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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 - June 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.

Overall Project Outcomes and Activities 

The results of qualitative studies from the Baseline, Intervention and Endline stages indicate changes related to KMC occurred at the district health office, hospital, health center, and even the community level. The changes included knowledge, attitudes and behaviors related to KMC, the LBW referral system for post-treatment from hospital to community, and implementation of KMC in hospital and community.

The knowledge, attitude, and behavior of KMC among health workers at hospitals and health centers related to KMC gradually started to increase from the Baseline to Endline phases (approximately the years). Based on baseline result, it shows that the knowledge of most health workers in hospitals and health centers is good enough on the understanding and benefits of KMC, but many still assume that KMC should be done by mothers using special sling cloth and babies still in incubator should not be treated by KMC. At the practical level, most still vary greatly among nurses of perinatology as well as midwives in health centers. Having been given standardized and certified KMC training (from Perinasia as a long-time organization in KMC training which has experts such as pediatricians, nutritionists, psychologists and lactation management experts), knowledge, attitudes, and especially the practice of KMC among health workers in both hospitals and health centers saw significant changes and the implementation of KMC is now done well and correctly. In fact, the hospitals began to show their commitment by establishing supporting facilities where KMC can be practiced properly and efficiently including the procurement of KMC slings, special continuous KMC rooms (especially in Koja Hospital which provided a room free of charge with three beds and toilets specially designed for LBW’s mothers conducting continuous KMC), with comfortable chairs (especially in RSUD Karawang, so that mothers feel more comfortable when doing intermittent KMC).

Another significant change is the development of a post-treatment system model for post-treatment LBW from the hospital to the community. The referral model in the form of picking up LBW at hospitals and monitoring LBW in the community is very beneficial for hospitals, DHO, health centers, and LBW families. This reference model provides excellent communication, collaboration, and cooperation between hospitals, DHO, and health centers. Previous passive communication, collaboration and cooperation spaces are becoming very active and ultimately enhancing the positive image of the three institutions involved. In fact, this reference model has been applied by hospitals and DHO to other health problems. This indicates that innovation of referral model conducted by the team is an innovation solves the problems that have been happening under the previous referral system.

The monitoring of KMC by health centers to LBW houses has an immediate effect on the implementation of KMC in the community. Pickup and monitoring by the health centers give a positive psychological impact on LBW family. In addition, there is a positive image of health workers in hospitals and health centers in the eyes of the community. This will have an impact on increasing community trust and compliance with health workers which will result in the reduction of neonatal mortality in the future.

PEER Health Cycle 2 Recipients