Kangaroo Mother Care: A Cost-effective Intervention for Preterm Infants in Low-and Middle-Income Countries
Most expectant mothers desire to carry their pregnancy to the full term of 39 weeks to 40 weeks [1]. However, the increasing incidence of preterm birth, or birth before 37 weeks of gestation, and lower survival rates are issues of global concern [2]. Globally, 15 million preterm infants are born every year, and more than one million die within 28 days of life [3,4]. Of these 15 million preterm births, 12 million occur in low- and middle-income countries (LMICs) [5,6]. Preterm birth may be classified as extreme preterm (less than 28 weeks of gestation), very preterm (28-31 weeks), or moderate to late preterm (32 to less than 37 completed weeks) [7].
This article describes the causes of preterm birth, kangaroo mother care (KMC) as an intervention necessary for preterm infants in LMICs and the challenge associated with the practice.
Original illustration by Cassandra Seal.
Causes of Preterm Birth
The two most common causes of preterm birth are either spontaneous or provider-initiated [8]. Globally, spontaneous preterm birth accounts for more than 50% of preterm births and occurs from an interaction of hereditary, environmental, and social factors. There are three main hereditary factors that increase the risk of spontaneous preterm birth: (a) an expectant mother being born preterm herself, (b) having siblings who were born preterm, and (c) experience of a previous spontaneous preterm birth [7]. In addition, the race/ethnicity of an expectant mother coupled with a lifestyle of tobacco- and alcohol-use predisposes her to spontaneous preterm birth [8,9]. Globally, black women, including women of African descent, compared to white women have an increased risk of premature uterine membrane rupture when pregnant, leading to spontaneous preterm birth [7].
In LMICs, the risk of spontaneous preterm birth is higher for South Asian women, including Pakistani and Indian women, compared to African women [10,11]. Prenatal exposure to environmental factors such as pesticides, air pollution, organic pollutants, and contaminated water can increase the risk of spontaneous preterm birth. Also, socioeconomic factors such as low education level and low income are also reported as risk factors for spontaneous preterm birth in LMICs [10]. Low education levels among mothers directly influence their employability and job security. The least educated women in a LMIC may be unemployed and earn a lower income than the minimum expected wage [10]. One indirect consequence of earning a low income is its adverse effect on nutrition, especially during pregnancy. To maintain a healthy pregnancy, varied diets, along with micro-and macro-nutrient supplementation, are required. However, with a low income, adequate nutrition may not be met, resulting in malnutrition, impaired fetal growth, and often leading to spontaneous birth [12].
In contrast, provider-initiated preterm birth is a medical intervention to induce birth before 37 completed weeks of gestation due to maternal or fetal indications [8]. Advanced maternal age and conditions, including diabetes, hypertension, and pre-eclampsia, are some common maternal indications for preterm birth [13,14]. Fetal growth restrictions and fetal distress are also causes of provider-initiated preterm birth [8,9]. In LMICs, provider-initiated births are lower since pregnancy monitoring and diagnostic tools are less accessible; however, effective monitoring of pregnancies and increased obstetric interventions account for higher provider-initiated preterm births in high-income countries [13,14].
“To maintain a healthy pregnancy, varied diets, along with micro-and macro-nutrient supplementation, are required. However, with a low income, adequate nutrition may not be met, resulting in malnutrition, impaired fetal growth, and often leading to spontaneous birth”
Preterm infants have under-developed body systems, which predisposes them to many complications that adversely influence their survival. Preterm infants are usually small and weigh less than 2500g. They often have thin shiny skin with visible veins and less subcutaneous fat that makes them rapidly loose heat and frequently causes hypothermia. Other complications include, infections, respiratory distress syndrome, bronchopulmonary dysplasia, necrotizing enterocolitis, and retinopathy of prematurity. These complications ultimately affect their long-term development and survival [16]. When preterm infants have lower gestational ages and birth weights, their complications and death are higher.
To improve the survival of preterm infants, interventions like kangaroo mother care (KMC) were developed and are known to reduce the risk of hypothermia and prevent infections. The World Health Organization (WHO) has recommended KMC as an alternative to conventional care of preterm infants in resource-constrained settings such as those of LMICs [17]. Conventional care of preterm infants often occurs in Neonatal Intensive Care Units (NICUs), where costly resources, including incubators, highly skilled personnel, and continuous logistical support, are required but mainly made available in high-income countries [18].
Kangaroo Mother Care and the Preterm Infant
The WHO (2003) describes KMC as the direct skin-to-skin contact of an infant on the mother’s bare chest or the chest of another caregiver, including the father of an infant [17]. KMC may be continuous or intermittent. Continuous KMC is the prolonged skin-to-skin contact lasting more than 20 hours each day whereas intermittent KMC is recurrent and over a shorter daily duration [18].
Edgar Rey introduced KMC in Bogota, Colombia, in 1978 in response to congested nurseries and scarce resources, including the lack of incubators. The gray mother kangaroo—a marsupial–keeps its tiny offspring in her pouch to provide warmth and nourishment until the offspring matures to survive outside on its own. Rey adopted this rationale of the marsupial pouch of the kangaroo to humans (Fig 1 and 2). An infant undergoing KMC is kept in an upright frog-like posture, between the mother’s breast, skin-to-skin, and under her clothes [18].
Figure 1 (Left): Baby Kangaroo in mother’s pouch. Source: super coloring.com
Figure 2 (Right): Baby in KMC Position. Source: WHO, 2003
KMC has several benefits, including reducing hypothermia, facilitating bonding, and increasing breastfeeding [18]. During KMC, the mother is used as an “incubator” to maintain the infant’s body temperature, preventing hypothermia. The mother’s breathing and heartbeat stimulate the preterm infant and decrease apneic episodes (15-20 minute cessations of breath) experienced commonly by preterm infants [18]. KMC establishes a mother-baby relationship and promotes bonding early on. It minimizes early separation of mother and baby during preterm infants’ admission into an NICU. Through bonding, mothers or other caregivers spend more time with their infants, increasing their confidence in better caring for them on discharge. Bonding also decreases the psychological stress and uncertainties experienced by mothers due to preterm delivery, thereby facilitating lactation and enhancing breast milk/breastfeeding.
Breast milk is expressed through techniques such as manual expression or pumps. The expressed breast milk is served through a feeding tube or the use of a cup and spoon for preterm infants with gestational ages less than 32 weeks due to their underdeveloped suckling and swallowing reflexes [19]. In contrast, moderate to late preterm infants who can suck directly from the breast are encouraged to do so with little support from the mother while in the KMC position. Therefore, with increased lactation accompanied by increased feeding, preterm infants gain weight, which is necessary for their survival [18,19]. Additionally, breastfeeding provides adequate immunity to the preterm infant and decreases the risk of severe infections. These include respiratory tract infections and hospital-acquired infections, which may increase the length and cost of hospital stay.
KMC establishes a mother-baby relationship and promotes bonding early on… Through bonding, mothers or other caregivers spend more time with their infants, increasing their confidence in better caring for them on discharge.
Despite the advantages of KMC to preterm infants, some challenges have been identified which affect its optimum use in LMICs. Among the challenges is mothers’ lack of knowledge of KMC and some traditional practices present in LMICs. Mothers’ lack of knowledge on the practical application of KMC and its associated benefits diminishes their willingness to accept and implement the method [20]. Some mothers fear the tiny infant may fall from the KMC position when they move around, while others assume the binders used to secure the preterm infant in the KMC position are too tight, making the infant uncomfortable. In LMICs, mothers and caregivers traditionally carry infants on their backs which makes the KMC position seem strange, contributing to their reluctance to the practice.
In patriarchal societies, fathers are often considered the head of the family. Fathers wield power, and their primary responsibility is to provide for the family. Based on this belief, fathers cannot engage in domestic chores, including infant care. Therefore, fathers fail to assist their spouses in offering skin-to-skin contact to an infant in the KMC position, which prevents the mother from undertaking other household duties. For example, cooking, depending on the method and source of fire used, may generate some heat, making an infant kept in the KMC position uncomfortable during the process, thus preventing the mother from practicing KMC [21].
To overcome this challenge, health care workers may provide education to mothers, fathers, and other family caregivers to improve the acceptability of KMC. Health care workers should explain and demonstrate the step-by-step process of KMC to mothers/family caregivers. Through this education, mothers can practice and gain more confidence, which may lessen their fear of the baby falling from the KMC position. Health care workers may also educate communities on the benefits of KMC and create awareness of male involvement to encourage their support of the practice 20. As a life-saving intervention for preterm infants, KMC must be widely utilized in LMICs to help achieve the sustainable development goal of reducing neonatal mortality from 19 per 1000 live births to 12 per 1000 live births by 2030 (SDG 3.2.2) [22].
Kokui Dziedzom Klutse is a Ph.D. student at the Lawrence S. Bloomberg Faculty of Nursing, University of Toronto. Before beginning her Ph.D. program, Kokui practiced as a pediatric nurse in Ghana. Her research interests are child health, newborn care, and implementation science.
References
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