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ORIGINAL ARTICLE
Year : 2016  |  Volume : 60  |  Issue : 4  |  Page : 302-308  

Rolling out of kangaroo mother care in secondary level facilities in Bihar-Some experiences


1 Additional Professor, Indian Institute of Public Health-Delhi, Public Health Foundation of India, India
2 Project Associate, Indian Institute of Public Health-Delhi, Public Health Foundation of India, India
3 Associate Professor, Indian Institute of Public Health-Delhi, Public Health Foundation of India, India
4 Health Specialist, UNICEF, Bihar, India

Date of Web Publication15-Dec-2016

Correspondence Address:
Sutapa B Neogi
Indian Institute of Public Health-Delhi, Public Health Foundation of India, Plot No. 47, Sector 44, Gurgaon, NCR, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-557X.195864

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   Abstract 


Background: Preterm birth is one of the leading causes of under-five child deaths worldwide and in India. Kangaroo mother care (KMC) is a powerful and easy-to-use method to promote health and well-being and reduce morbidity and mortality in preterm/low birth weight (LBW) babies. Objective: As the part of the roll-out of India Newborn Action Plan interventions, we implemented KMC in select facilities with an objective to assess the responsiveness of public health system to roll out KMC. Methods: KMC intervention was implemented in two select high priority districts, Gaya and Purnea in Bihar over the duration of 8 months from August 2015 to March 2016. The implementation of intervention was phased out into; situation analysis, implementation of intervention, and interim assessment. KMC model, as envisaged keeping in mind the building blocks of health system, was established in 6 identified health-care facilities. A pretested simple checklist was used to assess the awareness, knowledge, skills, and practice of KMC during baseline situational analysis and interim assessment phases for comparison. Results: The intervention clearly seemed to improve the awareness among auxiliary nurse midwives/nurses about KMC. Improvements were also observed in the availability of infrastructure required for KMC and support logistics like facility for manual expression of breast milk, cups/suitable devices such as paladi cups for feeding small babies and digital weighing scale. Although the recording of information regarding LBW babies and KMC practice improved, still there is scope for much improvement. Conclusion: There is a commitment at the national level to promote KMC in every facility. The present experience shows the possibility of rolling out KMC in secondary level facilities with support from government functionaries.

Keywords: Kangaroo mother care, low birth weight, preterm, skin-to-skin contact


How to cite this article:
Neogi SB, Chauhan M, Sharma J, Negandhi P, Sethy G. Rolling out of kangaroo mother care in secondary level facilities in Bihar-Some experiences. Indian J Public Health 2016;60:302-8

How to cite this URL:
Neogi SB, Chauhan M, Sharma J, Negandhi P, Sethy G. Rolling out of kangaroo mother care in secondary level facilities in Bihar-Some experiences. Indian J Public Health [serial online] 2016 [cited 2019 Jun 25];60:302-8. Available from: http://www.ijph.in/text.asp?2016/60/4/302/195864




   Introduction Top


The health sector has been seeing momentous changes over the past decade in all aspects of healthcare. India contributes to 42% of global burden of low birth weight (LBW) babies and about a quarter of preterms births. Nearly, 30% of neonates – 7.5 million are born with LBW, that is, birth weight <2500 g in India.[1] About 60% of the LBW infants are born at term, whereas the remaining 40% (around 3.5 million) are born preterm (before 37 weeks of gestation).[2] LBW is a major contributor to infant mortality accounting for 60%–80% of neonatal deaths [3] and two-thirds of infant deaths.[4] LBW infants are at 11–13 times increased risk of dying than normal weight infants.[5] Any reduction in mortality in India will influence the global rates.

Kangaroo mother care as a strategy

Interventions to improve care during childbirth and the postnatal period, as well as feeding, are likely to improve the immediate and long-term health and well-being of the individual infant and have a significant impact on reduction in neonatal and infant mortality at a population level. This is even more relevant for preterm and LBW infants, who often require consistent care and support until they are stabilized. Kangaroo mother care (KMC), defined as skin-to-skin contact between a mother and her newborn, frequent and exclusive or nearly exclusive breast milk feeding and early discharge from hospital has proven to be an alternative to conventional neonatal care for LBW babies.[6] Recent evidence indicates that KMC is closely associated with a significant reduction in the risk of overall mortality (relative risk [RR]: 0.60; 95% confidence interval [CI]: 0.39–0.93); nosocomial infections or sepsis (RR: 0.42; 95% CI: 0.24–0.73); hypothermia (RR: 0.23; 95% CI: 0.10–0.55). There is a reduction in the mean duration of hospital stay by 2.4 days. The long-term impact includes improvement in the average daily weight gain (3.9 g; 95% CI: 1.9–5.8 g) and breastfeeding (RR: 1.25; 95% CI: 1.06–1.47).[7] In the low- and middle-income countries, where financial and human resources for neonatal care are restricted, and hospital wards for LBW infants are over-crowded, this approach is feasible and seems to be an acceptable strategy. KMC also allows for continued care at home, even after discharge from the hospital. Both continuous and intermittent KMC have been associated with decreased risk of infection, hypothermia, and reduced duration of hospital stay.[7]

Global experiences

Experiences from community-based studies indicate that after discharge from hospitals, a continuation of KMC varies from 3.4% in Africa [8] to 75% in Bangladesh,[9] thereby emphasizing the significance of continuation of KMC at home. Continuing KMC at home is likely to increase the benefits of KMC manifolds.

Experiences from India

In India, the focus of NRHM on newborn care in recent years has been on child health-care strategies that are implementable not only at the facility but also within the community. The proportion of institutional deliveries has more than doubled since the launch of Janani Suraksha Yojana scheme.[10] Access to services and their utilization in facilities have increased manifold. Essential newborn care and care of sick babies have gained considerable attention and currently several guidelines are in place for the same.[11] Despite skin-to-skin contact traditionally being a part of child survival intervention packages, focused attention was a critical gap. Its implementation has not been satisfactory since KMC guidelines and policies were not in place until September 2014.[12]

Given the known benefits and challenges of KMC as a model of care for LBW babies, there is a felt need to create scientific evidence to address the feasibility of adaptation and scale-up of this model for LBW and preterm babies at the health facilities. In addition, there is also need to extend the implementation of KMC to the community, thereby increasing the coverage. It is pertinent to tailor the strategies for implementation of KMC according to the diverse socio-cultural needs and resources of the settings. There is evidence to show that context-specific strategies are more successful and should be focused in regions where the burden of neonatal morbidity and mortality and more specifically LBW is high.

The objective of this study was to roll out India Newborn Action Plan (INAP) interventions of which KMC was a key component. We implemented KMC in select facilities with an objective to assess the responsiveness of public health system to roll out KMC.


   Materials And Methods Top


As part of the rollout of INAP in Bihar, the KMC intervention was implemented in two select high priority districts, Gaya and Purnea. The intervention was divided into three phases; situation analysis, implementation of intervention, and interim assessment of the responsiveness of the public health system in the two districts. The initial assessment of all the health facilities in both the districts having a delivery load of more than 200 was conducted. The target facilities were assessed for infrastructure and logistics; care providers (nurses/ auxiliary nurse midwives [ANMs] on duty on the day of assessment) were assessed for awareness, knowledge, skills and practice of KMC using a pretested simple checklist. Based on the initial assessment, two sub-divisional hospitals (SDH) in Gaya, 3 referral hospitals (RH) and 1 Primary Health Centre (PHC) in Purnea district were identified for setting up KMC Corners. A KMC Corner would be a dedicated space in the postnatal ward of the hospital, with two or more beds earmarked for mothers who need to practice KMC for their babies until discharge from the hospital. This space would have all the requisite facilities for the implementation of KMC (such as a screen for privacy, beds to help the mother recline during KMC, cloths to wrap baby in KMC position).

During the implementation phase, efforts were put in to equip the identified facilities and health-care staff therein with required logistics and skills to facilitate the delivery of KMC services. The implementation phase lasted for 8 months from August 2015 to March 2016. Interim assessment was conducted in April 2016 to assess the improvement in awareness, knowledge, skills, and practice about KMC in the identified facilities of both the districts.

The INAP project was approved by Institutional Ethics Committee of Indian Institute of Public Health Delhi at the outset, and assessment of the implementation of KMC in the two districts of Bihar was part of the project activities. The data for the interim assessment were collected from the health-care facilities by talking to the staff as well as through observations. For the purpose of maintaining confidentiality, the names of the staff members have not been revealed anywhere in the paper.


   Results Top


The baseline situational analysis was conducted in 22 facilities in both the districts, wherein nurses and ANMs were interviewed regarding their knowledge, skills, and practices regarding KMC as well as the infrastructure available for KMC and the status of recording and reporting the practice of KMC. During the interim assessment, nurses and ANMs across the 6 facilities, where KMC set up was established, and the intervention was implemented over the preceding 8 months, were interviewed and observations were made to draw the results.

In the baseline assessment it was found that although a considerable number of ANMs/nurses (17, 77.3%) knew about KMC as an intervention, only 5 (23%) were aware about recommending KMC for LBW babies. Their knowledge on correct time to initiate breastfeeding was relatively poor (72.7%). Digital weighing machines were used to measure weight, but most of them (68%) referred all babies with LBW to newborn care corners (NBCCs), and the practice of KMC was not common. Adequate infrastructure was not made available to manage LBW babies. Furthermore, the system of recording and reporting though existed was not optimum to capture basic information on LBW babies [Table 1].
Table 1: A comparison between baseline and Interim assessment of key indicators pertaining to kangaroo mother care

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Kangaroo mother care intervention model

A KMC model was envisaged keeping in mind the building blocks of health system that was finalized in consultation with the district authorities. The implementation of intervention phase started with apprising the service providers and managers at district level about the KMC intervention as part of the INAP roll out and its importance for managing LBW babies. Official letters were issued for roll out of KMC intervention and assurance for providing all the necessary support toward its implementation by district level authorities was given.

In consultation with the respective district authorities and feasibility of implementation, a total of six health facilities were identified for setting up KMC Corners in both the districts two SDH in Gaya district and three RH and one PHC in Purnea district.

The names of the identified facilities are listed below:

  • In Gaya district-SDH Tekari and SDH Sherghati
  • In Purnea district-RH Damdaha, RH Rupauli, RHB anmankhi, and PHC Amour.


In both the districts separately, the medical officers-in-charge and block health managers of the selected facilities were sensitized about the importance of KMC. Not only the availability of suitable space was a hurdle for this intervention but also the availability of funds was a concern. The field team comprising of members from UNICEF and Public Health Foundation of India provided technical support to designate separate space/room in the facilities with basic amenities to practice KMC. Since no funds were earmarked for this activity in the Program Implementation Plan (PIP), Rogi Kalyan Samitis (RKS) provided the requisite financial support. The team facilitated the preparation of District-level newborn action plan where separate funds could be allocated to KMC. Information education and communication (IEC) departments of the districts were requested to display the necessary visual materials in all the KMC Corners.

The staff from labor room/postnatal ward were identified and given charge of KMC Corners and their duty schedules were rotated so as to have at least one staff dedicated to KMC Corners round the clock. The KMC component was discussed during monthly meetings, and its implementation was emphasized during trainings on Navjaat Shishu Suraksha Karyakram conducted for ANMs during the intervention period. Besides, on-site training and demonstrations were provided by the field team to the ANMs, nurses as well as the MAMTA workers (contract health workers based in the facilities for care of newborn babies and their mothers). In addition, KMC practice was emphasized in other overlapping trainings that the staff were exposed to.

The activities in KMC Corners of all the identified health facilities were closely monitored and supervised by the field team. It was also advocated to the government through District Health Society that KMC related indicators must be included in the existing Health Management and Information System.

The key points included in the intervention model are summarized in [Table 2].
Table 2: Components of kangaroo mother care implementation model with respect to WHO health systems framework

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The activities toward implementation of the model continued for 8 months after which an assessment was performed. The results [Table 2] demonstrated a definite improvement in the awareness among ANMs/nurses about KMC. Care providers were adept to providing KMC in the same facilities instead of referring every LBW baby to NBCC as was happening previously.

The intervention clearly seemed to impact the availability of infrastructure required for KMC as provision was made for separate space/room/beds for providing KMC in the selected facilities. Provisions such as the presence of curtains/separators/partitions were made to maintain the privacy of the mother-baby duo while practicing KMC. Facilities for manual expression of breast milk were also made available at four of the six health-care facilities. Although availability of digital weighing scale and cups/suitable devices like paladi cups for feeding small babies improved (100% and 50%, respectively) with efforts, yet the presence of room heaters and feeding tubes remained a concern.

Over a period of 8 months of intervention, the recording, and reporting of KMC improved a little. Though the availability of separate register to record the information about LBW babies increased to 50% and LBW babies receiving KMC started getting reported in half of the facilities, there is a lot of scope for further improvement.


   Discussion Top


An intervention model was developed and rolled out in select facilities in Bihar to institutionalize KMC. Its success can be noted in terms of increased awareness and knowledge about KMC among the care providers, significant improvement in terms of infrastructure, logistics, and ownership of the health-care providers over 8 months.

Our findings are similar to the experiences reported from other countries. Reports on KMC in four regions in Ghana indicated that after implementation of the program, 50% of total hospitals had a separate KMC ward and other 34% had been using beds in the postnatal ward for this purpose.[13] The practice of providing KMC to LBW babies was seen as a significant change, similar to our findings. Research from Africa and Asia highlights the success of KMC as a vertical, donor-driven strategy in tertiary care hospitals; however, dissemination at tertiary level hospitals was limited and cascading the strategy to lower health-care levels remained a challenge.[14],[15],[16],[17] Experience from South Africa revealed reluctance of hospital management to allocate dedicated space for mothers to practice KMC round-the-clock.[18] Besides training, innovation and improvization on other aspects of the health system, including infrastructure, human resource, community mobilization, behavior change, family support to facilitate and continue KMC implementation also deserve due importance.[17],[19],[20],[21] In our intervention model, we considered every aspect of health system strengthening so as to have a sustainable model in place.

Continuous supervision by a senior professional or other cadre is crucial, given the specialization required to care for vulnerable LBW and preterm babies. The current intervention utilized the existing workforce for the purpose of managing the LBW babies with the help of KMC, further burdening the already overburdened health-care workers. To manage the crunch of staff, at one major hospital in Malawi, in the absence of qualified staff, patient attendants were trained to run KMC ward under nursing and medical supervision.[22]

Facility-based studies conducted in India on KMC show significant benefits in terms of acceptability, feasibility, improved growth and reduced infections among newborns.[23],[24],[25] However, around 50% mothers go home within 48 h of delivery.[26] For ensuring optimum benefit; it is important to ensure that the mothers initiating KMC in the hospitals continue it even after discharge. There is, therefore, a need to link facility with community-based practice. Community-based research carried out by Indian Council of Medical Research (ICMR) covering diverse population groups (urban, rural, tribal) suggests that the method is acceptable to mothers and family members. The intervention package in the ICMR study included providing information on the benefits of KMC to mothers during the antenatal check-ups through IEC material, films on KMC and posters. Over 50% mothers initiated KMC within 72 h after delivery and 80% did so within a week, average duration being 5 h.[27] Nevertheless, this model had its challenges and barriers in terms of awareness and knowledge of KMC, continuation of KMC after discharge from the facility, support from family at home [21] and time that can be allocated to provide KMC, given other household chores.

Similar issues were reported in a multi-country analysis of 12 Asian and African countries and were rated as very major bottlenecks.[28] There was an overall lack of prioritization of KMC by regulatory bodies and lack of institutionalization of KMC. Financial barriers were also very prominently emphasized. Inadequate space for performing and monitoring KMC, poor referral and transport system, poor quality of KMC delivery and weak quality improvement measures were reported. Health information challenges were also acknowledged as one of the barriers for scaling up of KMC.[28]

Our model could address some of these challenges with the help of district authorities and the health-care staff. Every aspect of the intervention was owned by the district. With minimal investment, we could mobilize some funds from RKS for the intervention. Staff members were imparted training and mentoring on KMC implementation. Despite issues with availability of space and logistics, six facilities succeeded in setting up KMC corners and initiated implementation of KMC in 8 months' time.

However, the limited duration of the intervention was a relatively short time to assess the impact of any intervention. Moreover, the number of facilities where the model could be implemented was small. We, therefore, conducted an interim assessment to gauge the progress related to the implementation of the model and the challenges thereof. With these limitations, it is difficult to determine the sustainability and scalability of the model.

Experiences have shown that the pathway for KMC scale-up in low-income countries like for many other interventions has been donor-driven and has resulted in countries being dependent on this funding.[29] There is a need to integrate the budgetary allocation for KMC implementation in PIP to maintain the continuous influx of money to initiate and sustain this intervention. In India, there is a political commitment to promote KMC as a part of INAP and RMNCH+A.[30] However, the budget allocated for KMC is subsumed within the broad head of newborn health and hence does not catch the attention of district managers.


   Conclusion Top


To conclude, there is a commitment at the national level to promote KMC in every facility. Our experiences have shown that it is possible to roll-out KMC in secondary level facilities with support from government functionaries. With an intervention that lasted for less than a year in limited facilities, and initial success in the uptake of the program, we are yet to see how sustainable the efforts are in the long run.

Financial support and sponsorship

UNICEF, Bihar.

Conflicts of interest

Ghanshyam Sethy, Syed Hubbe Ali and Siddharth Reddy are affiliated to UNICEF Bihar (sponsor of the study and supplement). The views expressed in the paper are those of the individuals and not of the organizations they represent.

 
   References Top

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