|CHILD HEALTH IN THE HINTERLAND
|Year : 2021 | Volume
| Issue : 4 | Page : 280-283
A premature baby with respiratory distress in a rural primary health center: Role of technology in newborn care
Pavitra Mohan, Simran Jain, Gargi Goel, Sanjana Brahmawar Mohan
Basic Health Care Services, Udaipur, Rajasthan, India
|Date of Submission||23-Oct-2021|
|Date of Decision||29-Oct-2021|
|Date of Acceptance||30-Oct-2021|
|Date of Web Publication||29-Nov-2021|
Dr. Pavitra Mohan
Basic Health Care Services, 39, Krishna Colony, Bedla Road, Udaipur, Rajasthan
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Mohan P, Jain S, Goel G, Mohan SB. A premature baby with respiratory distress in a rural primary health center: Role of technology in newborn care. Indian Pediatr Case Rep 2021;1:280-3
|How to cite this URL:|
Mohan P, Jain S, Goel G, Mohan SB. A premature baby with respiratory distress in a rural primary health center: Role of technology in newborn care. Indian Pediatr Case Rep [serial online] 2021 [cited 2022 Jan 20];1:280-3. Available from: http://www.ipcares.org/text.asp?2021/1/4/280/331385
Over the last two decades, the place of childbirth in India has shifted from homes to hospitals: while in 2004–2005, 60% of all childbirths were at home, in 2018–2019, more than 80% of childbirths in 18 of the 22 Indian states took place in a health facility. This shift was noted in rural as well as urban areas. While the newborn mortality rate (NMR) has declined in the same period, the magnitude of reduction is not proportionate to the increase in institutional births. Insufficient improvement in the quality of maternal–newborn care is probably the reason for this inadequate decline in NMR.
Much has been said about the value of technology in improving newborn care. Indeed, technology has a huge potential to improve the quality of care for the three major leading causes of deaths in this vulnerable age group in India: neonatal sepsis, asphyxia, and low-birth weight. However, such technology is often developed for application in hospitals and well-resourced settings and may not be easy to deploy or use in reality in primary care settings.
Basic Health Care Services (BHS) runs a rural primary health center (PHC) in Dungarpur district of South Rajasthan as a public–private partnership. This PHC serves a total population of 25,000, the majority of whom (80%) belong to a scheduled tribe. A male family member has migrated to the city for labor from almost 60% of the households. The nearest referral hospital is 60 km away, and it takes a motorized vehicle about 2 h to travel this distance due to the poor condition of the roads.
The PHC is managed by a medical doctor, four nurses, qualified as general nurse midwives, a laboratory technician, a pharmacist, and a cleaning staff. The PHC staff can connect with the specialist doctors, including a pediatrician by telephone at all hours. About 30–40 childbirths are conducted in the PHC every month, about one-third of whom are low-birth weight.
We present the narrative of a baby who was born prematurely in this PHC and developed respiratory distress within 1 h of birth. Through this case, we aim at highlighting the value of appropriate, low-cost technology that, when deployed at scale, can lead to saving many newborn life in low-resource primary care settings. We further discuss the characteristics of technological solutions that are appropriate for such settings and emphasize the need for developing and deploying these solutions.
| Case Study|| |
Nisha (name changed), a 20-year-old woman presented to the PHC at 34-week gestation with spontaneous labor pains. She was a primigravida mother who gave a history of receiving four antenatal care visits in the village where her in-laws resided. Her spouse is a migrant laborer based in Ahmedabad. As is the custom, she had come to her parent's home for childbirth, which was in a village lying in the catchment area of our PHC. The pregnancy had been uneventful, and she continued to perform heavy work at home and farms during pregnancy. She had taken some iron–folic acid and calcium supplements during pregnancy, but her compliance was not adequate. When she presented to us during labor, she weighed 53.5 kg, and her height was 144 cm. Her hemoglobin was 8 g/dL.
Nisha's labor progressed normally, with the fetal heart rate (as monitored by a fetal Doppler), staying normal throughout. However, when the baby girl was born, she did not cry immediately. The attending staff resuscitated the baby as per standard protocol, and she started crying after a few minutes. The birth weight was 2271 g and the baby was placed on skin-to-skin contact with her mother for kangaroo mother care (KMC). The baby was noted to have tachypnea, chest in-drawing, and grunting; though perfusion was maintained, there was no cyanosis and the baby was moving her limbs actively. However, the condition continued to worsen, and 30 min after birth, pulse oximeter revealed oxygen saturation (SpO2) of 88%.
We made a clinical diagnosis of prematurity with severe respiratory distress, possibly hyaline membrane disease. Referral to a higher center was categorically ruled out by the mother and her female attendants, due to the absence of any a male kin member. Hence, we started teleconsultation with a neonatologist. In the meantime, the team started the baby on O2 at 1 lpm, using an O2 concentrator and nasal prongs. They also administered maintenance intravenous (IV) fluids and IV antibiotics. The blood sugar levels remained within normal limits. Respiratory distress continued with SpO2 fluctuating below 94%, despite receiving O2 and increasing the flow rate up to 4 lpm.
It was decided to use indigenously prepared continuous positive airway pressure (CPAP) to deliver O2 [Figure 1]. Nasal prongs were connected to a three-way cannula. Tubing from one end of the cannula was connected to the O2 concentrator, while a glass bottle filled with 10 cm of water was attached to the other end [Figure 2]. The depth of tubing in the water determined the CPAP pressure being provided.
|Figure 1: Simultaneous administration of indigenous continuous positive airway pressure and kangaroo mother care to the baby in the primary health center|
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|Figure 2: Components of the indigenous continuous positive airway pressure|
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After CPAP with 4 l of oxygen was started, the baby's saturation stabilized around 96% and respiratory rate normalized to around 54/min within 2 h. Over the next few hours, the baby became comfortable and stopped grunting, and we were able to progressively decrease the oxygen flow rate. After 24 h, the baby had a respiratory rate of 50/min, did not have any intercostal retractions, and was maintaining SpO2 above 95% on room air. The mother had continued to provide KMC throughout and had started breastfeeding when the baby was stable. Antibiotics were continued during hospital stay. On day-3, we discharged the baby, encouraging mother to continue exclusive breast feeding (EBF) and KMC at home.
The auxiliary nurse midwife (ANM) and accredited social health activist (ASHA) worker visited the mother and baby on regular intervals at home. They supported continuity of providing KMC and EBF. Throughout the first 4 weeks after birth, the mother and maternal grandmother alternated in providing KMC for 8–10 h per day. At the 6 weeks visit, the baby weighed 3350 g and was thriving.
| Discussion|| |
As enunciated in the Alma Ata declaration, appropriate technology made universally available is one of the important characteristics of PHC. Despite its promise, much of the available technology is not actually appropriate, especially in low-resource settings. For example, a radiant warmer that requires regular power supply will not be helpful if the power supply is erratic. In other cases, the skills required to operate the said technology can be imparted only after extensive training and, that too, in specialized settings, e.g., the use of intermittent positive pressure ventilation. Further, the costs of the technology being considered may be prohibitive, or maintenance may be expensive and unavailable. Therefore, many options of available technology remain unused or underused.
In contrast, the four technology-based solutions cited in this case are examples of the appropriate use of technology in low-resource settings. Small, portable pulse oximeters are inexpensive, easy to use, and critical in the assessment of respiratory distress. Oxygen is lifesaving for many patients in PHC settings, where referral to the next level of care may not be feasible, will be expensive, and may be too late. Oxygen concentrators are easy to use and low cost alternatives to heavy oxygen cylinders. However, their use requires regular power supply, which may be challenging in some settings. This can be overcome by models that are charged and operate on battery. In our PHC, we have limited power backup and a few O2 cylinders for backup. Indigenous CPAP is another simplified solution to the common problem of severe respiratory distress that can be life-saving, especially when managed by a skilled team. KMC is the simplest intervention that demonstrated a huge impact on newborn survival, growth, and bonding between mother and baby. It only requires a healthcare worker to train, support, and empower family members to participate in the care, development, and survival of their babies.
This case study illustrates the value of appropriate technology in saving newborn lives. However, much of healthcare technology is not appropriate in many low-resourced primary healthcare settings, due to expense, difficulties in deployment or use, and dependence on uninterrupted power, high-speed internet, or personnel with specialized skills. Pediatricians, primary care professionals, and technologists should come together to develop and deploy simple, affordable, and usable technology options that would help us inch closer toward the dream of primary healthcare for all, especially vulnerable populations who need it the most.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient's mother has given his consent for images and other clinical information to be reported in the journal. The patient's mother understands that names and initials will not be published and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
World Health Organization, Division of Child, Adolescent, Maternal and Reproductive Health has supported the project to integrate KMC within the PHC that we (BHS, www.bhs.org.in) run as a public–private partnership.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]