Giving birth before 37 weeks of pregnancy: How a premature birth affects a mum's physical and mental health

Much is said about premature babies, who are born before 37 weeks of pregnancy. However, less has been said about the mothers who delivered them, who are at risk for a number of health complications.

These may include postpartum depression (PPD) and other mental health issues like anxiety, post-traumatic stress disorder (PTSD), and even increased risk of heart disease and prolonged high blood pressure, leading to strokes.

While any delivery before Week 37 of gestation is considered a premature, or pre-term, birth, there are phases of severity. Premature newborns are classified as:

• Late pre-term: Born between Week 34 and 36 of gestation. Most pre-term births occur at this stage
• Moderately pre-term: Born between Week 32 and 34 of gestation
• Very pre-term: Born between Week 28 and 32 of gestation
• Extremely pre-term: Born before Week 28 of gestation

Globally, one out of 10 babies is born pre-term. Singapore’s figures are not far off, with around 3,500 babies born prematurely, or one in 11, according to Ministry of Health figures for 2017.  

This number is likely to rise, according to this National University Hospital report, driven by late or advanced maternal age, the presence of two or more health conditions or illnesses, and the rise of assisted reproductive technology (ART).

CAUSES OF PRE-TERM BIRTH

There is no single reason pre-term delivery happens. It tends to be due to one or more factors. Common reasons include:

• Diabetes
• Heart disease
• Placental issues such as placental abruption or placenta previa. In placental abruption, the placenta separates from the inner wall of the uterus before birth, decreasing or preventing the flow of oxygen and nutrients to the baby and causing bleeding in the mother. In placenta previa, the placenta attaches low in the uterus, potentially covering the cervix and causing bleeding during pregnancy, delivery, and even after.
• Pre-eclampsia, where the mother develops unusually high blood pressure or has elevated levels of protein in her urine, indicating kidney damage.
• Uterus or cervix issues
• Previous pre-term birth: A study in Norway found that women who had a pre-term birth had a 17.4 per cent chance of having another pre-term birth.
• Multiple pregnancy: The higher the number of babies in a single pregnancy, the greater the risk of giving birth before 37 weeks. According to the Johns Hopkins Medicine website, over 60 per cent of twins and nearly all multiple births are born premature.
• Vaginal bleeding
• Infections during pregnancy
• Excessive substance abuse, such as alcohol, drugs, or smoking during pregnancy

HOW A PRE-TERM BIRTH AFFECTS THE MOTHER

When a baby is born prematurely, they are at risk of various complications such as breathing, heart, brain and digestive issues as the organs are not yet fully developed. These can last from a few days to weeks or even months. More long-term complications include cerebral palsy, vision, hearing, and even dental issues.

The after-effects may not be as obvious for mothers but, depending on the severity of the pre-term birth, can affect their bonding and attachment with their newborns.

For example, if the baby is in the neonatal intensive care unit (NICU) and the mum is also in intensive care after giving birth, this creates a physical difficulty in bonding.

Seeing other mothers in the ward cuddling or feeding their newborns while their own preemie is connected to multiple lines or needles may trigger overwhelming emotions.

Dr Lee Wai Yen, a consultant from the Department of Obstetrics & Gynaecology at Singapore General Hospital (SGH), said: “This is an emotional time for women. Mothers worry about the well-being of their baby with thoughts like, ‘Will I lose my baby? Will my baby have developmental delays or lead a normal life in the future?’ and even a sense of guilt for having done something wrong that caused the early labour.”

While these anxieties and feelings may dissipate over time and with proper counselling, bonding and attachment issues tend to be temporary.

“I don’t think anyone should worry about this temporary separation,” said Dr Lee. “Once both mother and baby recover, they will have many years to come for their relationship, and it will be just as strong as with any full-term baby.”

THE LONG-TERM RISKS FOR MOTHERS

For mothers who have preeclampsia, their blood pressure will normalise after birth, but they continue to be at risk for chronic high blood pressure later in life.

According to a study from the American Heart Association Journals, mothers who have hypertensive disorders of pregnancy, like preeclampsia, are also at risk of heart failure, especially if they had such hypertensive disorders in recurring pregnancies.

The Journal of the American Heart Association reviewed studies evaluating the link between pre-term birth and risk of cardiovascular disease, coronary heart disease, and stroke in 5.8 million women, including 338,000 women with pre-term deliveries.

The data showed that giving birth early puts women at up to two times the risk for cardiovascular conditions and even deaths from coronary heart disease. Women who delivered their babies very pre-term (Week 32 or earlier) were more at risk of coronary heart disease, such as heart attacks, stroke, and heart failure.

The long-term effects of stress from a pre-term birth may also manifest in parental mental health. A 2014 study of 183 children born very pre-term (Week 30 or earlier) showed that when these pre-term babies turned seven, their parents were more likely to exhibit moderate to severe anxiety symptoms compared with parents of full-term babies.

They also reported higher levels of depression, poorer family functioning, and overall higher levels of parent stress.

However, not every pre-term birth results in such complications. Dr Sharon Foo, consultant obstetrician and gynaecologist and maternal-foetal medicine specialist from Thomson Specialists (Paragon), said: “Long-term medical implications vary based on the circumstances surrounding their delivery.

“For mothers who have had a spontaneous pre-term delivery, research suggests that there aren’t significant complications in the long run. It’s important to consider the specific context of each case.”

HELP FOR MOTHERS OF PRE-TERM BABIES

For mothers, and their immediate family and friends, keen observation and referral to healthcare professionals — be it their doctor, a psychologist, or other specialists — are crucial for long-term health and mental well-being.

Dr Foo emphasised that support from family and a caring healthcare environment are essential. “Qualitative research has identified psychological effects, including what mothers describe as ‘shattered expectations’, ‘helplessness and horror’, and worry about ‘the infant’s precarious health’ and ‘the need to adapt to the birth and care of a pre-term infant’ as key anxieties these mothers face,” she said.

For mums at risk of a pre-term delivery, Dr Lee at SGH encourages them to visit the NICU to reduce the fear of the unknown.

“At SGH, we refer these women to Neonatology colleagues for counselling. They will be provided information about the likelihood of neonatal survival and discuss short-term and long-term outcomes.“

Couples will also be advised on the neonatal care of their babies and what to expect once the baby is born.

Dr Lee also advised speaking to other parents of preemies to hear more about their journey and find inspiration, focusing on bringing their healthy baby home.