“So sometimes, it looks like it’s a neglected ward”: Health worker perspectives on implementing kangaroo mother care in southern Malawi

Introduction Kangaroo mother care (KMC) involves continuous skin-to-skin contact of baby on mother’s chest to provide warmth, frequent breastfeeding, recognizing danger signs of illness, and early discharge. Though KMC is safe, effective and recommended by the World Health Organization, implementation remains limited in practice. The objective of this study is to understand barriers and facilitators to KMC practice at tertiary and secondary health facilities in southern Malawi from the perspective of health workers. Methods This study is part of the “Integrating a neonatal healthcare package for Malawi” project in the Innovating for Maternal and Child Health in Africa initiative. In-depth interviews were conducted between May-Aug 2019 with a purposively drawn sample of service providers and supervisors working in newborn health at a large tertiary hospital and three district-level hospitals in southern Malawi. Data were analyzed using a thematic approach using NVivo 12 software (QSR International, Melbourne, Australia). Findings A total of 27 nurses, clinical officers, paediatricians and district health management officials were interviewed. Staff attitudes, inadequate resources and reliance on families emerged as key themes. Health workers from Malawi described KMC practice positively as a low-cost, low-technology solution appropriate for resource-constrained health settings. However, staff perceptions that KMC babies were clinically stable was associated with lower prioritization in care and poor monitoring practices. Neglect of the KMC ward by medical staff, inadequate staffing and reliance on caregivers for supplies were associated with women self-discharging early. Conclusion Though routine uptake of KMC was policy for stable low birthweight and preterm infants in the four hospitals, there were gaps in monitoring and maintenance of practice. While conceptualized as a low-cost intervention, sustainable implementation requires investments in technologies, staffing and hospital provisioning of basic supplies such as food, bedding, and KMC wraps. Strengthening hospital capacities to support KMC is needed as part of a continuum of care for premature infants.


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KMC involves continuous skin-to-skin contact on the mother's chest to keep the baby warm, 59 support for frequent feeding/exclusive breastfeeding, early recognition of any problems, and   Research setting 94 The study was conducted at a tertiary-level central hospital and three secondary-level district 95 hospitals in southern Malawi. The two government district hospitals and one private not-for-96 profit mission hospital included in this study serve as regional referral centres and represent the 97 highest level of care available in their districts. Essential services, including maternal and child 98 healthcare, are provided free of charge to patients in all four study sites. 100 The sample was purposively drawn to include health workers and supervisors working in  Staff attitudes 137 Health workers in general had positive perceptions of KMC, which was identified as a facilitator 138 of practice. They felt KMC is a good practice because it helps to save lives. Health workers 139 described that KMC promotes mother and infant bonding and frequent feeding. Health workers 140 shared that KMC was valuable as a low-cost, low-tech solution in their resource-constrained 141 health settings. Some also highlighted that KMC reduced workload and increased protection 142 from complications and infections as mothers closely monitored their infants and there were 143 fewer people handling the vulnerable neonate.

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"It is something very cheap. It's cheap and…it's the most effective way of helping our 145 premature babies to gain weight so fast!" District hospital nurse 146 "If the mother put the baby on kangaroo, it's easy for the mother to know that the baby is 147 sick or not because the mother sees the baby…All eyes of the mother is on her baby…. Though KMC babies were considered vulnerable as preterm and low birthweight infants, health 156 workers also perceived them as in stable condition. Health workers highlighted that only infants 157 that were clinically stable were eligible for KMC according to guidelines at their hospitals. Birth 158 asphyxia and respiratory distress were described as complications that preterm and low 159 birthweight newborns frequently experienced requiring critical care before starting KMC. 160 Additionally, delays in initiation may also occur while waiting for the mother's condition to 161 stabilize, such as recovery after a caesarean delivery. With an emphasis on stable health of 162 mother and infant prior to initiating KMC, health workers shared that it was a common attitude 163 that KMC babies were a low priority in comparison to those in critical care. This was associated 164 with irregular monitoring of the KMC ward and staff expected the mother to call for help if 165 complications arose.

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"Attitude… yah sometimes, you know, committing a crime by omission… some people 167 will just say, "aahh these KMC babies are stable, [so] let me concentrate on this one" and 168 yet, you forget that something can happen and the mom might not notice" District   if they are not available it makes monitoring a challenge" District hospital nurse 202 Health workers reported that sharing roles and responsibilities as a team between nurses and 203 clinicians supported effective KMC practice as well as appropriate infrastructure and supplies. 204 Health workers noted that having a dedicated KMC space with proper beds was a facilitator to 205 KMC practice at their health facilities.

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"I think we, since we have got better space now, better place the mum can stay, because 207 one of the issues that would make maybe make the mothers to abscond is the issues of  213 Health workers recalled that though mothers and their families rarely refused KMC, they often 214 wanted to go home after only a couple days, long before their baby had gained enough weight.

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Participants shared that the desire to go home stemmed from poor support at the hospital and a 216 reliance on families for care and supplies, such as food, clothes, KMC wraps and hats to keep the 217 baby warm. Some mentioned that the mother and her family were simply not expecting hospital 218 admission after delivery and were unprepared for an extended stay, such as bringing only one 219 cloth to wrap the newborn. Because the KMC wraps are not provided by the hospital, the family 220 must arrange for more clothes to be brought alongside supplies for daily living needs such as 221 food, clothes and bed linens, which was a burden for poor families served by these public 222 hospitals. Faced with poor medical attention, including lack of review by clinicians and 223 monitoring by nursing staff, as well as costs with maintaining her stay and concern about other 224 children at home, health workers shared that women and their families frequently self-discharged 225 early.

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"Sometimes, it's because at this hospital we don't provide meals as such they complain 227 that they don't have food so they run away. Others because they don't have a guardian 228 they choose to run away. Others, it's due to family issues and you will just discover the 229 other day they have absconded. But mostly it's due to having no guardians and no food.

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And also sometimes when they feel that the baby has gained a normal weight but they 231 haven't been reviewed by health personnel sometimes they just decide to go. " District 232 nursing officer 233 "Actually those parents maybe they don't have enough things at the hospital let's say 234 they don't have enough food, enough money to sustain them in the hospital, they will not 235 concentrate on what we tell them and they will prefer taking the baby home, to take care 236 for it at home. So that's the most important challenge that I have observed." District 237 hospital clinical officer 238 Leaving early was also associated with misunderstandings and difficulties around KMC practice. 239 Health workers shared that some mothers and caregivers agreed to initiate partly due to respect 240 or fear of health care workers rather than their comfort or understanding of the practice. Health Facilitators described by health workers included the availability of a caregiver to do KMC if the 253 mother is unable to and support of husbands, mothers-in-law and grandparents, visitation rights 254 for the mother's family and seeing peers practice KMC. However, because of a reliance of 255 families to support care during KMC at the hospital, a lack of social support also discouraged 256 mothers to continue. When the mother was alone with no one to help her, health workers shared 257 that it magnified her feelings of depression and desire to go home. where conceptualization of KMC is limited to a unit or a place within the hospital, rather than 287 part of the continuum of essential care for premature infants (16).

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Our research with health workers in Malawian hospitals demonstrate the assertion that while 289 KMC is a low-cost intervention, it is not a no-cost intervention (1). Though KMC is described as  been an effort to extend KMC practice to clinically unstable newborns, which was shown to be tracking vital signs, will be critical for clinically unstable newborns as well as for stable preterm 304 and low birthweight infants between monitoring visits. 306 Participants in this study highlighted the multiple roles that nurse midwives played from 307 counselling caregivers on initiation to being the main medical provider monitoring infants during 308 KMC as well as supporting labour, delivery and nursery wards during emergencies. The   317 Study participants highlighted that having a dedicated KMC ward facilitated the practice, which 318 is aligned with other studies in sub-Saharan Africa that described insufficient space as a critical 319 challenge (19,26,28,29,35,36). However, beyond a sufficient space, there is a need for family-320 centered care to support mothers and their companions during their extended stay at the hospital.

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While KMC may be lower cost to the medical system than conventional care, there are 322 considerable costs to the mother and her family. Investing in clothes, food, and entertainment 323 and learning opportunities for mothers to help pass the time may help mothers and their families 324 in their decision to stay and continue practicing KMC. 326 A strength of the study is that it elicited perspectives from a wide range of health workers in 327 Malawian hospitals that were purposefully sampled. A limitation is that district and tertiary 328 hospital interviews were not separated though they have different capacities. This is an area for 329 future research.