Kangaroo Mother Care_ Abwao_10.10.12

1. Kangaroo Mother Care
Core Group – Pre-meeting Session
October 10, 2012
Washington, DC
Dr. Stella Abwao
Technical Advisor, Newborn Health
MCHIP-Save the Children

2. 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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3. Causes of Newborn Deaths

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4. Definition of Preterm Birth
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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
Source: Lawn JE et al – CHERG preterm birth working group
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6. 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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7. 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
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.Malawi
2.Congo
3.Comoros
4.Zimbabwe
5.Equatorial
Guinea
6.Mozambique
7.Gabon
8.Pakistan
9.Indonesia
10.Mauritania
11.Botswana

8. 8
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

9. 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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10. 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 40
th
week of post-natal
gestational age, ideally with exclusive breastfeeding and
appropriate follow-up’
Acta Paediatrica 1998;87:440-5
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11. Practice/Elements of KMC
Used in care of stable premature/low birth weight babies
KMC Position
KMC Nutrition
Exclusive Breast feeding
KMC Counseling
EBM cup feeds
KMC Early Discharge
& Follow-Up
EBM N/G-tube feeds
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12. 12
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

13. 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
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Studies Observational (n=6) (one
Portuguese to be translated)
RCT (n= 9)
Mortality
6
Wt gain
6
No comparison group = 2
DATABASES
Pub Med LILACS, African Index
Medicus, and EMRO, Cochrane,
SEARCH TERMS
‘’Kangaroo mother care’, ‘Kangaroo
care*’ ‘Skin to skin’
Kangaroo mother care – Searches and screening
Morbidity
5 Mortality
4
Morbidity
1
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

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
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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15. Temperature Control
Swings in temperature KMC - constant temperature

16. Skin-to-skin contact for rewarming hypothermic neonates
Christensson K et al. Lancet 1998;352:1115
Cumulative proportion of rewarmed infants
0
20
40
60
80
100
060120180240300360420480540600
Time (minutes)
%

r
e
a
c
h
i
n
g

3
6
.
5
°
C
skin-to-skin
incubator
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17. 17
KMC - Effect on breastfeeding
Study Outcome KMC Control
Schmidt et al. Daily volume
Daily feeds
640 ml
12
400 ml
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Wahlberg et al. BF at discharge 77% 42%
Whitelaw et al. BF >6 weeks 55% 28%
Syfrett et al. Daily feeds
(GA<34w)
12 2
Affonso et al. Mothers'
attitude
confident aborted


*Better Breastfeeding rates with KMC*

18. KMC – Effect on Weight Gain
2 RCT’s
KMC 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

19. KMC – Effect on Infection
KMC Control
Sloan, 1994
Serious illness 5 % 18%
Lower Respiratory Infection 5% 13%
Charpak, 2001
Nosocomial 3.4% 6.8%
Lawn et al, 2010 (5 RCTs): 66% reduction in severe morbidity
for LBW <=2000g

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
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21. 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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22. 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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23. Mali
1 teaching hospital (2008),
3 regional (2009/10, 2
district (2009)
Tanzania
18 regional hospitals (MAISHA)
+ Zanzibar
Uganda
I teaching, 4 district hospital since
(2004), expanding to 3 districts
(2010)
Ghana
2 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)
Mozambique
5 regional (2009), 4 district
hospitals (2010)
KMC in Africa
a snapshot of scale up status
Nigeria
3 N/States, 2regional, 1
teaching hosp. with
expansion thro’ other
programs (PRRINN-MNCH)
Ethiopia
1 teaching hospital (1997), rolling
out to 7 regional, 1 zonal hospitals
(2009)
Cameroon
1 teaching hospital
KMC activities in several other countries not included
Rwanda
Started in 2007, expansion to all
district hospitals
Zimbabwe
1 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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24. KMC in Asia
Vietnam
India
Nepal
Indonesia
Bangladesh (CKMC)
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25. Scaling up KMC to save lives
some 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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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
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27. Available Resources












Kangaroo Mother Care
Implementation Guide
















Caring for the Newborn at Home: A Training Course For Community Health
Community Health Worker
-- 1












Caring for the Newborn at Home:
A training course for community heal th
worke r s
















Community Health Worker Manual

28. 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

29. For more information…
KMC Website Links/Resources
Web links
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=related
Various other KMC websites available based on specific KMC content
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30. Acknowledgements
Acknowledgements:
•‘Born Too Soon’ Team – for use of selected slides
Courtesy: Joy Lawn
•KMC implementing countries/partners – sharing
materials and photos

31. www.mchip.net
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THANK YOU!
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