Report on an international workshop on kangaroo mother care: lessons learned and a vision for the future

Effects of skin-to-skin contact in supported diagonal flexion positioning on movement quality in very preterm infants at term age

BACKGROUND

Preterm birth is associated with a high risk of long-term neuromotor disabilities such as coordination of movements, deficient antigravity limb movement, less adaptive postural control strategies, head deformities… AIMS: The aim of the present study was to examine the potential positive impact of a Supported Diagonal Flexion (SDF) skin-to-skin contact (SSC) positioning on the neuromotor development and movement quality of very preterm infants at term age.

STUDY DESIGN

Monocentric prospective matched-pair case-control study.

SUBJECTS

Thirty very preterm infants and their mother were proposed either SDF SSC positioning (n = 15) or Vertical SSC positioning (n = 15).

OUTCOME MEASURES

Amiel-Tison Neurological Assessment at Term (ATNAT) and observation of the spontaneous motor activity were assessed at term corrected age.

RESULTS

Infants in the SDF group had less dolichocephaly (adj. p = .014) and arms in candlestick position (adj. p = .048). Only 3 in the SDF group against 11 in the vertical group showed nonoptimal spontaneous motor activity. Infants in the SDF group had more positive signs such as foot-to-foot contact (adj. p = .047) or arms movements toward midline (adj. p = .046 and 0.011).

CONCLUSIONS

The present study shows that nonoptimal spontaneous motor activity was increased and dolichocephaly was more common in the vertical group. Consistently with current guidelines, it is critical to consider preterm infants' postures during SSC or while in incubators or cradles.

Determinants of Kangaroo Mother Care Uptake for Small Babies Along the Health Facility to Community Continuum in Karnataka, India

INTRODUCTION

Kangaroo mother care (KMC) scale-up is a proposed strategy to accelerate reduction in neonatal mortality rates. We aimed to identify determinants of KMC uptake for small babies (less than 2,000 g birth weight) along the health facility to community continuum in Karnataka, India.

METHODS

From June 2017 to March 2020, data on characteristics of health facilities and health care workers (HCWs) from 8 purposively selected health facilities were assessed. Knowledge, attitude, and support the mothers received for KMC uptake were assessed once between 4 weeks and 8 weeks unadjusted age of the cohort of babies. Secondary data on KMC were obtained from the district-wide implementation research project database. Bivariate analysis was used to assess the association of characteristics of health facilities, HCWs, mothers, and small babies with the day of KMC initiation and its duration. Log-binomial regression analysis was then computed to identify determinants of KMC.

RESULTS

We recruited 227 (91.5%) of 248 babies eligible to participate with a mean unadjusted age of 35.6 days (±7.5) and 1,693.9 g (±263.1 g) birth weight. KMC was initiated for 95.2% of 227 babies at the health facility; initiated at 3 days or earlier of life for 59.6% of 226 babies; and babies continued to receive KMC for more than 4 weeks (30.2 days [±8.4]) at home. Determinants of KMC initiation were HCWs' attitudes, initiation support at the health facility, and place of hospitalization. Determinants of KMC maintenance at the health facility were HCWs' skills and support the mother received at the facility after initiating KMC. Place of hospitalization and HCWs' knowledge determined KMC duration at home 1 week after discharge.

CONCLUSION

These findings emphasize the importance of competent HCWs and support for mothers at the health facility for initiation and maintenance of KMC within the health facility and 1 week after discharge.

Launching continuous kangaroo mother care through participatory action research in Iran

BACKGROUND

This study describes the launching of a unit for continuous kangaroo mother care (KMC) in a teaching hospital (Taleghani) in Iran.

METHODS

We used a participatory three-stage action research approach to establish a unit for continuous KMC: design (needs identification and planning for change); implementation (and reflection); and evaluation (and institutionalization). As part of the design and implementation stages, individual and focus group interviews were conducted with mothers, physicians, nurses, other healthcare personnel and policy makers. The evaluation was done by means of a standardized tool specifically developed for monitoring progress with the implementation of KMC.

RESULTS

Four themes relating to potential barriers to implementation emerged from the analysis of the staff interviews, namely barriers associated with the mother, the father, the physician and the health system. Mothers' experiences of barriers were grouped into five themes: personal discomfort, fear, healthcare provider attitudes and actions, infrastructure constraints and family matters. An implementation progress score of 27.05 out of 30 was achieved, indicating that the continuous KMC unit was on the path to institutionalization. Some of the gaps identified related to policies on resource allocation, the discharge and follow-up system, and the transportation of infants in the KMC position.

CONCLUSION

The study findings indicated that participatory action research is a suitable method for studying the establishment of a continuous KMC unit. When action research is practiced, there is a prospect of turning knowledge into action in the real world.

What influences the implementation of kangaroo mother care? An umbrella review

Background

Kangaroo mother care (KMC) is an evidence-based intervention that reduces morbidity and mortality in preterm infants. However, it has not yet been fully integrated into health systems around the world. The aim of this study is to provide a cogent summary of the evidence base of the key barriers and facilitators to implementing KMC.

Methods

An umbrella review of existing reviews on KMC was adopted to identify systematic and scoping reviews that analysed data from primary studies. Electronic English databases, including PubMed, Embase, CINAHL and Cochrane Library, and three Chinese databases were searched from inception to 1 July 2022. Studies were included if they performed a review of barriers and facilitators to KMC. Quality assessment of the retrieved reviews was performed by at least two reviewers independently using the Joanna Briggs Institute (JBI) critical appraisal checklist and risk of bias was assessed with the Risk of Bias Assessment Tool for Systematic Reviews (ROBIS) tool. This umbrella review protocol was documented in the PROSPERO registry (CRD42022327994).

Results

We generated 531 studies, and after the removal of duplicates and ineligible studies, six eligible reviews were included in the analysis. The five themes identified were environmental factors, professional factors, parent/family factors, access factors, and cultural factors, and the factors under each theme were divided into barriers or facilitators depending on the specific features of a given scenario.

Conclusions

Support from facility management and leadership and well-trained medical staff are of great significance to the successful integration of KMC into daily medical practice, while the parents of preterm infants and other family members should be educated and encouraged in KMC practice. Further research is needed to propose strategies and develop models for implementing KMC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05163-3.

Kangaroo Mother Care in Vietnam: A National Survey of a Middle-Income Country

Background: Kangaroo mother care (KMC) is a low-cost intervention that is indicated to be a highly effective practice for which adoption and implementation are lacking. We investigated the current provision of KMC in Vietnam and explored differences among levels of healthcare facility. Methods: A survey form was sent to 187 hospitals in Vietnam, representing the three levels (central, provincial and district) of public hospital-based maternity services. Results: Overall response rate was 74% (138/187 hospitals). Routine KMC implementation was estimated in 49% of the hospitals. Where KMC was implemented or was being introduced, half of the hospitals had a written protocol and a KMC-dedicated room, and held educational courses on KMC. KMC was mainly performed by the mother. Skin-to-skin contact was mostly performed for <12 h/day (55%), exclusive breastfeeding at discharge was very frequent (89%) and early discharge was considered in half of the hospitals (54%), while follow-up was not performed in 29% of the hospitals. Participants considered follow-up after discharge as the main barrier to KMC implementation, and indicated education (of both parents and health caregivers) and environment upgrades (KMC-dedicated room and equipment) as the most important facilitators. Conclusions: Our survey estimated a limited implementation of KMC in Vietnamese maternity hospitals, with marked variations across the different levels of maternity services. Areas of improvements include increasing the duration of skin-to-skin contact, arranging dedicated spaces for KMC, involving the relatives (especially at district level), extending the availability of a written protocol, improving the eligibility process, and implementing early discharge and follow-up monitoring.

Kangaroo mother care practices for low birthweight newborns in a district hospital in Indonesia

Purpose

Kangaroo mother care (KMC) was introduced in Indonesia 30 years ago, but the extent of its use has not been fully documented. Therefore, this study aimed to examine the use of KMC and evaluate the characteristics of infants who received KMC at Koja District Hospital in North Jakarta, Indonesia. This retrospective cohort study recorded the characteristics of infants with birthweights less than or equal to 2,200 g at the above-mentioned hospital.

Methods

Data collected from infant registers included gestational age, birthweight, Apgar score, number of complications, history of neonatal intensive care unit treatment, and KMC status. Cox regression analysis was conducted.

Results

This study found that 57.7% of infants received KMC. Infants with birthweights over 1,500 g were 2.16 times (95% CI: 1.20-3.89) more likely to receive KMC.

Conclusion

Efforts to promote KMC are recommended, specifically for infants with birthweights greater than 1,500 g. KMC for infants with other conditions can also be considered based on the infants' stability.

KANGAROO MOTHER CARE: A QUALITATIVE STUDY ON THE PRACTICE AND EXPERIENCES OF MOTHERS OF PRETERM NEONATES IN A TERTIARY TEACHING HOSPITAL IN EASTERN UGANDA

Introduction

Globally, neonatal deaths continues to be a challenge especially to to attainment of sustainable development goal 3. About 4 million neonatal deaths per year, with 99% of the deaths occurring in low and middle resource countries, 75% of these occurring in the first week of life. Prematurity remains an indirect leading cause of mortality and morbidity. Uganda's progress on the improvement of perinatal morbidity and mortality has largely stagnated at 27 deaths per 1,000 live births from the year 2006. One of the cost-effective readily available interventions that would curtail perinatal mortality is kangaroo mother care(KMC)- a low tech four decades old intervention. However challenges about its implementation persist on in Uganda despite intensified implementation and roll-out startegies in 2010. This study, the first of its kind to the best of our knowledge in eastern Uganda sought to find the facilitators and barriers of KMC.

Materials and methods

This was a qualitative study using in-depth interviews(IDI) carried out at a tertiary university teaching hospital. Twenty IDIs were carried out among mothers/caretakers using the phenomena theory. After each IDI, each transcript was analyzed by two researchers working independently using NVIVO software version 11 plus (QSR International, Burlington, Massachusetts) and themes and subthemes developed.

Results

Majority of mothers/caretakers, were adolescents and young adults and primiparous at 55%. The major facilitators to KMC were supportive staff that facilitated positive attitude, ability to substitute provider and family support.The major barriers were lack of family support, lack of male involvement, maternal stress and poor health and multiple gender roles, infrastructural challenges, and misconceptions associated with preterm births such as early sexual intercourse and lack of herbal medicine use.

Conclusion

More facility leadership involvement and engagement of mothers during antenatal, community and promotion of male involvement in sexual and reproductive health matters will improve uptake of KMC. This can be spearheadded by sexual and reproductive health, and neonatal and child health care service providers.

eHealth for neonatal nurse education despite Covid-19

Aim

The aim of this contemporary issue paper is to challenge the premise that the term “eHealth” is relatable to patient or service users only. It will be critically explored if the term can be broadened to include neonatal nurse education interventions.

Design

A review of current literature will form the basis for the critical discussion of the term eHealth, and why it can be associated with neonatal nurse education.

Methods

The critical discussion will identify and review past and current literature relating to eHealth and its origins. It will portray the viability of the term eHealth as more than just a patient associated intervention, and why it should also be encompassed as a neonatal nurse education option.

Conclusion

eHealth is traditionally identifiable as a service user intervention or source of information. The term should be broadened to encompass neonatal nurse education and used as a resource that is easily accessible and user friendly. This will in turn encourage the personal and professional development of neonatal nurses and should ultimately contribute to evidence based best practices in the clinical environment, despite the current global pandemic.

Barriers and Facilitators to Conducting Kangaroo Mother Care in Italian Neonatal Intensive Care Units

PURPOSE

This work aimed to investigate obstacles and facilitators for carrying out Kangaroo Mother Care (KMC) across Italian NICUs.

DESIGN AND METHODS

A survey that investigated Unit's characteristics, policies toward parents and KMC practice and policies was carried out. Data from 86 NICUs (80.4%) was collected. Descriptive statistics and Multiple Regression Models were computed.

RESULTS

Eighty-one NICUs provided KMC. These NICUs had a less restricted parental access policies (chi² = 7.373, p = .007). More than the 70% of the units did not have adequate facilities for parents. KMC daily length was positively predicted (R² = 0.18, F = 7.91, p = .001) by repeated sessions and documentation of KMC.

CONCLUSION

The implementation of KMC is characterized by different barriers and facilitators that determine the parent's possibility to provide KMC. Structural factors (e.g., adequate space and facilities) can support families in providing KMC. A unique result of this survey is that KMC documentation on medical records appears critical for improving its practice.

PRACTICE IMPLICATIONS

Although most of the Italian units provide KMC as a routine practice, improving its practical support would be beneficial to its implementation. A more formalized approach to KMC may strengthen staff habits to consider KMC like a standard care treatment.

What is stopping us? An implementation science study of kangaroo care in British Columbia's neonatal intensive care units

BACKGROUND

The goal of the Neonatal Intensive Care Unit (NICU) is to provide optimal care for preterm and sick infants while supporting their growth and development. The NICU environment can be stressful for preterm infants and often cannot adequately support their neurodevelopmental needs. Kangaroo Care (KC) is an evidence-based developmental care strategy that has been shown to be associated with improved short and long term neurodevelopmental outcomes for preterm infants. Despite evidence for best practice, uptake of the practice of KC in resource supported settings remains low. The aim of this study was to identify and describe healthcare providers' perspectives on the barriers and enablers of implementing KC.

METHODS

This qualitative study was set in 11 NICUs in British Columbia, Canada, ranging in size from 6 to 70 beds, with mixed levels of care from the less acute up to the most complex acute neonatal care. A total of 35 semi-structured healthcare provider interviews were conducted to understand their experiences providing KC in the NICU. Data were coded and emerging themes were identified. The Consolidated Framework for Implementation Research (CFIR) guided our research methods.

RESULTS

Four overarching themes were identified as barriers and enablers to KC by healthcare providers in their particular setting: 1) the NICU physical environment; 2) healthcare provider beliefs about KC; 3) clinical practice variation; and 4) parent presence. Depending on the specific features of a given site these factors functioned as an enabler or barrier to practicing KC.

CONCLUSIONS

A 'one size fits all' approach cannot be identified to guide Kangaroo Care implementation as it is a complex intervention and each NICU presents unique barriers and enablers to its uptake. Support for improving parental presence, shifting healthcare provider beliefs, identifying creative solutions to NICU design and space constraints, and the development of a provincial guideline for KC in NICUs may together provide the impetus to change practice and reduce barriers to KC for healthcare providers, families, and administrators at local and system levels.

How to improve the effectiveness and efficiency of Kangaroo Mother Care: a literature review of equipment supporting continuous Kangaroo Mother Care

OBJECTIVE

The objective of this study was to provide an overview of the equipment supporting Kangaroo Mother Care (KMC).

METHOD

The review adopted a five-stage methodological framework that included research question identification, relevant study identification and selection, and data charting, collating, summarizing, and reporting. We conducted reviews to analyze the current research on the design of KMC-supporting devices. Publications were identified from January 2008 to July 2020.

RESULTS

Using the inclusion criteria, 17 relevant studies were identified that concerned the design of supporting equipment for KMC. Five types of equipment improved the comfort of the mothers performing KMC, another five monitored the health and development of the infants, and four served as therapy for the infants. Three equipment types showed no significant effect in supporting KMC.

CONCLUSIONS

This study provides information on equipment that effectively and efficiently improves the quality of KMC.

Cost-effectiveness of a gestational age metabolic algorithm for preterm and small-for-gestational-age classification

Background

Preterm birth complications are the leading cause of death among children under 5 years of age, and this imposes a heavy burden on healthcare and social systems, particularly in low- and middle-income countries where reliable estimates of gestational age may be difficult to obtain. Metabolic analyte data can aid in accurately estimating gestational age. However, important costs are associated with this approach, which are related to the collection and analysis of newborn samples, and its cost-effectiveness has yet to be determined.

Objective

This study aimed to evaluate the cost-effectiveness of an internationally validated gestational age estimation algorithm based on neonatal blood spot metabolite data in combination with clinical and demographic variables (birthweight, sex, and multiple birth status) compared with a basic algorithm that uses only clinical and demographic variables in classifying infants as preterm or term (using a 37-week dichotomous preterm or term classification) and determining gestational age.

Study Design

The cost per correctly classified preterm infant and per correctly classified small-for-gestational-age infant for the metabolic algorithm vs the basic algorithm were estimated with data from an implementation study in Bangladesh.

Results

Over 1 year, the metabolic algorithm correctly classified an average of 8.7 (95% confidence interval, 1.3–14.7) additional preterm infants and 145.3 (95% confidence interval, 128.0–164.7) additional small-for-gestational-age infants per 1323 infants screened compared with the basic algorithm using only clinical and demographic variables. The incremental annual cost of adopting the metabolic algorithm was $100,031 (95% confidence interval, $86,354–$115,725). If setup costs were included, the cost was $120,496 (95% confidence interval, $106,322–$136,656). Compared with the basic algorithm, the incremental cost per preterm infant correctly classified by the metabolic algorithm is $11,542 ($13,903 with setup), and the incremental cost per small-for-gestational-age infant is $688 ($829 with setup).

Conclusion

This research quantifies the cost per detection of preterm or small-for-gestational-age infant in the implementation of a newborn screening program to aid in improved classification of preterm and, in particular, small-for-gestational-age infants in low- and middle-income countries.

Strategies discussed at the XIIth international conference on Kangaroo mother care for implementation on a countrywide scale

AIM

Building strategies for the country-level dissemination of Kangaroo mother care (KMC) to reduce the mortality rate in preterm and low birth weight babies and improve quality of life. KMC is an evidence-based healthcare method for these infants. However, KMC implementation at the global level remains low.

METHODS

The international network in Kangaroo mother brought 172 KMC professionals from 33 countries together for a 2-day workshop held in conjunction with the XIIth International KMC Conference in Bogota, Colombia, in November 2018. Participants worked in clusters to formulate strategies for country-level dissemination and scale-up according to seven pre-established objectives.

RESULTS

The minimum set of indicators for KMC scale-up proposed by the internationally diverse groups is presented. The strategies for KMC integration and implementation at the country level, as well as the approaches for convincing healthcare providers of the safety of KMC transportation, are also described. Finally, the main aspects concerning KMC follow-up and KMC for term infants are presented.

CONCLUSION

In this collaborative meeting, participants from low-, middle- and high-income countries combined their knowledge and experience to identify the best strategies to implement KMC at a countrywide scale.

Barriers and facilitators of kangaroo mother care adoption in five Chinese hospitals: a qualitative study

Background

Kangaroo mother care (KMC) has been proved to be a safe and cost-effective standard of care for preterm babies. China hasn’t adopted the KMC practice widely until recently. We aim to assess barriers and facilitators of KMC adoption in neonatal intensive care units (NICUs) and postnatal wards in China.

Methods

We conducted clinical observations and semi-structured interviews with nurses, physicians, and parents who performed KMC in seven NICUs and postnatal wards housed in five hospitals in different provinces of China between August and September 2018. The interviews provided first-hand stakeholder perspectives on barriers and facilitators of KMC implementation and sustainability. We further explored health system’s readiness and families’ willingness to sustain KMC practice following its pilot introduction. We coded data for emerging themes related to financial barriers, parent- and hospital-level perceived barriers, and facilitators of KMC adoption, specifically those unique in the Chinese context.

Results

Five hospitals with KMC pilot programs were selected for clinical observations and 38 semi-structured interviews were conducted. Common cultural barriers included concerns with the conflict with traditional postpartum confinement (Zuo-yue-zi) practice and grandparents’ resistance, while a strong family support is a facilitator for KMC adoption. Some parents reported anxiety and guilt associated with having a preterm baby, which can be a parental-level barrier to KMC. Hospital-level factors such as fear of nosocomial infection and shortage of staff and spaces impeded the KMC implementation, and supportive community and peer group organized by the hospital contributed to KMC uptake. Financial barriers included lodging costs for caregivers and supply costs for hospitals.

Conclusions

We provided a comprehensive in-depth report on the multi-level KMC barriers and facilitators in China. We recommend policy interventions specifically addressing these barriers and facilitators and increase family and peer support to improve KMC adoption in China. We also recommend that well-designed local cultural and economic feasibility and acceptability studies should be conducted before the KMC uptake.

Recent progress in global newborn health: thinking beyond acute to strategic care?

Advancements in neonatal care globally highlight ongoing disparities in neonatal outcomes between low-income countries (LICs) and high-income countries (HICs). Drivers of this gap are primarily prematurity, infection, and intrapartum-related events. Significant success is being achieved; however, for neonatal outcomes in LIC to approximate those of HICs within a generation, acceleration of the current trajectory of progress is needed. This requires a renewed focus on newborn-specific and newborn-sensitive strategies. Newborn-specific strategies are those directly affecting the well-being of the neonate. Newborn-sensitive strategies address the broader macro-environmental drivers that affect underlying neonatal outcomes such as decreased poverty, improved sanitation, and increased maternal empowerment and health. To create such an enabling macro-environment requires significant political will, financing, advocacy, and policy generation. This manuscript highlights recent advances in newborn research, programming, policy, and funding, and highlights key opportunities to bend the curve on advancing neonatal health globally.

The evolution of family-centered care: From supporting parent-delivered interventions to a model of family integrated care

There is increasing recognition that parents play a critical role in promoting the health outcomes of low birthweight and preterm infants. Despite a large body of literature on interventions and models to support family engagement in infant care, parent involvement in the delivery of care for such infants is still restricted in many neonatal intensive care units (NICUs). In this article, we propose a taxonomy for classifying parent-focused NICU interventions and parent-partnered care models to aid researchers, clinical teams, and health systems to evaluate existing and future approaches to care. The proposed framework has three levels: interventions to support parents, parent-delivered interventions, and multidimensional models of NICU care that explicitly incorporate parents and partners in the care of their preterm or low birthweight infant. We briefly review the available evidence for interventions at each level and highlight the strong level of research evidence to support the parent-delivered intervention of skin-to-skin contact (also known as the Kangaroo Care position) and for the Kangaroo mother care and family integrated care models of NICU care. We suggest directions for future research and model implementation to improve and scale-up parent partnership in the care of NICU infants.