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The efficacy of continuous kangaroo mother care (C-KMC) in reducing neonatal mortality and morbidity among low birthweight and premature infants has been confirmed. Despite the recommendations of the World Health Organization, UNICEF, and the Ministry of Health of Iran to use C-KMC for eligible hospitalized neonates, this type of care is not performed due to implementation problems. This protocol aims to describe the design, implementation, and assessment of C-KMC in one tertiary hospital by means of participatory action research.
The objective of this study is to design and implement a C-KMC program for neonates that will be performed in two phases using a stages-of-change model. The first phase will be conducted in three consecutive activities of designing, implementing, and assessing the introduction of C-KMC. The second phase of the study has a before-and-after design to assess the effectiveness of C-KMC by comparing the length of preterm neonates’ stay in hospital and exclusive breastfeeding at discharge before and after implementing C-KMC.
KMC is an important component of neonatal developmental care as part of family-centered care. Applying this type of care requires creating appropriate strategies, budget allocation, and clear and coordinated planning at different levels of the health system. The stages-of-change model is one of the appropriate approaches to the implementation of C-KMC.
Keywords: Continuous kangaroo mother care, Health services research, Premature infant, Health plan implementation
An estimated 2.5 million newborns die every year, of which the vast majority of deaths occurs in low- and lower-middle-income countries [1]. Premature birth is the leading cause of neonatal deaths around the world, accounting for 47% of deaths in children below 5 years of age in 2018 [2]. In addition to premature infants being at greater risk for neonatal mortality, these infants suffer more long-term health problems, physical disabilities, and lifelong mental disabilities than term infants [3]. Providing care for premature newborns imposes a heavy burden on healthcare [4, 5] and effective interventions require high technology, skilled staff, and an efficient care system in addition to high costs [6].
In line with the goals of sustainable development to reduce infant mortality in low-income and middle-income countries, we need low-cost care with high effectiveness [7].
KMC is a cost effective complementary method of caring for stable low birthweight (LBW) and preterm neonates [8, 9] that can contribute to improving the quality of care, as it ensures constant temperature regulation and improved survival of these infants. C-KMC is one of the 10 recommendations of the World Health Organization (WHO) for providing care for premature neonates [7]. Evidence-based studies have shown the efficacy of KMC to reduce mortality and morbidity in preterm neonates, prevent hypothermia and infection, improve maternal-infant attachment and increase the duration of exclusive breastfeeding [8–14].
KMC can be provided intermittently and continuously. Nyqvist et al. describe the difference as follows: “The hallmark of KMC is the kangaroo position: the infant is cared for skin-to-skin vertically between the mother’s breasts and below her clothes, 24 h / day, with father / substitute(s) participating as KMC providers. Intermittent KMC (for short periods once or a few times per day, for a variable number of days) is commonly employed in high-tech neonatal intensive care units.” [15].
Studies have shown that the duration of KMC can be increased by improving facilities [16]. The longer the care duration is, the greater the benefits obtained from it are and the better consequences of physical, mental and emotional development are for the premature infant who needs this care [6, 15].
Despite the recommendations of the WHO and UNICEF, on the use of C-KMC for eligible hospitalized neonates, this type of care is not implemented because of various barriers such as lack of physicians’` and nurses` preferences as well as limitation in appropriate place for carry out C-KMC. All cross-sectional studies conducted in Iran so far have focused on intermittent KMC [6, 17, 18] and the number of hours of KMC per day was below the recommended average for intermittent KMC [19].
This protocol describes a proposed study aimed at designing a C-KMC program for neonates and implementing and evaluating this program and the effect of C-KMC in a teaching hospital in North West Iran. The hospital had nearly 6500 deliveries in 2018, with 8% of neonates being preterm. There is a level III neonatal intensive care unit (NICU) with 25 beds and a neonatal ward with 15 beds.
At present, infants admitted to the neonatal ward or NICU receive 1 to 2 hours of KMC per shift at this hospital. According to the protocol, the minimum duration of this care is 1 hour. Care will continue after 1 hour as long as the mother has the ability and patience to do it. Typically, mothers can do this care for more than 2 hours in a shift. Consequently, each baby receives care for three to 6 hours (according to the mother’s ability) until now and before performing this plan.
The specific objectives of this study are to:
Identify the barriers and problems related to the introduction of C-KMC Implement C-KMC according to the principles of action research Evaluate progress with C-KMC implementationCompare exclusive breastfeeding rates at the time of hospital discharge for a period before and after introducing C-KMC
Compare the duration of hospitalization of neonates before and after the introduction of C-KMCThis study uses a mix- method design, which will be conducted in two phases. The first phase will use a participatory action research approach in three consecutive activities (design, implementation and evaluation) as part of the introduction of C-KMC. The second phase of the study is a quantitative before-and-after study aimed at assessing the effectiveness of C-KMC. Table 1 gives an overview of the study design.
Overview of the study design
1. reduces the length of hospital stay of preterm neonates / neonates
2. increases the rate of exclusive breastfeeding at discharge
• Mothers with preterm neonates
• Nurses and midwives
• Managers and health policy makers
• Sample size: until data saturation is reached
• Consecutive sample (before and after C-KMC implementation)
• Sample size: 208 = 104 per group
1. Interview guide (for focus group discussions and individual interviews)
2. Standardized progress-monitoring tool:
• Observations of service provision, care and records
• Interviews with health care providers (nurses, doctors, etc.)
Data collection sheet (questionnaire):
• Length of hospitalization (total and length of days in C-KMC)
• Feeding method(s) at discharge
• Other characteristics (e.g. gestational age and sex) – see Table Table2 2 for details
• Focus group discussions (health care providers and managers) and individual interviews (mothers)
• Application of the progress-monitoring tool
• Qualitative content analysis
• Data with normal distribution: paired t-test; Pearson correlation coefficient; ANOVA
• Paired nominal data: McNemar’s test
• Software: SPSS version 24
a NICU level III Neonatal intensive care unit that is capable of caring for neonates ANOVA analysis of variance, SPSS Statistical Package for Social Sciences, C-KMC contionuse kangaroo mother care
The participatory action research in this study is based on the approach of the stages-of-change model developed by Bergh et al. [20]. This model is a useful model for introducing C-KMCs in hospitals and is almost consistent with McNiff’s research action [21]. The stages-of-change model includes three main change phases, namely pre-implementation (readiness of stakeholders), implementation (readiness of system) and institutionalization (quality of care). Each phase consists of two steps or stages. Figure 1 illustrates this model for implementing C-KMC. The research group will use the results of the first study phase to inform the authorities about current care and necessary adaptations to improve the care with a view to get their commitment for the further administration and expansion of C-KMC.