Download - Kangaroo Mother Care in Malawi
KANGAROO MOTHER CARE
By
Charles Mhango
Student MSc.RH, BSc.NM
Outline
• Introduction
• Background
• Statistics
• Current practice
• Challenges
• Evidence based/best practices
• Recommendations
• Conclusion
• Reference
Introduction
• Kangaroo Mother Care is early, prolonged
continuous skin-to-skin contact between a mother
(or her surrogate) and her low birth weight (LBW)
infant (Ministry of Health, 2009)
• An effective way to meet LBW babies’ needs
• Warmth, breastfeeding, protection from infection,
stimulation, safety, love
• Can be continuous or intermittent
Introduction
• Applied only after stabilisation of the infant
• Results in early hospital discharge of LBW infants
• Considered equivalent to conventional neonatal
care for stable preterm infants
• Its elements are position, feeding and support
Introduction
• It is one of the interventions taken by government
that has helped Malawi to remain on track in
achieving MDG 4 (Zimba et al., 2012)
Background
• 1978: KMC first suggested by Dr Edgar Rey in
Bogotá, Colombia, in response to shortage of
incubators and severe hospital infections (Thukral,
Chawla, Agarwal, Deorari, & Paul, 2008)
• 1979: Together with Hector Martinez, they used the
idea in Bogotá, Colombia (“History of KMC,” 2014)
• 1984: First reported by UNICEF
Background
• 1985: Visits from USA, UK and Scandinavia to
Bogotá, Colombia
• 1st English report published in The Lancet by
Whitelaw and Sleath
• 1986: Early implementation in some African
countries
• Continued KMC research-found many benefits
(“History of KMC,” 2014)
Background
• 1998: First International Conference on KMC,
Baltimore, Maryland, USA (“History of KMC,” 2014)
• Supported by WHO and many organizations as a
life saving method of care
• WHO published guidelines (last updated 2003)
• 2011: May 15th - International KMC awareness day
Background – KMC in Malawi
• Early 1990s: KMC started at Bwaila Hospital
• Stopped after two deaths - associated with mortality
• 1999: KMC unit at Zomba Central Hospital
established
• EU funded renovation of nursery to include a KMC
unit
(Save the Children, 2007)
Background – KMC in Malawi
• 2000-2005: Introduction of KMC in 6 hospitals
• KMC introduced in Essential Newborn Care (ENC)
• Partnership to widen KMC services
• MOH/RHU, DHOs, Save the Children, KCN, CHAM
(Save the Children, 2007)
• 2005: KMC national guidelines (Revised 2009)
• ENC incorporated in RNM curriculum
Background – KMC in Malawi
• 2007: Retrospective KMC evaluation
• 5 hospitals doing well, 2 doing poorly (Bergh et al., 2007)
• 2009: KMC integrated in IMNC and CBMNC
training manuals
• By 2011, at least 121 health care facilities provided
some form of KMC services (Bergh et al., 2012)
Statistics - Global
• 7.6 million under five deaths
• 3 million neonatal deaths (40%)
• Preterm birth – leading cause (1.078 million; 14%)
• second from pneumonia in all under five deaths
(Liu et al., 2012)
Statistics - Global
• >75% of deaths of preterm births can be prevented
without intensive care i.e. KMC and infection control
(March of Dimes, PMNCH, Save the Children, &
WHO, 2012)
• If started in the first week KMC is associated with a
51% reduction in neonatal mortality for stable
babies weighing <2000g compared to incubator
care (Lawn et al., 2010)
Statistics - Global
• KMC can save up to 450 000 lives a year (March of
Dimes et al., 2012)
Statistics - Africa
• 3.552 million under five deaths
• 30% - neonatal deaths
• Preterm birth contributes 10%
(Liu et al., 2012)
Statistics - Malawi
• 18.1% preterm births – highest in the world (March
of Dimes et al., 2012)
• NMR: 31/1000 live births (NSO & IFC Macro, 2011)
• 37% due to preterm complications (Zimba et al.,
2012)
• ˃700 service providers, ˃15 tutors trained in KMC
and ˃1000 HSA sensitized to their role in supporting
KMC intervention (Zimba et al., 2012)
Current practice: The case of ZCH
Stabilisation of baby
Education + Demonstration
(mother + guardians)
Return demonstration
(mother + guardians)
Current practice: The case of ZCH
Current practice: The case of ZCH
Current practice: The case
of ZCH
Feeding
• Amount calculated per body weight
• Steadily increased by 5ml per day
• Amount increased if no weight gain, no abdominal distension nor vomiting
• <1500g fed 2 hourly
• >1500g fed 3 hourly
• Encouraged to breastfeed
Current practice: The case of ZCH
Daily monitoring
• Weighing using
electronic scale
• Vital signs
• Monitoring feeds
• Danger signs
• Clinical review
Support
• Emotional
• Health education +
Encouragement
• Physical
• Involvement of family
members
Current practice: The case of ZCH
• Mother competent with
KMC
• Mother able to feed
baby correctly
• Weight gain at least
15g/kg/day for 3
consecutive days after
regaining birth weight
• Baby weighing at least
1500g or more
• No any other major
illness
Discharge criteria
Current practice: The case of ZCH
• Given review date• Weekly
• Fortnight
• Community follow-up
rarely done• Use of HSAs
At discharge• Mother and guardians
advised to continue
KMC at home
Challenges
• Poor monitoring in the hospital
• Lack of resources
• Lack of infrastructure
• Frequent staff rotations (Bergh et al., 2012)
Challenges
• Poor data collection and utilization
• At facility level - poor documentation (Bergh et al., 2012)
• At policy level- unclear if data used to improve quality
(Bergh et al., 2014)
• Lack of prior knowledge about KMC
• 84% of mothers on KMC at Bwaila and ZCH were not
aware of the service prior to their hospitalisation
(Chisenga, Chalanda, & Ngwale, 2014)
Challenges
• Early discontinuation after discharge from hospital
• Lack of support
Although mothers and their attendants were informed
that family members can also practice KMC, no family
members did so at home (Parikh, Banker, Shah, & Bala,
2013)
At Bwaila and ZCH lack of support and multiple roles of
the mother affected compliance and continuation of KMC
after discharge (Chisenga, Chalanda, & Ngwale, 2014)
Challenges
• Lack of follow up after discharge
• Bergh et al. (2014) found that weak follow-up
arrangements such as lack of home visits and KMC
services close to the communities were a major
barrier to the successful implementation of KMC in
Malawi, Mali, Rwanda and Uganda
• Many mothers do not return for review because of the
difficulty they experienced in returning to the hospital
(Bergh et al., 2013)
Challenges
• Lack of supervision
• Donor project dependent
• Lack of transport
• Internal conflict between different health structures or
authorities
(Bergh et al., 2014)
Challenges
• KMC service data not part of existing national
information systems and nationally agreed
indicators (Zimba et al., 2012)
Evidence based / best practices
• Integration of KMC in national health guidelines
• Stabilisation of babies before initiating KMC
• Initiation of KMC as early as possible
• Mothers should be willing to participate in KMC
Evidence based / best practices
• Only remove baby in KMC position during cup
feeding, when changing nappies, visiting toilet, and
bathing
• Promoting KMC during antenatal care
• Prepares mothers in case of preterm birth
• Counselling of mothers on KMC should not only be
limited to mothers who have given birth to low birth
weight babies
Evidence based / best practices
• Use of trained support staff
• Patient attendants play an active role in KMC
implementation (Blencowe & Molyneux, 2005)
Evidence based / best practices
• KMC reduces pain in preterm neonates during
painful procedures
• In a randomised crossover trial, Johnston et al.
(2008) found that very preterm neonates appear to
have endogenous mechanisms elicited through skin-
to-skin maternal contact that decrease pain response,
though not as powerfully as in older preterm
neonates
Evidence based / best practices
• KMC reduces risk of infection
• A review of literature from randomised trials found
that KMC was associated with a reduced risk of
nosocomial infection at 41 weeks corrected
gestational age, severe illness and lower respiratory
tract disease at 6 months follow-up (Conde-Agudelo,
Diaz-Rossello, & Belizan, 2003)
Evidence based / best practices
• Prolonged KMC promote physical growth and motor
and mental development
• Findings by Bera et al. (2014) from a controlled
clinical trial on effect of KMC on growth and
development of low birth weight babies up to 12
months of age
Recommendations
• Improve follow-up system
• Empower health centres
• Promote use of community health team e.g. HSAs
• Use of village health committee
• Community awareness
• Prioritise KMC as a basic neonatal health service in
health centres
Recommendations
• Train support staff e.g. Patient attendants
• Introduce KMC in existing national information
systems e.g. HMIS
• Set up national indicators on KMC and include them
in MDHS
Recommendations
• There is need to balance the demands placed on
HSAs
• Integrate CBMNC package into the basic HSA (pre-
service) training
Conclusion
• KMC is a cost effective intervention that helps save
lives of LBW newborns
• It should be made available at all levels of care
• Engagement of communities is important for the
successful implantation of KMC
Reference
Bera, A., Ghosh, J., Singh, A. K., Hazra, A., Mukherjee, S., & Mukherjee, R.
(2014). Effect of kangaroo mother care on growth and development of
low birthweight babies up to 12 months of age: a controlled clinical trial.
Acta Paediatrica (Oslo, Norway: 1992), 103(6), 643–650.
doi:10.1111/apa.12618
Bergh, A.-M., Banda, L., Lipato, T., Ngwira, G., Luhanga, R., & Ligowe, R.
(2012). Evaluation of Kangaroo Mother Care services in Malawi. Save
the Children. Retrieved from
http://www.mchip.net/sites/default/file/Malawi%20KMC%20Report.PDF
Bergh, A.-M., Kerber, K., Abwao, S., Johnson, J. de-G., Aliganyira, P.,
Davy, K., … Zoungrana, J. (2014). Implementing facility-based
kangaroo mother care services: lessons from a multi-country study in
Africa. BMC Health Services Research, 14(1), 293. doi:10.1186/1472-
6963-14-293
Reference
Bergh, A.-M., Manu, R., Davy, K., Van Rooyen, E., Quansah Asare, G.,
Awoonor-williams, J., … Nang-Beifubah, A. (2013). Progress with the
Implementation of Kangaroo Mother Care in Four Regions in Ghana.
Ghana Medical Journal, 47(2), 57–63.
Bergh, A.-M., Van Rooyen, E., Lawn, J., Zimba, E., Ligowe, R., & Ciundu,
G. (2007). Retrospective evaluation of Kangaroo Mother Care
practices in Malawian hospitals. Ministry of Health. Retrieved from
http://www.healthynewbornnetwork.org/sites/default/files/resources/SN
L%202007.%20Malawi%20KMC%20Assessment%20Report.pdf
Blencowe, H., & Molyneux, E. M. (2005). Setting up kangaroo mother care
at Queen Elizabeth Central Hospital, Blantyre - a practical approach.
Malawi Medical Journal, 17(2), 39–42. doi:10.4314/mmj.v17i2.10873
Reference
• Chisenga, J. Z., Chalanda, M., & Ngwale, M. (2014). Kangaroo Mother
Care: A review of mothers experiences at Bwaila׳ hospital and Zomba
Central hospital (Malawi). Midwifery. doi:10.1016/j.midw.2014.04.008
• Conde-Agudelo, A., Diaz-Rossello, J. L., & Belizan, J. M. (2003).
Kangaroo mother care to reduce morbidity and mortality in low
birthweight infants. The Cochrane Database of Systematic Reviews, (2),
CD002771. doi:10.1002/14651858.CD002771
• History of KMC. (2014, March 23). Retrieved August 27, 2014, from
http://www.kangaroomothercare.com/beginning-KMC.aspx
Reference
Johnston, C. C., Filion, F., Campbell-Yeo, M., Goulet, C., Bell, L.,
McNaughton, K., … Walker, C.-D. (2008). Kangaroo mother care
diminishes pain from heel lance in very preterm neonates: A crossover
trial. BMC Pediatrics, 8, 13. doi:10.1186/1471-2431-8-13
Lawn, J. E., Mwansa-Kambafwile, J., Horta, B. L., Barros, F. C., &
Cousens, S. (2010). “Kangaroo mother care” to prevent neonatal
deaths due to preterm birth complications. International Journal of
Epidemiology, 39(suppl 1), i144–i154. doi:10.1093/ije/dyq031
Liu, L., Johnson, H. L., Cousens, S., Perin, J., Scott, S., Lawn, J. E., …
Black, R. E. (2012). Global, regional, and national causes of child
mortality: an updated systematic analysis for 2010 with time trends
since 2000. The Lancet, 379(9832), 2151–2161. doi:10.1016/S0140-
6736(12)60560-1
Reference
March of Dimes, PMNCH, Save the Children, & WHO. (2012). Born Too
Soon: The Global Action Report on Preterm Birth. (C. P. Howson, M. V.
Kinney, & J. E. Lawn, Eds.). Geneva: WHO.
Ministry of Health. (2009). Malawi National Kangaroo Mother Care
Guidelines (Revised.). Lilongwe: MOH. Retrieved from
http://www.healthynewbornnetwork.org/resource/malawi-national-kmc-
guidelines-2009
National Statistical Office, & IFC Macro. (2011). Malawi Demographic and
Health Survey 2010. Zomba: NSO and IFC Macro.
Parikh, S., Banker, D., Shah, U., & Bala, D. V. (2013). Barriers in
implementing community based Kangaroo Mother Care in low income
countries. NHL Journal of Medical Sciences, 2(1), 36–38.
Reference
Save the Children. (2007). Partnering for Kangaroo Mother Care scale-up
Malawi. Save the Children. Retrieved from
http://www.who.int/pmnch/events/2007/2007113_malawi_kangaroo.pdf
The Partnership for Maternal, Newborn & Child Health. (2013). The
PMNCH 2013 Report - Analysing Progress on Commitments to the
Global Strategy for Women’s and Children’s Health. Geneva: PMNCH.
Thukral, A., Chawla, D., Agarwal, R., Deorari, A. K., & Paul, V. K. (2008).
Kangaroo mother care--an alternative to conventional care. Indian
Journal of Pediatrics, 75(5), 497–503. doi:10.1007/s12098-008-0077-7
Reference
World Health Organisation. (2003). Kangaroo Mother Care: a Practical
Guide. Geneva: WHO. Retrieved from
http://whqlibdoc.who.int/publications/2003/9241590351.pdf?ua=1
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Colbourn, T., … Lawn, J. E. (2012). Newborn survival in Malawi: a
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