Translating research findings into practice--the implementation of kangaroo mother care in Ghana

Kangaroo mother care prior to clinical stabilisation: Implementation barriers and facilitators reported by caregivers and healthcare providers in Uganda

Kangaroo mother care (KMC) is an evidence-based method to improve newborn survival. However, scale-up even for stable newborns has been slow, with reported barriers to implementation. We examined facilitators and barriers to initiating KMC before stabilisation amongst neonates recruited to the OMWaNA study in Uganda. The OMWaNA study was a randomised controlled trial that examined the mortality effect of KMC prior to stabilisation amongst newborns weighing ≤2000 grams. At the four trial hospitals, we conducted focus group discussions (FGD) separately with caregivers and healthcare providers, in-depth interviews (IDI) with caregivers and key informant interviews (KII) with hospital administrators and healthcare providers. The World Health Organisation (WHO) Health Systems Building Blocks were used to guide thematic analysis. Eight FGDs (4 caregivers, 4 healthcare providers), 41 caregiver IDIs (26 mothers, 8 grandmothers, 7 fathers), and 23 KIIs were conducted. Key themes based on the building blocks were; family and community support/ involvement, health workforce, medical supplies and commodities, infrastructure and design, financing, and health facility leadership. We found that the presence of a family member in the hospital, adequate provision of healthcare workers knowledgeable in supporting KMC prior to stability, and adequate space for KMC beds where neonatal care is being delivered, can enable implementation of KMC before stability. Implementation barriers included fear of inadvertently causing harm to the newborn, inadequate space to practice KMC in the neonatal unit, and a limited number of trained healthcare workers coupled with insufficient medical supplies.

Launching continuous kangaroo mother care through participatory action research in Iran

BACKGROUND

This study describes the launching of a unit for continuous kangaroo mother care (KMC) in a teaching hospital (Taleghani) in Iran.

METHODS

We used a participatory three-stage action research approach to establish a unit for continuous KMC: design (needs identification and planning for change); implementation (and reflection); and evaluation (and institutionalization). As part of the design and implementation stages, individual and focus group interviews were conducted with mothers, physicians, nurses, other healthcare personnel and policy makers. The evaluation was done by means of a standardized tool specifically developed for monitoring progress with the implementation of KMC.

RESULTS

Four themes relating to potential barriers to implementation emerged from the analysis of the staff interviews, namely barriers associated with the mother, the father, the physician and the health system. Mothers' experiences of barriers were grouped into five themes: personal discomfort, fear, healthcare provider attitudes and actions, infrastructure constraints and family matters. An implementation progress score of 27.05 out of 30 was achieved, indicating that the continuous KMC unit was on the path to institutionalization. Some of the gaps identified related to policies on resource allocation, the discharge and follow-up system, and the transportation of infants in the KMC position.

CONCLUSION

The study findings indicated that participatory action research is a suitable method for studying the establishment of a continuous KMC unit. When action research is practiced, there is a prospect of turning knowledge into action in the real world.

Maternal factors and child health conditions at birth associated with preterm deaths in a tertiary health facility in Ghana: A retrospective analysis

Background

Preterm birth continues to be a leading cause of death for children under the age of 5 globally. This issue carries significant economic, psychological, and social costs for the families affected. Therefore, it is important to utilize available data to further research and understand the risk factors for preterm death.

Objective

The objective of this study was to determine maternal and infant complications that influence preterm deaths in a tertiary health facility in Ghana.

Methods

A retrospective analysis of data on preterm newborns was conducted at the neonatal intensive care unit of Korle Bu Teaching Hospital (KBTH NICU) in Ghana, covering the period January 2017 to May 2019. Pearson's Chi-square test of association was used to identify factors that were significantly associated with preterm death after admission at the NICU. The Poisson regression model was used to determine the risk factors of preterm death before discharge after admission to the NICU.

Results

Of the 1,203 preterm newborns admitted to the NICU in about two and half years, 355 (29.5%) died before discharge, 7.0% (n = 84) had normal birth weight (>2.5 kg), 3.3% (n = 40) had congenital anomalies and 30.5% (n = 367) were born between 34 and 37 gestational week. All 29 preterm newborns between the 18-25 gestational week died. None of the maternal conditions were significant risk factors of preterm death in the multivariable analysis. The risk of death at discharge was higher among preterm newborns with complications including hemorrhagic/hematological disorders of fetus (aRRR: 4.20, 95% CI: [1.70-10.35], p = 0.002), fetus/newborn infections (aRRR: 3.04, 95% CI: [1.02-9.04], p = 0.046), respiratory disorders (aRRR: 13.08, 95% CI: [5.50-31.10], p < 0.001), fetal growth disorders/restrictons (aRRR: 8.62, 95% CI: [3.64-20.43], p < 0.001) and other complications (aRRR: 14.57, 95% CI: [5.93-35.77], p < 0.001).

Conclusion

This study demonstrate that maternal factors are not significant risk factors of preterm deaths. Gestational age, birth weight, presence of complications and congenital anomalies at birth are significantly associated with preterm deaths. Interventions should focus more on child health conditions at birth to reduce the death of preterm newborns.

Barriers and facilitators to kangaroo mother care implementation in Cote d'Ivoire: a qualitative study

Background

Kangaroo Mother Care (KMC) is a high impact, low technology and cost-effective intervention for the care of preterm and low birth weight newborn. Cote d’Ivoire adopted the intervention and opened the first KMC unit in 2019. This study aimed to assess barriers and facilitators of KMC implementation in Cote d’Ivoire, a year after its introduction, as well as proposed solutions for improving KMC implementation in the country.

Method

This was a qualitative study, using semi-structured interviews, carried out in September 2020 in the first KMC unit opened at the Teaching Hospital of Treichville. The study involved healthcare providers providing KMC and mothers of newborn who were receiving or received KMC at the unit. A thematic analysis was performed using both inductive and deductive (Consolidated Framework for Implementation Research-driven) approaches. NVivo 12 was used to assist with coding.

Results

A total of 44 semi-structured interviews were conducted, 12 with healthcare providers and 32 with mothers. The barriers identified were lack of supplies, insufficiency of human resources, lack of space for admission, lack of home visits, lack of food for mothers, lack of collaboration between health services involved in newborn care, increased workload, the beliefs of carrying the baby on the chest, father’s resistance, low rate of exclusive breastfeeding, lack of community awareness. Facilitators identified were training of healthcare providers, strong leadership, the low cost of KMC, healthcare providers’ perceived value of KMC, mothers−healthcare providers’ relationship, mothers’ adherence to KMC and the capacity of the KMC unit to network with external organizations. The proposed solutions for improving KMC implementation were volunteer staff motivation, intensifying education and counselling of mothers and families, the recruitment of a psychologist and the involvement of all stakeholders.

Conclusion

Our study highlighted the challenges to implement KMC in Cote d’Ivoire with unique and specific barriers to implementation. We recommend to researchers and decision makers to respectively design strategies and adopt intervention that specifically address these barriers and facilitators to a better uptake of KMC. Decision makers should also take into account the proposed solutions for a better implementation and scaling up of KMC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07086-9.

A Survey of Neonatal Clinicians' Use, Needs, and Preferences for Kangaroo Care Devices

BACKGROUND

Decades of research supports the benefits of kangaroo care (KC) for the parent and newborn. Supportive KC devices may be an important tool clinicians can use to assist parents with KC. In recent years, there has been a rise in the availability of KC devices. However, the use, needs, and preferences for these supportive devices by neonatal clinicians have not been documented.

PURPOSE

To survey clinicians' use, needs, and preferences of KC supportive devices, and examine whether differences exist based on clinician and organizational characteristics.

METHODS

A cross-sectional, online survey was sent through neonatal organization Web sites, conferences, and social media.

RESULTS

Many clinicians (n = 68, 43%; N = 158) facilitated KC with a supportive device, with 81% of devices provided by the clinician's employer. The most important "Must Have" feature of a KC device was "Safety: Reduces patient falls if caregiver sleeps or needs to use hands" (84% of respondents) followed by washability (82%), and "immediate, effective access to the baby" (78%). Clinicians' responses did not differ based on hospital setting, type of unit, KC experience, or experience using a KC device.

IMPLICATIONS FOR PRACTICE

To support safe use of KC devices in neonatal intensive care unit (NICU) clinical care, a device must hold the proper KC position consistently, allow immediate access to the infant, and hold the infant in place without the parent's hands to prevent falls. Training is needed to ensure safe device use.

IMPLICATIONS FOR RESEARCH

Future research should evaluate the safety, efficacy, and cost-effectiveness of these devices.

Barriers and facilitators of facility-based kangaroo mother care in sub-Saharan Africa: a systematic review

Background

Hospital-based kangaroo mother care can help reduce preventable newborn deaths and has been recommended by the World Health Organization in the care of low birthweight babies weighing 2000 g or less. However, implementation has been limited. The objective of this review is to understand the barriers and facilitators of kangaroo mother care implementation in health facilities in sub-Saharan Africa, where there are the highest rates of neonatal mortality in the world.

Methods

A systematic search was performed on MEDLINE, Web of Science, Cumulative Index to Nursing and Allied Health, African Journals Online, African Index Medicus as well as the references of relevant articles. Inclusion criteria included primary research, facility-based kangaroo mother care in sub-Saharan Africa. Studies were assessed by the Critical Appraisal Skills Programme Qualitative Checklist and the National Institutes of Health quality assessment tools and underwent narrative synthesis.

Results

Thirty studies were included in the review. This review examined barriers and facilitators to kangaroo mother care practice at health systems level, health worker experiences and perspectives of mothers and their families. Strong local leadership was essential to overcome barriers of inadequate space, limited budget for supplies, inadequate staffing, lack of guidelines and policies and insufficient supportive supervision. Workload burdens, knowledge gaps and staff attitudes were highlighted as challenges at health workers’ level, which could be supported by sharing of best practices and success stories. Support for mothers and their families was also identified as a gap.

Conclusion

Building momentum for kangaroo mother care in health facilities in sub-Saharan Africa continues to be a challenge. Strengthening health systems and communication, prioritizing preterm infant care in public health strategies and supporting health workers and mothers and their families as partners in care are important to scale up. This will support sustainable kangaroo mother care implementation as well as strengthen quality of newborn care overall. PROSPERO registration: CRD42020166742.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03646-3.

What is stopping us? An implementation science study of kangaroo care in British Columbia's neonatal intensive care units

BACKGROUND

The goal of the Neonatal Intensive Care Unit (NICU) is to provide optimal care for preterm and sick infants while supporting their growth and development. The NICU environment can be stressful for preterm infants and often cannot adequately support their neurodevelopmental needs. Kangaroo Care (KC) is an evidence-based developmental care strategy that has been shown to be associated with improved short and long term neurodevelopmental outcomes for preterm infants. Despite evidence for best practice, uptake of the practice of KC in resource supported settings remains low. The aim of this study was to identify and describe healthcare providers' perspectives on the barriers and enablers of implementing KC.

METHODS

This qualitative study was set in 11 NICUs in British Columbia, Canada, ranging in size from 6 to 70 beds, with mixed levels of care from the less acute up to the most complex acute neonatal care. A total of 35 semi-structured healthcare provider interviews were conducted to understand their experiences providing KC in the NICU. Data were coded and emerging themes were identified. The Consolidated Framework for Implementation Research (CFIR) guided our research methods.

RESULTS

Four overarching themes were identified as barriers and enablers to KC by healthcare providers in their particular setting: 1) the NICU physical environment; 2) healthcare provider beliefs about KC; 3) clinical practice variation; and 4) parent presence. Depending on the specific features of a given site these factors functioned as an enabler or barrier to practicing KC.

CONCLUSIONS

A 'one size fits all' approach cannot be identified to guide Kangaroo Care implementation as it is a complex intervention and each NICU presents unique barriers and enablers to its uptake. Support for improving parental presence, shifting healthcare provider beliefs, identifying creative solutions to NICU design and space constraints, and the development of a provincial guideline for KC in NICUs may together provide the impetus to change practice and reduce barriers to KC for healthcare providers, families, and administrators at local and system levels.

Barriers for kangaroo mother care (KMC) acceptance, and practices in southern Ethiopia: a model for scaling up uptake and adherence using qualitative study

BACKGROUND

Globally, approximately 15 million babies are born preterm every year. Complications of prematurity are the leading cause of under-five mortality. There is overwhelming evidence from low, middle, and high-income countries supporting kangaroo mother care (KMC) as an effective strategy to prevent mortality in both preterm and low birth weight (LBW) babies. However, implementation and scale-up of KMC remains a challenge, especially in lowincome countries such as Ethiopia. This formative research study, part of a broader KMC implementation project in Southern Ethiopia, aimed to identify the barriers to KMC implementation and to devise a refined model to deliver KMC across the facility to community continuum.

METHODS

A formative research study was conducted in Southern Ethiopia using a qualitative explorative approach that involved both health service providers and community members. Twenty-fourin-depth interviewsand 14 focus group discussions were carried out with 144study participants. The study applied a grounded theory approach to identify,examine, analyse and extract emerging themes, and subsequently develop a model for KMC implementation.

RESULTS

Barriers to KMC practice included gaps in KMC knowledge, attitude and practices among parents of preterm and LBW babies;socioeconomic, cultural and structural factors; thecommunity's beliefs and valueswith respect to preterm and LBW babies;health professionals' acceptance of KMC as well as their motivation to implement practices; and shortage of supplies in health facilities.

CONCLUSIONS

Our study suggests a comprehensive approach with systematic interventions and support at maternal, family, community, facility and health care provider levels. We propose an implementation model that addresses this community to facility continuum.

"So sometimes, it looks like it's a neglected ward": Health worker perspectives on implementing kangaroo mother care in southern Malawi

Introduction

Kangaroo mother care (KMC) involves continuous skin-to-skin contact of baby on mother’s chest to provide warmth, frequent breastfeeding, recognizing danger signs of illness, and early discharge. Though KMC is safe, effective and recommended by the World Health Organization, implementation remains limited in practice. The objective of this study is to understand barriers and facilitators to KMC practice at tertiary and secondary health facilities in southern Malawi from the perspective of health workers.

Methods

This study is part of the “Integrating a neonatal healthcare package for Malawi” project in the Innovating for Maternal and Child Health in Africa initiative. In-depth interviews were conducted between May-Aug 2019 with a purposively drawn sample of service providers and supervisors working in newborn health at a large tertiary hospital and three district-level hospitals in southern Malawi. Data were analyzed using a thematic approach using NVivo 12 software (QSR International, Melbourne, Australia).

Findings

A total of 27 nurses, clinical officers, paediatricians and district health management officials were interviewed. Staff attitudes, inadequate resources and reliance on families emerged as key themes. Health workers from Malawi described KMC practice positively as a low-cost, low-technology solution appropriate for resource-constrained health settings. However, staff perceptions that KMC babies were clinically stable was associated with lower prioritization in care and poor monitoring practices. Neglect of the KMC ward by medical staff, inadequate staffing and reliance on caregivers for supplies were associated with women self-discharging early.

Conclusion

Though routine uptake of KMC was policy for stable low birthweight and preterm infants in the four hospitals, there were gaps in monitoring and maintenance of practice. While conceptualized as a low-cost intervention, sustainable implementation requires investments in technologies, staffing and hospital provisioning of basic supplies such as food, bedding, and KMC wraps. Strengthening hospital capacities to support KMC is needed as part of a continuum of care for premature infants.

Facilitating factors and barriers to accessibility and utilization of kangaroo mother care service among parents of low birth weight infants in Mangochi District, Malawi: a qualitative study

Background

Kangaroo Mother Care (KMC) is one of the interventions widely used in low-income countries to manage Low Birth Weight Infants (LBWIs), a global leading cause of neonatal and child mortality. LBWI largely contributes to neonatal mortality in Malawi despite the country strengthening and implementing KMC, nationwide, to enhance the survival of LBWIs. This qualitative study aimed to assess the facilitating factors and barriers to accessibility and utilization of KMC service by the parent of low birth weight infants (PLBWIs) in Mangochi District, Malawi.

Methods

Two focused group discussions assessed factors facilitating and hindering the accessibility and utilization of KMC service were conducted in April 2018 that reached out to (N = 12) participants; (n:6) PLBWI practicing KMC at Mangochi district hospital (MDH) referred from four health facilities and (n:6) high-risk pregnant mothers (HRPMs) visiting antenatal care (ANC) clinic at MDH. The availability of KMC at MDH was assessed using KMC availability checklist. The study used purposive, convenient and simple random sampling to identify eligible participants. Thematic analysis was used to analyze the findings.

Results

Sixteen themes emerged on facilitating factors and barriers to accessibility and utilization of KMC service by the PLBWIs. The identified themes included; availability of KMC providers, social factor (social support and maternal love), timing of KMC information, knowledge on KMC, health linkage systems, recognition of LBWIs, safety on the use of KMC, preference of LBWI’s care practice, lived experience on KMC practice, KMC expert clients, perceived causes of LBWI births, cultural/traditional factors, religious beliefs, health-seeking behavior, women empowerment and quality of care.

Conclusions

Although KMC was available in some of the health facilities, integration of KMC messages in ANC guidelines, community awareness and in sensitization of any health intervention may enhance KMC accessibility and utilization by the targeted population.

Protocol for a randomised trial of early kangaroo mother care compared to standard care on survival of pre-stabilised preterm neonates in The Gambia (eKMC)

BACKGROUND

Complications of preterm birth cause more than 1 million deaths each year, mostly within the first day after birth (47%) and before full post-natal stabilisation. Kangaroo mother care (KMC), provided as continuous skin-to-skin contact for 18 h per day to fully stabilised neonates ≤ 2000 g, reduces mortality by 36-51% at discharge or term-corrected age compared with incubator care. The mortality effect of starting continuous KMC before stabilisation is a priority evidence gap, which we aim to investigate in the eKMC trial, with a secondary aim of understanding mechanisms, particularly for infection prevention.

METHODS

We will conduct a single-site, non-blinded, individually randomised, controlled trial comparing two parallel groups to either early (within 24 h of admission) continuous KMC or standard care on incubator or radiant heater with KMC when clinically stable at > 24 h of admission. Eligible neonates (n = 392) are hospitalised singletons or twins < 2000 g and 1-24 h old at screening who are mild to moderately unstable as per a trial definition using cardio-respiratory parameters. Randomisation is stratified by weight category (< 1200 g; ≥ 1200 g) and in random permuted blocks of varying sizes with allocation of twins to the same arm. Participants are followed up to 28 ± 5 days of age with regular inpatient assessments plus criteria-led review in the event of clinical deterioration. The primary outcome is all-cause neonatal mortality by age 28 days. Secondary outcomes include the time to death, cardio-respiratory stability, hypothermia, exclusive breastfeeding at discharge, weight gain at age 28 days, clinically suspected infection (age 3 to 28 days), intestinal carriage of extended-spectrum beta-lactamase producing (ESBL) Klebsiella pneumoniae (age 28 days), and duration of the hospital stay. Intention-to-treat analysis will be applied for all outcomes, adjusting for twin gestation.

DISCUSSION

This is one of the first clinical trials to examine the KMC mortality effect in a pre-stabilised preterm population. Our findings will contribute to the global evidence base in addition to providing insights into the infection prevention mechanisms and safety of using this established intervention for the most vulnerable neonatal population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03555981. Submitted 8 May 2018 and registered 14 June 2018. Prospectively registered.

A multi-year analysis of kangaroo mother care outcomes in low birth weight babies at a Nyakahanga Hospital in rural Tanzania

BACKGROUND

Kangaroo Mother Care (KMC) requires few specialized resources, reduces mortality, and can be implemented in low resource environments. It is now recommended for implementation around the globe.

OBJECTIVES

This paper discusses KMC use with low birth weight newborns at a Tanzania hospital providing valuable outcomes assessment of KMC use in rural areas of sub-Saharan Africa.

METHODS

The research used retrospective records (136 Low Birth Weight (LBW) and 33 Very Low Birth Weight (VLBW) neonates) supplemented by observations. Data included weights (longitudinal), survival period, and cause of death if it occurred. This hospital's KMC use and study data began when the mother-baby dyad was referred, usually birth day.

RESULTS

This KMC group demonstrated 70% survival, but 77% of deaths occur within 24 hours. After the first 24 hours, KMC survival rate was 92%. Even VLBW neonates (<1000 g) had 37.5% survival among the KMC program. Prematurity and respiratory distress caused nearly half of the deaths, but hypothermia (19% of deaths) and infection were factors also.

CONCLUSION

Our study indicates the value of KMC in rural low resource environments. Results are comparable to KMC programs in urban areas where newborns begin KMC after stabilization and better than outcomes reported for comparable populations not practicing KMC in rural sub-Saharan Africa.

Operationalising kangaroo Mother care before stabilisation amongst low birth Weight Neonates in Africa (OMWaNA): protocol for a randomised controlled trial to examine mortality impact in Uganda

BACKGROUND

There are 2.5 million neonatal deaths each year; the majority occur within 48 h of birth, before stabilisation. Evidence from 11 trials shows that kangaroo mother care (KMC) significantly reduces mortality in stabilised neonates; however, data on its effect among neonates before stabilisation are lacking. The OMWaNA trial aims to determine the effect of initiating KMC before stabilisation on mortality within seven days relative to standard care. Secondary objectives include exploring pathways for the intervention's effects and assessing incremental costs and cost-effectiveness between arms.

METHODS

We will conduct a four-centre, open-label, individually randomised, superiority trial in Uganda with two parallel groups: an intervention arm allocated to receive KMC and a control arm receiving standard care. We will enrol 2188 neonates (1094 per arm) for whom the indication for KMC is 'uncertain', defined as receiving ≥ 1 therapy (e.g. oxygen). Admitted singleton, twin and triplet neonates (triplet if demise before admission of ≥ 1 baby) weighing ≥ 700-≤ 2000 g and aged ≥ 1-< 48 h are eligible. Treatment allocation is random in a 1:1 ratio between groups, stratified by weight and recruitment site. The primary outcome is mortality within seven days. Secondary outcomes include mortality within 28 days, hypothermia prevalence at 24 h, time from randomisation to stabilisation or death, admission duration, time from randomisation to exclusive breastmilk feeding, readmission frequency, daily weight gain, infant-caregiver attachment and women's wellbeing at 28 days. Primary analyses will be by intention-to-treat. Quantitative and qualitative data will be integrated in a process evaluation. Cost data will be collected and used in economic modelling.

DISCUSSION

The OMWaNA trial aims to assess the effectiveness of KMC in reducing mortality among neonates before stabilisation, a vulnerable population for whom its benefits are uncertain. The trial will improve understanding of pathways underlying the intervention's effects and will be among the first to rigorously compare the incremental cost and cost-effectiveness of KMC relative to standard care. The findings are expected to have broad applicability to hospitals in sub-Saharan Africa and southern Asia, where three-quarters of global newborn deaths occur, as well as important policy and programme implications.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02811432. Registered on 23 June 2016.

Barriers and enablers of kangaroo mother care implementation from a health systems perspective: a systematic review

Kangaroo Mother Care (KMC) is an evidence-based intervention that reduces neonatal morbidity and mortality. However, adoption among health systems has varied. Understanding the interaction between health system functions—leadership, financing, healthcare workers (HCWs), technologies, information and research, and service delivery—and KMC is essential to understanding KMC adoption. We present a systematic review of the barriers and enablers of KMC implementation from the perspective of health systems, with a focus on HCWs and health facilities. Using the search terms ‘kangaroo mother care’, ‘skin to skin (STS) care’ and ‘kangaroo care’, we searched Embase, Scopus, Web of Science, Pubmed, and World Health Organization Regional Databases. Reports and hand searched references from publications were also included. Screening and data abstraction were conducted by two independent reviewers using standardized forms. A conceptual model to assess KMC adoption themes was developed using NVivo software. Our search strategy yielded 2875 studies. We included 86 studies with qualitative data on KMC implementation from the perspective of HCWs and/or facilities. Six themes emerged on barriers and enablers to KMC adoption: buy-in and bonding; social support; time; medical concerns; training; and cultural norms. Analysis of interactions between HCWs and facilities yielded further barriers and enablers in the areas of training, communication, and support. HCWs and health facilities serve as two important adopters of Kangaroo Mother Care within a health system. The complex components of KMC lead to multifaceted barriers and enablers to integration, which inform facility, regional, and country-level recommendations for increasing adoption. Further research of methods to promote context-specific adoption of KMC at the health systems level is needed.

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.

The three waves in implementation of facility-based kangaroo mother care: a multi-country case study from Asia

Background

Kangaroo mother care has been highlighted as an effective intervention package to address high neonatal mortality pertaining to preterm births and low birth weight. However, KMC uptake and service coverage have not progressed well in many countries. The aim of this case study was to understand the institutionalisation processes of facility-based KMC services in three Asian countries (India, Indonesia and the Philippines) and the reasons for the slow uptake of KMC in these countries.

Methods

Three main data sources were available: background documents providing insight in the state of implementation of KMC in the three countries; visits to a selection of health facilities to gauge their progress with KMC implementation; and data from interviews and meetings with key stakeholders.

Results

The establishment of KMC services at individual facilities began many years before official prioritisation for scale-up. Three major themes were identified: pioneers of facility-based KMC; patterns of KMC knowledge and skills dissemination; and uptake and expansion of KMC services in relation to global trends and national policies.

Pioneers of facility-based KMC were introduced to the concept in the 1990s and established the practice in a few individual tertiary or teaching hospitals, without further spread. A training method beneficial to the initial establishment of KMC services in a country was to send institutional health-professional teams to learn abroad, notably in Colombia. Further in-country cascading took place afterwards and still later on KMC was integrated into newborn and obstetric care programs.

The patchy uptake and expansion of KMC services took place in three phases aligned with global trends of the time: the pioneer phase with individual champions while the global focus was on child survival (1998–2006); the newborn-care phase (2007–2012); and lastly the current phase where small babies are also included in action plans.

Conclusions

This paper illustrates the complexities of implementing a new healthcare intervention. Although preterm care is currently in the limelight, clear and concerted country-led KMC scale-up strategies with associated operational plans and budgets are essential for successful scale-up.

Innovative approaches for improving maternal and newborn health--A landscape analysis

Background

Essential interventions can improve maternal and newborn health (MNH) outcomes in low- and middle-income countries, but their implementation has been challenging. Innovative MNH approaches have the potential to accelerate progress and to lead to better health outcomes for women and newborns, but their added value to health systems remains incompletely understood. This study’s aim was to analyze the landscape of innovative MNH approaches and related published evidence.

Methods

Systematic literature review and descriptive analysis based on the MNH continuum of care framework and the World Health Organization health system building blocks, analyzing the range and nature of currently published MNH approaches that are considered innovative. We used 11 databases (MedLine, Web of Science, CINAHL, Cochrane, Popline, BLDS, ELDIS, 3ie, CAB direct, WHO Global Health Library and WHOLIS) as data source and extracted data according to our study protocol.

Results

Most innovative approaches in MNH are iterations of existing interventions, modified for contexts in which they had not been applied previously. Many aim at the direct organization and delivery of maternal and newborn health services or are primarily health workforce interventions. Innovative approaches also include health technologies, interventions based on community ownership and participation, and novel models of financing and policy making. Rigorous randomized trials to assess innovative MNH approaches are rare; most evaluations are smaller pilot studies. Few studies assessed intervention effects on health outcomes or focused on equity in health care delivery.

Conclusions

Future implementation and evaluation efforts need to assess innovations’ effects on health outcomes and provide evidence on potential for scale-up, considering cost, feasibility, appropriateness, and acceptability. Measuring equity is an important aspect to identify and target population groups at risk of service inequity. Innovative MNH interventions will need innovative implementation, evaluation and scale-up strategies for their sustainable integration into health systems.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-015-0784-9) contains supplementary material, which is available to authorized users.

Kangaroo mother care: a systematic review of barriers and enablers

OBJECTIVE

To investigate factors influencing the adoption of kangaroo mother care in different contexts.

METHODS

We searched PubMed, Embase, Scopus, Web of Science and the World Health Organization's regional databases, for studies on "kangaroo mother care" or "kangaroo care" or "skin-to-skin care" from 1 January 1960 to 19 August 2015, without language restrictions. We included programmatic reports and hand-searched references of published reviews and articles. Two independent reviewers screened articles and extracted data on carers, health system characteristics and contextual factors. We developed a conceptual model to analyse the integration of kangaroo mother care in health systems.

FINDINGS

We screened 2875 studies and included 112 studies that contained qualitative data on implementation. Kangaroo mother care was applied in different ways in different contexts. The studies show that there are several barriers to implementing kangaroo mother care, including the need for time, social support, medical care and family acceptance. Barriers within health systems included organization, financing and service delivery. In the broad context, cultural norms influenced perceptions and the success of adoption.

CONCLUSION

Kangaroo mother care is a complex intervention that is behaviour driven and includes multiple elements. Success of implementation requires high user engagement and stakeholder involvement. Future research includes designing and testing models of specific interventions to improve uptake.

Barriers and enablers of kangaroo mother care practice: a systematic review

Kangaroo mother care (KMC) is an evidence-based approach to reducing mortality and morbidity in preterm infants. Although KMC is a key intervention package in newborn health initiatives, there is limited systematic information available on the barriers to KMC practice that mothers and other stakeholders face while practicing KMC. This systematic review sought to identify the most frequently reported barriers to KMC practice for mothers, fathers, and health practitioners, as well as the most frequently reported enablers to practice for mothers. We searched nine electronic databases and relevant reference lists for publications reporting barriers or enablers to KMC practice. We identified 1,264 unique publications, of which 103 were included based on pre-specified criteria. Publications were scanned for all barriers / enablers. Each publication was also categorized based on its approach to identification of barriers / enablers, and more weight was assigned to publications which had systematically sought to understand factors influencing KMC practice. Four of the top five ranked barriers to KMC practice for mothers were resource-related: "Issues with the facility environment / resources," "negative impressions of staff attitudes or interactions with staff," "lack of help with KMC practice or other obligations," and "low awareness of KMC / infant health." Considering only publications from low- and middle-income countries, "pain / fatigue" was ranked higher than when considering all publications. Top enablers to practice were included "mother-infant attachment" and "support from family, friends, and other mentors." Our findings suggest that mother can understand and enjoy KMC, and it has benefits for mothers, infants, and families. However, continuous KMC may be physically and emotionally difficult, and often requires support from family members, health practitioners, or other mothers. These findings can serve as a starting point for researchers and program implementers looking to improve KMC programs.

Helping small babies survive: an evaluation of facility-based Kangaroo Mother Care implementation progress in Uganda

Introduction

Prematurity is the leading cause of newborn death in Uganda, accounting for 38% of the nation's 39,000 annual newborn deaths. Kangaroo mother care is a high-impact; cost-effective intervention that has been prioritized in policy in Uganda but implementation has been limited.

Methods

A standardised, cross-sectional, mixed-method evaluation design was used, employing semi-structured key-informant interviews and observations in 11 health care facilities implementing kangaroo mother care in Uganda.

Results

The facilities visited scored between 8.28 and 21.72 out of the possible 30 points with a median score of 14.71. Two of the 3 highest scoring hospitals were private, not-for-profit hospitals whereas the second highest scoring hospital was a central teaching hospital. Facilities with KMC services are not equally distributed throughout the country. Only 4 regions (Central 1, Central 2, East-Central and Southwest) plus the City of Kampala were identified as having facilities providing KMC services.

Conclusion

KMC services are not instituted with consistent levels of quality and are often dependent on private partner support. With increasing attention globally and in country, Uganda is in a unique position to accelerate access to and quality of health services for small babies across the country.

Implementing facility-based kangaroo mother care services: lessons from a multi-country study in Africa

BACKGROUND

Some countries have undertaken programs that included scaling up kangaroo mother care. The aim of this study was to systematically evaluate the implementation status of facility-based kangaroo mother care services in four African countries: Malawi, Mali, Rwanda and Uganda.

METHODS

A cross-sectional, mixed-method research design was used. Stakeholders provided background information at national meetings and in individual interviews. Facilities were assessed by means of a standardized tool previously applied in other settings, employing semi-structured key-informant interviews and observations in 39 health care facilities in the four countries. Each facility received a score out of a total of 30 according to six stages of implementation progress.

RESULTS

Across the four countries 95 per cent of health facilities assessed demonstrated some evidence of kangaroo mother care practice. Institutions that fared better had a longer history of kangaroo mother care implementation or had been developed as centres of excellence or had strong leaders championing the implementation process. Variation existed in the quality of implementation between facilities and across countries. Important factors identified in implementation are: training and orientation; supportive supervision; integrating kangaroo mother care into quality improvement; continuity of care; high-level buy in and support for kangaroo mother care implementation; and client-oriented care.

CONCLUSION

The integration of kangaroo mother care into routine newborn care services should be part of all maternal and newborn care initiatives and packages. Engaging ministries of health and other implementing partners from the outset may promote buy in and assist with the mobilization of resources for scaling up kangaroo mother care services. Mechanisms for monitoring these services should be integrated into existing health management information systems.

Progress with the implementation of kangaroo mother care in four regions in Ghana

AIM

To measure progress with the implementation of kangaroo mother care (KMC) for low birth-weight (LBW) infants at a health systems level.

DESIGN

Action research design, with district and regional hospitals as the unit of analysis.

SETTING

Four regions in Ghana, identified by the Ghana Health Service and UNICEF.

PARTICIPANTS

Health workers and officials, health care facilities and districts in the four regions.

INTERVENTION

A one-year implementation programme with three phases: (1) introduction to KMC, skills development in KMC practice and the management of implementation; (2) advanced skills development for regional steering committee members; and (3) an assessment of progress at the end of the intervention.

MAIN OUTCOME MEASURES

Description of practices, services and facilities for KMC and the identification of strengths and challenges.

RESULTS

Twenty-six of 38 hospitals (68%) demonstrated sufficient progress with KMC implementation. Half of the hospitals had designated a special ward for KMC. 66% of hospitals used a special record for infants receiving KMC. Two of the main challenges were lack of support for mothers who had to remain with their LBW infants in hospital and no follow-up review services for LBW infants in 39% of hospitals.

CONCLUSIONS

It was possible to roll out KMC in Ghana, but further support for the regions is needed to maintain the momentum. Lessons learned from this project could inform further scale-up of KMC and other projects in Ghana.