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Development of a referral system using kangaroo mother care for low birth weight babies

PI: Hadi Pratomo, Faculty of Public Health, Universitas Indonesia
USG-Supported Partner: Abdullah Baqui, Johns Hopkins University Bloomberg School of Public Health
Project dates: February 2015 - January 2018

Project Overview:

PH 2-6 Pratomo 2016Q1 photo 1
Observation in Perinatology Unit at Koja Hospital. (photo courtesy of PI Hadi Pratomo)
PH 2-6 Pratomo 2016Q1 photo 2
Home visit to low-birth weight infants (LBWI) post hospital care at Koja Hospital - Kangaroo Mother Care (KMC) is not continued at home. (photo courtesy of PI Hadi Pratomo)

The project aims to improve the survival of low birth weight infants (LBWI) using kangaroo mother care (KMC). The objectives are to address LBWI problems, improve the referral system from community to hospitals and vice versa, promote the sustainability of the KMC for increasing its survival, as well as reduction of both mortality and morbidity. The referral health system has been developed by the Ministry of Health. However, the implementation of this services including LBWI is still a big challenge. Coordination and follow-up of referral services after discharge from hospital is very weak. Through current policy on Universal Coverage of health services (BPJS), there is an opportunity to devise and strengthen the referral health system including cases of LBWI. The design of the study is a before and after intervention and is carried out at the hospital and community levels. The primary target population is families with LBWI born in either the hospital or community setting. In each district, the expected number of mothers with LBWI is estimated at 200 in each hospital, 100 in either primary health centers or private midwife clinics, and another 100 born at home delivery. The total sample will be approximately 800 mothers with LBWI. The secondary target populations are family members, cadres, health care providers, and decision makers. The formative research will be conducted to increase the possibility of an effective, acceptable, and sustainable intervention. Also, it will fine tune the proposed intervention adjusted to the existing condition. A quantitative study will follow with the aim to investigate LBWI survival and morbidity rates. Case fatality rates (CFR) due to major complications and neonatal mortality will be studied retrospectively both at the hospital and community settings. However, both neonatal morbidity and CFR will only be studied at the hospital level. The intervention will consists of Learning Organization, and training for personnel who will be involved in the care of LBWI for KMC and its referral system. An end-line study will be conducted to compare the knowledge and perception about KMC services and referral for LBWI using KMC before and after the intervention.

The primary outcome measure is improvements in LBWI outcomes such as survival, presence of complications, CFR, and cause of death after graduated from or receiving some KMC service. The secondary outcome measures include improvements in knowledge, opinion, and perception of health personnel about KMC and LBWI referral using KMC. To monitor implementation, several tools will be developed such as KMC admission criteria both in hospital and in the community setting.

The USG-Supported partner has extensive experience in the interventions to improve perinatal and neonatal survival in developing countries. Therefore, through this collaboration the research team will gain experience in conducting quality research in newborn care and publishing in the international journals.

Summary of Recent Activities:

As of June 2017, the team finished up conducting training in both study areas. In North Jakarta, the team trained the remaining (n=52) KPLDH (home visit team: medical doctors, midwives, and nurses) who were not participate in the previous trainings. These remaining KPLDH personnel were previously not planned to be trained. However, It was decided to train them to anticipate that all infants followed up in this study will be covered by KPLDH team. We completed all KMC training for health personnel from Puskesmas (Health Center) in Karawang District. The training included 4 batches for 110 personnel (medical doctors, midwife coordinators, DHO staffs).

Stakeholder meetings were conducted in North Jakarta and Karawang District to discuss preparation for KMC follow-up in the community. During this meeting, funding for transportation and referral to the community was discussed and agreed to be funded. The teams previous challenge in the referral system from hospital to community in terms of health personnel to pick up discharged infants with KMC care in hospital in Karawang District was solved through meeting with head of the District Health Office (DHO), head of Puskesmas, and hospital management agreeing to provide funding support. However, funding for the referral system is still a challenge in North Jakarta area.

We have finalized all instruments for data collection of KMC implementation, and monitoring and evaluation (M&E) of the implementation, both in the hospital and community. The instruments used are an adjusted baseline study instrument with additional key questions. The revision of instruments was done based on inputs from hospitals, DHOs, and Health Centers (HCs). There are three types of instruments: for mothers; infants; and health providers. Midwives and nurses were recruited to collect data while a medical doctor will act as a supervisor during clinical data collection. Currently, there were 726 infants delivered and referred to the Koja Hospital from the start of the PEER data collection completed in May 2017, of which, 130 infants were low birth weight (LBW) defined as less than 2500 grams. From this number of LBW infants, 76 infants were less than 2200 grams. All of infants weighing <2200 grams are included in the data. In Karawang Hospital, data collection is planned for early July 2017. Data collections in hospitals are expected to be completed by the end of November 2017, and data collection in the community will be completed by mid-January 2018.

The research team participated in an exchange visit to Da Nang Women and Children Hospital to share findings with neonatologist, pediatricians, midwives, nurses and researcher on KMC from Da Nang Women and Children Hospital. Submission of an article to the Asian Journal of Applied Science was done in May and the team is awaiting the decision.

PEER Health Cycle 2 Recipients