Have you ever held a newborn baby in your arms? I have often heard many people say, “I don’t know how to hold her.” Or, “I’m afraid I’ll hurt him.” We all have this natural sense that babies are vulnerable and need our warmth and protection.
As a neonatologist, I work every day to protect newborns, especially those ones who are very sick or born too early. Our intuitive feeling that babies need protection is true. In fact, the first few hours and days after delivery are the most critical.
In 2016 alone, 640,000 newborns in India died prematurely, or due to complications during delivery (especially related to breathing) and infections. Most deaths occur on the day of birth or in the first week of life. This period is so crucial that it has been given its own name — perinatal — meaning “around the time of birth” and includes stillbirths and deaths in the first seven days after birth.
One of the major risks newborns face is hypothermia (or when a baby’s body temperature falls below the normal range). Babies are just beginning to adapt to the external environmental temperature after being nourished in the warm insulated environment of their mother’s womb. Sometimes they are not able to maintain their own body heat, a challenge that is even more difficult for babies that are born too early or with low birth weight. Babies that get too cold can suffer serious illness, and even die.
I have often wondered whether hypothermia might be a problem in my own hospital, the Kalawati Saran Children’s Hospital (KSCH), Lady Hardinge Medical College, New Delhi. So, in 2016, we undertook a study to determine whether babies might be suffering from this condition when they arrived at the neonatal intensive care unit (NICU) from the delivery room, nearly half a mile away. We collected data by recording the temperatures of newborns as they were admitted to the NICU. Of 93 admissions that month, 70% of the neonates were found to be in various stages of hypothermia.
We (a team of doctors, nurses, labour room staff and I) brainstormed. We began by plugging gaps in labour room supplies. We stocked up on warm linen for newborns, placed thermometers on the walls to encourage staff to keep the ambient temperature above 25°C and placed a radiant warmer for newborns in operating theatres. We also noticed that batteries in the transportation incubators (TI) — used to transfer babies — weren’t working. Investigation showed that this was due to missing charging leads from the TIs. Using quality improvement approaches, we began making sequential changes to the way we worked. For instance, staff were trained on the importance of keeping the TIs charged. Charging leads were also taped with instructions on the TIs on how to charge them.
These small and minimal-cost changes paid off. We found that the percentage of newborns with a temperature below 36°C fell from 38% to 6% between July 2016 and February 2017. This also led to a reduction in neonatal deaths in our unit by over 38% during this period. It was a boost for quality improvement in newborn survival.
Buoyed by our success, my colleagues and I shared our experiences and approach across the country. In 2017, we created the Nationwide Quality of Care Network (NQOCN). Spread over 10 States in India, the NQOCN works with over 100 public, private and academic health facilities to help devise small-scale, localised, quality-improvement interventions for ensuring newborn survival. The aim is to create and draw from an eco-system of best practices in order to deliver the highest standards of care during childbirth.
Fortunately, the government too has launched several initiatives to ensure access to high quality care for mothers and newborns during the pregnancy and, especially, the perinatal period. In 2015, the ‘Dakshata’ programme was launched to strengthen the quality of care during and immediately after childbirth using the services of skilled medical officers, staff nurses and auxiliary nurse midwives. Two years later, ‘LaQshya’ was launched to help improve quality of care during institutional deliveries.
We must provide our newborns with the best quality of care, with a focus on rural areas and for low-income families. This means identifying and adopting simple interventions that not only keep babies warm but also ensure that they are safe and healthy during the immediate period around birth.
Vikram Datta is Director-Professor, Department of Neonatology, Lady Hardinge Medical College, New Delhi