By Joke Kujenya
PAIN, ONCE thought to be a post-birth experience, begins far earlier, according to the Kingdom of Eswatini’s Ministry of Health study just released.
The Ministry’s neonatal care clinical study has revealed that babies can feel pain while still in the womb dubbing it a finding that is reshaping how health practitioners approach maternal and neonatal care in the country.
The Ministry also stated that advances in medical understanding now recognise that unborn babies respond to painful stimuli from as early as the second trimester of pregnancy.
The report, published under the Neonatal Care Clinical Guidelines for the Kingdom of Eswatini, notes that pain perception begins when the foetal nervous system is sufficiently developed to register stress, discomfort, and sensory changes.
It described this as a vital consideration in antenatal and delivery care, stressing that pain awareness in the womb forms part of the broader human experience of newborn survival.
The Ministry explained that the foetus, like the newborn, reacts to distress through measurable physiological changes such as increased heart rate, altered oxygen levels, and muscular movement.
“These responses indicate that the baby’s nervous system is functioning and perceiving sensations, including pain,” the study noted, emphasising that foetal pain management should be considered in obstetric and neonatal procedures that may cause discomfort to the unborn child.
It says this revelation forms part of Eswatini’s broader national response to high neonatal mortality rates.
Furthermore, the Ministry’s report disclosed that about 20 newborns die per 1,000 live births, with most deaths occurring within the first week of life.
Also acknowledged by the Ministry is the fact that many of these deaths are preventable through improved clinical care, proper monitoring during labour, and postnatal management.
The study also pointed to the first 28 days of life – the neonatal period – as the most vulnerable stage for human survival.
It highlighted that approximately 7,000 newborns die globally every day, reflecting World Health Organization (WHO) data which links neonatal deaths to complications that could be avoided through early and sensitive intervention.
Also, the Eswatini Ministry of Health said it remains committed to reducing its neonatal mortality rate to below 10 deaths per 1,000 live births by 2030, aligning with the Sustainable Development Goals (SDGs).
Commenting on the study, Dr S.V. Magagula, Director of Health Services, stated in the report that the Ministry’s approach is anchored on compassion and evidence.
“Each of these deaths is a tragedy, particularly because many are preventable,” he said. “We will continue to strive to let our neonates thrive.”
He explained that the new guidelines not only address clinical management but also underline the emotional and sensory realities of babies, both before and after birth.
According to the study, understanding pain perception in the womb helps healthcare workers handle deliveries more carefully and supports the need for gentle neonatal practices.
The Ministry cautioned that procedures such as suctioning, physical stimulation, and resuscitation must always consider the newborn’s sensory thresholds.
“Deep and aggressive stimulation may cause stress and pain,” the guidelines warned, calling for a balance between life-saving interventions and the infant’s comfort.
The findings were drawn from collaborative work with WHO, UNICEF, and a technical team of paediatric specialists from the Mbabane, Hlathikulu, Piggs Peak, and Raleigh Fitkin Memorial hospitals.
Also, the resulting clinical manual –Eswatini’s first national neonatal guideline – compiles international best practices adapted to the country’s health system and community settings.
The document outlines comprehensive guidance from birth to early childhood development.
It details the correct steps for drying and stimulating the baby after delivery, delayed cord clamping, initiation of breastfeeding within the first hour, and the importance of maintaining skin-to-skin contact.
The Ministry stated that the practice of Kangaroo Mother Care (KMC) – where the baby is held closely against the mother’s chest – not only prevents hypothermia but also regulates the infant’s heartbeat and reduces stress.
These early measures, according to the report, soothe the baby and contribute to reduced pain and better adaptation to life outside the womb.
Moreover, the report emphasised that the sensory experience of newborns is complex and highly sensitive.
“Infants respond to light, sound, and touch from the moment of birth.
Care should therefore be nurturing, quiet, and warm,” the Ministry stated.
Hospitals were also directed to maintain controlled lighting and avoid loud noises in neonatal wards, ensuring that babies are handled minimally and gently to avoid physiological and behavioural stress.
The guidelines also noted that premature and low birth weight babies are particularly prone to pain and stress because their skin and nervous systems are underdeveloped.
These infants, the Ministry observed, experience pain more intensely and may not have the ability to regulate it.
Healthcare professionals were instructed to apply comforting methods such as KMC, gentle positioning, and non-invasive monitoring to reduce distress.
To address neonatal pain comprehensively, the Ministry introduced a specific chapter on pain assessment and management.
It stated that healthcare workers should recognise signs of pain in newborns, including facial grimacing, changes in heart rate, and irregular breathing.
“Pain in neonates should never be ignored,” the guidelines stressed. “Assessment must be routine, and interventions must be both preventive and responsive.”
In its practical recommendations, the Ministry outlined non-pharmacological interventions as the first line of comfort – including touch, soothing voices, and breastfeeding.
Where medical pain relief is necessary, clinicians are to use safe, evidence-based doses suited for neonatal physiology.
The guidelines also warned against outdated practices such as unnecessary suctioning and excessive handling, which can aggravate pain and stress responses in newborns.
The Ministry’s neonatal pain section represents a cultural and clinical shift in how Eswatini perceives the earliest stages of life.
By recognising that babies can experience pain even before birth, the government aims to improve not only survival rates but also the quality of care for newborns.
The report further noted that the awareness of foetal pain should guide decisions during maternal procedures, including intrauterine interventions, caesarean deliveries, and emergency resuscitations.
The guidelines further explore early childhood stimulation and nurturing care, underscoring that development begins long before language or movement.
“Stimulation sparks connections between brain cells and helps a baby’s brain to mature,” the Ministry stated.
It recommended that neonatal wards be well lit with soft, bright colours and that health workers and parents actively engage in talking to and comforting infants to support brain and emotional development.
For Eswatini’s Ministry of Health, neonatal care is now viewed as an unbroken continuum — beginning in the womb, extending through birth, and continuing into early childhood.
The Ministry said the inclusion of pain awareness is part of building a compassionate, science-driven system that treats every newborn as a sentient individual from conception.
The guidelines also call for stronger monitoring of high-risk pregnancies and improved referral systems for small and sick newborns. Hospitals are urged to adopt strict observation routines in the first 24 hours after birth, when most complications occur.
The report added that staff training remains central to sustaining these standards, ensuring that nurses, midwives, and doctors apply pain-sensitive, life-saving techniques consistently.
With the Ministry’s initiative, Eswatini joins a growing number of countries integrating foetal and neonatal pain management into national health policy, the report notes.
The guidelines, the Ministry also said, are a living document – to be revised regularly in line with new evidence and changing clinical realities.
Dr Magagula then concluded that the country’s renewed focus on neonatal survival is as much about empathy as it is about medical precision. “Children are the future,” he reiterated.
“We must care for them from their first heartbeat – even before they are born, Dr Magagula affirmed.”
