Missing doctors, untrained nursing staff led to baby deaths in Banswara
The probe team found that though the hospital has eight gynaecologists, the nursing staff was carrying out most of the deliveries.
A day after the health department took action against erring doctors and nursing staff of the Mahatma Gandhi Hospital in Banswara, HT on Tuesday got a copy of the inspection report which points towards glaring discrepancies.
After the death of 81 neonates at the district hospital till August 31, the health minister formed a committee to probe the deaths. The report was submitted on September 4 and based on it health minister Kali Charan Saraf on Monday suspended three doctors and put five on awaiting posting orders. Disciplinary action has been initiated against three doctors and four nursing staff.
The report states that the committee inspected the reproductive and child health (RCH) and high risk pregnancy (HRP) registers and gathered information about the treatment and facilities provided to the pregnant women by visiting their homes.
They found that the age of some pregnant women have been shown to be above 19 in the indoor ticket, while in reality they appeared to be between 17 and 19 years. Pregnancy at a young age can result in low birth weight and premature delivery, which can result in the death of newborns.
During the visit, the team found that the age of two mothers whose babies had died was 18 and 20. The 18-year-old had delivered for the first time, while it was the second delivery for the 20-year-old. The age of six other pregnant women who appeared to be between 16 and 18 years was shown between 22 and 25 years in the indoor ticket.
The four-member team, headed by Dr SM Mittal, also found that though the hospital has eight gynaecologists, the nursing staff was carrying out most of the deliveries. This could also be a reason for infant deaths. The gynaecologists were not there in the labour room except in case of caesareans. Necessary partograph was also not filled. Partograph is a composite graphical record of mother and foetus during labour and helps curb neonatal deaths.
It also came to notice that children born through caesarean are not regularly checked by paediatricians.
The committee also found that in few cases oxytocin was used for inducing early labour. According to rules, it should be used only when necessary.
Out of the eight nursing staff in the labour room, only two were skilled birth attendants (SBA). Due to a lack of trained SBA nurses, proper suction of newborn did not take place. At the hospital, the still birth figure is at 73/1000 per live births. It shows lack of quality services in the labour room.
The cloth used to clean newborns was found to be unsterilised and could lead to infections.
The district hospital had referred many delivery cases to Udaipur, which could have been performed at the hospital in Banswara.
Out of four operation theatres, radiation warmers were available only at one. There are high chances of a newborn catching an infection while being transferred to the radiation warmer in another OT.
The committee at Sick Newborn Care Unit (SNCU) also found that out of total eight nursing staff, two were untrained. Dr Pradyuman Jain at SNCU had not undergone 12-week ??? training. Also infection prevention protocol is not properly followed at SNCU.
On visiting the house of a newborn at Ragawa village in Talwara block it was found that the weight of a 24-year-old mother was not mentioned. On seeing her it appeared that she was around 35kg and the newborn weighed just 1,400 gram. Her husband said that they had visited the anganwari centre where she was vaccinated and given a few tablets. But not given nutritional supplement during pregnancy. The committee directed the chief medical and health officer to bring the woman to the district hospital and give her and the newborn proper care.
The team also found that the nursing staff often fought with each other and demand money for getting deliveries done.
Out of 81 deaths at SNCU, 42 were due to asphyxia, 20 due to prematurity with respiratory distress syndrome, five died of infection, two had congenital anomaly and 12 were of extremely low birth weight.