Research Article: Barriers and enablers for practicing kangaroo mother care (KMC) in rural Sindh, Pakistan

Date Published: June 17, 2019

Publisher: Public Library of Science

Author(s): Qamar Zaman Jamali, Rashed Shah, Farhana Shahid, Aisha Fatima, Saraswati Khalsa, Jana Spacek, Presha Regmi, Charles A. Ameh.

http://doi.org/10.1371/journal.pone.0213225

Abstract

More than 2.5 million newborns die each year, accounting for 47% of children dying worldwide before their age of five years. Complications of preterm birth are the leading cause of death among newborns. Pakistan is amongst the top ten countries with highest preterm birth rate per 1000 live births. Globally, Every Newborn Action Plan (ENAP) has emphasized on Kangaroo Mother Care (KMC) as an essential component of neonatal health initiatives.

We conducted this qualitative study with 12 in-depth interviews (IDIs) and 14 focus group discussion (FGD) sessions, in two health facilities of Sindh, Pakistan during October-December 2016, to understand the key barriers and enablers to a mother’s ability to practice KMC and the feasibility of implementing and improving these practices.

The findings revealed that community stakeholders were generally aware of health issues especially related to maternal and neonatal health. Both the health care providers and managers were supportive of implementing KMC in their respective health facilities as well as for continuous use of KMC at household level. In order to initiate KMC at facility level, study respondents emphasized on ensuring availability of equipment, supplies, water-sanitation facility, modified patient ward (e.g., curtain, separate room) and quality of services as well as training of health providers as critical prerequisites. Also in order to continue practicing KMC at household level, engaging the community and establishing functional referral linkage between community and facilities were focused issues in facility and community level FGDs and IDIs.

The study participants considered it feasible to initiate KMC practice at health facility and to continue practicing at home after returning from facility. Ensuring facility readiness to initiate KMC, improving capacity of health providers both at facility and community levels, coupled with focusing on community mobilization strategy, targeting specific audiences, may help policy makers and program planners to initiate KMC at health facility and keep KMC practice continued at household level.

Partial Text

More than 2.5 million newborns die each year, accounting for 47% of children dying before the age of five years worldwide [1]. Complications of preterm birth are the leading cause of death among newborns [2]. Of the fifteen million babies born too early each year, more than one million die due to complications related to preterm birth. Low birth weight (newborns weighing < 2,500 grams at birth), due to prematurity and/or restricted growth in utero, is also a major contributor of annual newborn and child deaths worldwide. Pakistan is amongst the ten countries with the greatest number of preterm births and the highest rates of preterm births per 1000 live births, with 860,000 babies born preterm and 75,000 children dying under the age of five due to direct preterm complications annually. Almost one in every three babies born in Pakistan (32%) is a low birth weight (LBW) baby [3]. World Health Organization (WHO) issued recommendations [4] for the care of preterm infants in November 2015, including kangaroo mother care (KMC). An international joint policy statement and endorsement also came from health professional associations (American Academy of Pediatrics, Council of International Neonatal Nurses, International Council of Nurses, American College of Obstetricians and Gynaecologists, International Federation of Gynaecology and Obstetrics, American College of Nurse-Midwives, International Paediatric Association and International Confederation of Midwives) for universal use of KMC for preterm and LBW Infants. The WHO has defined KMC as early, continuous, and prolonged skin–to–skin contact between the mother and babies; exclusive breastfeeding or breast milk feeding; early discharge after hospital–initiated KMC with continuation at home; and adequate support and follow–up for mothers at home[5]. KMC has three main components, including: thermal care through continuous skin-to-skin contact by being wrapped with a cloth to the bare chest of the care giver; support for exclusive breastfeeding or other appropriate feeding; and early recognition and response to complications [6]. Neonatal mortality analyses from a 2014 Cochrane review [7] (11 randomized controlled trials) and a 2016 meta-analysis by Boundy [8] (16 studies) found a 33 percent and 23 percent reduction in neonatal mortality, respectively, at the last follow-up when comparing KMC to conventional neonatal care. In both mortality analyses, all but two of the studies included were in resource poor countries. The systematic review conducted by Agudelo & Rosello [9] suggested KMC as an effective and safe alternative for conventional neonatal care for low birth weight (LBW), especially in settings with limited resources. In LBW newborns (< 2000 g) who are clinically stable, practicing KMC can reduce mortality and if widely applied could reduce deaths in preterm newborns [10]. This study followed a qualitative study design and recruited study participants by employing purposive sampling strategy based on convenience and availability of eligible study participants. A total of twelve IDIs and fourteen FGDs were conducted across both study sites. The numbers of participants in IDIs and FGDs in study districts are shown in Tables 1 and 2. Our findings are consistent with results from past research on health worker and community members’ perspectives on the feasibility of introducing KMC as well as key barriers and enablers affecting implementation. Health care providers, both at facility and community level, received several newborn care trainings such as Helping Babies to Breathe (HBB), Essential Newborn Care (ENC), neonatal umbilical cord care by using chlorhexidine, and similar other relevant training courses. However, we found that none of the health providers and managers had received any previous training on KMC in the selected study facilities. The respondents at facility level emphasized the critical need for KMC training as a prerequisite of implementing KMC at facility level. Relevant evidence exists in literature and echoes our findings as training opportunities are crucial to provide health care workers with knowledge and skills to facilitate KMC [14]. In a multi country study from Malawi, Mali, Rwanda, and Uganda, researchers found that in service training and including KMC in preservice curricula is a facilitator to implement KMC [15]. Expanding training to other health-care personnel, such as administrators and interns, also enabled KMC acceptance. Another study result also revealed in-service training of health-care workers as enhancer of KMC implementation [16]. Many nurses also found that integration of KMC into pre-service and training curricula was beneficial to accelerate its uptake [17, 18]. Our study results revealed feasibility to initiate KMC practice at health facility and to continue practicing at home after returning from facility in rural communities in Pakistan. Ensuring facility readiness to initiate KMC, improving capacity of health providers both at facility and community levels, coupled with focusing on community mobilization strategy, targeting specific audiences, may help policy makers and program planners to initiate KMC at health facility and keep KMC practice continued at household level in similar settings. Further research could help gathering more insights on these issues.   Source: http://doi.org/10.1371/journal.pone.0213225

 

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