This blog was originally published as a commentary in The Lancet here.
By Nathalie Charpak & Juan G Ruiz-Pelaez
In 1978, Edgar Rey was the director of a large and overcrowded neonatal unit in Bogota, Colombia. Shortage of incubators and prolonged hospital stay were harming and resulting in the deaths of already stable premature infants. To overcome those circumstances, Rey started an early discharge programme in which infants were placed in skin-to-skin contact on top of their mothers’ chests to ensure thermal stability (kangaroo position), and if the babies tolerated the position well and regulated their temperature, the mother and baby were sent home in the kangaroo position while receiving breastmilk-based nutrition and close ambulatory follow-up—ie, after discharge from hospital, kangaroo mother care was provided in specifically designated ambulatory outpatient clinics, where the family came for follow-up visits from discharge until up to 1 year after birth.1,2
The three components—kangaroo position, nutrition, and discharge policy—were shown to be safe and effective in a randomised controlled trial undertaken by our research team between 1993 and 1997,3, 4 and since then a large body of evidence has been built to support the effectiveness and safety of hospital-initiated kangaroo mother care.5, 6, 7Hospital-initiated kangaroo mother care is regarded as an essential component of appropriate health care for babies that are premature and with low birthweight in low-income and middle-income countries.8, 9 It has been shown to be economically efficient, and the timely discharge policy is the key component explaining the cost-effectiveness of hospital-initiated kangaroo mother care.10 However, many kangaroo mother care programmes do not include timely discharge and appropriate ambulatory follow-up.11
In many places in the world, mainly low-income countries, babies with low birthweight and who are premature are delivered outside hospitals. A large proportion of them might survive the transition to extrauterine life if appropriate nutrition and a neutral thermal environment are provided. Kangaroo mother care could be offered to these infants either as a transient measure while they are transported to hospital or as a community-based intervention. In The Lancet, Sarmila Mazumder and colleagues12 present new, strong evidence in this context, assessing the effectiveness and safety of a community-initiated kangaroo mother care programme as part of a large, well designed, randomised controlled trial in Haryana, India.
Community worker health teams visited homes and identified eligible babies with low birthweight (stable preterm and small for gestational age term infants younger than 3 days old) who could be safely placed in the kangaroo position and be breastfed. They were closely followed up during the first 28 days of life and outcomes were reported up to age 6 months. Risk of selection and measurement biases and confounding were properly addressed and minimised. Eligible newborn babies (n=8402) were randomly assigned to the intervention (n=4480) or the usual care group (n=3922), with additional procedures in place for twins and for infants born in the same household as another infant already in the study, resulting in the different sizes of the groups. Most births (6837 [81·4%]) occurred at a health facility, 36·2% (n=3045) infants had initiated breastfeeding within 1 h of birth, and infants were enrolled at an average age of about 30 h (SD 17). Compliance with kangaroo mother care was close to 100% in the intervention group. Results showed a reduction in neonatal mortality (up to age 28 days, hazard ratio 0·70, 95% CI 0·51–0·96; p=0·027), which persisted to age 6 months (0·75, 0·60–0·93; p=0·010). These effects were homogeneous across gestational age, sex, weight, and age at enrolment. Breastfeeding duration and somatic growth were also better in the intervention group.
We praise Mazumder and colleagues for undertaking this randomised controlled trial with kangaroo mother care initiated in the community with home visit follow-up in resource-limited settings. We are fully aware of the magnitude of the challenges these researchers have successfully met to deliver these thorough and robust results. This study provides not only fundamental evidence supporting community-initiated kangaroo mother care but also strong indirect evidence supporting the policy for timely discharge from hospital and provision of ambulatory follow-up to eligible mother–infant pairs who started kangaroo mother care in hospitals.
There are two main limitations in the generalizability of these results. First, the results only apply to stable infants, who are free from major adaptation problems to extrauterine life and who will be provided with close and appropriate ambulatory home-visit-based follow-up. Second, this study concentrates on babies with low birthweight, born and cared for outside of hospitals, or born in hospitals and discharged home within 72 h without initiation of kangaroo mother care. The authors make no comparison of outcomes between hospital-initiated and community-initiated kangaroo mother care, but between community care of babies with low birthweight with and without kangaroo mother care intervention. The study is not about whether community-initiated kangaroo mother care is as effective and safe as hospital-initiated kangaroo mother care.
Evidence from this study does not answer whether community-initiated kangaroo mother care could replace the hospital-initiated programme. Appropriate in-hospital care for the delivery and transition of the neonate to extrauterine life (including kangaroo mother care and timely discharge) should be available to all mothers and their newborn babies globally, and community-initiated kangaroo mother care should be regarded as a transient policy while universal access to hospital care of deliveries is achieved.