AN ADAPTED INCUBATOR FOR RURAL HOSPITALS IN DEVELOPING COUNTRIES
- VAN HEMEL BABY INCUBATOR -
Henk W.A. Voorhoeve, MD, PhD, DTM&H, Oscar Van Hemel, MD, PhD
Introduction
Until recently, there was just little attention for the care of newly born babies in developing countries. People are used to the fact that a low birth baby would easily dye.
Presumable, as a result of the great number of health workers out the western world who went to those countries, there is now also more attention for newborn care in the developing countries. But the great attention for neonatology in paediatric literature from the western world has also contributed to the recent development of newborn care in developing countries.
However, the introduction of the western methods of newborn care, specially the technologic advanced incubator of f.e. Siemens or Dräger was often a failure. They are not only too expensive ( > 10.000 Euro) for the low budget countries, but also technological to advanced to handle in a simple way. Beside that, in case of a technical problem, there are no spare parts available and there are no technicians who can handle those advanced incubators. So, those incubators are often used in a wrong way.(1).
The adapted incubator
As early as 1968, the second author working in Uganda at that time developed an adapted incubator with simplicity and transparency as an objective for heating, humidity and isolation. (2) The incubator is in fact a wooden box with at the front- and topside transparent "Perspex" to have a good view on the child.
To keep the baby warm, special during the cool nights, heating is realised with three ordinary electrical bulbs. They produce 95% heat and only 5% light and they can best be obtained locally. The heating is based on the chimney principle air passed the warm bulbs and afterwards a humidified rack with water in it and a long wet strip of cotton (3). Herewith, a high humidity ( > 80-90%) can be realised. This is essential for a newly born baby, beside the physical warm environment. By the chimney principle of air ventilation there is in the incubator no fan, no noise, no recycling of air (4). A thermostat situated at an air outlet regulates the temperature control. At the inner back site of the incubator a thermometer is fixed to read the temperature and beside the thermometer a hygrometer shows the humidity within (5).
Tests by a bacteriologist learned that the Van Hemel incubator has less bacterial growth than the conventional industrial ones because the air is not recycled. So, the baby is well isolated in the van Hemel incubator. For routine nursing care, there are arm inlets at the front side with "sleeves". The nurse or the mother, after cleansing their hands, can through the "sleeves" handle the baby as much as they wants.
Nurses say spontaneously: "they like the simplicity and the ease of regulating the temperature of the babies".
The Availability
The adapted Hemel Baby Incubator is available as a construction kit (6) and should be assembled locally. Here for a light booklet of visualised Assembly instructions are send with. (7) The kit is produced as a non-profit volunteer product at the cost of €280-.
Maintenance is simple done by a local technician because the local technician assembles the incubator locally.
Evaluation
Around the year 2003, we have now about 35 years of experiences with the technological adapted incubators. Even though this adapted incubator is never promoted, in the year 2003 more than 1000 of them are send in over 80 countries. (8) In Uganda and Kenya are 130 of them situated. During a survey (by OH) in April 2002 to those countries we saw them still working after 28 years. They still can continue their operations. We just advice new thermostats after 15 years as we saw too many spider webs between the electrical contacts.
Local imitations of this incubator are found and they have our full approval. The thermostat is
a modified industrial one which we make available to others for €50,-.
Paediatric experiences
- Both for mothers and nurses it was a strange experience that a baby should be undressed, naked go into the incubator. We had to explain that inside the incubator was the right temperature of 36-37 grade and that baby clothes should cause overheating of the baby! This should be avoided of course! And that an undressed baby gives a better observation.
- A baby incubator is specially used for babies with a low birth weight (< 2500 gr) or a very
low birth weight (< 1500 gr.) All children with a birth weight < 2500 gram are usually described as 'premature'. This is according the definition of the late Finish paediatrician YLPO around the year 1900. But a number of the children with a low birth weight are not just premature, but they are certainly also "small for their gestational age" (SGA).
The number of premature birth in developing countries is at least the double of that in the western world. There 5-7% of the babies are premature born and in developing countries this are 15-20% or even more, depending of the season.1,2
- In the first years that our adapted incubator was in use in Entebbe, Uganda, the growth of the small premature babies (< 2270 gr) was measured carefully and compared with figures of premature born babies (<2500gr) from a hospital in Amsterdam.(9) The growth of the children in Uganda and in Amsterdam was rather similar. It should be considered that the babies in Uganda just received Expressed Breast Milk (EBM) and the children in Amsterdam usually get artificial prepared powdered milk.
- During the years 1968-1974 we used the van Hemel incubator at the newly built RIJNOORD Hospital in the village Alphen aan den Rijn 3 (10). In the beginning the nurses who were used to the technical advanced incubators had some problems to accept the simple ones. But soon they were used to them and they realised the advantage, special for simple technical assistance by the own hospital technician. And the last were very enthusiast that they could provide this technical help them self in stead asking for a technician from the factory of the technical advanced incubators.
Light therapy
At that time it was recognised that the jaundice of some newly born babies disappeared by sunlight, especial the UV part of that light. To practise it in a hospital situation special UV lamps were produced by the industry. At that time for about f 1500,- . Because the jaundice also disappeared by ordinary light we suggested the use of an ordinary TL lamp. And with
One of the hospital technicians (J. van Gorp) we developed a wooden light therapy box with at least two TL lamps that fitted on the van Hemel incubator and could be used on an ordinary baby cot as well (11). The cost was just f 70- 3 Both the Van Hemel incubator and Voorhoeve's light therapy box were presented at the special MEDIA '73 exhibition "to doctors by doctors" Light therapy reduced jaundice in 3-4 days.(12)
To make light therapy safe even in rural circumstances the following instructions are given:
1. Cover eyes and the head of the baby, for example with aluminium foil.
2. Each baby should be exposed no longer than 3-4 hours a day.
3. The baby should be given extra fluid intake.
4. In general it will take 3-4 days for blood bilirubine to normalise. ( 12)
The incubator versus the "Kangoeroe" method
In the eighties of the 20th century we learned from Bogota in Columbia that premature babies could be kept warm on the mothers breasts. In that we found they had even less periods of apneu. So, this method is since than preferred above an incubator and even used in the Academic Hospitals of Amsterdam (AMC). 4 However, it is often difficult for mothers to keep a baby during 24 hours a day as a 'kangoeroe' baby on their breasts. Certainly during the night it is more comfortable for the mother with her baby in an incubator. In case of jaundice and light therapy is necessary this can best be given in the Van Hemel 's incubator.
But if a baby in the incubator has too many periods of apneu or "stop breathing" it is recommendable to introduce the kangoeroe method for some hours a day as well.
Conclusions and summary
1. It is our experience that the expensive industrial incubators are not at all applicable in rural hospitals in developing countries.
2. The adapted van Hemel incubator is rather appreciated in rural hospitals. After 35 years there are over 800 distributed around the world in Africa, Asia and Latin America.
3. It is a great advantage that the adapted Van Hemel incubator can be assembled and if necessary repaired by the local hospital technicians.
4. Together with Voorhoeve's light therapy box the Van Hemel incubator can be used if light therapy in jaundiced babies is necessary.
5. Even if the Kangoeroe method is accepted by the mothers and in use, the adapted incubator is necessary to release the mother, special during the night.
Literature
1. Van Eijk, R. Naitre et Croitre au Cameroun. PhD Thesis, University of Utrecht, 1986
2. Bantje, H. Seasonal variations in birthweight distribution in Ikwiriri village, Tanzania.
Trop Geogr. Med. 1982; 34: 213-223
3 Rijn en Gouwe, 17 mei 1973
4 De Leeuw, R. De 'Kangoeroe" methode. Ned Tijdschr Geneesk 1987;131: 1484-1487