Benefits of maternal participation in newborn nurseries
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《美国医学杂志》
Division of Neonatology, Department of Pediatrics, Institute of Maternal and Child Health, Medical College, Kozhikode, Kerala, India
Abstract
Objective: To evaluate the outcome of active involvement of mothers/mother substitutes in day-to-day care of high risk neonates admitted in a level II newborn care unit. Methods: An observational study was carried out over a period of eleven years incorporating active participation of mothers/substitute in the day to day care of their sick neonates. The outcome is assessed in terms of mortality due to the three major illnesses (asphyxia, sepsis and prematurity) during this phase. The data is compared with that of a similar level II care centre where conventional neonatal care is practised. Results: There is a significant and sustainable reduction in neonatal mortality due to the three major illnesses when the mothers are also involved in the neonatal care, in spite of a considerable increase in the number of admissions during this period. Conclusion: The concept of active participation of mother/substitute in neonatal nursery ensures 1:1 care at all times. It is a cheap and effective alternative to inadequacy of bed:nurse ratio (BNR).
Keywords: Bed:nurse ratio (BNR); Maternal participation; Neonatal care; Neonatal mortality
The conventional practice of separating sick neonates from their mothers in new born nurseries is a direct legacy of the western system of medicine.[1] When newborn special care nurseries were introduced in India, their concept, design and functioning were based entirely on western lines as experience in this newly emerging specialty was scant.
In the developing countries, the gap between the needs and availability of resources is wider than that in developed countries because the absolute number of high risk newborns like low birth weight, premature and asphyxiated babies is high.[2] A survey conducted by the National Neonatology Forum (NNF), India, in 1987 revealed an unsatisfying state of affairs prevailing in the various centers studied.[3] A second survey in 1997 of the same centers noted improvement in the field of equipments and other facilities except for nursing care, even though it forms the backbone of neonatal care.[4] There is an inadequacy of trained nursing personnel in neonatology units. The success of special care nursery units largely depends upon the availability of trained staff nurses. Under Indian circumstances, a level II newborn nursery should satisfy a BNR requirement of 4:1.[5]
The present study presents the results of eleven years of experience in this field, assesses the feasibility and advantages of utilizing mother's nursing skills in the care of their high risk newborns and analyses changes in the resultant mortality due to the three major illnesses that necessitate admission of babies in the newborn nursery.
Materials and methods
Institute of Maternal and Child Health [IMCH], Kozhikode, caters for five large districts of Northern Kerala comprising of almost one third of the state's population.[6] A 50-bedded nursery provides neonatal care for sick babies from nearly 25000 deliveries conducted here per year. On an average, about 70 babies are born at this institute daily. Among them, sick/potentially sick ones (criteria : gestational age < 34 weeks, birth weight < 1800 gm or > 4000 gm, infants of diabetic mothers, major congenital malformations, birth asphyxia, very sick mothers, depressed babies born through thick meconium) are directly admitted in the nursery. This group contributes to approximately 10% of the total deliveries. Some babies who require observation for at least 24 hours but do not satisfy the criteria for admission to nursery (vigorous babies born through meconium, those at risk for neonatal hyperbilirubinemia, minor birth injuries) are kept in a transit room. This group comprises about 5-8% of total deliveries. From the transit room, most babies are sent back to the mother after a period of observation. However, some of them who become sick are admitted in the nursery.
The nursery itself has a floor area of 750 square meters, with separate provisions for intensive care, care of the very low birth weight babies, intermediate care, sepsis and phototherapy. Staff pattern comprises of one professor, one assistant professor and two lecturers (8 AM to 2 PM) and an on-call duty medical officer (2 PM to 8 AM). Residents are distributed in such a way that at any given time during the day (8 AM to 8 PM), two each look after the labor room, postnatal wards and the transit room and one each in the other special care rooms within the nursery. During the night (8PM to 8 AM), there are two residents available in the labor rooms as well as in the nursery.
During the pre-intervention phase (before 1991), conventional neonatal care was practiced, wherein babies were virtually separated from their mothers. Mothers could visit, watch, feel and occasionally breast feed their babies. The BNR was approximately 10:1 at any given shift. During the interventional phase of the study (1991-2001), mothers/substitutes were allowed to nurse their babies. Babies were either exclusively breast fed or fed with expressed breast milk whenever it was feasible. BNR was approximately 12.5:1 at any given time, as the number of deliveries and admissions increased but staff strength remained the same.
As per standard recommendations, in order to maintain an adequate BNR of 4:1 (level II care) a minimum of 45 trained nursing personnel and 21 nursing assistants are to be distributed in equal time shifts.[5] However, the actual strength of the nursing staff was inadequate and remained fairly constant throughout the entire study period (14 nurses and 6 nursing assistants, respectively).
A mother substitute is permitted for a brief period of time whenever the mother is away from the nursery. Substitutes are also allowed when the mother is deceased, sick, during the post caesarean period or in case of twins/triplets. They are taught about aseptic methods, hand washing before and after handling the baby and healthy breast feeding practices including direct suckling and expression of breast milk in a hygienic manner. They are warned about the hazards of forced feeding. The theoretical talk on breast feeding by the nurse is replaced by live demonstrations by the 'long stay mothers'. Donor milk is resorted to whenever the mother is deceased or away from the hospital. During the pre intervention period and early part of interventional phase only HBsAg and VDRL negative mothers were permitted to donate milk. During the interventional phase, HIV screening was also made mandatory before donating milk. The mother/substitutes are forbidden from moving to other rooms and handling other babies. They are taught to identify the danger signals and alert the residents / staff nurses promptly.
Mortality statistics are compared with that of a similar level II newborn care nursery, to ascertain whether any improvement in mortality rates during the interventional phase is solely due to improvement in facilities and treatment modalities during this phase. Neonatal mortality included deaths during the first 28 days of life, as obtained from the nursery records and the follow up data from the out patient department. Allocation of the cause of death into three groups namely asphyxia, prematurity and sepsis was made as per strict guidelines. Congenital malformations, heart diseases and inborn errors of metabolism contributed to the rest of the deaths. Allocation was based on the primary cause of death certified by the medical officer-in-charge of the nursery. Significant growth of an organism in blood culture was taken as categorical evidence of sepsis. Limited autopsy was resorted to in cases with no obvious causes for death. Similar methods were employed at both the institutions studied.
Results
The data from IMCH during the pre-interventional and interventional phases with respect to the mortality rates due to the three major illnesses are shown table1. Data of 1989 and 1990 represent the pre-intervention phase and that of 1991 to 2001 represents the intervention phase of the study.
The decrease in trend of mortality due to asphyxia, prematurity and sepsis is shown graphically Figure1.
The deaths per 1000 livebirths from IMCH and another similar level II care centre in Kerala wherein conventional newborn care is practiced, is compared table2.
The mortality trends from these centers are compared and analyzed statistically. The arithmetic mean of deaths/1000 live births of IMCH showed a comparatively higher value (19.82 for IMCH compared to 16.16 for SAT hospital). The coefficient of variance is also higher for the data from IMCH (19.08) compared to that of SAT hospital (9.75). The mortality trend lines for both the centers, obtained after the application of Time series test (Trend analysis) are depicted in Figure2. Further, paired 't' test applied to the deaths/1000 live births from 1998 to 2001 demonstrated that a statistically significant difference existed between two data ('t' value being 7.7449, numerically higher than 4.541, the table value at 99% confidence limits).
The BNR of the second centre remained at 5:1 from 1989 to 2001.
Discussion
Good newborn care in India is confined only to major centers and teaching hospitals located in cities, as substantiated by the two surveys conducted by the National Neonatology Forum (NNF) India.[3],[4] There had been attempts in the country to get the mothers involved in the care of hospitalised sick infants.[7],[8] Subsequent evaluation and follow up definitely showed some beneficial effects. The above cited study at IMCH was undertaken to assess the feasibility and utility of training and guiding the mothers to nurse their sick infants round the clock so that the inadequacies in neonatal care due to shortage of staff nurses could be overcome.
On statistical analysis, the higher arithmetic mean of deaths/1000 livebirths of IMCH can be attributed to the high mortality rates that prevailed during the pre-intervention and the early part of intervention phase. A higher coefficient of variance however shows that IMCH had a much lesser consistency for mortality rates compared to SAT hospital.
Methods of Measuring Trend
1. The Free Hand or Graphic method.
2. The Semi Average Method
3. The Moving Average Method
4. The Methods of Least Squares.
Here we used the method of least squares. It is a mathematical method and with its help a trend line is fitted to the data. The sum of the squares of the deviation of the actual and computed values is least from this line. That is why this method is called the method of least squares. The line obtained by this method is known as the line of best fit.
The method of least square may be used either of fit a straight line trend or a parabolic trend.
The straight line trend is represented by the equation:
Yc=a+b X
Where Yc is used to designate the calculated or estimated values of Y ( In our studies we have used Y to represent death.)
a is the Y intercept or the value of the Y variable when X=0.
b represents the slope of the line, or the amount of change in Y variable that is associated with a change of one unit in X variable (We got a negative value for b , and hence the graph has a declining slope.)
The X variable in time series analysis represents time (years).
Trend analysis revealed a negative b-value for the former data, clearly indicating a downward trend of mortality rates. By the year 1998, the mortality rates of IMCH have clearly surpassed that of SAT hospital. Further analysis has showed that a statistically significant difference in mortality existed between the two centers during the subsequent years also, inspite of a BNR of 5:1 at the centre compared.
SAT hospital was chosen for comparison of data against IMCH as both these institutions were literally similar in almost all aspects including geography, ethnicity, socioeconomic status, literacy, infrastructure and staff pattern. Moreover, the admission criteria for both institutions were similar, in accordance with the guidelines laid down by NNF. The only notable difference was in the involvement of mothers in the nursery at the former. Hence, the reduction in neonatal mortality at IMCH is not merely a reflection of the overall improvement and recent advances in neonatal care over the years.
Short term and long term morbidity patterns were compared at IMCH during the two phases of the study. The former included pre-discharge problems like cross infections, aspiration of feeds, hypothermia, hypoglycemia and respiratory distress. No significant difference could be noted between the two phases. Mean duration of hospital stay was comparable for intensive care babies, preterms and jaundiced babies during both the phases. Long term morbidity was assessed during the weekly newborn follow up clinic at IMCH. The pattern of weight gain and attainment of developmental milestones were compared during both the phases and no significant difference was noted. A comparison of morbidity patterns at IMCH and SAT hospital could not be done as the details of morbidity from the second institution were not available.
Over the past several decades, many studies have shown the multiple beneficial effects of early rooming in. It has been shown that early events have long lasting effects on the mother-child attachment process.[10],[11] The practice of separating mothers from their sick neonates have been shown to have resulted in a number of problems, the most important being failure of lactation, a factor that is crucial for the survival of infants in India.[12] Opening the portals of newborn nurseries to mothers has improved the mother infant relationship leading to better lactation performance as well as early introduction of breastfeeding.[9] In addition, the informal 'mother to mother teaching programme' regarding healthy breastfeeding practices allays the anxiety of the new mothers, especially the primiparas, which is so crucial in establishing successful lactation.
Perhaps the most promising benefit of involving mothers in newborn care is that it reduces the workload of the nursing personnel. This aspect has to be viewed in light of the grossly inadequate BNR status of most neonatology units in the developing countries. This method definitely allows expert nursing care to be given to the sick neonates without denying basic care to other babies.
Another obvious advantage of this system is the economical aspect. A considerable amount of money can be saved in the form of monthly salaries payable to the nursing staff. In the present set up, it was calculated that an average of Rs 3.3 lakhs per month was the difference that existed between ensuring an appropriate strength of nursing staff and involvement of the mother/substitute. In developing countries where financial resources are very limited, such an economical advantage may well be a remarkable achievement.
However, as with most improvisation methods, permitting mothers inside the newborn nursery too has potential hazards due to ignorance and lack of responsibility. These may include attempts to force feed a sick baby and encouraging cross-infections within the nursery. However, these inherent risks were foreseen at the beginning of the study and purposeful measures were adopted to prevent them. Any attempts to involve mothers in newborn nurseries should make sure that the chances for such potential complications are appropriately tackled with. The major hindrance for implanting this system is fear of logistic problems of overcrowding. This notion is disproved by the present study as there was not even a single major epidemic when the mothers/substitutes were permitted to nurse the babies.
Thus the advantages of this system clearly outweigh the disadvantages. This system can be duplicated to all levels of neonatal care except in cases of critically ill and very immature neonates. While implementing such a strategy, extreme care should be taken for improvisation with limited resources and also developing appropriate technology.
Contributors
Dr. C.K Sasidharan - Concept, design and conduction of the study.
Dr. E. Gokul - Data compilation and Analysis.
Dr. P. Anoop - Data compilation and Analysis.
Dr. M. Vijayakumar - Data compilation
Acknowledgements
We thank Dr. C. Sulekha, Head of the Department of Pediatrics, Sree Avittom Thirunal Hospital, Thiruvanathapuram, Kerala, India, for kindly permitting us to make use of the hospital data from 1989 to 2001. The statistical support provided by Mr. ED Saani and Mr. JS Sudheesh is also acknowledged with gratitude.
References
1. Karan S. Mothers in neonatal nurseries - Can they be admitted with their high risk infants. Indian Pediatr 1986; 23: 1037-1044.
2. Daga SR, Daga AS. Reduction in Neonatal mortality with simple interventions. J Tropical Pediatr 1989; 35: 191.
3. Singh M, Deorari AK, Paul VK. Neonatal services in leading hospitals : A depressing scenario. Bullettin of National Neonatology Forum, India 1988; 3:2.
4. Singh M, Paul VK, Deorari AK. The state of India's neonatal care units in the mid nineties. Indian Pediatr 1997; 34: 696.
5. Singh M. Recommendations for creation of modest level II neonatal care facilities in India. Indian Pediatr 1992; 29: 889-894.
6. Banthia JK. Provisional population tables In Provisional population totals : Census of India 2001 ; New Delhi; Controller, Dept of Publications; 116.
7. Narayanan I. Experiences with mother/mother figure in a neonatal unit. Indian J Pediatr 1980; 47: 27.
8. Daga SR, Shinde SB. Mother's participation in neonatal intensive care and its impact. J Tropical Pediatr 1987; 33: 247.
9. Mathew NB, Khalil A, Sarkar R, Puri RK. Mortality in neonatal septicemia with involvement of mothers in management. Indian Pediatr 1991; 28: 1259-1264.
10. Rose J et al. The evidence for a "syndrome of mothering disability" consequent to threats to the survival of neonates. Am J Dis Child 1960; 100: 776.
11. Kennel JH et al. Discussing problems in newborn babies with their parents. Pediatrics 1960; 27: 832.
12. Formon SJ, Ziegler EB, Vasquez HB. Human milk and the small premature infants. Am J Dis Child 1997; 131: 463-470.(Sasidharan CK, Gokul E, A)
Abstract
Objective: To evaluate the outcome of active involvement of mothers/mother substitutes in day-to-day care of high risk neonates admitted in a level II newborn care unit. Methods: An observational study was carried out over a period of eleven years incorporating active participation of mothers/substitute in the day to day care of their sick neonates. The outcome is assessed in terms of mortality due to the three major illnesses (asphyxia, sepsis and prematurity) during this phase. The data is compared with that of a similar level II care centre where conventional neonatal care is practised. Results: There is a significant and sustainable reduction in neonatal mortality due to the three major illnesses when the mothers are also involved in the neonatal care, in spite of a considerable increase in the number of admissions during this period. Conclusion: The concept of active participation of mother/substitute in neonatal nursery ensures 1:1 care at all times. It is a cheap and effective alternative to inadequacy of bed:nurse ratio (BNR).
Keywords: Bed:nurse ratio (BNR); Maternal participation; Neonatal care; Neonatal mortality
The conventional practice of separating sick neonates from their mothers in new born nurseries is a direct legacy of the western system of medicine.[1] When newborn special care nurseries were introduced in India, their concept, design and functioning were based entirely on western lines as experience in this newly emerging specialty was scant.
In the developing countries, the gap between the needs and availability of resources is wider than that in developed countries because the absolute number of high risk newborns like low birth weight, premature and asphyxiated babies is high.[2] A survey conducted by the National Neonatology Forum (NNF), India, in 1987 revealed an unsatisfying state of affairs prevailing in the various centers studied.[3] A second survey in 1997 of the same centers noted improvement in the field of equipments and other facilities except for nursing care, even though it forms the backbone of neonatal care.[4] There is an inadequacy of trained nursing personnel in neonatology units. The success of special care nursery units largely depends upon the availability of trained staff nurses. Under Indian circumstances, a level II newborn nursery should satisfy a BNR requirement of 4:1.[5]
The present study presents the results of eleven years of experience in this field, assesses the feasibility and advantages of utilizing mother's nursing skills in the care of their high risk newborns and analyses changes in the resultant mortality due to the three major illnesses that necessitate admission of babies in the newborn nursery.
Materials and methods
Institute of Maternal and Child Health [IMCH], Kozhikode, caters for five large districts of Northern Kerala comprising of almost one third of the state's population.[6] A 50-bedded nursery provides neonatal care for sick babies from nearly 25000 deliveries conducted here per year. On an average, about 70 babies are born at this institute daily. Among them, sick/potentially sick ones (criteria : gestational age < 34 weeks, birth weight < 1800 gm or > 4000 gm, infants of diabetic mothers, major congenital malformations, birth asphyxia, very sick mothers, depressed babies born through thick meconium) are directly admitted in the nursery. This group contributes to approximately 10% of the total deliveries. Some babies who require observation for at least 24 hours but do not satisfy the criteria for admission to nursery (vigorous babies born through meconium, those at risk for neonatal hyperbilirubinemia, minor birth injuries) are kept in a transit room. This group comprises about 5-8% of total deliveries. From the transit room, most babies are sent back to the mother after a period of observation. However, some of them who become sick are admitted in the nursery.
The nursery itself has a floor area of 750 square meters, with separate provisions for intensive care, care of the very low birth weight babies, intermediate care, sepsis and phototherapy. Staff pattern comprises of one professor, one assistant professor and two lecturers (8 AM to 2 PM) and an on-call duty medical officer (2 PM to 8 AM). Residents are distributed in such a way that at any given time during the day (8 AM to 8 PM), two each look after the labor room, postnatal wards and the transit room and one each in the other special care rooms within the nursery. During the night (8PM to 8 AM), there are two residents available in the labor rooms as well as in the nursery.
During the pre-intervention phase (before 1991), conventional neonatal care was practiced, wherein babies were virtually separated from their mothers. Mothers could visit, watch, feel and occasionally breast feed their babies. The BNR was approximately 10:1 at any given shift. During the interventional phase of the study (1991-2001), mothers/substitutes were allowed to nurse their babies. Babies were either exclusively breast fed or fed with expressed breast milk whenever it was feasible. BNR was approximately 12.5:1 at any given time, as the number of deliveries and admissions increased but staff strength remained the same.
As per standard recommendations, in order to maintain an adequate BNR of 4:1 (level II care) a minimum of 45 trained nursing personnel and 21 nursing assistants are to be distributed in equal time shifts.[5] However, the actual strength of the nursing staff was inadequate and remained fairly constant throughout the entire study period (14 nurses and 6 nursing assistants, respectively).
A mother substitute is permitted for a brief period of time whenever the mother is away from the nursery. Substitutes are also allowed when the mother is deceased, sick, during the post caesarean period or in case of twins/triplets. They are taught about aseptic methods, hand washing before and after handling the baby and healthy breast feeding practices including direct suckling and expression of breast milk in a hygienic manner. They are warned about the hazards of forced feeding. The theoretical talk on breast feeding by the nurse is replaced by live demonstrations by the 'long stay mothers'. Donor milk is resorted to whenever the mother is deceased or away from the hospital. During the pre intervention period and early part of interventional phase only HBsAg and VDRL negative mothers were permitted to donate milk. During the interventional phase, HIV screening was also made mandatory before donating milk. The mother/substitutes are forbidden from moving to other rooms and handling other babies. They are taught to identify the danger signals and alert the residents / staff nurses promptly.
Mortality statistics are compared with that of a similar level II newborn care nursery, to ascertain whether any improvement in mortality rates during the interventional phase is solely due to improvement in facilities and treatment modalities during this phase. Neonatal mortality included deaths during the first 28 days of life, as obtained from the nursery records and the follow up data from the out patient department. Allocation of the cause of death into three groups namely asphyxia, prematurity and sepsis was made as per strict guidelines. Congenital malformations, heart diseases and inborn errors of metabolism contributed to the rest of the deaths. Allocation was based on the primary cause of death certified by the medical officer-in-charge of the nursery. Significant growth of an organism in blood culture was taken as categorical evidence of sepsis. Limited autopsy was resorted to in cases with no obvious causes for death. Similar methods were employed at both the institutions studied.
Results
The data from IMCH during the pre-interventional and interventional phases with respect to the mortality rates due to the three major illnesses are shown table1. Data of 1989 and 1990 represent the pre-intervention phase and that of 1991 to 2001 represents the intervention phase of the study.
The decrease in trend of mortality due to asphyxia, prematurity and sepsis is shown graphically Figure1.
The deaths per 1000 livebirths from IMCH and another similar level II care centre in Kerala wherein conventional newborn care is practiced, is compared table2.
The mortality trends from these centers are compared and analyzed statistically. The arithmetic mean of deaths/1000 live births of IMCH showed a comparatively higher value (19.82 for IMCH compared to 16.16 for SAT hospital). The coefficient of variance is also higher for the data from IMCH (19.08) compared to that of SAT hospital (9.75). The mortality trend lines for both the centers, obtained after the application of Time series test (Trend analysis) are depicted in Figure2. Further, paired 't' test applied to the deaths/1000 live births from 1998 to 2001 demonstrated that a statistically significant difference existed between two data ('t' value being 7.7449, numerically higher than 4.541, the table value at 99% confidence limits).
The BNR of the second centre remained at 5:1 from 1989 to 2001.
Discussion
Good newborn care in India is confined only to major centers and teaching hospitals located in cities, as substantiated by the two surveys conducted by the National Neonatology Forum (NNF) India.[3],[4] There had been attempts in the country to get the mothers involved in the care of hospitalised sick infants.[7],[8] Subsequent evaluation and follow up definitely showed some beneficial effects. The above cited study at IMCH was undertaken to assess the feasibility and utility of training and guiding the mothers to nurse their sick infants round the clock so that the inadequacies in neonatal care due to shortage of staff nurses could be overcome.
On statistical analysis, the higher arithmetic mean of deaths/1000 livebirths of IMCH can be attributed to the high mortality rates that prevailed during the pre-intervention and the early part of intervention phase. A higher coefficient of variance however shows that IMCH had a much lesser consistency for mortality rates compared to SAT hospital.
Methods of Measuring Trend
1. The Free Hand or Graphic method.
2. The Semi Average Method
3. The Moving Average Method
4. The Methods of Least Squares.
Here we used the method of least squares. It is a mathematical method and with its help a trend line is fitted to the data. The sum of the squares of the deviation of the actual and computed values is least from this line. That is why this method is called the method of least squares. The line obtained by this method is known as the line of best fit.
The method of least square may be used either of fit a straight line trend or a parabolic trend.
The straight line trend is represented by the equation:
Yc=a+b X
Where Yc is used to designate the calculated or estimated values of Y ( In our studies we have used Y to represent death.)
a is the Y intercept or the value of the Y variable when X=0.
b represents the slope of the line, or the amount of change in Y variable that is associated with a change of one unit in X variable (We got a negative value for b , and hence the graph has a declining slope.)
The X variable in time series analysis represents time (years).
Trend analysis revealed a negative b-value for the former data, clearly indicating a downward trend of mortality rates. By the year 1998, the mortality rates of IMCH have clearly surpassed that of SAT hospital. Further analysis has showed that a statistically significant difference in mortality existed between the two centers during the subsequent years also, inspite of a BNR of 5:1 at the centre compared.
SAT hospital was chosen for comparison of data against IMCH as both these institutions were literally similar in almost all aspects including geography, ethnicity, socioeconomic status, literacy, infrastructure and staff pattern. Moreover, the admission criteria for both institutions were similar, in accordance with the guidelines laid down by NNF. The only notable difference was in the involvement of mothers in the nursery at the former. Hence, the reduction in neonatal mortality at IMCH is not merely a reflection of the overall improvement and recent advances in neonatal care over the years.
Short term and long term morbidity patterns were compared at IMCH during the two phases of the study. The former included pre-discharge problems like cross infections, aspiration of feeds, hypothermia, hypoglycemia and respiratory distress. No significant difference could be noted between the two phases. Mean duration of hospital stay was comparable for intensive care babies, preterms and jaundiced babies during both the phases. Long term morbidity was assessed during the weekly newborn follow up clinic at IMCH. The pattern of weight gain and attainment of developmental milestones were compared during both the phases and no significant difference was noted. A comparison of morbidity patterns at IMCH and SAT hospital could not be done as the details of morbidity from the second institution were not available.
Over the past several decades, many studies have shown the multiple beneficial effects of early rooming in. It has been shown that early events have long lasting effects on the mother-child attachment process.[10],[11] The practice of separating mothers from their sick neonates have been shown to have resulted in a number of problems, the most important being failure of lactation, a factor that is crucial for the survival of infants in India.[12] Opening the portals of newborn nurseries to mothers has improved the mother infant relationship leading to better lactation performance as well as early introduction of breastfeeding.[9] In addition, the informal 'mother to mother teaching programme' regarding healthy breastfeeding practices allays the anxiety of the new mothers, especially the primiparas, which is so crucial in establishing successful lactation.
Perhaps the most promising benefit of involving mothers in newborn care is that it reduces the workload of the nursing personnel. This aspect has to be viewed in light of the grossly inadequate BNR status of most neonatology units in the developing countries. This method definitely allows expert nursing care to be given to the sick neonates without denying basic care to other babies.
Another obvious advantage of this system is the economical aspect. A considerable amount of money can be saved in the form of monthly salaries payable to the nursing staff. In the present set up, it was calculated that an average of Rs 3.3 lakhs per month was the difference that existed between ensuring an appropriate strength of nursing staff and involvement of the mother/substitute. In developing countries where financial resources are very limited, such an economical advantage may well be a remarkable achievement.
However, as with most improvisation methods, permitting mothers inside the newborn nursery too has potential hazards due to ignorance and lack of responsibility. These may include attempts to force feed a sick baby and encouraging cross-infections within the nursery. However, these inherent risks were foreseen at the beginning of the study and purposeful measures were adopted to prevent them. Any attempts to involve mothers in newborn nurseries should make sure that the chances for such potential complications are appropriately tackled with. The major hindrance for implanting this system is fear of logistic problems of overcrowding. This notion is disproved by the present study as there was not even a single major epidemic when the mothers/substitutes were permitted to nurse the babies.
Thus the advantages of this system clearly outweigh the disadvantages. This system can be duplicated to all levels of neonatal care except in cases of critically ill and very immature neonates. While implementing such a strategy, extreme care should be taken for improvisation with limited resources and also developing appropriate technology.
Contributors
Dr. C.K Sasidharan - Concept, design and conduction of the study.
Dr. E. Gokul - Data compilation and Analysis.
Dr. P. Anoop - Data compilation and Analysis.
Dr. M. Vijayakumar - Data compilation
Acknowledgements
We thank Dr. C. Sulekha, Head of the Department of Pediatrics, Sree Avittom Thirunal Hospital, Thiruvanathapuram, Kerala, India, for kindly permitting us to make use of the hospital data from 1989 to 2001. The statistical support provided by Mr. ED Saani and Mr. JS Sudheesh is also acknowledged with gratitude.
References
1. Karan S. Mothers in neonatal nurseries - Can they be admitted with their high risk infants. Indian Pediatr 1986; 23: 1037-1044.
2. Daga SR, Daga AS. Reduction in Neonatal mortality with simple interventions. J Tropical Pediatr 1989; 35: 191.
3. Singh M, Deorari AK, Paul VK. Neonatal services in leading hospitals : A depressing scenario. Bullettin of National Neonatology Forum, India 1988; 3:2.
4. Singh M, Paul VK, Deorari AK. The state of India's neonatal care units in the mid nineties. Indian Pediatr 1997; 34: 696.
5. Singh M. Recommendations for creation of modest level II neonatal care facilities in India. Indian Pediatr 1992; 29: 889-894.
6. Banthia JK. Provisional population tables In Provisional population totals : Census of India 2001 ; New Delhi; Controller, Dept of Publications; 116.
7. Narayanan I. Experiences with mother/mother figure in a neonatal unit. Indian J Pediatr 1980; 47: 27.
8. Daga SR, Shinde SB. Mother's participation in neonatal intensive care and its impact. J Tropical Pediatr 1987; 33: 247.
9. Mathew NB, Khalil A, Sarkar R, Puri RK. Mortality in neonatal septicemia with involvement of mothers in management. Indian Pediatr 1991; 28: 1259-1264.
10. Rose J et al. The evidence for a "syndrome of mothering disability" consequent to threats to the survival of neonates. Am J Dis Child 1960; 100: 776.
11. Kennel JH et al. Discussing problems in newborn babies with their parents. Pediatrics 1960; 27: 832.
12. Formon SJ, Ziegler EB, Vasquez HB. Human milk and the small premature infants. Am J Dis Child 1997; 131: 463-470.(Sasidharan CK, Gokul E, A)