Born Too Soon: Challenges of Premature Births in Armenia

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More than 13 million babies are born premature each year. A premature birth is one that occurs before 37 weeks of gestation, while a full term pregnancy lasts about 40 weeks. This means that globally, one out of every ten babies is born prematurely. These infants face a higher risk of infant mortality and morbidity, with prematurity being the main cause of infant mortality globally. Armenia’s Health Ministry does not have specific data on the number of premature babies who develop disabilities or other health complications later in life. Globally, one in ten preemies will have a disability, but this data is mainly based on developed countries due to the scarcity of information from countries like Armenia.

Preterm births can be classified into three categories: extremely preterm births (before 28 weeks of gestation), very preterm (28 to 32 weeks of gestation), and moderate to late preterm (32 to 37 weeks of gestation). Premature babies often have low birth weights. The term low birth weight is used when a baby weighs less than 2,500 grams regardless of gestational age. Very low birth weight is less than 1,500 grams, and extremely low birth weight is less than 1,000 grams. If a fetus is at least 22 weeks old and shows at least one sign of life, such as an easily visible heartbeat, definite movement of arms and legs, breathing, crying, sustained gasps, or visible cord pulsation, doctors are required to resuscitate the baby. 

Armenia’s Ministry of Health classifies premature births according to the weight of the newborns. In 2022, there were 35,667 live births registered in Armenia. Of these, 153 babies weighed 1,000 grams or less at birth; 252 weighed between 1000-1499 grams; 596 weighed between 1,500-1,999 grams, and 1,587 weighed between 2,000-2,499 grams. Thus, nearly 10% of babies born in Armenia in 2022 were premature, which aligns with the global average. 

Of the 153 babies born with extremely low weight, 60 did not survive, and 44 of them died within the first six days of life. In the category of very low birth weight (252 births),18 babies did not survive, with 14 passing away in the first six days. The mortality rate at birth decreases as birth weight increases; of the 2,305 babies born with low birth weight, only three died, all within the first six days. When considering all premature births, regardless of weight category, 97% of premature babies survive. However, survival rates are significantly lower for babies born weighing less than 1,000 grams, with only six in ten surviving. 

The NICU Journey  

A year ago, my knowledge about premature births and premature babies was almost non-existent. I had a vague understanding that early births occasionally happen but that it was not a significant concern. I had heard the term “preemie”, which in my mind meant a cute, tiny human. I could not fathom the struggle and heartache the term entailed. 

On April 28, 2023, I headed to work, as I did every Friday morning, rushing and eager to get to the office. Every Friday, I wrote our weekly news podcast, and it seemed something unexpected always happened right before recording. Little did I know that on that day my life as I knew it would abruptly be interrupted and that I would not go to work or home for another 75 days. I still had 11 weeks to go in my pregnancy, and as of the previous evening, I had no complications. Thus, I did not worry much about the headache that had kept me awake all night, or the high blood pressure. My doctor had advised me to call her if my blood pressure exceeded 130. I was hesitant to call, expecting to wait for hours at the hospital in a cramped corridor. I was not looking forward to it. 

That day, my wait was short. Upon hearing my symptoms and complaints, I was recommended for an urgent Doppler ultrasound test. Instead of the usual procedure — performing the ultrasound, then providing me with a written evaluation to give to my OB/GYN, the sonographer called my doctor directly to inform her that the baby weighed only 700 grams. He did not provide me with any other information, but I knew that this weight was too low for a 29-week pregnancy, as the average fetus weighs around 1,100 grams at this stage. 

We then faced three agonizing days of waiting to see how the fetus would grow. She was not receiving enough oxygen, so they began preparing her lungs for a potential preterm birth with three shots of steroids. We were also warned her lungs were underdeveloped and might fail her at birth. We were also warned that if she showed no signs of growth, keeping her in my womb could endanger her life. 

After three days of monitoring my blood pressure and the baby’s heartbeat, the decisive Doppler examination on Tuesday, May 2 revealed that she was not growing. We had to deliver her. Thus, my daughter Nare was born on what my husband told me was Harry Potter day to cheer me up, as I lay half-awake in the ICU. She was only 700 grams. The doctors gave us little hope she would survive. However, I had read that nine out of ten preemies survived, which gave me hope. Later, a neonatologist told us that for every success story, there were 10 losses. I then discovered that the nine in ten survival rate was a generalized estimate, including all categories of premature birth. Only recently, when I looked at official statistics in Armenia, did I discover that Nare’s survival chances were about 60%. For approximately 20 days, we were given little hope. Each day, my husband and I met with the head of the department, who repeatedly informed us that the situation was dire. However, I noticed that Nare’s breathing and heartbeat were stable, and the nurses reassured me that she was doing well. We were informed that her premature birth and low birth weight were both issues. After conducting my own research, I realized that she was very preterm and extremely low weight. Given that every gram and day of gestation can influence a baby’s survival, being very premature seemed more hopeful than being extremely premature. 

As I watched Nare overcome her feeding difficulties, breathe without tubes and ventilators, gain weight, and grow, I also saw many premature babies disappearing from the Neonatal Intensive Care Unit (NICU) just two or three days after their birth. Every time I entered the NICU, I would look for those tiny, fragile beings, hoping they had survived another day. But many of them didn’t. 

Premature Care Outside the Capital  

Serine Meliksetyan, the Head of the Neonatal Intensive Care Unit at the Republican Maternity Hospital, says that the Armenian Association of Neonatologists follows modern treatment protocols for treating premature babies. All NICUs in Yerevan follow similar methods and approaches, with staff attending regular training sessions. 

Meliksetyan highlights that a country’s wealth and resource allocation is what ultimately impacts the survival rates of premature babies. For instance, the daily cost of caring for a premature baby in the UK exceeds 1,000 GBP, while in the U.S., the average treatment cost is more than $1,500. 

In 2023, the Armenian government allocated approximately $300 million for the entire healthcare budget. If Armenia were to allocate a similar amount of resources for premature babies, it would consume nearly a third of the entire healthcare budget. 

While the care of premature babies in the NICUs generally adheres to global standards and best practices, post-discharge is often problematic. Many parents, ourselves included, hesitate to take their babies to polyclinics, the primary centers for outpatient treatment for premature babies post-discharge. Before our baby Nare was discharged from the NICU, the neonatologists informed us that we might not receive much help at the polyclinics and should primarily use their services for vaccinations. 

The majority of polyclinics in Armenia, particularly those outside of Yerevan, require radical updates and modernization. Despite this, we chose to take Nare to the polyclinic due to a recommended pediatrician who is also a neonatologist. The building appears largely unchanged since the Soviet era, with old and often broken furniture. We use the clinic only for check-ups so the doctor can listen to Nare’s lungs and measure her growth. However, the polyclinic lacks a chart for tracking the growth of prematurely born children. Instead, they adjust Nare’s measurements based on a chart for full-term babies. I asked the Health Ministry about this chart, and they said that it is included in a decree issued by the Health Minister in 2021. I mentioned the Fenton preterm growth chart, which I found online, to our pediatrician. She had not heard of it and asked me to bring it during our next visit. 

Living in Yerevan, I’m fortunate to have the opportunity to choose the pediatrician for Nare. I also have the luxury of taking her to regular physiotherapy sessions to boost her motor skills and swimming classes to build additional strength. However, premature babies born in other regions of Armenia, especially those with health complications, lack these privileges. 

In 2022, 40% of live births were registered outside of Yerevan, in the regions. While many pregnant women from nearby regions travel to Yerevan for delivery, for women in Syunik, Lori, or Tavush, a trip to Yerevan is neither easy nor affordable. Despite these obstacles, many parents of premature babies must make the journey for critical medical care. 

Mariam Sayadyan’s twins were born at 26 weeks gestation on November 11, 2020. They weighed 1,100 and 1,080 grams respectively. Sayadyan lives in Vayk, 138 kilometers away from Yerevan. She regularly takes her children to the local polyclinic for check-ups and describes the conditions at the local health center as “okay”. 

But, both of her twins have Retinopathy of Prematurity (ROP), an eye disease in premature babies caused by prolonged exposure to oxygen. If not monitored and treated promptly, the retina may be irreversibly damaged, leading to total blindness. A premature baby diagnosed with ROP needs to visit an eye doctor as frequently as every two weeks until the child is one year old, sometimes even longer. In addition to ROP, one of Sayadyan’s twins also has a heart condition that requires regular monitoring. 

“It’s very difficult [to travel to Yerevan] by taxi with two children. It is also very difficult financially. We have no other options in our region,” says Sayadyan. In addition to regular trips, she has to take her children to the capital whenever they get sick. 

My daughter also developed ROP. After her discharge, we took her for monthly screenings for three months. For us, the clinic is 20 minutes away, but for Sayadyan, it is a two-hour drive one way, and by taxi. 

In 2018, Varsik Gevorgyan’s daughter was born at 26 weeks gestation, weighing 750 grams. Gevorgyan preferred to take her daughter to Yerevan, as she was not comfortable with her local health center. She lives in Sevan, which is 60 kilometers from Yerevan. 

“I brought her to Yerevan almost every week, as she struggled with breathing and would turn blue,” says Gevorgyan, adding that these breathing issues persisted for about a year. 

“To be honest, I was somewhat afraid because she was born prematurely. I was concerned they might lack the necessary equipment,” explains Gevorgyan. 

UNICEF mandates the idea of “no child left behind”. Every child has the right to be healthy. However, each year, over ten thousand children born in Armenia lack the opportunities afforded to their peers in Yerevan. 

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