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A model for neonatal care

Jun 01, 2009

The sick and newborn care unit at a hospital in western India is proving to be a lifesaver for infants. The state-of-the-art facility provides free of cost treatment to those below poverty line and is being replicated across the state to reduce the infant mortality rate.

Guna, Madhya Pradesh: When Toofan Singh, a farmer from Aron village in Guna district of Madhya Pradesh, saw the deteriorating condition of his newborn son, he realised the only place where his baby had any chance of survival was at the Sick New Born Care Unit (SNBCU) in the district hospital in Guna. 

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Swaddling the baby in a faded black sheet and unmindful of the 45-degree afternoon heat, he took the baby to the unit only to be told by Dr Preeti Diwedi, the doctor on duty, that the baby was suffering from acute sepsis, affected bowels and shallow breathing.

Dr Diwedi, along with an attendant, placed the neonate in the special outborn section meant for children who are not born at the district hospital. He was put on an oxygen concentrator attached to a central oxygenation system while a pulse oximeter monitored his heartbeat. A separate infusion pipe helped ensure a steady flow of nutrient fluids, and a monitor placed on top of the bed noted his body temperature.

“The first 24 hours are crucial; after that the organs settle down,” says Dr Diwedi.

Toofan Singh’s son was one amongst eight babies in the outborn unit. Some of the babies have picked up serious infections by the time they are brought to this hospital. A separate inborn unit provides care for those babies who have been delivered at the district hospital itself.

“In Madhya Pradesh, 28 children were dying every hour, with about half of child deaths occurring in the neonatal period”

A fresh lease of life

The state-of-the-art SNBCU, set up last year, has provided a fresh lease of life to 2,941 of the 3,262 babies brought here, many in an extremely precarious situation at the time of their admission. Their average stay varies between one and two weeks, though some low-weight infants have spent over a month at this facility.

Guna district had one of the highest infant mortality rates in India. The central government’s reproductive and child health (RCH) programme had documented that “in Madhya Pradesh, 28 children were dying every hour, with about half of child deaths occurring in the neonatal period (28 days). Two-thirds of these deaths,” the report noted, “could have been averted by existing preventive and therapeutic interventions.” 

Based on these dismal figures, the Madhya Pradesh state government along with UNICEF launched the SNBCU in order to provide specialised care for neonates. Treatment here is provided free of cost to all BPL (below the poverty line) cardholders.  

The SNBCU was launched on December 14, 2007. So far, statistics reveal that there have been 1,437 inborn admissions, with the number of deaths being 176. There have been 925 outborn admissions, with the death rate proportionally higher, at 145. Already, doctors point out, the survival rate has gone up to 89%.

Dr Nayar, who heads the SNBCU, says: “Some sick babies are brought here the day they are born, but our experience shows the majority are brought a day or two later. The delay is invariably on the part of the parents who are now being informed that if they suspect any problem, the child should be rushed to this unit right away.” 

Worth emulation

The success of the Guna model is being replicated across all districts of the state including Shivpuri, Mansaur, Ratlam, Gwalior, Jabalpur and Bhopal. Forty-two units manned by a team of doctors, nurses, ward boys and dais are expected to be put in place within the next two years.

Other states are keen to copy this model; one unit has already been set up in Purnia in West Bengal. Orissa too is planning to set up similar units.

The Guna model has the potential to revolutionise the public health system because it provides integrated management of sick newborns. It has already upset the business of some local nursing homes, although the state government does not want to antagonise any of them and is in the process of holding a dialogue with private doctors so that they do deliveries of BPL cardholding mothers with the government reimbursing them.

The UNICEF state representative in Bhopal, Dr Hamid-el Bashir, maintains: “A revolution is unfolding in India, with Guna showing the way. Already, the Madhya Pradesh government wants to replicate this across all its districts for which they will receive full funding from the National Rural Health Mission (NRHM).”

“The government has put out an announcement for recruiting medical doctors with neonatal specialisation. UNICEF will take this medical staff to Guna for additional training before having them positioned in the district centres,” Bashir says, adding that if there is any delay in NRHM funds coming through, UNICEF will fill the gap.

Bashir believes that once the Guna model is replicated in the 50 districts of Madhya Pradesh, the infant mortality rate (IMR) will decline from 74 per 1,000 to 40 per 1,000.

The Madhya Pradesh government is simultaneously pushing institutional deliveries to ensure that maternal mortality shows a similar downslide. Implementation of the Janani Suraksha Yojana (JSY), by increasing institutional deliveries among BPL families, is helping reverse the adverse maternal mortality ratio.  

“We believe many more women die during childbirth, but their deaths go unreported”

Round-the-clock care

A maternal death audit conducted by UNICEF and local NGOs in 2006 highlighted the fact that while 50 maternal deaths had taken place in Shivpuri in 2006, the figure in Guna district was 56. These deaths are generally reported by ANMs (auxiliary nurse midwives) and local NGOs. Dr Ramani Atkuri, who worked with UNICEF-Bhopal, said, “This is only the tip of the iceberg. We believe many more women die during childbirth, but their deaths go unreported.”

“The cause of most of these deaths is haemorrhage, severe anaemia, eclampsia, malaria and sepsis,” Atkuri said.  

Here again, the Madhya Pradesh government’s emphasis on institutional deliveries has helped reverse the trend. A 24x7 call centre has been set up at the Guna district hospital to provide round-the-clock emergency transportation for pregnant women. This service is known as the Janani Express Yojana (JEY) ambulance service and is expected to reach the woman within half-an-hour of the call. 

Shahnawaz Khan, who heads the call centre, says: “The JEY has helped reduce travelling time from the village. Earlier, pregnant women living in remote corners were forced to use overcrowded public buses or tractors and bullock carts. Now they are brought to hospital in a safer and more comfortable manner.”

The success of the JEY has resulted in 22 ambulance services which feed 24 delivery centres in the more remote regions. Dr Ramvir Singh, chief medical officer, Guna, points out that, “from the 30,000 institutional deliveries that took place in 2008, 10,000 used the JEY facilities. The family members of the pregnant mother rang up the call centre and asked for an ambulance to be sent to their home. And mind you this is a free facility”.

Dr Manohar Agnani, commissioner, health, who is based in Bhopal confirms the success of both the JEY and the JSY. He says: “The latter scheme is paying Rs 1,600 to every woman who goes in for an institutional delivery. Overall, institutional deliveries have gone up from 26% to 76%, in a matter of three years, throughout Madhya Pradesh.” 

The other outstanding initiative has been to enter into a private-public partnership with private hospitals and nursing homes across the state to ensure that no pregnant BPL mother is turned away from a private facility.

Agnani says: “The Madhya Pradesh government is in the process of providing accreditation to a number of private hospitals that have agreed to do deliveries of mothers carrying BPL cards. They are then reimbursed at the rate of Rs 1,200 for a normal delivery and Rs 5,000 for every C-section they perform. Already, 25,000 deliveries have taken place in 2008 under this scheme.”

Not that these interventions have helped remove the prejudice against the girl-child. The number of male admissions to the SNBCU since the facility started shows male child admissions to be 68%, while that of the girl-child only 31%. This clearly indicates that with ultrasound machines being available at the village level, a large number of female foetuses are being aborted.

Toofan Singh was relieved when Dr Nayar informed him that he was eligible for reimbursement for his wife’s C-section even though it had taken place at a private hospital. “I’ve already spent Rs 11,000,” he told the doctors at the SNBCU. “You will get back between Rs 7,000 and Rs 9,000,” Dr Diwedi told him.

But what brought the smile back to his face was the news, a few days later, that his newborn had been brought back from the brink, and would survive.

“I would never have believed such a miracle could happen,” a happy Toofan Singh said when his baby was finally discharged from the SNBCU. “For someone like me, this is a miracle place.” 

Source : Infochange
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