**5.3 Feeding challenges as pre-term babies have a poor suck reflex and insufficient suck-swallow coordination**

Pre-term neonates have a poor coordination of the hunger-satiety cues, they also tire easily at suckling and may sleep off without effective feeding [16]. Unfortunately, their mothers do not usually recognize this challenge especially when the neonates tire and sleep off, the mothers tend to believe that they are full. In some communities, mothers use undesirable feeding options when the neonates are not able to suckle adequately such as giving sugar water instead of expressed breast milk [17]. Different breast-feeding methods for these pre-term neonates needs to be taught to their mothers and regular close monitoring implemented.

### **5.4 Health systems failure to create consistent awareness and education on pre-term neonatal care at the community level**

The health care systems have no clear strategies to promote preterm neonatal care at community level, for example, most mothers learn about KMC from health workers for the first time only after giving birth in the hospital [13]. Preterm labor and pre-mature neonates are not subjects discussed with the mothers during antenatal period. Peer -to- peer information sharing has been noted to be a major source of trusted information that most mothers relied on to care for pre-term neonates [13]. The mothers are, therefore, not mentally ready about what to expect and feel overwhelmed with anxiety once confronted with the demands of the preterm baby. Health systems that have community health structures such as village health teams (VHTs) or community health workers (CHWs), these have program specific trainings in most settings and pre-term neonatal care at community level is usually not one of the priorities. For example, the personnel are trained as community drug distributors for childhood illnesses, breastfeeding supporters, and as safe motherhood volunteers while others promote malaria prevention. Most health systems lack evidence informed policy and standard guidelines for pre-term neonatal care at the community level.

The education needs of parents being discharged from hospital need to be carefully assessed to empower them to take care of pre-term neonates at home and be provided with a discharge plan based on the needs of the pre-term neonate, their competencies and availability of resources for care. These educational needs are likely to change over time to information regarding growth and development. Health systems, therefore, need to design and adapt parental support structures at the community level that are dynamic at the different stages of baring a pre-term neonate.

### **5.5 Financial constraints for professional home care and health promotion**

A structured coordinated home care by health care professionals would provide parents an opportunity of support in their own physical environment making use of their own social support networks. However, the human resources to provide this and the supplies required is often lacking in the developing world.

It is difficult for most families in the developing world to afford materials that are required for the desired practice especially among the poorest communities. They often lack the basic supplies such as warm clothes for keeping the baby warm, no adequate clean water and sanitation facilities at the homesteads, as well as inadequate maternal nutrition often compounds the situation. In one study, mothers reported lack of funds to buy fuel (charcoal and paraffin) and oil to smear the baby or for accessing healthcare when the neonate gets sick [18].

#### *Current Topics in Caesarean Section*

Health systems would need to make commitments for an institutionalized approach of home care for pre-term neonates and act on the roles and obligations towards achieving agreed goals and rights. Decisions and actions towards financial obligations need to be based on evidence and rights. There is also be need to have clear accountability frame works for any financial commitments for home based care for pre-term neonates including institutionalized monitoring and evaluation systems that facilitate learning and progress.
