Implementing facility-based kangaroo mother care services: Lessons from a multi-country study in Africa

Background: Some countries have undertaken programs that included scaling up kangaroo mother care. The aim of this study was to systematically evaluate the implementation status of facility-based kangaroo mother care services in four African countries: Malawi, Mali, Rwanda and Uganda. Methods. A cross-sectional, mixed-method research design was used. Stakeholders provided background information at national meetings and in individual interviews. Facilities were assessed by means of a standardized tool previously applied in other settings, employing semi-structured key-informant interviews and observations in 39 health care facilities in the four countries. Each facility received a score out of a total of 30 according to six stages of implementation progress. Results: Across the four countries 95 per cent of health facilities assessed demonstrated some evidence of kangaroo mother care practice. Institutions that fared better had a longer history of kangaroo mother care implementation or had been developed as centres of excellence or had strong leaders championing the implementation process. Variation existed in the quality of implementation between facilities and across countries. Important factors identified in implementation are: training and orientation; supportive supervision; integrating kangaroo mother care into quality improvement; continuity of care; high-level buy in and support for kangaroo mother care implementation; and client-oriented care. Conclusion: The integration of kangaroo mother care into routine newborn care services should be part of all maternal and newborn care initiatives and packages. Engaging ministries of health and other implementing partners from the outset may promote buy in and assist with the mobilization of resources for scaling up kangaroo mother care services. Mechanisms for monitoring these services should be integrated into existing health management information systems. © 2014 Bergh et al.; licensee BioMed Central Ltd. A cross-sectional, mixed-method research design was used to analyse country KMC program performance. Qualitative and quantitative data collection methods were employed, including stakeholder meetings, semi-structured key-informant interviews and observations. Country visits took place between February and May 2012. The research protocol was approved by the Institutional Review Board of the Johns Hopkins Bloomberg School of Public Health (IRB no. 0004134). The ministries of health and all facility directors gave written permission for the study and key informants in facilities gave oral consent before being interviewed and showing the assessors the maternity or neonatal unit where KMC services were being provided. Sampling for this study took place at two levels. First, four countries – Malawi, Mali, Rwanda, and Uganda – were purposively selected as countries from which potentially rich information could be obtained, on the basis of their perceived progress with KMC implementation and existing platforms for delivering newborn care. Selected newborn statistics for the four countries are presented in Table 1 to give a sense of the burden of preterm birth and to demonstrate differences between countries. All four countries had received financial and/or technical support from the Saving Newborn Lives program and/or the Maternal and Child Health Integrated Program (MCHIP, and its predecessor ACCESS) for the implementation of KMC on its own or as part of essential newborn and/or obstetric care initiatives. In all countries different forms of support were also provided by other agencies or non-governmental organizations at different levels of the health system, either as part of an intervention or on an ad hoc basis. Selected national newborn statistics of the four study countries a2011 b2010 c2010–12. Second, in each country a sample of two groups of informants was selected – stakeholders representing higher-level structures in each country and health facilities representing the grassroots level of KMC implementation. Stakeholders included government, program developers and coordinators, regulatory bodies, professional associations, training and research institutions, health facilities, United Nations and other funding agencies, and non-governmental organizations involved in the improvement of newborn care or the implementation of KMC. A convenience sample of facilities to receive on-site visits was identified (total n = 39). Logistic and cost constraints did not allow for the use of probability sampling. It was, however, important to ensure that the assessed facilities included all levels of care, where applicable, and also to allow for sufficient geographic spread. Table 2 gives a summary of the types of facilities visited per country. Across all countries combined, more than one in every five facilities reportedly providing KMC services received a site visit, ranging from 100% of facilities in Mali with only seven facilities providing KMC services to 12% in Malawi, where 121 facilities were reported to provide these services. Summary of facility samples per country In three countries stakeholders were invited to a national plenary meeting to qualitatively solicit their views on KMC implementation. In Rwanda four individual qualitative interviews with stakeholder members served the same purpose. The number of meeting delegates ranged between 11 and 13 per country. Meetings were facilitated by a local representative of Save the Children and the agenda included feedback on the history and status of KMC implementation in the country and a discussion on the role of partners in KMC implementation, strengths and challenges, and recommendations for the way forward. The notes from these meetings and interviews were meant to complement the facility assessments by providing the back-drop and broader framework within which to understand the findings from the facility assessments. Facilities’ KMC services were assessed by means of a standardized, key-informant interview questionnaire and observation inventory [14] with quantitative and qualitative components that cover the following aspects of service and types of practices: the health care facility (including its baby-friendly status); neonatal and KMC facilities; skin-to-skin practices; history of KMC implementation; involvement of internal role players; physical and financial resources; KMC space (continuous and intermittent KMC); feeding and weight monitoring; referral, discharge and follow up; record keeping and documentation (including availability of job aids, counselling materials, and other tools); KMC education; staffing issues (orientation and training; rotations); and strengths and challenges. The tool, available as an online supplement (Additional file 1 ), had previously been applied in South African KMC outreach trials [15,16] and had been adapted for use in Malawi [17], Ghana [18], Nigeria [19], and Indonesia [20]. In each country a team of local assessors with clinical and/or training experience in KMC were trained in the use of the facility tool. Each team consisted of two to three assessors who prepared and visited facilities together. The facility leadership and staff were informed prior to the team’s visit and were requested to prepare a presentation as part of the assessment activities. The assessor team conducted interviews with KMC focal persons and other staff and members of the management team and observed KMC practices and service provision. Before the team left a site they provided verbal feedback to facility representatives and left a written report behind. All data collection activities were conducted in either English or French, according to the official language of the country or according to the preference of individual informants. In all four countries the local assessors played the role of interpreter during facility visits where informants felt more comfortable to provide information in a local language. During the facility visits each assessor completed his or her own questionnaire and any discrepancies between the assessors were resolved through discussion and consensus, with the final analysis consolidated by the lead investigator (A-MB). Descriptive statistics were generated from some of the questionnaire items and an implementation-progress score out of a possible total score of 30 was calculated for each facility. The scoring is divided according to six stages of change, with each stage having a weighted score (see Table 3): creating awareness (2 points); adopting the concept (2 points); taking ownership (mobilizing resources) (6 points); evidence of practice (7 points); evidence of routine and integration (7 points); sustainable practice (6 points) [14]. Scoring of facilities[16] The results from the analysis of the facility questionnaires and the themes derived from the open-ended items on the questionnaires were then compared with the themes recorded in the stakeholder meetings and interviews in order to get a sense of the development of KMC implementation in each country and of what appeared to be important facilitators and barriers to KMC implementation in each country and across countries. The final interpretation was confirmed by key role players in each country.