By Piper Sneed
Photo Credit: Live Science
An Introduction to Newborn Mortality and Neonatal Health Interventions:
Healthwise, children are most vulnerable during the first 28 days of their life. These first 28 days– a timeframe known as the newborn period– are accompanied by countless health threats including asphyxiation and trauma during delivery, complications related to prematurity, deadly infections, and/or congenital anomalies. To quantify the impact of these problems, in 2022, 47% of all deaths among children under the age of five occurred within the first 28 days of life, a percentage that accounts for 2.3 million newborns worldwide (WHO). While these data show an improvement in overall child survival since 1990, neonatal mortality rates remain high and have continued to experience a somewhat sluggish decline. Most notably, the decline in newborn mortality over the past twenty years has lagged behind the decline in post-newborn, under-five mortality rates. This has been especially evident since 2010, when the reduction in newborn mortality rates slowed down significantly. In light of these observations, it is currently estimated that 64 countries will fail to reach the Sustainable Development Goals target for all countries to reduce their neonatal mortality by 2030 unless immediate action is taken (WHO).
The majority of newborn deaths are concentrated in low and middle-income countries, most notably in sub-Saharan Africa and South Asia. In these regions, resources and healthcare personnel are often scarce and medical facilities tend to be poorly maintained. Since sub-Saharan Africa and South Asia have the highest newborn mortality rates, addressing the health needs of infants in these areas could have a major impact on global newborn survival (WHO).
To combat newborn fatalities, the World Health Organization advocates for a response centralized in primary care (2024). They cite that thermal protection, hygienic umbilical cord and skin care, early and exclusive breastfeeding, preventative treatments such as vaccinations, and close monitoring for signs of health problems are all important for safeguarding the health of newborn children. In high income countries, this often occurs in high-tech neonatal intensive care units (NICUs), where infants are privy to incubators, ventilators, IV medications, and around-the-clock monitoring (Uwaezuoke). This is, unfortunately, not easily achieved in low and middle-income countries, which lack the funds to support robust NICU programs. To improve the wellbeing of infants within the first month of their life, a simple, more cost-effective method of care is needed. This is where Kangaroo mother care comes in.
Kangaroo mother care (KMC) is an intervention for preterm and low birth weight infants involving skin-to-skin contact with the mother or other caregiver. Through holding the infant against the chest, KMC promotes thermoregulation, the process by which the body regulates its core temperature. Newborns are especially susceptible to poor thermoregulation for a variety of reasons. For one, newborn infants have a high body surface area to body volume area ratio, meaning they are susceptible to losing more heat than they produce. Additionally, newborns receive inadequate thermal insulation from their subcutaneous fat, are not able to shiver due to their low muscle bulk, and have an underdeveloped nervous system that does not respond well to cold (Uwaezuoke). KMC has been shown to improve an infant’s temperature regulation, which helps to stave off hypothermia, a condition that is associated with prematurity, birth asphyxia, and congenital anomalies. In addition to helping infants regulate their body temperature, KMC has been shown to promote breastfeeding, which satisfies another one of the WHO’s recommendations for newborn care (Uwaezuoke). KMC also has benefits for parents and health systems, such as promoting parent-child bonding and reducing the cost of care. Given these benefits, it serves to reason that augmenting the conventional method of care with KMC in low-income communities could be beneficial.
Since the physiological benefits of KMC apply to all newborns regardless of whether they were born in a low or high-income country, this article will instead be exploring the feasibility and impact of implementing KMC programs in low-income communities. It is important to note that the goal of instituting KMC programs is not to replace or discourage the development and implementation of new medical advances in low-income countries. Rather, it is a way to supplement the current standard of care so that costs can be brought down and infants can receive better, more personalized care.
To achieve a seamless integration of KMC into neonatal intensive care programs, public health officials must reach beyond data and numbers. In developing countries, many parents cannot afford the often insurmountable costs of taking care of a sick newborn, and as such, may be unable to give their child the best possible care. Furthermore, there is a widespread distrust of the healthcare system in many developing countries, which can cause parents to forgo getting their newborn the care that they need, even if they can reasonably afford it. KMC addresses these issues by lowering overhead costs and providing a new structure to newborn care, wherein parents don’t simply hand their newborn off to hospital staff, but rather get to be active participants in their child’s care. Given the persistence of high neonatal mortality rates, an easy, cost-effective, and parent-friendly solution is needed, especially in low-income countries where resources and funding may be scarce. While KMC alone will not solve the issue of neonatal mortality, it is a step in the right direction when it comes to expanding access to neonatal health services and improving quality of care.
KMC as a Means to Reduce the Cost of Newborn Care:
A major barrier to improving neonatal care in low-income countries is the financial burden that is unloaded onto parents. In most high-income countries, hospital bills are paid, at least in part, by insurance companies or the government. This is not a luxury afforded to people in many developing countries. In developing countries, parents are often responsible for paying their hospital bill in full, which may force them to make difficult decisions regarding their child’s health, such as transferring them to a government-run NICU that is generally of lesser quality (Sharma et al.). KMC may be a good solution to keep NICU costs down and help parents afford the best possible care for their child. On the financial side of things, KMC has been shown to be less expensive than the conventional method of care (CMC) in many under-resourced countries. For instance, in a randomized control trial on the effectiveness, feasibility, and acceptability of KMC in Ethiopia, Indonesia, and Mexico, Cattaneo et al. found that KMC was cheaper than CMC in terms of salaries (U.S. $11,788 compared with U.S. $29,888) and other operational costs (U.S. $7501 compared with U.S. $9876). Another study on the implementation of KMC in Nicaragua reported that instituting a KMC program in a referral hospital cost U.S. $23,113. Despite this high expense, it was found that the money saved from shorter hospitalization, elimination of incubators, and lower antibiotic and infant formula use (due to the reduction in infections and the increase in breastfeeding with KMC) made up for the start-up cost in one to two months. Moreover, the researchers estimated that if this program were to be implemented in 12 other facilities in Nicaragua, it would save around U.S. $166,000 after one year (Broughton et al.).
As established thus far, KMC is not a cost-free solution. Rather it is an intervention to expand and improve newborn healthcare at a reduced cost. While it can be somewhat expensive to implement KMC programs initially, the cost-benefit analyses of such programs are very promising. For example, one study analyzed the cost and impact of 16 different interventions in 60 countries considered high-priority by UNICEF (which collectively account for 93% of all under-five deaths). Among these interventions were KMC and things that KMC is known to promote, such as breastfeeding and prevention and management of hypothermia. The researchers estimated that increasing the use of these 16 interventions to 90% of newborns could save 0.59-1.08 million lives in South Asia at a cost of $0.90-1.76 billion. In sub-Saharan Africa, it was estimated that 0.45-0.80 million lives could be saved for around $0.68-1.32 billion (Darmstadt et al.). These may seem like large sums, but are in actuality, considered low-cost in the world of public health.
Aside from lower operational costs, KMC also helps reduce hospital bills by promoting earlier discharges. In their randomized control trial, Sanghita et al. found a statistically significant decrease in the duration of hospital stay in low birth weight infants randomized to the KMC group compared with low birth weight infants randomized to the CMC group. This was due to quicker weight gain and a reduction in the risk of hypothermia and hospital-acquired infections in the KMC group (Sanghita et al.). This result is supported by various other studies. Gathwalda et al, for example, found that the duration of hospital stay was significantly shorter for infants randomized to the KMC group (3.56 + 0.57 days) compared with infants randomized to the CMC group (6.80 + 1.30 days). Similarly, Brouhton et al, in their above-mentioned study on the effect of implementing KMC in a referral hospital in Nicaragua, reported that infants who received KMC care had a lower length of hospitalization by an average of 4.64 days. The length of a kangaroo mother care intervention varies drastically depending on the severity of the newborn’s health issues. This means that even with an early discharge, a newborn may still spend a long time in the hospital if need be. However, given the high operational costs and limited resources in many developing countries, a discharge of even a few days early can help parents and healthcare systems better afford high-quality neonatal care.
By lowering operational costs and decreasing the amount of time that newborns must stay in the hospital, KMC helps parents afford the care that their premature, low birth weight, or otherwise sick infant needs. By making newborn care more affordable, KMC helps expand access to care, which can ultimately have a huge impact on lowering newborn mortality rates.
Caregiver Opinions on KMC:
As previously demonstrated, there is strong evidence to suggest that KMC promotes newborn health and reduces the cost of healthcare. However, this evidence means very little if people in the communities where KMC is needed don’t support such programs. Since people from different countries have different beliefs and practices, it is important to assess whether caregivers from a given community would be willing to engage with KMC before spending the money to institute these programs. Very broadly speaking, a good deal of research has suggested that caregiver’s opinions on KMC are generally positive. A study that interviewed mothers of preterm and low birth weight infants receiving KMC in a hospital in Cote D’Ivoire cited that all mothers reported that KMC helped them feel more involved in their child’s care, as well as helped them gain experience and confidence in regards to caring for their child. The majority of mothers also reported believing that KMC is an effective method for improving newborn health and is simple and easy to follow (Bilal et al.). In a similar vein, a study on the use of KMC in a hospital in Chandigarh, India found that 96% of mothers and 82% of fathers accepted KMC. This study also found that 94% of mothers reported feeling more confident about caring for their child when they used KMC and 98% felt empowered to continue the use of KMC at home (Kumar et al.).
Although there has been a lot of support for KMC, some mothers have cited drawbacks, such as having to forgo work to spend time in the hospital and having difficulty continuing KMC after discharge due to a lack of familial support (Doukouré, 2022). This sentiment was also expressed by mothers in the aforementioned study on the implementation of KMC in Ethiopia. Mothers in this study cited a lack of familial support and a poor attitude towards KMC from community members who are unfamiliar with the practice as barriers to continuing KMC after discharge (Bilal et al.).
It is important to note that opinions on KMC vary from country to country and cannot be easily qualified. With that being said, these studies suggest that, in general, when KMC is introduced to new populations, it is seen as a favorable practice by many caregivers. To maximize awareness and acceptance of KMC by caregivers and community members, culturally-sensitive education is incredibly important, as is getting community leaders to advocate for the use of this practice. In addition, it is important that mothers and their children are provided with better follow-up and support from healthcare professionals, so that they can manage the continuation of KMC after they are discharged.
Challenges to Implementing KMC Programs in Low-Income Countries:
There are various challenges that accompany the implementation of KMC programs in low and middle-income countries. Securing the funds and resources to start up KMC programs is, of course, one major barrier. But more significant is that many parents are hesitant to engage with these programs due to a distrust of the healthcare system. A study on the use of KMC in Ethiopia, for instance, cited that the prevalence of home deliveries in the country is high due to factors such as a perceived lack of privacy, distrust in institutional delivery, and stories of bad experiences from elders. Additionally, many women reported that they prefer to give birth at home because it allows them to more easily perform traditional practices and ceremonies during and after birth (Bilal et al.). Distrust of the healthcare system also means that parents are less likely to take their home-delivered newborn to the hospital to be assessed. In Ethiopia, for instance, delays, poor documentation, and inadequate support from healthcare workers during the referral process discourages parents from engaging with hospitals (Bilal et al.). These are circumstances that are not uncommon in low and middle-income countries. Ganle et al. reported similar findings, namely that negative experiences with the healthcare system, unfriendly healthcare providers, cultural insensitivity, long wait times, a lack of privacy, and poor quality of care influenced women in Ghana to not utilize healthcare services before, during, and after the birth of their child (2014).
While there are surely many more factors that make it difficult to implement KMC programs, distrust in the healthcare system is conceivably the biggest obstacle. As was previously established, KMC is generally viewed positively by caregivers. However, KMC requires healthcare providers to teach parents how to effectively perform the intervention, meaning it is a practice that starts in the hospital. If parents are pessimistic about the care they will receive, engaging with the healthcare system in this way may be something they are unwilling to do. As such, successful implementation of KMC programs doesn’t just entail sourcing physical resources, but also making strides to improve the quality of care and perception of the healthcare system.
Conclusion:
Kangaroo mother care has many benefits, such as helping newborns grow, develop, and avoid illness, allowing parents to afford neonatal care, and empowering parents to be active in their child’s healthcare plan. It is a practice that all mothers and infants, whether they come from a low or high-income country, can and should partake in. However, KMC is especially useful in low-income communities where newborn mortality rates are high and resources are limited. Thanks to KMC’s ability to lower costs, improve neonatal outcomes, and empower parents to be an active part of their newborn’s care, KMC is a great addition to the current standard of care in developing countries.
While KMC provides a wealth of benefits, there are many obstacles to implementing KMC programs. It is clear from various studies on this matter that merely having the finances and physical resources to implement and upkeep these programs is not enough. The deeply entrenched negative views on the healthcare system in many developing countries mean that parents may miss out on the opportunity to learn about and ultimately practice KMC. While this is a complex problem with no straightforward answer, establishing education programs and gaining the support of community members is a good first step. By sharing knowledge about the benefits of kangaroo mother care and gaining the trust of parents and community members, newborn outcomes can be improved and the worldwide newborn mortality rate can be reduced.
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