Determinants of Kangaroo Mother Care Uptake for Small Babies Along the Health Facility to Community Continuum in Karnataka, India

Maryann Washington; Leah Macaden; Annetta Smith; Sumithra Selvam; Prem K. Mony

doi:10.9745/GHSP-D-22-00457

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FIGURE 1
Conceptual Framework for KMC Uptake Study in Karnataka, India
Abbreviation: KMC, kangaroo mother care.
^aSupportive supervision specialists were not recruited because they only facilitated processes of health facility preparedness or in capacity-building of health care workers (knowledge, attitude, and skills).
^bNot recruited to the study, but the role of on-site nurse mentors was indirectly studied through responses of mothers and foster KMC providers on support for KMC uptake at the health facility.
^cCommunity health workers’ input was indirectly studied from responses of mothers and foster KMC providers on the KMC maintenance support at home, after discharge from the health facility.
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FIGURE 2
Data Collection Points for KMC Uptake Study in Karnataka, India, June 2017–March 2020
Abbreviations: HCW, health care worker; KMC, kangaroo mother care.
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FIGURE 3
Participant Recruitment Process for KMC Uptake Study in Karnataka, India
Abbreviation: KMC, kangaroo mother care.
^a3 babies did not survive 28 days of life.
^b1 baby did not survive 28 days of life.

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TABLE 1.

Characteristics of Mothers and Babies Participating in KMC Uptake Study in Karnataka, India

Variables	No. (%)
Mothers (n=209)
Education
≤8^th grade	134 (64.1)
>8^th grade	75 (35.9)
Employed^a
Yes	127 (60.8)
No	82 (39.2)
Number of children
1 child	114 (54.5)
>1 child	95 (45.4)
Babies <2,000 g at birth (n=227)
Sex
Male	94 (41.4)
Female	133 (58.6)
Birth weight
≤1,500 g	48 (21.2)
>1,500 g	179 (78.9)
Place of birth^b
Public health facility	129 (56.8)
Private health facility	78 (34.4)
Home	20 (8.8)
Health status at birth^c
Well	37 (16.3)
Sick	190 (83.7)
Place of hospitalization^b
Public health facility	105 (46.3)
Private health facility	122 (53.7)
Hospitalization duration^b
≤3 days	102 (44.9)
>3 days	125 (55.1)

Abbreviation: KMC, kangaroo mother care.
↵^aThose in skilled and unskilled occupation grouped as employed since only a small percentage were under skilled category for binomial and log binomial regression analysis.
↵^bWere grouped under characteristics of health facilities for binomial and log binomial regression analysis.
↵^cAs reported in the district-wide project database.

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TABLE 2.

Bivariate Analyses of KMC Uptake by Characteristics of Health Facilities, Health Care Workers, Mothers, and Babies in Karnataka, India

Determinants	Day of Life of KMC Initiation, No. (%)(n=223)^a^,^c		uRR(95% CI)	KMC Duration-Day Before Discharge,No. (%) (n=216)^a^,^d		uRR(95% CI)	KMC Duration on 7^th Day After Discharge,No. (%) (n=219)^a^,^e		uRR(95% CI)
Determinants	≤3 days (n=133)	>3 days (n=90)	uRR(95% CI)	≥8 hrs (n=123)	<8 hrs (n=93)	uRR(95% CI)	≥8 hrs (n=98)	<8 hrs (n=121)	uRR(95% CI)
Characteristics of health facilities
Health facility preparedness,^c^,^e mean±SD	61.1±14.6	65.1±6.5	0.98 (0.98, 0.99)	63.8±12.7	61.4±11.6	0.99 (0.98, 1.00)	61.0±13.2	64.0±11.2	0.98 (0.97, 0.99)
Place of birth^c
Public	94 (70.7)	33 (36.7)	4.74 (1.60, 13.5)	75 (60.9)	51 (51.6)	1.71 (0.84, 3.47)	56 (57.1)	69 (57.0)	1.10 (0.86, 1.40)
Private	22 (16.5)	54 (60.0)	1.73 (0.58, 5.12)	34 (27.6)	36 (41.9)	1.35 (0.66, 2.72)	29 (29.6)	45 (37.0)	0.63 (0.34, 1.17)
Home	17 (12.8)	3 (3.3)	1.0	14 (11.4)	6 (6.5)	1.0	13 (13.3)	7 (5.8)	1.0
Hospitalization location^c^,^d^,^e
Public	91 (68.4)	14 (15.6)	4.83 (2.91, 8.01)	76 (61.8)	28 (30.1)	2.15 (1.15, 3.07)	54 (55.1)	49 (40.5)	1.31 (1.01, 1.67)
Private	42 (31.6)	76 (84.4)	1.0	47 (38.2)	65 (69.9)	1.0	44 (44.9)	72 (59.5)	1.0
Hospitalization duration^c
≤3 days	87 (65.4)	15 (16.7)	4.21 (2.58, 6.86)	63 (51.2)	38 (40.9)	1.27 (0.93, 1.74)	48 (49.0)	53 (43.8)	0.91 (0.71, 1.16)
>3 days	46 (34.6)	75 (83.3)	1.0	60 (48.8)	55 (59.1)	1.0	50 (51.0)	68 (56.2)	1.0
KMC initiation support,^c^,^d mean±SD	6.8±1.6	5.8±2.7	1.06 (1.01, 1.11)	6.8±1.9	6.1±1.7	1.10 (1.04, 1.17)	6.5±2.1	6.03±2.1	1.03 (0.9, 1.11)
KMC maintenance support,^c^,^d mean±SD	8.5±3.5	7.0±3.9	1.04 (1.01, 1.07)	8.6±3.4	7.4±3.8	1.04 (1.003, 1.06)	8.0±3.9	8.1±3.6	0.99 (0.95, 1.03)
Characteristics of HCWs
Knowledge,^e mean±SD	70.4±3.1	69.9±0.8	1.07 (0.98, 1.17)	70.2±2.7	70.3±2.3	0.99 (0.92, 1.06)	70.7±2.7	69.9±2.1	1.05 (1.01, 1.09)
Attitude,^c^,^d^,^e median (IQR)	77.0 (3.0)	71.0 (3.0)	1.09 (1.07, 1.11)	77.0 (6.0)	74.0 (5.0)	1.01 (0.99, 1.02)	76.0 (6.0)	74.0 (5.0)	1.02 (1.01, 1.05)
Skills,^c,d mean±SD	56.3±4.9	52.6±3.6	1.08 (1.05, 1.11)	55.8±5.0	53.7±4.2	1.05 (1.02, 1.08)	55.3±4.8	54.4±4.8	1.02 (0.99, 1.05)
Characteristics of mothers
Age in years, mean±SD	23.3±3.6	23.9±4.5	1.03 (0.98, 1.07)	23.5±3.6	23.4±4.3	1.00 (0.97, 1.02)	23.5±4.5	23.6±3.5	0.99 (0.95, 1.03)
Education^d
≤8th grade	89 (66.9)	53 (58.9)	1.22 (0.89, 1.68)	85 (69.1)	52 (55.9)	1.37 (1.01, 1.84)	59 (60.2)	79 (65.3)	0.91 (0.70, 1.16)
>8th grade	44 (33.1)	37 (41.1)	1.0	38 (30.9)	41 (44.1)	1.0	39 (39.8)	42 (34.7)	1.0
Employed
Yes	81 (60.9)	53 (58.9)	1.05 (0.76, 1.45)	78 (63.0)	51 (54.8)	1.22 (0.90, 1.65)	58 (59.2)	74 (61.2)	1.04 (0.81, 1.32)
No	52 (39.1)	37 (41.1)	1.0	45 (36.0)	42 (45.2)	1.0	40 (40.8)	47 (38.8	1.0
No. of children
1 child	68 (51.2)	54 (60.0)	1.24 (0.89, 1.72)	69 (56.1)	50 (53.8)	1.05 (0.77, 1.43)	57 (58.2)	63 (52.1)	1.11 (0.88, 1.41)
>1 child	65 (48.9)	36 (40.0)	1.0	54 (43.9)	43 (46.2)	1.0	41 (41.8)	58 (49.9)	1.0
Knowledge,^b mean±SD		–	–	–	–	–	17.6±3.0	17.4±3.4	1.01 (0.96, 1.06)
Attitude,^b median (IQR)	–	–	–	–	–	–	4.0 (0)	4.0 (0)	–
KMC maintenance support at home,^b median (IQR)	–	–	–	–	–	–	12 (20.8)	17 (20.0)	0.99 (0.98, 1.01)
Characteristics of small babies
Sex
Male	53 (39.8)	39 (43.3)	0.91 (0.66, 1.26)	57 (46.3)	36 (38.7)	0.83 (0.60, 1.15)	43 (43.9)	48 (39.7)	0.92 (0.72, 1.18)
Female	80 (60.2)	51 (56.7)	1.0	66 (53.7)	57 (61.3)	1.0	55 (56.1)	73 (60.3)	1.0
Birth weight, g^c
≤1,500	18 (13.5)	29 (32.2)	0.56 (0.42, 0.76)	23 (18.7)	25 (26.9)	0.77 (0.56, 1.08)	23 (23.5)	26 (21.5)	0.95 (0.70, 1.27)
>1,500	105 (86.5)	61 (67.8)	1.0	100 (81.3)	68 (73.1)	1.0	75 (76.5)	95 (78.5)	1.0
Status at birth^c^,^d
Well	16 (12.0)	19 (21.1)	0.69 (0.48, 0.99)	13 (10.6)	21 (22.6)	0.64 (0.46, 0.88)	17 (17.3)	20 (16.5)	0.97 (0.7, 1.34)
Sick	117 (88.0)	71 (78.9)	1.0	110 (89.4)	72 (77.4)	1.0	81 (82.7)	101 (83.5)	1.0

Abbreviations: CI, confidence interval; HCW, health care worker; IQR, interquartile range; KMC, kangaroo mother care; SD, standard deviation; uRR, unadjusted relative risk.
↵^aSubset of babies for whom KMC details were available in database.
↵^bNot included in bivariate analysis for “day of life of KMC initiation” and “duration of KMC on day before discharge” since these were assessed for more than 28 days after childbirth.
↵^cVariable selected for log binomial regression analysis for day of life of KMC initiation (P value up to .10).⁴⁰
↵^dVariable selected for log binomial regression analysis for KMC duration before discharge (P value up to .10).⁴⁰
↵^eVariables selected for log binomial regression analysis for day of life of KMC initiation for KMC duration on 7^th day after discharge (P value up to .10).⁴⁰

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TABLE 3.

Log Binomial Regression Analysis of Determinants of KMC Uptake in Karnataka, India

Determinants^a	Referent Group^b	Adjusted RR (95% CI)	P Value
KMC initiation (≤3 vs. >3 days)
Place of hospitalization	(Public vs. private^b)	2.68 (1.31, 5.51)	.007
HCWs’ attitude	(Median 77 vs. 71^b)	1.01 (1.00, 1.01)	.042
KMC initiation support at health facility	(Mean 8.5 vs. 7.0^b)	1.03 (1.02, 1.04)	.045
KMC duration on day before discharge from health facility (≥8 vs. <8 hrs)
HCWs’ skills	(Mean 55.8 vs. 53.7^b)	1.05 (1.01, 1.07)	.017
KMC maintenance support at facility	(Mean 8.6 vs. 7.4^b)	1.03 (1.003, 1.06)	.023
KMC duration on 7^th day after discharge from health facility (≥8 vs. 8 hrs)
Place of hospitalization	(Public vs. private^b)	1.31 (1.02, 1.68)	.035
HCWs’ knowledge	(Mean 70.7 vs. 69.9^b)	1.02 (1.01, 1.04)	.039

Abbreviations: CI, confidence interval; HCW, health care worker; KMC, kangaroo mother care; RR, relative risk.
↵^aDue to the small sample size, all variables selected could not be pushed to the log-binomial regression analysis model simultaneously. Instead, variables were inserted into the model stepwise. Hence, only those variables that are significantly associated are reported.
↵^bReferent group.

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TABLE 4.

Proposed Operational Framework for Catalyzing KMC Uptake Along the Health Facility to Community Continuum Based on Study Findings in Karnataka, India

Community	Health Facility	Community
Antenatal care	Pregnancy + childbirth + hospitalization of the low birth weight baby	Continuation of KMC for 4–6 weeks at home
CHWs’ Role^a	HCWs’ Role	CHWs’ Role
Educate and counsel mothers and the community on KMC and exclusive breastfeeding Inform about need for childbirth at a health facility Identify peer mothers as KMC champions Identify potential foster KMC providers	Support mothers at antenatal visits on KMC Ensure support from all HCWs, including peer mothers and foster KMC providers, for mothers to initiate and maintain KMC Recognize HCWs who promote KMC as champions Ensure foster KMC providers are identified and that they begin supervised KMC provision at the health facility before discharge	Reinforce information on KMC through home visits after discharge daily for a week; find ways to enhance KMC duration Encourage foster KMC providers to provide skin-to-skin contact or assist with household chores Ensure mothers monitor babies during KMC

Abbreviations: CHW, community health worker; HCW, health care worker; KMC, kangaroo mother care.
↵^aExtrapolated from this study’s findings.