The project was a collaboration between S.M.S. Medical College with the attached hospitals J K Lone and Mahila Chikitsalaya in Rajasthan, India, and Oslo University Hospital, Norway. J K Lone is a paediatric hospital (level II, changing to level III during the project), all neonates being referred from extramural units, covering more than 40,000 annual deliveries. Bed strength was originally 45 in the neonatal units Special Newborn Care Unit (SNCU) (for those not in need of respiratory support) and Neonatal Intensive Care Unit (NICU). Mahila Chikitsalaya is mainly an obstetrical hospital with 17,000 deliveries/year, and neonatal bed strength of 43 (no invasive respiratory care). Oslo University Hospital is level IIIb with 47 neonatal beds.
The main project period was 2013–2016, with scaled-down maintenance the following three years.
Before the initiation of the project, parents were not admitted into the neonatal wards. Four nurses were exchanged every 6 month between the neonatal units in India and Norway. After the first 3 years, the presence of Norwegian nurses was infrequent, whereas the group of Indian nurses trained in Norway kept expanding by 2 every half year. Three Indian paediatricians visited the Norwegian unit for 6 months each as observers. A Norwegian neonatologist held the academic responsibility. She supervised the Indians in Norway and visited the Indian unit for 14 days twice a year, in addition to web-based contact all 6 years.
The head of the milk bank in the Norwegian hospital spent approximately ten months in the Indian hospitals over the first 5 years. A devoted Indian senior consultant was appointed to head a new lactation centre with a milk bank. Full-time lactation counsellors and a technical assistant were also employed.
Department of Global Health, Oslo University Hospital conducted the overall administration of the project and visited India at least once a year. To facilitate the work of the nurses and secure momentum of the project, the office and the academic responsible physician had a continuous dialogue with the heads of the departments and the hospital administrations and met with the health authorities in the state of Rajasthan.
A fourfold program was developed (Table 1).
Education to enlighten health care workers and parents to the excellence of human milk
In Norway, the Indian nurses worked in a large neonatal unit with a strong focus on nutrition. They were exposed to a culture where the attitude to human milk and possible ways of feeding, makes human milk the obvious first choice. They experienced short-term advatages and learned about the long-term advantages of this practice. They obtained practical experience in assisting mothers with breastfeeding and expression of milk by hand or mechanical pumps and in feeding by cup and tube.
The Norwegian nurses in India had extended knowledge of intensive newborn care and all aspects of lactation. They provided theoretical and practical education individually, in small groups, seminars and workshops.
All nurses and doctors were trained and empowered to share knowledge.
The first lactation counsellors were, educated by head of the milk bank Oslo, Norwegian nurses and head of the new lactation centre. They were then entrusted with the main responsibility of providing mothers with knowledge that made them want to breastfeed. Every day all maternity and neonatal wards were visited by counsellors. In the later phase of the project all counsellors attended standardised eight hour theory and 32 h hands-on training courses.
To further improve and encourage the activity of all staff, follow-up regular training sessions were organized internally and with visiting specialists, giving lectures on the topic.
Lactation counselling to address the various challenges of breastfeeding
After convincing the mothers about the benefits of human milk, the counsellors provided general advice and mental support to enable lactation. Mothers who experienced problems were invited for individual guidance the same day.
Improving infants’ general condition
Indians and Norwegians worked closely together bedside, thereby quickly discovered and addressed procedures and systems possible to alter in order to improve care. Better nursing care was obtained mainly by empowering nurses in their skills and in their belief in the effect of their work. Teaching relevant theory and supervising bedside hands-on training in pain relief, developmental care and infection control were performed to minimise neonates’ energy expenditure, avoid infections and enhance their ability to tolerate enteral feeds and to suckle.
For better observations of the patients and relation to their families, every shift each infant was assigned a responsible nurse. “Nurses’ daily record” documenting nutrition, weight gain, temperature etc., was developed.
Infrastructure alterations in the hospital
All suggested alterations were discussed with nurses, doctors and head of the department, major changes also with the hospital administration.
I-Bringing mothers and their sick or preterm neonates together.
To allow mothers into the neonatal units, advantages, requirements, safety and precautions were thoroughly discussed with hospital authorities and all staff. Doctors persuaded the mother and the decision-maker in the family of the importance of mother and infant being together. Nurses facilitated physical contact between mother and infant. Depending on the condition of the infant the mother would touch, help change the diaper, sponge, feed or give kangaroo mother care (KMC). Mothers were provided with a place to sleep, eat and wash. All staff encouraged each other to respectfully welcome all mothers.
II-Defining human milk as the default nourishment.
In order to initiate prolactin secretion and thus early lactation, routines were established in collaboration with the maternity ward to help newborns to the breast within one hour of delivery. Doctors were committed to explicitly prescribe human milk whenever possible and nurses to strive to feed the right amount at the right time by optimal means and to document this. Mothers were urged to always provide fresh milk and contact the counsellors if needed.
III-Establishment of a lactation centre with milk bank and mil kitchens.
Some mothers produce milk in abundance, others are not able to produce the adequate amount for their baby, especially not the first days. To provide human milk for all neonates in the hospitals, a lactation centre with counsellors and milk bank as well as milk kitchens were established.
The centre accomodated room for individual, undisturbed counselling. The mother-infant dyads were observed in the feeding situation and tutored according to their needs. Mothers whose infants were not able to nurse from the breast were taught how to express milk by hand and by a mechanical pump.
In order to provide for the newborns who could not receive enough milk from their mothers, a milk bank was established. When a mother produced more milk than required by her infant, she was informed about the possibility to donate her surplus. This was the first milk bank in Rajasthan and several actions enhanced a positive attitude towards it. The inauguration was celebrated with the presence of the state health minister and broadcast in several media as an important advancement for Indian healthcare. A father of a healthy infant went around the hospital promoting the milk bank to the other fathers who then encouraged their wives. A member of staff with a healthy infant donated her milk.
Locally customized, detailed protocols were compiled describing the routines for handling milk and equipment (later contributing to national guidelines ). There was intense initial and regular training including technical procedures such as collection, pasteurization and storage as well as hygiene, quality control and tracing. Milk was daily transported in sealed bottles in a cool bag from the bank to the different units´ milk kitchens. To avoid waste and shortage, a system was established to keep track of the amount of milk each infant required and consumed every day.
In order to improve hand hygiene, every person entering the units receive individual instructions to remove jewellery, sacred threads, watches and similar and perform hand wash. Washbasins and soap were to be made accessible for everyone, and all reusable towels removed. Rubbing alcohol was to be available at every bedside.
Instead of sending linen to the hospital laundry where it would be dried on the ground outside among cars and livestock, it was organized for washing and drying inside the NICU.
Protocols for regular cleaning of all equipment were developed.
To limit the spread of infections from the older patients, doctors from the seven paediatric wards attending “their” neonates were rendered superfluous by one senior doctor taking the main responsibility for all patients in the NICU.
V-Assembling and increasing the number of neonatal beds.
Because of an inadequate number of beds in the neonatal units, all paediatric wards had a “neonatal cubicle”. Discussion with authorities was held with strong advocacy for the allocation of more beds and dedicated human resources to this group of patients.
Rounds were reorganized to facilitate information between doctors, nurses and parents.
All exchanged health workers answered a standard questionnaire (Additional file 1: Supplement 1) mid- and end period providing qualitative description and evaluation of the project including changes and achievement. Data on milk consumption and hand hygiene were retrieved from repeated structured three-day open observations in the units performed by the Norwegian nurses (Additional file 2: Supplement 2). Quantitative data on counselling and donated milk were obtained from lactation centre protocols. Nature of feed at discharge from two neonatal units after Caesarean section was recorded three months in 2015. Both units received milk from the bank, but as only one had project nurses and -counsellors, the impact of this could be suggested.
The project was not designed for research. There is a lack of structured data collection and large changes over time in the population. As advanced statistics is thus unfeasible, numbers are offered merely to create a picture of the situation.
The work was conducted following prevailing ethical principles.
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