N. Charpak / Mantoa Mokhachane/….etc Please put your name Training workshop N. Charpak / Mantoa Mokhachane/….etc Please put your name

Participants Colombia / USA / Canada / Finland / South Africa / Bhutan / Phillipines / Indonesia /Ghana / Algeria / France / Vietnam / Slovenia / Iran / Madagasgar Paediatrician / neonatologist / doctor/ midwife / nurse / UNICEF / KMC trainers / university medical and nursing educators / advisor to MoH Wide range of experience – mostly from teaching / tertiary hospitals Most countries already performed KMC training and implemented KMC

Objectives Define levels of health care What Knowledge on KMC is needed for each level Indicators for effective KMC training Training for KMC for transfer Training the mothers on how to practise KMC antenatally and after delivery Description of the content of KMC training at 3, 2 and 1 level is not included in this presentation

Level 1 health care Definition: Community level births at home +/- community worker Community health centre primary health centre People to be trained: TBA’s, Mothers, CHW, public health nurses, some doctor and nurse in primary health centre

Mother KMC training for the mother and a family member include: How to practise KMC The value of KMC emphasized Show them how to help the baby breathe Alarm signs in KMC position

KMC training of the TBA (part of level 1) should include the following Identify pregnant women in the community and refer How to identify risk In the pregnant women In the infant Opportunity to integrate Essential Newborn Care in the training resuscitation (Helping babies breath) Immediate thermal control - good drying, hat, immediate Kangaroo position Recognition of a small baby Weighing the baby Feeding the baby Transferring the baby to the nearest health care centre In KMC position Follow-up of mother and baby in the community if not transferred

KMC training to health workers at this Level 1 must include: Identify pregnant / labouring woman having a risk of premature delivery refer the mother before the baby is born ( in utero transfer) Opportunity to integrate Essential Newborn Care in the training resuscitation (Helping babies breath) Immediate thermal control - good drying, hat, immediate Kangaroo position Recognition of a small baby Assessment of gestational age Kangaroo mother care - put baby in a good position, secure well with wrapper, insulate Early feeding to prevent hypoglycaemia - teach mother to express colostrum, try baby at breast, spoon or syringe feeding with expressed colostrum, milk, donor milk, sugar water, Recognition of instability / warning signs of severe illness Referral to the nearest level of care with health worker, in the case of community delivery or level 2 of care Transport with mother in kangaroo position. If the mother cannot carry the baby, the father or other member of the family can carry the baby

Ideas of Indicators for effective KMC training at level 1 Mortality (including cause of death) Number of baby’s referred in KMC position Number of baby’s who arrive at referral centre with hypothermia Number of baby’s who arrive at referral centre with hypoglycaemia How many arrive at the referral centre with the mother How long was the baby and mother separated Number of baby's receiving breastfeeding within 1hr after birth Rates of breastfeeding at 6 weeks Rates of breastfeeding at 3 months

Discussion points Insulation against babys’ back – placenta (USA), blankets, plastic bag Most appropriate initial fluid to give baby – colostrum/donor milk/sugar solution (5%/10%) How to give initial fluid – spoon, syringe Need for mother to be transported with baby and challenges of achieving this in some settings. Emphasis on keeping mother with baby at all possible.

KMC training at Level 2 care Defined: District hospital, provincial, regional with or without NNU Doctors (general, paediatric, neonatal), midwives, obstetrician

Level 2 KMC training All training for level 1 Assessment of gestational age  for all health care workers. Use of a simple tool as the Usher(??) tool to evaluate gestational age Full KMC training if setting not able to take care of complications of prematurity ( jaundice, sepsis, respiratory distress, extreme prematurity) Initial management of immediate complication of prematurity Warning signs for illness / deterioration Referral if unstable Implementation of a KMC Follow up or refer for appropriate for follow-up (ophthalmology, neuro etc)

Ideas of Indicators for effective training at level 2 Mortality (including cause of death) Length of stay of preterm babies Breast feeding rates (number of babies exclusive breast feeding) Dose of KMC (number of hours/number of days) Infection rates during admission Hypothermia rates at referral hospital Follow up – referral rates

Discussion points Transport Jaundice treatment availability Father can be used to transport baby in kangaroo position especially if the mother delivered by Caesarean section Jaundice treatment availability If available KMC baby is not referred Accurate assessment of gestational age is important (different outcomes/management). Simplified tool like USHER can be used.

KMC training at Level 3 Defined – teaching / University hospital Neonatal intensive care / Neonatal units CPAP – advanced ventilation

KMC training for level 3 workers Full KMC : Kangaroo position, Kangaroo nutrition, KMC discharge policies with follow up Start in delivery room/ ICU What physiological changes to expect with KMC How to transfer a critically ill baby from an incubator into KMC position Written protocol video Which babies can be transferred back to 2nd level care after 40 weeks for high risk follow up KMC Follow-up and KMC data collection

Ideas of indicators for effective training level 3 Mortality in the unit and in the KMC ward and in the follow up How many babies arrive referred in KMC position Hypothermia rates at admission Breastfeeding How many babies put to breast within 1 hr Breastfeeding rates at discharge, 3 months, 6 months and 12 months corrected age Infection rates during hospital stay Duration of hospital stay and number of readmission Pattern of alimentation during hospital stay and at discharge and during the follow up

Discussion points Think about where mother will stay to continue KMC (shelters/KMC ward) before eventual transfer to level 2 Important to teach medical students / paediatric trainees / nutritional students / nursing students / midwife students Good relationship with university and Health Ministry