Sometimes, the solution to a big problem doesn’t lie in western technology. Sometimes the solution can be simple, writes Amy McDaid
More than 2.7 million newborns die each year, and low birth weight and preterm infants in developing countries contribute substantially to this figure. New Zealander Ray Avery, most recently in the news for reportedly threatening a researcher’s career prospects over findings that a medical product he’d developed didn’t work as well as expected, is seeking to make a difference by supplying his “Lifepod” incubators to poor and isolated communities around the world. Resembling small spaceships, they come with a big claim: each one can save the lives of up to 500 babies. Donate $20 and have your name inscribed on the Lifepod wall of heroes. Donate $20,000 and have your name inscribed on a Lifepod. Donate $50,000 and enjoy dinner with the man himself. But are incubators the best way to care for preterm infants?
Incubators, with their enclosed, temperature-controlled environment, are considered an essential part of the modern neonatal intensive care unit. Small, preterm infants lack the necessary brown fat that enables them to regulate their temperature. If they become hypothermic, they use more energy, which can result in low oxygen levels, low blood sugar levels, and even death. Yet the World Health Organisation highlights problems with incubators in developing countries. They are often not used properly due to lack of staff training. They are unable to be properly cleaned, posing a significant infection risk. They break down. But most significantly, they are frequently and often needlessly used to separate infants from their mothers.
Neonatal intensive care in developed countries such as New Zealand is high-tech. We save babies as young as 23 weeks gestation and as small as 500 grams. We monitor every breath, every heartbeat, we perform scans and x-rays, and diligently record urine output and bowel motions. We can perform complex surgeries.
Hospitals in developing countries do not have the ability to save the 5% of preterm babies born below 28 weeks gestation – with or without incubators. But with simple, essential care, such as warmth and feeding assistance, the 80% of preterm infants born between 32 and 37 weeks stand a good chance of survival.
In the 1970s, the Instituto Materno Infantil was the biggest neonatal unit in Colombia, and served the city’s poorest people. Overcrowding and infection were rife. The death rate of premature infants skyrocketed, and mothers, forbidden to touch their incubator-nursed babies, were abandoning them. Paediatrician Edgar Rey knew something had to be done. After reading a paper on the physiology of the kangaroo, and how the tiny immature kangaroo thermal regulates in its mothers pouch, latching onto the nipple and growing until it’s ready to emerge into the world, he decided to trial teaching mothers how to hold their babies against them – just like kangaroos. The results were astounding. Death rates and infection rates dropped. Fewer babies were abandoned.
Kangaroo Mother Care (KMC) is both powerful and simple. A mother can increase the temperature at her breasts by as much as two degrees in two minutes to warm her baby. Infants nursed in KMC have fewer apnoeic episodes, fewer infections and show increased cardiovascular and respiratory stability compared to babies nursed in incubators. They breastfeed earlier, they gain weight faster, they are calmer, have longer periods of sleep, more rapid brain development, and decreased crying.
KMC has been shown to improve bonding, and mothers are less depressed and feel more competent. Moreover, the effects are long lasting. Research published last year in the Journal of Pediatrics compared infants who were randomised at birth to receive either incubator care or kangaroo mother care in the mid 1990s in Colombia. Twenty years later, the Kangaroo care group had higher IQs, showed less aggression, less antisocial behaviour, and their parents were more protective and nurturing. If the father also carried the baby, there was a deeper family bond and less separation.
Now, developed countries are catching up, and the most advanced neonatal intensive care units have purpose-built facilities that enable parents to stay with their preterm babies for continuous skin-to-skin contact. In Sweden, the intensive care spaces have adult beds. There are family rooms, so parents and siblings can remain together. There are kitchens, and lounges, and play areas. In Malawi, KMC clinics are more basic — mothers and fathers line up on wooden benches perched on dirt floors, their babies on their chests, the tops of little heads poking out from underneath colourful wraps. Often, the mothers take their infants home with them, sometimes as early as 30 weeks gestation, with a trained healthcare worker following them up closely in the community. Balaka in Malawi saw their infant death rate drop from as high as 54% in 2012 to 1% in 2016 after the implementation of a KMC clinic.
Unfortunately, global coverage of Kangaroo Care remains low. Yet the World Health Organisation estimates that if it were made universally available, it would save the lives of over 450,000 newborns per year. The story of Carmela Torres demonstrates the difference KMC can make. In 1987, she gave birth two months early to a 1650-gram baby boy in the Colombian city of Bogota. He was whisked away from her into neonatal intensive care. She was only allowed to visit him for two hours a day, and she wasn’t allowed to touch him. On the third day, she received a phone call to say her baby had died. “They didn’t tell me the cause or the diagnosis. Just that he was dead. I hadn’t even named him yet.”
Ten years on, and Carmela Torres fell pregnant again. To her dismay, she gave birth to her second son at much the same weight and gestation as the first. But this time, Carmela was taught about Kangaroo Care, and the next day, she walked out of hospital with her tiny baby strapped to her chest. “Julian was very small and fragile but I was much happier taking him home with me than leaving him there, where my other baby had died. Feeding him wasn’t easy, but I had a lot of help. I carried him for a month, 24 hours a day, sharing shifts with my husband, until he hit his target weight of 2,500.”
On Ray Avery’s Lifepod website, a video gives us a glimpse behind the rough concrete walls of neonatal units in less developed countries. Old incubators flash on the screen, discarded in corners, ancient, dusty, in disrepair, portholes taped up with cellotape. Babies lie flat on their backs in cots, their spindly limbs splayed out, glowing blue under phototherapy lights. One small infant lies under an oxygen hood, his chest sucking in and out with the effort of breathing. We see no KMC. We only see one mother holding her baby, but she is being directed by a nurse to put him down.
Avery’s voice floats over, claiming millions of babies die because they don’t have access to incubators. But research has established that more babies die because of a lack of education around the benefits of skin-to-skin contact. The Nepalese babies he references, who take long “perilous” journeys to get to an incubator, often dying on the way, tragically highlight just how little knowledge there is around KMC in poor, isolated communities. I challenge him to tackle the biggest obstacle to KMC – healthcare worker education, and to apportion funds to organisations such as USAID and Save the Children, who are already working to establish KMC clinics in countries that do not have them.
Dr Julietta Villegas, one of the researchers in the Colombian KMC study, says, “if you take a mother, no matter what her economic background, and give her the tools and education she needs to look after her own child, it will have the same outcomes as if she were from a higher economic status. This is why we say, with kangaroo care, we fight inequality. We don’t just save lives, we change lives.”
Ray Avery is a wonderful inventor and philanthropist, and I do not doubt his heart for preterm infants. But incubators should not be the default way of caring for small babies, and in developing countries could cause more harm than good. Sometimes, the solution to a big problem doesn’t lie in western technology. Sometimes the solution can be simple. Sometimes, the solution is already right in front of us, willing and waiting to do everything they can to save the life of their baby.
Amy McDaid has worked as newborn intensive care nurse for over ten years, and has a postgraduate certificate in neonatal nursing from Massey University. She completed a Master of Creative Writing Degree at the University of Auckland in 2017, and won the Sir James Wallace Prize for her novel-in-progress.
Carmela Torres’ story appeared in an article on Mosaic Science, and is republished here under a Creative Commons Licence.