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Kangaroo Mother Care_ Abwao_10.10.12

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  • What are the causes that underlie these newborn deaths? Three major causes account for more than ¾ of neonatal deaths worldwide: preterm or low weight birth, infections, and asphyxia. Asphyxia accounts for nearly ¼ of all neonatal deaths.
  • First ever country estimates of preterm birth For 184 countries for the year 2010 Biggest ever input dataset for this issue – around 800 data inputs Most uncertain in sub Saharan Africa and South Asia
  • How to link to home, bringing KMC units to lower level facilities and promoting earlier discharge for in-patients with support close to home

Transcript

  • 1. Kangaroo Mother Care Core Group – Pre-meeting Session October 10, 2012 Washington, DCDr. Stella AbwaoTechnical Advisor, Newborn HealthMCHIP-Save the Children
  • 2. Kangaroo Mother Care (KMC) Presentation Outline Causes of newborn deaths Contribution of prematurity/ birth low weight to newborn deaths KMC Practice/ Elements of KMC KMC contribution to newborn survival KMC implementation - country highlights/ experiences KMC video show Q&A 2
  • 3. Causes of Newborn Deaths 3
  • 4. Definition of Preterm Birth 4
  • 5. Case definitions Preterm: infant born before 37 weeks of gestational age Low Birth Weight (LBW infant with birth weight less than ): 2500g regardless of gestational age Intrauterine growth restriction: infant small for gestational age, i.e. birth weight below the 10th percentile for gestational age 5 Source: Lawn JE et al – CHER preterm birth working group G
  • 6. 15 million babies are born too soon every year.. Global average rate of 11.1% 14.9 million (range 12.3 to 18.1 million) preterm babies affecting families all over the world 6
  • 7. Preterm births – where are the rates highest? 11 countries with preterm birth rates over 15%   1.Malawi 2.Congo 3.Comoros 4.Zimbabwe 5.Equatorial Guinea 6.Mozambique 7.Gabon 8.Pakistan 9.Indonesia 10.Mauritania 11.Botswana Of the 11 countries with the highest rates, 9 are in Africa Note: rates by country are available on the accompanying wall chart. Not applicable=non WHO Members State Source: Blencowe et al National, regional and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications
  • 8. W do preterm/ hy LBW babies die? Unable to control body temperature  Hypothermia  increases risk to infections Feeding difficulties, inappropriate/ inadequate feeding  leads to hypoglycemia  increases risk to infections Other causes of death  Breathing difficulties -respiratory distress syndrome, apnea,  Immature liver function (hyperbilirubinemia)  congenital malformations 8
  • 9. Thermal Care : Maintenance of WarmthMaintenance of warmth is essential for newbornsurvival and an important component of essentialnewborn care Immediate skin-to-skin contact for first 1-2 hours (for all babies-WHO) Wrapping baby in dry cloth making sure head and feet are covered appropriately Delaying bathing for at least 6 hours Monitoring baby’s temperature for hypothermia 9
  • 10. W is Kangaroo Mother Care? hatDefinition:‘Early, prolonged and continuous (as allowed bycircumstances) skin-to-skin contact between a mother (orsubstitute for the mother) and her low birthweight infant,both in hospital and after early discharge (depending oncircumstances), until at least the 40th week of post-natalgestational age, ideally with exclusive breastfeeding andappropriate follow-up’Acta Paediatrica 1998;87:440-5 10
  • 11. Practice/Elements of KMC Used in care of stable premature/ birth weight babies low KMC Position KMC Nutrition Exclusive Breast feeding KMC Counseling EBM cup feedsKMC Early Discharge& Follow-Up EBM N/ G-tube feeds 11
  • 12. W evidence exists on KMC? hatFacility-based KMC  Over 200 KMC publications  14 randomized control trials (RCTs)Studies have evaluated the effect of KMC on:  Mortality  Temperature  Breast-feeding  Weight gain  Infections 12
  • 13. Kangaroo mother care – Searches and screening DATABASES SEARCH TERMS Pub Med LILACS, African Index ‘’Kangaroo mother care’, ‘Kangaroo Medicus, and EMRO, Cochrane, care*’ ‘Skin to skin’ Total search results = 6127 Cochrane 1 (2003) PubMed 6072 Excluded studies LILACS 52, EMRO 2, AFRO 0 Not a study or trial = 502 Studies remaining after Outcome data not mortality or screening title or abstract serious morbidity or wt gain (or (n=524) breastfeeding) = ~20 No comparison group = 2 15 RCT (n= 9) Studies Observational (n=6) (one Portuguese to be translated) Mortality Morbidity Wt gain 6 5 6 Mortality Morbidity 4 1 1 Excluded as 3 2 Excluded as initiated KMC after 1 week of age BWT data 3 1 modelledSource: Lawn JE et al – IJE 2010 in press
  • 14. Potential for lives saved through Kangaroo Mother Care Cochrane review 2003 (3 studies): No difference in mortality compared to functioning incubator Cochrane review 2011 (16 studies): 40% reduction in mortality at time of discharge Lawn et al, 2010 (3 RCT): Mortality reduction 51% for babies < 2000g, in facilities, clinically stable and KMC started within one week compared to incubator care Compared to non-functioning incubators or no incubator care (warming room with charcoal fire, light bulb box, room heaters) - KMC is the best option! *However, incubators do have a role in the care of preterm babies who are unstable, have a medical problem, or when mother unable to practice KMC KMC could save about 450,000 babies each year if theLawn et al ‘Kangaroo mother care’ to prevent neonatal deaths due to preterm birth complications. Int J Epid: 142010, intervention reached 95% of preterm babies (LiST analysis)Conde Aguedelo Cochrane review 2011
  • 15. Temperature ControlSwings in temperature KMC - constant temperature
  • 16. Skin-to-skin contact for rewarming hypothermic neonatesChristensson K et al. Lancet 1998;352:1115 Cumulative proportion of rewarmed infants 100 % reaching 36.5°C 80 60 skin-to-skin 40 incubator 20 0 0 60 120 180 240 300 360 420 480 540 600 Time (minutes) 16
  • 17. KMC - Effect on breastfeedingStudy Outcome KMC ControlSchmidt et al. Daily volume 640 ml 400 ml Daily feeds 12 9Wahlberg et al. BF at discharge 77% 42%Whitelaw et al. BF >6 weeks 55% 28%Syfrett et al. Daily feeds 12 2 (GA<34w)Affonso et al. Mothers confident aborted attitude*Better Breastfeeding rates with KMC* 17
  • 18. KMC – Effect on Weight Gain2 RCT’s KMC Control Ramanathan, 2001 15.9 10.6* (g/day) Cattaneo, 1997 21.3 17.7* (g/day)Weight gain faster in K C group MEarlier hospital discharge by 3-7 daysWeight similar at 1 year of age
  • 19. KMC – Effect on Infection KMC Control Sloan, 1994 Se rio us illne s s 5% 18% Lo we r Re s p ira to ry I c tio n nfe 5% 13% Charpak, 2001 N s o c o m ia l o 3.4% 6.8% Lawn et al, 2010 (5 RCTs): 66% reduction in severe morbidity for L W<=2000g B
  • 20. KMC Implementation at Country Highlights/ Experiences KMC delivery approaches – facility based, ambulatory, community Most countries have initiated KMC at health facility levels Some countries are implementing ambulatory KMC with continued follow-up into the community or ‘testing’ community KMC Various countries have/ use:  KMC policies and guidelines  KMC training manuals, BCC materials  KMC program tools (registers, site assessment, admission/discharge criteria; follow up protocols, performance standards and quality improvement, etc)  KMC indicators 20
  • 21. 1998 International KMC Conference Bogotá Declaration "Kangaroo-Mother Care should be a basic right of the newborn, andshould be an integral part of the management of low birth weight and full-term newborns, in all settings and at all levels of care and in all countries" Second International Conference on Kangaroo Mother Care, 1998 21
  • 22. KMC in LAC Dec. 2011 - Regional KMC Network formed Kangaroo Foundation (‘F undacion Canguro’) – conducts KMC training in Bogota, Colombia KMC implementing countries  Colombia  Dominican Republic  Paraguay  Peru  Bolivia  Honduras  El Salvador  Nicaragua  Guatemala  Haiti 22
  • 23. KMC in Africa Scaling up a snapshot of scale up status Ethiopia 1 teaching hospital (1997), rolling Mainly referral out to 7 regional, 1 zonal hospitals (2009) hospitals Nigeria Tanzania 3 N/States, 2regional, 1 18 regional hospitals (MAISHA) teaching hosp. with + Zanzibar expansion thro’ otherprograms (PRRINN-MNCH) Uganda I teaching, 4 district hospital since Cameroon (2004), expanding to 3 districts 1 teaching hospital (2010) Mali Rwanda Started in 2007, expansion to all1 teaching hospital (2008), district hospitals 3 regional (2009/10, 2 district (2009) Ghana Mozambique 2 teaching hospitals in 2007, 45 regional (2009), 4 district regions in 2008, MRC & UNICEF hospitals (2010) At wide scale Malawi Zimbabwe 32 district, 2 regional, 2 1 national hospital South Africa central,7 mission hospitals, (Harare, since 2000), 2 > 100 hospitals in all provinces districts (MCHIP), other many with supervision / quality expanding – AKMC/CKMC districts (partners) tracking (SNL/ACCESS/MCHIP) 23 KMC activities in several other countries not included
  • 24. KMC in Asia Vietnam India Nepal Indonesia Bangladesh (CKMC) 24
  • 25. Scaling up KMC to save lives some research questions & needsServices closer to home•Some governments plan to expand KMC even further to district hospitals and healthcentres (e.g. Malawi, Tanzania, Mali)•Evidence needed for community initiation/continuation of KMC (e.g. Bangladesh, Ethiopia)Novel approaches•How to counteract staff shortages in health facilities (e.g. task shifting and use of patientattendants)Training and tracking•Shorter, integrated off-site training•1-2 day orientation workshops for district health management teams (HMTs), variousimplementers and partners•On-site facilitation and support • Monitoring quality implementation • Consistent indicators and measurement of scale up Large scale implementation is possible, with training either on-site or at centre of 25 excellence, but supervision/mentoring is crucial
  • 26. KMC Materials Various materials are available in several implementing countries  KMC training manuals and CDs  BCC materials - posters, client brochures, etc  Counseling materials  M&E and quality improvement tools  KMC tool kit 26
  • 27. Available ResourcesKangaroo Mother CareImplementation Guide Caring for the Newborn at Home: A training course for community h e a l t h w o rk e rs Community Health Worker Manual Caring for the Newborn at Home: A Training Course For Community Health Community Health Worker -- 1
  • 28. Available Resources• MCHIP’s KMC Implementation Guide (English & Spanish!) http://www.mchip.net/node/974• ‘Born Too Soon’ publicationAcknowledgements:•‘Born too Soon’ Team – for use of selected slides Courtesy: Joy Lawn & team•KMC implementing countries/partners – sharing materials and photos
  • 29. For more information… KMC W ebsite Links/ ResourcesW links ebMCHIP: http://www.mchip.net/Healthy Newborn Network (HNN):KMC http://www.healthynewbornnetwork.org/search/node/kmcKangaroo Foundation: http://fundacioncanguro.co/KMC India – 2012 KMC International Conference: http://www.kmcindia2012.org/KMC Support for parents and staff of premature babies: http://www.kangaroomothercare.com/Skin to skin contact – Support for KMC based on science and evidence:http://www.skintoskincontact.com/KMC Videos:WHO KMC video: http://www.youtube.com/watch?v=kAVMWa6BFPYLiving Proof KMC in Malawi: http://www.youtube.com/watch?v=pwNFuWh4X8QKMC in Tanzania: http://www.youtube.com/watch?v=MSm-LBgNo8k&feature=relatedKMC in Kenya: http://www.youtube.com/watch?v=Yc4dmA-OtEI&feature=relatedVarious other KMC websites available based on specific KMC content 29
  • 30. AcknowledgementsAcknowledgements:•‘Born Too Soon’ Team – for use of selected slides Courtesy: Joy Lawn partners – sharing•KMC implementing countries/materials and photos
  • 31. THANK YOU!www.mchip.net Follow us on: 31