The challenging road to sustainable kangaroo mother care practice and service: reflections from a South African health district

Abstract

Background

Kangaroo mother care (KMC) was introduced in the Tshwane Health District in South Africa in 1999. After more than two decades of the expansion of KMC services, we describe the KMC implementation trajectory in the district.

Methods

A group of district clinical specialists, clinicians and academics involved in KMC implementation wrote a reflection on the status of KMC in Tshwane District and lessons for sustaining KMC services and practice.

Results

The KMC implementation trajectory is described according to three phases: (1) a slow start (1999–2012); (2) consolidation (2012–2023); and (3) sustaining KMC beyond the COVID-19 pandemic. The Tshwane KMC programme activities are interpreted using a 10-component model for scaling up care for small and/or sick newborns at the district level. Major lessons for the sustainability of KMC practice and service include embedding system-wide supportive supervision in the health system’s budget, encouraging multidisciplinary teamwork, conducting regular KMC refresher activities, and working on improving data to enable meaningful action.

Conclusion

Despite great strides in KMC implementation and ongoing services in the Tshwane Health District, the road to continued sustainability remains challenging.

Introduction

Kangaroo mother care (KMC) is a care package for preterm and low birth weight (LBW) infants that originated in Colombia in the 1970s. KMC entails continuous and prolonged skin-to-skin contact between the newborn and the mother or parent, complemented by support for exclusive breastfeeding and/or breastmilk feeding. Another feature of facility-based KMC is timely discharge and regular follow-up [1, 2].

Over the past 15 years, increasing evidence has confirmed that KMC is a high-impact, safe, effective and beneficial method of caring for preterm and LBW infants in low- and high-resourced settings [3,4,5,6,7,8,9,10]. A 20-year follow-up study found that the positive effects of KMC were still evident in adolescents who had received KMC [11]. More recent studies also showed that KMC immediately after birth, even in unstable babies, improved survival in babies weighing 1.0–1.7999 kg by 25% [12]. The World Health Organization’s (WHO) 2023 position paper “calls on the global maternal, newborn and child health community, countries’ political and programmatic leadership, and families to support KMC as the foundation of small and/or sick newborn care in all settings” [1]. The current WHO recommendation states that “[k]angaroo mother care … for preterm or low-birth-weight infants should be started as soon as possible after birth” [13]. Since the inception of the Every Newborn Action Plan in 2014 [14], many low- and middle-income countries have initiated programmes to implement and scale up KMC services. Still, there is insufficient information on coverage and quality of care [15]. One of the more ambitious studies concerned the implementation of KMC in seven states in Ethiopia and India, where the continuation of services was transferred to the state health authorities at the end of the project [16]. The WHO also published a generic implementation strategy for KMC scale-up in 2023 [17].

This paper describes the trajectory of facility-based KMC implementation in the Tshwane Health District in Gauteng Province in South Africa. The authors – academics, clinicians and district clinical specialists – reflected together on the lessons learned about sustaining KMC services and practices in the district.

Tshwane District serves just over four million people (2022 census) [18] and includes Pretoria, the country’s capital. The nine public sector hospitals in Tshwane District include two central academic hospitals providing specialty and sub-specialty care (levels III and IV care), one provincial tertiary hospital (level III care), one regional hospital (levels II and III care) and five (sub)district hospitals (levels I and II care). The levels of care in the regional and district hospitals vary according to capacity and provider skill mix, and a referral system is in place. Nationally, all public hospitals with a maternity service are expected to have institutionalised KMC facilities, although coverage is incomplete [19].

History of KMC implementation in Tshwane District

First phase of implementation (1999–2012) – a slow start

The implementation of KMC in Tshwane District dates back to 1999 when the first KMC unit in Gauteng Province was opened at Kalafong Provincial Tertiary Hospital (KPTH) in Pretoria [20]. Outreaches to sensitise and train health care professionals in KMC were undertaken from KPTH to other hospitals in the district at various times. Between 2000 and 2002, training workshops were presented to participants from 15 other hospitals in the province. Six of these managed to implement KMC [21]. Training activities were then incorporated into the Fara Ngwana KMC initiative, which also covered mentoring and assessment visits to all the hospitals in Gauteng Province from 2003 to 2007 [22].

Nationally, KMC had also made its way into the Tshwane declaration of support for breastfeeding in South Africa and maternal and newborn policy frameworks in South Africa [23, 24] by 2012, with service guidelines proposed by the South African Initiative for Newborn Care [25].

Second phase of implementation (2012–2023) – consolidation

With establishing the Tshwane District Clinical Specialist Team (DCST) in 2012, the team assumed responsibility for KMC implementation, monitoring and supervision to help improve the quality of care and district-level health outcomes for mothers, newborns and children [26]. In 2013/4, the team embarked on a quality improvement initiative to implement KMC services in hospitals without KMC and strengthen service provision in hospitals with KMC programmes. Multidisciplinary teams from all hospitals were brought together at KPTH to report on the state of their KMC practice and services and to receive in-service training. Two more such workshops were organised, each time at a different hospital, so that hospitals could learn from each other and benchmark their practice. This was followed by a walk-through support visit to each hospital that included an assessment of the progress of facility-based KMC implementation [27, 28].

Over the next ten years, the DCST continued its supervisory function and engaged some ward-based outreach teams (community health workers) to promote KMC in the community. During this period, gaps in the quality of KMC service provision were observed, which were exacerbated by high staff turnovers and a large number of retirements, along with the coronavirus pandemic. The KMC unit in one of the district hospitals was even closed and converted into a general COVID-19 ward [29]. As a result of the DCST’s advocacy, this unit was re-opened in August 2022.

Third phase of implementation – sustaining KMC beyond COVID-19

As service provision started normalising after the coronavirus pandemic, the team reflected on current KMC services available and facilitators and barriers promoting or hindering sustainable services. In July 2023, the DCST conducted four KMC refresher workshops with neonatal staff from all nine public hospitals. Hospitals also reported on the state of KMC at their hospital and on achievements, strengths and challenges since 2013. Eight hospitals provided some form of KMC service (intermittent and/or continuous), whereas seven hospitals had designated KMC units where continuous KMC was practised. A district hospital added to the district after boundary demarcation in 2011 [30] was not providing any KMC service by 2023. One academic hospital only provided intermittent KMC due to space constraints and used the adjacent district hospital (not practising intermittent KMC) as the step-down facility for continuous KMC.

The location of the KMC units depended on the space available in each hospital. It could be inside the neonatal unit, adjacent to it, or in a separate building with its own staff component. Tertiary beds for continuous KMC have not increased since 2013 (45 beds). The regional hospital beds increased from 5 to 8, and the district hospital beds from 20 to 31.

In district hospitals, medical officers are shared across departments at night. Some hospitals with continuous KMC have nurses dedicated to KMC; some district hospitals also rotate nurses annually. The following cadres of allied health care professionals are involved in KMC services, either as routine or on a referral basis: dieticians, occupational therapists, speech-language therapists, physiotherapists, audiologists, psychologists, and social workers. In Tshwane District, follow-up of preterm and LBW infants is covered by paediatric outpatient departments and dedicated KMC clinics. Follow-up visits gradually decrease in frequency.

Hospitals providing continuous KMC use special KMC records and a discharge form, whereas some also use a special statistics form. We do not have information on the quality of the data recording. Reliable KMC data are, however, scarce, and there is no standardisation of the data collected. KMC has yet to be included in the province’s District Health Information System (DHIS).

Lessons for the sustainability of KMC practice and service

According to the KMC progress-monitoring model used in the previous outreaches in Tshwane District, institutionalisation of KMC requires integration into routine preterm and LBW care practices and a demonstration of elements of sustained practice (data available on KMC practice; evidence of continuous staff development) [22, 27, 31]. In a systematic review, Lennox et al. identified “continued programme activities” as a definition of sustainability in 86% of the literature [32]. When KMC implementation is driven by a limited-period project with additional funding and/or by an individual medical professional, the service often declines when the project ends, or the champion leaves [33, 34]. After a slow start in the first decade of the millennium, KMC programmes continued in Tshwane District. Hospitals have been able to integrate KMC into neonatal services as a routine practice over the past decade. Table 1 categorises the KMC programme activities in the Tshwane Health District according to a model proposed by a WHO-UNICEF consultation that incorporates the content of care for small and/or sick newborns, as well as the 10 components for scaling up this care at the district level [35].

[IMAGE OMITTED: SEE PDF]

Below, we describe some important lessons for sustaining KMC services that may also be relevant to other health districts in South Africa and other countries struggling to keep the quality of their KMC services on track.

System-wide supportive supervision embedded in the budget of the health system

Supportive supervision takes on different forms. The paediatric pair (paediatrician + neonatal nurse) in the DCST are the champions responsible for monitoring and supervising KMC implementation, inter alia through regular supervisory visits, onsite mentoring, training in the management of small and sick newborns, and regular reporting on and monitoring of KMC services. KMC work is also included in their performance appraisal. Furthermore, the pair are supported by the maternal pair (obstetrician + advanced midwife) and the primary health care (PHC) pair (family physician + PHC nurse) [34].

As part of continuous quality improvement, tertiary and regional hospitals must do outreach to district hospitals to share knowledge and skills to improve the quality of care at these hospitals. Online applications such as WhatsApp groups are also used to share knowledge and experience and ask for treatment guidance.

Continued supervision is essential to support established KMC units in improving and expanding their services. Since large-scale space reconfiguration is currently not feasible for implementing immediate continuous KMC, including having mothers’ beds in the neonatal unit [12, 13], the focus should be on strengthening intermittent KMC and initiating it earlier. Regular review of bed utilisation of the KMC units in a district could identify trends and ensure that beds are utilised effectively and equitably.

Multidisciplinary teamwork

Involving a variety of health professions and other health cadres in contributing to the care and support of KMC babies and their mothers has been part of KMC services in Tshwane District since 1999. Workshop invitations to hospitals and other KMC-related activities always contain a request to send a multidisciplinary team that includes not only doctors and nurses, but also dieticians, occupational therapists and other allied health workers. Initially, psychologists and speech-language therapists were not appointed at all the hospitals, but they have recently been included. Speech-language therapists play a pivotal role in assisting mothers with applying swallowing and feeding activation techniques to establish successful breastfeeding [36]. When a particular cadre of health worker is unavailable, task shifting is encouraged to involve other allied professionals to take over some care tasks. For example, in the absence of a psychologist, social workers are involved in counselling mothers with some of their psychological problems. Physiotherapists and nurses stand in for occupational therapists in demonstrating to mothers how to handle their small babies. With the necessary training, nurses, dieticians and occupational therapists could also assist mothers in applying a feeding activation intervention [36], which speech-language therapists usually perform.

Regular KMC refresher activities

Due to nursing staff rotations and migrations (retirements or transfers), new staff members do not necessarily have sufficient background in KMC, for example, in certain feeding practices and special skills like correctly securing the small newborn in the KMC position. KMC is included in other regular in-service training programmes, such as the Management of Small and Sick Newborns. The DCST monitors KMC as part of its supervisory and mentoring functions. It is advisable to hold regular, district-wide, multidisciplinary KMC refresher sessions every 2–3 years to update health professionals on the latest developments in KMC research and practice and for colleagues from different hospitals to learn from each other. This should be combined with strengthening onsite mentoring activities to reinforce the maximum preservation of clinical knowledge, skills and behaviour.

Hospitals should ensure that their in-service programmes are more systematic, including KMC topics regularly and keeping attendance registers. It is particularly challenging to motivate medical officers to attend KMC training. Many of them are junior doctors who rotate every few months. One option for improving in-service coverage is to accredit KMC topics as part of doctors’ compulsory continuous professional development activities, to identify specific doctors for further training in newborn care, and to include KMC on the agenda of morbidity and mortality review meetings.

Data for action

The availability of quality data for KMC and using existing data for planning and quality improvement deserve more attention to ensure the continued improvement and sustainability of KMC services. This should include identifying indicators for which routine data should be reported at district and facility level, even if all those indicators are not included in the DHIS [37]. Unavailability and poor information quality were also barriers in a KMC bottleneck analysis in 12 low- and middle-income countries [34]. When standard KMC indicator definitions are missing from the DHIS and health management information systems [38], proper recording is often overlooked, with limited interest and/or expertise to collect and utilise KMC data [33]. Additionally, developing indicators that accurately capture the different components of KMC is challenging [38].

Conclusion

Expanding KMC services has become increasingly important due to ever-stronger research evidence of its positive impact on improved neonatal outcomes. With the current global drive towards KMC implementation and scale-up, longitudinal case studies from elsewhere may enhance the understanding of what is needed to sustain KMC services. Although great strides have been made in KMC implementation in the Tshwane District, our descriptions highlighted the challenging road to continued sustainability. We also illustrated the value of a district-based team, like the DCST, as a formal operational unit for quality improvement of KMC services, system-wide supportive supervision, and regular workshops in a district.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

DCST:

District Clinical Specialist Team

DHIS:

District Health Information System

kg:

Kilogram

KMC:

Kangaroo mother care

KPTH:

Kalafong Provincial Tertiary Hospital

LBW:

Low birth weight

WHO:

World Health Organization

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