India: visiting a special care baby unit
Written by Claire Parker, a hospital midwife in the UK. She recently visited India in her role as a health campaigner for Save the Children.
Day one, part two | Read day one, part one
As we approached our destination we crossed a vast river on the fly-over, the main river and water source for the area. It was parched and completely bone dry.
On our arrival we met with Save the Children’s local partners, CECODECON, a health and sanitation NGO. We couldn’t have received a warmer welcome – coffee, flower garlands, red powder bindis were etched on our foreheads and we were all introduced to each other.
They took us to visit a primary healthcare facility in their town. One doctor is based here, responsible for a catchment population of 40,000 people.
The place was heaving; he sees around 200 people every day, supported only by two other ancillary staff. Whilst it was fantastic to see that the local community trust and utilise the services, it was humbling to see such a dedicated doctor work so hard to serve his community.
They also provide DOTS (directly observed treatment, short course) for tuberculosis, and have seen an incredible 85% coverage.
He explained to us about his hardships working there. In 2011 India initiated a free drug policy for about 175 medications, yet one of the biggest problems he faces is replenishment of his supplies from the state health department.
Malnutrition is one of the biggest health concerns for his community, reflected in the figures mentioned in my first blog. This again highlighted the importance of promoting exclusive breastfeeding and growth monitoring in improving the health of children here.
CECODECON, with support from Save the Children, largely focus on these issues, and have implemented community score cards to track progress in these areas and use results to steer their programmes – achievements they were proud to show us in their offices, displayed on their wall charts.
Meeting the doctor
From there we went to a district hospital in Tonk. A free government facility led by the Chief Medical Officer who explained to us the services provided there.
It’s a 200-bed, tertiary-level hospital serving a staggering 1.4 million. They are awaiting the build of a 100-bed maternity hospital in the near future.
Here they see 1,000 outpatients per day, conduct 20 births per day and have two operating/surgical rooms. Also there is a malnutrition ward, special-care baby unit and family planning, STI services. The staff include ten midwives, 29 female nurses and three obstetricians.
We asked the CEO what were the main constraints he faces at this hospital. He stated there aren’t enough staff for the number of patients, and the salary is poor, which in turn detracts staff from seeking employment here and impacts greatly on staff retention. Understandable.
Where I work in the UK we conduct about 12 births per day and have on duty at least 12-15 midwives per shift with three doctors. How they manage at this hospital with only ten midwives on their books and three doctors for maternity for 24-hour service provision I can’t imagine.
A worrying example of how this could affect safe intrapartum (during birth) care became evident whilst visiting the special care baby unit.
Here there were about four to five newborn babies in quite a well looked after ward with power and medicines, yet there were no incubators.
Instead each baby was on a resuscitation trolley, like we use in the UK, which is only for very short-term use immediately after the baby is born if it needs oxygen, an overhead heater and suction, for example.
But here these were being used as makeshift incubators, with the overhead heaters used continuously and oxygen being delivered via head-boxes instead. I enquired as to why these babies had been admitted and it seems that at least two that I saw were there due to prolonged labour and birth asphyxia.
I assumed these babies were transferred from the surrounding villages, yet sadly these labours had been managed from the outset within the hospital.
Lacking staff and equipment
I immediately began to question the level of care provided at this tertiary facility where labour had been allowed to become prolonged, and birth asphyxia had ensued undetected.
Was there any difference in labouring at home or in the hospital if the outcome was going to be the same?
For a nation striving to promote 100% ‘institutional deliveries’, I wondered if they were really ready for this with a lack of staff and equipment.
As we didn’t get to see the labour ward at this hospital, I reserved my judgment as we were soon to visit a maternity hospital in Delhi where I would see for myself the services offered.
For one baby there, attached to an IV and oxygen, with nasal flaring, sternal recession, pallid colour, and very poor tone on day three following birth, I wondered how long he could realistically remain on that makeshift incubator with no prospect of any further advanced treatment.
Even here, he hadn’t been offered any of his mother’s milk.