The first use of skin-to-skin contact from birth
Sr Agneta Jurisoo studied what little literature was available on KMC during 1987. The following year she and Dr Bergman arrived at a small mission hospital in Zimbabwe, where premature births were common. There were no incubators, poor transport over great distances, and overloaded referral centres: only one of ten premature babies lived. In the absence of incubators, they started a care plan in which the mother became the incubator. Instead of waiting for the baby to “stabilise”, the mother was used to stabilise premature infants immediately after birth.
It was immediately clear this was highly effective, no matter how small or how premature, stabilisation took a mere six hours. With minimal technological support in addition, now 5 of ten very low birth weight babies survived.
The following is extracted from notes prepared for Nursing Mothers Association of Australia, September 2011.
KANGAROO MOTHER CARE – THE PUBLIC HEALTH IMPERATIVE
MANAMA, ZIMBABWE – ORIGINS OF BIRTH KMC
At Manama Mission in southern Zimbabwe, in 1988, there was no equipment for caring for neonates, and no referral facilities. Survival of infants between 1000g and 1500g had been 10% in the previous 4 year period. Based on literature available on KMC from Colombia, a modification of this intervention was started as the management for low birth weight infants. Skin-to-skin contact was initiated from birth or from admission in all low birth weight infants. The infant was secured firmly to the mother’s chest, and kept there continuously day and night. The mother was encouraged to be ambulant after the first day, and slept at angle of 30 degrees from the horizontal. Infants were fed exclusively their own mothers breast milk, with small feeds started from birth, given 2 hourly. Initially feeds were given by nasogastric tube, after which breastfeeding was encouraged, mostly with a short intervening period of feeding by dropper or cup. Full volume feeds (180 to 220 ml/kg/day) were given by day 7 or 10, depending on the prematurity and the capacity of the infant. Bottles were not allowed in the hospital. The above required intensive psychological support from nursing staff to the mothers, though little other direct nursing care to infants. Infants below 1500g were given prophylactic antibiotics, penicillin and kanamycin, and an oral solution of aminophylline.
The results were dramatic. The overall survival of babies 1000g to 1500g improved from the above 10% to 50%, and survival of infants 1500g to 2000g improved from 70% to 90%. Attitudes of staff changed within weeks of the programme starting, nurses expected the infants to survive. All mothers breastfed their infants, a very small number needed nursing support to provide adequate volumes. On average, birth weight was regained in 7 days, after which the average daily weight gain (of all surviving infants) was 30 g per day. Those infants that survived stabilised by the first day, the survival of infants after the first week was 98%. All infants were scored for gestational age, generally prognosis was good for those above 32 weeks gestational age, and poor if 31 weeks or less. There were however two infants that survived being 28 or 29 weeks at birth. Infants were not discharged early, this was in a rural area where follow-up was not practical. They were therefore kept in hospital until they were 2500g, after which they were discharged as normal healthy infants, to be followed up by Rural Health Centres near their homes.
COMPARISONS THIRD WORLD
Prior to this, KMC was generally practiced only on stabilised babies. Comparisons from Third world contexts are difficult to make given the lack of controls and the paucity of articles. Data were available to compare results from Colombia, Mozambique and Ecuador. Each of these describe KMC started late, but with access to ventilators and some technology. Despite the latter, results from Manama with “Birth KMC” (but lacking technology) were either better or equivalent with respect to daily weight gain, total survival below 1500g, total survival below 2000g, and survival after first week. In particular, the daily weight gain noted was higher than that even seen in First World contexts.
Dr Ornella Lincetto, working in Mozambique, established a 6 bedded KMC unit in a large secondary level hospital with poor resources and few staff. Because the beds were so few, they were restricted to infants between 1200g and 1800g. Overall, 75% of these babies survived. However, only 39% of infants between 1880g and 2500g survived the care provided in conventional incubators.
POTENTIAL IMPACT OF KMC
Worldwide, 5 million children die annually. It is estimated that 65% of the global neonatal mortality rate is directly due to, or associated with, prematurity (Sanders 1985). This leads to a vicious cycle in survivors: effects of low birthweight continue into the fourth year, resulting in stunted children with decreased intellectual potential, and subsequently mothers who are short and at risk and conceive low birthweight babies themselves (Sanders 1985). The weakened mother and child are more susceptible to infections, which in turn exacerbate the nutritional status.
With modern technology – incubators, ventilators, intravenous feeding – survival of prematures is good. However, the majority of the worlds prematures do not have access to incubators. They do however have access to the habitat they require to survive, which presently only our ignorance denies them.
The State of the World’s Children 1995 (Grant, 1995) and the World Development Report 1993 (World Bank, 1993) provide information from which a calculation of the number of low birthweight infants (LBWI) born worldwide can be made, as well as resources to care for them. (Low birth weight is defined as less than 2500g)
Low Income countries LBW babies 15,6 million
Middle income countries (no LBW rate provided)
High income countries 0,64 million.
Comparing high income to low income countries, we find that the low income countries have
96% of the prematures (Grant 1995)
4.8% of the nurses (Grant 1995)
1.8% of the doctors (Grant 1995)
0.8% of the incubators (this author’s guesstimate)
Given this lack of incubators, if the 5 fold improvement in survival from Manama could be accomplished worldwide, the impact can be calculated. Assume 20% of the Low Income Countries’ 15.6 million LBWIs are between 1000 to 1499g.
Assume neonatal mortality rate (NMR) improved from 90% to 50%.
15,6 million x 20% x 90% 2,8 million
15,6 million x 20% x 50% 1,56 million
Potential lives saved 1,24 million per year
To this could be added survivors in larger babies, and further the survivors of improved breastfeeding.