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
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
1
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
• 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
• 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
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
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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:
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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:
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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