Around 1.06 million babies are born in Iraq every year. Unfortunately, about 15,000 babies die before completing one month of life, half of these succumb to complications of prematurity. A preterm is the baby born before completing at least 37 weeks of gestation, while a full- term baby is the one born after completing 37 weeks of pregnancy. Preterm babies are especially vulnerable as their bodies are not ready to maintain body temperature and sometimes the facial muscles are not ready for suckling at the breast. Breathing difficulties and susceptibility to infections is high. These babies need special support for thermos-regulation and feeding of breastmilk. Of all babies born premature, about 15-20% may require incubator care while a majority of clinically stable babies can be easily managed by Kangaroo Mother Care.
Kangaroo mother care (KMC), or skin-to-skin care, is a technique practiced on newborn, usually preterm, infants wherein the infant is held, skin-to-skin, with an adult. Kangaroo care for preterm infants may be restricted to a few hours per day (intermittent KMC) , but if they are medically stable that time may be extended. Both mothers and fathers or other care givers can provide kangaroo care. As breast milk feeding is an important component along with skin to skin care, mothers are a preferred care giver for KMC while other family members can support her for doing skin to skin care when mother has to rest or shower.
Iraq is one of the country following global Every Newborn Action Plan that aspires to bring down newborn deaths to 12 or less for every 1000 live births. The global plan envisages that at least half of stable preterm newborns or babies weighing less than 2000 grams will receive KMC and other supportive care by 2020; and then 75% by 2025. UNICEF Iraq is partnering with Ministry of Health to build health system capacity to end preventable newborn deaths and promote essential newborn care for all babies and small and sick newborn care for those born preterm or suffering complications such as breathing difficulties (asphyxia) and infections (sepsis).
Bringing Kangaroo Mother Care to Baghdad
UNICEF and Ministry of Health have partnered with Al-Elweya Maternity Teaching Hospital in Baghdad to initiate KMC practice. A five-member delegation attended a regional KMC workshop in Beirut in 2017, and 25 service providers from the hospital attended three day local courses in Baghdad. The team has started providing KMC intermittently to the babies admitted in intensive newborn care unit from 1st May 2018. The plan is to establish a full time KMC care practice as the team gains more experience and confidence. The hospital will be developed as a national training center for small and sick newborn care to provide mentoring to other tertiary hospital teams. Each tertiary hospital will then coach the district hospital teams in a phased approach to cover all district hospitals by 2020. It is an ambitious plan but very much doable with the leadership of Hospital Director Dr.Ulfat AL Naqash, and by support from Baghdad Ressafa DOH Focal person Dr.Anwar Mohammed Jasim, ENBC Manager Dr. Maha Rasheed Taha and Director General of PHD Dr. Riyad Abdul Ameer Hussein From Ministry of Health and the new Health Minister, Dr. Alaa Al-Alwan.
Al- Elweya Maternity Hospital complex consists of 10 buildings, and it includes operating rooms and theaters, delivery rooms, patient wards and a section for newborn care and premature infants. The hospital also has an external outpatient obstetric and gynecological clinic, women’s health center , pharmacy, emergency rooms, prenatal health center and nursery. Al-Elweya serves more than a million women on the east side of the Tigris River. The hospital had 9594 deliveries for the period 1st May – 30th October 2018 and 495 were identified as less than 2500 gm in weight. 1228 newborns were admitted to the Neonatal Intensive Care Unit (NICU) in this time period, since the hospital is a main referral hospital for managing complicated pregnancies at Al-Ressafa on the east side of Tigris River in Baghdad.
The hospital is sparkling clean and has a welcoming ambience. The hospital Director Dr. Ulfat Al-Naqash says “the mission of the hospital is to make it a nice place for mothers and their families as they go through the anxious times of pregnancy and child birth.”
UNICEF health and communication sections have provided support to develop posters on Kangaroo Mother Care and brochures for mothers to create awareness (Figure 1, Picture 1). The pediatrician Dr. Wassen Najim, says that KMC babies are visibly peaceful and gaining weight quickly as compared to incubator care. We are also trying to keep the mothers encouraged and happy. The unit has been re-furbished with government’s own resources to include toilet and shower facilities. New forms and tools have been developed to monitor progress of KMC babies and the outcomes are being closely monitored.
Figure 1: The KMC brochure
Picture 1: UNICEF and MoH focal points with a poster at KMC room
Experience of providing KMC Care for the first time
Al-Elweya Hospital initiated the provision of intermittent KMC starting in May 2018. Dr. Wassen admitted that she initially started with only one hour of KMC to test mothers’ acceptance. Now , she extended the intermittent KMC to be provided for 5-6 hours. One of the newborns benefiting from KMC, “Maha”, began weighed only one kilogram when she started KMC at the age of 20 days. After 10 days, Maha gained 300 grams; and after two months, she weighed 1.5 kilograms. She has since been discharged and is coming for regularly scheduled follow up visits to the hospital.
Forty seven eligible newborns have been provided with KMC at Al-Elweya Maternity Hospital since it was initiated (Figure 2). Their weight ranged from from 1250 -2000 grams. Of the 47 newborns, 21 of them gained proper weight for age during KMC and only one death was reported. Nearly half of mothers came back for follow up after discharge from hospital.
Fatima is another one of the babies on intermittent KMC. She was born at 25 weeks. Her mother said, “I was so devastated to see her so tiny and fragile but with KMC we are both very happy and she has gained weight. I am admitted to the KMC ward for last two weeks and waiting to go home as soon as possible but at the same time I want my baby to be healthy and safe.”
Picture 2: Team of Al-Elweya Hospital and UNICEF celebrating the establishment of KMC
Figure 2: Outcome of 47 KMC babies at the hospital
Challenges during KMC start-up phase
Some of the key challenges in initial start-up phase included the need for a dedicated space, lack of confidence among service providers to counsel mother son KMC practice, resistance from mother or family for extended hospital stay or skin to skin contact. Sustaining momentum and importance of engaging MOH and UNICEF leaders to provide visibility and recognition to the programme was important. The absence of KMC coverage indicator in hospital report was a barrier to regular reporting, which has been overcome with inclusion of newborn specific indicators in HMIS. Improving quality of care for small and sick newborns required regular case reviews and perinatal death reviews to understand modifiable factors. UNICEF Iraq is supporting MOH to institutionalize perinatal death reviews starting from 5 out of eighteen governorates.
Lessons learnt
- Involving MOH and hospital team in the initial trainings helped foster cooperation and team spirit
- Hospital manager’s commitment and leadership is key to start and sustain the initiative
- Keeping KMC within overall management of small and sick newborn care is important for holistic management of the baby
- Sharing learnings among UNICEF offices on WhatsApp was helpful together with website resources
Way Forward
- Develop the center as a national training hub with the potential to train teams from other countries in the region
- Organize study visit /establish tele-mentoring link with University of Pretoria or UNICEF Ghana
- Scale up to establish Intermittent KMC in Al-Zahraa Hospital/ Najaf Governorate on progress with support from Al-Elweya Hospital Team and in place plan to include another Governorate in the north of Iraq soon
- Encouraging mothers to connect and form a group like “Preemie Love Foundation” which started as a WhatsApp group in Kenya to hospital support for other mothers to do KMC and nutrition counselling at home visits.
Al- Elweya Maternity hospital – A developing centre of excellence
The hospital authorities with UNICEF support are part of an ambitious plan to be recognized as the first Centre of excellence for maternal and neonatal health care in Iraq.
- The hospital is the first to start Kangaroo mother care for preterm infants.
- Since 2016, the hospital is engaged in quality improvement mechanism through periodic self-assessment check lists and follow-up plans.
- The hospital initiated perinatal death reviews in May 2018.
As an outcome of implementation of these three initiatives, with support from UNICEF Iraq on procurement of essential equipment, the pre-discharge NMR in the hospital has declined from 37 per 1000 LB in 2017 to 25 by end of October 2018.
Picture 3: UNICEF team with DG of Public Health Directorate, Ministry of Health