Nandurbar, Maharashtra: The hall is christened “Mogra”, named after a flower the local tribal community revere — “Dev-Mogra” is one of the local deities. Around eight to 10 mothers, in their late teens and early 20s, dressed in signature striped gowns, are resting on reclining chairs, holding their newborns close to their bosom. It’s peaceful and comforting here; the mothers and their little ones, mostly Bhil and Pawra tribes, hailing from distant parts of Nandurbar district in north-western Maharashtra, are in a happy world of their own, away from their otherwise impoverished daily existence. A closer look at the babies, wrapped in warm layers, reveals a distinct commonality: they’re tiny, like delicate dolls. “Pre-term and extremely underweight,” remarks Vandana Valvi, a staff nurse, adding: “It will be days, perhaps even months, before their weight stabilises and they become healthy.” However, being here, at the plush Special Newborn Care Unit (SNCU) in Nandurbar’s civil hospital, is the best thing that could have happened to them. After all, the SNCU, with its state-of-the-art equipment and specialist doctors on call, has gained a reputation for providing a fighting chance to malnourished babies by employing an innovative intervention in neonatal care.
In the face of enormous challenges that confront maternal and child health in Nandurbar, an internationally established neonatal care strategy has been successfully introduced to save infants. Locally called “jadu ki jhappi”, or the “magical hug”, Kangaroo Mother Care (KMC) is virtually a no-cost method that has been implemented intensively across the district, where infant mortality rate (IMR) stands at 19.62 per 1,000 live births.
In 1978, KMC was introduced in Columbia, at Instituto Materno Infantil by Dr Edgar Rey Sanabria, professor of neonatology at the department of paediatrics, Universidad Nacional de Colombia. In 2017, department of public health and Unicef partnered to scale up KMC in the whole state and KMC has been rolled out in 36 SNCUs in the state including Nandurbar.
“The KMC practice is a high impact, low-cost intervention for saving lives of small (low birth weight and pre-term) and sick newborns. Nandurbar is a priority district for scaling up of the KMC and the prevalence of low birth weight babies in the district is high,” shares Dr Prashant Hingankar, district RMNCHA consultant coordinating the KMC project in the district. “The results,” he says, “are very encouraging. Unicef provided support for training, and monitoring to complement the efforts of the government of Maharashtra, which provides human resources, infrastructure and equipment and drugs. From April 2017 to May 2018, 1,222 newborns have benefited from KMC at civil hospital, Nandurbar.”
“I hold my baby for several hours every day,” says Sheetal Mangal More, 18, a Bhil mother. She delivered a girl who was 1.5 kg at birth but gained weight over the first fortnight. “I love it,” she says, about the KMC practice. More ably demonstrates what she’s learnt: reclining in the special chair she holds the child in a frog-like position carefully ensuring skin-to-skin contact. She wraps her arms around baby Saraswati, feeding her frequently. By the time the duo is ready to be discharged — they would have already spent over a month at the SNCU — doctors hope that Saraswati would be at least two kg. Difficult, but not impossible, they say.
The average normal birth-weight of an infant, according to Dr Ajay Wagh, medical officer, Nandurbar SNCU, should be at least 2.5 kg. “Most babies at the SNCU only weigh between one and 1.5 kg at birth,” he says. This unit admits critical babies from around the district, referred by medical officers stationed at rural hospitals or primary health centres.
“Once they are stable and gain weight, they are discharged from home and followed up by Asha (Accredited Social Health Activist) workers. KMC practice helps in remarkably improving the infant’s weight over a short period,” informs Nilima Valvi, matron, Nandurbar SNCU. The NRC is located right next to the SNCU and admission to both is free. Under the National Health Mission, NRCs have been set up to treat and manage children with severe acute malnutrition (SAM). From the signature apparel to specialised chairs for feeding to a nutritious diet and free medical care, both mother and child are well cared for.
Within the district, concerted effort has been made to enforce KMC practice in Akkalkuwa, Dhadgaon and Nawapur blocks, three of the most remote tribal areas, where poverty and malnutrition are rampant, reveals Mallinath Kallshetti, district collector. Tucked away in the forested hills of the Satpura mountains, hamlets in Dhadgaon and Akkalkuwa present topographical challenges in healthcare delivery — the terrain is undulating and many villages are not connected by all-weather roads. An Asha, a frontline health worker on whose shoulders rests the Herculean task of providing basic healthcare to the community, often has to trudge several kilometres for outreach.
Real-time challenges abound across the district: apart from the terrain, Nandurbar has widespread prevalence of sickle cell anaemia disease (SCD), a genetic blood disorder that is painful and could prove fatal, informs Dr Kantarao Satpute, additional civil surgeon and in charge of Nandurbar civil hospital. Adds Dr Hingankar, “Under NHM’s Sickle Cell Anaemia programme, 2,600 SCD patients and 34,000 carriers have been identified so far across the district.”
Take Reena Valvi, a Bhil mother admitted at the civil hospital NRC with her six-month-old daughter. Reena, who also has a six-year-old daughter, is severely anaemic and finds it difficult to nurse her baby, her fourth child. She has lost two sons. “When she came to the NRC, her haemoglobin (Hb) was two per cent (a normal adult female should have an Hb per cent between 11 and 15),” says the nurse. “The baby, too, is severely malnourished. Two blood transfusions later, Reena’s Hb percentage has increased to 9.5; the child’s weight is marginally up as well,” she added.
“It’s a struggle between life and death for many mothers like Reena,” says Dr Satpute. “For us, the challenge is to bring them to a healthcare facility in time,” Dr Satpute added. It’s barely been a year since the Maharashtra government included the KMC approach into its official critical neo-natal care strategy. Those who have benefited couldn’t be happier. But, Dr Hingankar says, the real test is in ensuring they follow it faithfully once they are back home, where the everyday financial struggles and social restraints on the way babies are raised, invariably end up reversing the progress made. “Constant monitoring and training of mothers is crucial,” he says.
When Sangita Raisingh Padvi’s baby was born, it weighed a mere 1.175 kg. Though she had a home delivery, she was immediately taken to the civil hospital SNCU. A fortnight later, the baby’s weight increased slightly, but the couple left for Dhadgaon Rural Hospital to be closer home. She stayed there for nearly a month. Two months after birth, the baby’s weight dipped to 1.055 kg. Fortunately, though, by the time the child completed six months its weight was up to 1.6 kg. This change has been the result of the KMC approach, the importance of which dawned on Padvi slowly. The mother is home now and regularly practices KMC, in addition to breast-feeding, even as she undertakes her laborious daily chores. Her baby though is still at great risk. And as the doctors at Dhadgaon Rural Hospital, who monitor the case on a daily basis, put it, “we all remain on our toes.”
— Charkha Features