Mother Newborn Care Unit: An innovation in care of small and sick newborns

Low birth weight infants, i.e., infants with a birth weight less than 2.5 kg constitute approximately 15% of all newborns worldwide but account for 70% of all newborn deaths. Most of these babies are born in low and middle-income countries (LMIC) in Asia and sub-Saharan Africa, and die within the first days of life. Reducing mortality among these infants is the key to achieving the United Nations Sustainable Development Goals target of reducing newborn mortality to as low as 12 deaths per 1000 live births by 2030.

Additionally, these newborns are at higher risk of developing various illnesses requiring care inside the newborn care unit. Those who survive are more likely to develop growth-related and neurodevelopment problems than babies born with normal birth weight.

Maternal and child health was identified as a Flagship Priority in 2014 in World Health Organization's South-East Asia Region under the leadership of Regional Director Dr Poonam Khetrapal Singh.

In India for example, it is worth noting that current mother and newborn care services are organised in such a way that if the baby is normal, the mother and baby stay together in the postnatal ward. But if the baby is sick or has low birth weight, they are separated from the mother and kept inside the special newborn care unit (SNCU) while the mother stays in the postnatal ward and visits the baby in SNCU only on the advice of the healthcare providers. However, it has been felt by the medical fraternity that this model of service delivery is not in the best interest of either the baby or the mother.

Involvement of mothers and families in the routine care of their newborns is essential not only for improving baby's short and long-term health and development outcomes, but also to improve the overall experience of care by families. It is here that the concept of 'zero separation' of the mothers with their small and sick babies after birth, and mother-newborn care unit (MNCU), comes in.

Mother-newborn care unit (MNCU) is an area inside the hospital/health facility wherein sick and small newborns are taken care of by their mothers on a 24×7 basis. Such an area can be created in hospitals/health facilities that provide special newborn care, i.e. care to babies who are not critically sick but do require oxygen support and intravenous fluids for a few days. Most babies requiring special newborn care can be managed with mothers in MNCU, and 80-85% of babies requiring care in these units who are not critically sick, can be managed with mothers in MNCU.

How Mother Newborn Care Unit evolved

Before looking at how MNCU came into being, it is important to understand a life-saving intervention called Kangaroo Mother Care (KMC). KMC refers to the process wherein the mother keeps her low birth weight baby in continuous skin-to-skin contact against her chest for a long period of time, and receives support for feeding the baby exclusively with breast milk. KMC is among the most effective interventions for low birth weight infants that not only reduces the risk of death by 40%, but also improves their growth and development along with mental health of the mother.

Currently, WHO recommends KMC when the infant's clinical condition has stabilized, which is normally achieved 3 days after birth. However, approximately 45% of newborn deaths occur within 24 hours of birth and 80% during the first week of life. Thus, majority of deaths among infants with low birth weight typically occur before Kangaroo Mother Care can be initiated.

Recently, new research has suggested that KMC initiated immediately within two hours of birth followed by continuous KMC, aiming for more than 20 hr/day (Immediate KMC) compared to the current guidelines (KMC after baby is clinically stable), improves newborn survival by 25%.

This multicountry research was coordinated by the World Health Organization in five countries; Ghana, India, Malawi, Nigeria, and Tanzania. In India, the study was conducted at Safdarjung Hospital, New Delhi

The implementation of Immediate KMC (iKMC) intervention required mothers to be with their small and sick newborns on a 24x7 basis in Newborn Intensive Care Unit to provide continuous KMC, against the present norm of separating sick newborns from their mothers. This lead to a restructuring of the existing newborn intensive care unit to accommodate the mother allowing her to stay with the baby, and hence the intervention of iKMC led to the innovation of "mother-newborn care unit (MNCU)". Thus, the first MNCU in India was born.

Dr Neena Raina, Regional Advisor, Child and Adoloscent Health, WHO-SEARO, said: 'Keeping mothers and babies together is the natural order. Achieving zero separation and ensuring optimal and respectful care for both the mother and the baby together as a unit is important for implementing life-saving interventions like immediate KMC. I urge all the Member States to explore how to convert newborn units to mother-newborn care units with universal KMC for all preterm or low birth weight newborns.'

Setting up of MNCU in India

Implementation of immediate KMC required the mother or surrogate (family member to provide KMC when the mother is not available) to be with their baby soon after birth and continue to be together 24×7 till being discharged, i.e. zero-separation. Since there was not enough space in the existing NICU to have mothers' beds inside, a new newborn care unit was designed with enough space to accommodate mother's bed with each baby. This new NICU was named as "Mother Newborn Care Unit (MNCU)" (Fig. 1). The infrastructure of MNCU included a toilet, bathing area, food and water, and a clinical examination cubicle for mothers, which are imperative to ensure respectful maternal care.

Like conventional NICU, all equipment for level II intensive care including radiant warmer (required during the time the mother/surrogate can not provide KMC), continuous positive airway pressure (CPAP) machine, oxygen and suction facilities, vital monitor, phototherapy unit, etc. are available (Fig. 2). Mothers are provided post-childbirth care inside the MNCU by obstetricians and neonatal nurses who are trained to provide essential postnatal care to mothers. "Mother as a resident of MNCU becomes an active caregiver and is involved in continuum of neonatal care," said Dr. Sugandha Arya, clinical investigator, for iKMC study. This is the first such model of care in the developing country settings that sets forth an example where mother and baby are cared for together from birth till discharge providing the concept of Zero separation.

Mother in NICU is Level II NICU where Mother and baby cared together 24X7

All provisions for level II newborn care

Platform to improve overall care of mothers and their small and sick newborns

The presence of mother with her baby 24X7 in MNCU provides her an opportunity to play a central role in her baby's care. Mothers in MNCU have less anxiety and stress as compared to mothers staying away from their babies in postnatal ward.

Delhi-based Pooja, a 25-year-old mother, who provided Immediate KMC in MNCU, said: "When baby is on my bare chest, I can feel his little fingers, feel him breathing and moving-a feeling I can't express in words.

MNCU also provides several opportunities to improve newborn care. A very important opportunity that MNCU provides is early exclusive breastmilk feeding and breastfeeding. Since the mother is with her baby in MNCU, expressed breast milk (EBM) is readily available as a first feed for initiation soon after birth. Mothers can provide prolonged, continuous, effective KMC for as long as 16-17 hours per day.

Skin-to-skin contact with the baby results in better lactation and it is easier to maintain babies on exclusive breastmilk feeding. Babies can be put to the breast earlier for non-nutritive sucking (NNS) which helps babies to develop feeding reflexes faster and improves the milk output of the mother by stimulating prolactin reflex.

Mothers in MNCU substantially contribute to the routine care of babies including feeding, changing diapers, and supporting the healthcare providers in routine monitoring of the babies, thus providing family-centred care to newborns which promotes early childhood development. The presence of mothers in MNCU gives ample opportunity to healthcare personnel to teach the mothers, healthy practices of neonatal care thus preparing them for taking care of neonates after discharge. Last but not the least, MNCU results in mother-newborn couplet care by Paediatrician and Obstetrician with better co-ordination of neonatal and maternal care.

Roshni, 22-years-old, who provided Immediate Kangaroo Mother Care in MNCU, shared her experience of how it made her feel empowered. "Usually, nurses do the needful in a NICU, however, MNCU, enables us to feel more connected to our newborns." Roshni further said that she has also taken it upon herself to counsel new mothers to help them understand how to provide KMC in MNCU. Nursing officer Ms Veena involved in Mother Newborn Care Unit feels mothers are less stressed here and babies' weight gain is better.

MNCU thus provides a platform to deliver holistic respectful care to both the mother and the newborn while maintaining the 'nature's norm' of zero separation and thus promoting Early Childhood Development.

Over 1.5 lakh newborn deaths can be prevented

Immediate KMC, delivered using the MNCU platform has been shown to reduce newborn mortality by 25% compared to conventional KMC implemented using the routine service delivery mechanism. This implies that at least 1,50,000 newborn deaths can be prevented globally every year if this model of care is adopted.The study results also show that babies in MNCU had 35% less incidence of low temperature and 18% less infections as compared to babies cared in conventional NICU.

There are several possible mechanisms by which Immediate KMC might have reduced newborn infections and thus better survival. Since the mother and baby are in close contact from birth, the baby is more likely to be colonized by the mother's protective microbiome and more likely to receive early breastfeeding. With fewer people needing to handle the baby, the risk of newborn infections is also reduced.

The results were published in May 2021 in the New England Journal of Medicine.

Addressing challenges

Even with all the advantages of this model of care, the MNCU innovation came with its set of challenges, that any unit/country might face when setting these up. However, all these challenges can be overcome by discussing with the health care providers (nursing colleagues and doctors) from the department of Obstetrics and Paediatrics.

To begin with, mothers need to be observed for about two hours after normal childbirth and six hours after caesarean section, and most sick and low birth weight babies need early transfer to MNCU for monitoring and management. This challenge is overcome by having a surrogate in the delivery area for transporting the baby to MNCU in the Kangaroo position. In the MNCU, the surrogate provides KMC till the mother reaches MNCU. Having a family member next to the mother in the labour room and in MNCU additionally contributes to support and respectful care for the mother.

Another major concern among Pediatricians and Policymakers has been that the presence of mothers in NICU will bring more infections. However, the iKMC study has shown that the presence of the mother next to the baby in MNCU reduces the risk of newborn infections. Experience of MNCU suggests mothers can be easily trained to follow infection control practices.

Thirdly, the majority of the babies who weigh less than 1.8 kg are preterm and many of them develop early difficult breathing requiring respiratory support in the form of continuous positive airway pressure (CPAP). Learning to provide CPAP in KMC position is an important challenge. The nasal Interface for CPAP is secured, and standard operating procedures for fixing it appropriately have been developed and implemented. A binder is used to maintain the baby's neck in a slightly extended position. A pulse oximeter is constantly used when the baby is in KMC position to monitor heart rate and oxygen saturation so that any sudden changes in vitals can be detected.

Providing CPAP in KMC position

Next, providing care to mothers from a few hours after birth is also a major concern in MNCU. An essential maternal-postnatal care package has been developed, and neonatal nurses are trained in implementing this package. Obstetricians take daily rounds for mothers and attend immediately to their urgent needs. "A strong co-operation, co-ordination, and collaboration between pediatricians and obstetricians is the cornerstone of MNCU," said Dr Pratima Mittal, study investigator from the Department of Obstetrics and Gynaecology, Safdarjung Hospital

Providing continuous Kangaroo Mother Care in MNCU, is also a challenge in itself. The most common reason for separation is the mother being not available due to medical reasons or for daily routines like bathing, using the toilet, etc. This challenge is overcome with the help of a surrogate who provides KMC in MNCU when the mother is not available. Another common reason for separation during iKMC is medical procedures and treatment of the baby including phototherapy. Some procedures like glucose monitoring, tube feeding, giving Intravenous (IV) injections can be done even while the baby is in KMC position. However, other procedures like inserting IV cannula, fixing CPAP cannula, putting an orogastric tube, phototherapy, etc. require separation, but the baby is immediately placed in KMC position following the procedure.

Also,initially, there were apprehensions among the health professionals and parents regarding the spread of COVID-19 infection in MNCU. However, with the use of COVID appropriate behaviour including strict use of mask, hand hygiene and respiratory hygiene, Safdarjung Hospital in Delhi has been running this facility successfully throughout the ongoing pandemic with 100% occupancy of 12 mothers with 12 to 18 babies, as many of these mothers have twin babies.

Making zero separation a reality

The World Health Organization is in the process of reviewing the current recommendations on the care of preterm or LBW newborns considering new evidence that has become available. However, it would require a change in the national policies to permit mother and surrogate in NICU 24×7, making the concept of zero-separation a reality.

"Keeping the mother and baby together right from birth with zero separation will revolutionize the way neonatal intensive care is practised for babies born early or small," said Dr Rajiv Bahl, Head of the newborn unit at WHO, Geneva, and the coordinator of the study. "When started at the soonest possible time, kangaroo mother care can save more lives, improve health outcomes and ensures the constant presence of the mother with her sick baby."

Till now most healthcare providers have been typically separating small and/or sick babies from their mothers and keeping them in specialised care in the newborn care units believing, that is best for them. This notion is now in question and well set to change.

Dr Harish Chellani, one of the study investigators, from Vardhman Mahavir Medical College and Safdarjung Hospital, India, said "New evidence suggests that zero separation of small and sick babies starting immediately after birth till discharge is a step towards early child development and this practice must be actively promoted.". He added that "to make zero separation a reality, we need change in policy, infrastructure, processes and most importantly mindset of health professionals". The presence of the mother in NICU 24 × 7 is a paradigm shift in the care of small and sick babies.

New special newborn care units (SNCUs) in district hospitals and NICUs in tertiary care hospitals should be designed with all the provisions for a mother to stay 24 × 7 as a caregiver to make them MNCU. Similarly, there is a need to adopt a new design when renovating already functional NICUs and SNCUs. This will also need certain policy changes, i.e., allowing mothers/surrogates in MNCU (same as that for family-centred care), shifting small babies from delivery areas to MNCU in KMC position, obstetric rounds inside MNCU, and giving essential care to mothers in MNCU by neonatal nurses. Pediatricians, Obsreticians and Policymakers need to be taken into confidence and convinced of the benefits of the presence of mothers in NICU 24x7 for the care of their small and sick babies. At the same time, the continuity of care from health facility to home must be strengthened and all babies must receive the benefits of KMC and responsive care through home visits.

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