Kangaroo mother care to prevent neonataldeaths due to preterm birth complicationsJoy E Lawn,1,2 Judith Mwansa-Kambafwile,1,3 Bernardo L Horta,4 Fernando C Barros4 andSimon Cousens5

1Saving Newborn Lives/Save the Children-USA, Cape Town, South Africa, 2Health Systems Strengthening Unit, Medical ResearchCouncil, Cape Town, South Africa, 3Department of Public Health, Faculty of Health Sciences, University of Cape Town, Cape Town,South Africa, 4Postgraduate Programme in Epidemiology, Universidade Federal de Pelotas, Pelotas, Brazil and 5Infectious DiseasesEpidemiology Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK.

Corresponding author. Saving Newborn Lives/Save the Children-USA, 11 South Way, Pinelands, Cape Town 7405, South Africa.E-mail: joylawn@yahoo.co.uk

Background Kangaroo mother care (KMC) includes thermal care through con-tinuous skin-to-skin contact, support for exclusive breastfeeding orother appropriate feeding, and early recognition/response to illness.Whilst increasingly accepted in both high- and low-income coun-tries, a Cochrane review (2003) did not find evidence of KMCsmortality benefit, and did not report neonatal-specific data.

Objectives The objectives of this study were to review the evidence, and esti-mate the effect of KMC on neonatal mortality due to complicationsof preterm birth.

Methods We conducted systematic reviews. Standardized abstraction tableswere used and study quality assessed by adapted GRADE method-ology. Meta-analyses were undertaken.

Results We identified 15 studies reporting mortality and/or morbidityoutcomes including nine randomized controlled trials (RCTs) andsix observational studies all from low- or middle-income settings.Except one, all were hospital-based and included only babies ofbirth-weight

Keywords Neonatal mortality, newborn care, preterm births, prematurity, lowbirthweight, Kangaroo Mother Care, Kangaroo Care, skin-to-skincare

BackgroundPreterm birth (

ObjectiveThis review aims to assess the effect on neonatal mor-tality from complications of preterm birth of KMCcompared to no care at all or compared to conven-tional care. A neonatal death in a baby with a birthweight of

Where studies only reported mortality for anothertime period (e.g. infant) we wrote to principal inves-tigators to request the neonatalspecific data. Giventhat most studies do not report cause specific mortal-ity, or even gestation-specific mortality, a birthweightlimit had to be defined as a surrogate. Based on birthweight and gestational age charts and on dataset withcause-specific mortality data by weight and gesta-tional age, a birth weight of 42000 g has previouslybeen defined by WHO as an acceptable equivalent forpreterm birth likely to be the major underlying causeof death.2 Studies of KMC which reported only weightgain, breastfeeding status or psycho-social outcomeswere not analysed here.

All studies meeting the inclusion criteria weredouble data abstracted into a standardized form. Weabstracted key variables with regard to the studyidentifiers and context, study design and limitations,intervention specifics, and outcome effects. Weassessed the quality of each of these studies using astandard approach developed by the Child HealthEpidemiology Reference Group (CHERG) based onan adaptation of the GRADE approach.12 For studieswhich reported mortality outcomes that were not neo-natal specific, we contacted the authors to request theneonatal specific data.

Analyses, and summary measuresWe planned a priori to conduct three meta-analyses,two for mortality outcomes (one with randomizedcontrolled trials (RCTs) as inputs and one with obser-vational studies), and one for morbidity outcomes(RCTs only). We also planned to undertake additionalsensitivity analysis to examine bias that may be intro-duced by excluding certain studies not meeting ourinclusion criteria. We conducted all meta-analysisusing STATA version 10.0 statistical software13 andreport the MantelHaenszel pooled relative risk (RR)and corresponding 95% confidence interval (CI).Heterogeneity between studies was summarizedusing the I2 statistic. If this statistic exceeded 10%then a random effects analysis was performed asopposed to fixed effects. We summarized the overallquality of evidence for each outcome and each datainput type using an adapted version of the GRADEprotocol table.12

ResultsOur searches identified 6127 titles (Figure 1).After initial screening of titles and abstracts wereviewed 524 papers for the outcomes of interest,including several in French, Spanish and Portuguese.We identified 15 studies of which nine studies8,1421

were either individually randomized (eight) or clusterrandomized trials (one),14 six were observationalstudies.2227 All the studies were from low ormiddle-income countriesColombia, Ethiopia,Ecuador, Ethiopia, Indonesia, Bangladesh, India,

Mexico and South Africa. None of the studies wereblinded, as this was not possible for KMC. Someof the studies only tracked pre-discharge mortality,but given the average length of stay of severalweeks and the fact that most deaths are in the firstfew days of life, this is unlikely to result in majorbias. The details of each study and quality assessmentusing GRADE are summarized in SupplementaryTable 1.

In all but one of the studies, the intervention wasonly offered to babies with birth weight

information.8,15 The Bangladesh community-basedKMC trial14 was excluded as discussed above.

Three studies, all from low/middle-income countries,were thus included in the final meta-analysis8,15,16

(Figure 2a). Only Charpaks study was in the previousCochrane mortality meta-analysis but in that analysisthe neonatal specific mortality data were notavailable. The studies were all of moderate or highquality. In our meta-analysis, KMC was associatedwith a major reduction in neonatal death for babies

was variably implemented in the different institutionsand data collection was through routine mortalityaudit. Two of the other studies had weight limits

DiscussionThis is the first meta-analysis presenting evidence ofthe mortality benefit of KMC. We report a largecause-specific decrease of 51% (95% CI 1871% reduc-tion) in neonatal deaths with birth weight of

pre-discharge mortality and did not cover the wholeneonatal period, giving rise to the possibility of anunder-estimation of post-discharge neonatal deaths.However there are also important potential biasesthat may result in an overestimation of effect size,notably the selection basis for starting KMC inthat only clinically stable preterm infants qualifyto start KMC hence this effect size may not be reflectthe reduction possible for all preterm deaths. Onlyone study specified a lower birth weight limit forstarting KMC (1000 g).27 It may be that in settingswith no medical care at all for the smallest babies,KMC may be better than nothingthis requires fur-ther evaluation.

Where as this review establishes a clear and majorimpact on neonatal mortality, many questions remainaround how to implement. Despite the high impactand apparent feasibility of KMC, few preterm babiesin low-income countries currently have access to thisintervention. No systematic data on global coverageare available. It appears that, in addition toColombia, a number of countries in Latin Americahave made progress in scaling up KMC.17,18 In Asiathere are many units now in Indonesia and some inIndia and Bangladesh but population coverageremains very low in these large countries. WithinAfrica, South Africa has multiple sites in almostevery province27,28 and has employed a low costmodel for lower levels in the health system whichdoes not require special units. Malawi has a numberof units but all at referral level.29 In most otherAfrican countries there are few if any units andthese are mainly in capital cities and their presencehas depended heavily on local champions to overcome

initial resistance. A few countries notably Malawi,29

Tanzania and Ghana now have plans in place to scaleup KMC to district hospital or even health centrelevel. To inform this process it is crucial to understandthe constraints to scale up. These constraints may bedue to lack of information about effectiveness, or isthere reluctance to change current practice even ifthere are multiple babies per incubator, or perhaps alack of trust in mothers and letting them onto neo-natal units? Is KMC seen as a poor country onlysolution? Formative work around these constraintsas well as analyses of cost and potential cost savingson nursing time and length of in-patient stay areneeded.

A priority research question concerns communityKMC. There is only one study examining KMC initi-ation at home, in a challenging setting in ruralBangladesh.14 This study demonstrated a substantialmortality benefit for babies

effective links to home after discharge. Given theinpatient stay of weeks or even months for very pre-term babies, early discharge with effective links to thehome would be of benefit to family and facility, buthow would this work in practice in weaker healthsystems and is there a risk of increasing mortalitypost-discharge?

ConclusionEvidence has been analysed from a number of RCTsand is consistent with a meta-analysis fromlarge-scale effectiveness evaluations. KMC has alarge effect on neonatal mortality and is also effectivein reducing morbidity. This evidence is sufficient torecommend the routine use of KMC in facilities for allstable babies

distant referral hospitals and understaffed and ill-equipped. If KMC were to reach high coverage throughimplementation at lower levels of the health system,the worlds annual one million neonatal deaths dueto preterm birth could be substantially reduced.

Supplementary dataSupplementary data are available at IJE online.

FundingBill & Melinda Gates Foundation (grant 43386) to theUS Fund for UNICEF to Promote evidence-baseddecision making in designing maternal, neonataland child health interventions in low- andmiddle-income countries; Save The Children USA

from the Bill & Melinda Gates Foundation (Grant50124) for Saving Newborn Lives. We also acknowl-edge the Global Alliance for Prevention of Prematurityand Stillbirths (http://www.gappsseattle.org).

AcknowledgementsWe are extremely grateful to Prof. Natalie Charpakand Prof. Rao Suman for sharing unpublished dataon neonatal-specific outcomes. We thank all membersof the Child Health Epidemiology Reference Group forhelpful comments and feedback on this work. We alsoacknowledge Rajiv Bahl of WHO and Abdullah Baquiof Johns Hopkins University, Baltimore, for insightfulreview of an earlier draft of this paper.

Conflict of interest: None declared.

KEY MESSAGES

KMC is a simple intervention to care for preterm newborns by tying the baby to the mothers front,providing thermal care through continuous skin to skin contact, increased breastfeeding, reducedinfections and early recognition of illness.

Previous reviews have not shown a significant mortality benefit, and included studies where theintervention started after 1 week of age (survival bias) and have combined varying mortality out-comes (predischarge, neonatal, 6 months and infant mortality). In addition several new studies havebeen published.

Our new meta-analysis of 3 RCTs shows major mortality reduction [51% (1871%)] for neonatalmortality in babies with birthweight

13 STATA/IC 10.1. Statistical Program. College Station, TX:STATA Corporation, 2008.

14 Sloan NL, Ahmed S, Mitra SN et al. Community-basedkangaroo mother care to prevent neonatal and infantmortality: a randomized, controlled cluster trial.Pediatrics 2008;121:e104759.

15 Suman RP, Udani R, Nanavati R. Kangaroo mother carefor low birthweight infants: a randomized controlled trial.Indian Pediatr 2008;45:1723.

16 Worku B, Kassie A. Kangaroo mother care: a randomizedcontrolled trial on effectiveness of early kangaroo mothercare for the low birthweight infants in Addis Ababa,Ethiopia. J Trop Pediatr 2005;51:937.

17 Sloan NL, Camacho LW, Rojas EP, Stern C. Kangaroomother method: randomised controlled trial of an alter-native method of care for stabilised low-birthweightinfants. Maternidad Isidro Ayora Study Team. Lancet1994;344:78285.

18 Cattaneo A, Davanzo R, Worku B et al. Kangaroo mothercare for low birthweight infants: a randomized controlledtrial in different settings. Acta Paediatrica 1998;87:97685.

19 Udani. Innovation: KEM Kangaroo Bag - For KangarooMother Care. R. http://kangaroo.javeriana.edu.co/encuen-tros/7encuentro/posters/Rekha%20Udani%204.pdf(September 2009, date last accessed).

20 Ramanathan K, Paul VK, Deorari AK, Taneja U,George G. Kangaroo Mother Care in very low birthweightinfants. Indian J Pediatr 2001;68:101923.

21 Roberts KL, Paynter C, McEwan B. A comparison of kan-garoo mother care and conventional cuddling care.Neonatal Netw 2000;19:3135.

22 Charpak N, Ruiz Pelaez JG, Charpak Y. Rey-Martinez.Kangaroo mother program: an alternative way of caringfor low birthweight infants? One year mortality in a twocohort study. Pediatrics 1994;94:80410.

23 Kambarami RA, Chidede O, Kowo DT. Kangaroo careversus incubator care in the management of wellpreterm infants. A pilot study. Ann Trop Paediatr 1998;18:8186.

24 Chwo MJ, Anderson GC, Good M, Dowling DA,Shiau SH, Chu DM. A randomized controlled trial ofearly kangaroo care for preterm infants: effects on tem-perature, weight, behavior, and acuity. J Nurs Res 2002;10:12942.

25 Lincetto O, Nazir AI, Cattaneo A. Kangaroomother care with limited resources. J Trop Pediatr 2000;46:29395.

26 Rodrigues MAG, Cano MAT. Estudo do ganho de peso eduracao da internacao do recem-nascido pre-termo debaixo peso com a utilizacao do metodo canguru. RevistaEletronica de Enfermagem 2006;8:18591.

27 Pattinson RC, Bergh A-M, Malan AF, Prinsloo R. Doeskangaroo mother care save lives? J Trop Pediatr 2006;52:43841.

28 Bergh AM, Arsalo I, Malan AF, Patrick M,Pattinson RC, Phillips N. Measuring implementationprogress in kangaroo mother care. Acta Paediatr 2005;94:11028.

29 Bergh AM, van Rooyen E, Lawn J, Zimba E, Ligowe R,Chiunda G. Retrospective Evaluation of KMC in Malawi.Malawi Save the Children Country Office: MRC SouthAfrica and University of Pretoria, 2007.

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