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/ birth
low
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
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Source: Lawn JE et al – CHER preterm birth working group
G

6. 15 million babies are born too soon every year..
Global average rate of 11.1%
14.9 million (range 12.3 to 18.1 million) preterm babies affecting families all over the world
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7. 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
Of the 11 countries with the highest rates, 9 are in Africa
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

8. W do preterm/
hy 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
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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. W is Kangaroo Mother Care?
hat
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 40th 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/ birth weight babies
low
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. W evidence exists on KMC?
hat
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
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13. Kangaroo mother care – Searches and screening
DATABASES SEARCH TERMS
Pub Med LILACS, African Index ‘’Kangaroo mother care’, ‘Kangaroo
Medicus, and EMRO, Cochrane, care*’ ‘Skin to skin’
Total search results = 6127
Cochrane 1 (2003)
PubMed 6072 Excluded studies
LILACS 52, EMRO 2, AFRO 0
Not a study or trial = 502
Studies remaining after Outcome data not mortality or
screening title or abstract serious morbidity or wt gain (or
(n=524) breastfeeding) = ~20
No comparison group = 2
15
RCT (n= 9) Studies Observational (n=6) (one
Portuguese to be translated)
Mortality Morbidity Wt gain
6 5 6 Mortality Morbidity
4 1
1 Excluded as
3 2 Excluded as initiated
KMC after 1 week of age
BWT data
3 1
modelled
Source: Lawn JE et al – IJE 2010 in press

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
KMC could save about 450,000 babies each year if the
Lawn et al ‘Kangaroo mother care’ to prevent neonatal deaths due to preterm birth complications. Int J Epid:
14
2010,
intervention reached 95% of preterm babies (LiST analysis)
Conde Aguedelo Cochrane review 2011

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
100
% reaching 36.5°C
80
60 skin-to-skin
40 incubator
20
0
0 60 120 180 240 300 360 420 480 540 600
Time (minutes)
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17. KMC - Effect on breastfeeding
Study Outcome KMC Control
Schmidt et al. Daily volume 640 ml 400 ml
Daily feeds 12 9
Wahlberg et al. BF at discharge 77% 42%
Whitelaw et al. BF >6 weeks 55% 28%
Syfrett et al. Daily feeds 12 2
(GA<34w)
Affonso et al. Mothers' confident aborted
attitude
*Better Breastfeeding rates with KMC*
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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 K C group
M
Earlier hospital discharge by 3-7 days
Weight similar at 1 year of age

19. KMC – Effect on Infection
KMC Control
 Sloan, 1994
Se rio us illne s s 5% 18%
Lo we r Re s p ira to ry I c tio n
nfe 5% 13%
 Charpak, 2001
N s o c o m ia l
o 3.4% 6.8%
Lawn et al, 2010 (5 RCTs): 66% reduction in severe morbidity
for L W<=2000g
B

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 (‘F undacion 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. KMC in Africa Scaling up
a snapshot of scale up status Ethiopia
1 teaching hospital (1997), rolling
Mainly referral out to 7 regional, 1 zonal hospitals
(2009)
hospitals
Nigeria Tanzania
3 N/States, 2regional, 1 18 regional hospitals (MAISHA)
teaching hosp. with + Zanzibar
expansion thro’ other
programs (PRRINN-MNCH)
Uganda
I teaching, 4 district hospital since
Cameroon (2004), expanding to 3 districts
1 teaching hospital (2010)
Mali Rwanda
Started in 2007, expansion to all
1 teaching hospital (2008),
district hospitals
3 regional (2009/10, 2
district (2009)
Ghana
Mozambique 2 teaching hospitals in 2007, 4
5 regional (2009), 4 district regions in 2008, MRC & UNICEF
hospitals (2010)
At wide scale Malawi
Zimbabwe 32 district, 2 regional, 2
1 national hospital South Africa central,7 mission hospitals,
(Harare, since 2000), 2 > 100 hospitals in all provinces
districts (MCHIP), other many with supervision / quality expanding – AKMC/CKMC
districts (partners) tracking (SNL/ACCESS/MCHIP) 23
KMC activities in several other countries not included

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
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excellence, but supervision/mentoring is crucial

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 h e a l t h
w o rk e rs
Community Health Worker Manual
Caring for the Newborn at Home: A Training Course For Community Health
Community Health Worker
-- 1

28. Available Resources
• MCHIP’s KMC Implementation Guide (English & Spanish!)
http://www.mchip.net/node/974
• ‘Born Too Soon’ publication
Acknowledgements:
•‘Born too Soon’ Team – for use of selected slides
Courtesy: Joy Lawn & team
•KMC implementing countries/partners – sharing materials and photos

29. For more information…
KMC W ebsite Links/
Resources
W links
eb
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
partners – sharing
•KMC implementing countries/
materials and photos

31. THANK YOU!
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