Scaling Up Kangaroo Mother Care in Ethiopia and India: A Multi-Site Implementation Research Study

Abstract

Background: Kangaroo Mother Care (KMC), defined as prolonged skin-to-skin contact of the low birth weight baby with the mother and exclusive breastfeeding, is highly effective in reducing neonatal mortality. Yet the coverage of KMC globally is <5%. We conducted this study to find ways to achieve sustainable improvements in coverage. Methods: This multi-site, implementation research study used a mixed-methods design in four regions of Ethiopia and three states of India, covering 8 million population. Formative research informed the initial implementation model, followed by rapid iterative cycles of implementation and review for model refinement based on qualitative and quantitative data on KMC coverage. Implementation models included three components: (1) activities to maximise access of babies to KMC-implementing facilities, (2) activities to ensure KMC was initiated and maintained in KMC-implementing facilities, and (3) activities to support continuation of KMC after discharge. Primary outcomes were coverage of effective KMC ( > 8 hours of skin to skin contact per day and exclusive breastfeeding) before discharge, and 7 days after discharge, among infants with birth weight <2000g born in study districts. Findings: At baseline, KMC coverage was virtually zero in all sites. The study produced an implementation model which was implemented in the entire study population. With the final model implemented, KMC was initiated for 68-86% of eligible infants in Ethiopian sites and 87-88% in Indian sites. KMC was initiated at a mean age of 1·2-9·7 days. Effective KMC was provided to 68% infants in Ethiopia and 55% in India at discharge. At a home visit 7 days after discharge, effective KMC was provided to 53%-66% of infants in all sites, except Karnataka (36%) and Oromia (17%). Interpretation: Our study is the first to show that KMC implementation to achieve high coverage is possible at scale in LMICs. Success factors include strong government leadership, health workers’ conviction of the importance of KMC, and changes in infrastructure, policy and practice to achieve zero separation between mothers and newborns. Funding Statement: The study was funded by the Bill and Melinda Gates Foundation Declaration of Interests: All authors declare no competing interests. Ethics Approval Statement: Individuals were not asked for consent to receive the intervention as it was the government’s standard of care. Individual written informed consent was requested from mothers, caregivers, and health workers for the collection of study data. For those unable to read, the information was read by a team member in the presence of a witness who subsequently signed the consent form based on mother’s decision. Ethics approvals were received from the ethics committees of the World Health Organization and the participating research institutions.