Home based KMC practices – feasibility and acceptability in deprived section of community in rural, tribal and urban

slums in India- a pilot study

Dr. Reeta Rasaily, Scientist EDiv. Of Reproductive & Child Health

ICMR, N. Delhi

feasibility and acceptability in deprived section of

Background

• LBW contributes to 28% of newborn death• KMC method (STS contact) reduces morbidity,

promote thermal regulation, improves breast feeding rates and early discharge in hospital born LBW babies

• Studies have shown this method could be adopted in the community(Q. Iftekhar, J. Perinatology 2003, Shivgarh study)

• Limited evidence available on impact on mortality of community KMC (Joy Lawn 2010, Cochrane review)

• Feasibility and acceptability of the method in different setting needs to be tested

Objective

• To test feasibility and acceptability of KMC by the mother / family members

• Compliance of the method

Participating centers:• PMC Anand, Gujrat, Anand municipality area: Urban

and periurban• NIAHRD, Cuttack, Orissa: Rural area• NIRRH Mumbai, Maharashtra: Rural tribal area

Study design & methodology

Study design: community based intervention (pilot) study

Study size: 100 newbornsInclusion criteria

– Home deliveries as well as hospital deliveries returning home within one wk of delivery

– B.wt. 1500-2000 grams Exclusion criteria:

– Sick mothers– Significant bleeding in mothers– Features suggestive of chorioamnioitis– Psychiatric illness– Post partum convulsions– Do not agree to participate in the study

Intervention:• Existing health care infrastructure of anganwadi

center were utilized for IEC session• KMC messages promoted as part of essential

newborn care during antenatal period by ANM, AWWs, ASHAs

• Counseled pregnant women and family members• At delivery, by TBA / ANM• Post partum period by ANM, TBA, AWW,

Reinforce other messages of health education, Feeding advise, Explain danger signs, distribute pictorial education material

• Apparel: KMC bag/ KMC blouse

Study design & methodology

Methodology (contd.)

Quantitative:• Demographic data• Delivery details• Newborn care practices• Time of initiation of KMC• No of hours of practice• Duration• Morbidity, Discomfort in mother

• Follow up -1 wk every day, alternate day 2 wk, 2nd month

• Weight: at birth and follow up

Qualitative: FGD before and after intervention, IDI

Quality assurance:

• Tools & SOP developed centrally• Centralised training for trainers at AIIMS for 3 days• Trainers trained project

staff, Mos, ANM, LHVs, AWWs, ASHAs at respective sites

• IEC of pregnant women and family members by health workers,

• Counseling sessions supervised by project staff• Data collection by separate staff

• Percentages of women accepting KMC method, • Percentages of women continuing KMC• Duration of KMC/day, • total number of days continuing KMC

Acceptability was defined as practicing skin to skin contact by mother/ care giver for any duration.

Acceptability was also assessed on day 7 after initiation of kangaroo mother care using a questionnaire incorporating Likert scale

Outcome measure

Results

• Study period: Jan 2010-Dec 2011• Enrollment: 12 months period (all 4 seasons)• Live birth =2567• LBW(upto 2000gms)= 129• Excluded =13

Maternal demographic and delivery and neonatal characteristics

Orissa(n=40)

Gujarat(n=45)

Maharashtra(n=31)

Total (n=116)

Age of women 23.2±5.4 25.3±3.8 23.5±3.7

IlliteratePrimary schoolMiddle school and above

42.515.042.5

20.024.455.5

48.412.938.7

35.318.146.5

Occupation: Housewife 92.5 82.2 43.3 75.6

Lives in Joint family 75.0 65.9 48.4 64.3

Primi para 67.5 55.6 51.6 58.6

Institutional delivery* 90.0 95.6 64.5 85.3

Delivery by skilled personal 90.0 99.6 64.5 85.3

Preterm 57.5 60.0 71.0 62.1

B.Wt.(mean±SD) 1650±168 1633±273 1837±173

*86% in pvt hospitals in Gujrat center

Maternal demographic and delivery and Counseling on KMCOrissa(n=40)

Gujarat(n=45)

Maharashtra(n=31)

Total(n=116)

During antenatal period

1-2 times3 or more timesNo

27.572.5

-

19.924.455.5

67.731.2

-

35.343.121.5

Family members

Once onlyTwice3 times or more timesNo

12.510.077.5

-

15.64.4

26.753.3

48.412.9

-38.7

23.58.7

36.731.3

Postnatal period

1-2 times3 times Did not receive

5.595.0

-

68.926.74.4

90.46.43.2

52.644.82.6

AcceptabilityOrissa(n=40)

Gujarat(n=45)

Maharashtra(n=31)

Total(n=116)

Time of initiation of KMC

Within 24 hrs24-<72 hrs72 hrs-<1wk>1 wk

37.550.012.5

-

8.913.326.751.1

12.932.354.8

-

19.831.029.319.8

Mode of providing KMC

Once in a whileAlmost always/intermittentlyNot given

-100.0

-

9.390.7

-

16.177.46.5

7.990.31.8

No. of hrs of KMC 8 4 3 5

Total no. days KMC given(median) 35 45 25

Family member provided KMC 37.5 16.7 22.6 25.7

Suggest KMC to others 100.0 86.7 90.3 92.2

66.7% Practiced KMC while sleeping in Gujrat, 37.9% in Mumbai

Was there any problems

Problems stated (10%)• Mothers: back pain during KMC for sitting in one

place for long time, body pain, knee pain

• Newborn: fast breathing, poor sucking, fever, cold to touch, yellow skin, vomiting after breast feeding, sticky eyes)

8(7%) deaths, not related to practice of KMC

Acceptability(n=106)

Questions No. yes Very muchDo feel comfortable during KMC ? 5 77 24

Does KMC bring you closer to baby? 7 75 24

Will you advise KMC for other babies? 4 100 2

Do you feel KMC hampers and interferes with your daily activity?

92 14 0

Do you think it is possible to practice KMC for longer time?

29 77 0

Will you continue to practice? 21 83 2

Are you happy about the process? 7 91 8

Would you prefer to care for your small babies at home (in future)?

14 91 1

Are you confident in handling the baby? 8 91 7

Are you confident in looking after the baby at home?

8 95 3

Conclusion• Community level initiation• Utilized AWW infrastructure• Counseling by health workers• Feasible to introduce through health system• Acceptance by mothers and family members :80%

initiated within 1 wk, provided KMC average 5 hrs/ day, median no. days 25-35

• Other family members, mother-in-law, husband also provided KMC (25%)

Further research needed to assess impact on mortality

Challenges:

• Skill building of health workers• Follow up strategy• Referral linkage • Strengthening referral facility• Enabling environment at home• Educational material for family members

Further health system research to identify barriers to and finding solutions

Acknowledgement:

• Site PIs:• NIRRH Mumbai:

– Dr. R. Kulkarni– Dr. S. Chauhan

• NIAHRD:– Dr. S. Swain– Ms. L. Kanugo

• Gujrat:– Dr. S.N. Vani– Dr. N. Kharood,

Health officials, health workers,community

Members of Steering Group:• Dr. H.P.S. Sachdev, N. Delhi• Dr. V.K. Paul, AIIMS• Dr. A.K. Deorari, AIIMS• Dr. R. Nanavati, KEM Mumbai• Dr. V. Kumar, Lucknow• Late Dr. G.K. Malik, Lucknow• Dr. R. Agarwal, AIIMS

Centralised Training:• AIIMS team• Shivgarh team

Data analysis: Mrs Garima

THANK YOU