Evaluation of Kangaroo Mother Care in Malawi

1. 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

2. 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

3. 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

4. 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?

5. 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

6. 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

7. 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

8. 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

9. 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 criteriabetween hospitals • Lack of appropriate follow-up systems, and major challenges in follow up and access

10. Missed opportunities Recommendations for immediate attention: • 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

11. 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

12. 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

13. 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