The Human Incubator
Sometimes, the best way to progress isn’t to advance — to step up with more money, more technology, more modernity. It’s to retreat.
Towards the end of the 1970s, the Mother and Child Institute in Bogota, Colombia, was in deep trouble. The institute was the city’s obstetrical reference hospital, where most of the city’s poor women went to give birth. Nurses and doctors were in short supply. In the newly created neonatal intensive care unit, there were so few incubators that premature babies had to share them — sometimes three to an incubator. The crowded conditions spread infections, which are particularly dangerous for preemies. The death rate was high.
Dr. Edgar Rey, the chief of the pediatrics department, could have attempted to do what many other hospital officials would have done: wage a political fight for more money, more incubators and more staff.
He would likely have lost. What was happening at the Mother and Child Institute was not unusual. Conditions were much better, in fact, than at most public hospitals in the third world. Hospitals that mainly serve the poor have very little political clout, which means that conditions in their wards sometimes seem to have been staged by Hieronymous Bosch. They have too much disease, too few nurses and sometimes no doctors at all. They can be so crowded that patients sleep on the floor and so broke that people must bring their own surgical gloves and thread. I recently visited a hospital in Ethiopia that didn’t even have water — the nurses washed their hands after they got home at night.
Rey thought about the basics. What is the purpose of an incubator? It is to keep a baby warm, oxygenated and nourished — to simulate as closely as possible the conditions of the womb. There is another mechanism for accomplishing these goals, Rey reasoned, the same one that cared for the baby during its months of gestation. Rey also felt, something that probably all mothers feel intuitively: that one reason babies in incubators did so poorly was that they were separated from their mothers. Was there a way to avoid the incubator by employing the baby’s mother instead?
What he came up with is an idea now known as kangaroo care. Aspects of kangaroo care are now in use even in wealthy countries — most hospitals in the United States, for example, have adopted some kangaroo care practices. But its real impact has been felt in poor countries, where it has saved countless preemies’ lives and helped others to survive with fewer problems.
In Rey’s system, a mother of a preemie puts the baby on her exposed chest, dressed only in a diaper and sometimes a cap, in an upright or semi-upright position. The baby is strapped in by a scarf or other cloth sling supporting its bottom, and all but its head is covered by mom’s shirt. The mother keeps the baby like that, skin-to-skin, as much as possible, even sleeping in a reclining chair. Fathers and other relatives or friends can wear the baby as well to give the mother a break. Even very premature infants can go home with their families (with regular follow-up visits) once they are stable and their mothers are given training.
The babies stay warm, their own temperature regulated by the sympathetic biological responses that occur when mother and infant are in close physical contact. The mother’s breasts, in fact, heat up or cool down depending on what the baby needs. The upright position helps prevent reflux and apnea. Feeling the mother’s breathing and heartbeat helps the babies to stabilize their own heart and respiratory rates. They sleep more. They can breastfeed at will, and the constant contact encourages the mother to produce more milk. Babies breastfeed earlier and gain more weight.
The physical closeness encourages emotional closeness, which leads to lower rates of abandonment of premature infants. This was a serious problem among the patients of Rey’s hospital; without being able to hold and bond with their babies, some mothers had little attachment to counter their feelings of being overwhelmed with the burdens of having a preemie. But kangaroo care also had enormous benefits for parents. Every parent, I think, can understand the importance of holding a baby instead of gazing at him in an incubator. With kangaroo care, parents and baby go through less stress. Nurses who practice kangaroo care also report that mothers also feel more confident and effective because they are the heroes in their babies’ care, instead of passive bystanders watching a mysterious process from a distance.
The hospitals were the third beneficiaries. Kangaroo care freed up incubators. Getting preemies home as soon as they were stable also lessened overcrowding and allowed nurses and doctors to concentrate on the patients who needed them most.
Kangaroo care has been widely studied. A trial in a Bogota hospital of 746 low birth weight babies randomly assigned to either kangaroo or conventional incubator care found that the kangaroo babies had shorter hospital stays, better growth of head circumference and fewer severe infections. They had slightly better rates of survival, but the difference was not statistically significant. Other studies have found fewer differences between kangaroo and conventional methods. A conservative summary of the evidence to date is that kangaroo care is at least as good as conventional treatment — and perhaps better.
In much of the world, however, whether a mother’s chest is better or worse than an incubator is not the point. Hospitals have no incubators, or have only a few. And millions of mothers never see a hospital — they give birth at home. In very poor countries, where pregnant women are unlikely to get the food and care they need, low birth weight babies are very common — nearly one in five babies in Malawi, for example, is too small. Nearly a million low birth weight babies die each year in poor countries. But thanks to kangaroo care, many of them can be saved. The Manama Mission Hospital in southwest Zimbabwe, for example, had available only antibiotics and piped oxygen in its neonatal unit. Survival rates for babies born under 1500 grams (3.3 lbs.) improved from 10 percent to 50 percent when kangaroo care was started in the 1980s. In 2003, the World Health Organization put kangaroo care on its list of endorsed practices.
Dr. Rey took a challenge that most people would assume requires more money, personnel and technology and solved it in a way that requires less of all three. I am not a romantic who wants to abandon modern medical care in favor of traditional solutions. People with AIDS in South Africa need antiretroviral therapy, not traditional healers’ home brews. If you are bitten by a cobra in India, you should not go to the temple. You should go to the hospital for antivenin. Modern medical care is essential and technology very often saves lives.
Kangaroo care, however, is modern medical care, by which I mean that its effectiveness is proven in randomized controlled trials — the strongest kind of evidence. And because it is powered by the human body alone, it is theoretically available to hundreds of millions of mothers who would otherwise have no hope of saving their babies.
But theoretical availability is only helpful for theoretical babies. Another of kangaroo care’s important innovations is that its inventors realized that ideas don’t travel by themselves. They established a way to get the practice from Bogota into hospitals and clinics all over the world — something that takes a lot more creativity and work than it sounds. On Saturday I’ll respond to comments and talk about how kangaroo care has been able to reach the places that need it most.
This column was originally published in The New York Times. Fixes appears every Tuesday in the Times Opinionator section.
Photo credit/caption: Agence France-Presse; A mother and child in Colombia, where the “kangaroo care” method was first used in the late 1970s.