Kangaroo mother care: EN-BIRTH multi-country validation study.

BACKGROUND: Kangaroo mother care (KMC) reduces mortality among stable neonates ≤2000 g. Lack of data tracking coverage and quality of KMC in both surveys and routine information systems impedes scale-up. This paper evaluates KMC measurement as part of the Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study. METHODS: The EN-BIRTH observational mixed-methods study was conducted in five hospitals in Bangladesh, Nepal and Tanzania from 2017 to 2018. Clinical observers collected time-stamped data as gold standard for mother-baby pairs in KMC wards/corners. To assess accuracy, we compared routine register-recorded and women's exit survey-reported coverage to observed data, using different recommended denominator options (≤2000 g and ≤ 2499 g). We analysed gaps in quality of provision and experience of KMC. In the Tanzanian hospitals, we assessed daily skin-to-skin duration/dose and feeding frequency. Qualitative data were collected from health workers and data collectors regarding barriers and enablers to routine register design, filling and use. RESULTS: Among 840 mother-baby pairs, compared to observed 100% coverage, both exit-survey reported (99.9%) and register-recorded coverage (92.9%) were highly valid measures with high sensitivity. KMC specific registers outperformed general registers. Enablers to register recording included perceptions of data usefulness, while barriers included duplication of data elements and overburdened health workers. Gaps in KMC quality were identified for position components including wearing a hat. In Temeke Tanzania, 10.6% of babies received daily KMC skin-to-skin duration/dose of ≥20 h and a further 75.3% received 12-19 h. Regular feeding ≥8 times/day was observed for 36.5% babies in Temeke Tanzania and 14.6% in Muhimbili Tanzania. Cup-feeding was the predominant assisted feeding method. Family support during admission was variable, grandmothers co-provided KMC more often in Bangladesh. No facility arrangements for other family members were reported by 45% of women at exit survey. CONCLUSIONS: Routine hospital KMC register data have potential to track coverage from hospital KMC wards/corners. Women accurately reported KMC at exit survey and evaluation for population-based surveys could be considered. Measurement of content, quality and experience of KMC need consensus on definitions. Prioritising further KMC measurement research is important so that high quality data can be used to accelerate scale-up of high impact care for the most vulnerable.

Effects of Dextrose Gel in Newborns at Risk for Neonatal Hypoglycemia in a Baby-Friendly Hospital.

OBJECTIVE: To describe the effects of the introduction of dextrose gel to the neonatal hypoglycemia (NH) protocol on exclusive breastfeeding rates at discharge and NICU admission rates among clinically well newborns born at 35 weeks gestation or greater who were at risk for NH in a Baby-Friendly hospital. DESIGN: Quasi-experimental, pre- and postintervention. SETTING: A suburban, Baby-Friendly hospital with approximately 2,000 births annually. PARTICIPANTS: Clinically well newborns born at 35 weeks gestation or greater at risk for NH who were admitted to the mother-baby unit. METHODS: We compared 198 newborns at risk for NH born in the 6-month period before the introduction of dextrose gel (November 15, 2016, through May 14, 2017) versus 203 newborns born in the 6-month period after the introduction (May 15, 2017, through November 14, 2017). In the preintervention group, the NH protocol included blood glucose monitoring, prolonged skin-to-skin contact, feeding, and dextrose administered intravenously. In the postintervention group, oral dextrose gel was added to the NH protocol. RESULTS: We found no differences in maternal or newborn characteristics between the pre- and postintervention groups. Dextrose gel was given to 50 newborns (approximately 25%) of 203 in the postintervention group. The proportion of newborns who were exclusively breastfed at discharge was similar between groups (56.6% of 198 vs. 59.1% of 203, p = .62), as were the NICU admission rates for hypoglycemia (2.5% of 198 vs. 1.5% of 203, p = .50). CONCLUSIONS: In a suburban Baby-Friendly hospital, introduction of dextrose gel into the NH protocol had no significant effect on exclusive breastfeeding at discharge or NICU admission rates.

Implementation of Kangaroo Mother Care - Challenges and Solutions.

Kangaroo Mother Care (KMC) is an efficient intervention that provides warmth, sensory stimulation, safety, protection against infections, breastfeeding, and bonding between infant and mother. The issues faced in implementing of KMC are highlighted herein, along with a suggestive plan for policy making for better implementation. With this plan, it will be easier to extend the approach to the community, where KMC has the potential to reach numerous LBW babies. Therefore, well-functioning facility-based services should be available before introducing KMC in the community, as community KMC must link with facility-based services for successful implementation. Community health workers and staff in facilities without KMC units should also be trained on KMC benefits and positioning. Each health facility implementing KMC services should have a written policy and guidelines that are based on national documents, and adapted to its specific level of health care.

Barriers and enablers to skin-to-skin contact at birth in healthy neonates - a qualitative study.

BACKGROUND: Skin to skin contact (SSC) at birth is the standard of care for newborns without risk factors. However, implementation of SSC at birth has been far from optimal. A qualitative study was undertaken to determine the barriers, enablers and potential solutions to implementation of SSC at birth in healthy newborn infants in a level III neonatal-care facility in Bangalore, India. METHODS: Consultants and residents/postgraduates (PG) from the departments of Obstetrics (n = 19) and Pediatrics (n = 14) and nurses (n = 8) in the labor room (LR) participated in the study. In depth interviews (IDI) and focus group discussions (FGD) were carried out with an interview guide and a moderators' guide containing inbuilt probes. Subjects of FGD were homogenous. All IDI and FGD were audio-taped, transcribed and analyzed using N VIVO version 9 (using free and tree nodes). Two authors separately coded the transcripts. Major and minor themes were identified. Rigor was ensured by triangulation and theoretical saturation. Informed consent and ethical approval was obtained. RESULTS: All subjects were aware of SSC at birth, some of its benefits and had practiced SSC. The major barriers identified were lack of personnel (nurses), time constraint, difficulty in deciding on eligibility for SSC, safety concerns, interference with clinical routines, and interdepartmental issues. Recall of an adverse event during SSC was also a major barrier. Furthermore, we found that most participants considered 1 h as impractical; and promoted 5-15 min SSC. Minor themes were gender bias of the newborn and cultural practices. The participants offered solutions such as assigning a helper exclusively for SSC, allowing a family member into the LR, continuing SSC after initial routines, antenatal counselling, constant reminders in the form of periodic sessions with audiovisual aids or posters in the obstetrics ward, training of new nurses and PG, and inclusion of SSC in medical and nursing curriculum. CONCLUSIONS: The major barriers to SSC at birth are lack of personnel, time constraint and safety concerns. Training, designated health personnel for SSC and teamwork are the key interventions likely to improve SSC at birth.

Readiness of hospitals to provide Kangaroo Mother Care (KMC) and documentation of KMC service delivery: Analysis of Malawi 2014 Emergency Obstetric and Newborn Care (EmONC) survey data.

BACKGROUND: Malawi introduced Kangaroo Mother Care (KMC) in 1999 as part of its efforts to address newborn morbidity and mortality and has continued to expand KMC services across the country. Yet, data on availability of KMC services and routine service provision are limited. METHODS: Data from the 2014 Emergency Obstetric Newborn Care (EmONC) survey, which was a census of all 87 hospitals in Malawi, were analyzed. The WHO service availability and readiness domains were used to generate indicators for KMC service readiness and an additional domain for documentation of KMC services was included. Levels of KMC service delivery were quantified using data extracted from a 12-month register review and a KMC initiation rate was calculated for each facility by dividing the reported number of babies initiated on KMC by the number of live births at facility. We defined three levels of KMC readiness and two levels of KMC operational status. RESULTS: 79% of hospitals (69/87) reported providing inpatient KMC services. More than half of the hospitals (62%; 54/87) met the most basic definition of readiness (staff, space for KMC and functional weighing scale) and 35% (30/87) met an expanded definition of readiness (guidelines, staff, space, scale and register in use). Only 15% (13/87) of hospitals had all KMC tracer items. Less than half of the hospitals (43%; 37/87) met criteria for KMC operational status at minimum levels (≥1/100 live births), and just 16% (14/87) met criteria for KMC operational status at routine levels (≥5/100 live births). CONCLUSIONS: Our study found large differences between reported levels of KMC services and documented levels of KMC readiness and service provision among hospitals in Malawi. It is recommended that facility assessments of services such as KMC include record reviews to better estimate service availability and delivery. Further efforts to strengthen the capacity of Malawian hospitals to deliver KMC are needed.

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.

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

BACKGROUND: Despite improvements in child survival in the past four decades, an estimated 6.3 million children under the age of five die each year, and more than 40% of these deaths occur in the neonatal period. Interventions to reduce neonatal mortality are needed. Kangaroo mother care (KMC) is one such life-saving intervention; however it has not yet been fully integrated into health systems around the world. Utilizing a conceptual framework for integration of targeted health interventions into health systems, we hypothesize that caregivers play a critical role in the adoption, diffusion, and assimilation of KMC. The objective of this research was to identify barriers and enablers of implementation and scale up of KMC from caregivers' perspective. METHODS: We searched Pubmed, Embase, Web of Science, Scopus, and WHO regional databases using search terms 'kangaroo mother care' or 'kangaroo care' or 'skin to skin care'. Studies published between January 1, 1960 and August 19, 2015 were included. To be eligible, published work had to be based on primary data collection regarding barriers or enablers of KMC implementation from the family perspective. Abstracted data were linked to the conceptual framework using a deductive approach, and themes were identified within each of the five framework areas using Nvivo software. RESULTS: We identified a total of 2875 abstracts. After removing duplicates and ineligible studies, 98 were included in the analysis. The majority of publications were published within the past 5 years, had a sample size less than 50, and recruited participants from health facilities. Approximately one-third of the studies were conducted in the Americas, and 26.5% were conducted in Africa. We identified four themes surrounding the interaction between families and the KMC intervention: buy in and bonding (i.e. benefits of KMC to mothers and infants and perceptions of bonding between mother and infant), social support (i.e. assistance from other people to perform KMC), sufficient time to perform KMC, and medical concerns about mother or newborn health. Furthermore, we identified barriers and enablers of KMC adoption by caregivers within the context of the health system regarding financing and service delivery. Embedded within the broad social context, barriers to KMC adoption by caregivers included adherence to traditional newborn practices, stigma surrounding having a preterm infant, and gender roles regarding childcare. CONCLUSION: Efforts to scale up and integrate KMC into health systems must reduce barriers in order to promote the uptake of the intervention by caregivers.

Kangaroo Care Education Effects on Nurses' Knowledge and Skills Confidence.

BACKGROUND: Less than 20% of the 996 NICUs in the United States routinely practice kangaroo care, due in part to the inadequate knowledge and skills confidence of nurses. Continuing education improves knowledge and skills acquisition, but the effects of a kangaroo care certification course on nurses' knowledge and skills confidence are unknown. METHOD: A pretest-posttest quasi-experiment was conducted. The Kangaroo Care Knowledge and Skills Confidence Tool was administered to 68 RNs at a 2.5-day course about kangaroo care evidence and skills. Measures of central tendency, dispersion, and paired t tests were conducted on 57 questionnaires. RESULTS: The nurses' characteristics were varied. The mean posttest Knowledge score (M = 88.54, SD = 6.13) was significantly higher than the pretest score (M = 78.7, SD = 8.30), t [54] = -9.1, p = .000), as was the posttest Skills Confidence score (pretest M = 32.06, SD = 3.49; posttest M = 26.80, SD = 5.22), t [53] = -8.459, p = .000). CONCLUSION: The nurses' knowledge and skills confidence of kangaroo care improved following continuing education, suggesting a need for continuing education in this area. J Contin Educ Nurs. 2016;47(11):518-524.

Kangaroo mother care: a multi-country analysis of health system bottlenecks and potential solutions.

BACKGROUND: Preterm birth is now the leading cause of under-five child deaths worldwide with one million direct deaths plus approximately another million where preterm is a risk factor for neonatal deaths due to other causes. There is strong evidence that kangaroo mother care (KMC) reduces mortality among babies with birth weight <2000 g (mostly preterm). KMC involves continuous skin-to-skin contact, breastfeeding support, and promotion of early hospital discharge with follow-up. The World Health Organization has endorsed KMC for stabilised newborns in health facilities in both high-income and low-resource settings. The objectives of this paper are to: (1) use a 12-country analysis to explore health system bottlenecks affecting the scale-up of KMC; (2) propose solutions to the most significant bottlenecks; and (3) outline priority actions for scale-up. METHODS: The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops involved technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks", factors that hinder the scale-up, of maternal-newborn intervention packages. We used quantitative and qualitative methods to analyse the bottleneck data, combined with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for KMC. RESULTS: Marked differences were found in the perceived severity of health system bottlenecks between Asian and African countries, with the former reporting more significant or very major bottlenecks for KMC with respect to all the health system building blocks. Community ownership and health financing bottlenecks were significant or very major bottlenecks for KMC in both low and high mortality contexts, particularly in South Asia. Significant bottlenecks were also reported for leadership and governance and health workforce building blocks. CONCLUSIONS: There are at least a dozen countries worldwide with national KMC programmes, and we identify three pathways to scale: (1) champion-led; (2) project-initiated; and (3) health systems designed. The combination of all three pathways may lead to more rapid scale-up. KMC has the potential to save lives, and change the face of facility-based newborn care, whilst empowering women to care for their preterm newborns.

Taking kangaroo mother care forward in South Africa: The role of district clinical specialist teams.

The global agenda for improved neonatal care includes the scale-up of kangaroo mother care (KMC) services. The establishment of district clinical specialist teams (DCSTs) in South Africa (SA) provides an excellent opportunity to enhance neonatal care at district level and ensure translation of policies, including the requirement for KMC implementation, into everyday clinical practice. Tshwane District in Gauteng Province, SA, has been experiencing an increasing strain on obstetric and neonatal services at central, tertiary and regional hospitals in recent years as a result of growing population numbers and rapid up-referral of patients, with limited down-referral of low-risk patients to district-level services. We describe a successful multidisciplinary quality improvement initiative under the leadership of the Tshwane DCST, in conjunction with experienced local KMC implementers, aimed at expanding the district's KMC services. The project subsequently served as a platform for improvement of other areas of neonatal care by means of a systematic approach.

[Baby follow-up in primary care: interface with the third stage of the kangaroo method]. / Seguimento do bebê na atenção básica: interface com a terceira etapa do método canguru.

OBJECTIVE: To know the perceptions of health professionals in primary care on the follow-up of preterm and/or low birth weight babies and their families, and the interface with the third stage of Kangaroo Care. METHOD: Exploratory and descriptive research with a qualitative approach, carried out in Basic Health Units in the municipality of Joinville, Santa Catarina. The data were collected between September and October of 2014, through semi-structured interviews, with 31 health professionals. Data treatment was performed through content analysis technique, thematic modality. RESULTS: The following categories emerged: Segment organization in Primary Care; The enigmatic preterm and/or low weight baby and childcare in primary health care; The interfaces of the third stage of Kangaroo Care with Primary Care. CONCLUSION: The use of Kangaroo Care in Primary Care is still shy, caring for preterm babies is fraught with uncertainty and still focused on the biomedical model.

Seguimento do bebê na atenção básica: interface com a terceira etapa do método canguru / Seguimiento del bebé en la atención básica: interface con la tercera etapa del método canguro / Baby follow-up in primary care: interface with the third stage of the kangaroo method

RESUMO Objetivo Conhecer as percepções dos profissionais de saúde da Atenção Básica sobre o seguimento do bebê pré-termo e/ou de baixo peso e sua família e a interface com a terceira etapa do Método Canguru. Método Pesquisa exploratório-descritiva, com abordagem qualitativa, realizada nas Unidades Básicas de Saúde do município de Joinville, Santa Catarina. Os dados foram coletados no período de setembro a outubro de 2014 através de entrevistas semiestruturadas com 31 profissionais de saúde. Para o tratamento dos dados, utilizou-se a técnica de Análise de Conteúdo, modalidade temática. Resultados Emergiram as categorias: Organização do seguimento na Atenção Básica; O enigmático bebê pré-termo e/ou de baixo peso e sua puericultura na Atenção Básica; As interfaces da terceira etapa do Método Canguru com a Atenção Básica. Conclusão A participação da Atenção Básica no Método Canguru ainda é tímida, o cuidado prestado ao bebê pré-termo é permeado de insegurança e ainda focado no modelo biomédico.

RESUMEN Objetivo conocer las percepciones de los profesionales de salud de atención de la Atención Primaria, sobre el seguimiento de los bebés pretérmino y/o de bajo peso al nacer y su familia, y la interfaz con la tercera etapa del Método Canguro. Método Estudio exploratorio, descriptivo, con abordaje cualitativo, realizado en Unidades Básicas de Salud en el municipio de Joinville, Santa Catarina. Los datos fueron recogidos entre septiembre a octubre, 2014, a través de entrevistas semiestructuradas con 31 profesionales de la salud. Para el tratamiento de los datos se utilizó la técnica de análisis de contenido, modalidad temática. Resultados Emergieron las siguientes categorías: La organización del seguimiento en la Atención Primaria; el enigmático bebé pretérmino y/o de bajo peso al nacer y su puericultura en la Atención Primaria; Las interfaces de la tercera etapa del Método Canguro con la Atención Básica. Conclusión La participación de la Atención Primaria en el Método Canguro aún es tímida, y el cuidado al bebé pretérmino está permeado de inseguridad y todavía está centrado en el modelo biomédico.

ABSTRACT Objective To know the perceptions of health professionals in primary care on the follow-up of preterm and/or low birth weight babies and their families, and the interface with the third stage of Kangaroo Care. Method Exploratory and descriptive research with a qualitative approach, carried out in Basic Health Units in the municipality of Joinville, Santa Catarina. The data were collected between September and October of 2014, through semi-structured interviews, with 31 health professionals. Data treatment was performed through content analysis technique, thematic modality. Results The following categories emerged: Segment organization in Primary Care; The enigmatic preterm and/or low weight baby and childcare in primary health care; The interfaces of the third stage of Kangaroo Care with Primary Care. Conclusion The use of Kangaroo Care in Primary Care is still shy, caring for preterm babies is fraught with uncertainty and still focused on the biomedical model.

Implementing skin-to-skin contact in the operating room following cesarean birth.

Immediate skin-to-skin contact (SSC) after birth benefits the health of mothers and newborns by increasing breastfeeding rates, stabilizing the newborn's temperature, and encouraging bonding (Moore, Anderson, Bergman, & Dowswell, 2012). Although immediate SSC after a vaginal birth was common practice at our hospital, it was rare in the operating room (OR) following a cesarean birth. To address this practice problem, we conducted a project to evaluate the feasibility of implementing SSC in the OR.

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.

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.

Challenges to skin-to-skin kangaroo care: cesarean delivery and critically ill NICU patients.

Although SSC following birth is known to be beneficial for both the mother and the baby, barriers continue to exist following cesarean delivery as well as for critically ill neonates. Neonates are sometimes deprived of this important benefit due to staff anxiety or inexperience. A collaborative approach between perinatal and neonatal team members can effectively introduce the practice as routine in the OB OR and the Level III NICU. Parents are valuable advocates for this essential best practice. Mothers and their offspring benefit both in the short term, as well as long term, when we address the barriers and overcome this clinical challenge.

Kangaroo mother care.

Kangaroo mother care is a safe, simple method to care for low birth weight infants. This article looks at its origins, what is involved in kangaroo mother care and reviews the evidence for improved outcomes resulting from its implementation.