1. Evaluation of Kangaroo Mother Care in Malawi Reuben Ligowe, 1 Anne-Marie Bergh, 2 Elise van Rooyen, 2 Joy Lawn, 3 Evelyn Zimba, 1 George Chiundu 1 1 Save the Children Malawi Country Office; 2 MRC Unit for Maternal and Infant Health Care Strategies and University of Pretoria; 3 Save the Children/Saving Newborn Lives

2. Background - Newborn deaths 1.2 million newborn deaths in Sub-Saharan Africa per year 60-90% in low birth weight infants 27% of deaths are directly due to preterm birth complications Malawi (2006): Under five mortality has been reduced by 30% in 5 years, but neonatal is not reducing so fast 14,900 newborns die every year (NMR 31/1000 live births) Newborn LBW rate of 20% Preterm births are the leading cause of newborn deaths 57% of births are in facilities Source: Opportunities for Africa’s Newborns. Eds Lawn and Kerber. 2007

3. Background – Kangaroo Mother Care Benefits of Kangaroo Mother Care are well known: To the mother To the baby To the hospital and the health system

4. Background – KMC in Malawi 1999: Establishment of KMC unit in Zomba Central Hospital (ZCH) with European Union funding 2000-2005: Introduction of KMC in 6 more hospitals with the support of Save the Children, and KMC was introduced as part of Essential Newborn Care (ENC) in Malawi 3 central hospitals (tertiary, public) 4 secondary (1 public, 3 mission) Training: Zomba as training centre – 5-10 days ’ training 2005: National guidelines for KMC 2007: Evaluation of the state of KMC implementation – purpose: What had worked and what not? Scaling-up to all district hospitals? Community links? How to deal with lack of human resources and long off site training time?

5. Methods for the evaluation Use of South African standardised progress-monitoring tool to get a sense of the nature of quality of KMC practice Qualitative data collected through discussions with key informants Visit to 6 hospitals supported by Save the Children for KMC Telephone conference with 7 th supported hospital Visit to 3 other health care facilities for comparison

6. Results Successful & sustainable KMC implementation: 5 of 7 supported hospitals 3 central hospitals & 2 mission hospitals Other 2 supported hospitals have KMC wards, but problems sustaining services (partly human resource challenges) 3 of supported hospitals have trained providers from other sites High awareness of KMC outside study hospitals Not all health workers have sufficient information and confidence to start KMC in other facilities

7. Achievements and strengths National: National KMC policy - 2004 KMC included in pre-service training for nurses High degree of awareness of KMC Institutional: Dedication of staff despite hardships Good use of visual material (posters and cards) Availability of KMC register

8. Challenges Human resources – management and perceptions: Health workers not perceiving newborn care as a priority in health system Insufficient nursing and clinical supervision in some units Staff shortages Staff rotations – staff with skills in KMC are lost Long off-site training, and limited on-site follow-up, especially if started in “ project mode ” Resistance to on site training by other trained staff – perceived loss of remuneration during off-site training Limited orientation of new health care staff in KMC

9. Challenges Implementation and follow-up: Perception that KMC can not be implemented without a special unit, special beds and heaters Improvement in quality of records, especially on feeding Simple feeding job aids needed to calculate and record volumes for expressed breast milk Variation in discharge criteria between hospitals Lack of appropriate follow-up systems, and major challenges in follow up and access

10. Missed opportunities Recommendations for immediate attention: (1)Introduce intermittent KMC for stable infants in neonatal unit Do not wait for establishment of a KMC unit Do not wait until the criteria is met for continuous KMC (2) Strengthening current feeding practices for all babies in KMC: Misunderstanding of “ feeding on demand ” — > Scheduled feeding times needed for LBW infants Supervision, using patient attendants to support mothers (3) Use of KMC (skin-to-skin position) to transport babies between home and facilities or between facilities

11. Potential for scaling up KMC Recommendations: Shorter, integrated off-site training & on-site facilitation / support 1-day workshops for district officials 2-day workshops for key implementers in district hospitals Factors crucial for sustainability: Active support of management at all levels Experienced person needed to drive the process Good communication and consultative participation Sending the right people for training – ongoing support essential Sensitisation of community health structures and local leaders Integration of KMC into current services – not project mentality Establishment of a community follow-up system essential

12. Conclusion There are awareness of the benefits of KMC in Malawi, even in hospitals and health centres not practising KMC Strong support from Ministry of Health, good partnerships Possible to design and implement a scale-up programme for Malawi to involve all district hospitals Tracking of practices and quality advisable Leadership and enough personnel are crucial

13. Final Conclusion Extreme lack of medical staff in Malawi - Only 3 national paediatricians in the country Novel approaches are therefore required - e.g. use of patient attendants Thank you