. Santa Engol, the programme manager of maternal and newborn health at Save the Children, says medically, the term prematurity or preterm birth or premature birth refers to the birth of a baby less than 37 weeks after the mother's last normal menstrual period (gestational age).
According to reports by the United Nations Children's Fund (UNICEF), each year, about 15 million babies (10% of all babies) are born prematurely around the world and 60% pre-term births in the world happen in Africa and Asia.
UNICEF reports also reveal that complications from preterm birth partly contribute to child death under the age of five, which accounts for over one million deaths each year globally.
Engol says despite these shocking discoveries, the general population is largely unaware of the risks and causes of preterm birth.
"Without a major push to reduce these deaths, the world will not reach the global targets in the sustainable development goal target 3.2 that seeks to end the preventable deaths of newborns and children under five years of age," she says
The situation in Uganda
According to the latest live birth and death data from UNICEF (2016), although Uganda is not among the top ten countries in the world with the largest numbers of preterm births, the number of those born prematurely is still high, standing at 226,000 annually, while deaths resulting from preterm birth complications stand at 9,800 annually in the country.
The top ten countries with the largest numbers of preterm births are India, China, Nigeria, Indonesia, United States, Bangladesh, Democratic Republic of Congo, Philippines and Ethiopia.
Engol says prematurity is one of the key causes of newborn mortality and morbidity in the country.
She explains that in Uganda, complications of prematurity are the leading cause of neonatal mortality and are directly responsible for 38% of neonatal deaths, and out of the 100% registered deliveries carried out in the country annually, 18% are premature deliveries.
She says complications from prematurity are also the third-largest cause of under-five mortality, after pneumonia and malaria.
"Each year, about 225,000 babies are born prematurely while the country loses, on an annual basis, up to 9,800 children under five from complications related to prematurity.
"To prevent prematurity, there is a strong need for pregnant mothers to attend all the required antenatal care visits, with the first visit starting in the first trimester," Engol says.
At Naguru Hospital, Kyomugisha says they deliver between 20 and 25 premature babies monthly, and of these between 8 and 10 die, especially those born at 20 weeks and below are very small, weighing 0.6kg and below, thus are considered as abortions.
According to policy alternatives on maternal health care services in Uganda, it is recommended for expectant mothers to have at least four antenatal visits to health facilities so that a mother can receive information, care and support to prevent premature deaths.
Causes and who is at risk
Dr. Lorraine Oriokot Kaggwa of Naguru Hospital says in recent times, pre-terms are not only surviving more and more, but are also thriving, noting that people are increasingly becoming aware of the causes of preterm births and how to avoid them.
She, however, explains that though some causes are spontaneous and one may not be able to identify them, other causes are known and preventable.
Those at risk include women who have had previous preterm birth, pregnancy with twins, triplets or other multiples, women who conceive through vitro fertilization, problems with the uterus, cervix or placenta, poor nutrition, some infections, particularly of the amniotic fluid and lower genital tract among others.
Some of the causes include urinary tract infections, which may stimulate early labour pains, diseases such as diabetes, high blood pressure, smoking, and obesity increase the risk of giving birth prematurely.
Experts say it is important for women to plan their pregnancies as this plays a critical role in having improved quality of life of a mother and unborn baby during pregnancy and thereafter.
"Ask yourself when you want to have this baby. Two months before the time you plan to become pregnant, visit a nurse or doctor to advise you in things like nutrition, especially folic acid, which is important in preventing neural tube defects. The health workers can also advise on what exercises to do to enable the body handle the baby to full term," Oriokot says.
She urges expectant mothers to attend at least four antenatal care visits, with the first visit starting in the first trimester so that a mother can receive information, care and support.
Oriokot says it is during antenatal care visits that checkups and tests for illnesses such as diabetes, HIV and other infections are done, adding that this helps health workers advise mothers how best to deal with such diseases during pregnancy, thus reducing the risks of giving birth to premature babies.
It is also very important to avoid substance abuse, such as smoking and alcohol consumption during pregnancy, as these have an effect on pregnancy. Alcohol interferes with the nutritional process by limiting the digestion and storage of vital nutrients that the baby needs to develop properly, while smoking cigarettes doubles a woman's risk of developing the placental problems that can contribute to preterm birth.
Complications preterm babies may be exposed to
Engol reveals that because these babies' lungs are not fully developed, the lungs cannot expand and contract normally and therefore they are at risk of developing respiratory distress syndrome, also known as Apnea.
Other complications are low blood pressure, intraventicular hemorrhage (bleeding in the brain) and loss of body heat rapidly, also known as hypothermia. This is because they do not have the stored body fat of a full term infant and they cannot generate enough heat to counteract what us lost through the surface of their bodies resulting in hypothermia.
Aiding their survival
Kyomugisha says there are three major things a mother must do to ensure a preterm baby survives.
Personal hygiene such as hand washing before breastfeeding or expressing breast milk and cleaning the nipples is crucial in preventing infections. A breastfeeding baby can be timely -- it can be two or three-hourly or more, depending on the recommendation at discharge.
Kyomugisha says pre-term babies cannot survive without warmth.
In this case, kangaroo mother care has been proven to be an effective method of improving health outcomes for premature and low birth weight babies. But when the baby is not skin-to-skin with the mother or caretaker, he or she can be wrapped in a blanket and a hat put on him.
"Keep a warm room at home and regular changing of nappies," says Engol.
Engol explains that exclusive breastfeeding of premature babies is crucial, because breast milk contains many important antibodies that help fight disease and prevent infection. It also contains proteins that promote growth, helping preemies grow at a faster rate than full-term babies.
But if a mother observes danger signs such as high temperature, breathing difficulties and feeding problems, she should return to a health facility for assessment.