Shared knowledge halved infant mortality

Eighteen incubators and heated beds stand side by side in the neonatal intensive care unit at Lady Hardinge Medical College & Kalawati Saran Hospital in New Delhi. The lights are dimmed. The only sounds in the room are the alarms that go off whenever a baby stops breathing. Most of the babies weigh less than a carton of milk.

At the foot of the beds, mothers and two fathers sit in chairs with their babies resting on their chests. Most of the babies are connected to breathing support while lying skin-to-skin with their mothers.

Just a few years ago, mothers were not allowed into the ward. Today, they are part of the treatment.

– When we began involving mothers and facilitating skin-to-skin contact and dedicated breastmilk feeding, we quickly saw that more babies survived, says project manager and physician at Lady Hardinge Medical College, Dr Sushma Nangia.

Within three years, mortality among newborns in the newborn wards was almost halved – from around 11.6 per cent to approximately 6 per cent.

A long-term partnership

Since 2012, the Department of Global Health at Oslo University Hospital (OUS) has collaborated with public hospitals in different states in India. The exchange programme is funded by Norec (Norwegian Agency for Exchange Cooperation).

The main objective of the project is to improve care for sick and premature newborns in New Delhi, while also giving Norwegian healthcare workers experience with conditions and treatments they rarely encounter in Norway.

Breast milk became treatment

– When we started the collaboration project, mothers were not breastfeeding. Babies were given formula instead. Formula companies had convinced people that this was the best option for their children. Of course, that was completely wrong, says Kristin Schjølberg, Head of the Department of Global Health at OUS.

– Breast milk is specifically designed for the baby receiving it. The child receives antibodies from the mother and is much better equipped to fight infections and disease, says Schjølberg.

One of the first major goals was therefore to establish a human milk bank and lactation management at the hospital. In 2017, the milk bank opened.

– Mothers receive guidance on how to establish breastfeeding, and donor milk is provided to the smallest babies until their mothers have established their own milk production. In this way, we ensure that all babies receive the important colostrum and antibodies found in breast milk, says Schjølberg.

At the wards, the proportion of babies receiving breast milk or donor milk increased from around 50 per cent to nearly 85 per cent. Around 35-40 per cent of premature babies now receive colostrum shortly after birth.

The milk bank operates according to national standards that the experts at the hospitals along with others in the country developed together. The model has since paved way to establish many new milk banks across India.

Mother as a living incubator

In addition to breastfeeding support, the method known as kangaroo mother care became an important part of the treatment. At the start of the project, mothers waited in a different ward until the babies receiving treatment were stable enough to be taken care of by the mother.

– It was generally believed that mothers could be a source of infection, and that they would not be able to process what they saw inside the intensive care ward. It was a completely different way of thinking about treatment, says Dr Sushma.

Gradually, the NICU began allowing mothers inside. First the KMC was initiated for the most stable babies, and later also with the sick and small ones on respitory support.

Skin-to-skin contact became the standard treatment.

– We quickly saw that the babies became more stable when their mothers stayed close. They gained weight faster and could be discharged earlier, says Dr Sushma.

She describes the mother as a “living incubator”.

– The mother’s body temperature adapts to the baby. When the child lies skin-to-skin, breathing, pulse and temperature become more stable. At the same time, the mother’s milk production increases, she explains.

First the mother, then the father

In recent years, fathers and grandmothers have also become involved.
This represented a major shift – both culturally and practically. The hospital had to establish changing rooms and make space for more family members in the ward.

– In the beginning, many people were sceptical. Where would the fathers change clothes? Did we have enough gowns? Would fathers make other mothers uncomfortable? Everything took time. But now fathers are part of the care for the babies, and the results have been overwhelmingly positive, says Dr Sushma.

She believes the most important change was that healthcare staff began to see parents as part of the treatment – not as visitors.

The care does not stop once the babies are discharged. More than 75 per cent of mothers now receive follow-up phone calls after leaving the neonatal intensive care unit.

Knowledge at the bedside

The collaboration has not primarily been about expensive equipment or advanced technology. It has been about changing the way people work.

– The presence of Norwegian nurses at the bedside helped improve bedside sills and practices. That made an enormous difference, says Dr Sushma.

– We do not come in for one day and disappear again. We are present at the bedside over time. That is when change happens, says Schjølberg.

Indian nurse Shalini Rawat participated in an exchange programme in Oslo from October 2019 to March 2020. She says the experience changed the way she works.

– The biggest change was the mindset. We saw how it is possible to work systematically with quality, even when resources are very different, says Rawat.

– We learned to prioritise better and organise our work around the sickest babies, she adds.

One nurse – ten babies

Every year, the neonatal intensive care unit in New Delhi treats between 2,700 and 3,000 babies. Around 250 new babies are admitted each month.

There are five nurses on duty during the morning shift, four in the evening and three at night.

At the same time, the ward may care for around 30 critically ill babies at once. Ten of them may require respiratory support or CPAP treatment simultaneously.

– One nurse in India may be responsible for ten critically ill babies at the same time. It is extremely demanding when several babies require respiratory support or intensive follow-up. It is a completely different reality from Norway, where there is usually one nurse per child, says Dr Sushma.

Becoming a better nurse

One of the Norwegian nurses who participated in the exchange programme in India is Sine Skiaker Ramsland. She worked at Lady Hardinge and Kalawati Saran Children’s Hospital from September 2024 to February 2025.

She believes the experience changed her as a nurse.

– It has definitely made me a better nurse. Both in the way I meet people and in the way I treat patients, she says.

Ramsland says she learned to think differently about resources and priorities.

– I have learned how to manage many children at the same time with very limited resources. I have become better at prioritising and finding alternative solutions when many things are happening at once.

Mutual learning

For Schjølberg, this mutual learning is one of the most important aspects of the project.

– We do not go to India only to teach. We also learn an enormous amount. When Norwegian nurses come to India, they become much more dependent on their clinical judgement. They do not have the same monitoring systems and technology around the patients as we do in Norway, she says.

She believes the exchange programmes make Norwegian healthcare workers more confident in their own assessments and priorities.

– You learn to see the child first, not just the machines around them. At the same time, you learn how to manage and prioritise many patients with limited resources.

Schjølberg also believes the collaboration has made OUS more aware of culture and communication in meetings with patients and colleagues from different backgrounds.

– We have actually become much more aware of our own culture and the way we work in Norwegian hospitals. Norwegian hospitals are becoming increasingly international. That makes it important to understand how culture influences both treatment and collaboration around patients, says Schjølberg.

From recipient to resource

Today, the hospitals see that the collaboration has entered a new phase.
Many of the routines and methods are now firmly established in the wards. Nurses are training new colleagues, and the milk bank is integrated into hospital operations.

Most of the nurses who participated in exchanges in Norway now work as mentors, training new colleagues at the hospital. The hospital in Delhi also contributes to training and advisory work in other parts of India.

The hospital now wants to use their experience to support other hospitals and countries.

– We know how much support we ourselves needed when we started this work. Now we want to help other hospitals that are where we were ten or twenty years ago, says Dr Sushma.