Care of preterm newborn, including kangaroo mother care

SARAH MOXON: Every year, there are an estimated 15 million preterm newborns. But these babies are born into four very different worlds. Approximately 11 million babies are born into high income countries. And of these babies, if they are born preterm, small, or sick, almost all of them will have access to high level intensive care if they should need it. On the right hand side of the figure, we see a world where 34 million babies are born in middle income countries and a further 40 million born in health facilities in low income countries. For many of these babies, care is not available if they are born early. And where care is available, the quality of care is often variable.

The fourth and largest world is the hidden world, where 50 million babies are born each year at home, many entering the world without any access to a health system, should they require it. Most of the information and resources that we have is focused on those 11 million babies born in high income countries. But some of the most rapid gains could be made to those babies born in facilities in low and middle income countries simply by improving the quality of care.

A recent study published in The Lancet Every Newborn series showed that 70% of preterm deaths could potentially be averted with facility-based supportive care or inpatient care that includes the following components– the provision of warmth, feeding support, safe oxygen therapy, the prevention and treatment of infections, effective phototherapy, and pain management. This requires a dedicated ward space, staffed by health workers with specialist training and skills. As we saw in the previous slide, most of the preterm babies born across the world currently do not have access to even this basic facility care. One of the simplest ways to deliver care to preterm newborns is an approach referred to as Kangaroo Mother Care.

Kangaroo Mother Care is a package of care for the preterm infant, where the infant is cared for in direct and continuous skin to skin contact with the mother in the kangaroo position, similar to a joey in a pouch, as you see in the picture in the right hand corner. Kangaroo Mother Care involves a number of components– firstly, thermal care; that is, the provision of warmth; support for the baby for exclusive breast milk feeding. Kangaroo babies will also need supportive care for infections and other complications, including supplemental oxygen and referral to a higher level of care when needed. Many kangaroo babies can be discharged early and continue to be held in the position at home, but will need careful followup.

There are multiple benefits to Kangaroo Mother Care. By reducing the need for expensive technologies, Kangaroo Mother Care has obvious application in low income settings and a growing evidence base. A study by Lawn and colleagues in 2010 demonstrated that Kangaroo Mother Care can reduce mortality in newborns weighing less than 2000 grammes by 51% when compared to conventional neonatal care. There is also strong evidence for reductions in infections, improved feeding and growth, mother-infant bonding, and long-term benefits for child development. Fundamentally, Kangaroo Mother Care empowers the mother as the main provider of care and contributes the overall humanisation of neonatal care.

Many neonatal units in high income countries are now adapting their approach to care for the preterm newborn to accommodate space for mothers to provide Kangaroo Mother Care. The figure in the next slide illustrates how care of preterm newborns fits into the health system overall and what the health system requirements are for each level of care.

At the top of the figure, we have basic newborn care– skilled birth attendants, especially trained midwives, are central to basic newborn care at birth. And every newborn baby needs a clean environment, warmth, and support for breastfeeding.

The second level shows the next level of care, where a baby that is born preterm may require more complex inpatient care in a dedicated ward with specially trained nursing and midwifery staff. Equipment is needed for the safe delivery of oxygen. Most preterm newborns will require feeding support to give expressed breast milk by nasogastric tube and some will also need intravenous fluids. This level of care requires support for prevention of infections and management of infections using antibiotics.

Kangaroo Mother Care is a cornerstone of this level of care and can be delivered prolonged and continuous as the mainstay of care. For stable babies, or delivered as tolerated, for less stable babies that may require more intensive supportive care. All mothers will require space and support to express breast milk and introduce breastfeeding. Kangaroo Mother Care is fundamental to this. The third level shows neonatal intensive care, which would be required for extremely premature and sick babies, for example, those born at less than 28 weeks, and will usually only be available in a tertiary level referral hospital, where advanced support, including ventilation and continuous positive airway pressure to support severe respiratory distress are available.

Such extremely premature babies will often require one on one nursing care.

Kangaroo Mother Care can still be provided for extremely sick and premature babies, usually intermittently. This is increasingly being used in high income countries to support their cognitive development and to support breast milk feeding and bonding. Most preterm newborns will require the middle level of care only, and this is where the focus for middle and lower income countries can make the most rapid and significant mortality reductions.

As part of the development of the Every Newborn action plan, the Every Newborn steering team carried out an analysis of health system bottlenecks, using a standard tool structured around seven health system building blocks. The tool is applied in 12 high burden countries in Africa and Asia, through a series of participatory workshops that engage country-level technical experts in maternal and newborn health to describe the bottlenecks or the factors hindering the scale-up of interventions for mothers and newborns. A detailed analysis of the bottlenecks helped us to identify priority actions for each of the interventions in the analysis, based on the most significant health system bottlenecks. Care of preterm newborns were explored in detail.

Based on the bottleneck analysis, the priority health system actions for care of preterm newborns fall into three health system building blocks– the health workforce, health financing, and community. Firstly, the health workforce– there is a real need for more staff, specially trained in the care of preterm and sick newborns and a critical human resource gap for a global neonatal nursing cadre, which should be given similar accreditation systems as midwifery. Currently, training programmes for neonatal nurses outside of high income countries are rare. Secondly, health financing– newborns are chronically neglected in national health budgets and an insurance plans. And out of pocket payments for a sick baby can be financially crippling for families.

This is not just the case in low income countries, but also in high income countries, where many families are reliant on health insurance plans. Finally, community ownership and partnership is fundamental. And this starts with a shift in attitude away from the fatalism that all small babies will inevitably die or become disabled. There’s a need for awareness of the needs of preterm newborns, in order to help create demand for quality care for preterm newborns that is family centred and includes Kangaroo Mother Care.

Central to the care of preterm newborns is empowering mothers to care for their vulnerable infants, starting with family centred care in the facility and support for discharge into the community. Vulnerable preterm survivors will require follow-up, including screening for disability and retinopathy of prematurity to support their physical and cognitive development. Critical to improving care of preterm newborns is better programme measurement of coverage and of quality.