|ORIGINAL CONTRIBUTION: PEDIATRICS
|Year : 2014 | Volume
| Issue : 3 | Page : 190-194
Kangaroo mother care in low birth weight babies: Measures to mitigate challenges in implementation
Alpanamayi Bera1, Parul Datta1, Avijit Hazra2, Jagabandhu Ghosh3, Syamal Sardar4, Anshuman Paria4
1 Administrative Department of Nursing Training School, Howrah District Hospital, Howrah, West Bengal, India
2 Department of Pharmacology, IPGME & R and SSKM Hospital, Kolkata, West Bengal, India
3 Department of Pediatrics, IPGME & R and SSKM Hospital, Kolkata, West Bengal, India
4 Department of Neonatology, IPGME & R and SSKM Hospital, Kolkata, West Bengal, India
|Date of Web Publication||27-May-2015|
Howrah District Hospital, Mahalaxmi Apartment, 222 G. T. Road, Belur Math, Howarh - 711 202, West Bengal
Source of Support: None, Conflict of Interest: None
Introduction: Kangaroo Mother Care (KMC) is a nonconventional low-cost method of newborn care. We tried to understand the difficulties faced by mothers during KMC and profile the corrective action. Materials and Methods: Over 3½ years, mothers of inborn low birth weight babies were taught and motivated by clinical nurse researcher to implement KMC. Gross congenital abnormality or nonconsenting mothers were exclusion factors. After demonstration sessions, KMC was implemented for 1 h on 1st day, 2 h on 2nd day, 3 h on 3rd day and then scaled up for as long as a mother felt comfortable. After discharge, KMC was continued at home till the infant attained 2500 g weight or 40 weeks corrected gestational age. Difficulties being faced both in hospital and at home were probed and remedial measures suggested accordingly. Results: Of 300 mother-baby pairs studied, 35 (11.67%) mothers could not implement KMC satisfactorily in hospital itself. Causes of failure related to mother, infant or socioeconomic factors, such as mother not feeling well enough, need to visit toilet, feeling hungry, lack of self-motivation, soiling of nappies, and interfering family members (especially maternal grandmother). To overcome these problems, both mother and father, and when required, other family members were counseled. Mother was instructed to visit the toilet just before KMC session and to take adequate food beforehand. Before discharge family support person was identified. After discharge, 6 (2%) additional mothers faced problems from lack of privacy, discouragement by mother-in-law or neighbors, lack of time and uncomfortable summer environment. Motivation and counseling at every follow-up visit rescued the situation. Conclusion: Regular supervision and counseling along with adequate initial demonstration are necessary for successful implementation of KMC.
Keywords: Implementation barrier, India, Kangaroo Mother Care, low birth weight
|How to cite this article:|
Bera A, Datta P, Hazra A, Ghosh J, Sardar S, Paria A. Kangaroo mother care in low birth weight babies: Measures to mitigate challenges in implementation. Astrocyte 2014;1:190-4
|How to cite this URL:|
Bera A, Datta P, Hazra A, Ghosh J, Sardar S, Paria A. Kangaroo mother care in low birth weight babies: Measures to mitigate challenges in implementation. Astrocyte [serial online] 2014 [cited 2019 Jul 16];1:190-4. Available from: http://www.astrocyte.in/text.asp?2014/1/3/190/157763
| Background|| |
Three-quarters of global neonatal deaths happen in the first week; the highest risk of death is on the 1st day of life. Low birth weight (LBW, i.e., birth weight <2500 g) and prematurity are important risk factors for death. Over 1 million children die each year due to complications of preterm birth and prematurity is now the second leading cause of death of under-five children next to pneumonia. 
The use of incubators is standard for care of LBW babies in most countries though it is not widely available in resource-constrained settings. Fortunately, an effective and affordable alternative approach is available for providing thermal care of preterm and LBW infants in the form of Kangaroo Mother Care (KMC).  This is a nonconventional method which is believed to confer significant survival benefit to such babies.  KMC refers to early, prolonged, and continuous skin-to-skin contact between the mother (or her substitute) and her newborn baby, both in hospital and after discharge, until at least 40 weeks of postnatal age.  It is a conceptually simple and elegant technique in which the role of the neonatal healthcare provider is basically to teach, coach, offer expert counseling, and closely monitor the mother-infant dyad. KMC is not "alternative medicine" approach but a scientifically sound, evidence-based intervention.  Postdischarge KMC is practiced at home when the baby is feeding well, growing and stable and the mother demonstrates competency in caring for the baby on her own. 
Kangaroo Mother Care was first introduced by Dr. Edgar Ray in 1978, as a substitute for the incubator, later continued by Dr. Martinez and Luis until creation of kangaroo foundation in 1994. Dr. Nathalie Charpak and Sister Susan Ludington-Hoe have worked tirelessly to establish worldwide implementation of KMC. , Despite many implementations, education and training efforts, some countries are finding it difficult to increase their coverage of this intervention.  KMC is acceptable to most mothers admitted in hospitals, but little is known about mothers continued unsupervised practice after discharge from hospitals. In stressful situations, when the infant has to remain in the hospital for longer duration, mothers practicing KMC feel more competent but lack of social support can negatively impact upon the process.
Kangaroo Mother Care offers many benefits-an updated Cochrane review reported that the practice is associated with 80% reduction in risk of hypothermia.  This may be the result of the positive impact on thermoregulation in the LBW newborn. ,,[ 10] Positive effect of KMC on vital physiological parameters of LBW babies has been observed in various studies. ,, A positive effect on neonatal mortality rate of LBW infants is also postulated. , Sustained effect of KMC on growth and development of LBW babies has been observed even at one year age; long after the intervention was stopped. ,,,
Kangaroo Mother Care offers other potential advantages, like, mother's empowerment and family bonding with the LBW infants. , Providing prolonged skin-to-skin care (SSC) seems to be a restorative as well as an energy-draining experience for the mother. A supportive environment naturally facilitates the experience, whereas social and environmental obstacles can make it stressful. When the process is experienced positively, it facilitates the growth of parental self-esteem and makes the parents ready to assume full responsibility for their child. 
In the context of specific health system constraints and sociocultural obstacles, an intervention might be perceived feasible in some countries but challenging in others. KMC is highly feasible in African Countries but challenging in Asia.  In West Bengal, India, the practice of KMC, though generally well received, is limited; some still consider newborn care through skin-to-skin contact as inappropriate and discourage the practice. Mothers discharged from the health facility who continue KMC at home may be ridiculed, making a home or community environment nonconducive for early discharge. The very simplicity of KMC makes its implementation challenging, as some healthcare providers, and even health administrators and policy makers, may find it less glamorous and it may be perceived as inappropriate in commercially driven technology dependent private institutional practice. 
With this background, the objective of this study was to understand the difficulties faced by mothers during actual implementation of KMC and suggest appropriate remedial action.
| Materials and Methods|| |
The study was designed as a prospective observational study in the setting of a tertiary care teaching hospital of West Bengal with level III Neonatal Intensive Care Unit facility. The study protocol was approved by the Institutional Ethics Committee, and an allied clinical trial was registered with Clinical Trial Registry India (CTRI/2013/07/003814).
The mothers of inborn LBW babies, who agreed to perform KMC, were included in the study. At first mothers were counseled regarding exclusive breastfeeding. Formal written consent of willing mothers was obtained for participation in the study. Sick mothers, those who lived a long distance from the hospital and might not be able to take part in follow-up and those with babies with gross congenital malformations were excluded from the study. Three hundred mother-baby pairs were recruited over a period of 3½ years. These 300 mother-baby pairs actually constituted the KMC arm of a nonrandomized controlled clinical trial to study the effect of KMC on growth and development of LBW babies up to 12 months age.  In this trial, mother-baby pairs, in sets of 5, were allocated to two groups in 3:2 ratio - the three babies with lower weight being allocated to the KMC arm. Thereby, 300 babies were allocated to KMC group and 200 to conventional care with exclusive breastfeeding. This nonrandom 3:2 allocation was done to address the ethical concern regarding denial of KMC to a section of the study participants - those in greater need of KMC were placed in the KMC arm. At a time, no more than 3 babies were taken up for KMC in-house to ensure that proper supervision of care could be maintained.
The mothers received guidance regarding exclusive breastfeeding and KMC and their benefits, followed by demonstration with the help of volunteer mothers. For implementing KMC, mothers were asked to use any front open light dress, like blouse and sari or gown. Babies were dressed with cap, socks, and nappy. Baby was placed in a KMC bag and then positioned upright inside mother's clothing against bare skin over the chest. The babies' head was turned to one side and in a slightly extended position to keep the airway patent, with abdomen at the level of mother's epigastrium, hips flexed and abducted in a "frog" position and arms flexed. Mother was encouraged to maintain eye to eye contact with the baby, when awake, and baby was allowed to suck on breasts at liberty.
Kangaroo Mother Care was initiated once the baby was hemodynamically stable and out of ventilator. On the 1st day, KMC was provided for 1 h, 2nd day 2 h, 3rd day 3 h, and gradually duration was increased to as long as the mother felt comfortable. Mothers who were initially hesitant were counseled and given further demonstrations until they were able to perform KMC confidently and correctly. The mothers were instructed to continue KMC at home after discharge until the baby reached 40 weeks of corrected age or 2500 g body weight, whichever was earlier. They were given dietary advice and told to increase the amount of calories, protein, fruits and vegetables they consumed, depending on the family's economic situation. They were also told to consume plenty of fluids. During in-house KMC session, mothers were asked daily regarding any problems related to their babies and KMC. After discharge, they were questioned at follow-up visits. Response of each mother was recorded and on completion of the study, the responses were analyzed using descriptive statistics.
| Results|| |
The gestational age of the KMC babies was 33.3 ± 2.97 weeks (mean ± standard deviation) at birth. The birth weight ranged from 719 to 2405 g, with mean ± standard deviation of 1481.4 ± 363.62 g. Intervention was started at 4.0 ± 2.52 days (range 1-15 days). The age of the mothers was 25.7 ± 5.19 years, and 56.2% of them came from an urban or semi-urban background. Data were available from all mothers recruited.
Of 300 mother-baby pairs studied, 41 (13.67%; 95% CI: 9.78-17.55%) mothers faced problems with KMC implementation; 35 (11.67%) could not implement KMC satisfactorily in hospital itself though after counseling they were able to complete the sessions. After discharge, additional 6 (2%) mothers faced problems in continuing KMC at home. The various problems faced by the mothers are summarized in [Table 1], categorized by the primary source of the problem. The remedial measures recommended are provided in [Table 2].
|Table 1: Problems Affecting KMC Implementation for Low Birth Weight Babies Reported by 41 Mothers |
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|Table 2: Remedial Measures for Mother, Infant or Socioeconomic Factors that Interfere with Smooth Implementation of KMC |
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Evidently, the remedial measures are largely self-evident. The nurse researcher took the lead in implementation of these measures and all 41 mothers eventually successfully implemented KMC for the required duration.
| Discussion|| |
Earlier studies have mentioned implementation barriers related to the mother like being tired, interference with household activities and difficulty in sleeping while continuing KMC for longer duration.  Despite these barriers KMC has been successfully implemented in Indian settings. ,, The present study also unearthed difficulties due to maternal anxiety over handling the very small baby, physical discomfort and neglect of household activities during KMC sessions at home. These problems could be addressed through counseling, and during KMC sessions both mother and baby were found deeply relaxed or in sleep. Most of the mothers enjoyed the KMC experience.
Poor access to information and ignorance of the need of KMC for LBW infant, no support from the male members, and ignorance about KMC process are also likely problems in implementing KMC. Low uptake of KMC services has been reported earlier,  linked with lack of regular in-facility meals for admitted mother. Some mothers in our setting also faced the same problem which was overcome by arranging extra meal from the hospital kitchen itself or with the assistance of family members.
A study from Cape Town, South Africa, showed that mothers did not continue KMC at home due to lack of time, as they are busy in other jobs. This is related to lack of knowledge and motivation (low priority for KMC, concerned about own health) rather than a genuine lack of time. In some situations, negative feedback has a deleterious impact on the mother's feelings, even though mothers are competent in practicing KMC. To thwart this deleterious effect, social support needs to be arranged as an integral component of KMC. 
We observed that in some cases maternal grandmothers or mother-in-laws were overly concerned about the health of the mother, and they did not allow her to continue KMC at home. Bhutta et al.  have suggested that KMC process is influenced by external factors at three different levels, that is, family-friends, community, and society. One study in Sweden identified four categories of parent's responses regarding support and barriers for performance of KMC.  Interestingly, the hospital staff and hospital environment factors were described by parents as both supportive and barriers for KMC application. Some mothers described the infant's feeding process as obstacles to KMC. Sleeping with an infant in skin-to-skin contact throughout the night in an uncomfortable sleeping position caused insufficient sleep.  In all cases, these difficulties and needs voiced by the mothers could be addressed through counseling and sensitization of the mother, father, and grandparents of the baby.
High-quality comprehensive care to neonates can be provided through holistic care of LBW babies and their mother. Mothers represent a captive audience during their stay at hospital, and this period is to be utilized to sensitize them and their family members, especially the father and grandparents of the baby. KMC can be integrated with other training packages and institutionalized within pre-service medical and nursing education including adequate practical experience.
However, it is noteworthy that education and training by themselves are unlikely to lead to the successful implementation of KMC. This must be accompanied by public sensitization and creation of awareness of the importance of KMC among health administrators, continuous support from health policy planners and appropriate national and institutional policies and guidelines. 
| Conclusion|| |
We can say that KMC represents a step toward making neonatal care less dependent on gadgets and more natural like marsupial babies. It is attractive not only because it can provide supportive and developmental care to LBW infants, but also confer additional advantages like maternal and family bonding and involvement with the LBW infant.  Some 10-18% mothers are likely to experience problems that can be solved through more intense motivation and counseling, involving the family members as well, when needed. Healthcare providers should be well-trained and competent for KMC practice, and themselves counseled to become efficient in motivating, training, and counseling mothers toward KMC implementation.
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[Table 1], [Table 2]
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