Barriers and enablers of health system adoption of kangaroo mother care: a systematic review of caregiver perspectives

Clinician Opinions and Approaches to Manage Risk Related to Safe Sleep During Skin-to-Skin Care

OBJECTIVE

To understand the opinions of clinicians about the risks, benefits, barriers, and facilitators to the practice of parent sleep during skin-to-skin care in hospital settings.

DESIGN

Cross-sectional survey.

SETTING

Online survey.

PARTICIPANTS

Clinicians who self-identified as infant care providers, that is, neonatal clinicians (N = 158).

METHODS

We sent an online survey invitation to neonatal clinicians through neonatal websites, conferences, and social media sites in the United States and used snowball recruitment. We used a risk management framework to analyze qualitative data. We used descriptive statistics and the chi-square and Fisher's exact tests to determine if opinions differed based on clinician and organizational characteristics.

RESULTS

Respondents' support of parent sleep during skin-to-skin care (yes/no) did not differ on the basis of whether the clinician had taken a formal course on skin-to-skin care, facilitated skin-to-skin care more than 100 times, or frequently promoted skin-to-skin care in current practice. Respondents who supported parent sleep (n = 93, 59% of respondents) reported greater implementation of risk control strategies than nonsupporters (n = 53 [57%] vs. n = 3 [5%]; p < .001), such as frequent monitoring of vital signs (n = 33 [35%] vs. n = 2 [3%]; p < .001), use of devices to support skin-to-skin care (n = 49 [53%] vs. n = 19 [29%]; p = .003), and proper positioning (n = 20 [22%] vs. n = 0 [0%]; p < .001). Nonsupporters more frequently reported that parent sleep during skin-to-skin care violates safe sleep recommendations, is habit forming for home, poses a fall risk, and jeopardizes the infant's airway.

CONCLUSION

Most respondents supported parent sleep during skin-to-skin care, but concerns regarding safety for the infant remained a barrier. The use of a risk management framework may help facilitate a systematic approach to improve the implementation of safe skin-to-skin practices.

Barriers and facilitators of kangaroo mother care adoption in five Chinese hospitals: a qualitative study

Background

Kangaroo mother care (KMC) has been proved to be a safe and cost-effective standard of care for preterm babies. China hasn’t adopted the KMC practice widely until recently. We aim to assess barriers and facilitators of KMC adoption in neonatal intensive care units (NICUs) and postnatal wards in China.

Methods

We conducted clinical observations and semi-structured interviews with nurses, physicians, and parents who performed KMC in seven NICUs and postnatal wards housed in five hospitals in different provinces of China between August and September 2018. The interviews provided first-hand stakeholder perspectives on barriers and facilitators of KMC implementation and sustainability. We further explored health system’s readiness and families’ willingness to sustain KMC practice following its pilot introduction. We coded data for emerging themes related to financial barriers, parent- and hospital-level perceived barriers, and facilitators of KMC adoption, specifically those unique in the Chinese context.

Results

Five hospitals with KMC pilot programs were selected for clinical observations and 38 semi-structured interviews were conducted. Common cultural barriers included concerns with the conflict with traditional postpartum confinement (Zuo-yue-zi) practice and grandparents’ resistance, while a strong family support is a facilitator for KMC adoption. Some parents reported anxiety and guilt associated with having a preterm baby, which can be a parental-level barrier to KMC. Hospital-level factors such as fear of nosocomial infection and shortage of staff and spaces impeded the KMC implementation, and supportive community and peer group organized by the hospital contributed to KMC uptake. Financial barriers included lodging costs for caregivers and supply costs for hospitals.

Conclusions

We provided a comprehensive in-depth report on the multi-level KMC barriers and facilitators in China. We recommend policy interventions specifically addressing these barriers and facilitators and increase family and peer support to improve KMC adoption in China. We also recommend that well-designed local cultural and economic feasibility and acceptability studies should be conducted before the KMC uptake.

A Randomized Trial of Continuous Versus Intermittent Skin-to-Skin Contact After Premature Birth and the Effects on Mother-Infant Interaction

BACKGROUND

Premature birth affects opportunities for interaction between infants and mothers. Skin-to-skin contact (SSC) is standard care in neonatal care but has not been sufficiently studied regarding the effects on interaction between preterm infant and mothers.

PURPOSE

The purpose of this study was to compare interaction between preterm infants and their mothers after continuous versus intermittent SSC from birth to discharge. A secondary aim was to study a potential dose-response effect between time in SSC and quality of interaction.

METHODS

Families were randomly assigned to either continuous (n = 17) or intermittent (n = 14) SSC before delivery. Interaction was measured from videotapes of a Still-Face Paradigm collected at 4 months' corrected age. Face-to-face interaction was coded according to Ainsworth's Maternal Sensitivity Scales and the Maternal Sensitivity and Responsivity Scales-R. Dose-response correlations were calculated between mean time spent in SSC and each of the interaction scales.

RESULTS

There were no statistically significant differences between groups in maternal interactive behavior toward their infants regarding sensitivity, interference, availability, acceptance, withdrawal, or intrusivity. There was no correlation between mean time in SSC and quality of interaction.

IMPLICATIONS FOR PRACTICE

Continuous SSC from birth to discharge was not superior to intermittent SSC concerning mother-infant interaction between preterm infants and their mothers at 4 months' corrected age. However, compared with other studies, mean time in SSC was also high in the intermittent group.

IMPLICATIONS FOR RESEARCH

Further studies are needed to find out how interaction between parents and preterm infants can be improved, supported, and facilitated in the neonatal intensive care unit (NICU) and whether there is an optimal dose for SSC.

Improving Skin-to-Skin Practice for babies in Kangaroo Mother Care in Malawi through the use of a customized baby wrap: A randomized control trial

Background

Complications of prematurity are a leading cause of newborn death in Malawi. Despite early adoption of Kangaroo mother care (KMC), coverage remains low and women have expressed challenges in using the traditional wrapper–chitenje. In 2016, a study was conducted to evaluate the acceptability and effectiveness of a customized KMC wrap in improving adherence to KMC practices among mothers.

Methods

Mother-baby dyads (301) were randomized to receive either a customized CarePlus Wrap developed by Lærdal Global Health or a traditional chitenje. Enrolled mother-baby dyads were assessed in the KMC ward at 2–3 days after of admission, and then again at 7–15 days post-discharge. Topics covered included skin-to-skin practices, breastfeeding, perceptions of the wrap, and family/community support. Chi square tests were used to assess associations between wrap type and KMC practices. The study received ethics approval.

Results

This study found that a customized KMC wrap is highly acceptable to women and improved skin-to-skin practices in facility-based KMC: 44% of mothers using a customized wrap reported 20 or more hours per day, compared to 33% of mothers using the traditional chitenje. Women using the customized wrap reported being comfortable in keeping the baby in skin-to-skin position more often than women using the chitenje (96% vs. 71%), and they were able to tie on the wrap themselves (86% vs. 10%). At the time of discharge from KMC, more women who used the customized wrap were satisfied with the wrap than those who used the traditional chitenje (94% vs. 56%). The customized wrap did not appear to impact other newborn practices, such as breastfeeding.

Conclusions

This study provides evidence that a customized KMC wrap is highly acceptable to mothers, and it can contribute to better skin-to-skin practices. Use of a customized wrap may be one mechanism to support mothers in practicing KMC and skin-to-skin contact in addition to other interventions.

An intervention to decrease time to parents' first hold of infants in the Neonatal Intensive Care Unit requiring respiratory support

BACKGROUND

There are many barriers to parental skin-to-skin contact for critically ill neonates. Our aims were to decrease median time to first parental hold of neonates requiring respiratory support from 6.4 to 3 days, and to increase the percentage of neonates held within the first 24 h after birth from 6 to 75%.

METHODS

Lean Six Sigma methodology was used to identify barriers to holding and opportunities for improvement.

INTERVENTION

A multifactorial improvement bundle was implemented to reduce the time to first parental hold of critically ill neonates.

RESULTS

Median time to first parental hold was reduced from 6.4 to 1.2 days (p < 0.01). Infants held within the first 24 h after birth increased from 6 to 35%. There was no increase in adverse events associated with parental holding.

CONCLUSIONS

Implementation of an improvement bundle resulted in a significant reduction in time to first parental hold of infants requiring respiratory support.

Factors Impacting Practice of Home Kangaroo Mother Care with Low Birth Weight Infants Following Hospital Discharge

OBJECTIVE

To identify enablers and barriers related to home Kangaroo Mother Care (KMC) adoption after hospital discharge.

STUDY DESIGN

An exploratory study, using a mixed methods evaluation, followed 60 mother-infant dyads from the hospital ward to 4 weeks post-hospital discharge.

RESULTS

Fifty-three of the mothers (88.3%) completed all study visits. The majority of mothers were breastfeeding and practicing skin-to-skin contact 4 weeks post-discharge. Seven mothers (13.2%) discontinued skin-to-skin contact at 4 weeks. KMC was practiced on average 3.3 h/day and 5.1 days/week. The top two enablers reported were significantly related to the amount of time skin-to-skin was practiced, with support for household responsibilities being most significant (U = 195, p = 0.008). Lack of privacy (p = 0.002) and lack of motivation (p = 0.034) were negatively correlated to duration of skin-to-skin contact.

CONCLUSION

Future programs may increase dissemination and adoption of home KMC by specifically addressing enablers and barriers correlated to duration of skin-to-skin contact.

Quality of Kangaroo Mother Care services in Ethiopia: Implications for policy and practice

Background

Providing high-quality kangaroo mother care (KMC) is a strategy proven to improve outcomes in premature babies. However, whether KMC is consistently and appropriately provided in Ethiopia is unclear. This study assesses the quality of KMC services in Ethiopia and the factors associated with its appropriate initiation among low birth weight neonates.

Methods

We used data from the 2016 national Emergency Obstetric and Newborn Care (EmONC) assessment which contains data on all health facilities providing delivery care services in Ethiopia (N = 3,804). We described the quality of KMC services provided to low-birth weight (LBW) babies in terms of infrastructure, processes and outcomes (survival status at discharge). We also explored the factors associated with appropriate KMC initiation using multivariable logistic regression models.

Results

The quality of KMC services in Ethiopia was poor. The facilities included scored only 59.0% on average on a basic index of service readiness. KMC was initiated for only 46.4% of all LBW babies included in the sample. Among those who received KMC, 66.7% survived, 13.3% died and 20.4% had no data on survival status at discharge. LBW babies born in health centers were twice more likely to receive KMC compared to those born in hospitals (AOR = 2.0, 95% CI: 1.3–3.0). Public facilities, those with a staff rotation policy in place for newborn care, and those with separate newborn corners were also more likely to initiate KMC for LBW babies.

Conclusions

We found low levels of appropriate KMC initiation, inadequate infrastructure and staffing, and poor survival among LBW babies in Ethiopia. Efforts must be made to improve the adoption of this life saving technique, particularly in hospitals and in the private sector where KMC remains underutilized. Facilities should also dedicate specific spaces for newborn care that enables mothers to provide KMC. In addition, improving record keeping and data quality for routine health data is a priority.

Kangaroo Mother Care implementation research to develop models for accelerating scale-up in India and Ethiopia: study protocol for an adequacy evaluation

INTRODUCTION

Kangaroo Mother Care (KMC) is the practice of early, continuous and prolonged skin-to-skin contact between the mother and the baby with exclusive breastfeeding. Despite clear evidence of impact in improving survival and health outcomes among low birth weight infants, KMC coverage has remained low and implementation has been limited. Consequently, only a small fraction of newborns that could benefit from KMC receive it.

METHODS AND ANALYSIS

This implementation research project aims to develop and evaluate district-level models for scaling up KMC in India and Ethiopia that can achieve high population coverage. The project includes formative research to identify barriers and contextual factors that affect implementation and utilisation of KMC and design scalable models to deliver KMC across the facility-community continuum. This will be followed by implementation and evaluation of these models in routine care settings, in an iterative fashion, with the aim of reaching a successful model for wider district, state and national-level scale-up. Implementation actions would happen at three levels: 'pre-KMC facility'-to maximise the number of newborns getting to a facility that provides KMC; 'KMC facility'-for initiation and maintenance of KMC; and 'post-KMC facility'-for continuation of KMC at home. Stable infants with birth weight<2000 g and born in the catchment population of the study KMC facilities would form the eligible population. The primary outcome will be coverage of KMC in the preceding 24 hours and will be measured at discharge from the KMC facility and 7 days after hospital discharge.

ETHICS AND DISSEMINATION

Ethics approval was obtained in all the project sites, and centrally by the Research Ethics Review Committee at the WHO. Results of the project will be submitted to a peer-reviewed journal for publication, in addition to national and global level dissemination.

STUDY STATUS

WHO approved protocol: V.4-12 May 2016-Protocol ID: ERC 2716. Study implementation beginning: April 2017. Study end: expected March 2019.

TRIAL REGISTRATION NUMBER

Community Empowerment Laboratory, Uttar Pradesh, India (ISRCTN12286667); St John's National Academy of Health Sciences, Bangalore, India and Karnataka Health Promotion Trust, Bangalore, India (CTRI/2017/07/008988); Society for Applied Studies, Delhi (NCT03098069); Oromia, Ethiopia (NCT03419416); Amhara, SNNPR and Tigray, Ethiopia (NCT03506698).

Mothers' perceptions of the practice of kangaroo mother care for preterm neonates in sub-Saharan Africa: a qualitative systematic review protocol

OBJECTIVE

The objective of this review is to explore the experiences of mothers with the practice of kangaroo mother care (KMC) for preterm neonates at home in sub-Saharan Africa.

INTRODUCTION

About 7000 newborn babies die every day around the world. About 80% of these deaths occur in sub-Saharan Africa and southern Asia. Preterm birth and low birth weight (LBW) are major causes of newborn deaths in these regions. Kangaroo mother care is an alternative way to care for LBW preterm neonates; however, the rate of practice remains low. Studies have identified a range of barriers, primarily at the healthcare system level, but there is a dearth of evidence on the factors and enablers at the community level.

INCLUSION CRITERIA

The review will consider studies conducted in sub-Saharan Africa on the perceptions and experiences of mothers who have given birth to preterm babies and have practiced KMC at home. Qualitative studies in English and French conducted from January 1979 to the present that exclusively use qualitative research methods including, but not limited to, phenomenology, grounded theory, ethnography, action research and feminist research will be included.

METHODS

PubMed, Embase, Web of Science, Scopus, African Index Medicus (AIM), Academic Search Complete, CINAHL complete, Education Source and Health source: Nursing/Academic Edition will be searched. Eligible studies will be critically appraised using the standardized Joanna Briggs Institute tool. Findings will be pooled using the meta-aggregative approach, and confidence will be assessed according to the ConQual approach.

Barriers and enablers for practicing kangaroo mother care (KMC) in rural Sindh, Pakistan

Background

More than 2.5 million newborns die each year, accounting for 47% of children dying worldwide before their age of five years. Complications of preterm birth are the leading cause of death among newborns. Pakistan is amongst the top ten countries with highest preterm birth rate per 1000 live births. Globally, Every Newborn Action Plan (ENAP) has emphasized on Kangaroo Mother Care (KMC) as an essential component of neonatal health initiatives.

Materials and methods

We conducted this qualitative study with 12 in-depth interviews (IDIs) and 14 focus group discussion (FGD) sessions, in two health facilities of Sindh, Pakistan during October-December 2016, to understand the key barriers and enablers to a mother's ability to practice KMC and the feasibility of implementing and improving these practices.

Results

The findings revealed that community stakeholders were generally aware of health issues especially related to maternal and neonatal health. Both the health care providers and managers were supportive of implementing KMC in their respective health facilities as well as for continuous use of KMC at household level. In order to initiate KMC at facility level, study respondents emphasized on ensuring availability of equipment, supplies, water-sanitation facility, modified patient ward (e.g., curtain, separate room) and quality of services as well as training of health providers as critical prerequisites. Also in order to continue practicing KMC at household level, engaging the community and establishing functional referral linkage between community and facilities were focused issues in facility and community level FGDs and IDIs.

Conclusion

The study participants considered it feasible to initiate KMC practice at health facility and to continue practicing at home after returning from facility. Ensuring facility readiness to initiate KMC, improving capacity of health providers both at facility and community levels, coupled with focusing on community mobilization strategy, targeting specific audiences, may help policy makers and program planners to initiate KMC at health facility and keep KMC practice continued at household level.

A time-motion analysis of the mothers staying in the neonatal care unit

Context:

In addition to various barriers studied for kangaroo mother care (KMC), time opportunities for better implementation of KMC need to be studied.

Aim:

Time–motion analysis of the mother's daily activities was carried out to identify scope to improve KMC.

Settings and Design:

This is a 24-h recall-based questionnaire study. Mothers were interviewed whose newborns were admitted at a tertiary and secondary care neonatal care unit of western India over a period of 9 months from November 2015 to July 2016.

Materials and Methods:

Mothers were approached when the preterm neonate and mother dyad was eligible for KMC, that is, when mothers were physically healthy and newborns were physiologically stable. A total of 60 mothers were enrolled in the study. Mothers’ daily activities were noted, and time spent in each activity was charted for 3 consecutive days. Missed time opportunities which could be used to increase daily KMC hours were studied.

Statistical Analysis Used:

To compare quantitative variables, two-sample unpaired t-test and one-way analysis of variance were used.

Results:

The average time of activities which consumed most was 8.24 h for sleep/rest, 3.46 h for meals/snacks, 4.89 h for breastfeeding, and a daily average of only 1.4 h was used for KMC. A quite a significant proportion, that is, 3.89 h, was spent for meeting relatives which could be used for KMC as well without affecting social meetings.

Conclusion:

Time–motion analysis was helpful to find out weak links in KMC implementation. Providing family-centered environment in terms of implementing KMC during meeting hours with family may augment KMC hours.

Mitigating Infant Medical Trauma in the NICU: Skin-to-Skin Contact as a Trauma-Informed, Age-Appropriate Best Practice

Infant medical trauma in the NICU is associated with serious and lasting consequences. Skin-to-skin contact (SSC) of infants with their parents is a nursing intervention that provides significant benefits and can mitigate the negative consequences of the infant's traumatic experiences in the NICU. The purpose of this article is to explain how SSC aligns with the concept of trauma-informed age-appropriate care (TIAAC) in the NICU. The evidence supporting SSC will be reviewed and discussed using TIAAC as a framework. SSC is an effective and evidence-based care strategy that reduces the infant's traumatic NICU experiences by improving parental proximity, attachment, and lactation; decreasing stress and pain; improving physiologic stability; supporting sleep; and enhancing neurologic outcomes.

Physiology of Stress and Use of Skin-to-Skin Care as a Stress-Reducing Intervention in the NICU

Advances in neonatal care have allowed for the increasing survival of critically ill infants. These infants experience significant stress related to painful procedures and physical separation from their parents. The purpose of this article is to describe the physiologic stress mechanisms that contribute to mortality and morbidity in infants in the NICU and the physiologic mechanisms by which skin-to-skin care (SSC) acts on the stress response system. Findings from current literature supporting the use of SSC and barriers and facilitators to implementation are reviewed. SSC is a safe and effective intervention to reduce stress for infants and their parents. Nurses play a key role in facilitating SSC to optimize outcomes of care in the NICU.

Feasibility assessment of an ergonomic baby wrap for kangaroo mother care: A mixed methods study from Nepal

BACKGROUND

Kangaroo mother care, an evidence based practice and a national policy for management of low birth weight newborns in Nepal, is not widely practiced. This implementation research study aimed to explore the consumer preference and acceptability of the traditional and a new ergonomic wrap on the continuation of kangaroo mother care in the facility and community following discharge.

METHODS

A mixed method feasibility study was done from May to October 2015. Ninety-six families of stable low birth weight newborns weighing 1800 to 2499 grams were counseled and taught to practice kangaroo mother care using both wraps. They were randomized into two groups of 48 with one group trying out the traditional wrap for the first six hours and the new wrap for the next six, and vice versa. Mothers were allowed to choose between the wraps for continuation of kangaroo mother care at the facility and post discharge. They were followed up telephonically weekly over 28 days postpartum to ascertain practice of kangaroo mother care. In-depth interviews with mothers (n = 12) and focus group discussions with health workers (n = 16) further evaluated the intervention. Descriptive statistics are presented for the quantitative part of the study.

RESULTS

Mothers in the two groups chose the new wrap with no significant difference (81.3% vs 89.6%, p = 0.24). Of the 96 randomized mothers, 85% chose the new wrap. During the hospital stay, six mothers dropped out and remaining 90 mothers who were discharged with the intention of continuing Kangaroo Mother Care, 78 and 12 mothers did so with the new and traditional wrap respectively. New wrap users (429.1 hours, 95% confidence interval [CI]: 351.7-470.3) performed skin-to-skin contact for an extra 77.4 hours overall than traditional wrap (351.7 hours, 95%CI: 259.3-444) users from first day to 28 day postpartum. Health workers and mothers reported positive experience with the new wrap as it was easy to wear without assistance, secure and flexible to move around in kangaroo mother care position.

CONCLUSIONS

Involvement of mothers and families with provision of ergonomic wraps showed improvement in kangaroo mother care practice during hospital stay and at home.

Observation study showed that the continuity of skin-to-skin contact with low-birthweight infants in Uganda was suboptimal

AIM

Kangaroo mother care (KMC) is a safe and effective method of reducing neonatal mortality in resource-limited settings, but there has been a lack of data on the duration of skin-to-skin contact (SSC) in busy, low-resource newborn units. Previous studies of intermittent KMC suggest the duration of SSC ranged from 10 minutes to 17 hours per day.

METHODS

This was an observational study of newborn infants born weighing less than 2000 g, which collected quantitative data on SSC over the first week after birth. The study took place in July 2016 in the newborn unit of a low-resource facility in Uganda.

RESULTS

The mean daily duration of SSC over the first week after birth was three hours. This differed significantly from the World Health Organization recommendation of at least 20 hours of SSC per day. SSC was provided by mothers most of the time (73.5%), but other family members also took part, especially on the day of birth.

CONCLUSION

Our study found a disappointingly low daily duration of SSC in this Ugandan newborn unit. However, advocacy and community education of SSC may help to decrease the stigma of KMC, improve overall acceptance and reduce the age at SSC initiation.

Starting the conversation: community perspectives on preterm birth and kangaroo mother care in southern Malawi

Background

Despite introduction of Kangaroo Mother Care (KMC) in Malawi over a decade ago, preterm birth remains the leading cause of neonatal mortality. Although KMC is initiated in the health care facility, robust community follow-up is critical for survival and optimal development of preterm and low birth weight infants post-discharge. The objective of this qualitative study was to gain insight into community and health worker understanding, attitudes, beliefs and practices around preterm and low birth weight babies and KMC in Malawi.

Methods

A total of 152 participants were interviewed in two districts in southern Malawi, Machinga and Thyolo, in April 2015. Focus group discussions (groups = 11, n = 132) were conducted with pregnant women, community members and women who have practiced KMC. In-depth interviews (n = 20) were conducted with fathers who have practiced KMC, community and religious leaders, and health workers. Purposive and snowball sampling were employed to identify participants. Thematic content analysis was conducted.

Findings

KMC mothers and fathers only learned about KMC and care for preterm newborns after delivery of a child in need of this care. Men typically were not included in KMC counseling due to societal gender roles. Health facilities were the main source of information on KMC, however informal networks among women provided some degree of knowledge exchange. Community leaders were regarded as major facilitators of health information, conveners, key influencers, and policy-makers. Religious leaders were regarded as advocates and emotional support for families with preterm infants. Finally, while many participants initially had negative feelings towards preterm births and KMC, the large majority saw a shift in their perceptions through health counseling, peer modeling, and personal success with KMC.

Conclusions

The findings offer several opportunities to improve KMC implementation including 1) earlier introduction of KMC to pregnant women and their families that are at-risk for preterm birth, 2) greater involvement of men in KMC counselling, practice and care for preterm infants, and 3) strengthening and defining partnerships with community and religious leaders. Finally, as parental perceptions of preterm infants and KMC improved with successful KMC practice, it is hopeful that KMC itself can positively affect social norms surrounding preterm infants, leading to a virtuous cycle of improved perceptions of preterm infants and increased uptake of KMC.

Kangaroo mother care for clinically unstable neonates weighing ≤2000 g: Is it feasible at a hospital in Uganda?

BACKGROUND

Kangaroo mother care (KMC) for stable neonates ≤2000 g (g) is associated with decreased mortality, sepsis, hypothermia, and length of stay compared to conventional care. The World Health Organization states that KMC "should be initiated… as soon as newborns are clinically stable" [12]. However, the majority of deaths occur in unstable neonates. We aimed to determine the proportion of admitted neonates meeting proposed instability criteria, assess the feasibility of providing KMC to unstable neonates, and evaluate the acceptability of this intervention to parents and providers at Jinja Regional Referral Hospital in Uganda.

METHODS

This was a mixed-methods study. We recorded data including birthweight, chronological age, and treatments administered from medical charts, and calculated the percentage of clinically unstable neonates, defined as the need for ≥2 medical therapies in the first 48 hours of admission. We enrolled a sample of neonates meeting pre-defined instability criteria. Mothers were counselled to provide KMC as close to continuously as possible. We calculated the median duration of KMC per episode and per day. To explore acceptability, we conducted semi-structured interviews with parents and newborn unit care providers, and analysed data using the thematic content approach.

FINDINGS

We included 254 neonates in the audit, 10 neonates in the feasibility sub-study, and 20 participants in the acceptability sub-study. Instability criteria were easily implementable, identifying 89% of neonates as unstable in the audit. The median duration of individual KMC episodes ranged from 115 to 134 minutes. The median daily duration ranged from 4.5 to 9.7 hours. Seventy-five percent of interviewees felt KMC could be used in neonates concurrently receiving other medical therapies. Barriers included lack of resources (beds/space, monitoring devices), privacy issues, inadequate education, and difficulties motivating mothers to devote time to KMC. Recommendations included staff/peer counselling, resources, family support, and community outreach.

CONCLUSIONS

There remains a need for an evidence-based approach to consistently define stability criteria for KMC to improve care. We found that KMC for unstable neonates weighing ≤2000g was feasible and acceptable at Jinja Hospital in Uganda. Randomised controlled trials are needed to demonstrate the effect of KMC on survival among unstable neonates in low-resource settings.

Report on an international workshop on kangaroo mother care: lessons learned and a vision for the future

Background

Globally, complications of prematurity are the leading cause of death in children under five. Preterm infants who survive their first month of life are at greater risk for various diseases and impairments in infancy, childhood and later life, representing a heavy social and economic burden for families, communities and health and social systems. Kangaroo mother care (KMC) is recommended as a beneficial and effective intervention for improving short- and long-term preterm birth outcomes in low- and high-income settings. Nevertheless, KMC is not as widely used as it should be. The International Network on KMC runs biennial workshops and congresses to help improve the coverage and quality of KMC worldwide. This paper reports the results of the two-day workshop held in November 2016, where 92 participants from 33 countries shared experiences in a series of round tables, group work sessions and plenaries.

Findings

Barriers to and enablers of KMC are discussed with regard to parents, health workers and the health system. Key factors for effective implementation and uptake relate to appropriate training for health staff, adherence to protocols and the creation of a welcoming environment for families. Recommendations for planning for national programmes are made according to a six-stage change model. Resources and the cost of making progress are discussed in terms of investment, maintenance, and acceleration and scaling-up costs. KMC training requirements are presented according to three levels of care. To ensure quality KMC, key requisites are proposed for the different KMC components and for sensitive communication with caregivers. The group attending to the monitoring and evaluation of KMC at a national and subnational level highlight the lack of standard indicator definitions. Key priorities for investment include health services research, harmonisation of indicators, development of a costing tool, programming and scaling up, and the follow-up of preterm infants.

Conclusion

It is hoped that this report will help to further scale-up and sustain KMC through a systematic approach that includes raising commitment, identifying key strategies to address the main barriers and using existing facilitators, ensuring training and quality, agreeing on indicators for monitoring and evaluation, and advancing implementation research.

Increasing Confidence and Ability in Implementing Kangaroo Mother Care Method Among Young Mothers

Mothers giving birth to low birth weight babies (LBWBs) have low confidence in caring for their babies because they are often still young and may lack the knowledge, experience, and ability to care for the baby. This research aims to determine the effect of education about kangaroo mother care (KMC) on the confidence and ability of young mothers to implement KMC. The research methodology used was a controlled-random experimental approach with pre- and post-test equivalent groups of 13 mothers and their LBWBs in the intervention group and 13 mothers and their LBWBs in the control group. Data were collected via an instrument measuring young mothers' confidence, the validity and reliability of which have been tested with a resulting r value of .941, and an observation sheet on KMC implementation. After conducting the education, the confidence score of young mothers and their ability to perform KMC increased meaningfully. The score of confidence of young mothers before education was 37 (p = .1555: and the ability score for KMC Implementation before education was 9 (p = .1555). The median score of confidence of young mothers after education in the intervention group was 87 and in the control group was 50 (p = .001, 95% CI 60.36-75.56), and ability median score for KMC implementation after education in the intervention group was 16 and in the control group was 12 (p = .001, 95% CI 1.50-1.88). KMC education should be conducted gradually, and it is necessary to involve the family, in order for KMC implementation to continue at home. A family visit can be done for LBWBs to evaluate the ability of the young mothers to implement KMC.

Comparison of conventional phototherapy and phototherapy along with Kangaroo mother care on cutaneous bilirubin of neonates with physiological jaundice

BACKGROUND

One of the adjuvant and desirable therapies is skin contact between mother and baby or Kangaroo mother care (KMC) that is a cheap, accessible, relaxing, noninvasive and easy method. This study aimed to compare the effect of conventional phototherapy method and phototherapy along with KMC on cutaneous bilirubin in neonates with physiological jaundice.

MATERIALS AND METHODS

In this randomized clinical trial, all infants with physiological jaundice who referred for phototherapy to Mofid Hospital of Shahid Beheshti University of Medical Sciences, Tehran, Iran were selected by convenience sampling based on inclusion criteria and were randomly assigned into two groups of conventional phototherapy (n = 35) and phototherapy along with KMC (n = 35).

RESULTS

The results showed that there was a significant difference in the average volume of skin bilirubin before treatment with cutaneous bilirubin every 24 h after treatment (p < .001). This significant difference was present in both intervention and control groups. Although the average volume of skin bilirubin every 24 h after treatment was lower in the intervention group than the control group, this difference was not statistically significant (p = .236). Mean duration of hospitalization of infants in the intervention group was significantly lower than the control group (2.09 versus 3.03 d, p < .001).

CONCLUSION

Although KMC along with phototherapy has a favorable effect on the reduction of cutaneous bilirubin in neonates with physiological jaundice, there are not significant differences in routine care. This may need to do KMC for a longer time (more than 1 h) which must be surveyed in the future studies. KMC was effective in reduction of the duration of hospitalization in jaundiced infants.