Scaling up kangaroo mother care in the Philippines using policy, regulatory and systems reform to drive changes in birth practices.

The WHO recommends kangaroo mother care (KMC) for stable preterm and low birthweight babies because it has been demonstrated to reduce mortality by up to half compared with conventional incubator-based care. Uptake of KMC in low/middle-income countries has been limited, despite its suitability for low-resource environments. This paper reviews factors that contributed to the adoption and expansion of KMC in the Philippines. Early introduction began in 1999 but national scale-up was slow until 2014 after which a significant improvement in national adoption was observed. The proportion of target hospitals implementing KMC rose from 3% to 43% between 2014 and 2019, with 53% of preterm and low birthweight babies receiving KMC by the end of this period. Expansion was led by the government which committed resources and formed partnerships with development partners and non-governmental organisations. Scale-up of KMC was built on the introduction of evidence-based newborn care practices around birth. Practice changes were promoted and supported by consensus-based policy, protocol, regulatory and health insurance changes led by multidisciplinary teams. A new approach to changing and sustaining clinical practice used hospital teams to conduct on-the-job clinical coaching and use local data to make environmental changes to support practices. Institutionalisation of early skin-to-skin contact, non-separation of mother and newborn and early initiation of exclusive breast feeding, with increased responsibility given to mothers, drove a cultural change among staff and families which allowed greater acceptance and uptake of KMC. Financial and programmatic support must be sustained and expanded to address ongoing challenges including staffing gaps, available space for KMC, willingness of some staff to adopt new practices and lack of resources for clinical coaching and follow-up.

Strategies discussed at the XIIth international conference on Kangaroo mother care for implementation on a countrywide scale.

AIM: Building strategies for the country-level dissemination of Kangaroo mother care (KMC) to reduce the mortality rate in preterm and low birth weight babies and improve quality of life. KMC is an evidence-based healthcare method for these infants. However, KMC implementation at the global level remains low. METHODS: The international network in Kangaroo mother brought 172 KMC professionals from 33 countries together for a 2-day workshop held in conjunction with the XIIth International KMC Conference in Bogota, Colombia, in November 2018. Participants worked in clusters to formulate strategies for country-level dissemination and scale-up according to seven pre-established objectives. RESULTS: The minimum set of indicators for KMC scale-up proposed by the internationally diverse groups is presented. The strategies for KMC integration and implementation at the country level, as well as the approaches for convincing healthcare providers of the safety of KMC transportation, are also described. Finally, the main aspects concerning KMC follow-up and KMC for term infants are presented. CONCLUSION: In this collaborative meeting, participants from low-, middle- and high-income countries combined their knowledge and experience to identify the best strategies to implement KMC at a countrywide scale.

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.

Consensus-based approach to develop a measurement framework and identify a core set of indicators to track implementation and progress towards effective coverage of facility-based Kangaroo Mother Care.

BACKGROUND: As efforts to scale up the delivery of Kangaroo Mother Care (KMC) in facilities are increasing, a standardized approach to measure implementation and progress towards effective coverage is needed. Here, we describe a consensus-based approach to develop a measurement framework and identify a core set of indicators for monitoring facility-based KMC that would be feasible to measure within existing systems. METHODS: The KMC measurement framework and core list of indicators were developed through: 1) scoping exercise to identify potential indicators through literature review and requests from researchers and program implementers; and 2) face-to-face consultations with KMC and measurement experts working at country and global levels to review candidate indicators and finalize selection and definitions. RESULTS: The KMC measurement framework includes two main components: 1) service readiness, based on the WHO building blocks framework; and 2) service delivery action sequence covering identification, service initiation, continuation to discharge, and follow-up to graduation. Consensus was reached on 10 core indicators for KMC, which were organized according to the measurement framework. We identified 4 service readiness indicators, capturing national level policy for KMC, availability of KMC indicators in HMIS, costed operational plans for KMC and availability of KMC services at health facilities with inpatient maternity services. Six indicators were defined for service delivery, including weighing of babies at birth, identification of those ≤2000 g, initiation of facility-based KMC, monitoring the quality of KMC, status of babies at discharge from the facility and levels of follow-up (according to country-specific protocol). CONCLUSIONS: These core KMC indicators, identified with input from a wide range of global and country-level KMC and measurement experts, can aid efforts to strengthen monitoring systems and facilitate global tracking of KMC implementation. As data collection systems advance, we encourage program managers and evaluators to document their experiences using this framework to measure progress and allow indicator refinement, with the overall aim of working towards sustainable, country-led data systems.

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.