Transcript Document

Kangaroo Mother Care Method
Quality Management and Quality Control
Difficulties and Resistances to the KMC
Implementation
TRAINING MANUAL
Module 7
Monitoring & Quality Management
in KMCP
The Kangaroo Mother Care method is implemented
in the context of care provided in a Kangaroo
Mother Care Program
• A KMC program needs monitoring to insure quality
of care and continuous improvement
• Monitoring and controlling the quality of care offered
in a KMC program must be adjusted to the particular
characteristics of each institution or region
Administrative Requirements & Benefits
of KMCP
The program must be supported by the institution’s administrators
• Parents must be included in the care model of their child, as an
essential part of the social and emotional setting where the child
must eventually go
– In-hospital KMCP must facilitate parents to be with their infant for
as long as possible, ideally 24 hours a day
• Early discharge for preterm and /or LBW infants to outpatient
care decreases hospital stay leading to less nosocomial infection
− Worldwide KMC’ implementation in Intensive and Intermediate
Care reduces the duration of hospitalization by 10 days an average
• The cost of hospital stay per day varies according to the type of
hospitalization: Intensive care unit, intermediate , basic care unit
or mother -newborn rooming -in
− Children hospitalized in Intensive Care kept in KP become stable
sooner, they are growing faster , then transferred earlier to cheaper
Intermediate Care
Human Resources for in Hospital’ KMC
Implementation
Full time staff: A nurse with at least one year experience
in newborns care and breastfeeding
On call staff
• A pediatrician part or not of NICU but must have work
experience in handling newborns and training in KMC
• A psychologist ideally part of the institution’s staff, having
experience in child or pediatric psychology and training in the
KMC
• Social worker, ophthalmologist, physical therapist ideally part
of the institution’s staff, having experience in newborn care
• All OB/GYN and midwifes part of the institution’s staff must be
aware of and follow the KMC.
Requirements for Hospital’ KMC
Implementation -1
Physical setting requirements in a neonatal unit
• In a neonatal care unit KMC adaptation takes place by each
child’s incubator, or in an in-hospital adaptation area, within
the NCU or next to it if existing
• The following items must be available in this area:
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A sink with water, soap, towel
An accessible toilet
A locker with keys for storing the family’s belongings
A desk with a cabinet file, which may be shared
Medical equipment required in a Neonatal Unit
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Gauged oxygen and air supply sources with neonatal flow meters
Pulse oxymeters , monitors for vital signs
Digital scales, height board , millimeter tape measurer
Audiovisual aid equipment (DVD, video projector, screen, white
board, among others)
Requirements for Hospital ’KMC
Implementation-2
Furniture and supplies
For each child participating of in-hospital KMCP
• A chair with back support and arm rest and foot rest , placed next
to the incubator, or in the kangaroo adaptation area.
• A breast feeding pillow
• Available Kangaroo support systems (girdles, etc)
• Gowns with frontal opening for caregivers
and
• Clinical histories and cards (carnet)
• Teaching aides (bulletin boards, displays, portfolios and educational
leaflets)
• Paper for printing formats and training materials
Outpatient KMCP-1
KMCP’ activities guarantee the systematic and uninterrupted monitoring of
the growth, nutrition and neurological, psychomotor and sensory
development of the preterm/LBW infant
– This is done during the every visit of the child to outpatient KMP until at
least 1 year of age
Preferably, the outpatient KMCP should be assumed as a separate cost unit
– The cost of administrative operation should be determined , making it a
self-sufficient and cost-effective unit.
Requirements for physical setting
• A room for group consultation to conduct the KMC consultation, to hold
patients waiting , to hold training/ educational sessions, observations,
archive and management of emergencies in children <1 year of age
• Individual area: a private office for individual activities ( nursing, social
work and psychology) and to conduct ophthalmology and optometry
exams
• Area for kangaroo adaptation activities
• Sink with soap and towels
• Diaper change area for use with the outpatient KMCP patients
• Fully accessible bathroom facilities
Outpatient Staff -2
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Pediatrician or MD trained and certified in KMC Method his work time depend of
the number of children
Nurse trained and certified in KMC Method with proven experience in management
of newborns. Full-time to ensure all training, in-hospital adaptation and consultation
Actions may be divided in morning and afternoon shifts as needed.
Assistant nurse trained and certified in KMC Method with proven experience in
management of newborns , full-time
Psychologist with proven pediatrics experience, trained in the KMC Method,
handling emotional and behavioral parents in crisis and experienced in neuro
psychomotor development tests. Full time or part time depending of workload
Speech/hearing pathologist, experienced in management of auditory evoked
potentials (AEP), and impedanceometry in infants
Optometrist trained in assessment of refractive disorders in infants < 1 year old
Physical therapist experienced in pediatrics, particularly infants and in newborns
stimulation
Occupational therapist experienced in pediatrics, particularly in infants.
Ophthalmologist trained in detection of retinopathy of preterm infants
Equipment & Supplies for Outpatient KMCP
Medical equipment:
• oxygen supplies and pulse oxymeter
• Equipment for sense organs exams
• Thermometer
• Neonatal and pediatric stethoscope
• Ambu-bag, appropriate laryngoscope and endotracheal tubes
• Appropriate suction equipment for preterm infant
• digital scales, metric measuring tape, height board
General supplies for the Outpatient Care Area
• Cleaning supplies
• Supplies for the Kangaroo Adaptation Area
– A chair for breastfeeding (with back support, arm & foot rest)
– Breastfeeding pillows
– Kangaroo girdles/ support system
Audiovisual and educational material
• Ideally a screen to show video during training
• Display bulletin boards, portfolios, leaflets on the kangaroo position, the danger
signs , the proper handling of ambulatory oxygen equipment, and breastfeeding
Quality of Health Care
Donabedian's Quality Framework: structure, process and
outcome : To measure quality in health care Donabedian
proposes to consider 3 elements of health care:
• Structure: physical and organizational aspects of care settings
(facilities, equipment, personnel, operational and financial
processes supporting medical care)
• Processes: activities carried out by the members of the
structure, to provide the products and services that make up
health care
• Resulting outcomes: a change in the current or future health
status of a patient, which can be attributed to the antecedent
health care.
Definitions in Quality of Care
Quality in health care: levels of excellence of a health service/ health care,
compared with accepted quality standards
Quality assurance : a program of monitoring and assessment of the different
aspects of a project/service, to ensure that the quality standards are satisfied
Quality assurance in health care : activities/programs assuring or improving the
quality of care, in a medical scenario or in a program including:
• The assessment of the quality of care and the identification of problems/
defects in the care supplied to overcome shortcomings found and the follow
and monitoring required, guaranteeing the effectiveness adapted measures
Quality indicators in health care ; norms, criteria, standards, direct qualitative
and quantitative measurement used in determined the quality of health care
Standards and guidelines provide the quality environment in which activities and
processes must move around; they also define the limitations imposed by
regulatory entities
Health outcomes (results) : effects of health care measured by the health state
achieved, the individual’s satisfaction, the preservation or restoration of his
function and his survival. outcomes are the effects of these processes and
products: a solution for a health issue, healing, relief and restitution of function
Cost results are the economic consequences of choosing a particular action
(diagnostic, preventive or therapeutic.
Elements for Quality Assurance in a KMCP
Quality improvement in health care: is a continuous process to identify problems in health
care, to propose solutions and to monitor these solutions in a regular and systematic way
The concepts of assurance and quality improvement are similar and complement each
other
Quality control: is a group of activities to assure adequate quality in products such as
manufactured goods it may also be applied to health care actions.
It includes all aspects of the production and delivery processes of the product/service , to
find defects is commonly emphasized
Distal – proximal continuum : is the description of the gradual movement along a health
status continuum
− The more proximal outcomes describe clinical indicators of illness, based on objective
(signs and data) and subjective (symptoms) information.
– The more distal outcomes describe the wider areas of mobility and independence,
functionality and performance in individual, work, family and social roles, finally,
satisfaction with life.
Risk adjustment is a way to remove/ control/reduce the effects of confounding factors where
the subjects of study are not randomly assigned to different treatments. Key confounding
factors are those related to the outcomes of interest
How to Use the Quality Assurance Tools
The use of the tools is based on the following strategies:.
a) Reactive : When faced with an unfavorable, unexpected
outcome, or atypical use of resources, a revision of the structure
and process is made in order to explain the phenomenon and
determine accountability.
• This reactive vigilance is commonly known as auditing
• From the reactive perspective, not only are unfavorable outcomes and
deaths routinely revised, but there are also investigations triggered by
specific complaints.
b) Preventive (proactive) : Specific and planned information is
systematically gathered for management monitoring and control.
• Such information is periodically analyzed and offers feedback to the
different actors responsible for all aspects of the Program.
• It is used to identify potential problems and to make performance
adjustments.
Processes Carried out to Implement the
KMC Method
The KMC method targets all preterm children below 37 weeks and/or
less than 2500g (international classification of low birth weight children).
– These children must be placed, at least, in a 2nd level institution,
with a Neonatal Unit
– If a preterm/ LBW infant is born in a 1st level institution, he must
be transferred to a Neonatal Unit, ideally in kangaroo position
• 1st level staff will need to receive training on proper transfer
and initial care
A protocol need to be established and adopted by the consensus of the
staff from the Neonatal Unit before implementing the KMC method
KMC P needs the support of the administration
It is necessary to sensitize and train OB/GYN and midwifes in the
delivery and emergency departments , according to the protocols that
each institution establishes for implementing the KMCP
In-Hospital Adaptation Processes
The in-hospital adaptation process first identify infants eligible for the KMCP and then
starts the adaptation
Who does it? A professional nurse, in cooperation with a psychologist
Where is it done? In delivery department , in rooming in accommodation , in the
neonatal unit.
What information does the mother receive? The team including a pediatrician explain
to the mother the risks of prematurity and the benefits of KMC
– The team will answer to the mother’s questions and address her doubts and
concerns and asks her to sign an informed a consent form
How is it conducted? It will be conducted individually or in groups
Where does it start? Each hospital must decide, according to its protocol where the inhospital adaptation process will begin in the delivery department , in rooming in
accommodation , in the neonatal unit or later
How does it begin? The decision to place a baby in KP is made by the pediatrician and
his team , they will decide of the length of session in KP
How is the baby fed? According to the KMC with the mother milk directly or using
extracted milk
In-Hospital Discharge processes
• Assess the successful completion of adaptation to the kangaroo position
– The baby regulates his temperature and gains weight since at least 2 days
• Assess the successful adaptation to the kangaroo nutrition
– The baby is able to suck-swallow and breath in a coordinate manner
– The mother knows how to breastfeed and to extract her milk
– The mother knows to use the alternative feeding method
• The mother and the family agree to come for follow up visit, including one the
day after discharge
– Suggest having a rooming-in facility for mothers who are difficult to monitor
• At discharge, the patient must carry a hospitalization epicrisis, with pertinent
data for subsequent outpatient management.
– This must be completed by the pediatrician, who will also decide whether to
prescribe medications or not.
– He or she must also complete the consent for transfer to the KMP.
• If transfer to a KMP in a different institution is required, it is handled as a
referral process.
Processes of FOLLOW UP to 40 WEEKS
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At admittance, assess if the mother is holding the baby correctly in KP
The KMCP team of professionals complete the clinical history
– Note both chronological and corrected ages
A nurse assesses and reinforces the correct use of the KMC method
A pediatrician conducts a complete physical assessment including anthropometric measurements
If the baby is using oxygen, a dynamic oxymetry will be taken
Recommendations and a plan of action will be made:
– Nutrition: outpatient kangaroo nutrition protocol
– Drugs: evidence based drugs designed for each program
• Compliance will be verified.
– Routine screening of all preterm babies by an ophthalmologist and routine head ultrasound
– Daily assessment by a pediatrician and a nurse until a weight gain of 15mg/kg/day is
achieved.
• These controls will become weekly until the 40thweek.
• Emergency care available until the 40thweek.
– Neurological evaluation based on Dr. Amiel -Tison, by a trained pediatrician .
– Psychological support for the mother and/or the family; group workshops.
– Instruction in child care, information leaflets on infant stimulation.
– Immunization at appropriate chronological ages.
Processes of FOLLOW UP from 40 WEEKS
to 1 Year of Correct Age
Complete physical assessment by the pediatrician every six weeks for the first
six months and every three months until the child is 12 to 18 months:
– Strict monitoring of the somatic growth curves
– Monitoring of the neurological and psychomotor development
– Optometry and audiology screening
– Assessment for hip dysplasia
– Immunization (preferably inactivated poliovirus and a-cellular pertussis)
– Assessment of infectious morbidity during follow up
– Health education
– Psychological support or workshops, according to each case
• Under certain circumstances such as BPD, ostomy, heart disease,
neurological dysfunction or low weight, these visits will be scheduled as the
child’s health state requires
In-Hospital Quality Indicators of a KMCP- 1
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“Initial dropout”:
– Recruited but not admitted. “Recruitment” index: number of patients that arrive to the
outpatient KMCP over the number of eligible patients discharged from a NCIU or an insurance
company.
– Ideal: 100%
– Accepted maximum: 100% of children weighing < 1800g or below 34 weeks of GA at birth
“Initial delay in admittance”:
– Number of patients admitted into the KMP after the first 48 hours after discharge, over the
number of patients referred to the KMCP.
– Ideal: 0%
– Accepted maximum :0%; no ‘kangaroo’ baby will be discharged in KP if no outpatient follow up
has been ensured in the next 24 hours.
“Non-observance of discharge criteria in an outpatient KMP”:
– Number of children admitted to a KMCP without complying with eligibility criteria for hospital
discharge, over the number of kangaroo patients discharged from hospital.
– Ideal: 0%
Exclusive breastfeeding (EBF), at discharge from kangaroo adaptation”:
– number of patients admitted into the KMCP with exclusive breastfeeding, over the number of
patients admitted to the KMCP (<10 days chronological age)
– Ideal: 0%
– Accepted minimum: 100% of hospitalized kangaroo children < 10 days of age whose mother is
willing and able to breastfeed.
In-Hospital Quality Indicator for a KMCP-2
“Exclusive breastfeeding (EBF), at discharge from kangaroo adaptation”:
– number of patients admitted into the KMCP with exclusive breastfeeding, over
the number of patients admitted to the KMCP (below 10 days chronological age)
– Ideal: 0%
– Accepted minimum: 100% of hospitalized kangaroo children < 10 days of age
and whose mother is willing and able to breastfeed.
“Accessibility to the Neonatal Care Unit”
– Number of hours of parental access to the Neonatal Care Unit over 24 hours.
– Ideal: 24hours ; accepted minimum: 12 hours
“Exposure to the kangaroo position in the Neonatal Care Unit”
– Number of hours per day that the patient is held in kangaroo position, during the
three- day adaptation before discharge, over 24 hours.
– Ideal: 24 hours a day (including breastfeeding)
– Accepted minimum: 8 hours a day
“Accessibility to the Neonatal Care Unit”
– Number of hours of parental access to the Neonatal Care Unit over 24 hours
– Ideal: 24hours ; aaccepted minimum: 12 hours
“Exposure to the kangaroo position in the Neonatal Care Unit”
– Number of hours/ day that the patient is held in KP, during the 3- 4 day
adaptation before discharge, over 24 hours.
– Ideal: 24 hours a day (including breastfeeding)
– Accepted minimum: 8 hours a day
Outpatients Quality Indicators at 40 Weeks
“Exclusive breastfeeding at 40 weeks”:
• Number of children fed exclusively with breast milk vs number of children completing phase I
• Ideal: 100% in patients > 34 weeks of GA at birth and 70% in patients ≤34 weeks of GA at birth
• Accepted minimum: 70% in patients 34 weeks of GA at birth or more and 50% in patients ≤ 34
weeks of GA at birth .
“Re-hospitalization at 40 weeks”
• Number of children in the KMP readmitted to the hospital during phase I, vs number of children
completing phase I
• Ideal: 0% ; accepted maximum: global 15%.
“Mortality at 40 weeks”
• Number of children in the KMCP who die vs. number of children admitted to the KMCP during
phase I
• Ideal: 0% ; accepted maximum: 1%
Mortality at home 40 weeks”
• Number of children who die at home vs number of children who die during phase I
• Ideal: 0% of preventable deaths; aaccepted maximum: 30%
“Weight, height and head circumference growth at 40 weeks”
• Number of children reaching 2500g, a height of 46 cm and 34 cm of head circumference at 40
weeks vs the total number of children participating of phase I
• deal: 100% , accepted minimum: cohort average weight of 2500g, height of 46 cm and head
circumference of 34 cm
“Emergency consultation before 40 weeks post conceptional age”
• Number of patients consulting at the emergency service in other institutions vs the number of
consultation visits in the KMCP.
• Ideal: 10% (referral to E.R. outside of the KMCP operating service), accepted maximum: 10%
Adherence Indicators at 40 Weeks
“Drop out 40 at weeks”:
– Number of patients who dropped out from the KMCP during phase I over the number of
patients who were admitted into the KMCP.
– Ideal: 10% , accepted maximum: 15%
“Ophthalmology 40 weeks”:
– Number of patients who were assessed by ophthalmology at the end of phase I of the
Program over the number of children who completed phase I of the Program.
– Ideal: 100%
– Accepted minimum: 100% of the children <37 weeks of gestational age
“Ultrasound 40 weeks”
– Number of patients having ultrasound performed on them over number of patients who
completed phase I of the program.
– Ideal: 100% , accepted minimum: 100%
“Neurological evaluation before 40 weeks of post conceptual age”
– Number of patients who received neurological evaluation for muscle tone assessment at
the end of phase I over the number of children who completed phase I of the Program.
– Ideal: 100% ; accepted minimum: 100%
“Immunization at 40 weeks”
– Number of patients who have been received Hepatitis B and BCG vaccines upon reaching
2000g over number of children who reached 2000g.
– Ideal: 100% of all candidates, Accepted minimum: 100% of all candidates
Adherence Indicators at 1 Year
“Optometry and audiology at one year”
– Number of patients assessed by optometry and audiology upon completion of
phase II of the Program vs the number of children who completed phase II
– Ideal: 100%, accepted minimum: 100%
“X-rays of the hips”
– Number of patients on who x-rays of the hips were taken at the end of phase II of
the Program over the number of children who completed phase II
– Ideal: 100% , accepted minimum: 100%
“Neurologic development and psychomotor development at one year”
– Number of patients who were assessed with neurologic (at least four) and
psychomotor (at least two) evaluations at the end of phase II over the number of
children who completed phase II
– Ideal: 100% , accepted minimum: 100%
“Complete immunization schedule at one year”
– Number of patients who have received the complete immunization scheme at 1
year of age by the end of phase II of the Program over the number of children who
completed phase II
– Ideal: 100%, accepted minimum: 100%
Quality Indicators at 1 Year of Corrected Age
Outcomes indicators
“Drop out at 1 year”: Number of patients who dropped out from the KMP during phase II vs number of patients admitted
into the KMCP in phase II
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Ideal: 10%, accepted maximum: 20%
“Breastfeeding at 1 year”: Number of children who were breastfed during their 1st year of life vs the number of children
completing phase II
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Ideal: 100%, accepted minimum: 30%
“Rehospitalization at 1 year”: Number of children readmitted to hospital during phase II vs the number of children
completing phase II
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Ideal: 15% in patients without bronchopulmonary dysplasia (BPD) – 30% in patients with BPD, accepted maximum: 30%
“Mortality at 1 year”: Number of children who die in phase II vs the number of children admitted to phase II
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Ideal: 2% , accepted maximum: 4%
Weight, height and head circumference growth at 1 year”: Number of children who reached 8500g, height 71cm, 45 cm
head circumference at the end of phase II vs the number of children completing phase II
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Ideal: 100% , accepted minimum: cohort average weight 8500g, height 71 cm, 45 cm head circumference
“Sensory and neurological sequel and psychomotor delay”: Number of sensory impairment, psychomotor &d neurological
delays by the end of phase II vs the number of children who completed phase II
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Ideal: 100%, accepted minimum: 100%
“Malnutrition at 1 year”: Number of patients with W/H or a BMI below 3rd percentile by the end of phase II of the Program
over the number of children who completed phase II of the Program.
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Ideal: 0% , aaccepted maximum: 0% in patients who exhibit W/H below 3rd percentile at the time of completion of
phase II of the Program.
Difficulties
and
Resistances to the KMC Implementation
Recommended Strategies
Difficulties in KMC Implementation
In spite of evidence on the efficacy, safety and benefits of the KMC
– There is still a lot of resistance to its implementation
– There is generalized inertia in its dissemination
– Implementation of a Kangaroo Mother Program is a process
of change that requires management will and dedication
3 categories of resistance are limiting the KMC implementation
1. The KMC Method is considered as lower quality, non-technological care
and is perceived as “the poor man’s alternative”
2. The health care team considers the KMC Method to represent an added
work load
3. There is not enough room in the Neonatal Unit to accommodate the
mothers and the families
The KMC Method is a “the poor man’s alternative”
• Source of resistance: health care staff
• Frequency: very frequent; it is almost always evident from the first contact
with the KMC Method.
• Type of argument given: indirect; a prejudice is formed before considering
the evidence.
• Recommended strategies
– Demonstrate Evidence Based good results (Cochrane 2011)
– The KMCM was initially conceived for poor countries now it is
implemented worldwide with excellent results
– The KMC Method is the way to transform how we care for preterm
and/or low birth weight infants
• it is a physiological, humane and emotionally appropriate
intervention for complementing neonatal care for all those low birth
weight newborns that need it
The KMC Method is an added work load for the
Heath team
• Source of resistance: health care staff
• Frequency: This resistance is important in almost all KMCP implemented in
developed or developing countries
• Type of argument given: direct and valid, based on a reality such as
– Insufficient staff
– Lack of expertise on how to engage parents in the care of their infant
Recommended strategies :
• Invite staff from KMCP to share their experience.
• Invite candidates from the new KMCP to visit existing ones .
• Show how mother, once trained, becomes an effective source of help in the
Unit and not another source of concern.
• Demonstrate that any additional work, particularly regarding training, is
justified by the benefits it offers
• Explain that the mother/father, rather than replacing the nurse, become
students in a learning process, under the guidance of the nursing staff.
There is not enough room in the Neonatal
Unit to accommodate mothers / families
• Source of resistance: managerial and health care staff.
• Frequency: very frequent it is almost always evident from the first contact with the
KMC Method.
• Type of argument given: indirect; a prejudice. An increase in the number of
people (mothers) in a reduced space increases the occurrence of infection in the Unit.
• Recommended strategies
– Invite staff from other Units with in-hospital KMCP, to share their
experiences.
– Show how the mother, once trained, becomes an effective source of help
in the Unit and not another issue to worry about or a hindrance.
– Share results from Units with the same physical structure and space,
where the KMC Method was introduced without increase in hospital
acquired infections.
– A mother can be in the Unit without great increase in infrastructure.
Simple, comfortable chairs can be donated or acquired by the institution
and are sufficient to address this issue.
Resistance to the Kangaroo Position-1
1.Close contact between a naked baby and the person holding it (usually the mother) is
considered incorrect , unusual or inappropriate in cultures where physical contact is
restricted because it is too intimate or because babies are usually carried on the back.
Source of resistance: cultural reaction, from the health care staff and the community .KMC method
forces them to make important changes in the traditional way of caring for their babies.
Frequency: this barrier does not exist in societies where physical expression of emotions is part of
the culture.
Type of argument given: is an indirect but valid argument, which is determined by culture.
Recommended strategy
– The solution must come from the the local teams and from communities
• local solutions found and adopted by consensus with the families with the health
professionals.
– It is useful to identify a baby ‘carrier’ or ‘holder’, accepted and easily acquired by
the community which allows adopting the kangaroo position without impairing
the mother’s basic activities.
– Once this barrier is overcome, parents experience satisfaction and real relief and
their testimonials may be used for helping new candidates who have encountered
the same problem.
Resistance to the Kangaroo Position-2
2.Mothers lack adequate privacy
Source of resistance: in some cultures, it is inappropriate to show her bare skin in public, while
breastfeeding or while placing her baby in kangaroo position.
This hinders the collective (group) kangaroo adaptation process and generates rejection from the
mothers and the health care staff.
Frequency: there are variations from country to country, but it is almost always present at the
beginning of a program.
Type of argument given: real and valid.
Recommended strategy:
– Provide adequate robes for kangaroo adaptation and for breastfeeding, to
guarantee privacy for the mothers. If a father is present, and out of
respect for the mother’s privacy, a screen or a separate room for adapting
to the breast may be provided.
– Some mothers may feel more comfortable with female health care staff.
– Reach agreements or find solutions by consensus with the mothers and
fathers participating in the adaptation activities.
KMP in the National Maternity Hospital in El Salvador
I am not sure also that this photo is well adapted as on the previous slide it was resistance
to male presence, it is not connected with the topic.
Resistance to the Kangaroo Position-3
3. In warmer climates, children “do not need” to wear caps and socks
Source of resistance: mainly health care personnel who think that, in regions with warm climate,
ambient temperature is enough to avoid heat loss in kangaroo position. Therefore, their use is
inappropriate and unnecessary. Which is an erroneous belief
Frequency: it is mostly manifested in developing countries, among the poorest living warmer
climates.
Type of argument given: indirect and mistaken; based on an imperfect knowledge of the physiology
of the preterm newborn.
Recommended strategy
– Share all available information on thermal regulation in premature infants.
– Show the existing statistics on decreased rates of hypothermia after
universal introduction of the use of a cap.
– Recommend the use of caps without strings to tie.
Resistance to the Kangaroo Position-4
4.The use of diapers is problematic : This resistance can be due to cultural, financial and/or
religious reasons, diapers are not used to collect urine and stool because they are considered
inappropriate for mothers who carry their children on the thorax.
This is a high impact issue since it generates total rejection of the KMC method
Source of resistance: multiple reasons (cultural, financial and educational). The diaper is
not used for cultural, financial and educational reasons ; then the kangaroo position becomes
impossible for mother and baby .
Type of argument given: direct and based on real facts, which are not easily modified.
Recommended strategy
• This barrier must be addressed with sensitivity with an unambiguous language.
• The solutions proposed must be economically viable.
– In the case of cloth diapers, the problem is not only to purchase it but also to the
time to clean and dry
• Educational material for parents and health care staff, on the use and advantages of
diapers.
• Practical demonstrations of solutions implemented by other institutions which are
regarded as excellent) are also valuable.
Resistance to the Kangaroo Position-5
5. Health staff does not believe in the need to hold the baby in kangaroo position 24 h/24
Source of resistance: health care personnel
Frequency: very frequent, even after implementation of the KMC method
Type of argument given: not valid; it originates in the following 2 errors:
• Failure to differentiate various degrees of immaturity, and consider weight rather than
gestational age
– A 42-week old infant, and a 32-week one, weighing 1700g, do not have the same
characteristics or prognosis; neither do they require similar management strategies.
• Erroneous interpretation of research results (continuous vs. intermittent KP)
– In the majority of studies with intermittent KP, the child who is not in KP is in an
incubator/ similar device
Recommended strategy
– Give the correct information and promote better individual classification of risk for
each child
– Provide analogies with the traditional use of an incubator
– Request health personnel to use growth curves according to the child’s gestational
age and monitor initial daily weight gain, indicating any variation occurring when the
baby is not in KP
– Show to parents that when the child has an adequate thermal regulation, he will be
ask to be taken out it of KP
Resistance to the Kangaroo Position-6
6. Mothers complain about having to hold the baby in KP 24 hours a day
Source of resistance: mothers and families. Some mothers are tired as a consequence of KP during
24 h . Some unit are not offering comfortable setting for mother due to lack of equipment and mainly
to lack of commitment of the health staff. a
Frequency: universal, with various degrees of intensity.
Type of argument given: real and valid.
Recommended strategy:
• Administrators and health staff must understand and accept the importance of
providing comfort to caretakers while they hold their babies.
• Insist on the need for having a baby holder - such as an elastic girdle - that allows
carrying the baby while relaxing, sleeping and carrying out simple activities safely
• Request solidarity from the family and particularly from the father, to help with the
task of carrying the child++
• It is worth insisting to the mother/e family / professionals involved, that this stage will
not last long, but it is vital for the preterm infant
• It is the baby who decides when to leave the KP
– He will begin to perspire, scream and reject the position when he is capable of
regulating temperature on his own.
Resistance to the Kangaroo Position-7
7. The mother requires ‘authorization’ to devote herself to the kangaroo
position
Source of resistance: father and other family members(mother in law)
Frequency: in specific cultures where the husband and the mother in law are entitled to
deciding the mother’s role and the tasks assigned to her.
Recommended strategy:
– Education during kangaroo adaptation in the hospital
– Engage the family in law in kangaroo care and reach an agreement
before discharge, so that the mother can permanently hold her baby
at home, even if it means not being able to do other tasks.
– In many cultures around the world, training the mother in law and the
grandmother is very important.
– Encourage the participation of other family members in caring for the
child to help the mother carry out some other tasks.
Resistance to the Kangaroo Position-8
8.Restricted participation of the father in child care : There are numerous cultural
barriers to prevent the to care for their preterm infants ; mothers and female health e staff are often
reluctant to allow them to participate.
Fathers want to participate in the baby’s care to contribute to their survival, but their role has not
been well defined in this entire process.
Source of resistance: mother, female health professionals and other family members.
Frequency: very frequent, regardless of the socioeconomic level of the family.
Type of argument given: it is not a real argument, is more of a pretext linked to cultural beliefs.
Recommend strategies
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Let the parents know that every person is able o keep the child in KP
Promote the participation of fathers in the care of preterm infants after work / during the
night, to counter the argument that fathers work during the day
Present testimonials from other ‘kangaroo fathers’ , to generate reflection on the capacity
of other fathers to do it, and willingness to take on the challenge
Make fathers participating in the care of their ‘kangaroo’ infants visible to others,
contributing to break existing barriers and inviting a commitment.
Highlight the fathers’ feelings of satisfaction and competence
Emphasize the value that the participation of the father and the other members of the
health care team has for the mother’s rest.
Get the father to participate in the kangaroo position with his child, before discharge
Resistance to the Kangaroo Nutrition
3 types of resistance were identified for the Kangaroo Nutrition
• Nursing the baby is not of vital importance and it requires more work
• There is no alternative for breast milk and supplements are indicated
• Artificial milk is considered to be an indicator of economic prosperity
Resistance to the Kangaroo Nutrition -1
1. Nursing the baby is not of vital importance and it requires too much work.
Training and helping mothers who nurse a preterm infant requires ability, time and effort.
This is perhaps one of the barriers with the greatest impact.
Source of resistance: health care personnel
Frequency: very frequent, almost universal, especially when there is easy access to
formula.
Type of argument given: real in terms of work load, based on lack of information in terms
of vital need.
Recommended strategies
– Train the staff to support and educate mothers in breastfeeding.
• This means knowledge, time and mastery, especially when dealing with
preterm infants
– Transmit information on the physical and psychological benefits of breast
feeding for the preterm child and his mother.
– Provide feedback for the health personnel by sharing the results of
children who were not breastfed after discharge from the hospital.
Resistance to the Kangaroo Nutrition 2 & 3
2. There is no alternative for breast milk and supplements are indicated. : ½ of LBW
infants has an adequate growth and development with exclusive breastfeeding,
the other ½ needs nutritional supplement
Source of resistance: health policy makers, health staff and real financial difficulties.
Frequency: varying degrees of intensity in a given region or social class within the same country.
Type of argument given: based on real factors.
Recommended strategy:
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It is important to avoid rigid attitudes and to recognize that a problem exists.
It is important to look for viable solutions with local contexts.
Invite health care policy makers to analyze the problem and to find solutions
Coordinate efforts with breastfeeding programs and/or supplementation in special cases.
3. Artificial milk is considered to be an indicator of economic prosperity.
Source of resistance: the mother and the family.
Frequency: less and less frequent, due in part to breastfeeding promotion efforts around the world.
Type of argument given: error of interpretation.
Recommended strategy:
• Provide education on the importance and benefits of breastfeeding
• Avoid rigid attitude, offer mothers what is best for their preterm infant
• Include support programs for mothers on breastfeeding plus supplement.
Resistance to Early Discharge
Concern about child safety upon discharge
The health staff worries about the safety of children after early discharge to their
home even if discharge requirements have been met.
Source of resistance: health staff, administrators
Frequency: it is common, especially when decision-makers have not seen a kangaroo
program operating adequately, including early discharge to the child’s home.
Type of argument given: prejudice, when there are conditions for early discharge; real
when there are not.
Recommended strategy:
– Establish a system to assess the degree of preparedness of the mother/ family for
early discharge.
– Implement mother-child ‘kangaroo’ rooming-in facilities, other members of the
family is also trained, and the father’s participation is encouraged.
– Achieving permanence in mothers who live in places of difficult access in in a
rooming-in facility, until the child no longer needs continuous monitoring.
– Guarantee transitional housing where mothers can attend outpatient consultation
with the required frequency.
Resistance to Early Discharge and Follow up
Where is s no policy for follow up for high risk children
In many countries there is no close follow up of preterm or high risk children,
where there is such a program, often the staff has not received KMC training
Source of resistance: health care staff, administrators.
Frequency: normal practice
Type of argument given: is more a pretext, and an attitude issue of political willingness
than a situation generated by lack of resources. Training of health staff for high risk follow
up may be insufficient or nonexistent.
Recommended strategy: It is not easy to resolve.
Understanding of early intervention in outpatient follow up must be encouraged, since it
protects costly investments initially made in the Neonatal Unit
• High risk consultation to 1 year of corrected age by one single team must be ensured
– it should be done from in-hospital kangaroo adaptation to 1 year corrected age.
– If that is not possible, from the beginning of kangaroo follow up to at least 1 year of
corrected age
• Promote monitoring the impact of costly interventions required by preterm children
• Promote training programs in quality high risk follow up
Others Expressions of Resistances to KMC
“We have enough doctors and incubators; cost is not really a problem for us”.
Comment: doctors and incubators are good but KMC is an human approach to care for LBW
infant helping them to be more happy and more healthy
“The mother’s stay may increase the rate of nosocomial infection and interfere with the
work of nurses and doctors”.
Comment: the mother must begin the KMC as soon as possible. She must be given the
possibility of staying with her child as long as possible . Mother’s direct contact with her child
decreases the risk of infection
“A few days won’t change anything; the mother is usually too tired after delivery and needs
to rest. She will let us know when she is ready”.
Comment: the KMC Method decreases the separation time and helps to develop a better
relationship and communication between the mother, the father and their child.
‘’We can take the place of the mother and the father in the Unit; we love our small patient
and know how to handle these fragile children”.
Comment: Love is good, mother and father can ‘t be replaced ,they are responsible for the child
“Our fathers and mothers will never accept that much work; they cannot give as much of their
time as the Colombian parents do”.
Comment: the KMCM empowers the families of the preterm infants .Parents are the first and
best caregivers of their child.
CONCLUSION
Before implementing a Kangaroo Mother Program, any health care
institution ( admin. and health staff) should ask these questions :
• Is the Kangaroo Mother Method applicable and appropriate?
• Is the Kangaroo Mother Method accepted:
– By the health staff?
– By the community?
– By the authorities?
• What strategies have been planned to diminish resistance to change?
• Which groups are responsible for implementing the strategy?
– Have they been amply sensitized and made aware of the importance of
their contribution to the success of the KMP?
• How can the program be monitored ?
• How to maintain and improved the quality of care ?