An nalysis of Kangaroo Mother Care (KMC) in Malawi

1. KANGAROO MOTHER CARE
By
Charles Mhango
Student MSc.RH, BSc.NM

2. Outline
• Introduction
• Background
• Statistics
• Current practice
• Challenges
• Evidence based/best practices
• Recommendations
• Conclusion
• Reference

3. 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

4. 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

5. 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)

6. 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

7. 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)

8. 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

9. 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)

10. 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

11. 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)

12. 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)

13. 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)

14. Statistics - Global
• KMC can save up to 450 000 lives a year (March of
Dimes et al., 2012)

15. Statistics - Africa
• 3.552 million under five deaths
• 30% - neonatal deaths
• Preterm birth contributes 10%
(Liu et al., 2012)

16. 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)

17. Current practice: The case of ZCH
Stabilisation of
baby
Education +
Demonstration
(mother +
guardians)
Return
demonstration
(mother +
guardians)

18. Current practice: The case of ZCH

19. Current practice: The case of ZCH

20. 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

21. 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

22. Current practice: The case of ZCH
Discharge criteria
• 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

23. 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

24. Challenges
• Poor monitoring in the hospital
• Lack of resources
• Lack of infrastructure
• Frequent staff rotations (Bergh et al., 2012)

25. 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)

26. 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)

27. 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)

28. Challenges
• Lack of supervision
• Donor project dependent
• Lack of transport
• Internal conflict between different health structures or
authorities
(Bergh et al., 2014)

29. Challenges
• KMC service data not part of existing national
information systems and nationally agreed
indicators (Zimba et al., 2012)

30. 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

31. 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

32. Evidence based / best practices
• Use of trained support staff
• Patient attendants play an active role in KMC
implementation (Blencowe & Molyneux, 2005)

33. 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

34. 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)

35. 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

36. 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

37. 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

38. Recommendations
• There is need to balance the demands placed on
HSAs
• Integrate CBMNC package into the basic HSA (pre-service)
training

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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.
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Ministry of Health. (2009). Malawi National Kangaroo Mother Care
Guidelines (Revised.). Lilongwe: MOH. Retrieved from
http://www.healthynewbornnetwork.org/resource/malawi-national-kmc-guidelines-
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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.

45. 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
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46. 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
Zimba, E., Kinney, M. V., Kachale, F., Waltensperger, K. Z., Blencowe, H.,
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