Kangaroo mother care in sub-Saharan Africa
An interview with lead author of 'Mothers’ perceptions of the practice of kangaroo mother care for preterm neonates in sub-Saharan Africa: a systematic review of qualitative evidence', Pontius Bayo
Image credit: UNICEF Ethiopia/2017/Meklit Mersha
What was the motivation for conducting the review?
As an obstetrician, it was very distressing for me to see pre-term babies die.
Humanitarian workers had supplied brand new incubators to several health facilities in South Sudan, but they are often left unused because we have no constant electricity to run this high energy consumption equipment, and few staff skilled to use them. It is important that the context, the realities on the ground, must always be considered in any project planning if there is to be value for money and justice delivered to the beneficiaries and to public health.
In a low-resource setting kangaroo mother care (KMC) is the cheapest, evidence-based intervention to adopt to help save the lives of pre-term babies. The evidence is overwhelming, and the benefits are clear. Why it is not invested in, despite the overwhelming evidence, baffled the team.
We undertook to educate our mothers on KMC and practice it within the facility. Some of the mothers were not willing to stay longer in the hospital, which is understandable considering the economic and security challenges in South Sudan, and yet we were not able to follow up the mothers at home owing to lack of resources. We were not sure if the mothers would continue with the practice at home, and the realities that affect the practice of KMC at a community level were not well known.
When we tried to look for information in the literature on what the difficulties could be for the mothers and their families in practicing KMC at home, and what could motivate them to sustain the practice in low-resource settings like that of South Sudan, we found that this information was scarce in the literature and was not organized.
We decided to organize it into key messages to present to the world, and hopefully it can lead to improvements in the implementation of KMC and the survival rates of preterm neonates in Sub-Saharan Africa.
Why is it important to focus on sub-Saharan Africa?
Sub-Saharan Africa is the region that presents the most embarrassingly high figures for neonatal mortality; it is the region that will continue to lack properly equipped and well-staffed neonatal ICUs, yet it is also the region that will continue to present the highest numbers of preterm babies.
The communities and families in this part of world will continue to have poor access to adequate healthcare for the near future and particularly for those rural communities. With the economic hardships coupled with conflicts and corrupt officials in positions of power in most parts of the region, well-functioning health systems are still decades away for most countries.
Kangaroo mother care is an effective intervention that can be applied in low-resource settings to help prevent the deaths of pre-term babies.
What cultural factors may influence the practice of kangaroo mother care at a community level?
The tradition of carrying babies at the back seems to be deeply entrenched. I remember growing up as children, even as boys, we would fashion objects into a ‘baby’ to carry on our backs. It is not easy to change to carrying babies at the chest as an adult, and it is probably embarrassing for the mother.
One positive finding from this review is that at least the communities are aware that neonates need warmth to survive - this is very important. They also have ways to ensure this warmth is delivered, for example lighting lamps or charcoal stoves or any other source of fire. So it would be easy to modify and integrate KMC into these contextual cultural realities.
We also found that the mothers who participated in these studies relied a lot on their peers for KMC information, encouragement and support. This is an asset the healthcare system can rely on to promote KMC in the community; these are champions that support the delivery of key messages to communities early, before or during pregnancy.
What challenges to practicing kangaroo mother care were found in the study?
Firstly, the healthcare systems present to the mothers and the families the idea of KMC very late, often only after the families are faced with the reality of a preterm birth. By this time, the mothers are often feeling very anxious, and may be in denial.
I did some self-reflection and felt guilty as a clinician that I hadn’t also done enough to promote KMC to increase its uptake. The fact that KMC information is not well packaged into the antenatal care information is simply a failure on the part of the healthcare system. To assume that all pregnancies will go to term is living in denial in obstetric practice, and for those mothers at risk of having preterm births, a clear plan of what to expect should be given way before.
Secondly, as I have mentioned, the communities have traditional positions for carrying neonates, mainly on the back. They also have traditional methods of keeping babies warm, usually by lighting lamps. So carrying a neonate on an open chest is stigmatizing to them. Moreover, some community members think that they could have stolen stuff, because the position of the baby resembles something being hidden.
Thirdly, the different components of KMC can be cumbersome. The practice makes mothers assume certain positions for too long and they cannot sleep comfortably at night. Others find it difficult to breastfeed, while other mothers are simply anxious and fear the baby will fall if they turn or take on another task simultaneously.
Lastly, the other aspect is the family conditions; the male partners and other family members need to take part in the practice. They can also support with other household activities and encourage the mothers to continue with KMC. Unfortunately, the gender roles assigned to women by society in the communities of the Sub-Saharan Africa place a lot of burden on women, and this blinds men to the contribution they could make to undertaking household activities.
What are the key points or ‘takeaways’ from the study for clinicians?
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Start KMC education early during pregnancy or even before.
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Use experienced mothers who successfully went through the process as ambassadors to promote the practice.
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Recognize the traditional ways community members have for keeping babies warm and integrate KMC education into what is being practiced.
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Critically assess the support structures mothers have at home to be able to continue with KMC practice after discharge, and engage with those family members to encourage and solicit their support.
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It might be important to plan for home visits to continue supporting the mothers and monitor continued practice.
Is there anything you would like to elaborate, especially in the sub-Saharan African context?
I would like to stress the issue of inequity in accessing high-tech care for preterm neonates, which undermines the quest for universal health coverage. Functional high-technology equipment in the developing world is usually more available in the private sector than in the public facilities where the majority of the poor rural communities access care. It is therefore important that KMC is made more feasible and accessible to this less privileged population through the public healthcare system. Particular attention needs to be paid to contextual differences, especially the cultural, social and economic realities that exist.
The health system gaps identified in this review need further investigation; whether KMC is emphasized in the policy documents and whether it is included in the guidelines and protocols used in the public health facilities. It is also important to re-examine how much the intervention is emphasized in training schools.
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