Quality of Kangaroo Mother Care services in Ethiopia: Implications for policy and practice

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Study Justification:
The study titled “Quality of Kangaroo Mother Care services in Ethiopia: Implications for policy and practice” aimed to assess the quality of Kangaroo Mother Care (KMC) services in Ethiopia and identify factors associated with appropriate initiation of KMC for low birth weight neonates. This study is important because KMC has been proven to improve outcomes in premature babies, but its consistent and appropriate provision in Ethiopia is unclear. By evaluating the quality of KMC services and identifying barriers to its initiation, this study provides valuable insights for policymakers and practitioners to improve the adoption of this life-saving technique.
Highlights:
1. The quality of KMC services in Ethiopia was found to be poor.
2. Only 46.4% of low birth weight babies included in the study received KMC.
3. LBW babies born in health centers were twice as likely to receive KMC compared to those born in hospitals.
4. Public facilities, those with a staff rotation policy for newborn care, and those with separate newborn corners were more likely to initiate KMC for LBW babies.
5. Efforts must be made to improve the adoption of KMC, particularly in hospitals and the private sector where it remains underutilized.
6. Facilities should dedicate specific spaces for newborn care to enable mothers to provide KMC.
7. Improving record keeping and data quality for routine health data is a priority.
Recommendations:
1. Increase awareness and training on KMC for healthcare providers to ensure appropriate initiation and provision of KMC.
2. Improve infrastructure and staffing in healthcare facilities to support the implementation of KMC.
3. Develop and implement policies that promote the use of KMC, particularly in hospitals and the private sector.
4. Establish separate newborn corners in healthcare facilities to facilitate KMC provision.
5. Strengthen record keeping and data quality for routine health data to monitor the implementation and impact of KMC.
Key Role Players:
1. Ministry of Health: Responsible for developing and implementing policies related to KMC.
2. Healthcare providers: Responsible for initiating and providing KMC to low birth weight babies.
3. Training institutions: Responsible for providing education and training on KMC to healthcare providers.
4. Facility managers: Responsible for ensuring infrastructure and staffing support for KMC implementation.
5. Professional associations: Responsible for advocating for the importance of KMC and supporting healthcare providers in its implementation.
Cost Items for Planning Recommendations:
1. Training programs: Budget for developing and delivering KMC training programs for healthcare providers.
2. Infrastructure improvement: Budget for renovating or establishing separate newborn corners in healthcare facilities.
3. Staffing: Budget for hiring and training additional healthcare providers to support KMC implementation.
4. Equipment and supplies: Budget for procuring necessary equipment and supplies for KMC provision.
5. Monitoring and evaluation: Budget for establishing systems to monitor and evaluate the implementation and impact of KMC.
Please note that the provided cost items are examples and may vary based on the specific context and needs of each healthcare facility or organization.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is rated 8 because it provides specific data from the 2016 national Emergency Obstetric and Newborn Care (EmONC) assessment in Ethiopia. The study describes the quality of Kangaroo Mother Care (KMC) services in terms of infrastructure, processes, and outcomes. It also explores the factors associated with appropriate KMC initiation. The study provides percentages and odds ratios to support its findings. To improve the evidence, the abstract could include more details about the methodology, such as the sample size and data collection methods. Additionally, it could provide more specific information about the factors associated with KMC initiation and the limitations of the study.

Background Providing high-quality kangaroo mother care (KMC) is a strategy proven to improve outcomes in premature babies. However, whether KMC is consistently and appropriately provided in Ethiopia is unclear. This study assesses the quality of KMC services in Ethiopia and the factors associated with its appropriate initiation among low birth weight neonates. Methods We used data from the 2016 national Emergency Obstetric and Newborn Care (EmONC) assessment which contains data on all health facilities providing delivery care services in Ethiopia (N = 3,804). We described the quality of KMC services provided to low-birth weight (LBW) babies in terms of infrastructure, processes and outcomes (survival status at discharge). We also explored the factors associated with appropriate KMC initiation using multivariable logistic regression models. Results The quality of KMC services in Ethiopia was poor. The facilities included scored only 59.0% on average on a basic index of service readiness. KMC was initiated for only 46.4% of all LBW babies included in the sample. Among those who received KMC, 66.7% survived, 13.3% died and 20.4% had no data on survival status at discharge. LBW babies born in health centers were twice more likely to receive KMC compared to those born in hospitals (AOR = 2.0, 95% CI: 1.3–3.0). Public facilities, those with a staff rotation policy in place for newborn care, and those with separate newborn corners were also more likely to initiate KMC for LBW babies. Conclusions We found low levels of appropriate KMC initiation, inadequate infrastructure and staffing, and poor survival among LBW babies in Ethiopia. Efforts must be made to improve the adoption of this life saving technique, particularly in hospitals and in the private sector where KMC remains underutilized. Facilities should also dedicate specific spaces for newborn care that enables mothers to provide KMC. In addition, improving record keeping and data quality for routine health data is a priority.

We used data from the 2016 Ethiopian Emergency Obstetrics and Newborn care (EmONC) assessment [12]. The EmONC assessment was a national cross-sectional survey of all public hospitals, health centers and private facilities (higher clinics and above) that provided maternal and newborn health services and reported attending births in the past 12 months. The EmONC assessment did not include health posts or medium and small private clinics because these facilities are not expected to attend deliveries. Of the eligible 4,385 facilities in all nine regions and two city administrations in Ethiopia, 3,804 facilities were assessed (including 293 hospitals, 3,459 health centers and 52 clinics). A total of 11 facilities were not accessible due to political unrest or staff refusal. The survey used 13 questionnaires including 12 health facility assessment modules and one health system assessment module. These were adapted from the Averting Maternal Death and Disability program [12]. The survey collected data on EmONC signal functions, facility readiness (including the availability of equipment, guidelines, human resources, infection prevention measures, etc.), volume of services and maternal and newborn outcomes [12–13]. A module on newborn complications was designed to collect information on premature babies weighing less than 2000 grams. Trained data collectors extracted information from charts identified through facility registries or from the staff. In each facility, interviewers were expected to review charts for the last three LBW babies born in the past 12 months. Data on treatments provided and survival status were extracted. In most facilities, only one LBW baby chart was reviewed. We measured KMC quality using the three domains of quality defined by Donabedian: infrastructure, processes and outcomes [14]. Structural quality was assessed using all facilities included in the national EmONC survey. We used three indicators of service availability (facility density, maternity bed density and core health workforce density) and by one index for service readiness. These indicators were adapted from the WHO Service Availability and Readiness Assessment (SARA) manual. Facility density was calculated by the number of health facilities providing maternity care per 10,000 population. Maternity bed density was calculated by the number of maternity beds per 1,000 pregnant women and the health work force density was calculated by the number of core medical professionals per 10,000 population [11, 15–16]. The service readiness index was based the availability of a series of items necessary for the provision of maternal and newborn care including specific indicators related to KMC. The index covered four domains: infrastructure and equipment, essential medicine and commodities, core staffing and guidelines, job aids and documentation. The items and calculations are described in S1 Appendix. Process quality was assessed using a binary variable for whether KMC was initiated for each LBW baby. This is a measure of appropriate treatment and competent care [17]. Because most facilities had data on only one LBW baby, we selected only the last LBW baby per facility. Because KMC cannot be initiated until the baby is stable, we also looked at the proportion of LBW babies that were initially put in incubators. Outcomes were assessed based on the survival status at discharge for all LBW babies who received KMC. Process quality and outcomes were only assessed in the subset of facilities with data on LBW babies. We selected a series of facility- and provider-level covariates that may be associated with quality of care. These were selected based on prior literature on the factors affecting health care provider performance and quality in low income countries [17]. Facility characteristics included facility type (hospitals or maternal and child health (MCH) specialty centers, health centers and higher clinics), urban location, managing authority (public or private), whether the facility had a separate newborn corner, a newborn intensive care unit (NICU) and a policy in place for staff rotation. Facility types were based on definitions by the Federal Ministry of Health. Hospitals and MCH specialty centers generally have operating theaters while health centers and clinics do not. Provider characteristics included cadre, work experience in years, age, gender, and whether the provider had a written job description. Infrastructure processes and outcomes were assessed using descriptive statistics. We also looked at associations between each of the facility- and provider-level covariates and appropriate KMC initiation using bivariable logistic regressions. Covariates with a p-value of ≤0.25 were considered for inclusion in the multivariable logistic regression model with the forward likelihood ratio method. In the final multivariable model, a p-value<0.05 was used to determine statistical significance. All analyzes were performed using SPSS version 21TM software. Ethical approval for the original survey was granted by the Scientific and Ethical Review Office of the Ethiopian Public Health Institute (EPHI). The Federal Ministry of Health of Ethiopia granted access to the data for this analysis. The institutional review board of Mekelle University considers this analysis as exempt from ethical review as it is a secondary analysis of de identified data.

The recommendations to improve access to Kangaroo Mother Care (KMC) services in Ethiopia are as follows:

1. Improve infrastructure and service readiness: Efforts should be made to enhance the infrastructure of healthcare facilities and ensure the availability of necessary equipment, essential medicines, and commodities for maternal and newborn care, including specific indicators related to KMC.

2. Increase initiation of KMC for low birth weight (LBW) babies: Promote the appropriate initiation of KMC for all eligible LBW babies through training and capacity building for healthcare providers. This will ensure that they are knowledgeable about the benefits and proper implementation of KMC.

3. Strengthen staffing and training: Ensure an adequate number of trained healthcare providers, particularly those specializing in maternal and newborn care. Implement policies that support staff rotation and continuous training to improve the initiation of KMC for LBW babies.

4. Enhance data collection and record-keeping: Improve record keeping and data quality for routine health data. Strengthen data collection systems and provide training on data management to ensure accurate and reliable data on KMC initiation, processes, and outcomes.

5. Promote collaboration and knowledge sharing: Foster collaboration between different healthcare facilities, including public and private sectors, to improve the adoption and utilization of KMC. Share best practices, experiences, and lessons learned to contribute to the overall improvement of maternal health services, including KMC.

By implementing these recommendations, access to high-quality KMC services for maternal health in Ethiopia is expected to improve, leading to better outcomes for LBW babies and their mothers.
AI Innovations Description
The recommendation to improve access to maternal health, specifically in relation to Kangaroo Mother Care (KMC) services in Ethiopia, is to focus on the following areas:

1. Improve infrastructure and service readiness: The study found that the quality of KMC services in Ethiopia was poor, with facilities scoring only 59.0% on average on a basic index of service readiness. Efforts should be made to enhance the infrastructure and availability of necessary equipment, essential medicines, and commodities for maternal and newborn care, including specific indicators related to KMC.

2. Increase initiation of KMC for low birth weight (LBW) babies: The study revealed that KMC was initiated for only 46.4% of all LBW babies included in the sample. It is crucial to promote the appropriate initiation of KMC for all eligible LBW babies. This can be achieved through training and capacity building for healthcare providers, ensuring they are knowledgeable about the benefits and proper implementation of KMC.

3. Strengthen staffing and training: Inadequate staffing was identified as a contributing factor to the low levels of appropriate KMC initiation. Facilities with a staff rotation policy in place for newborn care were more likely to initiate KMC for LBW babies. Therefore, it is important to ensure an adequate number of trained healthcare providers, particularly those specializing in maternal and newborn care, and to implement policies that support staff rotation and continuous training.

4. Enhance data collection and record-keeping: The study highlighted the need to improve record keeping and data quality for routine health data. Accurate and reliable data on KMC initiation, processes, and outcomes are essential for monitoring and evaluating the effectiveness of interventions and identifying areas for improvement. Strengthening data collection systems and providing training on data management can help address this issue.

5. Promote collaboration and knowledge sharing: Efforts should be made to foster collaboration between different healthcare facilities, including public and private sectors, to improve the adoption and utilization of KMC. Sharing best practices, experiences, and lessons learned can contribute to the overall improvement of maternal health services, including KMC.

By implementing these recommendations, it is expected that access to high-quality KMC services for maternal health in Ethiopia will be improved, leading to better outcomes for LBW babies and their mothers.
AI Innovations Methodology
The methodology used in the study to simulate the impact of the main recommendations on improving access to maternal health in Ethiopia involved the following steps:

1. Data collection: The study utilized data from the 2016 Ethiopian Emergency Obstetrics and Newborn Care (EmONC) assessment. This national cross-sectional survey collected data from 3,804 health facilities providing delivery care services in Ethiopia, including hospitals, health centers, and private facilities.

2. Assessment of KMC services: The quality of KMC services provided to low-birth weight (LBW) babies was assessed in terms of infrastructure, processes, and outcomes. The study measured service availability, service readiness, and the initiation of KMC for LBW babies.

3. Statistical analysis: The study used descriptive statistics to analyze the infrastructure, processes, and outcomes of KMC services. Bivariable logistic regressions were conducted to identify associations between facility and provider characteristics and the initiation of appropriate KMC. Covariates with a p-value of ≤0.25 were considered for inclusion in the multivariable logistic regression model.

4. Identification of factors associated with appropriate KMC initiation: The study identified factors associated with the appropriate initiation of KMC for LBW babies, such as facility type, urban location, managing authority, presence of a separate newborn corner, and staff rotation policy.

5. Recommendations for improvement: Based on the findings, the study provided recommendations to improve access to maternal health, specifically in relation to KMC services. These recommendations focused on improving infrastructure and service readiness, increasing the initiation of KMC for LBW babies, strengthening staffing and training, enhancing data collection and record-keeping, and promoting collaboration and knowledge sharing.

By implementing these recommendations, it is expected that access to high-quality KMC services for maternal health in Ethiopia will be improved, leading to better outcomes for LBW babies and their mothers.

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