Scaling a lifesaving intervention: Skin-to-skin for mothers and babies

Babies born prematurely often need help with temperature regulation, something their little bodies cannot do on their own. Typically, these infants go into incubators.

But mothers have a natural way of helping their babies regulate their temperatures by holding them skin-to-skin and exclusively breastfeeding, when possible. It’s known as kangaroo mother care, or KMC. In fact, data suggests that when a mother holds twins on her chest, the breasts can respond independently depending on the infants’ thermal needs.

Low birthweight and preterm births are the leading causes of death among children under the age of 5, and a growing body of evidence suggests that KMC can save more lives than traditional incubator care.

KMC is still innovative decades after it was first pioneered in Colombia in 1978 “because it’s a very big change of practice,” according to Nathalie Charpak, the founder and director of the Fundación Canguro Colombia, which advises countries around the world on the practice. “It’s so complicated to implement, to change medical practice, that it’s still an innovation.”

Efforts are underway to scale up KMC. In Cameroon, the KMC Development Impact Bond, or DIB, highlights the role that innovative financing can play. And the World Health Organization is exploring models to increase the adoption of KMC, beginning in India and Ethiopia.

The COVID-19 pandemic led to massive disruptions to small and sick newborn care, with more than half of neonatal health care providers surveyed from across 62 countries reporting that KMC was discontinued or discouraged. Now, these examples demonstrate how to accelerate the spread of this practice even in the most difficult circumstances.

The first pay-for-results model for KMC

Cameroon, where 20,000 newborn babies die every year because they are born before term or with low birth weight, is home to the first — and so far only — DIB for KMC.

In a DIB, an investor provides upfront capital for an intervention that is implemented by one or more service providers. If the program achieves the results that were agreed upon in advance, then the outcome funders pay the investor based on how well the intervention worked.

In this case, Grand Challenges Canada provided $800,000 for work implemented by Fondation Kangourou Cameroun.

Program delivery for the Cameroon KMC DIB began in 2019 and concluded in September. The Cameroon Ministry of Public Health and Nutrition International paid $2.43 million, with the ministry using funding from the Global Financing Facility for Women, Children and Adolescents, a trust fund housed at the World Bank, to cover 80% of its outcome payments.

The DIB funded improvements to hospital facilities, including access to clean water and toilets, refrigerators to store breast milk, and chairs where mothers could sit with their babies in the KMC position. It also funded a train-the-trainer approach, which proved critical given the high turnover of clinical staff.

Hortance Manjo, country program director for Fondation Kangourou Cameroun, spoke with Devex from Garoua, a port city in the northern region of Cameroon.

The area is more conservative than other parts of the country. So when women were asked to hold their babies skin-to-skin, “having fathers or brothers in the room, or other males in the room, made the mothers uncomfortable,” she said. Fondation Kangourou Cameroun ensured that mothers had access to cloths to cover their chests, made from materials that were thin enough to ensure they do not overheat during the hot season in Garoua.

Despite the challenges posed by COVID-19, the program met, and in some cases exceeded, its goals, according to independently verified results. Ten hospitals were equipped to deliver KMC, 47 doctors and nurses were trained to deliver it, 121 community health workers were trained to support KMC hospital transfers, and 1,221 babies received quality KMC in program hospitals, according to a project report released last month.

Evidence of value of earlier KMC

In the early weeks and months of the COVID-19 pandemic, fear, uncertainty, and confusion dictated how many neonatal intensive care units responded, Charpak said. But after the initial lockdowns, decision making was increasingly based on evidence that the benefits of KMC far outweighed the risks of COVID-19.

And the latest evidence suggests that KMC should start immediately after birth, not just once a baby becomes stable, Charpak added.

A study conducted in Ghana, India, Malawi, Nigeria, Tanzania came to a premature end because the data and safety monitoring board felt it would be unethical to continue the research given the compelling evidence of the benefits of immediate KMC. WHO is expected to release new guidelines based on this evidence later this year, Charpak said.

But the global health community should be mindful of how complicated protocols of standardization can stand in the way of KMC scale-up, said Dr. Zulfiqar A. Bhutta, founding director of the Center of Excellence in Women and Child Health at the Aga Khan University.

“Had the KMC community not been so focused on it’s either my way or the highway, this would have rolled out much faster,” he said. “We didn’t even start community-based KMC for almost a decade because we wanted to start in the facilities.”

KMC would have scaled more quickly in more places if it started in the community, Bhutta said, referencing a randomized control trial in Pakistan on the effectiveness of community KMC over standard essential newborn care.

A model to scale up KMC globally

Before the COVID-19 pandemic, Ethiopia and India participated in a WHO-coordinated study on models to scale up KMC to more than 80% coverage in select districts of Ethiopia and India.

While the results have yet to be published, Dr. Suman Rao, a WHO consultant on KMC and professor of neonatology at St. John’s Medical College in Bangalore, India, said the work yielded a few important lessons.

One is the centrality of the conviction of the health force to promote and sustain KMC. Another is the importance of investing in infrastructure, particularly as new research on the benefits of immediate KMC before stabilization suggests the value of mother and newborn intensive care units where babies can get intensive care in the KMC position. The researchers also saw how critical it is for mothers to feel they are members of the team in managing their babies’ care.

When the second wave of COVID-19 hit India in March 2021, neonatal care saw many complications, with mothers who tested positive for COVID-19 unable to enter neonatal ICUs.

“But the fear factor, which was there in the first wave, was far lower in the second wave,” Rao said. “The knee-jerk reaction of separating mother and baby was not there.”

In addition to the challenges posed by COVID-19, some of the challenges in financing KMC include keeping babies in the hospital until discharge is medically appropriate in facilities where neonatal care is not free for patients and compensating mothers or families for the loss of income resulting from extended stays in the hospital, Rao said.

While innovating financing mechanisms could drive more investment into KMC, Bhutta emphasized the need for government investment, saying KMC is sufficiently informed by evidence that it’s time for the practice to go from project mode to the mainstream.