Premature babies are born before 37 weeks of gestation. There are three main sub-categories in pre-term birth: extremely preterm (< 28 weeks of gestation), very preterm (28 to < 32 weeks) and moderate to late preterm (32 to <37 weeks). According to Born too soon, the World Health Organisation (WHO) Global Action Report on Preterm Birth (2012), around 15 million babies are born prematurely (before 37 weeks of gestation) worldwide. Prematurity is the world’s single biggest cause of death in babies under 4 weeks old, and the second cause of deaths of children under 5 years old, after pneumonia. Among those preterm babies who survive, many face a lifetime of disability. The main challenges are for those babies born extremely premature. The charity Bliss estimates that around 60,000 babies are born prematurely in the UK every year. Many premature babies with a gestational age near 37 weeks will not need special hospital care. At any given time, around 40% of all babies admitted in a neonatal unit in the UK will have been born prematurely. For those premature babies who need special hospital care, the average length of stay depends greatly on their gestational age. According to the Bliss website, the average length of stay is 94 days for babies born before 25 weeks, 44 days for babies between 26 and 32 weeks, and 13 days for babies between 33 and 36 weeks (for comparison, babies over 37 weeks who need special hospital care stay for an average of 4 days).
Despite the challenges, the WHO report Born too soon sends a clear, positive message: many premature babies can be saved with feasible, cost-effective care solutions. The report contains proven solutions to provide the highest standard of care for these babies, and reduce their high rates of death and disability. One of its recommendations is Kangaroo Mother Care (KMC). KMC was developed in the 1970s as a way to improve survival rates of premature babies in hospitals in which there was a lack of incubators. The baby is put in “early, prolonged and continuous direct skin-to-skin contact with her mother or another family member to provide stable warmth and to encourage frequent and exclusive breastfeeding” (WHO, 2012). KMC can be applied with continuous skin-to-skin contact, 24 hours a day, as an alternative to incubator care. There is also the possibility of intermittent KMC; on this option, KMC is applied for limited periods, for example one or two hours per day (Blomqvist and Hedberg Nyqvist, 2011).
According to the Jill and Nils Bergman, two well-respected authorities in KMC and authors of the book “Hold your prem”, there are three key parts to KMC (KMC website):
- Skin-to-skin contact between the baby’s front and the mother’s chest, with the baby just wearing a nappy and (if needed for warmth) a cap. Skin-to-skin (ideally from birth, but helpful at any time) should ideally be continuous day and night. However, shorter periods (intermittent KMC) are still helpful (for more information on skin-to-skin, see the article in the LLLGB website “What’s the big deal with skin-to-skin” ).
- Exclusive breastfeeding, if possible by the baby directly breastfeeding from the mother’s breast. For very premature babies, expressing milk and the use of fortifiers may be needed.
- Support to the dyad, which includes looking after the medical, emotional, psychological and physical well-being of mother and baby.
KMC can help with early recognition/response to illness. Lawn et al (2010) published a study showing that commencing KMC in the first week of life showed a significant reduction in neonatal mortality amongst preterm babies (with birth weight <2000 g) when compared with standard (incubator) care. KMC has also been also found to be highly effective in reducing severe illness, particularly infections. A Cochrane systematic review from 2014 on standards of care for premature babies (Conde-Agudelo et al, 2014) reported that KMC was associated with a reduction in the risk of mortality, hospital-acquired infection, and length of hospital stay. Moreover, KMC was found to increase some measures of infant growth, as well as encourage breastfeeding. KMC can also play a crucial role in mother-baby bonding. According to Blomqvist and Hedberg Nyqvist (2011) “Research has shown that, compared with mothers whose infants receive conventional neonatal care, mothers who provide KMC are less depressed and less anxious, consider themselves more competent, feel stronger in their maternal role, have a more positive mood and perceive their children as being less abnormal”.
Many associate KMC with low-income countries, in which high standards in neonatal care may be difficult to achieve. However, the benefits of KMC are also documented in high-income countries. Blomqvist and Hedberg Nyqvist (2011) conducted an evaluation of a Swedish high-technology neonatal unit, which allowed moderately preterm babies to have at least one parent present 24 hours per day. The study found that the mothers embraced KMC and gave a positive a positive evaluation based on their experience, and valued the possibility of starting KMC as early as possible. Although the role of the mother in providing KMC is crucial, other members of her support network can help with KMC, allowing the mother to get adequate rest. KMC can also help fathers of premature babies gain confidence in their role. Blomqvist et al (2012) conducted a study of fathers’ experiences of providing KMC for their premature babies. The babies on this study were between 28 and 34 weeks, and did not have any life threatening condition; the length of hospital stay ranged from 15 to 53 days, with a mean of 27 days. Fathers reported that KMC helped them to attain their paternal role and to cope with the unexpected situation. Providing KMC was something the fathers did voluntarily, and one father described the method as natural. The fathers regarded the infant’s period of stay at the neonatal unit with KMC as a positive experience for themselves, did not express that they feel worried about the baby during the hospital stay.
Despite WHO recommendations, and the many proven benefits of KMC, uptake has been patchy. Hedberg Nyqvist (2016) highlights that common obstacles for the successful implementation of KMC include the ignorance by health professionals about the benefits of KMC for babies and families (with many perceiving KMC simply as “nice for the parents”, with no real medical benefit). Some staff may also think that it is only appropriate in low-income settings (“an inferior poor man’s alternative”). Another barrier is the restrictions many neonatal units place on the presence of parents and families (with the parents only allowed to stay for a few hours a day, instead of 24 hours). Hedberg Nyqvist also suggests that, even when staff are willing to encourage KMC, they may be worried about safety considerations, and that testing whether the baby is clinically stable to allow KMC is time-consuming. Even in settings in which KMC is encouraged, difficulties can arise. Blomqvist et al (2012) reported that, although the fathers in the study were positive about the staff in the neonatal unit and described them as supportive, they also felt confused when staff members made conflicting statements and displayed conflicting behaviour. Different shifts had different approaches, and fathers “often worried about which ‘rules’ would apply during the next shift or what was expected of them as fathers”. Blomqvist and Hedberg Nyqvist (2011) found that the mothers in their study felt that the information received from the healthcare professionals about the practical application of the method was not sufficient. In particular, they found provision of KMC during the night exhausting, and they would have liked more support and information on that aspect.
Successful KMC is highly dependent on the support parents receive, and the role of health professionals is crucial. Caring for a premature baby can be very stressful. Staff in the neonatal unit can actively support parents by making them feel welcome, and establishing appropriate procedures and settings which allow parents 24-hour access to their babies. They can also help by performing some components of the baby’s care (for example tube and cup feeding, especially during the night), so that parents can get sufficient rest. Health professionals can provide timely information to parents (both orally and in writing) about the practicalities of KMC, including the possibility of sharing the task with others members of their support network, to provide parents with opportunities to rest. It is important that health professionals supporting the parents of a premature baby have good knowledge of the benefits and practicalities of KMC, and in general a positive attitude towards the method. Quoting Ban Ki-moon in the foreword of the Born to soon WHO report: “We know what to do. And we all have a role to play. […] Let us change the future for millions of babies born too soon, for their mothers and families, and indeed for entire countries. Enabling infants to survive and thrive is an imperative for building the future we want”.
Bliss website Neonatal Care in the UK, facts and statistics https://www.bliss.org.uk/pages/category/statistics
Blomqvist YT, Nyqvist KH. (2011) Swedish mothers’ experience of continuous Kangaroo Mother Care, J Clin Nurs, 20, 1472–80. http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2702.2010.03369.x/full
Blomqvist YT, Rubertsson C, Kylberg E, Jöreskog K, Nyqvist KH. (2012) Kangaroo Mother Care helps fathers of preterm infants gain confidence in the paternal role, J Adv Nurs, 68, 1988–96. http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2648.2011.05886.x/full
Conde-Agudelo A, Diaz-Rossello J. (2014) Kangaroo mother care to reduce morbidity and mortality in low birthweight infants, Cochrane Database Syst Rev., Apr 22;(4):CD002771. doi: 10.1002/14651858.CD002771.pub3. http://www.ncbi.nlm.nih.gov/pubmed/24752403
Kangaroo Mother Care website http://www.kangaroomothercare.com/
Lawn JE, Mwansa-Kambafwile J, Horta BL, Barros FC, Cousens S. (2010) ‘Kangaroo mother care’ to prevent neonatal deaths due to preterm birth complications Int J Epidemiol., 39 (1), i144-54. doi: 10.1093/ije/dyq031. http ://www.ncbi.nlm.nih.gov/pubmed/20348117
Nyqvist, K. H. (2016), Given the benefits of Kangaroo mother care, why has its routine uptake been so slow?. Acta Paediatrica, 105: 341–342. doi: 10.1111/apa.13236 http://onlinelibrary.wiley.com/doi/10.1111/apa.13236/full
World Health Organization (2012) Born too soon. The Global Action Report on Preterm Birth. http://www.who.int/pmnch/media/news/2012/preterm_birth_report/en/