Impact of community-initiated Kangaroo Mother Care on survival of low birth weight infants: study protocol for a randomized controlled trial

Kangaroo Mother Care for Low-Birth-Weight Babies in Low and Middle-Income Countries: A Narrative Review

In low and middle-income countries (LMICs), the infant mortality rate is much higher than the high-income countries (HICs). The higher infant mortality is due to low birth weight (LBW) a combination of intra-uterine growth retardation (IUGR) and prematurity, which are risk factors for acquiring infectious diseases amongst newborns. Kangaroo mother care (KMC) is a neonatal procedure that is carried out in newborn infants, especially in preterm babies and LBW babies. It is skin-to-skin contact between a mother's bare chest and a stable infant. KMC is an important intervention in reducing infant mortality rates in LMICs. A comprehensive literature and data search was done using key databases like PubMed and Google Scholar. A total of 42 articles out of 1,168 articles were selected for review after screening and elimination of the repeated articles. Through this review we have tried to analyse the benefits of KMC in newborns, the need for the participation of fathers and family members, and the need for implementation of this practice at a broader level by policy formulation in LMICs. We have also discussed the need for KMC for the prevention of infant mortality in LBW newborns in LMICs.

Effect of kangaroo mother care initiated in community settings on financial risk protection of low-income households: a randomised controlled trial in Haryana, India

INTRODUCTION

Many families in low-income and middle-income countries have high out-of-pocket expenditures (OOPE) for healthcare, and some face impoverishment. We aimed to assess the effect of Kangaroo Mother Care initiated in community setting (ciKMC) on financial risk protection estimated by healthcare OOPE, catastrophic healthcare expenditure (CHE) and impoverishment due to healthcare seeking for low birthweight infants, using a randomised controlled trial design.

METHODS

We included 4475 low birthweight infants randomised to a ciKMC (2491 infants) and a control (1984 infants) arm, in a large trial conducted between 2017 and 2018 in Haryana, India. We used generalised linear models of the Gaussian family with an identity link to estimate the mean difference in healthcare OOPE, and Cox regression to estimate the HRs for CHE and impoverishment, between the trial arms.

RESULTS

Overall, in the 8-week observation period, the mean healthcare OOPE per infant was lower (US$20.0) in the ciKMC arm compared with the control arm (US$25.6) that is, difference of -US$5.5, 95% CI -US$11.4 to US$0.3, p=0.06). Among infants who sought care it was US$8.5 (95% CI -US$17.0 to -US$0.03, p=0.03) lower in the ciKMC arm compared with the control arm. The HR for impoverishment due to healthcare seeking was 0.56 (95% CI 0.36 to 0.89, p=0.01) and it was 0.91 (95% CI 0.74 to 1.12, p=0.37) for CHE.

CONCLUSION

ciKMC can substantially reduce the cost of care seeking and the risk of impoverishment for households. Our findings show that supporting mothers to provide KMC to low birthweight infants at home, in addition to reducing early infant mortality, may provide financial risk protection.

TRIAL REGISTRATION NUMBER

CTRI/2017/10/010114.

A Narrative Review of Kangaroo Mother Care (KMC) and Its Effects on and Benefits for Low Birth Weight (LBW) Babies

Kangaroo mother care (KMC) is a preventative, economical method for infants with low birth weight (LBW). KMC benefits LBW infants in a number of ways. This review standpoints the effect of KMC on the weight gain of LBW neonates. KMC also improves breastfeeding rates during the hospital stay as well as at home. KMC can be provided not only by mothers but also by fathers and other adults in the family. However, it is not routinely practiced in hospitals. Short-term and long-term KMC is beneficial for survival, neurodevelopment, breastfeeding, and mother-infant bonding. Preterm infants are more likely to experience neonatal mortality and morbidity due to acute breathing problems, gastrointestinal problems, autoimmune disorders, and neurological defects as compared to full-term and normal-weight infants. A thorough literature search was conducted using key databases like PubMed and Google Scholar, as well as Medical Subject Heading (MeSH) terms and related keywords. Clinical health experts also believed that implementing KMC would assist mothers in developing more solid emotional bonds with their newborns. As a result, both mothers and their newborns felt more secure, and the babies were more relaxed. KMC was also seen to support the infants' growth and development, which improved the mothers' sense of connection. It is crucial to remember that KMC works better for babies with very low birth weight (VLBW). The mother-child relationship enhances sucking-feeding, and KMC infants have higher means of growth parameters.

Effect of community-initiated kangaroo mother care on breastfeeding performance in low birthweight infants: A randomized clinical trial

This individually randomized trial was conducted to estimate the effect of promoting community-initiated kangaroo mother care (ciKMC) in low birthweight (LBW) infants on infant breastfeeding performance. It was designed as a substudy within a larger primary trial on ciKMC and infant survival. Five hundred fifty stable LBW mother-infant dyads (1500-2250 g) who provided consent, were consecutively enroled for breastfeeding performance assessment. The ciKMC intervention included promotion and support of continuous skin-to-skin contact and exclusive breastfeeding (EBF) through home visits during the neonatal period. The primary outcome was effective breastfeeding performance indicated by an infant breastfeeding assessment tool score of ≥10 after the end of the neonatal period. As secondary outcomes, we reported maternal satisfaction related to infant breastfeeding, and EBF after the end of the neonatal period. We completed outcome assessments in 96% of participants. In the ciKMC arm, 92% of the infants showed effective breastfeeding performance against 81% in the control arm [adjusted prevalence ratio (aPR): 1.24, 95% confidence interval (CI): 1.16-1.32]. In the ciKMC arm, 65% of the mothers reported to be very satisfied with their infants' breastfeeding against 51% in the control arm (aPR: 1.22, 95% CI: 1.05-1.41). The proportion of infants practicing EBF was 89% in the ciKMC arm against 45% in the control arm (aPR: 1.62, 95% CI: 1.45-1.81). Our study findings suggest that promotion of ciKMC can improve effective breastfeeding, EBF and maternal satisfaction related to breastfeeding in LBW infants.

Anthropometric Indicators as Predictors of Mortality in Early Life Among Low Birthweight Indian Infants

Background

Low birthweight (LBW) babies (<2.5 kg) are at higher risk of mortality and weight for height z score is currently recommended for identifying infants at risk of mortality.

Objective

To compare different anthropometric measures at 28-day of age in a cohort of LBW Indian infants for predicting mortality between 28-day and 180-day of age.

Methods

We used data from an individually randomized controlled trial of LBW infants weighing between 1,500 and 2,250 g. Sensitivity, specificity, positive, and negative likelihood ratios, positive and negative predictive values, and area under receiver operating characteristics curves (AUC) were used to estimate the discrimination of mortality risk. The Cox regression was used to estimate hazard ratios and population attributable fraction for each anthropometric indicator. These estimates were calculated for individual as well as combinations of anthropometric indicators at the cut-off of –2 and –3 SD of the WHO 2006 growth standards.

Results

Severe underweight (weight-for-age z-scores [WAZ] < –3) had a sensitivity of 75.0%, specificity of 68.0% with an AUC of 0.72. The risk of death was higher (HR 6.18; 95% CI 4.29–8.90) with a population attributable fraction of 0.63 (95% CI 0.52–0.72) for infants severely underweight at 28-day of age. Combination of different anthropometric measures did not perform better than individual measures.

Conclusion

Severe underweight (WAZ < –3) better discriminated deaths among LBW infants < 6 months of age. It can be considered for diagnosis of nutritionally at-risk infants in this age group.

Clinical Trial Registration

[ClinicalTrials.gov], identifier [NCT02653534].

Linear Growth Trajectories, Catch-up Growth, and Its Predictors Among North Indian Small-for-Gestational Age Low Birthweight Infants: A Secondary Data Analysis

Background

Low birthweight small-for-gestational-age (SGA-LBW) (birthweight below the 10th percentile for gestational age; SGA-LBW) infants are at an increased risk of poor postnatal growth outcomes. Linear growth trajectories of SGA-LBW infants are less studied in South Asian settings including India.

Objectives

To describe the linear growth trajectories of the SGA-LBW infants compared with appropriate-for-gestational-age LBW (AGA-LBW) infants during the first 6 months of life. In addition, we estimated catch-up growth (ΔLAZ > 0.67) in SGA-LBW infants and their performance against the WHO linear growth velocity cut-offs. Additionally, we studied factors associated with poor catch-up growth in SGA-LBW infants.

Methods

The data utilized came from an individually randomized controlled trial that included low birthweight (LBW) infants weighing 1,500–2,250 g at birth. A total of 8,360 LBW infants were included. For comparison between SGA-LBW and AGA-LBW infants, we presented unadjusted and adjusted estimates for mean differences (MDs) or risk ratios (RRs) for the outcomes of length, linear growth velocity, length for age z-score (LAZ) score, and stunting. We estimated the proportion of catch-up growth. Generalized linear models of the Poisson family with log links were used to identify factors associated with poor catch-up growth in SGA-LBW infants.

Results

Low birthweight small-for-gestational-age infants had a higher risk of stunting, lower attained length, and a lower LAZ score throughout the first 6 months of life compared with AGA-LBW infants, with differences being maximum at 28 days and minimum at 6 months of age. The linear growth velocity in SGA-LBW infants compared with AGA-LBW infants was significantly lower during the birth–28 day period [MD −0.19, 95% confidence interval (CI): −0.28 to −0.10] and higher during the 3- to 6-month period (MD 0.17, 95% CI: 0.06–0.28). Among the SGA-LBW infants, 55% showed catch-up growth for length at 6 months of age. Lower wealth quintiles, high birth order, home birth, male child, term delivery, non-exclusive breastfeeding, and pneumonia were associated with the higher risk of poor catch-up in linear growth among SGA-LBW infants.

Conclusion

Small for gestational age (SGA) status at birth, independent of gestational age, is a determinant of poor postnatal linear growth. Promotion of institutional deliveries, exclusive breastfeeding, and prevention and early treatment of pneumonia may be helpful to improve linear growth in SGA-LBW infants during early infancy.

Clinical Trial Registration

[https://clinicaltrials.gov/], identifier [NCT02653534].

Effect of Community-Initiated Kangaroo Mother Care on Fecal Biomarkers of Gut Function in Low Birth Weight Infants in North India: A Randomized Clinical Trial

This individually randomized trial was conducted to estimate the effect of promoting community-initiated Kangaroo Mother Care (ciKMC) in low birth weight (LBW) infants on gut inflammation and permeability. Participants included 200 stable LBW infants (weighing 1,500-2,250 g) in North India enrolled between May and October 2017. The ciKMC intervention included promotion and support of continuous skin-to-skin contact and exclusive breastfeeding through home visits. The mothers in the intervention arm were supported to practice ciKMC until 28 days after birth, i.e., the neonatal period, or till the baby wriggled out of KMC position, if earlier. Infant stool specimens were collected during the first week of birth, and within 1 week after end of the neonatal period. Concentrations of fecal neopterin (nmol/L), myeloperoxidase (ng/mL), and alpha-1-antitrypsin (μg/mL) were determined using ELISA, and composite enteric enteropathy (EE) score at the end of the neonatal period was calculated by principal component analysis. We did not find any substantial difference in means between the ciKMC and control arm infants in the log-transformed values of neopterin (0.03; 95% CI -0.15 to 0.21), myeloperoxidase (0.28; 95% CI -0.05 to 0.61) and alpha-1-antitrypsin (0.02; 95% CI -0.30 to 0.34). The mean (SD) composite EE score was 13.6 (7.5) in the ciKMC and 12.4 (8.3) in the control arm infants, and the adjusted difference in means was, 0.4 (95% CI -1.8 to 2.7). Our findings suggest that the promotion of ciKMC did not affect gut inflammation and permeability in our target population of LBW infants in North India.

The Effect of Skin-to-Skin Contact on Postoperative Depression and Physical Recovery of Parturients after Cesarean Section in Obstetrics and Gynecology Department

The effect of skin-to-skin contact (SSC) on postpartum depression and physical rehabilitation of cesarean section women was explored. 280 parturients undergoing cesarean section were selected and were rolled into two groups randomly. The parturients in the control group (Con group, 140 cases) received routine care, and those in the experimental group (Exp group, 140 cases) received SSC on the basis of routine care. The postpartum depression and physical recovery of parturients in two groups were compared. It was found that, in the Exp group, the number of pregnant women with no or with very mild depression was much more 85% vs. 55%), the number of women with adequate lactation was more (53 cases vs. 27 cases), the first lactation time (FLT) was dramatically shorter (41.25 ± 4.81 h vs. 58.43 ± 5.43 h), the breastfeeding success rate (BFSR) and breastfeeding rate (BFR) were obvious higher, the days for uterine involution was much shorter (6.96 ± 1.13 days vs. 9.47 ± 1.75 days), the descent of uterine fundus 24 hours after delivery (24 h-DUF) was obviously larger (3.17 ± 0.26 mm vs. 1.56 ± 0.43 mm), the duration of lochia (DOL) was remarkably shorter (33.21 ± 5.32 days vs. 25.32 ± 3.54 days), and the Visual Analogue Scale (VAS) score was lower (4.88 ± 0.32 points vs. 3.41 ± 0.53 points), showing statistical differences for all above indicators (P < 0.05). It suggested that SSC could effectively relieve the postpartum depression of uterine parturients, promote the lactation, increase the BFR, facilitate uterine involution, and alleviate chronic uterine inflammation and postpartum pain, showing high clinical application and promotion value.

Understanding Perceptions and Practices for Designing an Appropriate Community-Based Kangaroo Mother Care Implementation Package: Qualitative Exploratory Study

Background

Low birth weight (LBW) is a common outcome of preterm birth, which increases the risk of an infant’s morbidity and mortality. Approximately 20 million infants are born with LBW globally per year. Since a significant number of births in Pakistan take place at home, it is important to focus on the use of kangaroo mother care (KMC), the practice of skin-to-skin contact, in communities to prevent neonatal mortality and morbidity.

Objective

We employed a formative research approach to understand the context of communities and facilities with regard to neonatal care and KMC practice. The broader aims were to inform the design and delivery of culturally appropriate platforms to introduce KMC in communities, and develop effective recruitment and retention strategies of KMC in rural areas of the Dadu district in the Sindh province of Pakistan.

Methods

We conducted focus group discussions, in-depth interviews, and key informant interviews with families of LBW babies, community members, health care providers, and hospital administrators to identify barriers, enablers, and a knowledge base for KMC interventions.

Results

Newborn care practices in communities were found to be suboptimal. The community was generally unaware of the KMC intervention for the care of LBW babies. However, facility health care providers, the community, and family members were willing to provide KMC to improve outcomes. We found significant support from the community members and health care providers for KMC practices. Mothers were also ready to provide intermittent KMC. The administrative staff at the hospitals accepted the introduction of KMC practices for LBW babies.

Conclusions

KMC as a method of treating LBW babies is widely accepted in the community. This formative research provides strategically valuable information that will be helpful for developing effective implementation strategies by identifying common community practices for LBW babies, along with identifying the barriers and enablers to KMC practice.

Health equity impact of community-initiated kangaroo mother care: a randomized controlled trial

Background

Kangaroo mother care (KMC) can substantially enhance overall survival of low birthweight babies. In a large randomized controlled trial, we recently showed that supporting mothers to provide community initiated KMC (ciKMC) can reduce mortality among infants up to 180 days of life by 25% (hazard ratio (HR) 0.75). With the current analysis, we aimed to explore if ciKMC promotion leads to increased inequity in survival.

Methods

In the trial we randomized 8402 low birthweight babies to a ciKMC (4480 babies) and a control (3922 babies) arm, between 2015 and 2018 in Haryana, India. We estimated the difference in concentration indices, which measure inequality, between babies in the ciKMC and control arms for survival until 180 days of life. Further, we compared the effect of ciKMC promotion across subgroups defined by socioeconomic status, caste, maternal literacy, infant’s sex, and religion.

Results

Our intervention did not increase survival inequity, as the concentration index in the ciKMC arm of the trial was 0.05 (95% CI -0.07 to 0.17) lower than in the control arm. Survival impact was higher among those belonging to the lower two wealth quintiles, those born to illiterate mothers and those belonging to religions other than Hindu.

Conclusions

We found that ciKMC promotion did not increase inequity in survival associated with wealth. The beneficial impact of ciKMC tended to be larger among vulnerable groups. Supporting mothers to provide KMC at home to low birthweight babies will not increase and could indeed reduce inequities in infant survival.

Trial registration

ClinicalTrials.gov, NCT02653534. Registered January 12, 2016—Retrospectively registered.

Effect of Community-Based Kangaroo Mother Care Package on Neonatal Mortality Among Preterm and Low Birthweight Infants in Rural Pakistan: Protocol for a Cluster Randomized Controlled Trial

BACKGROUND

Neonatal mortality due to preterm birth and low birthweight remains a significant challenge in Pakistan. Kangaroo mother care (KMC) is a unique, low-cost intervention proven to reduce neonatal mortality and morbidity and increase exclusive breastfeeding rates. However, KMC has not been attempted in community settings in Pakistan. We aim to implement and evaluate the effectiveness of a community-based KMC package to reduce neonatal morbidity and mortality among preterm and low birthweight (LBW) infants, which will provide evidence for policy development and the large-scale implementation of KMC across the country.

OBJECTIVE

The primary objective of this trial is to reduce neonatal mortality among preterm and LBW infants. The secondary objectives are growth (measured as weight gain), reduced incidence of possible serious bacterial infection, and increased exclusive breastfeeding and continued breastfeeding practices.

METHODS

We designed a community-based cluster randomized controlled trial in one rural district of Pakistan. Stable, LBW babies (weighing 1200 grams to 2500 grams) are included in the study. The community KMC package, consisting of the KMC kit, information and counseling material, and community mobilization through KMC champions (village volunteers), was designed after preliminary research in the same geographical location and implemented in intervention clusters. The standard essential newborn care is offered in the control clusters. Infants are recruited and followed up by independent teams of data collectors. Data are collected on the duration of skin-to-skin contact, growth, breastfeeding practices, morbidities, neonatal mortality, and neurodevelopment status. Data analysis will be conducted based on the intention to treat principle. The Cox regression model will be used to assess the primary outcome of neonatal mortality. The secondary outcomes will be evaluated using linear or logistic regression.

RESULTS

The Ethics Review Committee of Aga Khan University, Pakistan, approved the study protocol in February 2017. Data collection began in August 2019 and will be completed in December 2021. Data analyses are yet to be completed.

CONCLUSIONS

This intervention may be effective in preventing sepsis and subsequently improve survival in LBW newborns in Pakistan and other low-income and middle-income countries worldwide.

TRIAL REGISTRATION

clinicaltrials.gov NCT03545204; https://clinicaltrials.gov/ct2/show/NCT03545204.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/28156.

Effect of Community-Initiated Kangaroo Mother Care on Postpartum Depressive Symptoms and Stress Among Mothers of Low-Birth-Weight Infants: A Randomized Clinical Trial

IMPORTANCE

Approximately 1 in 5 women in low- and middle-income countries experience postpartum depression, and the risk is higher among mothers of low-birth-weight (LBW) infants. Kangaroo mother care (KMC) is effective in improving survival among LBW infants, but the benefits of KMC for mothers are not well described.

OBJECTIVE

To estimate the effects of community-initiated KMC (ciKMC) on maternal risk of moderate-to-severe postpartum depressive symptoms and on salivary cortisol concentration, a biomarker of stress.

DESIGN, SETTING, AND PARTICIPANTS

This was an unmasked, parallel-group, individually randomized clinical trial. Participants included 1950 mothers of stable LBW infants (weighing 1500-2250 g) in rural and semiurban low-income populations in North India enrolled between April 2017 and March 2018. Data analysis was performed from January to July 2020.

INTERVENTIONS

Eligible participants were randomly assigned to the intervention or control group by block randomization. The mothers in the intervention group were supported to practice ciKMC until 28 days after birth or until the infant wriggled out of the KMC position (ie, was no longer staying in the KMC position). The intervention included promotion and support of skin-to-skin contact and exclusive breastfeeding through home visits.

MAIN OUTCOMES AND MEASURES

Postpartum depressive symptoms at the end of the neonatal period were measured using the Patient Health Questionnaire-9, with a score of 10 or higher used to identify moderate-to-severe depressive symptoms. Salivary cortisol concentration was measured in a subsample of 550 mothers before and after breastfeeding on day 28 after birth.

RESULTS

Of the 1950 participants (mean [SD] age, 23 [3.5] years), outcome assessment was completed for 974 of 1047 participants (93%) in the intervention group and 852 of 903 participants (94%) in the control group. Sixty-four percent of participants (1175 of 1826 participants) belonged to the lowest 3 wealth quintiles. The proportion of mothers with moderate-to-severe postpartum depressive symptoms was 10.8% (95% CI, 8.9%-12.9%; 105 of 974 mothers) in the intervention group vs 13.6% (95% CI, 11.4%-16.1%; 116 of 852 mothers) in the control group. The adjusted relative risk of moderate-to-severe maternal postpartum depressive symptoms was 0.75 (95% CI, 0.59-0.96), or an efficacy of 25%. There was no difference in day-28 salivary cortisol concentration between the ciKMC and control group mothers before or after breastfeeding. The analysis estimated that supporting 36 mothers to perform KMC at home would prevent 1 mother from experiencing moderate-to-severe postpartum depressive symptoms.

CONCLUSIONS AND RELEVANCE

These findings suggest that ciKMC practice may substantially reduce the risk of moderate-to-severe maternal postpartum depressive symptoms. This evidence supports KMC as an intervention to be incorporated in essential newborn care programs in low- and middle-income settings.

TRIAL REGISTRATION

Clinical Trials Registry-India Identifier: CTRI/2017/04/008430.

The Kaplan Meier estimates of mortality and its predictors among newborns admitted with low birth weight at public hospitals in Ethiopia

BACKGROUND

Globally, every year greater than twenty million newborns are born weighing less than 2500grams, of which over 96% of them were in developing countries. It contributes to sixty to eighty percent of all neonatal deaths, annually. These infants weighing less than 2500gram will have a poor immune system and are at risk of morbidity and mortality. This study was aimed to investigate the survival status and predictors of mortality among neonates admitted with low birth weight at public hospitals in Ethiopia.

METHOD

A prospective cohort study was conducted among selected 216 newborns admitted with low birth weight who were admitted in neonatal intensive care unit at Arba Minch General hospital, Sawla General Hospital and Chencha district hospital from 1st March 2018 to 28st February 2019. Data were entered into Epi data version 3.02 and exported to STATA V 14 for analysis. The Kaplan Meier survival curve together with log rank test was used to estimate the survival time of the newborns. Variables which had p-value <0.05 in multivariable analysis using the cox proportional hazard model were declared as statistically significant.

RESULT

The cumulative proportion of surviving at the end of third days was 99.01% (95%CI: 96.11, 99.75). Similarly it was 97.81% (95%CI: 94.25, 99.18), 96.27% (95%CI: 91.76, 98.33) and 94.33% (95%CI: 88.72, 97.19) at the end of fourth, fifth and sixth day respectively. The overall mean survival time was 17.13 days (95%CI: 12.76, 21.49). The incidence of mortality among neonates admitted with low birth weight was 83 per 1000 live births. Mothers with DM (AHR:4.79; 95%CI:1.15, 19.8), maternal HIV infection(AHR:6.47;95%CI:1.43,29.3), not keeping the newborn under KMC(AHR:13.0;95%CI:3.42, 49.5) and initiating exclusive breast feeding within one hour(AHR:0.19;95%CI:0.04, 0.95) were statistically significant in multivariable cox regression analysis.

CONCLUSION

The risk of mortality among neonates admitted with low birth weight was high at the early admission period and the incidence of mortality was high. Maternal history of diabetes mellitus, HIV/AIDS infection, keeping the newborn under kangaroo mother care and exclusive breast feeding initiation were statistically significant predictors of mortality. Special emphasis should be given for neonates with low birth weight at the early follow up periods and Kangaroo mother care practice should be a usual practice.

Community initiated kangaroo mother care and early child development in low birth weight infants in India-a randomized controlled trial

BACKGROUND

In a randomized controlled trial (RCT) with 8402 stable low birthweight (LBW) infants, majority being late preterm or term small for gestational age, community-initiated KMC (ciKMC) showed a significant improvement in survival. However, the effect of ciKMC on neurodevelopment is unclear. This is important to elucidate as children born with low birth weight are at high risk of neurodevelopmental deficits. In the first 552 stable LBW infants enrolled in the above trial, we evaluated the effect of ciKMC on neurodevelopmental outcomes during infancy.

METHOD

This RCT was conducted among 552 stable LBW infants, majorly late preterm or term small for gestational age infants without any problems at birth and weighing 1500-2250 g at birth. The intervention comprised of promotion of skin-to-skin contact and exclusive breastfeeding by trained intervention delivery team through home visits. The intervention group mother-infant-dyads were supported to practice ciKMC till day 28 after birth or until the baby wriggled-out. All infants in the intervention and control groups received Home Based Post Natal Care (HBPNC) visits by government health workers. Cognitive, language, motor and socio-emotional outcomes were assessed at infant-ages 6- and 12-months using Bayley Scale of Infant Development (BSID-III). Other outcomes measured were infant temperament, maternal depression, maternal sense of competence, mother-infant bonding and home-environment. We performed post-hoc equivalence testing using two one-sided tests of equivalence (TOST) to provide evidence that ciKMC does not do harm in terms of neurodevelopment.

RESULTS

In the intervention arm, the median (IQR) time to initiate ciKMC was 48 (48 to 72) hours after birth. The mean (SD) duration of skin-to-skin-contact was 27.9 (3.9) days with a mean (SD) of 8.7 (3.5) hours per day. We did not find significant effect of ciKMC on any of the child developmental outcomes during infancy. The TOST analysis demonstrated that composite scores for cognitive, language and motor domains at 12 months among the study arms were statistically equivalent.

CONCLUSION

Our study was unable to capture any effect of ciKMC on neurodevelopment during infancy in this sample of stable late preterm or term small for gestational age infants. Long term follow-up may provide meaningful insights.

TRIAL REGISTRATION

The trial is registered at clinicaltrials.gov NCT02631343 dated February 17, 2016; Retrospectively registered.

The Effect of Skin-to-Skin Contact on Maternal Anxiety, Heart Rate, and Oxygen Saturation during the Vaccination of One-Month-Old Infants

This study aimed to reduce maternal anxiety scores and heart rates, increase oxygen saturation linked to vaccination processes with Skin-to skin contact (SSC). The study is a prospective, multicenter, paired, randomized, controlled trial. This experimental study was conducted with a pretest-posttest control group. The study was carried out with 128 mothers of infants. A Sociodemographic Questionnaire, the State Anxiety Inventory and a pulse oximeter were used in the data collection. In the study, SSC began to be given to the infants in the intervention group five minutes before vaccination and the infant was left in SSC for an uninterrupted 15 minutes following the vaccination. The maternal anxiety scores were noted before and after the vaccination process. The mothers' heart rates and oxygen saturation were monitored a total of three times. The anxiety scores of the intervention group decreased while oxygen saturation increased after the vaccination as compared to the control group. The heart rate decreased in the intervention group but increased in the control group. The study revealed that SSC reduced scores of maternal anxiety and heart rates and increased oxygen saturation during the vaccination process.

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.

Effect of community-initiated kangaroo mother care on survival of infants with low birthweight: a randomised controlled trial

BACKGROUND

Coverage of kangaroo mother care remains very low despite WHO recommendations for its use for babies with low birthweight in health facilities for over a decade. Initiating kangaroo mother care at the community level is a promising strategy to increase coverage. However, knowledge of the efficacy of community-initiated kangaroo mother care is still lacking. We aimed to assess the effect of community-initiated kangaroo mother care provided to babies weighing 1500-2250 g on neonatal and infant survival.

METHODS

In this randomised controlled, superiority trial, undertaken in Haryana, India, we enrolled babies weighing 1500-2250 g at home within 72 h of birth, if not already initiated in kangaroo mother care, irrespective of place of birth (ie, home or health facility) and who were stable and feeding. The first eligible infants in households were randomly assigned (1:1) to the intervention (community-initiated kangaroo mother care) or control group by block randomisation using permuted blocks of variable size. Twins were allocated to the same group. For second eligible infants in the same household as an enrolled infant, if the first infant was assigned to the intervention group the second infant was also assigned to this group, whereas if the first infant was assigned to the control group the second infant was randomly assigned (1:1) to the intervention or control group. Mothers and infants in the intervention group were visited at home (days 1-3, 5, 7, 10, 14, 21, and 28) to support kangaroo mother care (ie, skin-to-skin contact and exclusive breastfeeding). The control group received routine care. The two primary outcomes were mortality between enrolment and 28 days and between enrolment and 180 days. Analysis was by intention to treat and adjusted for clustering within households. The effect of the intervention on mortality was assessed with person-time in the denominator using Cox proportional hazards model. This study is registered with ClinicalTrials.gov, NCT02653534 and NCT02631343, and is now closed to new participants.

FINDINGS

Between July 30, 2015, and Oct 31, 2018, 8402 babies were enrolled, of whom 4480 were assigned to the intervention group and 3922 to the control group. Most births (6837 [81·4%]) occurred at a health facility, 36·2% (n=3045) had initiated breastfeeding within 1 h of birth, and infants were enrolled at an average of about 30 h (SD 17) of age. Vital status was known for 4470 infants in the intervention group and 3914 in the control group at age 28 days, and for 3653 in the intervention group and 3331 in the control group at age 180 days. Between enrolment and 28 days, 73 infants died in 4423 periods of 28 days in the intervention group and 90 deaths in 3859 periods of 28 days in the control group (hazard ratio [HR] 0·70, 95% CI 0·51-0·96; p=0·027). Between enrolment and 180 days, 158 infants died in 3965 periods of 180 days in the intervention group and 184 infants died in 3514 periods of 180 days in the control group (HR 0·75, 0·60-0·93; p=0·010). The risk ratios for death were almost the same as the HRs (28-day mortality 0·71, 95% CI 0·52- 0·97; p=0·032; 180-day mortality 0·76, 0·60-0·95; p=0·017).

INTERPRETATION

Community-initiated kangaroo mother care substantially improves newborn baby and infant survival. In low-income and middle-income countries, incorporation of kangaroo mother care for all infants with low birthweight, irrespective of place of birth, could substantially reduce neonatal and infant mortality.

FUNDING

Research Council of Norway and University of Bergen.

Community-based maternal and newborn educational care packages for improving neonatal health and survival in low- and middle-income countries

BACKGROUND

In low- and middle-income countries (LMICs), health services are under-utilised, and several studies have reported improvements in neonatal outcomes following health education imparted to mothers in homes, at health units, or in hospitals. However, evaluating health educational strategy to deliver newborn care, such as one-to-one counselling or group counselling via peer or support groups, or delivered by health professionals, requires rigorous assessment of methodological design and quality, as well as assessment of cost-effectiveness, affordability, sustainability, and reproducibility in diverse health systems.

OBJECTIVES

To compare a community health educational strategy versus no strategy or the existing approach to health education on maternal and newborn care in LMICs, as imparted to mothers or their family members specifically in community settings during the antenatal and/or postnatal period, in terms of effectiveness for improving neonatal health and survival (i.e. neonatal mortality, neonatal morbidity, access to health care, and cost).

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 4), in the Cochrane Library, MEDLINE via PubMed (1966 to 2 May 2017), Embase (1980 to 2 May 2017), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 2 May 2017). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

Community-based randomised controlled, cluster-randomised, or quasi-randomised controlled trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted the data. We assessed the quality of evidence using the GRADE method and prepared 'Summary of findings' tables.

MAIN RESULTS

We included in this review 33 original trials (reported in 62 separate articles), which were conducted across Africa and Central and South America, with most reported from Asia, specifically India, Pakistan, and Bangladesh. Of the 33 community educational interventions provided, 16 included family members in educational counselling, most frequently the mother-in-law or the expectant father. Most studies (n = 14) required one-to-one counselling between a healthcare worker and a mother, and 12 interventions involved group counselling for mothers and occasionally family members; the remaining seven incorporated components of both counselling methods. Our analyses show that community health educational interventions had a significant impact on reducing overall neonatal mortality (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.78 to 0.96; random-effects model; 26 studies; n = 553,111; I² = 88%; very low-quality evidence), early neonatal mortality (RR 0.74, 95% CI 0.66 to 0.84; random-effects model; 15 studies that included 3 subsets from 3 studies; n = 321,588; I² = 86%; very low-quality evidence), late neonatal mortality (RR 0.54, 95% CI 0.40 to 0.74; random-effects model; 11 studies; n = 186,643; I² = 88%; very low-quality evidence), and perinatal mortality (RR 0.83, 95% CI 0.75 to 0.91; random-effects model; 15 studies; n = 262,613; I² = 81%; very low-quality evidence). Moreover, community health educational interventions increased utilisation of any antenatal care (RR 1.16, 95% CI 1.11 to 1.22; random-effects model; 18 studies; n = 307,528; I² = 96%) and initiation of breastfeeding (RR 1.56, 95% CI 1.37 to 1.77; random-effects model; 19 studies; n = 126,375; I² = 99%). In contrast, community health educational interventions were found to have a non-significant impact on use of modern contraceptives (RR 1.10, 95% CI 0.86 to 1.41; random-effects model; 3 studies; n = 22,237; I² = 80%); presence of skilled birth attendance at birth (RR 1.09, 95% CI 0.94 to 1.25; random-effects model; 10 studies; n = 117,870; I² = 97%); utilisation of clean delivery kits (RR 4.44, 95% CI 0.71 to 27.76; random-effects model; 2 studies; n = 17,087; I² = 98%); and care-seeking (RR 1.11, 95% CI 0.97 to 1.27; random-effects model; 7 studies; n = 46,154; I² = 93%). Cost-effectiveness analysis conducted in seven studies demonstrated that the cost-effectiveness for intervention packages ranged between USD 910 and USD 11,975 for newborn lives saved and newborn deaths averted. For averted disability-adjusted life-year, costs ranged from USD 79 to USD 146, depending on the intervention strategy; for cost per year of lost lives averted, the most effective strategy was peer counsellors, and the cost was USD 33.

AUTHORS' CONCLUSIONS

This review offers encouraging evidence on the value of integrating packages of interventions with educational components delivered by a range of community workers in group settings in LMICs, with groups consisting of mothers, and additional education for family members, for improved neonatal survival, especially early and late neonatal survival.