Kangaroo Mother Care

Core Group – Pre-meeting SessionOctober 10, 2012

Washington, DC

Dr. Stella AbwaoTechnical Advisor, Newborn HealthMCHIP-Save the Children

Kangaroo Mother Care (KMC) Presentation Outline

Causes of newborn deaths

Contribution of prematurity/low birth weight to newborn deaths

KMC Practice/Elements of KMC

KMC contribution to newborn survival

KMC implementation - country highlights/experiences

KMC video show

Q & A

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Causes of Newborn Deaths

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Definition of Preterm Birth

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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

Source: Lawn JE et al – CHERG preterm birth working group

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Global average rate of 11.1%14.9 million (range 12.3 to 18.1 million) preterm babies affecting families all over the world

15 million babies are born too soon every year..

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Note: rates by country are available on the accompanying wall chart. Not applicable=non WHO Members StateSource: 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

Of the 11 countries with the highest rates, 9 are in Africa

Preterm births – where are the rates highest?

11 countries with preterm birth rates over 15% 

1.Malawi2.Congo

3.Comoros4.Zimbabwe

5.Equatorial Guinea6.Mozambique

7.Gabon8.Pakistan

9.Indonesia10.Mauritania

11.Botswana

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Why do preterm/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

Thermal Care : Maintenance of Warmth

Maintenance of warmth is essential for newborn

survival and an important component of essential

newborn 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

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What is Kangaroo Mother Care?

Definition:

‘Early, prolonged and continuous (as allowed by circumstances) skin-to-skin contact between a mother (or substitute for the mother) and her low birthweight infant, both in hospital and after early discharge (depending on circumstances), until at least the 40th week of post-natal gestational age, ideally with exclusive breastfeeding and appropriate follow-up’

Acta Paediatrica 1998;87:440-5

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Practice/Elements of KMCUsed in care of stable premature/low birth weight

babies KMC Position

KMC Nutrition Exclusive Breast feeding

KMC Counseling

EBM cup feedsKMC Early Discharge& Follow-Up

EBM N/G-tube feeds

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What evidence exists on KMC?

Facility-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

Total search results = 6127

Cochrane 1 (2003)PubMed 6072

LILACS 52, EMRO 2, AFRO 0

Studies remaining after screening title or abstract

(n=524)

Not a study or trial = 502

Outcome data not mortality or serious morbidity or wt gain (or breastfeeding) = ~20

15 Studies Observational (n=6) (one

Portuguese to be translated)RCT (n= 9)

Mortality6

Wt gain6

No comparison group = 2

DATABASESPub Med LILACS, African Index Medicus, and EMRO, Cochrane,

SEARCH TERMS‘’Kangaroo mother care’, ‘Kangaroo

care*’ ‘Skin to skin’

Kangaroo mother care – Searches and screening

Morbidity5 Mortality

4Morbidity

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3 1 2 Excluded as initiated

KMC after 1 week of age 3

Excluded studies

Source: Lawn JE et al – IJE 2010 in press

1 Excluded as BWT data modelled

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

Lawn et al ‘Kangaroo mother care’ to prevent neonatal deaths due to preterm birth complications. Int J Epid: 2010,Conde Aguedelo Cochrane review 2011

KMC could save about 450,000 babies each year if the intervention reached 95% of preterm babies (LiST analysis)

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Temperature Control

Swings in temperature KMC - constant temperature

Skin-to-skin contact for rewarming hypothermic neonatesChristensson K et al. Lancet 1998;352:1115

Cumulative proportion of rewarmed infants

0

20

40

60

80

100

0 60 120 180 240 300 360 420 480 540 600

Time (minutes)

% r

each

ing

36.5

°C

skin-to-skinincubator

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KMC - Effect on breastfeeding

Study Outcome KMC Control

Schmidt et al. Daily volume Daily feeds

640 ml 12

400 ml 9

Wahlberg et al. BF at discharge 77% 42%

Whitelaw et al. BF >6 weeks 55% 28%

Syfrett et al. Daily feeds (GA<34w)

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Affonso et al. Mothers' attitude

confident aborted

*Better Breastfeeding rates with KMC*

KMC – Effect on Weight Gain

2 RCT’sKMC Control

Ramanathan, 2001 15.9 10.6* (g/day)

Cattaneo, 1997 21.3 17.7* (g/day)

Weight gain faster in KMC group Earlier hospital discharge by 3-7 days Weight similar at 1 year of age

KMC – Effect on Infection

KMC Control Sloan, 1994

Serious illness 5 % 18%Lower Respiratory Infection 5% 13%

Charpak, 2001Nosocomial 3.4% 6.8%

Lawn et al, 2010 (5 RCTs): 66% reduction in severe morbidity

for LBW <=2000g

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

1998 International KMC Conference Bogotá Declaration

"Kangaroo-Mother Care should be a basic right of the newborn, and should 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

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KMC in LAC

Dec. 2011 - Regional KMC Network formed

Kangaroo Foundation (‘Fundacion Canguro’) – conducts KMC training in Bogota, Colombia

KMC implementing countries Colombia Dominican Republic Paraguay Peru Bolivia Honduras El Salvador Nicaragua Guatemala Haiti

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Mali 1 teaching hospital (2008),

3 regional (2009/10, 2 district (2009)

Tanzania18 regional hospitals (MAISHA)

+ Zanzibar

UgandaI teaching, 4 district hospital since

(2004), expanding to 3 districts (2010)

Ghana2 teaching hospitals in 2007, 4 regions in 2008, MRC & UNICEF

Malawi 32 district, 2 regional, 2

central,7 mission hospitals, expanding – AKMC/CKMC

(SNL/ACCESS/MCHIP)

Mozambique5 regional (2009), 4 district

hospitals (2010)

KMC in Africa a snapshot of scale up status

Nigeria3 N/States, 2regional, 1

teaching hosp. with expansion thro’ other

programs (PRRINN-MNCH)

Ethiopia1 teaching hospital (1997), rolling out to 7 regional, 1 zonal hospitals

(2009)

Cameroon 1 teaching hospital

KMC activities in several other countries not included

RwandaStarted in 2007, expansion to all

district hospitals

Zimbabwe1 national hospital

(Harare, since 2000), 2 districts (MCHIP), other

districts (partners)

Mainly referral hospitals

South Africa> 100 hospitals in all provinces many with supervision / quality

tracking

At wide scale

Scaling up

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KMC in Asia

Vietnam India Nepal Indonesia Bangladesh (CKMC)

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Scaling up KMC to save livessome research questions & needs

Services closer to home•Some governments plan to expand KMC even further to district hospitals and health centres (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 patient attendants)

Training and tracking•Shorter, integrated off-site training•1-2 day orientation workshops for district health management teams (HMTs), various implementers 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 excellence, but supervision/mentoring is crucial

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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

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Available Resources

Kangaroo Mother Care Implementation Guide

Caring for the Newborn at Home: A Training Course For Community Health Community Health Worker

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Caring for the Newborn at Home: A training course for community hea lth

w o rke rs

Community Health Worker Manual

Available Resources

Acknowledgements:•‘Born too Soon’ Team – for use of selected slides

Courtesy: Joy Lawn & team•KMC implementing countries/partners – sharing materials and photos

• MCHIP’s KMC Implementation Guide (English & Spanish!) http://www.mchip.net/node/974

• ‘Born Too Soon’ publication

For more information…KMC Website Links/Resources

Web linksMCHIP: http://www.mchip.net/Healthy Newborn Network (HNN):KMC http://www.healthynewbornnetwork.org/search/node/kmcKangaroo 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=kAVMWa6BFPYLiving Proof KMC in Malawi: http://www.youtube.com/watch?v=pwNFuWh4X8QKMC in Tanzania: http://www.youtube.com/watch?v=MSm-LBgNo8k&feature=relatedKMC in Kenya: http://www.youtube.com/watch?v=Yc4dmA-OtEI&feature=related

Various other KMC websites available based on specific KMC content

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Acknowledgements

Acknowledgements:

•‘Born Too Soon’ Team – for use of selected slides

Courtesy: Joy Lawn

•KMC implementing countries/partners – sharing materials and photos

www.mchip.net

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THANK YOU!

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