Predictors for opting for Kangaroo Mother Care in Pakistan and infant development outcomes: Results of a quasi-experimental study

doi:10.21203/rs.3.rs-4896494/v1

Background:Although Kangaroo Mother Care (KMC) is recognized to improve maternal and child health outcomes globally, there are cultural concerns for uptake in Pakistan. In this study we aim to (i) identify socio-demographics of mothers who opt for the KMC program, and (ii) to compare the growth and development milestones, mortality, and other health choices between the KMC and a control group after a one-year period.

Methods:We conducted a quasi-experimental study in a tertiary health sector of Lahore, Pakistan. KMC was adopted by mothers based on self-selection. A follow up of 200 mothers in each group was performed. Data was analyzed using both bivariate regression and Mann-Whitney U tests.

Results: We found maternal socio-demographic predictors for enrollment in KMC to be working mothers, living in nuclear unit, having less children, higher family income, more prenatal visits, higher literacy, and living closer to the health center. Infants who received KMC, compared to the control group, showed significantly higher means for breastfeeding within two hours, breastfeeding exclusively for six months, breastfeeding up to one year, and complete vaccination in first year. Infant development milestones were also significantly higher in KMC groups. Neonatal death of baby was significantly lower in the KMC group. Infant weight gain, length gain, and head circumference gain for children in the KMC group was also greater.

Conclusions: We conclude that KMC is an impactful low-cost intervention that should be rolled out across the country to secure maternal and child health targets and meet SDGs. However, partner social and health administrative interventions are critical to support uptake in disadvantaged women and families to overcome cultural and institutional barriers to ensure successful implementation across the large population of Pakistan.

Kangaroo mother care

Pakistan

infant development

breast-feeding

neonatal death

vaccination

child health

To meet Pakistan’s maternal and child health Sustainable Development Goals (SDG) there is need for collective efforts by stakeholders and multiple partner interventions [1]. Kangaroo Mother Care (KMC) involves skin-to-skin contact of mothers and infant post-delivery; which is recommended for up to 24 hours in a day, and is continued until the infant reaches term, infant weight is around 2,500g, or the infant rejects KMC [2]. In 2003, the World Health Organization (WHO) released its first guidelines on key aspects of KMC including position, feeding, nutrition and discharge, and ambulatory follow-up [3]. Introducing KMC in developing countries like Pakistan has obvious benefits. First, it is a low-cost intervention, and second, it is an alternative to missing health services such as incubators at hospitals and advanced health centers in under-resourced and remote areas [1].

However, there is concern about how many mothers in Pakistan opt for the program given high incidence of illiteracy and low health awareness in majority women of Pakistan [5]. Decisions of mothers in Pakistan to opt for KMC are also strongly associated with cultural factors such as confidence and trust in innovative health recommendations not backed by traditions and culture [6], permission of in-laws and spouse [7], the triple shift burden and time poverty [8,9]. This may be why countries like Pakistan have not made concentrated efforts to implement KMC as standard care across all public and private sector services for maternal and child health [7]. In order to plan prudent upscale of KMC in the country it is important not only to assess its impact on infant development, but also to identify characteristics of women who choose to opt for this program.

Development of child post KMC

Observational studies have shown a reduction in mortality after KMC, along with better mental development and better results in motor tests [2]. A systematic literature review and meta-analysis of 124 studies, estimating the association between KMC and neonatal outcomes, confirmed that infants in the KMC program, compared to conventional care, have lower mortality, neonatal sepsis, hypothermia, hypoglycemia, hospital readmission, mean respiratory rate, and pain measures [10]. KMC infants also had increased exclusive breastfeeding, higher oxygen saturation, and head circumference growth. In a randomized controlled trial (RCT) including only low birth weight infants, the KMC infants were evidenced to show less nosocomial infections and less hospital stay compared to the control group [11]. However, there were no differences in risk of dying, or growth indices in both groups.

In another study that examined whether KMC benefited premature infants, it was found that infants showed more alertness and less gaze aversion in the KMC group [12]. At six months, infants in the KMC group scored higher on the Bayley Mental Developmental Index and the Psychomotor Developmental Index compared to the control group. More positive results from a RCT in India found that infants in the KMC group experienced reduced hypothermia, higher oxygen saturations, and stable respiratory rates [13]. However, there were no statistically significant differences in the incidence of hyperthermia, sepsis, apnea, onset of breastfeeding, and hospital stay between the KMC and control group. Evidence from Iran also showed improvement and stabilizing of vital signs of newborns in the KMC group, including average temperature and arterial oxygen saturation rates [14]. However, no significant differences in the mean heart and respiration rate between the KMC and control group were found.

In an RCT conducted in Columbia, the long-term effects of KMC were investigated to assess if there was any impact after 20 years in adulthood [11]. It was found that the effects of KMC at one year on intelligence quotient and home environment were still present 20 years later, and that KMC parents were more protective and nurturing, evidenced by reduced school absenteeism and reduced hyperactivity, aggressiveness, externalization, and socio-deviant conduct. In addition, neuroimaging showed larger volume of the left caudate nucleus in the KMC group. In a RCT in Australia no differences were found between the KMC versus the control group in terms of maintenance of or rise in temperature in infant, weight gain, length of stay in the hospital, and duration of breastfeeding [15]. Some of the reasons that may have influenced lack of differences, according to the authors, were (i) the self-selected nature of the sample, (ii) infants were relatively older and healthier than those reported in previous studies, and (iii) errors in reporting of data for temperatures and weights because of variations in the procedures for weighing and temperature-taking and the lack of systematic calibration of scales and thermometers.

In a review of 12 countries from the Middle East, it was found that KMC is helpful in decreasing duration of hospital stay, reducing pain intensity in newborns undergoing painful procedures, and that there was a longer duration of exclusive breastfeeding [16]. In addition, improvements were found in the neonatal weight gain, and infants’ physiological, behavioral, and psychosocial outcomes in the KMC groups compared to the control. A local study from Pakistan revealed that KMC infants, who were stable and with birth weight between 1.5 to 2.5 kg, benefited from exclusive breast-feeding, and reduction in neonatal mortality and morbidity [17]. Another local study found that intermittent KMC was effective for improving weight-gain in neonates admitted in the neonatal intensive care unit compared to the control group [18].

Cultural and practical uptake of KMC

Evidence from western countries suggests that even women from advantaged and more literate backgrounds face certain challenges in opting for KMC, due to exhaustion pre and post pregnancy, and less information provided by healthcare institute about the practical application of the method [19]. A systematic literature review of 112 studies summarized the barriers to uptake of KMC by mothers, which included lack of time, social support, and family acceptance [20]. In addition, barriers in efficiency of healthcare system were highlighted, which included lack of organization, financing, and service delivery. In another study an attempt was made to identify factors involved in unsuccessful KMC implementation in 15 developing countries [21]. It was found that key aspects of managing the KMC program, such as early-discharge, ambulatory follow-up, and regular visitation of mother’s post discharge, were difficult to implement. There were also cultural barriers, such as resistance from health professionals, mothers, and families due to cultural beliefs.

Twenty-one percent of women in India who had taken part in the KMC program indicated that they did not feel comfortable practicing the kangaroo method, and 27% indicated facing barriers in continuing with KMC when they returned home [13]. This was mainly because of time and home management burden, but also because 14% of mothers felt that the conventional method of care was better, and because 36% fathers did not support mothers giving KMC at home. Another study summarizing results from Muslim and conservative countries concluded that there is low awareness in mothers about the KMC process, and that mother’s experience pain and fatigue, and lack of help or support from family members in practicing KMC [16]. Overall, the study concluded that KMC practice remains difficult and cannot be practiced alone by mother without the support and cooperation of family members. Furthermore, in even more conservative countries like Afghanistan, KMC was considered as a shameful practice, as it involved skin to skin contact and removal of the clothes of the mother [22].

A study from Iraq reported that the cultural practice in Muslim countries and joint families is that the baby is separated from the mother after birth by family members and in-laws, making uptake of KMC or complete observance of KMC impossible [23]. Known benefits for developing countries to adopt KMC include low-cost [13] and that nurses can be trained in short periods of time to support mothers to adopt KMC [14]. In fact, KMC has been known to be launched in developing nations as a compensation for understaffing and availability of medical equipment to care for premature or low birth weight infants [15]. Thus, the greater applicability for a country like Pakistan which suffers from critical resource and staffing shortages in the health sector [24].

Local studies have attempted to understand the supply-side and uptake issues related to implementation of KMC. It was found that health facility readiness in Pakistan is missing, and there is critical need for investment of equipment, supplies, water-sanitation facilities, privacy in 7ard for mother such as a curtain, and quality training of nurses instructing mothers for KMC [7]. There are controversies and challenges in initiation of KMC in many hospitals of Pakistan due to the resistance from healthcare providers and health administration who consider KMC a non-traditional practice [17]. Another study from Pakistan confirmed that barriers to initiating KMC included tiredness after delivery, cesarean section delivery, employment of mothers, and cultural barriers [25].

It has also been highlighted in Pakistan that the mortality rate of neonates was high in infants provided KMC, and that there is critical need to follow the WHO guidelines for implementing early KMC [26]. Findings from rural Pakistan indicated major barriers to uptake with women not wanting to provide KMC to low birth-weight infants as they felt shame, fear, and in some cases did not want to keep the child at all [27]. Environmental issues were also a problem such as hot and sticky weather and not wanting to make skin contact with the infant, along with lack of transportation and finances to visit healthcare for follow-up. Above all, rural women were found to face immense social barriers due to excessive burden of managing the home and care of dependents which prevented observance of KMC even when there was willingness. On a positive note, some local scholars conducted qualitative interviews to understand willingness to support KMC in communities and found that though there was less awareness and practice, family members were willing and eager to try KMC, especially to save low-birth infants [28].

Aim and significance of the study

In lieu of the cultural barriers and that major factors preventing satisfactory maternal and health outcomes in the country include low rates of exclusive breastfeeding [29], incomplete vaccination [30], high infant mortality rates [31], and inadequate growth parameters [32], we had two aims of this study: First, to identify which socio-demographics of women are associated with choice to opt for the KMC program, and second, to compare the development milestones, mortality, and choices for breastfeeding and vaccination between the KMC and control group after a one-year period. Based on these study findings we will be able to advise better health and social policy to support mothers to opt for KMC and to upscale KMC services across maternal care and obstetric wards of the country. In the long run, we believe that KMC adoption in the country will help improve infant survival and development outcomes and keep Pakistan on target to meet the SDGs.

Study design

This quasi-experimental study had a control and an experiment group, with the assignment of participants based on self-selection. The study took place in the Obstetrics and Gynecology Department (O&GD) of a public sector hospital in Lahore, Pakistan [33], which provides free services and caters to 60,0000 outpatients annually. The hospital is visited by underprivileged families of Lahore and other periphery cities and villages where tertiary care facilities are not available. The study was approved by the university and hospital research ethics committee of Services Institute of Medical Services. Informed consent was taken from all participants, and no one was coerced to participate or remain in the program.

Study population and inclusion criteria

A total sample size of 400 (200 in each group), who completed the follow-up of one year, was taken according to the standard WHO sample size calculation using the confidence level of 95% and power of test 90% [34]. Babies born between January 2020 to December 2022 fulfilling the inclusion criteria were included in the study through non-probability consecutive sampling. The inclusion criterion for streaming into the experiment group were: (i) women who were able to follow the program instructions, (ii) permanent residents of Lahore and its periphery and willing to be part of program for the one-year time period, and (iii) live newborn babies delivered either vaginally or through caesarean section with birth weight of 1.5 to 2 kg, with gestational age between 28 to 36 weeks, and (iv) stable babies not requiring incubators or ICU care. The exclusion criterion for streaming in the experiment group were: (i) an infant or mother diagnosed with a life-threatening ailment, major disease, or major malformations, (ii) early-detected major conditions arising from perinatal problems, such as severe hypoxic–ischemic encephalopathy, pulmonary hypertension, and (iii) incidence of severe infection measured as nosocomial infections requiring systemic antibiotics or infections, severe respiratory distress, and hypothermia episodes (temperature less than 35°C).

Study variables

The following 16 socio-demographics of participants was collected: age, parity, literacy, occupation, family monthly income, regional belonging, distance from healthcare, number of family members, number of children, number of prenatal visits, marital status, gender of baby, duration of pregnancy, mode of delivery, hypothermia, and sepsis within 72 hours. Study variables collected to assess primary outcomes included: mortality, growth of infant (weight, height, and head circumference), developmental milestones, breastfeeding, and vaccination. Mortality was measured as the proportion of children dying after enrolment at birth to one year of age. Table 1 summarizes the study primary outcome variables and their respective coding.

Recruitment and allocation

An observer especially assigned for the study reviewed the records of the delivery room daily and identified newborn infants eligible for the program. Once an infant was identified as eligible, parents were interviewed by a study nurse and invited to participate in the study. If they agreed to be part of the KMC group, informed consent was taken. Participants assigned to the control group received conventional care. Conventional care consisted of keeping newborns in open cots with either air conditioning or heating dependent on the weather, and according to their needs. Mothers were guided about benefits of exclusive breastfeeding and supported to initiate breastfeeding.

Study intervention and training of mothers for KMC

Services Hospital has a KMC unit established by UNICEF. Mothers in the KMC group were asked to stay in the hospital as long as necessary to demonstrate that the adaptation was appropriate before discharge. For this study, mothers were provided the following guidance and support for implementation of KMC: (i) upright kangaroo positioning and skin to skin contact of mother and infant for 24 hours a day (Figure 1), and (ii) monitoring of exclusive breastfeeding. A comprehensive IEC (information, education, and communication) package designed to educate parents and families about the advantages of KMC for the survival and well-being of low birth weight newborns was also provided. This package includes flip charts, wall mounts, and a detailed video explaining the steps and benefits of KMC. It also covers the potential implementation of a buddy system, where skin-to-skin contact can be provided by other family members.

The KMC unit room temperature was kept at 25-28°C to support infant’s temperature remained within the normal range due to the mother’s body heat. KMC was done by grandmothers in immediate postpartum period for mothers who had undergone a caesarean section. Infants remained in the kangaroo position until they no longer accepted it by demonstrating discomfort, pushing out limbs, and crying and fussing when mothers try to return them to the upright position. In both groups mothers were also taught to feed babies their own breast milk by cup and spoon until breastfeeding could be established adequately.

During the hospital stay daily monitoring of both groups was done to record (i) weight gain, (ii) signs of sepsis and signs of hypothermia (temperature<35°C), and (iii) physiological parameters (heart rate, respiratory rate, and temperature). Infants of both groups were discharged when they demonstrated (i) no adaptation problems to extrauterine life, (ii) weight gain of at least 20g /day for three consecutive days, (iii) no overt illness, or I/V medication, and had received proper treatment for infection or concomitant condition if needed, and (iv) they could suck and swallow properly, and successful breastfeeding had started.

Additional support provided to both KMC and control group

If some babies had trouble taking up breastfeeding, mothers were supported to extract breast milk and feed infant with a spoon. For some pre-term infants (≤32 week) breast milk had to be supplemented with specialized human milk fortifier, to cover protein needs, under close supervision of hospital staff. During hospital stay, scheduled feeding of infant at every 2–3 hours was administered. Both mothers and families were counselled that after discharge, putting baby on their front at home can increase the risk of sudden infant death syndrome. Mothers were taught to practice hand washing and general sanitary measures before handling and after washing infants. Mothers were also encouraged to take a balanced diet with fruit, vegetables, and dairy products to ensure good milk supply. They were asked to apply/massage safe topical oils to the body of the baby, which enhances the emotional bonding of mother and wellbeing of baby. Before discharge mothers were counselled about symptoms of respiratory tract infections and need for hospital admission as preterm babies are at high risk of infection. Family was counselled to start weaning at six months of age with semisolids and to support mothers at home for proper care of these babies. Mothers were also guided about reporting to hospital earlier in case of any problem regarding their own and baby health.

Data collection and follow-up

After discharge, both groups were given appointments for the outpatient clinic for care and follow-up. To minimize contamination bias, infants of the KMC and control groups took place on different days of the week. The duration of KMC at home was specified to the family of at least 8 hours or more. The follow-up appointments took place (i) at six weeks after birth, (ii) monthly till six months of age, and (iii) quarterly up till one year of infant birth. At each visit growth parameters of infant, qualitative questions related to development milestones, and breastfeeding and vaccination status of infants was recorded. At each visit information about breastfeeding practices, vaccination status of infants, growth parameters (height, weight, and head circumference) of infant, and development milestones (holding head, sitting without support, roll over, crawling, babbling, and producing two syllable sounds) were recorded according to the Centre of Disease Control (CDC) growth charts [35].

We completed follow-up of 200 cases in both KMC and control group. At the end of one year, we were left with 195 babies in KMC and 171 in control group as mortality occurred in 5 (2 deaths in early neonatal period and 3 infant deaths) in KMC group, and 29 (18 deaths in early neonatal, 10 in late neonatal period, and 1 infant death) in control group. Follow-up is always a problem in low- and middle-income countries, as people generally live far away and have problems with conveyance and funds for transport, which hinders their access to health services. The majority of study participants (72.8%) were booked antenatal patients and based on digital records, we adopted strong follow-up by regular telephonic reminders of scheduled appointments and incentivization through provision of free multivitamins and vaccination to both mother and child at each follow-up visit.

Data analysis

Data was entered in the hospital computerized data base by nurses and clinicians. Practitioners assessing infants the hospital and later at follow-up could not be blinded, given that kangaroo mothers were holding their infants in the kangaroo position at time of the interviews and clinical exam. The hypotheses of this study was that children provided KMC, compared to the control group, would show better results for (i) exclusive breastfeeding and vaccination, (ii) growth parameters, including weight, length, and head circumference, (iii) development milestones, and (iv) mortality. We used SPSS 25.0 to analyze the data. First, we applied bivariate odds regression to predict higher chance of enrolling in the KMC program. Next, we used the Mann-Whitney U test to compare the mean ranks between the KMC and control groups (independent variables) with the study independent variables (exclusive breastfeeding and vaccination; growth parameters; development milestones; mortality). P-values of less than 0.05 were considered significant. The analysis was performed from the intention-to-treat perspective (effectiveness as opposed to efficacy), which means that all subjects were analyzed according to the group to which they were allocated, regardless of compliance with treatment or contamination of the intervention.

Sociodemographic characteristics

Table 2 presents the sociodemographic characteristics of the participants. Many of the mothers in both the KMC (50.0%) and control (31.5%) group are between the ages of 30–34 years. The majority of mothers is either illiterate or has studied till secondary level (grade 10) (KMC= 85.5%; control=91.0%). Similarly, the majority are housewives (KMC=82.0%; control=93.0%) and have a household income of below PKR 60,000 (USD 215.5) (KMC=87.0%; control=94.0%). The data confirms that mothers visiting tertiary care public sector hospitals of Pakistan are some of the most disadvantage women with regards literacy, employment, and wealth status. This is the group that require more health and social interventions for improved practices for maternal care and to prevent maternal and infant mortality. Many mothers belong to houses with family members above nine people (KMC=28.0%; control=52.0%) and are some are either divorced or widowed (KMC=10.0%; control=14.0%).

Sociodemographic predictors for opting in KMC

Table 3 presents predictors for mother enrolled in the KMC intervention. Mothers of the following demographics have higher probability of opting for KMC in Pakistan: (i) mothers who were working or employed (p<0.001), (ii) mothers with less family members or living in nuclear units (p<0.001), (iii) mothers with less children (p=0.007), (vi) mothers with higher family income (p=0.010), (v) mothers who had more prenatal visits with healthcare providers (p=0.031), (vi) literate mothers (p=0.039), and (vii) mothers living closer to the healthcare center (p=0.050). Interestingly, despite high incidence of son preference we found no association with gender of baby and choice to enroll in KMC. We also did not find any significant association with mode of delivery, duration of pregnancy, and marital status.

Comparison for exclusive breastfeeding and vaccination

Table 4 presents the Mann-Whitney U test results for KMC and control group with respect to breastfeeding practices and vaccination. The results reveal that (i) breastfeeding within two hours was significantly higher in the KMC group compared to the control group with a large effect size of r=0.88; (ii) breastfed exclusively for six months was significantly higher in the KMC group, with a medium effect size of r=0.68; (iii) breastfeeding up to one year was significantly higher in the KMC group, with a medium effect size of r=0.54; and (iv) complete vaccination in first year was significantly higher in the KMC group, with a medium effect size of r=0.57.

Comparison for growth parameters

Figures 1-3 present the comparisons for infant weight gain, length gain, and head circumference gain for children in the KMC group versus the control group. The gains for all three growth parameters show better results in the KMC group compared to the control group.

Comparison for development milestones and mortality

Table 5 presents the Mann-Whitney U test results for the KMC and control group with respect to development milestones of child and death of baby. Significant results with small effects included (i) infant holding head up at 3 months being higher in the KMC group, with a small effect size of r=0.26; and (ii) infant sitting without support curved at 6 months showing as higher in the KMC group, with a small effect size of r=0.28.

Significant results with medium effects included (i) infant rolling over at 8 months was higher in the KMC group, with an effect size of r=0.41; (ii) infant crawling at 10 months was higher in the KMC group, with an effect size of r=0.47; (iii) infant babbling at 6 months was higher in the KMC group, with an effect size of r=0.38; and (vi) infant making two syllable sounds at 9 months was higher in the KMC group, with an effect size of r=0.43.

With respect to neonatal death of baby we found that results were significantly higher in the control group, with a medium effect size of r=0.36.

The objective of this study was first to identify which socio-demographics of mothers are associated with choice to opt for the KMC program, in consideration of the socio-cultural barriers to uptake in Pakistan and second, to compare the development milestones, mortality, and breastfeeding and one-year vaccination practices between the KMC and control group after one-year of infant birth. Expectedly, we found the following maternal characteristic to be associated with low uptake: low literacy, living in large or joint families, having more children, poverty, low prenatal visits, and distance to health center. Previous studies from developing regions confirm that socio-economic deprivations of low literacy and poverty prevent women from opting for KMC due to [36]. Women with more children and dependents also have time management issues in implementing KMC [37], whereas more work pressure and interference from in-laws prevents mothers from having private time with newborn [38].

A local study investigating socio-economic deprivations of women adopting KMC in Pakistan, revealed that considerable women suffer from anemia and health problems during pregnancy, and suffer from poverty and low literacy, compromising KMC practices and health outcomes [39]. In this way, though KMC is a low-cost intervention, the complexity is that it still requires advantaged socio-demographic backgrounds of mothers and strong social support networks for uptake and for women to be able to practice it for complete efficacy. Findings for prenatal visits and distance from healthcare confirm supply-side issues in Pakistan related to effective services for maternal health [40]. Evidence confirms that most women have long distances to travel and have both mobility and financial issues in pursuing prenatal checkups or antenatal checkups, which would prevent women from opting into the KMC program [41].

This is why the role of community health workers (CHWs) is immense, as the majority of Pakistan’s mothers come from rural and remote areas or underdeveloped urban areas [42]. For successful KMC implementation upon discharge and within homes, there is a need for the following services by CHWs: (i) continued counseling for continuation of KMC in mothers and families, (ii) maintaining an infection-free environment for mother and infant in the homes, (iii) home-based data collection and follow-up at residences, such as checking skin-to-skin contact, recording temperature of the baby and any feeding problems. Needed also would be the requisite training of CHWs for antenatal care and KMC, along with effective referral system to support them.

We also found that unemployed mothers have less odds of opting for KMC. This is contrary to previous research from developing nations which suggests that employed mothers face barriers in pursuing KMC, due to greater pressure to return to work after birth of child [43,44]. Out study findings suggest that unemployed mothers in Pakistan may actually have more work burden and responsibilities of care within the home, and less privacy or support from in-laws and family members to practice KMC [45]. It may also be that unemployed mothers have less decision-making power to opt for KMC as they do not contribute to household income [46]. Local studies also suggest that informal sector and semi-skilled workers may report themselves as unemployed or that they may be temporarily unemployed and hopeful to be back at work, for example in contractual teaching jobs and so such women would also be less inclined to pursue KMC [47].

We found significantly positive outcomes for all study indicators for maternal practices and infant development. Mothers of the KMC group showed comparatively better practices for breastfeeding and one-year vaccination, and infants showed better development milestones for holding head up at three months, sitting without support curved at six months, rolling over at eight months, crawling at ten months, babbling at six months, and making two syllable sounds at nine months. Neonatal death of baby was significantly lower in the KMC group. In addition, infant weight gain, length gain, and head circumference gain for children in the KMC group was also greater. Our results confirm other studies from Muslim and conservative nations about KMC leading to improvements in breastfeeding [48], complete vaccination [49], development milestones in infants [50], and reduced mortality [51].

Limitations of the study were the small sample size and data collection from only one tertiary healthcare center. Data related to maternal health indicators were not collected and we recommend that future research considers the impact of KMC on the physical and mental health of the mother, perceptions of parental skills, and also on the maternal-child relationship and bonding. We also acknowledge that perhaps the positive results in the KMC group may be because of self-selection and also the initial advantages of infants in the KMC group. At that same time, there are considerable strengths of this study including that (i) it was completed in an overburdened and understaffed tertiary setting, and was completed based on the extra time invested by the researchers, (ii) it is the first study reported from Pakistan which has a long follow-up of one year comparing babies provided KMC and CC, and (iii) it has implications for incorporation of KMC across the public and private sector of Pakistan, in consideration of socio-cultural interventions that would support uptake in disadvantaged women and families of the country.

We conclude that KMC is an important low-cost intervention that should be rolled out across the country to secure maternal and child health targets and to meet SDGs, however, partner social interventions are critical to support uptake in disadvantaged women and families to overcome cultural and environmental barriers and ensure successful implementation across the large population of Pakistan. Based on our findings we recommend increased support for unemployed women and illiterate mothers to adopt KMC through additional training and awareness support. We also need family awareness sessions to improve support for women living in joint families and those with more children so there is less time poverty in such women and family assistance to observe KMC. Poor, unemployed women, and those living far from the health center, may need additional subsidies and travel allowances or ambulatory services to opt in and remain in the program. Finally, prenatal visits need to be assured through the primary healthcare sector and community health workers to secure uptake of KMC. Overall, Pakistan suffers from critical issues related to low incidence of exclusive breastfeeding, incomplete vaccination, high infant mortality rates, and inadequate growth parameters with issues of undernutrition, stunting and wasting. In order to tackle all these issues simultaneously, our study confirms that KMC can be an effective and low-cost intervention deployed with minimum training and time delays across health centers of the country.

CHW Community health worker

CI Confidence interval

IEC Information, education, and communication

KMC Kangaroo Mother Care

RCT Randomized controlled trial

SDG Sustainable Development Goal

WHO World Health Organization

Ethics approval and consent to participate

The study was approved by the Lahore Services Hospital Research Ethics Committee. The study was conducted in accordance with the Declaration of Helsinki. Informed consent was taken from all participants.

Consent for publication

Not applicable.

Availability of data and materials

The data is available from the corresponding author upon reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Authors’ contributions

TW conceptualized the project, gained ethical approval, and oversaw the entire project. GR supervised the data collection and intervention delivery. SRJ analysed the data, prepared the results and wrote the manuscript. HZS supervised data collection. JZ and TI assisted in data collection. AZW performed data collection and data entry. AM and FF reviewed the final manuscript for important intellectual content. All authors read and approved the final version of the manuscript.

Acknowledgements

We acknowledge all the mothers that participated in the study. We are also grateful for the help and efficient work of all providers at the hospital, especially our supervising nurses (Ms. Shahnaz Ali, Ms. Sanam Hasan, Ms. Nargis Yusuf), and our pediatric colleagues Dr. Ayesha Hanif, Dr. Umer Usman, Dr. Iqra Zamir and Dr. Tooba Javed).

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Table 1: Summary of primary outcome variables of study and their respective coding

*Primary outcome variables*	*Coding and labeling*
Breast feeding initiation within first two hours	No, Yes
Breastfeeding exclusive (only fed on breastmilk in first 6months)	No, Yes
Breastfeeding up to one year	No, Yes
Complete vaccination at one year	No, Yes
Weight of infant at birth, six weeks, six months, and one year	Measured in kgs
Length of infant at birth, six weeks, six months, and one year	Measured in cms
Head circumference of infant at birth, six weeks, six months, and one year	Measured in cms
Hold head up at three months	Satisfactory, Unsatisfactory
Sit without support curved six months	Satisfactory, Unsatisfactory
Roll over at eight months	Satisfactory, Unsatisfactory
Crawling at ten months	Satisfactory, Unsatisfactory
Babbles at six months	Satisfactory, Unsatisfactory
Two syllable sounds at nine months	Satisfactory, Unsatisfactory
Death of baby	Early neonatal death (0-7 days), late neonatal death (8-28 days), post neonatal death (after 28 days)

Table 2: Sociodemographic characteristics of participants (n=400)

Variables

KMC

(n=200)

Control

(n=200)

Age of mother

18–24

25–29

30–34

35–39

19 (9.5%)

48 (24.0%)

100 (50.0%)

33 (16.5%)

34 (17.0%)

62 (31.0%)

63 (31.5%)

41 (20.5%)

Literacy

Illiterate

Secondary

Graduation

25 (12.5%)

146 (73.0%)

29 (14.5%)

77 (38.5%)

105 (52.5%)

18 (9.0%)

Occupation

Housewife

Working

164 (82.0%)

36 (18.0%)

186 (93.0%)

14 (07.0%)

Monthly household income (in PKR)

10,000–30,000

31,000–60,000

More than 60,000

73 (36.5%)

101 (50.5%)

26 (13.0%)

119 (58.5%)

71 (35.5%)

32 (16.0%)

Number of family members

2–4 people

5–8 people

9 and above people

45 (22.5%)

99 (49.5%)

56 (28.0%)

44 (22.0%)

52 (26.0%)

104 (52.0%)

Marital status

Divorced/widowed

Currently married

20 (10.0%)

180 (90.0%)

28 (14.0%)

172 (86.0%)

Table 3: Bivariate regression results predicting mothers choice to enroll in KMC (n=200)

Variables

Odds ratio

95% CI

p-value

Age of mother

18–24

25–29

30–34

35–39

1.44

1.04

0.50

1

0.69–2.97

0.57–1.88

0.29–0.88

0.324

0.898

0.117

Literacy

Graduate

Secondary

Primary

Illiterate

4.96

1.12

1.95

1

2.36–8.41

0.52–2.41

0.94–4.04

<0.001

0.757

0.072

Occupation

Working

Housewife

2.91

1

1.51–5.59

0.001

Monthly household income (in PKR)

More than 61,000

31,000-60,000

10,000-40,000

2.70

1.80

1

1.26–5.76

0.76–4.29

0.010

0.181

Number of family members

2-4 people

5-8 people

9 and above people

1.889

0.525

1

1.13–7.25

0.07–3.83

0.526

0.531

Marital status

Currently married

Divorced/widowed

1.57

1

0.62–3.93

0.336

Number of prenatal visits

3 or more

2 or less

2.59

1

1.49–4.51

0.001

Distance from healthcare center

Less than 5km

More than 5km

1.34

1

0.67–2.67

0.402

Regional belonging

Urban

Rural

3.99

1

2.58–6.17

<0.001

Duration of pregnancy

35 weeks and above

34 weeks or below

1.979

1

1.30–2.99

0.001

Mode of delivery

Vaginal delivery

Caesarean section

1.51

1

0.77–1.70

0.483

Gender of baby

Male

Female

1.86

1

0.58–1.28

0.483

Parity of mother

One child

Two or more

3.98

1

1.72–9.20

0.001

Hypothermia after delivery

No

Yes

2.57

1

1.06–4.72

<0.001

Sepsis within 72 hours of delivery

No

Yes

4.41

1

2.25–7.65

<0.001

Table 4: Mann-Whitney U test comparisons for KMC and control group for breastfeeding practices and complete vaccination in first year

	*Group*	N	*Mean Rank*	*Mann-Whitney U*	Z	*p-value*
Breastfeeding within two hours	KMC Control Total	200 200 400	247.50 153.50	10600.00	-9.446	<0.001
Breastfed exclusively (six months)	KMC Control Total	200 200 400	230.50 170.50	14000.00	-6.061	<0.001
Breastfeeding up to one year	KMC Control Total	200 200 400	232.50 168.50	13600.00	-6.424	<0.001
Complete vaccination in first year	KMC Control Total	200 200 400	222.50 178.50	15600.00	-6.332	<0.001

Table 5: Mann-Whitney U test results for development milestones and mortality

	*Group*	N	*Mean Rank*	*Mann-Whitney U*	Z	*p-value*
Hold head up at three months	KMC CC Total	200 200 400	232.50 168.50	13600.00	-7.333	<0.001
Sits without support curved at six months	KMC CC Total	200 200 400	231.00 170.00	13900.00	-7.266	<0.001
Rolls over at eight months	KMC CC Total	200 200 400	228.50 172.50	14400.00	-6.807	<0.001
Crawling at ten months	KMC CC Total	200 200 400	227.50 173.50	14600.00	-6.621	<0.001
Babbles at six months	KMC CC Total	200 200 400	229.00 172.00	14300.00	-6.900	<0.001
Two syllable sounds at 9 months	KMC CC Total	200 200 400	224.03 171.84	14349.50	-6.721	<0.001
Neonatal death of baby	KMC CC Total	200 200 400	191.46 209.54	18192.50	-3.236	0.001

No competing interests reported.

Predictors for opting for Kangaroo Mother Care in Pakistan and infant development outcomes: Results of a quasi-experimental study

Status:

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Abstract

Figures

Background

Methods

Results

Discussion

Conclusions

Abbreviations

Declarations

References

Tables

Additional Declarations

Status:

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