Kangaroo Mother Care implementation research to develop models for accelerating scale-up in India and Ethiopia: study protocol for an adequacy evaluation

Abstract

IntroductionKangaroo Mother Care (KMC) is the practice of early, continuous and prolonged skin-to-skin contact between the mother and the baby with exclusive breastfeeding. Despite clear evidence of impact in improving survival and health outcomes among low birth weight infants, KMC coverage has remained low and implementation has been limited. Consequently, only a small fraction of newborns that could benefit from KMC receive it.Methods and analysisThis implementation research project aims to develop and evaluate district-level models for scaling up KMC in India and Ethiopia that can achieve high population coverage. The project includes formative research to identify barriers and contextual factors that affect implementation and utilisation of KMC and design scalable models to deliver KMC across the facility-community continuum. This will be followed by implementation and evaluation of these models in routine care settings, in an iterative fashion, with the aim of reaching a successful model for wider district, state and national-level scale-up. Implementation actions would happen at three levels: ‘pre-KMC facility’—to maximise the number of newborns getting to a facility that provides KMC; ‘KMC facility’—for initiation and maintenance of KMC; and ‘post-KMC facility’—for continuation of KMC at home. Stable infants with birth weight<2000 g and born in the catchment population of the study KMC facilities would form the eligible population. The primary outcome will be coverage of KMC in the preceding 24 hours and will be measured at discharge from the KMC facility and 7 days after hospital discharge.Ethics and disseminationEthics approval was obtained in all the project sites, and centrally by the Research Ethics Review Committee at the WHO. Results of the project will be submitted to a peer-reviewed journal for publication, in addition to national and global level dissemination.Study statusWHO approved protocol: V.4—12 May 2016—Protocol ID: ERC 2716. Study implementation beginning: April 2017. Study end: expected March 2019.Trial registration numberCommunity Empowerment Laboratory, Uttar Pradesh, India (NCT12286667); St John's National Academy of Health Sciences, Bangalore, India and Karnataka Health Promotion Trust, Bangalore, India (CTRI/2017/07/008988); Society for Applied Studies, Delhi (NCT03098069); Oromia, Ethiopia (NCT03419416); Amhara, SNNPR and Tigray, Ethiopia (NCT03506698).

Government‐led initiative increased the effective use of Kangaroo Mother Care in a region of North India

“…This study was based on the principles of implementation science and we used an iterative process and a mixed-method design to develop the final implementation model. 8,12 From 1 March 2018 to 28 February 2019, 26964 babies were born in the entire district, including in facilities and at home and 918 (3%) weighed <2000g at birth. Of these, 762 were eligible for KMC initiation and 662 (87%) were initiated (Table 1).…”

“…3 Kangaroo Mother Care (KMC) has been shown to reduce mortality, morbidity and the duration of hospital stays. [4][5][6][7] However, its coverage is very low in India, as in other countries, and implementing it remains a challenge.. [8][9][10][11] A multicountry study coordinated by the World Health Organization (WHO) was conducted in 7 sites in India and Ethiopia to scale up KMC in health facilities and after babies were discharged home. The WHO wanted to investigate a range of experiences from diverse contexts and identify lessons learnt across all of the sites.…”

Accelerated scale‐up of Kangaroo Mother Care: Evidence and experience from an implementation‐research initiative in south India

“…While the current health policy is supportive of KMC, implementation is hampered by the bottlenecks in health systems. 7,8 Often KMC is restricted to skin-to-skin care for a few minutes, and the recent evidence that supports prolonged or continuous KMC for newborns under 2000 g is yet to be internalised in facilities as well as in the community. Barriers exist in both public and private facilities, the latter of which are a major provider of services in India.…”

“…9,10 A lack of models that integrate a facility and community continuum, combined with poor monitoring, have limited the adoption of KMC across population settings. 8 Population coverage is also affected by the cultural and social barriers surrounding decision making and care preferences of people. [11][12][13][14] Implementation science, programme science and mixed-methods research can inform the design of interventions intended to be implemented at scale.…”

“…[11][12][13][14] Implementation science, programme science and mixed-methods research can inform the design of interventions intended to be implemented at scale. [14][15][16] As part of World Health Organization (WHO) funded initiative in India and Ethiopia, 8 we undertook implementation research to understand and address the barriers and facilitating factors to KMC uptake, in government facilities, private facilities and the community, in a high priority district (Koppal) of the south Indian state of Karnataka. Formative assessments that included qualitative inquiry led to the development, testing and fine-tuning of interventions and the implementation model.…”