Re-envisioning Kangaroo Mother Care Implementation Through a Socioecological Model: Lessons From Malawi.

INTRODUCTION: Kangaroo mother care (KMC) is a critical strategy to care for preterm and low birth weight infants in resource-limited settings. Despite evidence of its effectiveness and low cost, coverage has remained low, largely due to sociocultural barriers. We aimed to better understand social norms and community perceptions of preterm infants and KMC (facility-initiated and community-continued) in Malawi, a country with a high preterm birth rate, to inform a pilot social and behavior change program. METHODS: In this qualitative study, we conducted 11 focus group discussions and 20 in-depth interviews. Participants were identified through purposive and snowball sampling and included pregnant women, parents engaged in KMC, health workers, community members, and religious leaders. Audio recordings were transcribed and translated into English. An inductive thematic analysis was applied. RESULTS: Our analysis revealed 3 key injunctive norms influencing KMC engagement in this setting: (1) a perception that although preterm infants are abnormal, they should still be cared for, (2) an understanding that men should provide for their families while women should care for their families, and (3) families and communities should support one another. These norms operated at the community, family, household, and individual levels. Community members enforced social norms but also offered social support. Family members supported KMC parents as well. Both KMC parents actively engaged in the practice; however, their interest in and ability to manage its demands were influenced by the prevailing social norms, their economic situation, family obligations, and the mother's health status. CONCLUSION: KMC efforts can be strengthened by incorporating context-specific actions to bolster social norms that align with KMC and shift those that discourage it. Activities must include a focus on the community and family levels to engender meaningful change at the household level.

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

BACKGROUND: Complications of prematurity are a leading cause of newborn death in Malawi. Despite early adoption of Kangaroo mother care (KMC), coverage remains low and women have expressed challenges in using the traditional wrapper-chitenje. In 2016, a study was conducted to evaluate the acceptability and effectiveness of a customized KMC wrap in improving adherence to KMC practices among mothers. METHODS: Mother-baby dyads (301) were randomized to receive either a customized CarePlus Wrap developed by Lærdal Global Health or a traditional chitenje. Enrolled mother-baby dyads were assessed in the KMC ward at 2-3 days after of admission, and then again at 7-15 days post-discharge. Topics covered included skin-to-skin practices, breastfeeding, perceptions of the wrap, and family/community support. Chi square tests were used to assess associations between wrap type and KMC practices. The study received ethics approval. RESULTS: This study found that a customized KMC wrap is highly acceptable to women and improved skin-to-skin practices in facility-based KMC: 44% of mothers using a customized wrap reported 20 or more hours per day, compared to 33% of mothers using the traditional chitenje. Women using the customized wrap reported being comfortable in keeping the baby in skin-to-skin position more often than women using the chitenje (96% vs. 71%), and they were able to tie on the wrap themselves (86% vs. 10%). At the time of discharge from KMC, more women who used the customized wrap were satisfied with the wrap than those who used the traditional chitenje (94% vs. 56%). The customized wrap did not appear to impact other newborn practices, such as breastfeeding. CONCLUSIONS: This study provides evidence that a customized KMC wrap is highly acceptable to mothers, and it can contribute to better skin-to-skin practices. Use of a customized wrap may be one mechanism to support mothers in practicing KMC and skin-to-skin contact in addition to other interventions.

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

BACKGROUND: Despite introduction of Kangaroo Mother Care (KMC) in Malawi over a decade ago, preterm birth remains the leading cause of neonatal mortality. Although KMC is initiated in the health care facility, robust community follow-up is critical for survival and optimal development of preterm and low birth weight infants post-discharge. The objective of this qualitative study was to gain insight into community and health worker understanding, attitudes, beliefs and practices around preterm and low birth weight babies and KMC in Malawi. METHODS: A total of 152 participants were interviewed in two districts in southern Malawi, Machinga and Thyolo, in April 2015. Focus group discussions (groups = 11, n = 132) were conducted with pregnant women, community members and women who have practiced KMC. In-depth interviews (n = 20) were conducted with fathers who have practiced KMC, community and religious leaders, and health workers. Purposive and snowball sampling were employed to identify participants. Thematic content analysis was conducted. FINDINGS: KMC mothers and fathers only learned about KMC and care for preterm newborns after delivery of a child in need of this care. Men typically were not included in KMC counseling due to societal gender roles. Health facilities were the main source of information on KMC, however informal networks among women provided some degree of knowledge exchange. Community leaders were regarded as major facilitators of health information, conveners, key influencers, and policy-makers. Religious leaders were regarded as advocates and emotional support for families with preterm infants. Finally, while many participants initially had negative feelings towards preterm births and KMC, the large majority saw a shift in their perceptions through health counseling, peer modeling, and personal success with KMC. CONCLUSIONS: The findings offer several opportunities to improve KMC implementation including 1) earlier introduction of KMC to pregnant women and their families that are at-risk for preterm birth, 2) greater involvement of men in KMC counselling, practice and care for preterm infants, and 3) strengthening and defining partnerships with community and religious leaders. Finally, as parental perceptions of preterm infants and KMC improved with successful KMC practice, it is hopeful that KMC itself can positively affect social norms surrounding preterm infants, leading to a virtuous cycle of improved perceptions of preterm infants and increased uptake of KMC.