PRETERM LABOUR

The following information is to be used as a guide to and at the discretion of the end-user and should not replace a doctor’s opinion.

OVERVIEW

Preterm labour is the experiencing of contractions before 37 completed weeks of pregnancy. A full-term pregnancy lasts approximately 40 weeks, and most foetal organ development, particularly of the lungs, brain, and digestive system, is completed in the final weeks before this point.

When a baby is born before 37 weeks, they are classified as preterm (or premature) and may face significant challenges adapting to life outside the womb. The degree of risk depends largely on how early the birth occurs. A baby born at 36 weeks faces very different challenges to one born at 24 weeks.

An estimated 13.4 million babies are born preterm globally. Preterm birth complications are the leading cause of death in children under five years of age.

Preterm labour does not always lead to preterm birth. Many women experience contractions or other warning signs that settle without delivery. However, any symptoms of early labour before 37 weeks must be assessed by a healthcare provider immediately. Early intervention can significantly improve outcomes for both mother and baby.

PRETERM BIRTH IN SOUTH AFRICA

South Africa is among the top five countries in the world for preterm birth rates: 13% of all infants are born preterm. Unfortunately, there has been no meaningful change in the preterm birth rate over the past decade, and preterm birth still causes almost 50% of neonatal deaths in the country.

Preterm labour is reported by 16% of South African mothers; of these, over 27% were HIV-infected, showing the significant impact of HIV on preterm birth risk.

South Africa’s high preterm burden is largely due to a complex interaction of high rates of HIV, hypertension in pregnancy, adolescent pregnancy, poverty, food insecurity, gender-based violence, under-resourced healthcare facilities, and too few mothers receiving adequate antenatal care, particularly in rural and peri-urban communities.

WARNING SIGNS: WHAT TO WATCH FOR BEFORE 37 WEEKS

Recognising the early warning signs of preterm labour is critically important. The sooner it is assessed, the more options are available to delay delivery and improve outcomes for your baby:

Go to your nearest maternity facility immediately if you experience:

Regular or frequent contractions (four or more in an hour) even if not painful, and especially if they feel like period cramps or rhythmic tightening
Persistent lower back pain: dull, constant low back pain that does not ease with rest or change of position, particularly if new or unusual for you
Pelvic pressure or heaviness: a feeling that the baby is pushing down, or pressure in the vaginal area
Changes in vaginal discharge: discharge that becomes heavier, watery, mucus-like, pink-tinged, or blood-streaked (this may be a sign that the mucus plug coming away)
Rupture of membranes (“waters breaking”): a gush or constant trickle of clear or pale fluid that you cannot control, even if not accompanied by pain. Before 37 weeks this is called Preterm Prelabour Rupture of Membranes (PPROM*)
Abdominal cramping, with or without diarrhoea
A general sense that something is wrong: trust your instincts

IMPORTANT

It is important to know that many women who experience these symptoms do not go on to deliver preterm. However, all symptoms before 37 weeks require immediate professional assessment. Do not wait to see if symptoms resolve on their own. Consult a qualified healthcare professional to assess your cervix, monitor contractions, and determine whether intervention is needed.

*PPROM: A SPECIFIC WARNING

Preterm Prelabour Rupture of Membranes (PPROM) is when the waters break before 37 weeks without labour starting, and is responsible for approximately one-third of all preterm births globally. In South Africa, research from King Edward VIII Hospital (KwaZulu-Natal) found a 12% preterm birth rate at the facility, with PPROM being a major contributor. PPROM carries additional risks of infection (chorioamnionitis) for both mother and baby, and requires hospitalisation and careful monitoring. If your waters break before 37 weeks, go to hospital

RISK FACTORS AND CAUSES

The causes of preterm labour are complex and often caused by several factors interacting to trigger early birth:

HIV INFECTION IN PREGNANCY

South Africa has one of the world’s highest rates of HIV among pregnant women; over 27% in some places. HIV infection is a well-established risk factor for preterm birth, linked to immune activation and inflammation. The interaction between antiretroviral therapy (ART) and preterm risk is complex and continues to be studied.
HYPERTENSION IN PREGNANCY

Hypertensive disorders (pre-eclampsia, gestational hypertension) are among the leading causes of both spontaneous and medically indicated preterm birth in South Africa. Studies in Cape Town found that 20% of stillbirths were associated with hypertensive disease. These conditions are detectable and manageable through regular antenatal blood pressure monitoring.
PREVIOUS PRETERM BIRTH

Having delivered prematurely before is one of the strongest predictors of recurrence. Women with a prior preterm birth should inform their antenatal care team immediately, as they may be eligible for preventive interventions such as cervical length monitoring, progesterone supplementation, or cervical cerclage (a minor surgical procedure performed during pregnancy where a doctor sews the cervix closed).
INFECTION & PPROM

Infections, including urinary tract infections (UTIs), sexually transmitted infections (STIs), bacterial vaginosis, and chorioamnionitis (infection of the membranes), are major drivers of preterm labour in South Africa. They trigger inflammatory pathways that can initiate contractions. Untreated infections and PPROM together contribute significantly to the preterm birth burden.
ADOLESCENT & ADVANCED MATERNAL AGE

Both very young mothers (under20 years) and women over 35 have elevated preterm birth risk. South Africa has high rates of teenage pregnancy, which is associated with preterm birth, low birth weight, and inadequate antenatal care. Women aged above 35 are 1.63 times more likely to deliver preterm.
MULTIPLE PREGNANCY

Carrying twins or higher-order multiples dramatically increases preterm birth risk: studies show multiple pregnancies are 3.43 times more likely to result in preterm birth. Multiple pregnancies are more common with assisted reproduction (IVF) and are classified as high-risk, requiring specialist antenatal management from early pregnancy.
ALCOHOL USE IN PREGNANCY

South Africa has among the highest rates of foetal alcohol spectrum disorder (FASD) in the world, particularly in the Western Cape. Maternal alcohol use is one of the strongest risk factors for preterm birth. No amount of alcohol has been proven safe in pregnancy.
INADEQUATE ANTENATAL CARE

Fewer than four antenatal visits is a consistently identified risk factor for preterm birth across sub-Saharan Africa. Late booking (after 20 weeks) denies women and clinicians the opportunity to identify and address modifiable risk factors early. The South African National Department of Health recommends first booking at 12 weeks or as soon as pregnancy is confirmed.
SHORT INTER-PREGNANCY INTERVAL

Falling pregnant again too soon after a previous birth, typically within 18 months, increases preterm birth risk. The uterus and maternal nutritional stores need time to recover between pregnancies. Spacing births appropriately through family planning reduces this risk.
CERVICAL INSUFFICIENCY & UTERINE FACTORS

A short or weakened cervix (cervical insufficiency), uterine abnormalities (such as fibroids or an abnormally shaped uterus), and placental complications (placenta praevia, placental abruption) all increase the risk of preterm labour. Cervical length can be measured by ultrasound and, when short, may be treated preventively.
POVERTY, STRESS & GENDER-BASED VIOLENCE

Psychosocial stress, including poverty, food insecurity, domestic violence, and trauma, activates stress hormones (cortisol) that can initiate preterm labour pathways. In South Africa, where intimate partner violence affects a significant proportion of pregnant women, this pathway is a real and underappreciated contributor to preterm birth.
SMOKING & SUBSTANCE USE

Tobacco smoking reduces placental blood flow and is associated with increased preterm birth risk, PPROM, and placental abruption. Methamphetamine (“tik”) use, a significant problem in the Western Cape, is also associated with preterm birth and neonatal complications. Quitting smoking at any stage of pregnancy reduces risk.

HOW DOES BEING BORN TOO EARLY AFFECT A BABY?

The earlier a baby is born, the greater the risk of complications. South African research shows that approximately 45% of all neonatal deaths in South Africa are linked to preterm-related complications. A multi-country study across South Asia and sub-Saharan Africa found that 14% of all preterm infants died during the neonatal period, with mortality reaching 37.6% for births under 34 weeks.

The good news is that many preterm complications are preventable or treatable with appropriate care. The most common short-term and long-term outcomes include:

RESPIRATORY DISTRESS SYNDROME (RDS)
BRAIN BLEEDS (INTRAVENTRICULAR HAEMORRHAGE)

Fragile blood vessels in the premature brain can rupture, causing bleeding. This is more common in very preterm babies and can lead to long-term neurological challenges. Magnesium sulphate given to mothers before very early preterm delivery offers significant brain protection to the baby.
INFECTION / SEPSIS
HYPOTHERMIA

Preterm babies have very little body fat and cannot regulate their body temperature. Hypothermia can rapidly become life-threatening. Kangaroo Mother Care (KMC), which is when a baby maintains skin-to-skin contact with the mother, is highly effective at maintaining warmth and is actively implemented across South African hospitals.
FEEDING DIFFICULTIES

The sucking and swallowing reflex develops at around 32–34 weeks. Very preterm babies often cannot feed directly at the breast or bottle initially. Expressed breast milk given via tube is the preferred feeding method in the neonatal unit; breastmilk provides protective antibodies that preterm infants critically need.
LONG-TERM DEVELOPMENTAL CHALLENGES

Extreme preterm survivors face higher rates of cerebral palsy, developmental delay, learning difficulties, hearing and vision problems, and chronic lung disease. The degree of long-term impact depends on how early the birth occurred, the severity of neonatal complications, and the quality of follow-up care received.
NECROTISING ENTEROCOLITIS (NEC)

A serious gut condition affecting premature babies where intestinal tissue becomes inflamed and may die. NEC is associated with formula feeding and can be significantly reduced through exclusive breastmilk feeding (another critical reason to support breastfeeding of premature infants).
MATERNAL MENTAL HEALTH IMPACT

A preterm birth is a major psychological event for mothers and families. Anxiety, depression, grief, and post-traumatic stress are common following preterm delivery, particularly when a baby requires extended NICU care. Mothers need psychological support alongside their physical care.

MEDICAL MANAGEMENT OF PRETERM LABOUR

When preterm labour is diagnosed or suspected, healthcare providers will assess both the mother and baby and decide on the most appropriate management. Management priorities include:

ANTENATAL CORTICOSTEROIDS (ACS)

When preterm birth appears likely before 34 weeks, a course of corticosteroids is given to the mother to accelerate foetal lung maturity. This is one of the most effective and cost-effective interventions in obstetrics as corticosteroids reduce the risk of respiratory distress syndrome and intraventricular haemorrhage in the baby, two of the most common and deadly preterm complications.
MAGNESIUM SULPHATE FOR NEUROPROTECTION

When birth before 32 weeks appears imminent, magnesium sulphate (MgSO₄) is administered intravenously to the mother. It has been shown to reduce the risk and severity of cerebral palsy in very preterm infants, one of the most significant long-term complications of extreme prematurity. Clinical monitoring for signs of toxicity is essential during administration.
TOCOLYTICS (DRUGS TO SLOW OR DELAY LABOUR)

Tocolytic medications (such as nifedipine or atosiban) aim to slow or temporarily halt contractions. These are not used to stop preterm labour permanently, but to create a window of 48 hours or more for corticosteroids to take effect and/or for transfer to a facility with appropriate neonatal care. Tocolytics are not used when delivery is considered necessary for maternal or foetal safety (e.g. severe pre-eclampsia, placental abruption, foetal distress).
ANTIBIOTICS

Antibiotics are routinely used in the management of PPROM to reduce infection risk (chorioamnionitis and neonatal sepsis) and to prolong the pregnancy safely. In women with intact membranes, antibiotics are given if group B streptococcus (GBS) infection is confirmed or suspected, or if there are signs of infection. They are not routinely given in preterm labour with intact membranes without a specific indication.
CERVICAL CERCLAGE (STITCH)

For women with a short cervix or cervical insufficiency, a surgical stitch placed around the cervix (cerclage) can help keep it closed and delay preterm birth. It is usually performed for women who have had PPROM, spontaneous preterm birth, or mid-trimester loss in a previous pregnancy. “Rescue cerclage” can be performed in women with a dilating cervix and exposed, unruptured membranes at 16–27 weeks.
VAGINAL PROGESTERONE
IN-UTERO TRANSFER

If delivery appears imminent at a facility that does not haver neonatal intensive care capacity, common in rural provinces, the goal is to transfer the mother (with the baby still in the womb) to a higher-level facility before delivery. Being born in a facility with appropriate NICU capacity is one of the most powerful determinants of survival for very preterm infants. This is why calling for help immediately matters so much.
IDENTIFYING AND TREATING UNDERLYING CAUSES

Where an underlying cause of preterm labour is identified, such as a UTI, STI, bacterial vaginosis, or hypertensive disorder, treating it directly is a priority. Treating an identified infection may resolve early labour or significantly delay delivery. Blood pressure management in pre-eclampsia is critical not only to prolong pregnancy safely, but to protect maternal life.

THE CRITICAL ROLE OF ANTENATAL CARE

Early, regular, and high-quality antenatal care (ANC) is the single most powerful tool for preventing and managing preterm birth. Despite free ANC services being available at public facilities throughout South Africa, uptake remains less than optimal. While over 90% of South African women theoretically have access to antenatal services, only 63.2% actually attend ANC visits. Late booking (after 20 weeks) remains a pervasive challenge.

The South African National Department of Health recommends that all pregnant women book their first ANC visit at 12 weeks of gestation, or as soon as pregnancy is confirmed. At your antenatal appointments, healthcare providers will:

Measure your blood pressure and screen for pre-eclampsia
Test for HIV, syphilis, UTIs, and other infections
Screen for anaemia and nutritional deficiencies
Assess foetal growth and wellbeing
Identify risk factors for preterm birth and refer for specialist care where indicated
Administer preventive treatments such as iron, folic acid, and calcium supplementation
Offer counselling on nutrition, substance use, and mental health

LATE BOOKING INCREASES RISK

A Cape Town study found that late initiation of ANC was associated with increased adverse outcomes including stillbirth. Fewer than 4 ANC visits was identified across multiple sub-Saharan African studies as a significant independent risk factor for preterm birth. Going early and going regularly protects you and your baby.

THE BONITAS MATERNITY PROGRAMME

The Bonitas Mother & Child Care Benefit provides comprehensive, risk-funded pre- and post-natal care, including coverage for 12 antenatal consultations, ultrasound scans, delivery, and an allowance for antenatal classes (plan dependent). Register as early as possible on the Maternity Programme to make full use of these benefits.

LIFESTYLE INTERVENTIONS THAT REDUCE PRETERM BIRTH RISK

While not all preterm births can be prevented, there are meaningful lifestyle choices that you can make to reduce your risk:

BOOK ANTENATAL CARE EARLY AND ATTEND ALL VISITS
STOP SMOKING AND AVOID ALL ALCOHOL AND RECREATIONAL DRUGS

South Africa has one of the world’s highest rates of foetal alcohol syndrome, and sub-Saharan African research identifies alcohol use as among the strongest risk factors for preterm birth. There is no safe level of alcohol in pregnancy. Smoking increases preterm labour and PPROM risk. Stopping at any point in pregnancy improves outcomes.
EAT WELL AND TAKE PRESCRIBED SUPPLEMENTS
TEST AND TREAT INFECTIONS PROMPTLY

UTIs, bacterial vaginosis, syphilis, and other STIs are treatable and must be treated during pregnancy. Do not ignore unusual vaginal discharge, burning on urination, or lower abdominal pain. These can trigger the inflammatory cascade that initiates preterm labour. Regular ANC includes screening for these conditions.
MANAGE HIV WITH FULL ADHERENCE TO ART

If you are living with HIV, consistent adherence to antiretroviral therapy (ART) is essential. While some ART regimens have been associated with modest preterm birth risk, the benefits of viral suppression, for your health and your baby’s, far outweigh any risk. Do not stop ART without consulting your healthcare provider.
MANAGE BLOOD PRESSURE AND CHRONIC CONDITIONS

Hypertension is a major driver of preterm birth in South Africa. If you have existing hypertension, diabetes, or kidney disease, ensure these are well controlled before and during pregnancy. Attend all specialist referrals. Learn to recognise the warning signs of pre-eclampsia: sudden swelling of the face, hands or feet; severe headache; visual disturbances; and upper abdominal pain.
REDUCE AND MANAGE STRESS

Chronic stress activates cortisol pathways that may contribute to preterm labour. While individual stress management cannot solve structural poverty or violence, practices such as rest, social support, and connecting with community resources matter. If you are experiencing domestic or intimate partner violence, your antenatal clinic, social worker, or the GBV helpline (0800 150 150) can help you access safety and support.
SPACE YOUR PREGNANCIES WITH FAMILY PLANNING
STAY WELL HYDRATED

Dehydration can trigger uterine contractions. Drink adequate amounts of clean water throughout the day; at least 8 glasses. Avoid excessive caffeine (not more than one cup of coffee or two cups of tea per day). If you notice contractions, rest, hydrate, and seek assessment if they persist.
SHARE YOUR MEDICAL HISTORY WITH YOUR ANTENATAL TEAM

Do not withhold information about previous preterm births, terminations, miscarriages, uterine surgery, or any chronic conditions, even if you feel embarrassed. This history is essential for identifying your risk profile and offering you the most appropriate preventive care. Your healthcare team is there to support you without judgement.

PRETERM LABOUR

PRETERM LABOUR

The following information is to be used as a guide to and at the discretion of the end-user and should not replace a doctor’s opinion.

OVERVIEW

PRETERM BIRTH IN SOUTH AFRICA

WARNING SIGNS: WHAT TO WATCH FOR BEFORE 37 WEEKS

RISK FACTORS AND CAUSES

HOW DOES BEING BORN TOO EARLY AFFECT A BABY?

MEDICAL MANAGEMENT OF PRETERM LABOUR

THE CRITICAL ROLE OF ANTENATAL CARE

LIFESTYLE INTERVENTIONS THAT REDUCE PRETERM BIRTH RISK

FURTHER READING