Evaluation of Kangaroo Mother

Care in Malawi

Reuben Ligowe,1 Anne-Marie Bergh,2 Elise van Rooyen,2 Joy Lawn,3

Evelyn Zimba,1 George Chiundu1

1 Save the Children Malawi Country Office; 2 MRC Unit for Maternal and Infant Health Care Strategies and University of Pretoria; 3 Save the Children/Saving 

Newborn Lives 

Background - Newborn deaths

• 1.2 million newborn deaths in Sub-Saharan Africa per year• 60-90% in low birth weight infants• 27% of deaths are directly due to preterm birth complications

• Malawi (2006): • Under five mortality has been reduced by 30% in 5 years, but

neonatal is not reducing so fast• 14,900 newborns die every year (NMR 31/1000 live births)• Newborn LBW rate of 20%• Preterm births are the leading cause of newborn deaths• 57% of births are in facilities

Source: Opportunities for Africa’s Newborns. Eds Lawn and Kerber. 2007

Background – Kangaroo Mother Care

Benefits of Kangaroo Mother Care are well known:

• To the mother

• To the baby

• To the hospital and the health system

Background – KMC in Malawi

• 1999: Establishment of KMC unit in Zomba Central Hospital (ZCH) with European Union funding

• 2000-2005: Introduction of KMC in 6 more hospitals with the support of Save the Children, and KMC was introduced as part of Essential Newborn Care (ENC) in Malawi

• 3 central hospitals (tertiary, public)• 4 secondary (1 public, 3 mission)• Training: Zomba as training centre – 5-10 days’ training

• 2005: National guidelines for KMC

• 2007: Evaluation of the state of KMC implementation – purpose:• What had worked and what not?• Scaling-up to all district hospitals? Community links? • How to deal with lack of human resources and long off site training time?

Methods for the evaluation

• Use of South African standardised progress-monitoring tool to get a sense of the nature of quality of KMC practice

• Qualitative data collected through discussions with key informants

• Visit to 6 hospitals supported by Save the Children for KMC

• Telephone conference with 7th supported hospital

• Visit to 3 other health care facilities for comparison

Results

• Successful & sustainable KMC implementation:

• 5 of 7 supported hospitals

• 3 central hospitals & 2 mission hospitals

• Other 2 supported hospitals have KMC wards, but problems sustaining services (partly human resource challenges)

• 3 of supported hospitals have trained providers from other sites

• High awareness of KMC outside study hospitals

• Not all health workers have sufficient information and confidence to start KMC in other facilities

Achievements and strengths

National:

• National KMC policy - 2004

• KMC included in pre-service training for nurses

• High degree of awareness of KMC

Institutional:

• Dedication of staff despite hardships

• Good use of visual material (posters and cards)

• Availability of KMC register

Challenges

Human resources – management and perceptions:• Health workers not perceiving newborn care as a priority in

health system• Insufficient nursing and clinical supervision in some units • Staff shortages • Staff rotations – staff with skills in KMC are lost• Long off-site training, and limited on-site follow-up, especially

if started in “project mode” • Resistance to on site training by other trained staff –

perceived loss of remuneration during off-site training • Limited orientation of new health care staff in KMC

Challenges

Implementation and follow-up:

• Perception that KMC can not be implemented without a special unit, special beds and heaters

• Improvement in quality of records, especially on feeding

• Simple feeding job aids needed to calculate and record volumes for expressed breast milk

• Variation in discharge criteria between hospitals

• Lack of appropriate follow-up systems, and major challenges in follow up and access

Missed opportunities

Recommendations for immediate attention:(1) Introduce intermittent KMC for stable infants in neonatal unit

• Do not wait for establishment of a KMC unit• Do not wait until the criteria is met for continuous KMC

(2) Strengthening current feeding practices for all babies in KMC:

• Misunderstanding of “feeding on demand” —>• Scheduled feeding times needed for LBW infants• Supervision, using patient attendants to support mothers

(3) Use of KMC (skin-to-skin position) to transport babies between home and facilities or between facilities

Potential for scaling up KMC

Recommendations:• Shorter, integrated off-site training & on-site facilitation / support• 1-day workshops for district officials • 2-day workshops for key implementers in district hospitals

Factors crucial for sustainability:• Active support of management at all levels• Experienced person needed to drive the process• Good communication and consultative participation• Sending the right people for training – ongoing support essential• Sensitisation of community health structures and local leaders• Integration of KMC into current services –not project mentality• Establishment of a community follow-up system essential

Conclusion

• There are awareness of the benefits of KMC in Malawi,

even in hospitals and health centres not practising KMC

• Strong support from Ministry of Health, good partnerships

• Possible to design and implement a scale-up programme

for Malawi to involve all district hospitals

• Tracking of practices and quality advisable

• Leadership and enough personnel are crucial

Final Conclusion

• Extreme lack of medical staff in Malawi - Only 3 national paediatricians in the country

• Novel approaches are therefore required - e.g. use of patient attendants

Thank you