Kangaroo mother care: a multi-country analysis of health system bottlenecks and potential solutions

Linda Vesel, Anne-Marie Bergh, Kate J Kerber, Bina Valsangkar, Goldy Mazia, Sarah G Moxon, Hannah Blencowe, Gary L Darmstadt, Joseph de Graft Johnson, Kim E Dickson, Juan Ruiz Peláez, Severin von Xylander, Joy E Lawn, KMC Research Acceleration Group, Linda Vesel, Anne-Marie Bergh, Kate J Kerber, Bina Valsangkar, Goldy Mazia, Sarah G Moxon, Hannah Blencowe, Gary L Darmstadt, Joseph de Graft Johnson, Kim E Dickson, Juan Ruiz Peláez, Severin von Xylander, Joy E Lawn, KMC Research Acceleration Group

Abstract

Background: Preterm birth is now the leading cause of under-five child deaths worldwide with one million direct deaths plus approximately another million where preterm is a risk factor for neonatal deaths due to other causes. There is strong evidence that kangaroo mother care (KMC) reduces mortality among babies with birth weight <2000 g (mostly preterm). KMC involves continuous skin-to-skin contact, breastfeeding support, and promotion of early hospital discharge with follow-up. The World Health Organization has endorsed KMC for stabilised newborns in health facilities in both high-income and low-resource settings. The objectives of this paper are to: (1) use a 12-country analysis to explore health system bottlenecks affecting the scale-up of KMC; (2) propose solutions to the most significant bottlenecks; and (3) outline priority actions for scale-up.

Methods: The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops involved technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks", factors that hinder the scale-up, of maternal-newborn intervention packages. We used quantitative and qualitative methods to analyse the bottleneck data, combined with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for KMC.

Results: Marked differences were found in the perceived severity of health system bottlenecks between Asian and African countries, with the former reporting more significant or very major bottlenecks for KMC with respect to all the health system building blocks. Community ownership and health financing bottlenecks were significant or very major bottlenecks for KMC in both low and high mortality contexts, particularly in South Asia. Significant bottlenecks were also reported for leadership and governance and health workforce building blocks.

Conclusions: There are at least a dozen countries worldwide with national KMC programmes, and we identify three pathways to scale: (1) champion-led; (2) project-initiated; and (3) health systems designed. The combination of all three pathways may lead to more rapid scale-up. KMC has the potential to save lives, and change the face of facility-based newborn care, whilst empowering women to care for their preterm newborns.

Figures

Figure 1
Figure 1
Kangaroo Mother Care, showing health systems requirements by level of care. Any items available at the basic level should be available at the higher level. For more details of special care and neonatal intensive care requirements see Moxon et al. paper on inpatient care of small and sick newborns in this supplement. KMC: Kangaroo Mother Care. Part A: Kangaroo mother care for preterm babies. Part B: Care of term babies. 1KMC is not the same as skin-to-skin care alone. KMC involves continuous prolonged skin-to-skin contact with the infant placed on top of the mother's chest in a prone vertical position (Kangaroo Position), support for breastmilk feeding and a supportive environment. Neonatal intensive care image source: Syane Luntungan/Jhpiego. Intermediate or special care image source: ©EFCNI. Basic preterm care image source: Save the Children. Basic newborn care image source: Joyce Godwin.
Figure 2
Figure 2
Very major or significant health system bottlenecks for kangaroo mother care. NMR: Neonatal mortality rate. *Cameroon, Kenya, Malawi, Uganda, Bangladesh, Nepal, Vietnam. **Democratic Republic of Congo, Nigeria, Afghanistan, India, Pakistan. See additional file 2 for more details.
Figure 3
Figure 3
Individual country grading of health system bottlenecks for kangaroo mother care. Part A: Heat map showing individual country grading of health system bottlenecks for kangaroo mother care. Part B: Table showing total number of countries grading significant or major for calculating priority building blocks. DRC: Democratic Republic of the Congo.
Figure 4
Figure 4
Overcoming socio-cultural barriers to the scale-up of kangaroo mother care and preterm care. Both caregivers and providers may have barriers to the uptake of KMC. Local context must be taken into account to understand and overcome these barriers. Based on literature and programme experience of the authorship team, we summarise some of the common barriers faced and enablers found. KMC: kangaroo mother care. Mother practicing KMC image source: Save the Children. Mother practicing KMC image source: Pep Bonet/NOOR for Save the Children. Father practicing KMC image source: Erica Pineros/Save the Children. Mother practicing KMC image source: ©EFCNI. Mother practicing KMC with baby with long-term oxygen treatment image source: ©Fundación Canguro. Mother practicing KMC with nurse by her side: Ritam Banerjee/Save the Children. Mother practicing KMC with twin babies: Jordi Matas/Save the Children
Figure 5
Figure 5
Pathways from policy to implementation for kangaroo mother care. Countries have followed different pathways in introducing and expanding implementation of KMC services. Based on a review of the processes in a small number of countries in Latin America, South Asia and Africa that now have KMC services in more than half of facilities that conduct births and adapting from previous work, we have identified three entry points: champion(s), a project-based approach, and a health system-designed programme [26,30]. KMC: kangaroo mother care. LAC: Latin American and Caribbean.
Figure 6
Figure 6
Key messages and action points for scale-up of kangaroo mother care. KMC: kangaroo mother care

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