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Required citation:
Government of Maharashtra, UNICEF, KMC Foundation of India, 2021.
Home Based Kangaroo Mother Care: Manual for implementation at Primary Health Care level.
Government of Maharashtra.
The authors and their employers and the presentations of the materials in this report do not imply any
expression of opinion on the part of the Government of Maharashtra or UNICEF or KMC Foundation of
India regarding the endorsement by these agencies. The views expressed in this manual do not
necessarily reect the views or policies of these agencies. This work may be copied, redistributed and
adapted for non-commercial purposes provided that the work is appropriately cited.
Published by:
State Family Welfare Bureau, Government of Maharashtra RB Mills Road,
Naidu Hospital Campus, Pune 411 001,
ISBN Number:
List of Contributors:
Principal Author
Prof. Shashi N Vani, M.D., D. Ped., FIAP, FNNF
Managing Trustee KMC Foundation, India,
Emeritus Professor of Paediatrics including Neonatology,


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Managing Trustee KMC Foundation, India,
Emeritus Professor of Paediatrics including Neonatology,
P S Medical College, Karamsad, Gujarat.
ADVISORY GROUP
Government of Maharashtra
1. Dr. Pradeep Vyas, IAS, Additional Chief Secretary
2. Ramaswami N., IAS, Commissioner, Health Services and MD NHM
3. Dr. Archana Patil, Director of Health Services
4. Dr. Ramchandra Hankare, DD RCH
5. Dr. Ashish Bharati, Assistant Director, Department of Public Health
UNICEF
1. Smt. Rajeshwari Chandrashekhar, Chief of the Field Ofce, UNICEF, Mumbai
2. Dr. Khanindra Bhuyan, Health Specialist
3. Dr. Mangesh Gadhari, Health ofcer
4. Dr. Prashant Hingankar, Consultant
Expert Reviewers
1. Prof. Simin Irani, MD, FNNF, Retd. Professor and HOD of Neonatology, Seth GS Medical College,
K E M Hospital Mumbai and Somaiya Medical College, Mumbai
2. Prof. Nikhil Kharod, MD, Joint Secretary KMC Foundation, R etd. Prof. and HOD Paediatrics,
P S M C, and CEO, Tribhuvan Foundation, Anand, Gujarat


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P S M C, and CEO, Tribhuvan Foundation, Anand, Gujarat
3. Prof. Rekha Udani, MD, Retd. Professor and HOD of Neonatology, K E M Hospital Mumbai and
B Y Patil Hospital, Navi Mumbai
4. Prof. L S Deshmukh, MD, DM (Neonatology), Prof and HOD of Medical College, Aurangabad
5. Prof. Ruchi Nanavati, MD, Prof and HOD, Neonatology, K E M Hospital Mumbai
6. Prof. Sushma Malik, MD, Prof and HOD, Neonatology, Nair Hospital, Mumbai,
Members of KMC Foundation, India
7. Dr. Parag Dagli, MD, Trustee KMCF, India, Neonatal and Pediatric intensivist,
Director Apple Children Hospital, Ahmedabad
8. Dr. Jatin Mistri, MD, MRCPCH (UK) , CCST (Neonatal medicine,) UK, Trustee KMCF , India
9. Dr. Ravi Parikh, MD, D Ped, MRCPCH (UK), CCST ( Neonatal Medicine) UK, Trustee, KMCF, India


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CONTENTS
Abbreviations used in this manual 1 3.B.3 Skills required for feeding LBWI during HBKMC 30
About this manual for Healthcare Providers for 3.C. Kangaroo Discharge and Follow Up of
Home Based Kangaroo Mother Care 2 newborns receiving HBKMC 31
3.C.1 Planned early discharge and random
CHAPTER ONE: early discharge 32
A few basic facts of newborn healthcare for HCPs 3 3.C.2 General schedule for home visits of
ASHA workers 33
1.1 A few important Denitions: 3
3.C.3 Activities of the ASHA/HCPs during the home
1.2 Why should we take care of our newborns? 3
visits of a baby in HBKMC 33
1.3 Basic principles of newborn care: 3
3.C.4 Checklist for activities during follow up home
1.4 Levels of newborn care 4 visits of ASHA/CHWs 36
1.5 Why should we promote Homebased
Kangaroo Mother Care in India? 4 CHAPTER FOUR:
1.6 Different groups needing HBKMC in India. 4 Communication and Counseling for promoting HBKMC 38
CHAPTER TWO: CHAPTER FIVE:


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CHAPTER TWO: CHAPTER FIVE:
Basics and Benets of Kangaroo Mother Care 6 Reports of Home Based Kangaroo Mother Care 40
2.1 What is KMC? 6
2.2 WHO denition of KMC 6 CHAPTER SIX:
2.3 Benets of KMC 6 Practice of Home Based KMC during COVID Pandemic 41
2.4 Role of KMC in Early Child Development (ECD) 8
2.5 A few basic aspects of KMC 8 CHAPTER SEVEN:
2.6 When to stop KMC? 10 Experiences of Home Based KMC in Gujarat
and Maharashtra 44
2.7 Scope of Kangaroo Mother Care in community 10
A. Gujarat 44
CHAPTER THREE: B. Maharashtra 46
Practice guidelines for Home Based Kangaroo
Mother Care 11 REFERENCES 48
3.A. Kangaroo Position: 11
ANNEXURES: 52
3.A.1 Which babies are eligible for HBKMC? 11
1. Suggested recording & reporting formats
3.A.2 Who can provide KMC? 12
for HBKMC 52
3.A.3 Facilities and support expected from family
2. Frequently asked questions (FAQs) about KMC 56
members for HBKMC 12
3. KMC Pretest (Sample Questionnaire) 62
3.A.4 Advance preparations for KMC at home 13


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3. KMC Pretest (Sample Questionnaire) 62
3.A.4 Advance preparations for KMC at home 13
4. Question bank for self-learning exercise 64
3.A.5 Immediate preparations just before the actual
start of KP/KMC 15 5. Training for KMC 68
3.A.6 Actual procedure of Kangaroo Position/KMC 16 6. Budget for HBKMC roll out in a district 71
3.A.7 Caring the baby in Kangaroo Position at homes 18 7. Additional resources 72
3.A.8 Monitoring the infant during KMC 18 7.1 Important skills for use of simple instruments 72
3.A.9 Danger signals of the baby during KMC and 7.2 Classication of the newborns in view of further
actions to be taken 18 management 74
3.B. Kangaroo Nutrition 21 7.3 Minor Problems of Newborns 76
3.B.1 Steps for successful breast feeding for stable 7.4 The Common Traditional Practices affecting
ow birth weight babies 22 Newborn care 79
3.B.2 Feeding of unstable(sick) and too small babies 7.5 A few common difculties of breast feeding 82
(VLBWI/ELBWI) 25


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National Health Mission
8th Floor, Arogya Bhavan,
St. George’s Hospital Compound,
P. D. Mello Road,
Mumbai 400 001.
Dr. Ramaswami. N, IAS,
Commissioner Health Services,
MD (NHM) GOM
MESSAGE
Kangaroo Mother Care (KMC) is an evidence based, simple, cost-effective way of caring for low
birth weight infants and has already been promoted at various levels of public health facilities in the state
of Maharashtra. Considering the importance of this intervention, having guidelines for practicing KMC
at home is the need of hour particularly in tribal areas where prevalence of low birth weight is high.
This manual gives a clear guidance to service providers especially frontline health workers on how
home based KMC can be implemented for caring of low birth weight newborn at the village level. Many
tips for care of the new born babies by the mothers / ASHAs / ANMs at the village level are highlighted,
which will be very useful.


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which will be very useful.
I hope that this manual will also be used by programme managers for supervision during field level
visits and will help in reducing child mortality and malnutrition in the tribal areas of the state.
I appreciate the support of KMC Foundation of India and UNICEF in formulating this manual for
health workers.


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United Nations Children’s Fund
UNICEF Office for Maharashtra-
B wing, 4th Floor, 215, Atrium,
Behind Courtayrd Marriott Hotel,
Andheri Kurla Road, Chakala,
Andheri (East), Mumbai - 400 093,
Maharashtra, India.
PREFACE
Promoting maternal and newborn health and routine immunization are two important priorities for
UNICEF. Even though Maharashtra has made great progress in reducing the maternal and newborn
death rates, the progress is uneven. Tribal, urban slum and rural populations are the most disadvantaged
groups, in these population groups, neonatal mortality is higher than the state averages, therefore
different Reproductive Maternal Neonatal Child Health and Adolescent interventions need to be
prioritized. There is evidence to show that in some of the tribal areas as well as urban slums, the neonatal
mortality rates are higher than the state average. Government officials are held accountable by activists


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for the higher levels of malnutrition among women and children of the tribal blocks. I am happy that
partnership between UNICEF, KMC Foundation of India and Public Health Department catalyzed the
roll out the first ever Home Based Kangaroo Mother Care (HBKMC) programme in 78 tribal blocks in
the state since 2019, reaching thousands of low birth weight babies.
This manual, authored by Prof. Shashi Vani, who first started in the Kangaroo Mother Care ward in
India way back in 1993 at the neonatology division of the Civil Hospital and B.J. Medical College,
Ahmedabad, will go a long way in improving skills of frontline functionaries and mothers on Kangaroo
Mother Care and breast feeding among the low birth weight babies. It is an opportune moment for
promoting home based KMC, which is an effective, simple and affordable intervention for improving
survival, growth and development of low birth weight babies.


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survival, growth and development of low birth weight babies.
On behalf of UNICEF, I assure the highest commitment for the realization of the rights of the most
disadvantaged children in Maharashtra and for the scale up of home based KMC in the state.
Rajeshwari Chandrasekar
Chief of the Field Office


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ABBREVIATIONS
Abbreviation Complete term
AKP Alternate KMC Provider/ Surrogate KMC Provider
AWW Angan Wadi Worker
ANM Auxiliary Nurse Midwife
CHW Community Health Worker
EBM Expressed Breast Milk
ENBC Essential Newborn Care
ECD Early Child Development
FKC Father Kangaroo Care
HBKMC Home Based Kangaroo Mother Care
HBNC Home Based Newborn care
HCP Health Care Providers
IMNCI Integrated Management of Newborn and Childhood Illnesses
IYCF Infant and Young Child Feeding
IMR Infant Mortality Rate
IV Intravenous
KMC Kangaroo Mother Care
KP Kangaroo Position
KC Kangaroo Care
LBW Low Birth Weight
LMP Last Menstrual Period
MOM Mother's Own Milk
NGO Non Government Organization
NICU Neonatal Intensive Care Unit
NSCU Newborn Special Care Unit
NSSK Navjaat Shishu Suraksha Karyakram
ROP Retinopathy of Prematurity
SBA Skilled Birth Attendant
SNCU Special Newborn Care Unit
UNICEF United Nations Children Fund
WHO World Health Organization
| 1 |


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ABOUT THIS MANUAL FOR
HEALTHCARE PROVIDERS FOR HOME BASED
KANGAROO MOTHER CARE
We are happy to prepare this manual for the a few sections on training and a few practical aspects
promotion of Home Based Kangaroo Mother Care of newborn care which will be useful for the workers
(HBKMC) by the Healthcare Providers (HCP) who in remote areas. The trainees are advised to refer to
provide services to mother, newborn and child in our the training module and guideline for HBNC for
country. The main focus is ASHAs, AWWs and details of other components of HBNC. In this manual,
ANMs, who are the frontline workers / {Community only the components of HBKMC and the relevant
health workers (CHW) in the health system}. HBKMC aspects are highlighted. HCPs have some
is very much needed in India in different situations, information and knowledge about KMC through
and it has not been addressed properly. This manual different training programs of Essential Newborn


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should help to ll this void. In the difcult to reach Care (ENBC), Navjaat Shishu Surakha Karyakram
villages and tribal areas, the facilities of road, (NSSK) and others. But have no skills and condence
transport and communication are very poor. Poverty, to guide mothers for KMC as detailed capacity
illiteracy and gender discrimination are prevalent. building is not done. This manual is prepared to build
Health care facilities are situated in faraway places the missing gaps of knowledge and skills about KMC
making it very difcult for the public to access these. as relevant to home based care in remote rural and
In such situations, home based newborn care tribal villages and hamlets and urban slums.
(HBNC) including KMC has proved to be of great use
and helps to save many newborns. In urban slums,
the problems are even more complex including
poverty, poor infrastructure, poor water, sanitation
and hygiene services, fragmented health services,


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and hygiene services, fragmented health services,
due to which health services are not utilized properly.
The promotion of HBKMC should be a part of
Essential newborn care (ENBC) and HBNC and not
to be considered as an independent topic. This
separate manual is prepared with the main objective
that if basic knowledge and skills are provided to the
mothers, they can practice HBKMC so that newborn
babies get the best results of this simple, yet a very
useful intervention with several benets.
We have tried to make this manual as simple and
practical as possible. Practical guidelines for all the
three major components of KMC i.e. Kangaroo
Position, Nutrition and Discharge and follow up are
provided. Important subjects like communication and
counselling for improving the quality and coverage
of HBKMC, records and reporting and a special
chapter on practice of KMC during the current Covid
19 pandemic have been added. Annexures include
Fig. 1: Kangaroo Mother Care
| 2 |


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CHAPTER ONE
A FEW BASIC FACTS OF NEWBORN HEALTHCARE
FOR HCPS /CHWs
It will be useful to refresh a few basic facts of 1.2 Why should we take care of our
newborn care before we proceed for care of the
newborns?
newborn babies with HBKMC.
First 1000 days of life from conception to two
years of life of the child are the most important
1.1 Important Denitions:
period of life for survival, growth and
Newborn baby: A baby from the time of birth development. Adequate health promotion and
l
to 28 days or rst four weeks of age. nutrition during this 1000 days period is not only
critical for pregnant women's survival but also for
Full term baby: A baby born between 37 to
l
the survival of the newborn, his/ her ability to
41 weeks and six days of gestational age/
grow and learn, which helps in breaking the
pregnancy {Born between 253 to 293 days
intergenerational cycle of poverty and
after the date of rst day of last menstrual
malnutrition. As per the estimates developed by
period (LMP)}.


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malnutrition. As per the estimates developed by
period (LMP)}.
the United Nations Inter-agency Group for Child
Preterm or Premature baby (born too soon): Mortality Estimation, an estimated 522,000 new
l
A baby born before 37 weeks of gestational born babies died out of 824,000 children below
age /pregnancy (Born before 253 days after ve years who died in India in 2020; most of these
the rst day of the last menstrual period). deaths are preventable.
Birth weight of a baby: The earliest weight The indirect impact of Covid 19 pandemic may
l
recorded soon after birth of a baby preferably have exacerbated the neonatal mortality rates in
in rst two hours of life. In case the weight different states of India and simple interventions
cannot be recorded within the rst 2 hours due like early exclusive breast feeding and KMC,
to several issues, the rst weight recorded together with skilled birth attendance can save


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to several issues, the rst weight recorded together with skilled birth attendance can save
within the rst seven days of life is considered lives of many newborn babies.
as birth weight. In that case, it is desired that
along with the weight record, the day on
1.3 Basic principles of newborn care:
which the weight is measured should be
mentioned. For example: Birth weight of baby a) Ensure regular breathing.
of Sita 1.7 KG (on 5th day of life).
b) Preserve adequate body warmth, adopt
l Low Birth Weight baby - (born too small): The warm chain for newborn care.
baby whose birth weight is less than 2500
c) Provide optimum nutrition, preferably
grams.
exclusive Mother's Own Milk (MOM) either
l An Infant: A child from the time of birth till as direct breastfeeding or as expressed breast
completing one year of age. The rst month of milk.
life is described as the neonatal period and
d) Hand washing and other measures of
the remaining 11 months period is called post


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d) Hand washing and other measures of
the remaining 11 months period is called post
prevention of infections including observing
neonatal period.
clean delivery practices with ve/six cleans.
Clean chain of baby care and avoiding
| 3 |


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CHAPTER ONE
A FEW BASIC FACTS OF NEWBORN HEALTHCARE FOR HCPS /CHWs
harmful traditional newborn care practices 1.5 Why should we promote Home
which are likely to introduce infections
based Kangaroo Mother Care in
(Unhygienic cord care, pre lacteal feeds,
India?
application of Kajal in eyes, bottle feeding
etc.)
HBKMC is required in developing countries like
e) Early identication of danger signals in India for the following reasons:
newborn, immediate prompt actions and if
Ample scientic evidence recommends that simple
required referral to higher care hospitals
interventions like KMC including breast milk
with all due precautions and preparations.
feeding (Early initiation of breastfeeding, use of
These basic principles of care are applicable
expressed breast milk, exclusive breast milk
to all the newborns including full term or
feeding etc.), hand washing and other infection
premature, healthy or sick and whether
prevention measures if done well and widely, can


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premature, healthy or sick and whether
prevention measures if done well and widely, can
delivered at home or hospital.
prevent most neonatal deaths.
A systematic review conducted in 2016 showed
1.4 Levels of newborn care:
that at discharge or 40-41 weeks of
postmenstrual age(PMA), KMC was associated
Primary or essential newborn care: Required
l
with signicant reduction in the risk of mortality
for almost 85% of all the newborns. The care
(40%), infections acquired in the hospitals (65%)
includes making sure of good breathing,
and hypothermia (78%) in newborns.
keeping mother and her baby together in skin
to skin contact, keeping adequately warm, India has a huge number of LBW and preterm
promoting breastfeeding, infection prevention newborns who have very high rates of death and
measures and early detection of danger illnesses. HBNC including HBKMC through
signals and appropriate actions, if required ASHAs, AWWs, ANMs with proper training can


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signals and appropriate actions, if required ASHAs, AWWs, ANMs with proper training can
and referral to higher centres with suitable save the lives of many of these babies.
precautions and care.
Special care or intermediary care: Required 1.6 Different groups needing HBKMC
l
for about 10 to 12% of the newborn babies.
in India
Includes oxygen therapy, intravenous uids
and medications, antibiotics, phototherapy, Similar to HBNC, HBKMC is offered in following
gavage feeding etc. Usually given in special different scenario:
newborn care units (SNCUs) or level
II/Intermediate care units. Group I
Intensive care or tertiary care: Required for The baby is delivered in a hospital and following
l
about 3 to 5% of newborn babies. Can be the hospital protocols, KMC is started under the
given only by specially trained specialists instructions of doctors and trained nurses. Once
doctors and nurses in advanced care units the baby starts showing consistent improvement,


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doctors and nurses in advanced care units the baby starts showing consistent improvement,
with sophisticated equipment and advanced the newborn is discharged from hospital as per the
management. laid down protocol and subsequent care including
KMC is continued at home with regularly
Specialized Care for the newborns: Surgical
l scheduled follow up visits to the hospital.
care, foetal therapy etc.
| 4 |


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CHAPTER ONE
A FEW BASIC FACTS OF NEWBORN HEALTHCARE FOR HCPS /CHWs
Group II Group III
In this group, the baby is delivered in the hospital In this group, the baby is delivered at home and
and the baby is eligible to receive KMC. But the the subsequent care of the newborn has to be
mother is not able to stay in the hospital for her given only at home.
personal, socio-cultural reasons or the facility
In all these cases, through regular home visits, the
does not have expertise and/or equipment to
ASHAs have the opportunity to offer good quality
provide care for the small and sick newborn, who
of HBNC including HBKMC and improve the
is cared for at home.
chances of survival of the newborn, especially the
small and sick babies.
Fig. 2: KMC at home for twins
| 5 |


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CHAPTER TWO
BASICS AND BENEFITS OF KANGAROO
MOTHER CARE (KMC)
2.1 What is KMC? 2.3 Benets of KMC:
KMC is an evidence based, low cost, yet high impact, There are several benets for the baby, for the
simple and natural method of care of newborns with mother, family members, hospital, community and
added benets to low birth weight and preterm ultimately to the nation.
babies. It is a method of holding the newborn directly
ü Benets of KMC to the baby:
in skin to skin contact on mother’s chest in between
her breasts, without any layer of clothing in between, l High potential to reduce deaths and
with baby’s neck slightly extended and the body of sickness of preterm and LBW newborns
the baby is in as much vertical position as possible so (Almost up to 40% of total neonatal
that mother and baby can have eye to eye contact mortality can be prevented).
and both are covered together from above. The
Prevents neonatal hypothermia (Body
l
newborn is breastfed every two hours. This is better


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Prevents neonatal hypothermia (Body
l
newborn is breastfed every two hours. This is better
cooling).
described as a loving body hug than mere supercial
skin to skin touch. l Helps to warm up the newborn who
already has thermal stress (mild cooling of
the body).
Develops thermal synchrony between
l
mother’s body temperature and baby’s
body temperature (When the baby’s body
temperature reduces slightly, mother’s body
temperature rises a little high and vice
versa).
Increases the duration of exclusive breast
l
milk feeding, resulting in better weight gain,
growth.
Reduces the risk of severe neonatal
l
infections including hospital acquired
(Nosocomial) infections as well as
Fig. 3: Helping mother for KMC
septicaemia (severe infection affecting
multiple organs).
2.2 WHO denition of KMC:
Increases mother baby bonding.
l
KMC consists of- early, prolonged and continuous Facilitates early physiological stability of
l


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l
KMC consists of- early, prolonged and continuous Facilitates early physiological stability of
l
skin to skin contact between the mother and her heart rate and respiration of the neonate.
baby, with exclusive breast feeding whenever
Promotes good quality sleep and improves
l
possible, early discharge with adequate follow up
neuro development and behaviour
and support and initiation of practice in the facility
development.
and continuation at home.
| 6 |


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CHAPTER TWO
BASICS AND BENEFITS OF KANGAROO MOTHER CARE (KMC)
Benets of KMC to Newborn Babies
rates of illnesses
Many long term and
and deaths
other benets
Prevents body cooling
Satises all ve sensations
(Hypothermia), maintains
(taste, Smell, Vision,
body temperature
Touch , hearing)
Improves breast feeding
and growth
Pain
chances of infections Prevents reduction of
blood sugar
Improves good quiet sleep
Stabilizes heart rate, respirations
Improves brain and colour of baby
development
Improv es mother baby bonding,
fee ling of safety and security
Reduces the requirement of oxygen and There is increased bonding between mother
l l
episodes of apnoeic attacks (Temporary and her baby.
cessation of breathing for more than 20
Mother feels empowered and condent to
l
seconds at a time, often causing choking of
take care of her small baby in the hospital
respirations and bluish discolouration of
and continue the same care at home after
skin due to lack of oxygen) which frequently


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and continue the same care at home after
skin due to lack of oxygen) which frequently
discharge (Applicable for hospital
occur in very preterm babies.
delivered babies).
Reduces the neonatal stress and improves
l
Less chances of post -partum (After
l
the feeling of security in the baby and
delivery) depression and psychosis in
babies cry less.
mother.
Reduces the feeling of mild to moderate
l
Better supply of breast milk due to increased
l
pain following simple procedures like heel
production of hormones.
prick, venepuncture, testing for Retinopathy
of Prematurity etc. l Earlier involution of uterus and stopping of
post -partum bleeding in mother.
In short, all the ve senses of the baby i.e.
l
touch, smell, hearing, vision and taste are l Early return to home settings.
satised very early resulting in better
ü Benets of KMC to the family:
neurodevelopment.
Economical due to lesser stay of the baby and
ü Benets of KMC to mother:
mother in the hospital and less use of


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ü Benets of KMC to mother:
mother in the hospital and less use of
Due to active involvement in the care of small medications, oxygen etc. (Applicable for
and even sick baby soon after birth: hospital delivered babies).
| 7 |


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CHAPTER TWO
BASICS AND BENEFITS OF KANGAROO MOTHER CARE (KMC)
Improved quality of breast feeding and less growth, they get their mental stimulation through love
l
chances of illness to the baby. and affection and achieve their full potential of
development and become happy, healthy and
Better family support and involvement of
l
responsible adults. To be effective ECD should be
family members in the care of the baby.
started as early as possible after birth:
Early return to work and routine family life.
l
KMC provides the best start to LBW and preterm
l
l Reduced incidence of child abandonment babies who are prone to developmental
and abuse. problems.
l Benets of KMC to the hospital: (Applicable l In the rst few hours after birth, the baby’s brain
only for hospital delivered cases). is very responsive to various modes of brain
stimulation which lay a strong foundation for
Saves money on health care costs of small
l
immediate and long -term development.


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Saves money on health care costs of small
l
immediate and long -term development.
and sick newborn and even during post -
natal period. Immediate skin to skin contact soon after birth
l
provides an excellent opportunity and lays the
Better use of manpower and infrastructure.
l
strong foundation for early child development.
Reduced requirements of antibiotics and
l
KMC provides a womb-like environment and
other medications, oxygen, formulae etc. l
during KMC, the baby gets good sleep, cries
l Less chances of hospital acquired infections less, feels less pain, feels secure and stress free.
which are much more difcult to treat. All these help for the better brain development of
the baby along with the added benets of breast
Less burden on nursing staff due to more
l
feeding.
involvement of the mother in the care of her
baby. During KMC, breast feeding is encouraged
l
which adds to development of the brain. Breast
ü Benets to Community and the Nation:


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l
which adds to development of the brain. Breast
ü Benets to Community and the Nation:
milk has several components which help for
Better orientation in good newborn care
l better mental development of the child.
practices and better participation.
KMC stimulates all the ve sensations which help
l
Better quality of survival (Thriving well)
l in early brain development.
among the LBW and pre -term infants.
Reduction in cost of newborn care due to
l 2.5 A few basic aspects of KMC:
multiple reasons and better utilization of the
funds. ü KMC has three major components:
Better quality of intelligent future citizens. A Kangaroo Position- Skin to skin contact
l
between mother and her baby preferably in
vertical position and eye to eye contact.
2.4 Role of KMC in Early Child
B Kangaroo Nutrition- Exclusive breast milk
Development (ECD):
feeding as much as possible.
Currently our goal for newborn care is not to just
C Kangaroo Discharge and Follow Up-


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Currently our goal for newborn care is not to just
C Kangaroo Discharge and Follow Up-
ensure only the survival but also to ensure that babies
Planned early discharge and regular follow up
thrive well. Along with good nutrition and physical
including follow up for neuro-motor, neuro-
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CHAPTER TWO
BASICS AND BENEFITS OF KANGAROO MOTHER CARE (KMC)
behaviour and sensory development for all half hours and preferably combined with
babies. breast milk feeding. This prolonged skin to
skin contact can be labelled as Kangaroo
All carried out in a supportive environment, both
Care. Skin to skin contact for a few minutes
in facility as well as at home.
cannot be labelled as Kangaroo Care. In
ü Early skin to skin contact, soon after birth: case of hospital delivered cases, routine
weighing, Vitamin K administration and
Early skin to skin contact is advised soon after
birth dose vaccination of BCG, Hepatitis B
birth, in the labour room itself for all the babies
and OPV can be done after the initial one to
irrespective of gestation age and birth weight
one and half hours of direct skin to skin
except for those who require immediate
contact on mother’s chest.
attention for resuscitation or other life -saving
interventions. It is helpful for following: ü Duration of KMC:


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interventions. It is helpful for following: ü Duration of KMC:
l Rapid physiological stability for the baby, l Ideally KMC should be given for a total of at
in terms of heart rate and respirations. least 20 hours in a day, which improves
survival of the LBW and preterm babies.
Preventing cooling of the baby soon after
l
birth. Mother can continue providing KMC as
l
long as it is comfortable for her. She can
Stimulating early breast milk production.
l
then hand over the baby for continuing
l Developing early bonding between mother KMC to Alternate Kangaroo Care Provider
and her baby. (AKP), if available or keep the baby in her
bed for a break and again continue with
All the benets of non -separation of the
l
more sessions.
mother and her baby including reducing
the mental stress of mother as well as the During the 24 hours, the total hours of KMC
l
baby. given are calculated by adding the hours
given by mother as well as by the AKP in
Reduction of chances of early neonatal
l


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given by mother as well as by the AKP in
Reduction of chances of early neonatal
l
different sessions.
infections.
ü Types of KMC:
Continuous KMC:
l
The longer the duration of KMC, the better
are the impacts. It should be ideally given
for almost 24 hours in a day, or at least for
more than 20 hours in a day. Only
obligatory breaks are taken by the mother
for her bath, food and other personal needs
and for the baby for diaper change, cup
feeding, routine clinical examinations etc.
Fig. 4: Immediate skin to skin contact soon after The support from Alternate KMC Provider
birth/baby on mother’s abdomen soon after birth (AKP) from the family is very helpful for
giving continuous KMC.
Ideally this early skin to skin contact should
l
be prolonged for at least one to one and a
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CHAPTER TWO
BASICS AND BENEFITS OF KANGAROO MOTHER CARE (KMC)
l Intermittent KMC: 2.7 Scope of Kangaroo Mother Care in
KMC is given for a few hours at a time with community:
long breaks in between each session. This
ü KMC can be given to:
type is mainly done for extremely LBWI and
stabilized sick babies and also when the All the stable LBW babies including preterm
l
mother is recovering from surgery like CS, babies even at home.
tubal ligation etc. where support from AKP
It can be given to term babies also as much
l
is not available.
as they are comfortable in KMC position in
the initial few days after birth.
2.6 When to stop KMC?
For sick babies, if hospitalization is not
l
If the mother and baby are comfortable, KMC should possible, as a measure to relieve pain and
be continued till the baby’s weight is more than 2500 reduce stress.
gm. Around that time, the baby starts wriggling in
For transport of the newborn wherever
l
Kangaroo Position to show that s/he is


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For transport of the newborn wherever
l
Kangaroo Position to show that s/he is
required for taking to higher centers for
uncomfortable, pulls her limbs out, cries every time
hospitalization or for follow up for special
the mother tries to put the baby in skin-to-skin
check of eyes, hearing and assessment for
contact. This is when it is safe to advise the mother to
brain development or for regular
wean the baby gradually from KMC. Breast feeding
assessment of nutrition and growth and for
must continue. Mother can return to the occasional
immunizations etc.
KMC after giving bath, or just before sleep or during
cold nights.
ü Don’ts of Kangaroo Mother Care:
Do not bathe till the infant weighs
l
2500gand stable. Body sponging may be
done.
Do not handle infant too frequently.
l
Do not give bottle feed.
l
l Do not allow infant to be in contact with sick Fig. 5: KMC ward in Govt hospital, Maharashtra
people.
During KMC, as far as possible do not hold
l
the baby horizontally, particularly the


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people.
During KMC, as far as possible do not hold
l
the baby horizontally, particularly the
babies who are very premature or very
small.
Do not apply any cream or oil on the
l
umbilical stump.
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CHAPTER THREE
PRACTICE GUIDELINES FOR HOME BASED
KANGAROO MOTHER CARE
In this chapter practice guidelines are provided for
guiding mothers for KMC at homes. Basic 3.A.1 Which babies are eligible for
approach remains the same as that of facility
HBKMC?
based KMC.
ü Recommendations:
Broadly three major components are included in
KMC: l Generally, all newborn babies born at home
who are not having serious problems
A) Kangaroo Position.
irrespective of weight or maturity should be
B) Kangaroo Nutrition. provided KMC (skin to skin contact/kangaroo
position).
C) Kangaroo (discharge and ) follow up.
Ensure all LBW and premature babies receive
l
(The component of planned early discharge as a
KMC.
part of KMC is not applicable in case of Home
based KMC in group 2 and group 3. Ideally, neonates having serious problems
l
should be referred to hospitals having Mother
Regular follow up is very important for all the
and Newborn Care Units, Special Newborn
three groups of HBKMC).


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and Newborn Care Units, Special Newborn
three groups of HBKMC).
Care Units or Neonatal Intensive care Units,
where better care can be given. But if that is
3.A Kangaroo Position: not possible, even these babies with serious
problems can be kept in Kangaroo position
ü Topics covered in this chapter:
and feeding with expressed breast milk can
3.A.1 Which babies are eligible for HBKMC? be tried.
l
3.A.2 Who can provide KMC? ü General guidelines in hospitals:
l
3.A.3 Facilities and support expected from The timing and initiation of FBKMC depends
l
family members for HBKMC. on the birth weight and stability of the infant.
In the facilities, following guidelines are
3.A.4 Advance preparations for KMC at
l
provided, which may not be applicable at
home.
homes as well:
3.A.5 Immediate preparations just before the
l
1. Birth weight more than 1800 grams and less
actual start of KP/KMC.
than 2500 grams:
3.A.6 Actual procedure of Kangaroo
l
These infants are generally stable at birth.


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than 2500 grams:
3.A.6 Actual procedure of Kangaroo
l
These infants are generally stable at birth.
Position/KMC.
Therefore, in most such cases KMC can be
l 3.A.7 Caring the baby in Kangaroo Position initiated soon after birth in the labour room
at home. and continued in the postnatal ward. The
neonate weighing less than 2000gm should
3.A.8 Monitoring the infant during KMC.
l
be accorded priority for initiating KMC
l 3.A.9 Danger signals of the baby during considering the huge burden of LBW infants in
KMC and actions to be taken. the country.
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CHAPTER THREE
PRACTICE GUIDELINES FOR HOME BASED KANGAROO MOTHER CARE (3.A KANGAROO POSITION)
2. Birth weight more than 1200g and less than Should maintain basic standards of personal
l
1800g: hygiene (Proper hand wash, daily bath,
clipped ngernails, tied up hair, clean
Many infants in this group have signicant
washed clothes). No skin infections,
problems in the neonatal period. Such infants
especially on mother’s chest.
may need care in a Special Newborn Care
Unit (SNCU) or a Newborn Intensive Care Mother should not be smoking or drinking
l
Unit (NICU), which can be provided while the alcohol or any addictive drugs during
mother provides KMC in these units. KMC can pregnancy and lactation period and
be given to a hemodynamically stable infant especially during the time providing KMC.
receiving IV uids, antibiotics and oxygen.
The term KMC is very often misinterpreted that
The duration may be gradually increased and
only mothers can provide KMC, which is not true.


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The duration may be gradually increased and
only mothers can provide KMC, which is not true.
thereafter the infant may be transferred to a
Other adult family members including father,
dedicated KMC ward.
mother -in -law, grand -parents, uncle, aunt, sister
3. Birth weight less than 1200g: or any responsible, willing and healthy person can
also be an alternate KMC provider (AKP). Even
These infants frequently experience serious
friends, neighbours and staff members also can be
prematurity related morbidity often starting
AKPs with approval from mother and her family
soon after birth. It may take days to weeks
members. The alternate KMC provider should be
before the infant’s condition allows initiation
having the same attributes as that of mother when
of KMC. Duration of KMC should be
offering KMC.
gradually increased based on tolerance of the
infant.
3.A.3 Facilities and support expected
(Recent studies have demonstrated that even
from family members for HBKMC:


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(Recent studies have demonstrated that even
from family members for HBKMC:
very sick babies can be managed and
interventions and investigations can be done
ü A supportive family is a very important pre
when the baby is in Kangaroo Position under
requisite for successful KMC:
expert supervision and guidance in neonatal
intensive care units with many advantages l Family members should allow mother to do
including further reduction of mortality). KMC frequently and for prolonged time as
required.
3.A.2 Who can provide KMC? l Provide her a clean, well ventilated place at
home for KMC with some privacy.
ü Best person is the mother:
Observe the baby closely when the mother is
l
She should be
sleeping either with the baby on her chest in
kangaroo position or the baby lying next to
Medically and physically t, in good health,
l
her in the same bed.
free from serious medical problems.
Baby is covered well and kept warm and
Willing and capable of holding the baby in l
l


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Baby is covered well and kept warm and
Willing and capable of holding the baby in l
l
clean when not undergoing KMC.
KMC position continuously for at least 20
hours a day or at least one and half hour per
Be an AKP and relieve the mother for some
l
session and have such frequent sessions in a
time and help in providing KMC to the baby.
day and carry on for many days as required.
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CHAPTER THREE
PRACTICE GUIDELINES FOR HOME BASED KANGAROO MOTHER CARE (3.A KANGAROO POSITION)
Try to learn about the early signs of danger house, without exposure to direct drafts of
l
signals in babies and refer to the hospital wind, can be selected. If mud oor is there,
immediately. fresh cow dung plastering may be avoided for
some weeks prior to delivery. As far as
Help mother with routine domestic chores and
l
possible, only wet mopping of the oor must
to take care of other children, if any.
be promoted. Direct dusty sweeping should
l Take mother for regular follow up as per be avoided wherever a newborn is being
schedule for routine check -up of growth and cared for. Mother with a newborn should be
immunizations and special neuro away from cattle sheds as much as possible
developmental follow up, screening for ROP, and also from poultry. Rat holes should be
hearing etc. lled and cleared away. Cockroaches, lizards
should be cleared as much as possible.


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hearing etc. lled and cleared away. Cockroaches, lizards
should be cleared as much as possible.
Provide plenty of clean washed clothes,
l
Environment must be free of water logging
diapers for the use of the baby and also for the
and lth to minimize the menace of
use of the mother.
mosquitoes, ies and other insects.
Provision of food and other personal
l
If a cot is available, ne. If not, a mattress or
requirements, including soap, clothes and
mat can be spread on the oor. Two pillows
other needs.
may be provided so that the mother can adopt
l Provision of water and nearby facilities for a reclining position while lying or sleeping
toilet, bath etc. for mother are desirable. with the baby in kangaroo position. While
providing KMC, the mother can rest against a
wall or a pillar with the help of pillows or cloth
3.A.4 Advance Preparations for KMC
bundles for support, if a reclining chair
at Home:
(preferably with a footrest) is not available.


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bundles for support, if a reclining chair
at Home:
(preferably with a footrest) is not available.
The number to call an emergency ambulance
l Use of mosquito nets must be encouraged.
l
to be displayed prominently in the house so
Use of mosquito repellent coils and chemical
that when need arises, immediate contact can
preparations should be avoided.
be established.
ü Supplies needed during KMC to be arranged
The address and the directions of the
l
beforehand:
hospital to be referred in case of emergency
preferably including the phone numbers of *Clothing for the baby:
l
persons to be contacted during emergency.
Caps two, socks and mittens two pairs, if
l
l Selection and preparation of a place for possible. (If not available, cotton cloth pieces
KMC at home very often, the homes are very can be used to cover head as well as feet and
small and congested. Even in such homes, hand depending on the season).
wherever possible, a well ventilated, clean
Front open baby cloth/zabla – four (No


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wherever possible, a well ventilated, clean
Front open baby cloth/zabla – four (No
area can be prepared for mother and her l
hooks should be used in clothes for babies to
baby to remain together. Cobwebs, dirt and
avoid injuries).
dust to be removed. If possible, simple
whitewashing of the walls can be done before (Extra pairs are recommended for use, in case
l
the arrival of the baby. A well -lighted, of wetting or soiling by baby).
ventilated area adjoining a window in the
Blanket/shawl to cover from above.
l
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CHAPTER THREE
PRACTICE GUIDELINES FOR HOME BASED KANGAROO MOTHER CARE (3.A KANGAROO POSITION)
In case, a support binder is not available, an inches x 15 inches, about 12 to 15 pieces are
l
extra dupatta, bedsheet or shawl for xing the collected in advance. If possible, the edges
baby properly in Kangaroo position. may be stitched to avoid tethering. For use as
a washable diaper, the cloth can be folded in
*Diapers for babies:
l
three or four layers depending on the size of
l Disposable diapers are not very often the baby. A waist band should be tied to the
available, or these may not be affordable for baby and this folded cloth can be tucked as a
poor families. Very often because of the cost diaper in front and back. This multi layered
involved, even when they are used, frequent fold of cloth helps in preventing direct soiling
changing is not done leading to local of the mother's chest and abdomen. It can be


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changing is not done leading to local of the mother's chest and abdomen. It can be
irritation, rashes and skin infections. easily tucked and removed after use. After
Traditional loin cloths used for babies are soiling, the cloth can be easily unfolded,
often single layered and do not help in washed and dried. They are denitely very
preventing wetting or soiling. Quite a few helpful to mother. They also help in reducing
mothers do not opt for KMC because of the pollution due to disposable diapers.
dislike of soiling and wetting by the baby
*Support garment such as a Kangaroo Bag
l
when KMC is being done. Even when they do
or different types of wraps for KMC. Their
offer KMC, the duration is shortened because
use is not an absolute must. But any such
of frequent wetting of the mother's chest and
extra supporting garment helps in keeping the
abdomen by the baby. Keeping all these
baby secure in KMC position and also
factors in mind, following improvisation is


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baby secure in KMC position and also
factors in mind, following improvisation is
provides additional safety from slipping down
suggested.
or sudden undue exion or extension of the
l Cotton cloths made up of smooth absorbent neck of the baby and preventing very rare
and easily washable material of about 15 chances of life -threatening catastrophes for
Fig. 6: Home made reusable cloth diapers.
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CHAPTER THREE
PRACTICE GUIDELINES FOR HOME BASED KANGAROO MOTHER CARE (3.A KANGAROO POSITION)
the delicate small, pre -term baby. The use of Mother must practice the technique of hand
l
such support garments help mothers to have washing properly before handling her baby.
some safe mobility with baby in kangaroo
She should take a good bath and attend to her
l
position and at least one hand of the mother
personal hygiene before starting KMC.
can be free with which she can perform a few
simple tasks at home (drying clothes, washing l Wherever possible, KMC can be offered by
small items, cutting vegetables, simple AKPs till mother’s infections are cleared.
cooking or even some recreation activities
Mother should know how to detect early signs
l
(like playing sitting games with cards, reading
of danger signals in her small baby and take
etc.).
immediate remedial measures as much as
*Clothing for mother: possible.
l


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etc.).
immediate remedial measures as much as
*Clothing for mother: possible.
l
l Any front open, culturally acceptable, l She should remove her jewellery like chains or
comfortable garment can be used by mothers threads from the neck, bangles, ring, wrist
for KMC. It can be traditional saree and watches, pins, clips to avoid accidental injury
blouse, kurta, gowns and even men’s shirts. to her baby. Her hair should be tied up
Preferably cotton, well washed and sundried, properly.
to be changed every day after bath.
Mother can be trained to keep the record of
l
All the bed sheets or old cotton dhotis/ sarees how many hours of KMC she had offered in
l
etc. which are to be used for mother and baby 24 hours.
in post -partum period, along with baby and
Mother must prepare a place, preferably in
l
mother’s clothes and diapers to be collected
her own bed to keep the baby clean, warm
well in advance, well washed, sun dried and
and safe and free from mosquitoes, ies,


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well in advance, well washed, sun dried and
and safe and free from mosquitoes, ies,
kept aside for the use after the birth of the
cockroaches, rats etc., when she is not
baby.
offering KMC and at times, baby may have to
be kept alone for a short while when mother
During COVID 19 pandemic following additional
has to go for bath, food.
items should be collected in advance:
ü *Preparation of baby for Kangaroo Position
About four to ve masks prepared from cotton
(KP)/KMC:
cloths (for washing and reusing).
All the preparations must be done in a warm
Soap and provision of water for frequent hand
and clean area, away from direct wind and
wash; Sanitizers if possible.
draughts.
Baby’s clothes must be removed or opened
3.A.5 Immediate preparations just l
from the front, only the back may be covered.
before the actual start of KP/KMC:
Baby is to be clad only with an appropriate
l
ü *Preparation of mother before actual start of size diaper and cap to cover the head.


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l
ü *Preparation of mother before actual start of size diaper and cap to cover the head.
KP/KMC: (Considerable amount of body heat (about
10% of total body heat in a neonate) is lost
Mother should be aware of the difculties that
l
from the head. Hence it is very important to
she will face while providing KMC and should
cover his/her head with a cap to prevent
be mentally prepared for the same. Help from
cooling of the baby's body.
family members will be a great relief to her.
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CHAPTER THREE
PRACTICE GUIDELINES FOR HOME BASED KANGAROO MOTHER CARE (3.A KANGAROO POSITION)
Cooling of body parts and the resulting The arms of the baby should be bent/exed in
l l
complications are more in pre -term and LBW such a way that they lie above the breasts on
babies. the mother's chest and the two feet of the baby
should be just below the breasts in a bent/
If ready made diapers are not available/
l
exed position. The hips should be bent/
affordable, locally improvised ones can be
exed and stretched out/ abducted in a frog-
used.
like position.
If available, a KMC bag/ wrap or such
l
supporting garment can be used to hold the
Head turned to
baby securely in Kangaroo Position and that Baby between one side
may allow the mother to move around. mother’s breasts
Frog-leg
3.A.6 Actual procedure of Kangaroo Support baby’s position
bottom
Position:
The mother should sit or stand as per her
l
Figure: How to hold the newborn in Kangaroo
preference, comfortably in a clean, warm,


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l
Figure: How to hold the newborn in Kangaroo
preference, comfortably in a clean, warm,
Position (reproduced from Kangaroo Mother Care and
well ventilated place away from winds.
optimal feeding of low birth weight infants: Operational
Her chest in between her breasts, should be Guidelines, Ministry of Health and Family Welfare,
l
exposed by opening the hooks of the upper GOI, September 2014)
garment.
Mother should support the baby's bottom with
l
Mother can have a bath before starting KMC.
l one hand.
Specially washing the chest before KMC is not
The baby’s body should be turned towards the
needed. l
mother and held as much straight as possible
The baby should be carefully lifted with a
l with as much maximum body contact as
blanket on her/his back and the bare chest of
possible.
the baby should be put in direct contact of
The head may be adjusted in such a way that
mother’s chest in between her breasts in such l
mother and baby can have direct eye to eye


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mother’s chest in between her breasts in such l
mother and baby can have direct eye to eye
a way that head of the baby lies just below the
contact.
chin of the mother (at such a level that mother
can kiss baby’s head on the top easily) in as Baby’s abdomen should not be tightly bound
l
much vertical position as possible and the so that easy breathing is possible for the baby.
head of the baby is turned to any one side so
Mother’s breathing stimulates the infant, thus
that baby’s nose, mouth remain free and not l
reducing the occurrence of apnoea (stoppage
compressed in mother’s breasts or body fat.
of breathing in between).
Neck is slightly extended to make sure that the
l
A very useful check list has been suggested by the
airway remains open.
United States Institute for KMC training, which is
l Head should be given support from the back very helpful for checking the safe positioning for
of the neck in such a way that it is neither too skin to skin contact in KMC.


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of the neck in such a way that it is neither too skin to skin contact in KMC.
much bent in front nor too much bent back.
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CHAPTER THREE
PRACTICE GUIDELINES FOR HOME BASED KANGAROO MOTHER CARE (3.A KANGAROO POSITION)
Checklist for safe positioning for skin to skin Whenever binders, bags or wraps are used for the
contact/ kangaroo positioning: baby for Kangaroo positioning, mother must be
trained to move the baby safely in and out of
Face can be seen.
l
supports with one hand placed behind the neck on
l Head of the baby is in snifng position so as back and lightly support the lower part of the
mother and baby can have eye to eye contact. baby’s jaw with her thumb and ngers to prevent
baby’s head from slipping and blocking the
Nose and mouth are not covered.
l
airway when the baby is in upright position and
l Head is turned to one side, neck is straight, not place the other hand under baby’s bottom for
bent. support.
l Shoulders are at against Mom’s chest. l Explain to the mother that she can breastfeed
in the kangaroo position. In fact, it is easier to
Chest to Chest with Mom.
l


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in the kangaroo position. In fact, it is easier to
Chest to Chest with Mom.
l
feed in that position. Holding the baby near
Legs are exed/ bent from knees.
l the breast stimulates milk production.
Little upright, not at, on bed/chair.
l Mother can take care of twins too. Each baby
l
Cover the back with blanket or sheet. is kept on each side of her chest. She may
l
want to alter their position. Initially she may
Both (Mother and baby) are being watched
l feed one baby at a time. Later she will be able
while sleeping.
to feed them simultaneously from both the
Baby is being monitored. breasts.
l
If no one can watch you and your baby after l Mother can rest with the baby in the kangaroo
feeding and when sleep is likely- put your baby on position. When she is likely to fall into a deep
his / her back in a safe place. sleep, at home, it is advisable to keep the
baby at her side in the same bed or AKP may
Once a proper kangaroo position with or without


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baby at her side in the same bed or AKP may
Once a proper kangaroo position with or without
take over for KMC. When direct observation
the help of a kangaroo bag, lycra or some wrap is
is not possible at home, it is better to interrupt
achieved, the baby is to be kept in that position for
KMC while the mother is sleeping, to be safe
as long as possible, so that baby remains warm
for the baby.
and calm, gets good sleep and gets all the benets
of KMC. Baby needs to have a good cycle of quiet During follow up visits to mother, CHWs must talk
sleep for about one hour, so that good brain to her and listen to her medical as well as personal
growth happens. For the newborn to get one cycle social constraints and try to help her as much as
of good sleep for one hour, the mother has to hold possible. Initially the mother may be frustrated
the baby in kangaroo position for at least one and because of feeding problems of the small baby.


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the baby in kangaroo position for at least one and because of feeding problems of the small baby.
half hours. The longer sessions in KMC are very She should be guided for feeding the baby with
much useful. Ideally KMC should be done for all expressed breast milk and the different feeding
the 24 hours of the day continuously to get the best techniques and encouraged to continue KMC.
results. If support from family members or Support in the initial stages are of great
alternate care providers is available, KMC can be importance for the successful continuation of
tried for as long as possible. Disruptions in shorter KMC.
intervals and frequent handling of the newborn
should be avoided. That will not do good for the
small babies.
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CHAPTER THREE
PRACTICE GUIDELINES FOR HOME BASED KANGAROO MOTHER CARE (3.A KANGAROO POSITION)
3.A.8 Monitoring the infant during
KMC:
Babies should be monitored carefully during
HBKMC, particularly in early stages.
Infant’s airway is clear.
l
Breathing is regular.
l
Colour is pink.
l
Body temperature is maintained well.
l
3.A.9 Danger signals of the baby
during KMC and actions to be taken:
During every home visit, the CHWs should have a
thorough check up of the baby and monitor for
following parameters herself and also make sure
that mother and family members including AKP
Fig. 7: HBKMC by mother.
can recollect about how to recognize the same.
Temperature.
l
3.A.7 Caring the baby in Kangaroo
Breathing pattern.
l
Position at homes Heart beats.
l
Color of the baby.
At homes, the mothers do not have constant l
Overall activity and movements.
guidance or supervision from any health care l
Feeding.
functionaries. Hence it is important to provide l


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Feeding.
functionaries. Hence it is important to provide l
some tips for care during KMC. l General well being.
Most of the necessary care of the baby including Ø Body temperature of the baby is recorded by
feeding is possible while in kangaroo position. measuring axillary temperature with a
Baby has to be moved out only for changing the thermometer (Preferably with a digital
diapers, hygiene and cord care and whenever thermometer).
required for cup feeding. S/he has to be taken out
If a thermometer is not available, body
l
of KMC for at least one complete check -up during
temperature can be assessed by a palpatory
the home visits of the CHW. If the baby is secured
method, by palpating soles of feet and
well in Kangaroo Position, during daytime, mother
abdomen with dorsum of the examiner’s
can walk about and do some of her light daily
hand.
chores and recreational activities with some care.
If feet and abdomen, both are warm to touch,
Throughout, attention must be paid for providing l


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If feet and abdomen, both are warm to touch,
Throughout, attention must be paid for providing l
nothing to worry.
appropriate support to the baby's neck and
bottom to prevent any accidents due to undue neck
If the feet feel cooler and the abdomen/body
l
movements and slipping of the baby.
is warm, the baby is likely to have thermal
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CHAPTER THREE
PRACTICE GUIDELINES FOR HOME BASED KANGAROO MOTHER CARE (3.A KANGAROO POSITION)
stress and immediate skin to skin contact in
KMC and covering with a blanket from above,
will help to warm up the baby.
If the feet and abdomen/body both feel cold,
l
the baby is likely to be in moderate to severe
hypothermia and immediate action must be
taken to rewarm the baby.
Putting the baby only in kangaroo position
l
will not help when the baby is a moderate to
severe cold as KMC may take some time to
warm up the baby. Ideally, the baby has to be
put under a warmer.
In situations when warmer or some heating
l
devices are not available at homes, if
possible, a cotton bundle of cloth can be
warmed by rubbing on a heated thick iron
pan (“tawa” (used in Indian homes for
making chapati/roti) and the heated pad of
cloth is rst tested for the degree of heat by
rubbing on mother’s/care takers’ own cheek
and if found tolerable, then applied on baby’s
body (abdomen or thighs)to rewarm the


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and if found tolerable, then applied on baby’s
body (abdomen or thighs)to rewarm the
baby. This may have to be repeated several
times to rewarm the baby adequately. Care
must be taken to act quickly and safely so as
not to cause burns on the baby's delicate chest
and abdomen and also to rewarm the baby’s
body.
If the baby fails to rewarm despite efforts for
l
more than one hour, the possibility of severe
infection (sepsis) should be considered and
urgent steps for referral to a hospital must be
taken. If that is not possible immediately, the
local ANM may be requested to give
injectable Gentamicin one dose and then
arrange for transfer to the proper hospital.
Do not use a hot water bottle or bag for
l
keeping the baby warm. Use of hot water
bottles in these situations is not encouraged
much due to possibilities of accidents and
problems. Chances of availability of a proper
Fig. 8: Palpatory method of temp
assessment of the newborns. rubber water bag are less in these places. If a
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CHAPTER THREE
PRACTICE GUIDELINES FOR HOME BASED KANGAROO MOTHER CARE (3.A KANGAROO POSITION)
glass bottle with hot water is used, it may Explain that if breathing stops for 20 seconds
l
break causing injuries or the lid of the hot or more, the baby becomes blue (Blue lips and
water bottle may be loosely closed allowing face), this may be a sign of serious illness.
water to leak out and cause burns to baby or
Teach her to stimulate the baby by gently
l
wetting the baby and causing hypothermia
rubbing the back or head or tickling the soles
depending on the temperature of the water
of feet and by rocking movements until the
lled in the bottle/bag.
baby starts breathing again. If the baby is still
Ø Observing breathing rate, depth and not breathing, the mother should go to a
regularity: Usually the breathing rate in a hospital immediately.
newborn is around 40 per minute and
variable. If the respiration rate is less than 20
a) Flicking the soul


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variable. If the respiration rate is less than 20
a) Flicking the soul
per minute or more than 60 per minute, it is a
sign of a serious problem. It is also suggested
to observe the pattern of breathing of the
baby. If breathing is laboured or very shallow,
it indicates a problem. If the rhythm of
breathing is very irregular or breathing stops
for a few seconds continuously, described as
apnoea, it also indicates a problem. If
breathing stops for more than continuous
twenty seconds and may or may not be
b) Rubbing the back
associated with changes in heart rate and
bluish discoloration, it indicates serious
problem. Preterm babies often get frequent
such temporary episodes of stopping of
breathing described as apnoea. If immediate
action is not taken, brain damage can occur
leading to many long term consequences like
ts, delayed brain development or even death
due to lack of oxygen.
What to do in cases of apnoea?
Fig. 9: Physical stimulation for neonatal apnea cases


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What to do in cases of apnoea?
Fig. 9: Physical stimulation for neonatal apnea cases
Teach the mother to observe the baby’s
l
breathing pattern and explain normal
breathing which appears regular and easy
Very fast or slow breathing and laboured
breathing without any undue efforts.
breathing as seen by chest indrawing,
Explain what a temporary stoppage of grunting and nasal aring are also signs of a
l
breathing / apnoea means and what ill serious problem in a baby.
effects it has on a baby. It could be a sign of
Ø Excessive frothing from mouth and even
serious illness for the baby.
nose: Froth or secretions should be
immediately wiped with a clean cloth
wrapped around the index nger of the
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CHAPTER THREE
PRACTICE GUIDELINES FOR HOME BASED KANGAROO MOTHER CARE (3.B KANGAROO NUTRITION)
attendant and sweeping through mouth and of suspected serious infections/ sepsis before
nose gently and turning the head to one side referral.
and even lifting the head slightly above and
Ø Danger Signs
slightly tilted back so that airway remains
open. A simple algorithm is suggested for easy
remembrance of most of the danger signals.
Ø Difculty in feeding: it may be in different
grades. Baby may stop feeding totally or may A - Apnoea- Breathing stops for more than 20
be slow or drowsy to feed or vomits frequently seconds continuously. Frequent and long
or excessive crying while feeding. spells.
Ø Abnormal movements of body and B - Breathing difculty- very fast or slow/
eye/convulsions: Whenever a neonate has Irregular rate and rhythm.
abnormal movements or eye movements, the
C - Chest indrawing, grunting, froth from mouth.
attendant should roll the baby on his/her side


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C - Chest indrawing, grunting, froth from mouth.
attendant should roll the baby on his/her side
and position in such a way that the airway C - Cold hands and feet.
remains open and report to the HCP.
C - Convulsions/abnormal movements or
Ø Frequent loose motions/diarrhoea: behaviour.
Dehydration should be prevented. Increase
D - Decreased feeding, stops feeding or vomits.
frequency of breast feeding and if quantity of
D - Decreased activity, weakness or lethargy.
urine passed in previous 12 hours is less and
colour of urine becomes dark yellow due to
D - Diarrhoea/loose watery stools.
concentration, which could be a sign of severe
D - Distension/ fullness of abdomen.
dehydration, use of ORS in between feeds to
be given. H - Hypothermia (Cold limbs/body),
Hyperthermia (Fever).
Ø Boils and pustules over the skin- Oral
Cotrimoxazole can be given by Anganwadi
workers or ANMs if less than 5 boils are
3.B Kangaroo Nutrition:
present.


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workers or ANMs if less than 5 boils are
3.B Kangaroo Nutrition:
present.
Ø Yellow discolouration of eyes and Feeding of New-born in HB KMC-Special
skin/jaundice* Considerations.
Ø Undue fullness of stomach/abdomen with or (The CHW is advised also to read manuals of
without vomiting* Infant and Young Child Feeding and guidelines
for feeding of the newborns in facility based
Ø Excessive bleeding from umbilical cord or
KMC for more details).
from any other parts of the body*
In this manual, only the salient points of optimal
In all these situations, refer the newborn to a
feeding of LBW and preterm babies in home
hospital. Recently community-based nurses
situations are mentioned.
like Auxiliary Nurse Midwives are being
trained for giving injection Vitamin K to The most important component of KMC is to
prevent bleeding in neonates (Haemorrhagic promote exclusive breast milk feeding.
disease of newborn) and Injection Appropriate feeding of LBWI improves their


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disease of newborn) and Injection Appropriate feeding of LBWI improves their
Gentamicin as the rst treatment for the cases chances of survival and is important for their
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CHAPTER THREE
PRACTICE GUIDELINES FOR HOME BASED KANGAROO MOTHER CARE (3.B KANGAROO NUTRITION)
optimum growth and development. The nutritional babies breastfeeding should be started before
needs of infants with similar birth weight may vary one hour of birth and exclusive breastfeeding
depending upon whether the infant is appropriate should be continued for six months.
for gestational age (AGA) or small for gestational
Breastfeeding should be continued for babies
l
age (SGA). Broad principles of feeding the baby
having birth weight more than 1800g and
during HBKMC are the same as those of hospital
born more than 34 weeks of gestation as
based KMC. But depending on the resources and
calculated from the rst day of the last
expertise available with the attending HCP, certain
menstrual period.
modications have to be made. Only such
situations are highlighted here. l In the weight group of 1200 to 1800 gm
babies who are mature, may be able to take


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babies who are mature, may be able to take
In this chapter following aspects have been
direct breast feeding
described:
Ø Immediate skin to skin contact, delayed cord
Ø 3.B.1 Steps for successful breastfeeding for
cutting, initiate early breast feeding.
stable LBW and preterm babies.
Soon after the delivery, put the baby directly
l
Ø 3.B.2 Feeding of unstable (sick) and too small
in skin to skin contact on the mother's
babies (VLBWI/ELBWI).
abdomen even before cutting the cord.
Ø 3.B.3 Skills required for feeding LBWI during Immediate drying may not be required at this
HBKMC. stage.
Every effort should be made to provide breast If the baby does not start breathing or crying
l
milk to LBWI. immediately within the rst few seconds after
birth, urgent resuscitation will have to be done
on priority basis as per the guidelines.
3.B.1 Steps for successful breast
Then cut the cord after about one to three
feeding for stable low birth weight l
minutes or when cord pulsations stop
babies:


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feeding for stable low birth weight l
minutes or when cord pulsations stop
babies:
naturally (Physiological cord cutting) and then
quickly dry/ mop the baby with a clean warm
Ø What to feed and how to give?
towel and discard the wet towel and place the
Breast milk is the best choice for all the
baby on mother’s abdomen, who will crawl to
babies.
the chest in between her breasts and attach on
It is ideal food for all infants including those the breast nipple and start sucking. A mature
who are LBW. baby can have a breast crawl seeking for the
breast nipple on the mother's chest.
WHO recommends that all LBWI,
irrespective of their gestation, be fed with l Let the baby remain on the mother's chest in
breast milk. between her breasts for at least one to one
and half hours continuously.
The goal is to enable every LBWI to receive
feeding directly and exclusively from Ø Soon after birth, breast feeding should be


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feeding directly and exclusively from Ø Soon after birth, breast feeding should be
his/her mother’s breast at the earliest. initiated as early as possible, within half to
one hour for following reasons.
HBKMC is started for all the stable and even
l
The newly born is very alert and active within
l
mildly sick babies and in all the newborn
the rst half to one hour of birth.
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CHAPTER THREE
PRACTICE GUIDELINES FOR HOME BASED KANGAROO MOTHER CARE (3.B KANGAROO NUTRITION)
Fig. 10: Direct breastfeeding and burping
In the immediate period after birth, baby’s There is strong bonding of love and sentiments
l l
sucking is quite powerful and that increases between mother and baby.
the chances of successful breast feeding.
There is a rapid decrease in vaginal bleeding
l
Newborn gets colostrum through early breast in the mother after delivery, rapid shrinking of
l
milk, which contains many disease preventing uterus and reduction in breast engorgement
factors, therefore is considered as the rst and swelling.
vaccine for the newly born baby.
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CHAPTER THREE
PRACTICE GUIDELINES FOR HOME BASED KANGAROO MOTHER CARE (3.B KANGAROO NUTRITION)
Ø Continue exclusive breast feeding till the Ø Proper method of holding the baby for
baby completes six months of age. breastfeeding (Positioning).
Ø Do not give even water in between the feeds l The whole body should be supported.
during rst six months because.
The head, neck and back of the baby remain
l
By giving other liquids, the amount of breast in straight line.
l
milk taken by the baby reduces and nutrition
Mother is comfortably positioned while sitting
l
suffers.
or lying down.
Baby is liable to get serious infections through
l
Her eyes should be xed on the baby.
l
contaminated water (used for diluting the milk
or cleaning the vessels of feeding) and Ø Proper method of attaching the baby to
develop loose motions. mother’s breast (Latching).
In the rst six months after birth, even in hot Four signs of proper latching:
l
summer months, the baby does not require


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l
summer months, the baby does not require
Baby’s mouth is wide open.
l
additional water. Frequent breast feeding can
be given, which has enough water content for l The lower lip is turned outside.
the baby's requirement.
Child’s chin is touching the mother's breast.
l
Ø There is no need for prelacteal feeds. The black areola around the breast nipple is
l
Traditionally giving sugar water, jaggery, mostly in the baby's mouth.
l
honey, ghee etc. as pre lacteal feeds, delays
In short, we can remember following simple
establishment of breast feeding and increases
rules:
the chances of infection and loose motions
B to B: Take the baby to breast rather than
and other serious illnesses in the baby. l
bringing the breast to baby by bending of
Ø Promote breast feeding by proper
mother which is very uncomfortable for
attachment or latching of the baby to breast.
prolonged breast feeding.
By proper latching, nipple sores/swelling,
l T to T: Hold the baby in such a way that the
l


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By proper latching, nipple sores/swelling,
l T to T: Hold the baby in such a way that the
l
therefore, breast engorgement and pain do
baby's tummy remains on the mother's
not occur.
tummy.
During each feeding, the baby should feed on
l N to N: Put the baby on the mother's breast so
l
one breast till it is empty and then shifted to
that the baby's nose touches the mother's
another breast. Next time, feeding should
nipples.
start from the other breast rst.
Ø Factors that can inuence proper
During 24 hours of a day, the newborn should
l breastfeeding:
breastfeed at least 10 to 12 times including
regular night feeds. It should be given as l Feeding given through bottle.
many times as the baby indicates by signs of
Inexperienced mother.
l
hunger. Some babies demand frequent feeds,
Mother does not have the support of an
whereas some babies may take less and only l
experienced person.
with some effort, take more. But forced
feeding should not be done.
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CHAPTER THREE
PRACTICE GUIDELINES FOR HOME BASED KANGAROO MOTHER CARE (3.B KANGAROO NUTRITION)
Retracted nipples are often considered a Chances of infections increase because of
l l
problem for proper breastfeeding. But we unhygienic handling of the paciers.
should encourage the baby to suck on areola,
Ø Gripe waters and various traditional herbal
the black area surrounding the nipple, rather
preparations etc. Not needed at all.
than only on nipple. Retracted nipple is not a
problem if proper latching on areola is Ø What is to be done after breastfeeding?
achieved. Due to negative pressure created
After breastfeeding, the baby should be
l
while sucking on the areola, the embedded
burped well by holding straight on mother’s
nipple does come out.
shoulders and patting gently on the baby's
Ø In case, the baby is not properly latched, back.
following problems can occur.
Only after the baby burps (takes out the
l


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following problems can occur.
Only after the baby burps (takes out the
l
Mother gets sore nipples or cracked nipples swallowed wind), should the baby should be
l
and severe pain. laid at on his/her back.
l Breast is not fully emptied leading to breast l Before allowing the baby to lie down on its
engorgement (Filled with too much of milk) back (Supine position) the baby can be turned
and breast becomes very hard and difcult to on its tummy (prone position) in such a way
suck and/or swelling, redness and pain that the baby's nose is not being pressed and
develop further making breastfeeding s/he is able to breathe comfortably and
difcult. allowed to remain in that position for some
time.
Baby does not get enough milk to satisfy
l
hunger and continues to suck frequently on l Mother must observe her baby frequently, if
nipples leading to cracks, bleeding and the baby is put on the tummy to avoid
severe pain. suffocation.


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severe pain. suffocation.
l Due to improper emptying, further breast milk l Keep the baby next to the mother in the same
secretion reduces, baby keeps crying, and bed or continue in Kangaroo position, so that
does not feed well resulting in less weight it is easier for frequent breastfeeding and the
gain. baby also remains warm.
Ø Breast feed the baby as many times as it Ø The more the baby feeds, more breast milk
demands and even during nights because. will be produced.
l By proper latching and frequent l If the mother is condent, healthy and calm
breastfeeding more milk is produced. while breastfeeding, the baby has no
problems.
By demand feeding and frequent feeding,
l
breast engorgement/swelling does not occur.
3.B.2 Feeding of unstable(sick) and
Night feeding increases the secretion of
l
too small babies (VLBWI/ELBWI):
breast milk producing hormone prolactin and
the mother feels comfortable.
(Babies with body weight less than


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the mother feels comfortable.
(Babies with body weight less than
Ø Do not give paciers or Bottle feeding. 1500/1000g, often have cardio -respiratory
problems, temperature instability, abdominal
By giving paciers/nipples, the baby has
l
distension or serious acute illness such as
problems sucking on the breast.
asphyxia or sepsis).
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CHAPTER THREE
PRACTICE GUIDELINES FOR HOME BASED KANGAROO MOTHER CARE (3.B KANGAROO NUTRITION)
a) Offer expressed breast milk by cup/spoon/ general, we can divide the babies according
paladai etc.; (Provided IV uids or Tube to their birth weight (wherever weighing is
feeding is not possible and consider transfer possible) in three broad categories and
to higher centre, if possible). decide the method of feeding.
b) As the infant improves, put her /him directly ü Category I: The babies with birth weight less
on the breast to stimulate milk production. than 1200g.
c) Initiate KMC once the baby stabilizes or as ü Category II: The babies with birth weight
more than 1200g and less than 1800g.
early as possible.
(KMC/KP can be given even in many sick babies ü Category III: The babies with birth weight
more than 1800g but less than 2500g.
under supervision and guidance of experienced
persons.).
Wherever weighing is not possible, the worker has
to decide according to the baby's apparent size


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Wherever weighing is not possible, the worker has
to decide according to the baby's apparent size
Many preterm infants have feeding difculties
and behaviour of sucking, swallowing and
initially because of:
breathing coordination.
Inability to coordinate suck, swallow and
l
breathing. ü The babies in category III, having weight
more than 1800g, are generally capable of
Immature and sluggish gut.
l direct breastfeeding like mature newborns,
Systemic illness. with good coordination of sucking,
l
swallowing and breathing.
Full term small for gestational age infants
because of being weak or sick, may also ü The babies in category I, having birth weight
experience: less than 1200g, will mostly have to start with
expressed breast milk (EBM), being given
Poor attachment and sucking effort on the
l with a cup, spoon or the traditional feeder
breast.
“paladai”. Some of these very small babies
Poor swallowing. should ideally be given intravenous uids or
l


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Poor swallowing. should ideally be given intravenous uids or
l
tube feeding in the rst few days of life which
Easy tiredness (And hence poor intake).
l
can be given only in hospitals. Wherever it is
l Vomiting, regurgitation or abdominal not possible, the only available option will be
distension. feeding with expressed breast milk from
mother. The baby can be shifted to direct
Ø Lower the birth weight, greater is the
breastfeeding as early as possible.
likelihood of feeding difculties.
Ø Feeding of category II babies with birth
Most of the times, HBKMC is being continued
l
weight more than 1200g and less than
for more days only for small babies who are
1800g:
either pre -term babies (Born before full term
of 37 to 41weeks and six days of gestation as The mode of feeding can depend on the
l
calculated from the rst day of LMP) or those baby's ability of having good coordination of
who are full term and yet have birth weight sucking, swallowing, and breathing. Baby


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who are full term and yet have birth weight sucking, swallowing, and breathing. Baby
less than 2500g. At times, CHW may nd it may be put directly on the mother's breast. If
difcult to differentiate these categories the baby is having good sucking efforts and
according to their maturity. Therefore, in coordination of sucking and swallowing,
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CHAPTER THREE
PRACTICE GUIDELINES FOR HOME BASED KANGAROO MOTHER CARE (3.B KANGAROO NUTRITION)
direct breastfeeding can be continued.
Sometimes it should be tried several times in
the rst two/ three days to judge the capacity
of the baby for direct breastfeeding. So, in
between, the baby may have to be given
expressed breast milk directly with a cup, by
spoon from cup or some suitable method.
Some babies in this weight group do not have
good coordination of sucking and swallowing
for a longer time. In that case, feeding with
EBM has to be continued for a longer time.
The efforts should be to shift to direct
breastfeeding as early as possible.
Fig. 13: Method of expressing breast milk
Figure 11: Collection of EBM
Figure 12: Paladai Feeding Figure 14: Spoon Feding
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CHAPTER THREE
PRACTICE GUIDELINES FOR HOME BASED KANGAROO MOTHER CARE (3.B KANGAROO NUTRITION)
Every effort should be made to provide breast Very small babies should be given about 10 to
milk to LBWI. 12 feeds within 24 hours at 1 to 2 hours
interval including night feeds (which are very
(Either as direct breastfeeding or as expressed
often missed) as per the signs of hunger.
breast milk).
Ø The smaller the baby the smaller is the
Ø How often to feed? interval in between feeds.
All Term and stable newborns: (Who had a In case of small babies/ very LBW/ very
lusty cry soon after birth and apparently did preterm babies, the feeding schedule may
not have any other problem or defect like cleft start clockwise at xed time intervals and later
lip or palate, which might affect direct gradually shift to demand feeding. Whenever
breastfeeding) Ideally these neonates must be top feeding is being given, the baby may be


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breastfeeding) Ideally these neonates must be top feeding is being given, the baby may be
put to mother’s breast and feeding started as put to breast rst and try for suckling and then
early as possible within half to one hour of top milk can be given. This will enable breast
birth. It will ensure colostrum feeding and no milk ow to continue and facilitate early direct
pre lacteal feeds are required). breastfeeding.
Other small babies: (with delayed cry, Ø What to do if mother’s milk is not available or
difculty in breathing or some problem) may is less than the required amount?
have to be given feeds as early as possible
All efforts must be made to have own
after birth once they are stabilized in terms of
mother’s milk for baby’s feeding.
heart rate and respirations. First feed for very
small babies may not be delayed for more Ensure continued ow of breast milk in the
than four hours after birth to ensure colostrum mother who has a small baby. Because of the


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than four hours after birth to ensure colostrum mother who has a small baby. Because of the
feeding. If for some reason feeding of breast poor or no sucking effort by the LBWI (due to
milk is delayed in very small babies, problems sickness, weakness or poor reexes) and
may occur because of less energy and less maternal anxiety, the breast milk output may
sugar content in the baby's blood and the remain low. Breast milk inadequacy must be
baby may get ts in the form of abnormal prevented and tackled by frequent
movements of body and limbs and eyes counselling of mother and her family
leading to brain damage and other members. In addition, breast milk should be
complications. To avoid such serious expressed frequently ( both during day and
immediate and long-term complications, the night) to provide EBM to the baby including
baby may be given either some donor mother during nights and help to increase the milk


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baby may be given either some donor mother during nights and help to increase the milk
milk/animal milk/ formula and attempts to ow. The expressed milk can be stored in
feed its own mother’s milk should continue. room air only for about 4 to six hours.
During HBKMC, continued supervision and (In refrigerators, in regular compartments, it
guidance to CHWs is not possible. Hence can be stored for 24 hours and in a deep
mothers may be advised to give breast milk freezer, it can be kept for two to four weeks. In
alternatives in the beginning, only for very resource restricted regions this facility is
small and very premature babies, to avoid generally not available).
complications due to less sugar/energy in
Ø Whenever, due to some reason, mother’s
blood.
own milk is not available or inadequate,
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CHAPTER THREE
PRACTICE GUIDELINES FOR HOME BASED KANGAROO MOTHER CARE (3.B KANGAROO NUTRITION)
other options may have to be tried in order of In some cases, the recorded weight is not very
l
preference: accurate and makes further monitoring
difcult.
Donor mother’s milk (Facility of breast milk
l
banks are mostly not available in these When monitoring day-to-day weight is difcult,
regions) (Wet nursing if possible). the worker may have to assess the adequacy of
feeding by recording the approximate quantity of
Formula milk (Preterm formula may not be
l
urine passed in previous 24 hours, cry of the baby,
available easily).
duration of quiet sleep, nature of stools the baby
l Processed dairy milk (May not be available has passed and general well-being of the baby.
in many regions).
In case of newborns and more so in case of small
l Animal milks like cow, buffalo, goat, camel babies, it is difcult to assess in the rst few days as
etc. the baby may not pass urine within the rst 24 to


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etc. the baby may not pass urine within the rst 24 to
48 hours some -times. In the rst few days, the
Except in the case of buffalo milk containing high
baby may be losing weight despite adequate
fat, all other animal milk can be given after boiling
feeds. Usually, the newborn babies lose up to 7%
well and without further dilution.
of the birth weight in the rst few days of life and
In case of buffalo milk, the cream has to be should not be exceeding 10% of birth weight at
removed after boiling and cooling and then it can any time.
be given without any further dilution. Animal milk
Ø The smaller the size of the baby and the more
as substitutes are not very ideal. But in resource
premature the baby, longer time will be
restricted situations, it could be the only available
taken to regain the original birth weight.
practical solution. In many places, nowadays
processed dairy milk pouches are available, in But latest by 10 to 15 days after birth, the


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processed dairy milk pouches are available, in But latest by 10 to 15 days after birth, the
which fat content is standardized and the milk is baby should have regained his/her original
pasteurized and stored. This is a preferred option birth weight. CHWs may have to rely more on
rather than directly collected animal milk which is detailed history of feeding and general
not processed for fat content nor pasteurized. behaviour of the baby to assess adequacy of
feeding.
Ø How to decide whether a baby is getting
adequate feed? Ø Remedial measures if breast feeding is
suspected to be inadequate:
Regular proper weighing is the best method to
l
decide about weight gain pattern and decide First of all, establish that breast milk is really
l
about the adequacy of feeds. But it has several inadequate and should not depend on the
difculties in home situations. perception of the mother or her family
members.
Good accurate weighing scales are not
l


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members.
Good accurate weighing scales are not
l
available. For monitoring the newborn’s daily Check for the correct technique of feeding in
l
weight uctuation in terms of a few grams like terms of positioning of the baby for
5 to 10 g will have to be recorded. Such breastfeeding and attachment on the breast
sensitive scales are not available for the use including areola and not just nipple sucking.
during home visits of HCPs.
Make sure the night feeds are not missed. That
l
l In case of home deliveries and even in some is often the common reason for inadequate
hospital deliveries, birth weight is not weight gain.
recorded or not possible soon after birth.
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CHAPTER THREE
PRACTICE GUIDELINES FOR HOME BASED KANGAROO MOTHER CARE (3.B KANGAROO NUTRITION)
Counsel mother and her family members and refrigerator (2 to 8degrees C) for 24 hours
l
build condence of mother that she can get safely.
adequate breast milk as per the needs of her
Ø What precautions must be taken during and
baby.
after feeds in very LBWI/ small babies with
She can be educated to know about early expressed breast milk?
l
signs of hunger cues in the baby.
The mothers to have patience rst while
Regular follow up and reassurance must feeding the small babies. The babies may take
l
continue during every home visit of the CHW. a long time to complete feeding in one
If possible, weigh the baby regularly. session.
Strict hand washing before feeding the baby
3.B.3 Skills required for feeding LBWI and proper cleaning of cup, spoon or
whatever utensils that are used for feeding
during HBKMC:
must be done with soap and water to prevent


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during HBKMC:
must be done with soap and water to prevent
a) Manual expression of milk and its storage: infections and loose motions sometimes with
vomiting.
Stepwise instructions to mother:
Bottle feeding should be avoided all the time.
Wash your hands well with soap and water
l
In poor set up, infections, regurgitation of
before expressing breast milk.
feeds and other complications are most
l Put a clean container under the breast for likely with the use of bottles.
collecting milk.
Breast milk secretion also suffers following
Massage the breasts gently towards the
l
nipple confusion during bottle feeding.
nipple.
When cup/spoon/paladai or such top
Place your thumb and index nger opposite
l
feeding is being given, all precautions must
each other just outside the dark circle around
be taken to prevent regurgitation and
the nipple (Areola).
aspiration.
Now press back towards your chest, then
l
b) Feeding with a cup
gently squeeze to release the milk.


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Now press back towards your chest, then
l
b) Feeding with a cup
gently squeeze to release the milk.
Following instructions are given to mother or
Repeat the same step in different positions
l
caregiver who will be feeding with cup or with
around the dark circle surrounding the nipple
a spoon from cup
(areola).
The baby should be awake and held sitting
l
If expressed milk cannot be given immediately
l
upright on the caretaker's lap.
after collection, it has to be stored and used
when necessary. EBM can be kept at room Take a measured amount of milk in a wide
l
temperature for at least 6 hours without mouth container with rounded edges. Directly
signicant risk of spoiling. Any milk not fed apply this cup with rounded edges containing
within 6 hours after expression, should be milk on the upper lip of the baby. The baby will
discarded if kept only at room temperature. In open the mouth and actively start sucking the
refrigerator (if available) EBM can be stored milk.


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CHAPTER THREE
PRACTICE GUIDELINES FOR HOME BASED KANGAROO MOTHER CARE (3.C KANGAROO DISCHARGE AND FOLLOW UP OF NEWBORN RECEIVING HBKMC)
c) Feeding with spoon from cup In case a baby gets regurgitation of feeds
l
through nose or mouth, immediately the baby
Take a small quantity of milk from the
l
may be held vertically and with a clean cloth
container in a spoon.
wrapped around the caretaker's index nger,
l Hold the spoon so that it touches the upper lip the mouth and nose may be wiped clean and
of the infant and the mouth is opened. milk and other uids should be removed. The
baby may be put in a prone position for a
The baby may start sucking the milk or tilt the
l
short while and patted on the back to remove
spoon so that milk reaches the infant's upper
the aspirated milk from the baby's breathing
lip.
passages.
If possible, allow the infant to take the milk by
l
A mucus sucker may be given to the mother
him/herself and do not pour it into the infant's l


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l
A mucus sucker may be given to the mother
him/herself and do not pour it into the infant's l
with proper instructions to use. It must be
mouth. Feed the infant slowly, make sure that
sterile, disposable and readily available for
milk already given, is swallowed fully before
use in case of sudden aspirations of being fed
giving anymore.
by the baby.
When the infant has had enough, S/he will
l
The CHW makes sure that mother knows the
close his/her mouth and will not take any l
correct use of the same. (Her training must be
more.
proper, and the procedure must be directly
l Do not force feed the infant observed carefully before allowing mother to
do the suction with the mucus sucker) If the
Estimate the amount of milk taken in the same
l
worker does not know about proper use or
way as for cup feeding.
mother cannot be taught well about the use of
Feeds must be given from an angle of the
l mucus sucker, it should not be used at all.
mouth slowly. Direct pouring of large


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l mucus sucker, it should not be used at all.
mouth slowly. Direct pouring of large
quantities in the baby's mouth should be
3.C Kangaroo Discharge and Follow
avoided.
Up of newborn receiving HBKMC:
The quantity of feed must be gradually
l
increased. Early discharge and regular follow up together
form the third most important component of KMC
Soon after feeding a very LBWI, the baby
l
should not be immediately put on his back This component needs to be promoted very much
(Supine). After feeding, at least for a short especially in the context of Home Based Newborn
time, the baby can be lifted vertically for a few Care (HBNC) including KMC to achieve the
minutes (Burping done) and then the baby successful outcome for the small and sick
should be put on his/her tummy (Prone) or newborns.
rolled on his/her left lateral side. The left
Following aspects are discussed in this chapter:
lateral position may be given with the support


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Following aspects are discussed in this chapter:
lateral position may be given with the support
of a small pillow or a roll of clothes even when Ø Planned early discharge and random early
the baby has to be left alone at home and discharge.
mother has to go for a bath or some other
Ø General schedule for home visits of ASHA
purpose and there is no one to watch the
workers.
baby.
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CHAPTER THREE
PRACTICE GUIDELINES FOR HOME BASED KANGAROO MOTHER CARE (3.C KANGAROO DISCHARGE AND FOLLOW UP OF NEWBORN RECEIVING HBKMC)
Ø Activities of the ASHA/HCPs during the l No other major problems in the baby.
home visits of a baby in HBKMC.
Mother is condent of continuing care of the
l
Ø Checklist for activities during follow up home small baby at home as guided in the hospital.
visits of ASHA/CHWs.
Family members are willing to support the
l
Ø Suggested timetable of key activities of mother for KMC at home.
HBNC of ASHA workers with special
Ø Random early discharge in hospital
reference to HBKMC including promotion of
delivered baby:
breastfeeding.
In Indian context, many mothers do have
(* Group I: Hospital delivered, and hospital
institutional deliveries, but after delivery, do not
cared for babies including KMC and
stay in the hospital for even the minimum required
discharged as per the hospital policy.
time for the care of small and weak babies due to


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discharged as per the hospital policy.
time for the care of small and weak babies due to
* Group II: Hospital delivered babies but left several reasons and get early discharge and go
early without satisfying the discharge home. This is what we describe as random early
criteria of the hospital. discharge in case of group II against the planned
early discharge in case of group I. In case of
* Group III: Home delivered and home cared
group III who are home delivered, the
for babies.)
considerations of discharge are not relevant.
The follow up of mother and baby with KMC
3.C.1 Planned early discharge of
should be done as a part of HBNC, when hospital
hospital delivered baby:
visits are not possible, through home visits by an
ASHA who are trained in KMC and breastfeeding
The component of discharge is relevant more for
and detection of danger signs. The follow up visits
the group I babies who have delivered in the
are mandatory-
hospitals and received care including KMC and


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are mandatory-
hospitals and received care including KMC and
then discharged after fullling proper criteria laid To monitor general wellbeing and adequate
l
down by the hospital. In case of KMC they get physical growth.
planned early discharge after making certain
To assess neurological development.
l
criteria for the continued safety of babies after
leaving/ being discharged from the hospital. l To detect illness at an earlier stage and initiate
proper management.
These minimum criteria include the following:
To ensure that mother has understood all the
l
The preterm or LBWI infant is able to maintain
l
instructions regarding administration of
body temperature with KMC and no external
supplementary micronutrients like iron,
sources of additional heating are required.
calcium, phosphorus and vitamins.
Baby is capable of oral feeding as direct
l
For routine immunization of the infant.
l
breastfeeding or expressed breast milk.
To make sure that mother can recognize
l


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l
breastfeeding or expressed breast milk.
To make sure that mother can recognize
l
(Or other alternative top feeds)
danger signs and seek prompt care at the
l Before discharge, baby had satisfactory earliest.
weight gain of at least 15 g/Kg /day for a
minimum of three consecutive days.
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CHAPTER THREE
PRACTICE GUIDELINES FOR HOME BASED KANGAROO MOTHER CARE (3.C KANGAROO DISCHARGE AND FOLLOW UP OF NEWBORN RECEIVING HBKMC)
3.C.2 General schedule for home visits
of ASHA workers is as follows:
Antenatal visits as per schedule.
l
Postnatal visits.
l
In case of home deliveries- seven visits.
In case of hospital deliveries- six visits.
1st visit - at the time of birth, if possible or as
l
early as possible after birth within rst 48
hours.
l 2nd visit- on 3rd day after birth. Fig. 15: Home visits by health worker
3rd visit- 7th day after birth.
l
In case of feeding with expressed breast
l
4th visit- 14th day after birth.
l milk, check for the technique of expression,
5th visit- 21st day after birth. collection and storage of milk, hygienic
l
handling, quantity of milk expressed,
6th visit- 28th day after birth.
l
frequency of feeds including night feeds, any
7th visit – 42nd day after birth. other difculties related to breast milk
l
feeding.


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7th visit – 42nd day after birth. other difculties related to breast milk
l
feeding.
3.C.3 Activities of the ASHA/CHWs Adequacy of feeds can be judged by amount
l
during the home visits of a baby in of urine passed after the rst few days of
birth, quality of sleep and stools and mainly
HBKMC:
by the weight gain pattern.
During every home visit, CHW should have a
In the rst few days the baby may be losing
thorough check of the baby and carry out the
weight. At no stage, the weight loss should be
following:
more than 10% of birth weight. Generally, by
Reinforcement of knowledge and skills 10th day after birth in case of a full term baby
l
required for essential newborn care. and by 14th day after birth in case of preterm
baby, the birth weight is regained. Thereafter
Depending on the stage of requirement,
l there is daily weight gain of about 15 to 20 g
counselling for the KMC for initiation,
per KG of weight. Quite often, the CHW do
continuation of breastfeeding.


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per KG of weight. Quite often, the CHW do
continuation of breastfeeding.
not have good sensitive weighing scales
For increasing the duration of KMC, in those suitable for monitoring small weight
l
cases where KMC is to be continued. uctuations of newborns. Hence their
judgement is often based on the general well
To ensure support from family members as
l
being of the baby and history of amount of
AKPs.
urine passed and sleep and behaviour of the
Breast feeding- technique, adequacy of baby.
breast feeds and weight gain.
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CHAPTER THREE
PRACTICE GUIDELINES FOR HOME BASED KANGAROO MOTHER CARE (3.C KANGAROO DISCHARGE AND FOLLOW UP OF NEWBORN RECEIVING HBKMC)
Correct method of hand washing and other During a follow -up visit:
l
infection prevention measures.
Weigh a baby.
l
To make sure that mother and family members
l
Obtain a history from mother.
l
including AKP recollect about detection of
danger signs preferably in early stages and l If she is doing KMC at home: Proper plotting
aware of immediate actions to be taken. of KMC duration by hours and number feeds
and weight on KMC chart.
To explain to them about the importance of
l
regular follow up at nearby hospitals. l Breastfeeding and other feeding options as
appropriate.
To guide them, wherever possible, when and
l
where to refer in case of emergency or for l Whether there are any danger signs in the
special check -up of eyes and ear hearing and baby.
assessment for brain development and how to
Ask the mother if she has any other related
l


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assessment for brain development and how to
Ask the mother if she has any other related
l
transport the baby in direct skin to skin
concerns.
contact on chest (Kangaroo Position) to
Perform a general physical and systemic
suitable facility. l
examination of the baby.
Education and empowerment of mother
l
Encourage mother and family members to
regarding feeding problems and detecting l
continue KMC and prolong the duration as
signals at the early stages, infection control
long as possible and advise them to seek
measures and her other questions and
immediate care when there are any danger
anxieties.
signs.
To ensure proper childcare practices of the
l
Make sure they know what actions to be taken
mother such as baby bath, body sponging, l
immediately before taking the baby to
changing the clothes, diapers, play and
hospital in case of apnoea, vomiting,
stimulation activities.
aspiration of feeds etc, and avoid all possible
Advice regarding Immunizations.


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aspiration of feeds etc, and avoid all possible
Advice regarding Immunizations.
l delays in referral and how to carry the baby in
(If possible, advise regarding micronutrient skin-to-skin contact while travelling to the
l
supplements to LBWI/PT babies for Vitamin health centre. Mother should know where to
D, Iron, calcium and phosphorus as go and whom to contact.
Multivitamin preparations and Iron and
Praise the mother for taking care of the baby
l
Calcium drops as learnt from the doctors or
and schedule the next visit.
nurses during monthly health and nutrition
meetings at village level).
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CHAPTER THREE
PRACTICE GUIDELINES FOR HOME BASED KANGAROO MOTHER CARE (3.C KANGAROO DISCHARGE AND FOLLOW UP OF NEWBORN RECEIVING HBKMC)
Removing Bangles Cutting Nails Palms
Fingers Thumb Nails
Wrist Washing Knuckles
Drying
Fig. 16: Steps of handwashing
|35|


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CHAPTER THREE
PRACTICE GUIDELINES FOR HOME BASED KANGAROO MOTHER CARE (3.C KANGAROO DISCHARGE AND FOLLOW UP OF NEWBORN RECEIVING HBKMC)
3.C.4 Checklist for activities during follow up home visits of ASHA/CHWs.
Following components must be checked during the follow up visits:
KMC * Check the KMC position.
* Duration of direct skin to skin contact (history regarding KMC hr. per day).
* Continuation of night KMC.
* Filling up the KMC chart correctly.
* Clothing.
* Body temperature.
* Support for the mother and baby from family.
* Does the baby show any signs of KMC intolerance?
* Is it time to wean the baby from KMC?
(Usually around 40 weeks of gestational age or just before) depending on
environmental temperature, encourage the mother and the family to
continue KMC as much as possible.
Breastfeeding * Is it exclusive?
If the baby is on direct breastfeeding, during early visits, check for the
proper positioning, latching and feeding during KMC; at the end, praise the


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proper positioning, latching and feeding during KMC; at the end, praise the
mother and encourage her to continue breastfeeding.
If she is giving expressed breast milk or top milk, ensure number of feeds,
ensure regarding night feeds, amount at each feed and the technique of
giving the milk. In case of expressed breast milk, check for the method of
expression, collection and storage also.
* Advise if there are any breast problems?
Ÿ Inverted nipple.
Ÿ Cracked nipple.
Ÿ Engorged breast.
Ÿ Abscess on breast tissue.
Ÿ Any other.
In case of top milk, hygienic handling during feeding also must be ensured.
* If she is giving milk supplements, advise her on how to increase
breastfeeding and decrease supplements.
* Check for adequacy of feeding.
* Ask about and look for any feeding problems and provide support.
(*If the baby is taking formula supplements or other feeds, check their safety,
adequacy; make sure that the family has enough supply).


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adequacy; make sure that the family has enough supply).
Growth * Weigh the baby at every visit and compare weight gain from the last visit.
monitoring & If weight gain is adequate, i.e. at least 15g/kg/d. on average, praise the
Anthropometry mother. If it is inadequate, ask and look for possible problems, causes and
solutions; These are generally related to inadequate KMC, missing feeds at
night, inadequate feeding or illness. (To check KMC hours/d and feeding
amount for adequate daily weight gain, please refer to KMC chart if
available).
* Record on growth charts, if provided.
* Head circumference may be recorded every week if possible.
* Length may be recorded once in two weeks if possible.
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CHAPTER THREE
PRACTICE GUIDELINES FOR HOME BASED KANGAROO MOTHER CARE (3.C KANGAROO DISCHARGE AND FOLLOW UP OF NEWBORN RECEIVING HBKMC)
Illness * Physical and systemic examination of baby.
* Ask and look for signs of any illness either reported by mother or not
reported.
* Manage any illness according to local protocols and guidelines.
If required, help from ANM may be taken for Inj. Gentamicin or oral
medications.
* In cases not on exclusive breastfeeding, ask and look particularly for signs
of diarrhea or any feeding problem.
Counselling * Hygiene and infection prevention measures are advised
Do not miss the opportunity to reinforce about KMC, exclusive
breastfeeding and mother’s awareness of danger signs
Counsel for hand washing and other infection prevention measures
including those for COVID prevention
Discuss other aspects of care like baby bath, clothing, early stimulation etc.
Neurodevelopment * Neurodevelopmental assessment- Follow RBSK protocols in MCP card.


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Neurodevelopment * Neurodevelopmental assessment- Follow RBSK protocols in MCP card.
& Neurosensory * Neurosensory assessment.
Assessment * Arrange for:
Ÿ Eye examination: for the preterm babies for detection of Retinopathy of
Prematurity (ROP) by third/fourth week after birth.
Ÿ Screening for Hearing assessment: Clinical evaluation at 40 weeks of
post menstrual age and in case questionable, repeat at 6 weeks of
chronologic age.
Drugs * If the infant has been prescribed any drugs from the hospital in case of
group I or II babies, make sure the mother follows the advice and gets
sufcient supplies. (e.g. Caffeine, antibiotics etc.) If possible preterm and
small babies can get Vit D3, Calcium, Phosphate and Iron supplements from
ANM.
Immunization * Check that the baby is immunized as per the immunization schedule of GOI.
Mother's concerns * Ask the mother about any other problem, including personal, household
and social problems.


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and social problems.
* Try to discuss with family members also and nd the best solution for all of them.
Next follow up visit * Always schedule or conrm the next visit.
* Do not miss the opportunity to check and advice on hygiene.
* Reinforce the mother’s awareness of danger signs that need prompt care.
Special Follow * If these are required for other medical or physical problems.
up visits * If abnormal neurodevelopment - encourage the mother to attend the special
clinic and refer to Physiotherapy/Occupational therapy.
(Wherever possible)
* If the baby is found to be normal in terms of Growth & Development,
encourage the mother to attend the special follow up clinic till one year of
age to detect any deviation from normal in development.
* If possible, USG skull at discharge and at 40 weeks of post menstrual age/
full term to rule out periventricular leukomalacia and other abnormalities for
those who can go to hospital with these facilities.


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those who can go to hospital with these facilities.
* X-ray or USG hip in all preterms at 3 mo. to rule out congenital dislocation of hip.)
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CHAPTER FOUR
COMMUNICATION AND COUNSELLING FOR
PROMOTING HBKMC
Introduction: l Multiple sessions at multiple stages are
recommended.
The World Health Organization denes
It is very helpful to have responsible family
counseling as a well-focused process, limited in l
members with the mother during counselling
time and specic, which uses the interaction to
sessions. Encourage mother to bring her
help people deal with their problems and respond
mother/mother-in-law, husband or any other
in a proper way to specic difculties in order to
responsible adult family member. It helps to
develop new coping strategies. Community health
build a positive attitude of the family and
workers should learn the art of counselling
ensure family support to the mother, which is
properly.
particularly crucial for home based KMC.
Ø During the sessions of communicating and
Recognizing and supporting LBWI is very
counselling with mother and her family l
challenging in resource restricted regions.


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counselling with mother and her family l
challenging in resource restricted regions.
members, the counsellor should follow a few
Poor access to health care and infrequent
general rules.
postnatal contacts with community healthcare
ü GALPAC workers necessitate that caregivers are
equipped with basic knowledge on evidence
Greet them rst and talk to them courteously.
l
based, life-saving neonatal care practices at
Ask questions in such a way that the client is
l home.
willing to have a frank discussion with you.
It helps to overcome the socio-cultural barriers
l
Listen to what they have to say with interest.
l and anxiety regarding handling of a small,
Have direct eye to eye contact during
delicate LBW infant both by the mother and
conversations. While they are talking please
alternate care providers from the family.
do not divert your attention to some other
Also helps in developing better rapport with
activity like talking on phone, writing l
the CHW and ensuring better family support


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activity like talking on phone, writing l
the CHW and ensuring better family support
something or not being attentive.
and involvement in the care of the newborn
Praise rst for whatever good thing they might
l and regular follow up including
have done. Do not start with some negative
immunizations.
points. They should feel relaxed talking to
you. Ø Who should be counselled?
Antenatal and pre birth( Just before the birth
Advise them what best they can do in the l
l
of the baby) counselling to all the pregnant
given situation and convey the messages the
women and family members.
way they will understand.
Postnatal to the mother and other responsible
Check and conrm that they have understood l
l
family members (father, grandmothers, sister
your instructions properly and it is possible for
etc.)/ Alternate KMC providers (AKP).
them to do.
Counselling is ideally done for an individual
Effective counselling is the most important
l
mother. Occasionally group sessions can be


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Effective counselling is the most important
l
mother. Occasionally group sessions can be
prerequisite for a successful KMC including
conducted in the community.
promotion of early and exclusive
breastfeeding.
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CHAPTER FOUR
COMMUNICATION AND COUNSELLING FOR PROMOTING HBKMC
Ø Following sessions are recommended for l To develop good rapport, if not done already
counselling:
To alleviate any fear and clear any queries
l
1) Antenatal Counselling: that they may have regarding care of
newborn.
(During antenatal period, during monthly
nutrition and health days, or home visits of Messages during this counselling:
CHWs in the rst trimester of pregnancy for
What is KMC?
l
distribution of iron folic acid tablets, tetanus or
Td injections, health check-up sessions of l Why should it be done? (Benets).
mothers etc.). At that time, along with other
Who can provide KMC?
l
topics of pregnancy and delivery, mother
must be given following messages related to: l How to provide KMC/- proper KMC position?
Getting mother and baby ready.
* What is KMC and its benets.
When and how long to provide KMC?
l
* Need of KMC for LBW infants.
Monitoring during KMC.
l
* Immediate early skin to skin contact of


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l
* Need of KMC for LBW infants.
Monitoring during KMC.
l
* Immediate early skin to skin contact of
baby on mother’s chest soon after l Mother and her family members must be told
delivery. about the possible danger signals and how to
identify at the early stages and what actions
* Signicance of promotion of breast crawl
should be taken immediately.
and early initiation of breastfeeding.
3A session of counseling is very much desirable
2) Pre-Initiation counselling:
during the time when mother is continuing with
One session should be held just before the KMC. This will help in improving the quality of
infant is ready for KMC, along with KMC in terms of prolonged duration and
responsible members of the family encourage mother’s efforts to successfully continue
(Obligatory) (Along with routine essential KMC till the baby is ready to be weaned from KMC
newborn care including cord care, feeding,
danger signals etc.)
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CHAPTER FIVE
REPORTS OF HOME BASED KANGAROO
MOTHER CARE
Health care workers are expected to include a few What is the average duration of KMC in 24
l
details about the practice of KMC also in their hours for each baby?
existing records and reports of Home Based
Calculated as the total duration for 24 hours
l
Newborn Care (HBNC).
for two consecutive days prior to stopping
Ø Why are these records needed? KMC?.
A properly maintained quality record reects What was the reason for not completing
l l
the quality of services given. KMC?
The information provides an idea about the * Baby develop some illness or problems?
l
progress made so far, what gaps need to be
* Mother became ill or had some physical
addressed?
problems? (backache / Stitch pain? /FP
Also gives some ideas about why mothers are operation? etc.)/Mother had
l
not able to comply and how we can help them. family/social/cultural problems.
Following simple information can be easily What was the type of feeding during KMC:
l l


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Following simple information can be easily What was the type of feeding during KMC:
l l
documented by ASHA or ANM, who conduct breastfeeding or expressed breast milk/top
the home visits for follow up of mothers with milk?
newborns as per their planned schedule.
i) Type of feeding when the baby started on
AWW can also help for recording the
KMC?
information.
ii) Type of feeding for at least two days prior
Ø How many LBW babies are being given KMC
to stopping KMC?
in your service area?
Weight of the baby when started on KMC and
l
Number of total live births in your area/ total
l
when KMC was stopped.
live births.
Whether the baby had any problems while
l
Number of live babies whose birth weight is
l
being given KMC?
recorded.
Ø This baseline information will be helpful
Of them, how many were having LBW (Birth
l
weight less than 2500g. l To know about the progress , quality and
outcome of KMC.
Of the total number of LBW babies, how many
l


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outcome of KMC.
Of the total number of LBW babies, how many
l
LBW babies were given KMC? l To nd out the gaps in terms of training,
manpower, supplies etc.
On which day of life KMC was started for
l
each baby? l To help nding any remedial solutions.
How many mothers could complete KMC for To begin with, a simple home based format is
l
the baby? being suggested here. With proper guidance,
mothers/ family members with elementary
Till baby reaches 2500g of wt. /40 weeks
l
education should be able to ll in on their own,
after the rst day of Last Menstrual Period
which can be compiled by the ASHAs. Suggested
(LMP).
formats for recording are given in the annexure.
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CHAPTER SIX
PRACTICE OF HOME BASED KMC DURING
COVID PANDEMIC
Background: required and can keep the baby with her. No
reason to separate the baby from her/his
Almost since Dec. 2019, COVID 19 pandemic has
mother.
devastated the world. It is once in a 100 year crisis
All the mothers who are having a history of a
and progress made in decades has been reversed. l
close positive contact at home or in the close
Despite many efforts, the pandemic continues in
family or neighbourhood also can continue
the world. Vaccines developed against the virus
with breastfeeding and KMC and continue to
have been administered in India. Prevention
keep the baby with them.
strategies in terms of avoiding gathering of
people, physical distancing, use of masks in public If many cases are being reported from the
l
places, hand washing and Covid 19 vaccination region and routine tests of all mothers are not
need to be continued. Professional agencies like done, it is better to treat each case like a


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need to be continued. Professional agencies like done, it is better to treat each case like a
Federation of Obstetrics and Gynaecological positive case and take full precautions from
Societies of India, Indian Academy of Pediatrics, the beginning rather than wait for the test and
National Neonatology Forum and Ministry of further conrmation.
Health and Family Welfare, Government of India
All the precautions of respiratory hygiene,
have maternal and newborn practices during l
including use of masks, frequent hand wash,
Covid 19 pandemic.
cleaning all the contact surfaces and all other
l Considering the possible risk of baby getting infection prevention measures should
infection and suffering because of this disease continue in each and every case irrespective
against the multiple problems that occur due of mother’s status of COVID test.
to separating the baby from his/her mother, it
If the mother is tested positive and very sick, if
has been observed that benets of keeping l


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If the mother is tested positive and very sick, if
has been observed that benets of keeping l
possible, her breastmilk can be expressed
the mother and her baby together and
and given to the baby. All the procedures
encouraging breastfeeding in all babies and
including expression of breast milk,
KMC in LBW babies are much more and
collection, storage and administration should
breastfeeding and KMC need to be
be done with strict precautions of infection
encouraged. Only in a few situations that may
control.
not be possible. In that case decisions can be
made depending on the given context. If mother is very sick and even expressed
l
breast milk is not possible, the baby may be
given alternate feeds like other known donor’s
Current guidelines:
milk, or animal milk whichever is available, in
Irrespective of the status for COVID 19 order of preference. Wherever possible
l
positive, in all mothers soon after birth the standardized processed milk from known


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l
positive, in all mothers soon after birth the standardized processed milk from known
newborn can be given for early direct skin to diaries as pouches should be preferred to raw
skin contact. All precautions for infection animal milk. But in remote areas that option or
control must be strictly followed. formula milk may not be possible. Mother’s
own milk should be given as early as possible.
All the mothers who are tested positive and
l
At times attempts for re-lactation by the
having no symptoms or mild symptoms should
mother to continue breastfeeding after some
continue with breastfeeding and KMC as
break will be necessary.
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CHAPTER SIX
PRACTICE OF HOME BASED KMC DURING COVID PANDEMIC
As far as possible, a sick mother or her baby proper. It must cover the nose and mouth
l
should be taken to a hospital for further care. including chin to prevent droplet infection.
Only if that is not possible, management The masks can be prepared at home or
should continue at home with the help of procured. Generally, they are of double
ANMs. layered cotton material (Can be prepared at
home from used clothes like bedsheets,
All the suspected cases or the contacts of
l
sarees, handkerchiefs etc.) All the family
suspected or positive cases should be
members also should wear masks when
reported for further appropriate measures by
coming near the mother or baby. Masks
the concerned department of health.
should be washed daily and can be reused. At
Ø Infection prevention measures during COVID least four masks should be there for the mother
19 pandemic so that they can be frequently washed and


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19 pandemic so that they can be frequently washed and
used. Masks should not be used for the
Most important advice is that all mothers,
newborn baby and other children below ve
family members and health care providers
years of age in the family. It may be harmful.
should follow strict infection prevention
measures. As far as possible, use of sanitizers which
l
contain alcohol are to be avoided when small
Mother must wash her hands properly with
l
babies are being handled for breastfeeding.
soap and water at least for forty seconds
Only in situations where soap and water
before picking up the baby or before and
facilities are not available, sanitizers may be
after touching any other objects. She must be
used.
trained to follow all the steps of handwashing
methodically and her technique may be
observed several times to make sure she does
it well. (Mothers may not have a wristwatch or
clock for timing the handwash. In that case a
simple useful tip: she can recite some poem or


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clock for timing the handwash. In that case a
simple useful tip: she can recite some poem or
her favourite religious or non -religious
song/jingle or some count by which roughly
40 to 60 seconds are marked mentally)
It is not required to wash the mother's breasts
l
before feeding every time. A good daily bath
and use of washed and preferably sun dried
clothes is adequate for personal hygiene of Fig. 17: HBKMC during Covid times
mother or her helpers including AKPs, if there
are. If a mother who is tested positive,
Physical/ social distance to be practiced as
l
accidentally happens to cough or sneeze on
much as possible within homes, preferably a
her chest, she has to wash her chest with soap
distance of at least 6 feet or at least minimum of
and water before giving breast feeds.
3 feet is maintained from visitors and even
Otherwise, it is not necessary.
family members who are likely to be contacts.
Mother (or those who take care of the baby)
l


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family members who are likely to be contacts.
Mother (or those who take care of the baby)
l
Mother should follow other rules of cleanliness
should wear masks when feeding the baby l
and infection prevention and control measures
or offering KMC. The use of mask must be
such as keep minimum necessary items near her
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CHAPTER SIX
PRACTICE OF HOME BASED KMC DURING COVID PANDEMIC
and avoid cluttering with many items. Keep all If you have a cough, fever or difculty in
l
the items clean and especially after someone breathing, immediately contact your doctor. Or
handles them. (eg. Vessels, clothes, medicine visit the nearby hospital where all facilities for
bottles, papers, items for personal use etc.). testing and management are available.
The health care provider also should observe During hospital stay, it is specially recommended
l l
all these rules like wearing the mask during her to keep the mothers with COVID 19 positive
home visits and even during her travel to the status and their newborns together in a separate
village. They should observe physical distancing ward or place with some privacy. They should
from other persons and even mother as much as not be grouped together with other COVID
possible. She should preferably carry her own positive persons in the same ward. It helps in


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possible. She should preferably carry her own positive persons in the same ward. It helps in
soap and sanitizer and wash her hands every many ways including promotion of successful
time before entering for home visit. As far as exclusive breastfeeding in all cases and quality
possible soap and water should be used for KMC for low birth weight babies.
hand wash.
Postnatal anxiety and depression are common
l
It is also important to improve ventilation by among parents and family members with
l
using exhaust fans or promoting cross COVID positive test, nancial difculties, social
ventilation for prevention of Covid 19. distancing and birth of a low birth weight or
preterm baby. The family should be offered
Avoid using public transport.
l
psychosocial support for handling the situation.
Avoid contact with persons suffering from
l
If the newborn is ill, s/he requires specialized
l
cough, fever, difculty in breathing etc.
care in NICU. Mother must be allowed to visit


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l
cough, fever, difculty in breathing etc.
care in NICU. Mother must be allowed to visit
l Avoid touching the mouth, nose and eyes as her baby with proper IPC measures.
much as possible.
Fig. 18: KMC during Covid times Fig. 19: KMC during Covid times
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CHAPTER SEVEN
EXPERIENCE OF HOME BASED KMC IN
GUJARAT AND MAHARASHTRA
A. Gujarat: mothers for KMC and they will be ready to do
KMC in subsequent deliveries also. A few
We introduced the Facility based KMC for the
mothers did have some minor problems. But
rst time in India at the neonatology division
most of them are easily manageable. We
of Civil hospital, Ahmedabad, as a part of an
presented different aspects of this study in four
International multicentric study in the year
international KMC conferences (Kigali,
1993. The rst KMC ward was created. The
Rwanda, Trieste, Italy and Port Elizabeth,
KMC program has continued and scaled up
Cape Town, South Africa and Manila,
successfully since then.
Philippines) and in various national
In the year 2005, for the rst time in India, conferences in India.
Home based (Community based) KMC was
Similar studies are also available from urban
introduced in the rural project of SEWA Rural,
slums of Gujarat.
Zagadia, a reputed voluntary service


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slums of Gujarat.
Zagadia, a reputed voluntary service
Indian Council of Medical Research
organization, as a part of their project of
conducted a similar multicentric study in
home based newborn care. Following
Gujarat, Maharashtra and Odisha, and
favourable experience over many years in
reported good results, “Community based
that project, we introduced HB KMC through
Kangaroo Mother Care and Low Birth Weight
many other voluntary health care
babies.” which was published in Indian
organizations of Gujarat working in rural
Journal of Scientic Research.
areas.
HBKMC is continuing successfully in all these
In the year 2014 and 15, a systematic, well
blocks in Gujarat with very good results and
planned research project was conducted for
now coverage is gradually increasing. We
one full year through ve voluntary service
have a draft guideline, job aids and teaching
organizations of Gujarat {SEWA Rural
slides prepared in local languages of Gujarati
Jhagadia (Rural/Tribal), Tribhuvan


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slides prepared in local languages of Gujarati
Jhagadia (Rural/Tribal), Tribhuvan
and Oriya and recently one updated version
Foundation, Anand ( Rural), Bhansali trust,
in English for the state of Maharashtra.
Sami block of ICDS ( Rural), Gram Sewa trust,
Kharel (Rural/Tribal) and JNPCT at A special issue of newsletter of KMC
Dharampur, a very backward tribal area} to Foundation, India has been brought out on
study the safety, feasibility and acceptability HBKMC in resource restricted regions of India
of HBKMC in resource restricted regions of including Gujarat with a special plea to
Gujarat. The study area covered 146 villages promote home based KMC as a part of home
and a population of more than 2 lakhs, (97 based newborn care in deprived sections of
deliveries with 102 LBWI including ve sets of the communities in India as soon as possible.
twins were included). Mothers’ perception In the current situation it has a very great


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twins were included). Mothers’ perception In the current situation it has a very great
about KMC was collected through interviews. potential to save many more newborns in our
The results were very encouraging. country.
Majority of mothers expressed that they were Recently WHO has realized the signicance
very happy doing KMC and willing to keep of promotion of HBKMC in communities and
their babies with them and if need be, they will have initiated multicentric pilot projects in
be happy to advise and encourage other
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CHAPTER SEVEN
EXPERIENCE OF HOME BASED KMC IN GUJARAT AND MAHARASHTRA
states of UP, Karnataka and Haryana. The Initial few days expressed breast milk was
study from Haryana has shown very given by a spoon from the cup and gradually
encouraging results, acclaimed well and shifted to direct breastfeeding. KMC
published in the reputed journal The Lancet. continued for almost 6 to 8 hours per day and
mother and her mother-in-law alternated for
A few case histories from Gujarat are given
KMC. Vaccination of the baby was done. The
here which will highlight the situations in
baby was given KMC for almost 40 days and
which HBKMC has been found to be not
exclusive breast milk feeding continued. The
merely useful but also lifesaving! We now
AWW worker guided them throughout with
have many more such stories to share and
multiple home visits. The baby is thriving well
have followed up data for many years on
to date. Today the child is doing well and
quite a few of these babies given HBKMC.


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to date. Today the child is doing well and
quite a few of these babies given HBKMC.
attending school. No neurologic or
developmental problems have been noted so
1. An extremely LBW baby weighing 600 far.
grams alive and thrive following HBKMC.
A primi mother Sitaben had a spontaneous
normal vaginal delivery in the very early
hours of the day in a Government SNCU in a
small district, near the city of Patan in Gujarat.
and had an ELBW baby , the exact LMP not
known. The baby cried well immediately and
weighed only 600 grams at birth. The Nurse
attended the delivery. The duty doctor was
informed about the delivery of an ELBW baby.
Fig. 20: An extremely low birth weight baby saved
He did not expect this tiny baby girl to live through home based KMC
long. So, he did not even examine the neonate
and advised the family members to take the
2. LBW twin babies saved following HBKMC:
baby to a bigger hospital as facilities for the
(Source: Tribhuvandas Foundation, Anand).


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baby to a bigger hospital as facilities for the
(Source: Tribhuvandas Foundation, Anand).
care of such a small baby were not available
in that hospital. As the relatives expressed Twin babies of father Laljibhai and mother
their inability to go to the bigger hospital even Manjuben.
though all services were available free of cost,
Parents are very poor farm labourers. Twins
the doctor advised them to take the baby
were born at home with a birth weight of 1.2
home. The village Anganwadi worker, trained
Kg. and 1.6Kg weight. Due to economic
for essential newborn care including KMC, at
constraints, they could not afford to lose their
Sami ICDS project of Bhansali Trust, was told
daily wages and take the twins to a bigger
about the mother returning home with a very
hospital even though the hospital was nearby
tiny baby. She immediately went to the house
and all the services were free of cost. The
of Sitaben and advised her and her mother -in
Community Health Worker advised the


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of Sitaben and advised her and her mother -in
Community Health Worker advised the
-law about KMC and breastfeeding. She
parents about KMC and breast feeding and
counselled them and motivated them to take
had regular home visits. Father and mother
care of the baby as long as it is living. Luckily,
both offered KMC by taking turns and breast
mother-in-law agreed and started KMC and
feeding was given. Both the kids are thriving
even made the mother also provide KMC.
well without any neurological problem.
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CHAPTER SEVEN
EXPERIENCE OF HOME BASED KMC IN GUJARAT AND MAHARASHTRA
We have several such examples of home
based KMC in poor families in remote
resource constrained regions in communities
where KMC including breast milk feeding
have helped for the good nurture and well
thriving.
B. Maharashtra:
In Maharashtra, the Department of Public
Fig. 21: LBW twins cared through HBKMC Health has been leading the roll out of the
Home Based KMC in 78 tribal blocks since
2019. The state level training of the trainers
3. An extremely LBW baby weighing 920
was conducted by the senior trainers of KMC
grams saved through HBKMC in the project
Foundation of India, Department of Public
areas of Sewa Rural, the rural-tribal block of
Health, Government of Maharashtra and
Zagadia.
UNICEF on 5 December 2019. This was
followed by the block level trainings, which
During home visits, the community health
were supported by UNICEF.
worker detected a very small baby weighing
920 grams. Parents were advised for


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worker detected a very small baby weighing
920 grams. Parents were advised for
The 136,000 KMC bags were procured and
hospitalization in SEWA Rural hospital, all
50,000 KMC Cards were printed utilizing
services including transport free of cost. But
funds from the National Health Mission. As
parents could not agree because of their own
per HBKMC report during 2020-21, home
problems. The CHW got instructions about
based KMC was provided to 42660 low birth
KMC through the mobile app “M Techo”
weight newborn babies from 78 tribal blocks.
developed by the NGO for the Government of
In the case of 1369 babies, KMC was given
Gujarat. Accordingly, she advised the mother
by members other than the mother herself.
and the family. KMC and breast milk feeding
were given and the baby had regular home
visits by the CHW. The baby reported to be
thriving well.
Fig. 22: ELBW saved through HBKMC Fig. 23: Training of ASHAs for HBKMC in Maharashtra
|46|


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CHAPTER SEVEN
EXPERIENCE OF HOME BASED KMC IN GUJARAT AND MAHARASHTRA
Fig. 24: HBKMC in Gadhchiroli district of Maharashtra
Riya is a healthy and active child, sleeping
comfortably as mother provides her for Kangaroo
mother care. She was born at 8 months and was
weighing only 1.7Kg at birth. Riya’s mother,
Geeta was living in Nagpur with her husband.
When COVID 19 pandemic started, she and her
husband came back to her village in the month of
May 2020. She delivered a baby at the 8th month
of her pregnancy at the local Primary Health
Center. She was counselled on breastfeeding and
KMC and was provided with KMC bags by Ms.
Sulochana Marskolhe, ASHA, who continued to
monitor the newborn during the HBNC visits. She
encouraged Geeta and her family members for
KMC. Riya is a beautiful child who turned 3 month
old. She weighs 4.6 kilograms.
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Pediatr. 1997; 86: P645-650. Home Kangaroo Mother Care with Low Birth
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37) Mullany I C. – “Neonatal Hypothermia in low J. Trop. Pediatr.2019 Feb 14 pii: fmz007.doi:
resource settings” Semin Perinatol 2010; 10-1093/ trop ej / fmz007.
36:426-433.
46) Mazumder S, Taneja S, Dalpath SK, Gupta R,
38) Charpak N, Ruiz- Pelaez JG, Charpak Y. Dube B, Sinha B, Bhatia K, Yoshida S,
“Rey Martinez Kangaroo Mother Program; Norheim OF, Bahl R, Sommerfelt H, Bhandari
An alternate way for caring for Low Birth N, Martians J. “Impact of Community
Weight Infants -One year mortality in a two Initiated Kangaroo Mother Care on survival
cohort study”; Paediatrics: 1994: 94:804- of Low Birth Weight Infants” Study protocol
810. for a randomized controlled trial. Trials 2017
Jun 7: 18(1):262 doi:10.1186/s13063-


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810. for a randomized controlled trial. Trials 2017
Jun 7: 18(1):262 doi:10.1186/s13063-
39) Darmstadt G I, Kumar V, Yadav R, Singh V, 017-1991-7.
Singh P, Mohanty S et al. “Introduction of
community -based skin to skin care in rural 47) Mazumder Sarmila , Sunita Taneja et al
Uttar Pradesh, India” J .Perinatol 2006;26: “Impact of Community Initiated Kangaroo
597-604. Mother Care on survival of Infants with low
birthweight: a randomized controlled trial
40) Singh M, Rao G, Malhotra A K, Deorari A K- L a n c e t O c t 0 4 2 0 1 9
“Assessment of newborn baby's temperature DOI:https://doi.org/10.1016/SO140-
by human touch: A potentially useful primary 6736(19)32223-8.
care strategy”- Indian Pediatr.1992; 29: 449-
452. 48) Daga Subhashchandra:” Reinforcing
Kangaroo Mother Care uptake in resource
41) Bang AT, Bang R A, Baitule S B, Reddy M H, limited settings” Maternal health Neonatol
Deshmukh MD- “Effect of home based Perinatol 2018; 4:26 Doi: 10,1186/s


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Deshmukh MD- “Effect of home based Perinatol 2018; 4:26 Doi: 10,1186/s
neonatal care and management of sepsis on 40748-018-0091-3.
neonatal mortality; Field trial in rural India”
The Lancet 1999; 354: 1955-1961.
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REFERENCES
49) Lawn Joy E., Dickson Kim E, Mathai Matthews 53) Ahmed, S., Mitra, S., Chowdhury, A., et al
and Moxon Sarah G: Every Woman, Every Community Kangaroo Mother Care:
Newborn Vol. 15, Supplement 2, Sep. 2015. Implementation and potential for neonatal
survival and health in very low income
50) Participant's manual- Newborn care at the settings. J . Perinatol 31, 361-367 (2011)
Facilities- Training of Staff Nurses and http://doi.org/10.1038/jp.2010.131.
Auxiliary Nurse Midwives (ANMs) 2017. By
Government of Gujarat, Public Health 53) Uwaezuoke S N,” Kangaroo Mother Care in
Foundation of India and Micronutrient resource limited settings” Dove press open
Initiative. access journal (2017) Vol.2017:7Pages 11-
18, http:// doi.org / 10.2147 /
51) Navjat Shishu Suraksha Karyakram- Basic RRN.S138773.
Newborn Care and Resuscitation Program
Manual. 54) My Techo- a mobile phone application for the
use of Community based health care


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Manual. 54) My Techo- a mobile phone application for the
use of Community based health care
Ministry of Health and Family Welfare, providers of women and children Details
Government of India. Available from from” techo@gujarat.gov.in”.
h t t p : / n r h m . g o v . i n / n r h m -
components/rmnch-a/childhealth- 55) Conde Agudelo A, Diaz –Rossello JL.
immunization/child-health/guidelines.html. Cochrane Database of Systematic Review
2016 Issue 8.
52) Kangaroo Mother Care – Implementation
guide (2012) MCHIP, Save the Children and 56) UNICEF, WHO, World Bank, United Nations.
others. Levels & Trends in Child Mortality: Report
2020.
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ANNEXURES
ANNEXURE 1: SUGGESTED RECORDING & REPORTING FORMATS FOR HBKMC
A) HOME BASED DAILY RECORD OF NEWBORN
Name of Mother:
Name of Baby: Date of Birth:
Place of Delivery: Mode of Birth:
Diagnosis / Problems:
Date of Starting Home Care:
B) REPORTING FORMAT FOR HOME BASED KMC BY ASHAS
Name of Asha worker:
Address:
Sr. Name Name DOB Birth Gestational Visit on Duration Breast Weight Danger
No. of of Weight Age which (hours) feeding Gain sign
the the day of done Daily Yes/
Baby Mother after KMC every No
birth given two
every hours?
day
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ANNEXURES
ANNEXURE 1: SUGGESTED RECORDING & REPORTING FORMATS FOR HBKMC
C) CASE SUMMARY OF BABY WHO HAD KMC BY ASHA/CHW
Name of ASHA/CHW:
Address of Family:
Serial Number: Name of Mother:
Name of baby:
LMP: Date of Birth: Time:
Mode of Delivery N/CS/Assisted:
Ft/PT/LBW: Early STSC in LR Y/ N EIBF Y/ N
Wt. at Birth: Wt at start of KMC:
Wt. end of KMC:
Mode of feeding DBF/EBM Other At KMC start: At KMC End:
Average duration of KMC per 24 hours: for last two days before stopping MC Any help by AKP?
Any problem for baby before KMC?
Any problem during KMC?
Total number of visits by ASHA/CHW
Any problems noted during home visits
KMC completed? Y/ N Spl Follow UP Neuro exam Y/ N
If no, what are the reasons?
a) Problem in baby:
b) Problem in Mother ILLness/personal/social reasons:
ROP check-up Y/ N When and Where?
Hearing screening Y/ N When and where:
Any other comment:
Signature of CHW:
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ANNEXURES
ANNEXURE 1: SUGGESTED RECORDING & REPORTING FORMATS FOR HBKMC
D) HOME BASED KMC REPORT FORMAT FOR COMPILATION FROM SUB-CENTER / URBAN WARD TO DISTRICT
LEVELS
Name of District/block/PHC/subcenter/urban ward (for compilation from lower to higher levels):
Month
Sl No Indicator
1 Total live births
Out of total live birth,
2 Low Birth Weight Children
(Less than 2.5 kg)
Out of Total Low Birth
3 Weight Children how many
received KMC at Facility
Out of Total Low Birth
4 Weight Children how many
received KMC at Home
Out of the children who
received KMC at Home
5 how many children receive
KMC from a member other
than Mother
How many children received
6 KMC more than 20 hours
everyday
How many children received
7 KMC between 10 to 20
hours everyday
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ANNEXURES
ANNEXURE 1: SUGGESTED RECORDING & REPORTING FORMATS FOR HBKMC
D) HOME BASED KMC REPORT FORMAT FOR COMPILATION FROM SUB-CENTER / URBAN WARD TO DISTRICT
LEVELS
Name of District/block/PHC/subcenter/urban ward (for compilation from lower to higher levels):
Month
Sl No Indicator
How many children received
8 KMC for less than 10 hours
everyday
Out of toal children given KMC,
9 how many had weight gain
as per HBNC guidelines
Out of children who received
KMC at Home how many
10
children identied with
danger signs
Out of low birth weight
children how many mother
11
counselled for KMC by
ANM/MO
Out of the mother's who give
12 KMC, how many mothers had
difculty in breastfeeding
Out of children who received
KMC at Home how many
13
children died at home or
in facility
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ANNEXURES
ANNEXURE 2: FREQUENTLY ASKED QUESTIONS (FAQs) ABOUT KMC
ANNEXURE 2: FREQUENTLY ASKED QUESTIONS (FAQs) ABOUT KMC
1) What is KMC? accepted even when this time of care through
skin to skin contact is offered by AKPs like father,
KMC is a method of holding the baby on
grandparents, neighbour etc.
mother’s chest in between her breasts so that
mother and baby can have direct skin to skin,
chest to chest or body contact- a loving body 4) When will my baby, who has been started on
hug, which has several benets to newborn, KMC, be discharged from the hospital?
mother, community, hospital and ultimately to
Your baby will be discharged with proper
the nation.
planning, when you are keeping the baby in
KMC for a longer duration like almost the whole
2) Why is it called Kangaroo Mother Care? day with the help of your family members. Baby
is breastfeeding well or you are able to express
This method of holding the baby in skin to skin
milk and feed the baby orally with the help of a


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This method of holding the baby in skin to skin
milk and feed the baby orally with the help of a
contact and providing warmth, breastfeeding,
small cup, spoon or traditional feeders like
promoting bonding and non-separation of
paladai. Baby is doing well on KMC and able to
mother and her baby are similar to the method
maintain body heat well and also starts gaining
of care the animal Kangaroo offers to its baby
weight of about 15-20g/Kg body wt./day for
by keeping it in her pouch in the abdomen. The
at least three consecutive days. As a mother, you
Paediatrician from Bogota, Columbia, Dr Edgar
are quite condent of taking care of your baby
Ray conceptualized this method of care and
at home as guided by doctors and the nurses.
named it Kangaroo Mother Carebecause of
Your family members must assure all support for
these similarities.
the care of your baby for giving KMC when
needed, helping with daily chores at home and


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the care of your baby for giving KMC when
needed, helping with daily chores at home and
3) Does it mean that KMC has to be given only by helping you to go to hospital for follow up visits
the mother as the name suggests? as required.
No, it does not mean that this method of care
has to be given only by the mother. KMC 5) What should be the weight of my baby at the
includes three main components- Kangaroo time of discharge?
Position (keeping the baby on mother’s chest),
There are no xed criteria for weight for
Kangaroo Nutrition (Promoting feeding of the
discharge.
baby with exclusive breast milk either as direct
breastfeeding or as expressed breast milk) and
Kangaroo discharge and follow up (Planned 6) How long should KMC be done in a day?
early discharge and regularly scheduled follow
KMC should be continued as long as possible,
up for breastfeeding, growth, Immunizations
even up to 24 hours a day with the help of AKPs
and neurodevelopment including neuro sensory


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even up to 24 hours a day with the help of AKPs
and neurodevelopment including neuro sensory
at home. One session should be for a minimum
and behavioural development even after KMC
of continuous one hour of effective KMC (for
has been stopped. The “M” component
ensuring one hour of effective skin to skin
indicates the signicance attached to breast milk
contact, KMC should be advised for at least one
feeding in KMC and breast milk only mother can
and half hours). It is not meant that mother
produce, hence the term KMC is conventionally
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ANNEXURES
ANNEXURE 2: FREQUENTLY ASKED QUESTIONS (FAQs) ABOUT KMC
should stop KMC at the end of One and a half 11) How many times a day should the baby be
hour. She can continue as long as she is breastfed?
comfortable in one session for more than one
A LBW baby should be fed every 2 hours at least
hour also.
12 times a day. Initial few days you may offer
feed at decided time intervals. As the baby
7) Why should KMC be given continuously for a grows, after an initial few days ideally, you
minimum of one to one and half hours? should be guided by the hunger cues of the baby
and gradually shift to demand feeding.
During KMC the baby gets a sound sleep and
during that time the brain functions develop
better. One sleep cycle is generally one hour. If 12) Should the baby be fed at night too?
the baby is disturbed in between the sleep cycle,
Yes, the night feeds should not be missed as milk
the baby is stressed and the development of the
output increases during night. Even when


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the baby is stressed and the development of the
output increases during night. Even when
brain is likely to suffer. To achieve one good hour
offering expressed breast milk, night feeds
of undisturbed sleep cycle, we advise for at least
should not be missed, which is very often the
one and half hours taking into account some
case.
time taken for the mother and baby for adjusting
initially on chest to chest contact and then baby
to go for sound deep sleep. 13) Doctor, I am really very scared to take such a
small baby home. Will you please tell me what
I should watch for and when I should bring the
8) What is the best time of day to do KMC?
baby urgently?
KMC can be done all through the day and night.
Always make sure that the baby’s nose is open
and the baby is breathing comfortably. When
9) If I am able to give KMC for only a few hours in baby is in Kangaroo position, (observe all the
a day, will it be of any benet to the baby? instructions as per the checklist given to you)


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a day, will it be of any benet to the baby? instructions as per the checklist given to you)
keep a watch on baby’s breathing and
Denitely, the longer you can give KMC, more
movements. In case of change in the pattern of
benets will be there. But even a few hours of
breathing, stoppage of breathing or any change
KMC also are of some benet. So it is worth
in the movement of the baby, contact a local
giving even a few hours in a day. Efforts must
healthcare provider immediately. In case of
always continue to increase the sessions and
stoppage of breathing for more than 20 seconds
total duration of KMC as early as possible and
at a stretch, rst try to stimulate the baby by
as much as possible. If you can keep a record of
icking on the sole of feet or rubbing on the back
the number of hours you are giving KMC it will
a few times. The baby will start breathing most of
help you to improve further.
the time. Only after that, call for further help.


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help you to improve further.
the time. Only after that, call for further help.
Also watch for any feeding problems, baby feels
10) How should the baby be fed while on KMC?
too hot or cold on touch, yellow colouration of
Mother should try to directly breast feed her skin or eyes, any swelling or discharge from
baby while providing KMC. In case the baby is cord or eyes or abnormal behaviour or
too weak to suckle, breast milk should be movements of hands and body (Convulsions),
expressed and given to the baby with a cup, loose, watery motions, refusal to take feeds and
spoon or paladai. any such abnormal presentations. In other
words, when you feel that the baby is not doing
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ANNEXURES
ANNEXURE 2: FREQUENTLY ASKED QUESTIONS (FAQs) ABOUT KMC
well, seek help from the health care worker or kicking the abdomen or cries or fusses every
preferably go to the hospital, if possible. You time you try to keep the baby in kangaroo
may carry the baby in KMC position if possible, position. It means the baby does not require
during transport. KMC anymore. For a few more weeks, the baby
may like to be in Kangaroo position for a short
while just before sleeping or soon after bath or
14) What should I do if the baby stops breathing?
during a cold environment.
Stimulate the baby by icking on the soles of feet
or rubbing on the back of the baby to see
18) Who can give KMC at home after discharge
whether the baby responds. If not, immediately
from hospital?
call 108 and reach out to the health facility with
an emergency paediatric unit. If frequent such Apart from mother, any responsible and willing
episodes of stoppage of breathing occur in a adult family member like husband,


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episodes of stoppage of breathing occur in a adult family member like husband,
baby, it will be useful to admit the baby in grandmother, aunt, or even a willing
hospital for a few days. neighbour/friend can serve as Alternate KMC
Provider (AKP). The AKP must observe all the
precautions of safety and personal cleanliness
15) What should I do if my baby appears lethargic
including cutting the nails, remove ring, bangles,
or not taking feeds properly?
chains etc. have a good bath, wear clean
If the baby shows any signs mentioned earlier, washed clothes, proper handwashing and all
inform ASHA or ANM or take the baby to the possible measures of infection prevention. Know
hospital. the correct technique of holding the baby in KP
and feeding with expressed breast milk, if
required. They must be able to watch for the
16) What medicines should I give to the baby after
early signs of danger and take suitable
bringing it home?
measures. They should not be smoking or taking


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bringing it home?
measures. They should not be smoking or taking
At the time of discharge from the hospital,
alcohol or any drugs.
doctors would have explained to you. Or else
the ANM will tell you during health and nutrition
19) Can I do my household chores after going
days or during her home visit to you. You will
home with the baby?
need to give iron which helps for making blood,
Vitamin D, calcium and phosphorus for making If the baby is securely placed on your chest with
the bones of the baby stronger and if your baby the help of a dupatta or shawl or some special
has any other problem, she might be given KMC bag or wrap, you can move about with the
suitable medicine according to the problem. The baby and carry on with simple domestic chores.
details of giving the medicine will be explained During your movements you should always
to you. support the neck of the baby from behind to
prevent sudden jerks and excessive bending of
the neck in front or back. This may be very


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prevent sudden jerks and excessive bending of
the neck in front or back. This may be very
17) Till what age should I continue KMC?
dangerous at times. Also support the bottom of
The baby will decide the time of stopping KMC.
the baby from below to prevent accidental
This usually happens when the baby reaches
slipping and fall. All strenuous work may be
around 37 to 41 weeks after LMP or weighs
avoided. During that time help of AKP can be
above 2500 grams. At this time, the baby starts
availed of, if available. If no help is available, it
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ANNEXURES
ANNEXURE 2: FREQUENTLY ASKED QUESTIONS (FAQs) ABOUT KMC
will be safer to keep the baby in his/her bed the stitches may not hurt. Mother can adjust
properly covered and away from the direct draft herself to a position of comfort so that stitches
of wind and then do the domestic work. may not hurt.
20) What precautions should be taken at home 24) During summer I feel hot and uncomfortable
during KMC? when I keep the baby in KMC. What should I
do?
Please do not keep the baby horizontally in
Kangaroo Position, do not handle the baby If you feel hot/too warm and humid when the
excessively, do not give bottle feeds, do not baby is kept in Kangaroo Position, you may
permit contact with any sick persons, do not give cover the baby well and switch on the fan if
bath to the baby till weight gain above 2500 g is available. If you perspire more, just wipe off the
achieved, but only sponge the baby with soft, sweat over the chest with a clean dry cloth and


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achieved, but only sponge the baby with soft, sweat over the chest with a clean dry cloth and
clean cotton cloth soaked with lukewarm water then continue KMC.
in a warm cozy place.
25) Won’t the baby feel hot?
21) Can I use something to tie the baby to me?
No, the baby will not feel hot when kept in KMC.
Yes. A soft and strong, clean dupatta, shawl or Rather they are predisposed to become cold due
such cloth can be used for securing the baby on to the following reasons:( Specially the preterm
mother’s chest during KMC. It should not be tied babies)
too tightly. That may sometimes suffocate the
* They have a higher ratio of skin surface to
baby. The use of specially prepared KMC bag or
body weight.
wrap is very helpful, if available. It adds to the
safety and comfort of the baby and mother also * They have decreased subcutaneous fat with
feels secure to move around with the baby in less insulation capacity.
KMC on direct skin to skin /chest to chest


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KMC on direct skin to skin /chest to chest
* They have limited capacity to shiver and
contact. But it is not a must.
conserve body heat. In premature babies
stores of a special type of brown fat is less
22) Can I do KMC with my clothes on my chest? developed and therefore body heat
production is less.
No, mother/AKP cannot do KMC with blouse,
shirt or any layer of clothing of the mother on * The small babies are unable to consume
their chest. This disrupts the direct skin to skin enough calories to provide nutrients for
contact between mother/AKP and the baby and body heat production and growth.
does not help for keeping the baby warm and
* Oxygen consumption is limited in some
get many other benets.
preterm babies because of lung immaturity.
* There is increased heat loss due to extended
23) My stitches hurt when I have to sit with the
posture and immature skin.
baby in KMC?
They tend to lose body heat easily due to several
By keeping the baby on the mother's chest and
mechanisms.


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By keeping the baby on the mother's chest and
mechanisms.
reclining for about 35 to 45degrres while sitting,
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ANNEXURES
ANNEXURE 2: FREQUENTLY ASKED QUESTIONS (FAQs) ABOUT KMC
26) What is the normal body temperature of the the mother for KMC and give her privacy to put
baby? the baby in the KMC position. A healthy adult of
the family can provide KMC to give mother
Normal body temperature of a newborn baby is
some time off. Family members can take over
36.5 to 37.5 degrees C.
other tasks of mother, so that she can devote
exclusive time to her infant.They can help for
27) Can I do KMC, if my baby has fever? regular follow up and take mother for special
follow up.
Yes, KMC can be done even when the baby has
a fever. If baby’s body temperature increases by
one degree C, the mother's body temperature 31) What can be done if a family does not support
decreases by 1 degree C. The reverse also can the mother for providing KMC?
occur This is called thermal synchrony during
It is important for the whole family to be aware
KMC. In hot summer time when environmental


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It is important for the whole family to be aware
KMC. In hot summer time when environmental
of all the benets of KMC. Family should be
temperature rises, many newborns also have
counselled for this in the hospital where the baby
high body temperature. In such situation, a few
was started on KMC or by ASHA or ANM at
observers in the Indian set up have noted that
home. Family should be made to understand
KMC helps in preventing the rise of body
and contribute towards the wellbeing of the
temperature of the baby. More studies are to be
baby.
undertaken to conrm these ndings.
32) When do we need to have a repeat checkup
28) When can I give a bath to the baby?
for the baby?
Give a bath to the baby when the baby's weight
You will be given a regular schedule of follow up
reaches around 2500g, and no other problems
depending on the condition of your baby. You
are noted. Use lukewarm water for bath in a
will be told to come to the hospital as early as
warm environment and dry the baby


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will be told to come to the hospital as early as
warm environment and dry the baby
possible. Till the baby reaches about 37 weeks
immediately.
after LMP, twice a week checkup will be
required. After that, till 40 weeks after LMP, and
29) If I have to interrupt KMC for a short duration, /or till wt. reaches above 2500g. at least once a
what precautions should I take? week, a checkup will be required.
The baby should be adequately clothed-head
cap, socks, mittens and well covered body and 33) What checkup will be done during these visits?
kept in a clean, warm bed, in supine
They will check up the weight, length and the
position/prone position with head turned to one
head circumference to make sure that the baby
side as shown by the CHW/ in hospital.
is getting adequate feeding and growing well.
General checkup of the baby will be done to
30) How can family members offer support for make sure that the baby does not have any
KMC? problems. Suitable vaccinations will be done


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KMC? problems. Suitable vaccinations will be done
and if you have any concerns, that will be
A supportive family is a prerequisite for the
addressed. Then they will check up for brain
successful KMC. Family should give
development of the baby by doing a special
psychological support and encouragement to
examination. They will make sure you are giving
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ANNEXURES
ANNEXURE 2: FREQUENTLY ASKED QUESTIONS (FAQs) ABOUT KMC
proper KMC and exclusive breastfeeding. In a few districts, developmental and early
Advice will be given for how to improve the intervention centers (DEIC)have been started by
quality of care better and also check up whether health departments. Their help can be taken for
you are able to watch for the danger signals and the developmental checkup of the preterm and
know whom to contact and how to reach the LBW babies. Your local CHW will be able to
doctor. guide you and help for these special checkups
for your small babies.
34) In case I am not able to go to the hospital for a
repeat checkup, what should I do? 35) How can I travel with my small baby for
hospital visits? Is it safe for my baby?
When hospital visits are not possible, you can
call your hospital doctor, if available and consult If you take proper precautions to cover your


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call your hospital doctor, if available and consult If you take proper precautions to cover your
for further care. If that is also difcult, then local baby properly with cap, diaper, socks and
CHW like ASHA or ANM can be contacted. mitten and cover well with blankets and
Mostly, they will contact you and give advice constantly observe your baby during travel, it
regarding essential newborn care including will be safe to travel with the baby. Always be
KMC and breastfeeding and help you for further with your baby during hospital visits. In case you
reference if some serious concern is there. are very sick and not able to accompany the
baby, some responsible adult family member
In case of preterm babies/or LBW babies with
can carry the baby. In that case, please try to
less than 1750g birth weight or those babies
give expressed breast milk for feeding on the
who had some serious problem and required
way in a clean container. If long distance travel is


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who had some serious problem and required
way in a clean container. If long distance travel is
oxygen treatment for a few days, special eye
there in a vehicle, preferably the vehicle should
check-up (ROP) must be done before one month
be stopped and only then feeds should be given.
of age of the baby. This helps in taking prompt
This helps to avoid possible milk aspiration in a
early treatment in case of some eye damage
moving vehicle.
which may occur following oxygen treatment
and prevent blindness in future. This is very Carrying the baby in Kangaroo Position/KMC
important and if facilities are not available and breastfeeding is very safe during travel and
locally, all efforts must be done to visit bigger ideal for the babies who are otherwise normal
hospitals where such an expert facility is and healthy or mildly sick. Even for seriously ill
available. babies, KMC during transport is much better
particularly when a specially equipped transport


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particularly when a specially equipped transport
Similarly, it is advisable to get a checkup for
team is not available. KMC transport helps to
hearing done before 40 weeks of age from LMP.
prevent body cooling, chances of infections and
If some problem with hearing is detected early
unnecessary jolts during travel leading to serious
and suitable treatment given to the baby, long
problems of head injuries and other
term problems including speech problems can
complications.
be avoided. This facility for hearing checkup of
the tiny babies is available only in very few
hospitals. Your CHW may guide you for that.
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ANNEXURES
ANNEXURE 3: KMC PRETEST (SAMPLE QUESTIONNAIRE)
ANNEXURE 3: KMC PRETEST (SAMPLE QUESTIONNAIRE)
Q. 1 : What does KMC stand for? Q. 5 : In Kangaroo Position, the baby should be
placed
a. Skin to skin contact.
a. On mother’s chest in between the breasts.
b. Prolonged skin to skin contact.
b. On mother’s chest in between the breasts in
c. Kangaroo Method of Care.
as much vertical position as possible and
d. Kangaroo Mother Care. lower limbs exed in frog leg position.
c. On mother’s chest in between the breasts
Q. 2 : Where did KMC start? so that baby’s chest and abdomen are in
contact with the mother’s chest and baby’s
a. Australia.
neck slightly extended to have open airway
b. England.
and eye to eye contact with the mother and
c. Colombia. limbs in frog like position.
d. India. d. Baby on mother’s chest and feeding on
breast.
Q. 3 : Why is KMC given to the Newborn?
Mention if the following statements are true (T) or
a. To prevent hypothermia.
false(F)


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Mention if the following statements are true (T) or
a. To prevent hypothermia.
false(F)
b. To prevent neonatal jaundice.
Q.6: KMC has to be given only by mothers.
c. To prevent infections.
Q.7: It is difcult to breastfeed while giving
d. All of the above. KMC.
Q.8: KMC can prevent neonatal infections.
Q. 4 : Kangaroo Mother Care includes
Q.9: KMC is not required for term babies.
a. Immediate skin to skin contact after birth of
Q.10: KMC is not required in hot and humid
the baby.
weather.
b. Early and prolonged skin to skin contact for
Q.11: Mother cannot work while giving KMC.
the baby.
Q.12: KMC can prevent only hypothermia in the
c. A loving, systematic hug of the baby by
baby.
mother.
Q.13: KMC helps with neurodevelopment.
d. A loving, systematic hug of the baby
combined with breast milk feeding as much Q.14: KMC can be given during neonatal
as possible and planned discharge and transport.
regular follow up.
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ANNEXURES
ANNEXURE 3: KMC PRETEST (SAMPLE QUESTIONNAIRE)
Q.15: KMC cannot be given without special Q.20: KMC helps in reducing neonatal mortality.
binders.
Q.21: KMC makes breastfeeding difcult.
Q.16: Early skin to skin contact soon after delivery
Q.22: Home based KMC needs preparation in
is the same as KMC.
the facility.
Q.17: Home based KMC is not very ethical and
Q.23: It is important to tell mothers about danger
safe.
signals in their newborn .
Q.18: The longer the duration of KMC in a day
Q.24: National guidelines help in promoting
the better is the effect on the baby.
KMC in a country.
Q.19: KMC can help in relieving mild to
Q.25: Implementation of KMC at national level
moderate pain in newborns.
does not involve any expenses.
Answer Key to Pre-test
Q1-d, Q2-c, Q3- d, Q4-d, Q5-c, Q6-F, Q7-F, Q8-T, Q9-F, Q10-F, Q11-F, Q12-F, Q13-T, Q14-T,
Q15-F, Q16-F, Q17-F, Q18-T, Q19-T, Q 20-T Q21-F, Q22-T, Q23-T, Q24- T, Q25-F
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ANNEXURES
ANNEXURE 4: QUESTION BANK FOR SELF-LEARNING EXERCISE (AND FOR PRE AND POST-TESTS)
ANNEXURE 4: QUESTION BANK FOR SELF-LEARNING EXERCISE (AND FOR PRE AND POST-TESTS)
(Answer key given in the end) Q.4. How many feeds should a small baby
receive in a day?
Q.1. Which of the following statements correctly
describes a well small baby? a) Two to Four.
a) Feeds by cup, stays warm with skin to skin b) Eight to Twelve.
care, has abnormal movements.
c) Five to Six.
b) Feeds by cup, stays warm with skin to skin
d) Twenty-Four.
care, weighs 1600g.
c) Breastfeds poorly, breathes with difculty,
Q.5. Which of the following indicates feeding
maintains temperature with KMC.
intolerance and the need for advanced care?
d) Feeds by cup, weighs 1200g, maintains
a) Spitting up small amounts.
temperature only when KMC is given.
b) Tense abdominal distension.
Q.2. Which of the following is an important step c) Passing stools 6 to 8 times a day.
in the care of a small baby?


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in the care of a small baby?
d) Crying before each feeding.
a) Teaching the mother to give bath to baby
and keep the baby clean and dry.
Q.6. When should the mother or other providers
wash their hands in order to protect a small
b) Giving the small baby lots of time in early
baby?
morning sunlight.
a) Before touching the baby and before
c) Preventing infection by washing hands
preparing a feeding.
before touching the baby.
b) Before greeting the family.
d) Weighing the small baby twice a day.
c) Before leaving home for follow up of the
Q.3. Shortly after birth, the feet of the baby with baby.
1800g weight feel cold. But the abdomen is
d) Before preparing baby’s bed.
warm to touch. After placing the baby in
Kangaroo position, the baby’s temperature
Q.7. A small baby needs to be referred for
remains the same. Which of the following
advanced care to a hospital one hour away.
actions should be taken?
What should you do to prepare the baby for
a) Place the baby in sunlight.
transport?


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What should you do to prepare the baby for
a) Place the baby in sunlight.
transport?
b) Bathe the baby in warm water.
a) Change the clothes of the baby and keep
expressed breast milk ready to feed on the
c) Call the health worker.
way.
d) Remove the wet diaper and cover the
b) Communicate with health care providers at
mother and baby in skin to skin on chest
the receiving facility and the family, and
with a blanket.
prepare a referral note.
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ANNEXURES
ANNEXURE 4: QUESTION BANK FOR SELF-LEARNING EXERCISE (AND FOR PRE AND POST-TESTS)
c) Mother can rest at home. Relatives can take b) Similar cost to the client.
the baby for further care.
c) Longer duration of exclusive breastfeeding.
d) Baby to be carried in skin to skin position
d) It is easier for mother.
during travel by mother or any helpers
from the family.
Q.12. Baby Leela was born at home and is now
being cared for with the KMC method. She is
Q.8. Baby of Ganga weighs 1200 g after one
able to take direct breastfeeding. But
hour of birth He is more likely to have a
becomes tired frequently. Her weight is not
problem with
increasing. In order to ensure enough
a) Low blood sugar. nourishment to the baby the ASHA worker
teaches the mother to:
b) Warmth.
a) Give goat milk by paladai.
c) Infections.
b) Bottle feed expressed breast milk.
d) All of the above.
c) Give sugar water in between.
Q.9. Baby of Anjana has a birth weight of 1400g. d) Give expressed breast milk by cup.


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Q.9. Baby of Anjana has a birth weight of 1400g. d) Give expressed breast milk by cup.
He will benet most from:
a) A small amount of sugar water in the rst Q.13. While observing a mother expressing breast
day of life. milk, the doctor notices that she massages
the breast from the outside toward the
b) Prolonged skin to skin contact on mother’s
nipple. The doctor encourages the mother to:
chest.
a) Massage the breast in the opposite
c) Antibiotics by injection.
direction.
d) Cord care by applying medicines on the
b) Massage both the breasts at the same time.
cut stump to prevent infection.
c) Continue the correct technique.
Q.10. Kangaroo Mother Care d) All of the above.
a) Should be given only by the mother.
Q.14. Danger signs in LBW babies are:
b) Should only be given in hospital under the
direct guidance of doctors. a) Different than for normal weight babies.
c) Both a and b. b) Can be mostly managed at home.


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c) Both a and b. b) Can be mostly managed at home.
d) Is a natural method for caring for LBW c) Serious and include feeding and breathing
infants. problems.
d) Can be detected only by the nurses and
Q.11. The most important advantage of KMC doctors.
compared to conventional care include:
a) Can be done by providers if mothers are
busy.
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ANNEXURES
ANNEXURE 4: QUESTION BANK FOR SELF-LEARNING EXERCISE (AND FOR PRE AND POST-TESTS)
Q.15. Early feeding of LBW babies with only breast b) The mother should keep a hot water bottle
milk can result in: wrapped in cloth next to baby to keep the
baby warm on the way.
a) More dehydration and eventual
hypoglycemia. c) The mother should carry the baby in skin to
skin contact on her chest during travel.
b) Superior rates of weight gain.
d) The mother or her helper should ensure that
c) High incidence of vomiting and diarrhoea
the baby is periodically given sugar water
in preterm babies.
on the way.
d) Slow gastric emptying in babies less than
37 weeks.
Q.19. How long should the baby be given only
breast feeding?
Q.16. Essential newborn care for ALL babies,
a) First four months of life.
regardless of weight, should include which
one of the following? b) First six months of life.
a) Cord stump should be kept clean and dry. c) As long as the mother wishes.


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a) Cord stump should be kept clean and dry. c) As long as the mother wishes.
b) Intermittent KMC. d) As long as the baby can take.
c) Preventive drugs for malaria.
Q.20. During hot summer months, the baby of
d) All of the above.
Meena has developed a fever. Baby is
breastfeeding well. How will you manage
Q.17. A mother has been practising KMC at home this child?
for four weeks. Her baby now weighs
a) Arrange for ambulance to take to hospital.
2500grams. When she returns for a follow -
up visit, the doctor advises her that she can: b) Call the ANM to give Inj. Gentamicin.
a) Continue KMC until the baby gains more c) Advise KMC and continue breastfeeding.
weight.
d) KMC cannot be given when the baby has
b) Discontinue KMC if the baby is otherwise fever.
well, but fusses when kept in kangaroo
position.
• Indicate true T or false F in the following
c) Return after one week for follow up. statements
d) Baby has to be sent for check up for ROP


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c) Return after one week for follow up. statements
d) Baby has to be sent for check up for ROP
by specialist doctor. Q.21. Ideally Kangaroo Mother Care has three
major components ie, Kangaroo Position,
Kangaroo Nutrition and Kangaroo
Q.18. During home visit the CHW nds the baby is
Discharge.
not taking feeds and appears unconscious.
She should encourage following except:
Q.22. Kangaroo Mother Care can be given only by
a) Encourage mother to express breast milk in
mother as suggested by the name.
a bottle to feed on the way to hospital.
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ANNEXURES
ANNEXURE 4: QUESTION BANK FOR SELF-LEARNING EXERCISE (AND FOR PRE AND POST-TESTS)
Q.23. Hair on father’s chest is not a barrier for Q.27. Expressed breast milk can be stored in room
giving skin to skin contact on father’s chest. temperature for about ten hours.
Q.24. Soon after birth, for baby of Nirmala, cord Q.28. Zero separation of mother and the newborn
was cut immediately, the baby was dried baby helps in improving the neuroprotection,
well by a clean dry towel, the wet towel was early stabilization of physiological
removed, the baby was covered well and parameters, and early start for successful
kept in a separate cradle. This is the correct breastfeeding.
sequence of caring for the baby in the rst
few minutes after birth.
Q.29. Baby of Glory had to be given a heel prick
for collecting blood for investigations. Mother
Q.25. Mother Hasina had twins. One baby had to kept her baby in KMC.It is good for the baby.
be given top feeds as mother cannot get


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be given top feeds as mother cannot get
enough milk for two babies .
Q.30. The best place for care of the preterm baby is
the mother's chest.
Q.26. Baby of Leela is delivered by Caesarean
section and it is not possible to start
immediate skin to skin contact on the
mother's chest and to start breastfeeding
within one hour of birth.
Answer Key:
Q1-b, Q2- C, Q3- d, Q4- b, Q5-b, Q6- a, Q7- b and d, Q8- d, Q9-b, Q10-d, Q11-c, Q12-d,
Q13-c. Q14- c, Q15-b, Q16- a, Q17- b, Q18-b, Q19-b, Q20-c, Q21-T, Q22-F, Q23- T, Q 24-F,
Q25-F, Q26- F, Q27- F, Q28- T, Q29-T, Q30- T
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ANNEXURES
ANNEXURE 5: TRAINING FOR KMC SUGGESTED AGENDA FOR TRAINING CHWs FOR HBKMC
ANNEXURE 5: TRAINING FOR KMC SUGGESTED AGENDA FOR TRAINING CHWs FOR HBKMC
It can be as a continuous program for one or two (a loving hug between the neonate and the
days (Preferable) or split into few sessions a day and mother or Alternate KMC Provider AKP).
spread over a few days. or one full day program and
Initial counselling with mother and her family
l
reinforcement again during monthly meetings.
members.
(One session each time); (It should be always
emphasized that KMC is one part of essential care of
Advanced preparations for HBKMC
the newborns with special emphasis on care of
LBWI). l Collecting the supplies.
Selecting and preparing the place.
l
Session I: Introduction -30 minutes
v Welcome to the program and objectives of the Immediate preparations just before putting the
training. baby on KP
v Introduction of participants. l Preparing the neonate.
v Pretest. l Preparing the mother.


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v Introduction of participants. l Preparing the neonate.
v Pretest. l Preparing the mother.
l Magnitude of problem of new -born care in l Actual positioning the baby on mother’s chest
India and challenges. and the precautions to be taken (Check list).
l Denitions and classications of the l Monitoring during Kangaroo position.
newborns.
Identication of danger signals as early as
l
Basic principles of care of new-borns with possible.
l
special reference to LBWI including preterm
Training the AKP also for KMC.
l
babies.
Practice with dolls; (Video demonstration and visit to
Session II: Basics and benets of KMC- 45 minutes
KMC mother if possible).
v What is KMC? Origin of KMC.
Session IV: KMC Nutrition –Important
Benets of KMC.
l
considerations
Benets to baby, mother, family, society,
l
Promotion of exclusive breast milk feeding as far as
hospital and nation.
possible and other alternatives as possible-
Basics of KMC- Denition, Description,
l


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possible and other alternatives as possible-
Basics of KMC- Denition, Description,
l
Discussion and video presentation- 90 minutes.
Components, Scope.
Golden rules of breastfeeding (early initiation,
Duration in each session, Types (Intermittent, l
exclusive breastfeeding for rst six months of life.
Continuous), when to stop and other details.
What to feed? How to feed? How much to feed?
l
Session III: Practical aspects of KMC How often to feed? How to assess adequacy of
feeds? Etc.
Kangaroo Position and hands on demonstration
l
and video- 90 minutes. l Supplementation of Micronutrients.
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ANNEXURES
ANNEXURE 5: TRAINING FOR KMC SUGGESTED AGENDA FOR TRAINING CHWs FOR HBKMC
Alternatives to mother’s own milk (when Session VI: Recording and reporting about KMC
l
absolutely necessary). and use of MCP card-30 minutes
Technique of Expressed breast milk expression, Why is recording important?
l l
collection, storage and administration by
Proper method of lling the records and reports.
l
different modes ie cup, spoon, paladai etc.
Methods to sustain lactation when direct
l Session VII: Communication and Counselling for
breastfeeding is not possible and only EBM has
improving the quality of KMC- 30 minutes
to be given.
Basic objectives and signicance of
l
Hygienic handling of breast milk feeding and
l communication and counselling.
top feeding.
Basic principles of counselling – Greet, Ask,
l
Assessment for adequacy of feeding.
l Listen, Praise, Advise and Communicate
Skills for collecting EBM and different methods of (GALPAC).
l
feeding can be shown by video clips; Technique


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l
feeding can be shown by video clips; Technique
When to counsel? What points should be
l
of handwashing by demonstration; Technique of
emphasized during each session?
weighing the baby by demonstration.
Multiple stages of counselling:
l
Session V: Regular follow up of KMC babies-30 v During Antenatal care; * before delivery and just
minutes before initiating KMC.
l Why is follow up important? l During the practice of KMC.
l Home based follow up frequency and checklist l During follow up home visits after completion of
of activities during each follow up visit for both KMC.
baby and mother.
If possible, facility based regular follow up is Session VIII: Open house discussion on barriers and
l
ideal; If not possible, at least for special follow up enablers /(problems and possible solutions) for
for neurological assessment, ROP and hearing practice of HB KMC – 30 minutes
screening, follow up at facility.
Introduction, objectives of the workshop, Pre-test;


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screening, follow up at facility.
Introduction, objectives of the workshop, Pre-test;
Routine follow up includes complete Post-test, certicates, valedictory etc.- 45 minutes.
l
examination of the baby, assessment of
Two tea breaks and one lunch break—total one hour.
breastfeeding, growth, advice for vaccinations,
(If it is a continuous one day program)
and any other concern of mother, checkup for
danger signals if any. Total duration of minimum 8 hours.
l How to establish link with the facility and notes PPT, Video, guidelines/module/ charts etc. will be
and other details of referral and transfer/ used during training.
transport including skin to skin contact during
transport.
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ANNEXURES
ANNEXURE 5: TRAINING FOR KMC SUGGESTED AGENDA FOR TRAINING CHWs FOR HBKMC
List of skills to be checked at the end of the training: mobile number/phone number of the referral
hospital or the doctor, List of danger signals,
Technique of holding a small/ preterm baby and
l
Mamta card or mother and child protection card
the precautions while handling a LBW baby.
( MCP card) and how to use them.
Technique of weighing a small baby accurately.
l
Carrying the baby in Kangaroo position during
l
l Drying and wrapping the baby. referral visits to hospital or other places.
Preparing a clean well -ventilated place for
l
HBKMC. Reference materials:
Collecting the needed supplies. Manual for HBKMC for CHWs (by aKMCF and
l l
others).
Preparing the baby for Kangaroo positioning
l
Training charts and videos (by KMCF and
l
Use of KMC bag/ wrap, if available.
l
others).
Demonstration of preparing washable,re -
l
** MOHFW GOI publications:
usable cloth diapers for the baby.


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l
** MOHFW GOI publications:
usable cloth diapers for the baby.
* Guidelines for KMC and optimal feeding
Kangaroo position.
l
for LBWI.
Keeping the baby warm and clean when not on
l
* Guidelines for Home based newborn care.
skin to skin contact on mother’s (AKP’s) chest.
* NSSK manual.
Monitoring the baby and early detection of
l
danger signals and immediate actions to be * ASHA training booklets.
taken.
* IYCF training module.
Positioning and latching for breastfeeding.
l
* Mother and Child protection Card.
Technique of hand washing and other infection
l
* Manual on early child development/care
prevention measures.
during rst 1000 days.
Technique of Expression of breast milk,
l
* MCP card.
collection, storage and administration
hygienically.
Noting down the emergency ambulance service
l
number/ name, address, directions/route,
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ANNEXURES
ANNEXURE 6: BUDGET FOR HB KMC ROLL OUT IN A DISTRICT (PROPOSED FOR 100 TRAINEES)
ANNEXURE 6: BUDGET FOR HB KMC ROLL OUT IN A DISTRICT (PROPOSED FOR 100 TRAINEES)
Unit cost Total cost
Sr. Name of the item Total units
Rupees (INR)
1. One day training of block level trainers (MOs/Block
Community Mobilizers/District community mobilizers)
a. Travel@Rs.500/person for 100 persons 500 100 50,000
b. Lunch/Tea @Rs. 200 per person for 100 persons 200 100 20,000
c. Honorarium for 2 trainers ( @ Rs. 2000/per trainer) 2000 2 4000
2. One day training of all ASHAs/ASHA facilitators
A. Travel@Rs.100/person for 1000 persons 100 1000 100,000
B. Lunch/Tea@Rs.200 per person for 1000 persons 200 1000 200,000
3. KMC Bags
a 10,000 KMC bags@Rs.50 per bag 50 10,000 500,000
b Printing of reporting formats 26,000 26,000
c Health education and training materials 150 100 15000
d Incidental Expenses 50 100 5000
TOTAL 9,20,000
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ANNEXURES
ANNEXURE 7: ADDITIONAL RESOURCES (7.1 IMPORTANT SKILLS FOR USE OF SIMPLE INSTRUMENTS)
ANNEXURE 7: ADDITIONAL RESOURCES
(7.1 IMPORTANT SKILLS FOR USE OF SIMPLE INSTRUMENTS)
Recording of the weight of the newborn: Better method suggested:
For use in the community very accurate scales Do not undress the baby; Weigh the baby with
l
reading a minimum of 10 grams should be the clothes.
available. They must be easy to use and easy to carry
Then undress the baby and quickly transfer the
l
during home visits. Currently available scales are not
baby and in another set of warm clean clothes
very useful for monitoring the progress in newborns
and cover well immediately.
and particularly small babies who are being given
Leave the original baby clothes on the weighing
KMC. l
pan and weigh only the clothes.
Generally, two types are available: Deduct the weight of the clothes from that of the
l
total weight of the baby with the clothes and get
1) Infant weighing scales with pans.


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l
total weight of the baby with the clothes and get
1) Infant weighing scales with pans.
the actual weight of the baby.
2) Infant weighing sling scales with hook and bag.
Advantages of this method: No need to undress
l
Using infant weighing scales with a pan: the baby and expose the baby on weighing
scale.
Usually a minimum of 100 or a few with 50 grams
accuracy are available. l In case, the baby passes urine or stools while
recording the weight, that remains in the left out
Ensure the weighing machine is placed on a at
l
clothes on the weighing pan and even helps for
surface and the pan is placed centrally.
accurate weight calculation.
Adjust the scale to zero each time before
l
Even in hospitals this method is very useful and
l
recording the weight.
safe for the baby.
Place a clean towel or clean paper on the pan.
l
This method is very useful especially for very
l
l Adjust the setting to zero. small babies and when digital scales are used.


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l
l Adjust the setting to zero. small babies and when digital scales are used.
l Before undressing the newborn, make sure that l Strongly recommended for use in community for
the room temperature is maintained well. LBW and preterm babies.
Undress and place the baby on the weighing
l
Use of colour coded sling weighing scale:
pan.
Hold the scale by the top bar, keeping the
Make sure that the baby is placed centrally on l
l
adjustment knob at eye level.
the pan.
Turn the screw until “0” is visible.
Record the reading on the case notes with l
l
mother and your register. Remove sling from the hook and place it on a
l
clean cloth.
Inform the mother about baby’s weight.
l
Place baby in the sling with minimum clothes on
Remove the baby from the weighing scale and l
l
and put the sling back on the hook.
dress back quickly.
Hold the top bar carefully, lift the scale and sling
Remove the used towel or paper. l
l
along with the baby, until the knob is at eye level.
Clean the pan if it is soiled.


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l
along with the baby, until the knob is at eye level.
Clean the pan if it is soiled.
l
Read the weight and record in register.
l
Gently unhook the sling with baby.
l
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ANNEXURES
ANNEXURE 7: ADDITIONAL RESOURCES (7.1 IMPORTANT SKILLS FOR USE OF SIMPLE INSTRUMENTS)
Remove the baby from sling and hand over the The armpit of the baby should be cleaned and
l l
baby to mother. dried before taking the temperature.
Record the weight and inform the mother. Make sure the thermometer is wiped and clean.
l l
If the baby is born 1-2 months early or weighs
l
Steps:
less than 1500g. refer to a facility for admission.
Use digital thermometer.
If weight is not possible and baby looks very l
l
small, follow the guidelines for care of LBW l Place the tip of the thermometer under the baby’s
baby at home by continuing KMC, keeping the arm, in the middle of the armpit against the bare
baby warm and feeding with expressed breast skin.
milk till baby is ready for breastfeeding. Proper
Gently hold the baby’s arm against the body.
l
handwashing and infection prevention
Keep the thermometer in place at least for three
measures must be practised. l
minutes or till it beeps.


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measures must be practised. l
minutes or till it beeps.
Recording of axillary temperature of the baby: Remove the thermometer and read the
l
temperature.
Normal Temperature in a newborn is 36.5-37.4
degrees Celsius. Accurate recording of temperature Keep the thermometer in a sterile container after
l
is particularly desired when the baby is wiping it clean preferably with spirit swab if
available or with soap and water.
Sick.
l
Record the temperature in baby’s case notes with
Low birth weight / Preterm. l
l
mother and records with the worker.
When baby is suspected to be cold or very
l
Whenever thermometer use is not possible,
warm to touch. l
temperature assessment can be done by touch
When the baby is being given warmth by
l (Palpatory) method, which is already described
keeping in KMC.
in detail.
When feet of the baby felt cold to touch.
l (** When the baby remains persistently very cold


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When feet of the baby felt cold to touch.
l (** When the baby remains persistently very cold
When the baby is being cooled for having high (Both feet and abdomen feel cold to touch and do not
l
body temperature when ill or during peak of the improve with simple measures like covering the body
summer with very hot environmental and hospital transfer is not likely or delayed, the
temperature or covered with many layers of following method can be tried.
clothing.
In such difcult situation at homes, if possible, a
When accurate temperature is needed, use of a cotton bundle of cloth can be warmed by rubbing on
thermometer is needed. The Health worker may a heated thick iron pan (“tawa” (used in Indian
carry one or even the family may have one. A homes for making chapati/roti) and the heated pad
temperature taken in the axilla (under the armpit) is of cloth is rst tested for the degree of heat by rubbing


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one of the safest methods to record the temperature. on mother’s/care takers’ own cheek and if found
tolerable, then applied on baby’s body to rewarm the
The procedure of recording the axillary
baby. This may have to be repeated several times to
temperature.
rewarm the baby adequately. Care must be taken to
act quickly and safely so as not to cause burns on the
Precautions to be taken:
baby's delicate chest and abdomen and also to
The worker should wash hands before recording
l rewarm the baby’s body.
a baby’s temperature.
(Recommended only in desperate cases where no
Keep the baby warm throughout the procedure.
l other alternatives are possible.)
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ANNEXURES
ANNEXURE 7: ADDITIONAL RESOURCES (7.2 CLASSIFICATION OF THE NEWBORNS IN VIEW OF FURTHER MANAGEMENT)
ANNEXURE 7: ADDITIONAL RESOURCES
(7.2 CLASSIFICATION OF THE NEWBORNS IN VIEW OF FURTHER MANAGEMENT)
Fig. 25: Different groups of neonates
Sr. No. Signs Full term (LBW) baby Pre-term baby
1 Creases on the Deep and covering the whole sole. Lighter and often only in the
soles of feet anterior portions of the foot.
2 Ears Fully developed. Normal shape & rm. Flattened, folded, shapeless,
soft and easy to bend.
3 Breasts Well developed. Black, well pigmented Not so well developed. Small
areola around the nipple. nipple and less pigmented,
light coloured areola.
4 Genitalia Well-developed Creases on the Less developed Less creases.
overlying skin. Dark colored skin. Light colored skin.
5 Hair on scalp Dense / Thick Sparse.
6 Lanugo hair on Usually only on the shoulders and All over the shoulder and
the body very less. soft hair.
7 Nails on ngers Well developed Less developed.


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the body very less. soft hair.
7 Nails on ngers Well developed Less developed.
8 Mode of Breast Can suck and swallow well. Difculty in continuous sucking
and not so well co-ordinated
sucking, swallowing.
9 Crying Vigorous Weak.
10 General appearance Well exed joints of hands and feet Hands & feet (bending) exion
(at elbow, wrist, hip, knee). Vigorous may not be complete.
movements when awake, Less activities and movements
Good tone of muscles. Muscles tone much less.
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ANNEXURES
ANNEXURE 7: ADDITIONAL RESOURCES (7.2 CLASSIFICATION OF THE NEWBORNS IN VIEW OF FURTHER MANAGEMENT)
Full term (LBW) baby Pre-term baby
Deep and more sole creases Lighter and less sole creases
Well developed ears Folded, soft ears
Well developed breast nodule Less developed breast nodule
Well developed genital organs Less developed genital organs
Fig. 26: Differences of Full term and preterm newborn babies.
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ANNEXURES
ANNEXURE 7: ADDITIONAL RESOURCES (ANNEXURE 7.3: MINOR PROBLEMS OF NEWBORNS)
ANNEXURE 7: ADDITIONAL RESOURCES
(ANNEXURE 7.3: MINOR PROBLEMS OF NEWBORNS)
For the minor problems of the newborns, no special Stools:
care is required. But, we have to make sure that there
• 2 - 3 days after birth, the newborn passes 6 - 7
are no signs of any serious illness. In case, some signs
stools in 24 hours.
of serious illness are observed, immediately the baby
should be taken to bigger hospitals. • To begin with it is dark green or brown in colour
and then gradually turns yellow.
Vomiting: • Many healthy babies pass small quantities of
stool frequently in a day.
• At the time of birth, the baby can gulp down
some amount of amniotic uid and because of • Make sure about any other signs of serious
that gastric irritation can occur and the baby can illness, less quantity of urine, not taking feeds
get vomiting in the rst 2 - 3 days after birth. properly, fever or very cold body, lethargic,


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get vomiting in the rst 2 - 3 days after birth. properly, fever or very cold body, lethargic,
abdominal distension etc.
• This vomiting will stop spontaneously, No
medicines are needed. • If any of these serious signs are present, one oral
dose of co-trimoxazole should be given before
• Make sure whether there are any serious signs?
transporting the baby to a big hospital.
for e.g., not passing stool, abdominal distension,
green bilious vomiting or blood in vomitus. • Are there any other signs of dehydration? In
case dehydration signs are observed, frequent
breastfeeding and oral rehydration solution
Regurgitation of feeds:
should be given.
• It is common for the newborn to throw out some
amount of milk soon after breastfeeding.
Constipation:
• If the baby is burped well by putting on the back
• Many normal newborns pass stools only once in
soon after breastfeeding or the baby is made to
5 - 6 days. The stool is normal in consistency and


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soon after breastfeeding or the baby is made to
5 - 6 days. The stool is normal in consistency and
lie down in a slightly head up position, a lot of
the child is otherwise normal. No treatment is
relief can be there for the baby.
required.
• Watch for any other signs of serious illness e.g.,
• Verify whether any other serious problems co-
continuous regurgitation of feeds, abdominal
exist. e.g., vomiting, distension of abdomen,
colic, excessive crying and irritability, no proper
excessive crying, lethargy, refusal to take feeds
weight gain or even actual weight loss.
etc.
Stool / Urine:
Fact to remember:
• Generally, a baby passes stool within the rst 24
Do not give any laxatives to newborn babies.
hours after birth and urine within the rst 48
hours after birth.
Fever:
• If passing urine/stool are very much delayed
than the accepted time interval, the baby should • On the second and third day after birth, the


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than the accepted time interval, the baby should • On the second and third day after birth, the
be taken to a bigger hospital for further newborn loses some amount of body uids and
examination. develops fever, known as dehydration fever.
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ANNEXURES
ANNEXURE 7: ADDITIONAL RESOURCES (ANNEXURE 7.3: MINOR PROBLEMS OF NEWBORNS)
Frequent breastfeeding is the main treatment at Skin problems:
that stage.
• Mild rashes (not pustules) on the head / neck /
• In hot weather or in a very warm area, the body / axilla may be seen. No treatment is
newborn's body temperature increases. For the required.
treatment, the room temperature should be
• If pus containing rashes are present less than 10
brought down (with the help of measures like
in number, only antibiotic topical cream or
hanging wet towels on the windows / use of
gentian violet may be applied.
curtains). If too much clothing is put on the baby,
a few can be removed. (fan can be switched on But, if pus containing rashes (pustules) more than 10
if available). are seen simultaneously or there is a big abscess,
oral antibiotics will be required.
• Watch out for any other concurrent serious


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oral antibiotics will be required.
• Watch out for any other concurrent serious
problems like loose motions, vomiting, fast • Many times, skin over the scalp (head) peels off
breathing or any other difculty in breathing, and face is congested and reddish, soon after
not breastfeeding well, lethargy, fullness of birth. If the baby is feeding well and no other
anterior fontanelle etc. problem, no treatment is required. But, fever,
weakness or refusal to feed are present, the
baby may be taken to a skin specialist or bigger
Excessive Crying:
hospital for further conrmation.
• Newborns can cry if hungry, thirsty or wetting
• Many times, bluish spots are seen on baby’s
the diaper. This is a normal cry for the baby
buttocks soon after birth (Mongolian spots)
(Sometimes, a baby can cry if very tight clothing
which gradually fade away and no treatment is
or tight elastic of socks or belt are used. Only
required.
loose comfortable clothing should be used for


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required.
loose comfortable clothing should be used for
the baby and a clean place for sleeping). There
should be no hooks or buttons in baby’s clothes. Engorgement of baby’s breast/s:
Occasionally insect bites or antbites also can the
• In the newly born boys, occasionally engorged
reason for crying
breasts are seen. They subside within a few days
• An experienced mother can identify from the and no treatment is required. The breast nodule
nature of excessive crying of the baby, whether should not be squeezed, nor removal of milk
the baby is crying because of some discomfort attempted.
or some illness.
• Watch out for any concomitant signs of serious Common eye problems in newborn:
illness: e.g., fever, hypothermia (cool hands, feet
• Soon after birth, occasionally, a bloody spot
and body of the baby) not taking breastfeeding,
may be seen in the baby's eye. No treatment is
lethargy, fullness of anterior fontanelle, swelling
required.
over any part of the baby’s body etc.


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lethargy, fullness of anterior fontanelle, swelling
required.
over any part of the baby’s body etc.
• At times, soon after birth, the baby's eyes stick
together. Soon after delivery, eyes should be
Bleeding from vagina:
properly cleaned with boiled and clean water
Many girls have bleeding or discharge from vagina and drops of breast milk can be put in baby’s
(Lower parts) in the rst week of birth. It is normal and eyes 2 -3 times in a day. If necessary, as per
does not require any specic treatment. doctor’s advice, antibiotic eye drops or ointment
may be put.
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ANNEXURES
ANNEXURE 7: ADDITIONAL RESOURCES (ANNEXURE 7.3: MINOR PROBLEMS OF NEWBORNS)
Hiccups: Watch out for serious signs like:
• Hiccups are very common in the newborn • Jaundice noticed within the rst and second day
period. No treatment is required. If necessary, after life.
the baby may be burped properly by holding it
• Deep jaundice extending over palms and soles
vertically and putting on his/her back.
also.
• Either high or low body temperature.
Swelling on the head:
• Lethargic or lax baby.
• During difcult labour, some bleeding occurs on
the head and swelling is seen. This swollen part • Not breastfeeding properly.
of the head will subside on its own gradually
• Low birth weight, weak baby. (Referral required)
and no special treatment is required.
• Watch out for any concurrent serious signs eg.
Cord infection:
delayed crying soon after birth, the baby
remains lethargic or unconscious, has ts, not • If there is pus discharge from the cord stump and


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remains lethargic or unconscious, has ts, not • If there is pus discharge from the cord stump and
breastfeeding, difculty in breathing etc. Urgent redness and swelling around the skin of the cord
referral to hospital required. stump, it is necessary to apply antibiotic cream
or ointment.
Tremors: • If the baby is very weak and low birth weight,
even antibiotic injections may be required.
• Tremors (shaking of hands and legs )are very
common in newborns and not very serious. • At times, after the cord has dried and fallen, a
small reddish swelling is noted (umbilical
• Watch out for any concurrent serious signs, eg.
granuloma). It will shrink and subside if common
continued tremors for a longer time, tremors
edible salt is applied on it 2 or 3 times a day for
while breastfeeding, fever or cold feel of the
about 5 to 7 days. All the hygienic precautions
baby’s hands, feet, chest and abdomen, not
should be taken including proper hand wash
breastfeeding properly, laxity, swelling of


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should be taken including proper hand wash
breastfeeding properly, laxity, swelling of
and use of clean salt.
fontanelle (top of head) etc. (Referral required.)
Thrush in the mouth or on the tongue:
Jaundice (yellow discoloration of skin):
• Whenever, baby is breastfeeding and if the
• Jaundice means yellowish color of eyes and
maternal personal hygiene is not good, the baby
skin.
may get a whitish patch on the tongue or mouth
• In many newborns, yellowish discoloration of (called thrush)and breastfeeding becomes
face, eyes and chest is seen after about 3rd day difcult. Such patches also occur in the mouth of
after birth and gradually fades by about 6th or very sick and premature babies. This will
7th day after birth. This is very common. If the subside after applying gentian violet lotion 2 - 3
baby continues to feed well, special treatment is times a day for about 3 to 5 days. Many times,
not required. whitish curd is seen soon after breastfeeding if


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not required. whitish curd is seen soon after breastfeeding if
some milk remains in the mouth. This can be
easily wiped clean with a cloth piece and the
baby does not have any problem in feeding.
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ANNEXURES
ANNEXURE 7: ADDITIONAL RESOURCES (ANNEXURE 7.4: THE COMMON TRADITIONAL PRACTICES AFFECTING NEWBORN CARE)
ANNEXURE 7: ADDITIONAL RESOURCES
(ANNEXURE 7.4: THE COMMON TRADITIONAL PRACTICES AFFECTING NEWBORN CARE)
In our community, several practices related to Harmful Practices:
pregnancy and newborn care are widely prevalent.
• Not to take any care during pregnancy
These practices have originated from age-old
considering it to be a normal and natural event.
traditions. Many times, these traditions appear to
have started with some good objective, but its effects • To ignore girls and not give enough nutrition.
are not very benecial today or could be even
• Selective female feticide / termination of
harmful. In newborn care, the elderly women
pregnancy.
members of the family particularly, the mother-in-
• Feeding the pregnant woman less,(especially in
law or grandmother play an important role and often
the last trimester) thinking that it helps in keeping


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the last trimester) thinking that it helps in keeping
support by traditional birth attendants is very
the baby small and facilitates easy, normal
decisive. Many traditions have roots in old traditional
delivery.
medicine systems like Ayurveda. In our vast country,
in different states, a wide variety of traditions are • Because of wrong beliefs not to give nutritious
seen, which have been inuenced by the local foods like milk, banana, potato etc. to pregnant
community factors. Status of education, economy women.
and community factors play an important part in
• In the case of non-vegetarians, not to give eggs
these traditional practices.
and meat to pregnant women.
Not that, all our traditional practices are bad. But
• Excessive physical strain during pregnancy.
very few systematic studies have been carried out.
Because of the general mentality that all that is old is • Not take iron / folic tablets, thinking it will give


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bad and all that is new is good, many of our good black complexion to the baby.
traditions have not been brought to attention. Hence,
here a list has been given which distinguishes good
Traditional practices related to delivery of the baby:
and harmful practices separately. We cannot claim
that this list is complete. But you can evaluate the local ü Useful, good / benecial practices:
traditional practices of your area by this approach.
• To prepare a separate clean area in the house
We should preserve our good traditional practices. for delivery.
We should immediately stop all the harmful practices.
• To warm up the delivery room with the help of a
If some practices are found to be not very harmful,
traditional oven.
then there is no objection in continuing the same.
• To give warm fomentation to the mother after
Now, many harmful modern practices have also
delivery.
been started in our community and it is important to


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delivery.
been started in our community and it is important to
stop them also. By constant community contact and • Soon after delivery, if the newly born appears
experience, we can learn our local traditional, pale or bluish, then start the respirations by
cultural practices and decide whether they are good blowing through the air passages.
and bad and then attempt to create public awareness
• Clean the baby’s mouth by wiping with a cloth
through community education.
piece.
Following details will be of help.
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ANNEXURES
ANNEXURE 7: ADDITIONAL RESOURCES (ANNEXURE 7.4: THE COMMON TRADITIONAL PRACTICES AFFECTING NEWBORN CARE)
Harmful Traditional Practices: • To keep the room warm with a traditional oven,
where mother and baby are kept.
• To conduct delivery in a dark, ill ventilated area
or even in a cattle shed. • To body massage the baby by applying oil or
ghee.
• To conduct delivery by an untrained birth
attendant and old lady. • To wrap the baby in 2 to 4 layers of cloth and put
a cap on the baby's head.
• Not to wash hands before conducting delivery
or even if the hands are washed, wipe them with • To massage the baby and keep in the morning
dirty clothes. sunlight.
• After delivery, use of dirty pads for the mother. • To prevent eye infection, put a few drops of
breast milk in the baby's eyes.
• Adopt a traditional pushing method (Kalla) for
speeding up the delivery. • If the baby is not able to breastfeed directly,
express the milk from the mother's breasts and


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express the milk from the mother's breasts and
• Frequent intravaginal exams, with dirty hands
give it to the baby with a spoon or paladai from
and applying “Ghee” on the external surface of
a cup.
vagina before delivery.
• Use of a traditional cradle for laying the baby.
• In order to expel the placenta, induce vomiting
of the mother by putting her hair in the mouth. • Singing traditional lullabies and other songs to
babies at the time of sleeping.
• To hold the baby upside down and hit the baby
hard soon after birth, to make the baby cry.
Harmful Practices:
• In order to make the baby cry immediately after
birth, to blow hard in the baby's ears or make • Not giving nutritious foods to mothers like
loud noises with vessels. banana, papaya, curds, cold milk (and in case
of non- vegetarian families, sh) etc. considering
• To use unclean items like old scissors, used
them “cold” foods, not to give legumes, potato
blades, knife, sickle etc. to cut the baby’s cord


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them “cold” foods, not to give legumes, potato
blades, knife, sickle etc. to cut the baby’s cord
etc. as “gas producing” and such wrong beliefs.
after birth.
• Soon after the delivery, within a short time, the
• To apply unclean substances like Ghee, Cow
mother is made to do heavy physical work at
dung, ash etc. on the cut cord stump.
home, farm etc.
• To use a dirty cloth piece to clean the baby's
• Putting the mother and baby in a dark, ill
mouth.
ventilated, not so clean area and not allowing
even light exercises to the mother.
Traditional Practices of newborn care after birth:
• To ignore girl children.
ü Good and benecial practices:
• To hurry up for a baby bath, soon after birth.
• After delivery, give traditional homemade
• To throw away the early breast milk - colostrum.
calorie rich food to mother like groundnut laddu,
methi pak and such sweets.(Rich in Iron and • To give prelacteal foods such as honey, ghee,
calorie). jiggery etc.


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calorie). jiggery etc.
• To keep the mother and baby dyad isolated in a • Delaying the starting of breastfeeding under
separate room for about 40 days after birth. wrong notions and ideas e.g., bad omen, bad
time etc. Waiting for some rituals before starting
• Breastfeeding the baby as a natural rule.
the rst feed.
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ANNEXURES
ANNEXURE 7: ADDITIONAL RESOURCES (ANNEXURE 7.4: THE COMMON TRADITIONAL PRACTICES AFFECTING NEWBORN CARE)
• To give gripe water, water, tea, honey and other • Not allow pregnant women to go out during
traditional herbal preparations to baby along eclipse time.
with breastfeeding.
• To feed the mother with certain special, calorie
• To put oil drops in the ear and nose of the baby, rich food with an idea to increase the quantity of
with the wrong idea of cleaning the ear and breast milk (Halwa, coconut, ginger, garlic etc.)
eyes.
• To believe in superstitions when the newborn is Facts to remember:
sick such as “casting the evil eye” (nazar utarna)
To begin with, encourage useful traditional practices.
, tying threads on wrist etc.
Only after that explain about the harmful practices
• To apply kajal, surma (dry soot powder) etc., in and motivate them to stop these practices. Do not
baby’s eyes. worry about the harmless practices which are neither


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baby’s eyes. worry about the harmless practices which are neither
useful nor harmful for the time being, you can ignore
• In cases of acute diarrheas or for putting the
them.
baby to sleep, use of opium products through
traditional preparations.
Modern newborn practices which are being blindly
• To keep a knife under a baby's pillow for
imitated and harmful to our newborns:
protection.
• Use of feeding bottles for giving milk to babies.
• To allow the use of paciers and rubber nipples
in the baby's mouth to stop crying. • Use of powdered milks/formula instead of
breastfeeding.
Some traditional practices which are neither very • Use of commercially prepared cereal foods
harmful nor much useful: rather than using home made fresh, clean,
nutritious, cheap cereals included in the
• Piercing nose and ears for girls and sometimes
traditional family food.
for boys also. In some communities, circumcision


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traditional family food.
for boys also. In some communities, circumcision
is a must for the boys. (If these procedures are • Use of expensive baby soaps, baby powder,
done with aseptic instruments, they can be baby shampoos etc.
performed about one month after the 3rd dose
• Use of paciers and nipples.
of DPT vaccination).
• Excessive, unnecessary use of drugs and tonics.
• To massage the scalp on fontanelle, to straighten
the baby’s neck etc. • Prenatal examination of sex of the foetus and
selective female feticide.
• To rear the baby with clothes borrowed from
others (or collected by “begging”) (in cases of
frequent infant deaths).
• To put a black dot on forehead or behind the ear
etc., to put a waistband or bangles, amulets etc
to avoid the effect of “evil eyes” (nazar utarna)
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ANNEXURES
ANNEXURE 7: ADDITIONAL RESOURCES (ANNEXURE 7.5: A FEW COMMON DIFFICULTIES OF BREASTFEEDING)
ANNEXURE 7: ADDITIONAL RESOURCES
(ANNEXURE 7.5: A FEW COMMON DIFFICULTIES OF BREASTFEEDING)
Flat / Small nipple:
• Length of the nipple is not very important.
• It is important that during breastfeeding, both the nipple as well as the surrounding dark area known as areola
should be pulled into the baby's mouth.
• Console mother that at nipples will not be problematic for successful breastfeeding.
• Explain to her the proper method of attachment / latching to the breast.
Swelling or cracks on nipples:
If the baby is not properly latched to the mother's breast during feeding, nipple swelling or cracks occur.
Causes of nipple swelling: Treatment of cracked nipples:
• Improper latching • Continue breastfeeding.
• Feeding only on nipples • Shift the baby a little from where
it is sucking
• Frequent use of soap and water • While feeding on breast ensure
that s urrounding dark areola is


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• Frequent use of soap and water • While feeding on breast ensure
that s urrounding dark areola is
also in baby’s mouth along
with nipple.
• Fungal infection on nipple • After completion of feeding, apply
a f ew drops of breast milk on the
Flat nipple
affected nipple and allow it to dry.
Frequent washing is n ot required.
Engorgement (or too much lling of milk) of breasts:
After delivery more milk ows in the breast from 2nd, 3rd day onwards. At this stage, if the baby has either not
started feeding or not properly latching on breast, the breasts are not emptied fully and milk lls in the breasts and
engorgement occurs resulting in swelling and pain.
Measures for prevention: Treatment
• Start breast feeding early. • Hot water fomentation.
• Frequent breast feeding • Express breast milk very softly and once the
breast lling becomes less, start breast feeding
• Proper method of latching attachment to
by properly latching. (The expressed breast
breast.


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• Proper method of latching attachment to
by properly latching. (The expressed breast
breast.
milk can be fed to the baby with a spoon).
• If there is too much pain, one tablet of
paracetamol can be given to the mother.
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ANNEXURES
ANNEXURE 7: ADDITIONAL RESOURCES (ANNEXURE 7.5: A FEW COMMON DIFFICULTIES OF BREASTFEEDING)
Pus formation in breasts (Abscess):
• If the breast engorgement / swelling or cracked nipples are not managed properly in time, pus can form
leading to breast abscess. Mother gets a high fever and severe pain. There may be pain in the axilla because
of the swollen local lymph glands.
Management:
Pain killer tablets (Paracetamol), antibiotics (eg. cotrimoxazole) Incision and drainage of the pus will be required.
Continue breastfeeding from the unaffected side.
Not enough milk:
• First conrm that the mother's complaint is valid.
• If the baby is passing adequate urine and has satisfactory weight gain, only reassurance for the mother is
needed with proper counselling and guidance for the correct technique of breastfeeding.
Causes of not enough milk:
Difculty in feeding on breast Mother’s mental condition
• Late starting • Lack of self condence
• Tension, worry


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• Late starting • Lack of self condence
• Tension, worry
• Not giving frequent feeding
• Not willing for breastfeeding
• Not feeding during night
• Tired
• Every time, feeding for less time.
• Improper latching/attachment. Mother’s physical condition
• Illness
• Use of paciers/nipples
• Pain
• Offering other uids (eg. water) along with
• Smoking
breastfeeding.
Baby’s condition:
Sick and extreme preterm or LBW baby; Local defects in mouth like cleft palate and others Management includes
regular frequent counselling and guidance, if the baby is getting not enough breast milk and suitable management
for the sick baby or the mother.
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Proper hand washing Preparing the baby for KP in a warm Removing upper garment to
clean area Cap, diaper and socks for baby bare the chest of baby
Adjusting the baby on mother’s bare Covering the baby and mother Baby comfortably adjusted in
chest for direct skin to skin contact. together from above Kangaroo Position
A loving body hug!
Mother relaxing comfortably Happy mother with Simple chores holding the baby in
with baby in KP her baby on her chest KP with due support
Simple activities holding Adjusting twins for Neighbour helping with Keeping baby safe and
the baby in KP KP on mother one of the triplets for KP comfortable when not in KP
Fig. 27: Steps for Kangaroo Position/KMC


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Printed in 2021
For further information, please contact:
Prof. Shashi N Vani, M.D., D. Ped., FIAP, FNNF
Managing Trustee KMC Foundation, India
Emeritus Professor of Paediatrics including Neonatology,
P S Medical College, Karamsad, Gujarat.
Email: shashinvani@googlemail.com
Director of Health Services,
State Family Welfare Bureau, Department of Public Health
Raj Bahadur Mill Road, Naidu Hospital Compound, Pune - 411 001.
Email: sfwbcell@gmail.com
Health Specialist,
United Nations Children's Fund
215 Atrium, Andheri - Kurla Road, Hanuman Nagar, Andheri (East), Mumbai - 400 059.
Email: kbhuyan@unicef.org


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KANGAROO MOTHER CARE
Kangaroo is an animal
found in Australia. She
invariably delivers a
premature baby. The
premature, baby kangaroo
stays in the pouch of her
mother, where it gets
warmth and exclusive
breast feeding till it is
mature enough to survive
outside.


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Milestones in KMC History
• Team of pediatricians started KMC in Instituto Materno Infantil
(IMI) in Bogota, Colombia
1978
• KMC was introduced in India
1994
• WHO formally endorsed KMC and published KMC practice
guidelines
2003
• Centres of excellence established at three centres AIIMS, PGI
Chandigarh & KEM, Mumbai
2004
• MOHFW, Government of India’s Operational guidelines on KMC
& optimal feeding of LBW
2014


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What is KMC?
Kangaroo Mother Care (KMC) is a simple method
of care for low birth weight infants that includes
early and prolonged skin-to-skin contact with the
mother (or a substitute caregiver) and exclusive &
frequent breastfeeding.
Short: 4 hours daily* extended: 5-8 hours daily* long: 9-12
hours daily* Continuous: More than12 hours daily*
Benefits to the newborn
 Stabilizes body temperature
 Decrease morbidities; better neurodevelopment
 Early discharge
 Promotes breastfeeding; prevents infection
 Encourages bonding in mother & Child


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Skin-to-Skin contact
However, KMC should not be
confused with routine skin-to-skin
care at birth.
“World Health Organization (WHO)
recommends skin-to-skin care immediately
after delivery for every newborn, irrespective
of the birth weight”


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KMC can be provided by mother, father and other adult family
members who is willing, healthy with basic standards of hygiene


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How to provide KMC?
Counseling; Effective counseling for the initiation of KMC is a
pre-requisite to overcome socio-cultural barriers and anxiety
towards handling a low birth weight infant by the mother and health
care providers
Clothing
Mother: Any front-open, light dress as per the
local culture, not mandatory to have any special
dress
Infant: should be dressed in cap, socks,
disposable diapers and front-open sleeveless
shirt or ‘Jhabala’ made of a soft natural fabric
like cotton.


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KMC Position
1. The infant should be placed between
the mother’s breasts in an upright
position.
2. The head should be turned to one side
and (cid:141)in a slightly extended position.
3. The hips should be flexed and
abducted in a “frog” position; the
arms should also be flexed.
4. The infant’s abdomen should be at
the level of the mother’s epigastrium.
5. Support the infant from the bottom
with a (cid:141)sling/binder.


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Mother in the KMC position can walk, stand,
sit, or engage in activities. If comfortable, mother
can sleep in KMC position with her infant
Infants receiving KMC should be monitored (cid:141)carefully during
KMC to ensure that the infant’s airway is clear, breathing is
regular, colour is pink and s/he is maintaining temperature.


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Discharge & Follow-up
Follow-up
Discharge
• Follow-up is a fundamental
The infant is
prerequisite of KMC, to make a
• Stable and not on parenteral
regular assessment of growth,
medication
sensory functions, behaviour and
• Maintaining temperature in neurodevelopment.
mother’s bed for 3 • ASHA will continue to provide
consecutive days at room care to the infant under HBNC in
the community, following
temperature
discharge
• Gaining 15-20 grams per day
• First Follow-up should be at one
for at least 3 consecutive days
week, followed by fortnightly
• Accepting feeds directly from
follow-ups till next two visits.
breast (preferable) by spoon, Additional follow-up visits may
paladai or cup be done until s/he reaches 40
PMA/2500 grams.


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OPTIMAL FEEDING OF LOW BIRTH
WEIGHT INFANTS
Low birth weight (LBW)
infants need optimal nutrition
during the neonatal period
for proper growth and
development. Appropriate
feeding of low birth weight
and very low birth weight
infants improves their
chances of survival and is
important for their optimum
growth and development.


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Breastfeeding
The best milk for LBW infants is mother’s milk.
All else is inferior.
In case mother’s milk is not available, then the
choices in the order of preference are:
• Expressed donor milk from other lactating mothers.
• Formula milk- When not enough breast milk is available to
meet the needs of a LBW infant, formula milk may be given
with proper preparation and hygiene.
• Animal Milk- Cow or buffalo milk are the last choice Such
milks are unsuitable and may be given with great caution
without dilution with alternate methods of feeding.
“Bottle feeding is not appreciated”


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Alternative feeding methods
Feeding tube
Paladai
Feeding tube, spoon,
Cup
paladai or cup are the
alternative methods
of feeding when
direct breastfeeding is
Spoon
not possible.


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Feeding progression: Infant should progress from the initial method through the
intermediate steps to feeding exclusively from the breast directly.


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Monitoring of infants for adequate feeding
Infants lose weight in the first few days, loss would not exceed
10-15% of the birth weight.
They regain their birth weight by about 2 weeks and then 15-20
grams per kilogram of their own body weight per day.
For infants below 1,500 grams (less than 32 weeks), use a
postnatal growth chart to plot weight every day until they are of
40 weeks PMA or 2500 grams.
If the infant has inadequate weight gain, the provider should
check the amount of intake, and assess and spluttering/ spillage.
Nipple and breast problems in the mother should be looked for.


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KMC Roll out plan;
The aim is to advocate KMC to be
practiced for all infants eligible for KMC at public health facilities.
Model KMC services to
be established in 25
Regional & State
Resource Centers by the
end of 2017
KMC services to be
provided in all SNCUs
and well-functioning
NBSUs (at CHCs and
FRUs) across the country


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States level activities;
• State level orientation cum planning workshops for KMC roll
out.
• Identification of medical colleges as state resource centers.
• Initially, saturate the SNCUs with KMC services on priority..
• Develop resource pool for training and ensure adequate and
trained human resource at SNCU.
• Seek support from respective state lead development partners
to ensure KMC implementation
• Review progress of implementation every quarter.
• Developing linkages with RBSK and community follow-up by
ASHA also integrate KMC into FBNC.


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District Level activities
• Carry out civil work/refabrication necessary
for ensuring KMC.
• Conduct orientation/refresher trainings of
counsellors and health providers
• Identify high case load facilities for ensuring
KMC services.
• Ensure record keeping and timely reporting at
facilities


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Developing a KMC Unit
Infrastructure;
• KMC Unit of 8-10 beds recommended for every hospital with
SNCU.
• KMCU must be the integral part of the existing/new upcoming
SNCUs/MCH wings/Postnatal wards & NBSU
• The neonatal units at all Medical Colleges to be strengthened to
provide appropriate newborn care including KMC.
Human Resource; Available regularly with most SNCUs. Therefore,
utilize from regular supply and may budget, if required.
Capacity Building; The existing training modules for F-IMNCI and
FBNC may be used for orientation.
Specifications; Refer to guidelines for detailed budget calculations
“However, provision of KMC should not wait for the establishment of KMCU’


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Kangaroo mother care
Implementation strategy for scale-up
adaptable to different country contexts
HEALTH
FOR ALL


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european foundation for
the care of newborn infants
Cover photo credits (from top clockwise): ©Lund-Malmö NIDCAP Center/Stina Klemming; ©Safdarjung Hospital/
Harish Chellani; ©LD Photography/Idowu Olamide; ©WHO/Gato Borrero; ©Lund-Malmö NIDCAP Center/Stina Klemming


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Kangaroo mother care: implementation strategy for scale-up adaptable to different country contexts
ISBN 978-92-4-007163-6 (electronic version)
ISBN 978-92-4-007164-3 (print version)
© World Health Organization 2023
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Contents
Acknowledgements v
Abbreviations vii
Glossary viii
Introduction 1
– Global vision and position on kangaroo mother care 1
– Rationale for an implementation strategy for kangaroo mother care scale-up 2
– Purpose of the implementation strategy 4
– Audience for the implementation strategy 4
– Process of development of the implementation strategy 4
The case for KMC 7
– Saves lives, advances human capital 7
– Humanizes care, empowers and benefits the mother 7
– Springboard to improve delivery of quality small and/or sick newborn and maternal care 8
– Cost-effective intervention plus long-term economic benefits 9
– Promotes sustainable development 9
Considerations for designing a KMC implementation strategy 11
– Lessons learned from national efforts to scale up KMC 11
– Evidence from implementation research 17
Guiding principles for KMC implementation 21
– Recognize the mother’s role as primary caregiver 21
– Meet the needs of the mother 22


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– Recognize the mother’s role as primary caregiver 21
– Meet the needs of the mother 22
– Implement KMC as the foundation of small and/or sick newborn care 22
– Deliver KMC at all levels of facility care and in the community 24
– Adapt implementation by country-income settings and health system contexts 25
– Align with World Health Organization guidelines 26
– General programmatic principles 27
iii


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Implementation strategy to achieve scale-up 31
– Engage political leadership and develop KMC-supportive policies with a national
KMC implementation plan 31
– Increase availability, capacity and motivation of health-care providers 33
– Reorganize service delivery to fulfil the needs of mothers and infants simultaneously 34
– Upgrade infrastructure and design of maternal–newborn care to create a conducive
environment for KMC 35
– Develop robust data systems and use data for quality improvement 36
– Create a functional network of care and improve referral transport 39
Operationalizing the implementation strategy 41
– National planning and coordination of KMC implementation 41
– Subnational-level planning and implementation 42
Path forward 47
References 48
Boy Arkestal, born nine weeks preterm, in immediate
KMC, Lund-Malmö NIDCAP Center, Stockholm.
iv
Kangaroo
mother
care:
Implementation
strategy
©Lund-Malmö
NIDCAP
Center/Stina
Klemming


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Acknowledgements
WHO extends sincere appreciation to the Kangaroo Mother Care (KMC) Working Group convened by
the WHO Strategic and Technical Advisory Group of Experts (STAGE) for Maternal, Newborn, Child and
Adolescent Health and Nutrition (MNCAH&N), listed below. All the participating organizations endorsed
the position paper.
STAGE MNCAH&N KMC Working Group
Chairs: Gary Darmstadt, Prematurity Research Center, Department of Pediatrics, Stanford University
School of Medicine, Stanford, California, United States of America; Betty Kirkwood, London School of
Hygiene and Tropical Medicine (LSHTM), United Kingdom of Great Britain and Northern Ireland
Country MNCAH programme managers: Queen Dube, Ministry of Health, Malawi; Sumita Ghosh,
Ministry of Health, India
Bilateral agencies: Meena Gandhi, United Kingdom Foreign, Commonwealth and Development Office
(UK-FCDO); Lars Gronseth, Norwegian Agency for Development Cooperation (NORAD); Aya Hasegawa


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(UK-FCDO); Lars Gronseth, Norwegian Agency for Development Cooperation (NORAD); Aya Hasegawa
and Keiko Osaki, Japan International Cooperation Agency (JICA); Lily Kak, United States Agency for
International Development, USAID
Donor organizations: Sufia Askari and Mihretab Salasibew, Children’s Investment Fund Foundation
(CIFF); Maneesh Batra and Hema Magge, Bill & Melinda Gates Foundation; Tore Laerdal,
Laerdal Foundation
Professional associations and nongovernmental organizations: Nathalie Charpak, Kangaroo
Foundation, Colombia; Elizabeth Franklin, International Confederation of Midwives (ICM); Bo Jacobsson,
International Federation of Gynaecology and Obstetrics (FIGO); Janna Patterson, American Academy
of Pediatrics (AAP); Roberta Petrucci, Médecins Sans Frontières (MSF) International, Switzerland; Nalini
Singhal, International Paediatric Association (IPA); Karen Walker, Councill of International Neonatal
Nurses (COINN); Steve Wall, Save the Children


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Nurses (COINN); Steve Wall, Save the Children
Parent groups and organizations: Tasmin Bota (Preemie Connect), South Africa; Viviana Fernandez,
Fundación para Padres de Niños Prematuros (FUNDAPREMA), Costa Rica; Silke Mader, European
Foundation for the Care of Newborn Infants (EFCNI), Germany
United Nations organizations: Kim Dickson, Tedbabe Degefie Hailegebriel and Luwei Pearson (UNICEF);
Rajiv Bahl and Shuchita Gupta (WHO; served as the Secretariat for the working group); Mickey Chopra
(World Bank)
Specialized agencies/partnerships: Teesta Dey, Partnership for Maternal, Newborn and Child
Health (PMNCH)
vv


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vvviii
©WHO/Yoshi
Shimizu
International experts and scientists: Ebunoluwa Adejuyigbe, Obafemi Awolowo University, Ile-Ife,
Nigeria; Zulfiqar Bhutta, Centre for Global Child Health, Canada and Aga Khan University, Pakistan;
Harish Chellani, Vardhman Mahavir Medical College and Safdarjung Hospital, India; Nicholas Embleton,
neonatal paediatrician, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, United
Kingdom; Abiy Seifu Estifanos, School of Public Health of Addis Ababa University, Ethiopia; Joy Lawn,
LSHTM; Jan Lucas Ket, paediatrician and past director, Rotary International; Sarmila Mazumder,
Society for Applied Studies, India; Peter Waiswa, Makerere University School of Public Health,
Uganda; Dilys Walker, University of California, San Francisco, United States; Bjorn Westrup, Karolinska
Institutet, Sweden
Shuchita Gupta (WHO) led the writing of the document with substantial guidance and input to writing


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Shuchita Gupta (WHO) led the writing of the document with substantial guidance and input to writing
and review from Rajiv Bahl (WHO), Gary Darmstadt and Betty Kirkwood. Linda Vesel (consultant) helped
in preparing the first draft.
Members of the WHO STAGE for MNCAH&N provided input and reviewed and approved the final
document on their or their organization’s behalf. Many other stakeholders who participated in the
regular STAGE meetings and Anayda Portela (WHO) also provided valuable inputs on the content.
Health workers attending a mother with newborn in KMC at a hospital in Mongolia.
KKaannggaarroooo
mmootthheerr
ccaarree::
IImmpplleemmeennttaattiioonn
ssttrraatteeggyy


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Abbreviations
24/7 24 hours a day, seven days a week
CI confidence interval
DHIS2 a health management information platform (formerly known as
District Health Information Software 2)
ENAP Every Newborn Action Plan
HMIS health management information system
KMC kangaroo mother care
LBW low birth weight
MNCAH&N maternal, newborn, child and adolescent health and nutrition
SDG Sustainable Development Goal
STAGE WHO Strategic and Technical Advisory Group of Experts
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
WHO World Health Organization
vii


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Glossary
Every Newborn Action Every Newborn Action Plan (ENAP) is a global framework to end preventable
Plan (ENAP) maternal and newborn deaths and stillbirths. The plan sets an action and
measurement agenda for integration within national newborn health plans
based on the latest epidemiology, evidence, global and country learning. Led by
WHO and UNICEF, its preparation was guided by the advice of experts, partners,
and the outcome of several multistakeholder consultations. The final plan was
endorsed by 194 Member States at the 67th session of the World Health Assembly
in May 2014, who committed to put the recommended actions in practice. The
WHO Director-General has been requested to monitor progress towards the
achievement of the global targets and report periodically to the World Health
Assembly until 2030 (1).
Health management A health management information system is the system of routine data


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Health management A health management information system is the system of routine data
information system collection, processing, reporting, analysis and use in health-care facilities and
in the community. It provides essential information for national policy-makers,
district health managers, facility administrators and health workers across
health-system levels, serving as the backbone of national health service delivery
programmes (2).
Kangaroo mother care The care of preterm or low-birth-weight infants in continuous and prolonged
(KMC) (i.e. 8–24 hours per day, for as many hours as possible) skin-to-skin contact
initiated immediately after birth unless the newborn is critically sick, with
support for exclusive breastfeeding or breast-milk feeding (3). An additional
feature of KMC, when initiated in health-care facilities, is timely discharge from
the neonatal intensive or special care unit to a lower level of care within the


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the neonatal intensive or special care unit to a lower level of care within the
facility or at home, with continued skin-to-skin contact and close monitoring (4).
Low-birth-weight infant An infant who weighs less than 2500 g at birth, irrespective of gestational age.
Newborn mortality Death of a newborn in the first 28 days after birth. Reported as neonatal mortality
rate (i.e. newborn deaths in the first 28 days after birth per 1000 live births).
Preterm infant An infant who is born before 37 completed weeks of gestation.
Sick newborn A newborn who requires medical care.
Small and/or sick The package of facility-based, inpatient care for small and/or sick newborns
newborn care comprising interventions to deal with complications arising from preterm birth
and/or low birth weight, and neonatal infections (sepsis, meningitis, pneumonia
and those causing diarrhoea) (5).
viviiiii
Kangaroo
mother
care:
Implementation
strategy


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Small and/or sick
Type of care
newborn care (continued) Level Standards of care and evidence-based interventions
provided
Primary Essential Immediate newborn care (thorough drying, skin-to-skin contact
newborn of the newborn with the mother, delayed cord clamping, hygienic
care cord care); neonatal resuscitation (for those who need it); early
initiation and support for exclusive breastfeeding; routine care
(Vitamin K, eye care and vaccinations, weighing and clinical
examinations); prevention of mother-to-child transmission of HIV;
assessment, management and referral of bacterial infections,
jaundice and diarrhoea, feeding problems, birth defects and
other problems; pre-discharge advice on mother and baby care
and follow-up.
Secondary Special Thermal care; comfort and pain management; kangaroo mother
newborn care; assisted feeding for optimal nutrition (cup feeding and
care nasogastric feeding); safe administration of oxygen; prevention


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care nasogastric feeding); safe administration of oxygen; prevention
of apnoea; detection and management of neonatal infection;
detection and management of hypoglycaemia, jaundice,
anaemia and neonatal encephalopathy; seizure management;
safe administration of intravenous fluids; detection and referral
management of birth defects.
Transition to intensive care: continuous positive airway pressure;
exchange transfusion; detection and management of necrotizing
enterocolitis (NEC); specialized follow-up of infants at high risk
(including preterm).
Tertiary Intensive Advanced feeding support (e.g. parenteral nutrition); mechanical/
newborn assisted ventilation, including intubation; screening and
care treatment for retinopathy of prematurity; surfactant treatment;
investigation and management of birth defects; paediatric surgery;
genetic services.
WHO Strategic and An external advisory group of technical experts that provides strategic and


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WHO Strategic and An external advisory group of technical experts that provides strategic and
Technical Advisory Group technical advice to WHO on matters relating to maternal, newborn, child
of Experts (STAGE) for and adolescent health and nutrition. Its scope includes global priorities
Maternal, Newborn, Child and emerging issues for which policies, strategies, recommendations and
and Adolescent Health intervention packages should be developed or updated to help Member States
and Nutrition (MNCAH&N) in reaching relevant Sustainable Development Goal targets. The group reports
directly to the Director-General of WHO (6).
References for glossary
1. Every newborn: an action plan to end preventable deaths. Geneva: World Health Organization; 2014
(https://apps.who.int/iris/handle/10665/127938).
2. Every newborn progress report 2019. Geneva: World Health Organization and United Nations Children’s Fund (UNICEF); 2019


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(https://resourcecentre.savethechildren.net/document/every-newborn-progress-report-2019/, accessed 30 November 2022).
3. WHO recommendations on interventions to improve preterm birth outcomes. Geneva: World Health Organization; 2015
(https://apps.who.int/iris/handle/10665/183037).
4. Charpak N, Ruiz-Peláez JG, Figueroa de CZ, Charpak Y. Kangaroo mother versus traditional care for newborn infants ≤2000 grams:
a randomized, controlled trial. Pediatrics. 1997;100(4):682–8. doi:10.1542/peds.100.4.682
5. Survive and thrive: transforming care for every small and sick newborn. Geneva: World Health Organization; 2019
(https://apps.who.int/iris/handle/10665/326495)
6. Strategic and Technical Advisory Group of Experts (STAGE). Handbook on maternal, newborn, child, adolescent health & nutrition.
Geneva: World Health Organization; 2022 (https://cdn.who.int/media/docs/default-source/mca-documents/stage/stage-mncahn-
handbook-final.pdf, accessed 21 April 2023).
ix


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x
©Lund-Malmö
NIDCAP
Center/Stina
Klemming
1
Boy Laike was born five weeks preterm and very sick with hyperthyroidism, needing treatment for
many weeks. After initial short stabilization he had early KMC and his parents kept up continuous
skin-to-skin contact throughout his hospitalization. Lund-Malmö NIDCAP Center, Stockholm.


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Introduction
Global vision and position on kangaroo mother care
Kangaroo mother care (KMC) is the care of preterm or low-birth-weight (LBW) infants in continuous
and prolonged (i.e. 8–24 hours per day, for as many hours as possible) skin-to-skin contact starting
immediately after birth,a with support for exclusive breastfeeding or breast-milk feeding. An additional
feature of KMC, when initiated in health-care facilities, is timely discharge from the neonatal intensive
or special care unit to a lower level of care within the facility or at home, with continued skin-to-skin
contact and close monitoring (1,2).
The global Kangaroo Mother Care Working Group convened by the WHO Maternal, Newborn, Child and
Adolescent Health and Nutrition (MNCAH&N) Strategic and Technical Advisory Group of Experts (STAGE)
envisions that the mother and infant receive respectful care and are enabled to remain together from


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birth, irrespective of their clinical condition, unless either of them are critically sick. Every preterm
or LBW infant in low-, middle- and high-income settings should receive KMC immediately after birth
along with other essential evidence-based interventions to improve their survival, growth, health
and development.
The KMC Global Position Paper puts forward this vision and the joint position of the KMC Working Group
on implementing KMC as an integral component of small and/or sick newborn care within national
maternal, newborn and child health programmes (1,2). It emphasizes the importance of KMC for all
preterm (gestational age at birth < 37 weeks) or LBW (birth weight < 2.5 kg) infants, both well and sick
(1). It also highlights new evidence of its myriad benefits for infants, mothers and families, and calls for
global collaborative action to implement KMC at scale for global impact. It reinforces the unique value


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of KMC in humanizing the care of infants by providing cost-effective, high-quality care, regardless of
technological or resource gaps, empowering and building the confidence of mothers and caregivers to
lead the physical and emotional care of their infants, and improving the survival, health and well-being
of mothers and infants alike.
Achieving KMC implementation at scale requires:
• a system-wide perspective and structural changes to place mothers and infants at the centre of care
by keeping and caring for them together after birth;
• a commitment by political and programme leadership to implement KMC as the foundation of small
and/or sick newborn care;
• a dedicated budget for implementing KMC as part of small and/or sick newborn care in national
maternal, newborn and child health programmes; and
• developing and implementing a monitoring and evaluation framework to track progress.


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• developing and implementing a monitoring and evaluation framework to track progress.
a After initial care at birth for facility births, unless the infant is unable to breathe spontaneously even after resuscitation, is in
shock or requires mechanical ventilation; and immediately after birth for home births, unless the infant has any danger signs or
is below the country cut-off for gestational age or birth weight for admission to a newborn care unit.
1


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Implementing immediate KMC for small and/or sick newborns
is the optimal approach to save newborn lives in all settings.
It should not be seen as a low-resource strategy; indeed, it is
superior to current high-tech strategies (1).
Rationale for an implementation strategy for kangaroo
mother care scale-up
Coverage gap despite World Health Organization guidelines and national policies
There are few published studies on population-based coverage of KMC, but it is known that KMC
coverage is low worldwide, despite long-standing WHO guidelines, country-level policies, and
continued advocacy and efforts by global organizations. In 2019, only 32% of the 90 countries that
reported progress on the Every Newborn Action Plan (ENAP) had an updated policy or guideline on
KMC (3). Even in countries with policies or guidelines on KMC, these are often not translated into
programmatic implementation because of multiple implementation bottlenecks (4,5). Increases in


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programmatic implementation because of multiple implementation bottlenecks (4,5). Increases in
KMC coverage at national or subnational levels have been documented in only a few countries, with
diverse implementation approaches and encouraging but suboptimal results. For example, in the
Philippines, following a national-level scale-up effort starting in 2015, some 53% of preterm or LBW
infants (< 2000 g/< 36 weeks) received KMC in a sample of 45 hospitals in 2019 (6). In Bangladesh,
national efforts to scale up KMC starting in 2016 led to 22% of preterm or LBW infants (< 2000 g) in the
national dataset for KMC within the DHIS2 data platform receiving KMC in 2020 (7). Malawi developed
a national KMC policy and incorporated KMC into the Ministry of Health workplan and in its essential
health-care package for maternal and neonatal health in 2005–2006; yet in 2017, only 22% of potentially


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eligible infants were initiated on KMC nationally (8,9). Similarly, in Colombia, where KMC became part of
Government policy in 2009, approximately 63% of eligible babies had access to KMC in 2021 (10).
Variable understanding of the intervention and how to implement it
There is variability among different stakeholders in their understanding of the KMC intervention and
how to implement it. Studies implementing or evaluating KMC often either do not define it or the
definition varies in terms of components such as skin-to-skin contact alone or with support for exclusive
breastfeeding, as well as the number of hours of KMC per day required for effectiveness (11,12). The
mechanisms through which KMC has been introduced and scaled up in different country settings have
also varied, and governments have used different programmatic approaches for KMC implementation
(4,13,14). Health-care facilities at different levels of care provide KMC across countries, and there is


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variability in the practices, coverage, type, and quality of services and data availability and quality.
New evidence and guidelines are now available that facilitate consensus on the implementation
aspects of KMC. In addition, lessons learned and evidence are available on health system intervention
strategies that have successfully achieved high population coverage of continuous and prolonged
KMC (15,16). Having consensus on the implementation strategy adaptable to diverse country contexts
will help country programme managers and health workers to implement KMC for all preterm or LBW
infants at all levels of facility care and in the community.
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Opportunity to integrate with small and/or sick newborn care scale-up
KMC is a complex intervention, both as individual practice and as a programmatic component of
small and/or sick newborn care. On one hand, specific behaviours are required from the infant's
mother and family to carry and feed their preterm or LBW infant for a prolonged period. On the other
hand, the health system needs to be ready to provide essential clinical interventions and supportive
services that promote respectful and quality care for both mother and infant as a unit in one place, to
enable the mother and family to practise KMC. Thus, KMC implementation requires the co-location
of maternal and infant care so that mother and infant can remain together after birth, even when a
preterm or LBW infant is sick and needs care in a newborn special or intensive care unit. KMC calls for
close collaboration between paediatric and maternal care providers and promotes family involvement


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close collaboration between paediatric and maternal care providers and promotes family involvement
in maternal–newborn care, with the mother as the primary caregiver for her newborn, even when the
infant is preterm, LBW or sick. Thus, the KMC implementation strategy defines the fundamental model
for envisioning, redesigning and implementing optimal care of all preterm or LBW infants, both well
and sick, using KMC as the fulcrum.
With renewed interest and investment in the prioritization and scale-up of small and/or sick newborn
care in the past few years, there is a window of opportunity to emphasize and integrate the evidence-
based practice of KMC as the foundation for strengthening small and/or sick newborn care within
maternal, newborn and child health programmes (18,19). While the focus of small and/or sick newborn
care strengthening is likely to be at secondary or level-2 facilities, the renewed vision around KMC


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scale-up provides an opportunity to reorganize and strengthen service delivery for preterm or LBW
newborns at all levels of care.
Introduction 3
©WHO/PAHO.
Country:
Colombia


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Purpose of the implementation strategy
The purpose of developing the implementation strategy is to:
• guide countries in implementing KMC for all preterm or LBW infants, both well and sick, as the
foundation of small and/or sick newborn care at different levels of care in the facility and community,
according to their specific health system and cultural or social contexts;
• enunciate the programmatic principles for implementing KMC as an integral component of small
and/or sick newborn care and the ways and means to achieve them.
Audience for the implementation strategy
The KMC implementation strategy targets a broad audience. These include policy-makers and
programme managers at national, regional and local levels, government and nongovernmental
organizations working in the area of maternal and newborn care, global and national professional
associations, public and private hospital management at all levels of care, and facility- and community-
based maternal and infant care providers.


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based maternal and infant care providers.
Process of development of the implementation strategy
The preparation of the KMC implementation strategy was led by the World Health Organization, with
inputs from a designated KMC working group, convened by the WHO STAGE for MNCAH&N (20). (See
Acknowledgements for details of working group composition.)
In accordance with WHO procedures for declarations of interests (DOIs) (21), all external experts
acting in their individual capacity were asked to declare in writing any competing interests (whether
academic, financial or other) using the standard WHO DOI form. The WHO Secretariat reviewed all
DOI forms to determine whether any conflicts of interest existed. For this work, none of the experts
had any conflicts of interest that could pose any risk to the document development process or reduce
its credibility.
Independent, renowned global experts were appointed as chairs and WHO served as the Secretariat for


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Independent, renowned global experts were appointed as chairs and WHO served as the Secretariat for
the Working Group. Brainstorming sessions and online consultations were organized with all members
to develop the first draft, using the existing evidence syntheses available from the systematic reviews
commissioned for the WHO Guidelines for the care of preterm or LBW infants (1). New systematic
reviews were commissioned where required. The chairs and all the Working Group members reviewed
and provided their feedback on the outline and content of the draft document. Any differences in
opinion were discussed among the Working Group members in regular online group meetings.
Additional meetings were organized with individual members and the Working Group chairs to address
specific concerns when required. The aim of the meetings was to reach consensus on the contents,
including terminology and strategies.


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including terminology and strategies.
The secretariat collated feedback from all participants and finalized the content of the document.
Organizational nominees discussed the document within their organizations to provide their
organizations’ views and endorsement. The final adoption of the content of the document was done by
consensus, defined as full agreement among all Working Group members. The implementation strategy
was endorsed by all participating organizations and approved by the WHO STAGE for MNCAH&N, which
reports directly to the WHO Director-General.
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Introduction 5
©Lund-Malmö
NIDCAP
Center/Stina
Klemming
Persson Pettersen, born eight weeks preterm, in KMC with his mother. He was
inacontinuous KMC for his first week of life. Lund-Malmö NIDCAP Center, Stockholm.


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66
©Lund-Malmö
NIDCAP
Center/Stina
Klemming
2
Boy Rajai, born via caesarean section almost 12 weeks preterm, received
immediate skin-to-skin contact with the aunt (sister of the mother) since the father
could not make it from work in time. Lund-Malmö NIDCAP Center, Stockholm.


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The case for KMC
Saves lives, advances human capital
Rich evidence from diverse settings highlights the utility of KMC in helping preterm or LBW infants
to survive and thrive. The numerous benefits include: a 32% reduction in neonatal mortality; a 25%
reduction in mortality by six months of age; a 68% reduction in hypothermia at discharge or by 28
days after birth; a 15% reduction in severe infections or sepsis; a 48% increased duration of exclusive
breastfeeding at facility discharge, as well as improvements in growth (22). Thus, KMC directly
contributes to Sustainable Development Goals (SDG) target 3.2 to reduce neonatal mortality to at least
as low as 12 per 1000 live births and and under-five mortality to at least as low as 25 per 1000 live births
by 2030 (23).
Preterm or LBW infants are also at increased risk of adverse long-term outcomes. These include
increased risk of chronic diseases involving various organ systems, and neurodevelopmental and


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increased risk of chronic diseases involving various organ systems, and neurodevelopmental and
cognitive disorders persisting from childhood into adulthood or manifesting in adulthood, which can
substantially impact human capital and hence the economy of a country (24). Preventive interventions
for preterm birth are few at present and have limited impact. KMC not only improves survival but
also has long-lasting social and behavioural benefits. Preterm or LBW infants who received KMC
have reduced school absenteeism, hyperactivity, aggressiveness and externalization disorders. As
adults, they are more protective and nurturing parents, receive higher hourly wages, and are less
likely to engage in socio-deviant conduct (24). Twenty-year-olds who received KMC as infants also
had significantly larger brains and improved brain function (e.g. intelligence, attention, memory
and coordination) (25). Thus, KMC contributes to long-term health and well-being, and longer-term
human capital.


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human capital.
Humanizes care, empowers and benefits the mother
Well-intentioned designs of health systems and service delivery mechanisms have marginalized and
disempowered mothers from participating more actively in their own and their infant’s care, especially
when the infant is born preterm or with LBW and is sick. KMC allows the mother to take a central role in
her and her infant’s care, reversing the power imbalance between mothers and health-care providers
or health systems. It facilitates respectful maternal care and empowers new mothers as primary
care providers, even when an infant is preterm or LBW and sick. KMC builds mothers’ confidence
to care for their infants; enhances satisfaction with the quality of care provided to them and their
infant; and improves bonding and attachment (12,26–28). Additionally, it has several physiological
and psychological health benefits for mothers. Mothers who practise KMC have a 24% lower risk


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and psychological health benefits for mothers. Mothers who practise KMC have a 24% lower risk
of moderate to severe depressive symptoms with consistently lower scores related to postpartum
maternal stress and anxiety, and a trend towards better general psychosocial well-being (28). Studies
suggest that skin-to-skin contact immediately after birth may also decrease the duration of the third
stage of labour (29) and may reduce postpartum haemorrhage (30).
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Springboard to improve delivery of quality small and/
or sick newborn and maternal care
ENAP has proposed new coverage targets for small and/or sick newborn care for 2020–2025 (18). The
new global target is that 80% of countries should have a national implementation plan in place in at
least half of the country, with an adequate number of functional level-2 inpatient units linked to level-1
units for small and/or sick newborns, with family-centred care. The national and subnational targets
are that 80% of districts (or equivalent subnational units) should have at least one level-2 inpatient unit
to care for small and/or sick newborns, with respiratory support including the provision of continuous
positive airway pressure (18). Functional referral linkages from lower to higher levels of care are
also required.
It is envisaged that countries achieve this coverage with quality defined using WHO standards (31). The


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WHO standards for improving the quality of maternal and infant care in health-care facilities specify
that every woman and infant receive routine, evidence-based care and management of complications
during the postnatal period, according to WHO guidelines, with respect and preserving their dignity.
The standards further stipulate that preterm or LBW infants should stay with their mothers or carers,
with minimal separation, and receive KMC as soon as possible after birth. All mothers, carers or families
should be able to participate actively in their infant’s care, decision-making, exercising the right to
informed consent, and making choices in an environment where their socioeconomic, emotional and
cultural needs are respected and supported (31).
Evidence-based interventions for small and/or sick newborn care include KMC alongside other
interventions such as: assisted feeding; safe administration of oxygen; detection and management


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interventions such as: assisted feeding; safe administration of oxygen; detection and management
of neonatal infection, neonatal jaundice, neonatal encephalopathy and congenital abnormalities;
and management of preterm respiratory distress with continuous positive airway pressure (1,19). Any
well-equipped level-2 inpatient newborn care unit can provide all these interventions. However, the
experience of care for mothers and infants depends on keeping and caring for them together after
birth and ensuring family involvement in care (31). Therefore, enabling the mothers and infants to
remain together and caring for them as a unit in one place while practicing KMC from birth becomes
the default standard of care for preterm or LBW infants, even when they are sick. This model of care
allows high-quality medical care for the mother and infant while ensuring thermal protection, exclusive
breastfeeding, and improved interaction between mother or carer and infant, all of which contribute to


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nurturing neurodevelopmental care. Direct and active involvement of the father or partner and families
in maternal–newborn care also leads to better preparedness for discharge and opportunities for better
emotional and social support for the mother.
Hence, the scale-up of small and/or sick newborn care with KMC at its core will promote the
implementation of all essential quality parameters and help improve the delivery of quality maternal
and small and/or sick newborn care across all settings. However, it is important to note that KMC can be
implemented even by countries that do not have well-established small and/or sick newborn care. KMC
could be the tip of the spear for establishing small and/or sick newborn care in such settings.
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Cost-effective intervention plus long-term economic benefits
KMC is a highly cost-effective intervention; the cost of providing KMC in a health-care facility is lower
than that of conventional newborn care and it is more effective in improving short- and long-term
infant outcomes. The incremental cost–utility ratio of KMC compared with conventional care is
estimated to be US$ 1546 lower per extra quality-adjusted life year gained (32). The costs for successful
scale-up of KMC are also affordable. The total incremental cost of scaling up KMC (i.e. cost of KMC over
and above other small and/or sick newborn care) across a district was US$ 59 in Ethiopia and US$ 72 in
India per eligible infant in the population (33). The efficiencies of care, human resources and reduced
dependency on high-cost equipment achieved with immediate KMC could result in even higher cost–
effectiveness. KMC is also likely to result in long-term economic benefits owing to better long-term


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outcomes for infants and the restructuring of health systems for more efficient combined maternal and
infant service delivery. Therefore, while the implementation and scale up of KMC, especially immediate
KMC, will require dedicated investment at the start, it will yield a high return on this investment in time
to come.
Promotes sustainable development
Besides saving lives and contributing to enhanced human capital for a strengthened economy, KMC
promotes sustainable development in multiple ways.
KMC empowers the mother to take a central role in her infant’s care as the primary caregiver and is
fundamental to the SDG target 5.1 of ending all forms of discrimination against all women everywhere
to achieve gender equality and empower all women. It lays the foundation for the reorganization
of service delivery for maternal–newborn care that is people-centred and follows a primary health
care approach rather than relying on advanced technology and energy-heavy solutions such as


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care approach rather than relying on advanced technology and energy-heavy solutions such as
incubators and radiant warmers. Hence, it can also contribute to SDG target 7.3 to improve global
energy efficiency and ensure access to affordable, reliable, sustainable and modern energy by cutting
waste. Additionally, KMC calls for infrastructure modifications for the combined care of mother–infant
dyads by cross-disciplinary providers, through innovative design approaches that are likely to be more
efficient, sustainable and resilient. It ensures high-quality care for the mother–infant dyad at all levels
of health-care facilities and in the community, with attendant benefits of improving survival and long-
term health and development. Hence, delivered as part of universal health coverage, KMC will promote
SDG target 9.1 to develop quality, reliable, sustainable and resilient infrastructure to support economic


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development and human well-being, focused on affordable and equitable access for all.
The global efforts to scale up KMC with country buy-in are likely to promote multistakeholder
partnerships to mobilize and share knowledge, expertise, technology and financial resources for
achieving related SDGs in all countries, particularly developing countries (target 17.16). Monitoring and
evaluating KMC implementation will require strengthening existing health data systems, and ongoing
consultative and capacity-building processes for developing and measuring indicators for KMC and
small and/or sick newborn care.
KMC reduces infant deaths, improves maternal well-being and
parental experience of care, enhances human capital, promotes
sustainable development and is highly cost-effective (1).
The case for KMC 9


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New mothers with their infants at Felege
Hiwot Hospital in Bahir Dar, Ethiopia.
1100
©WHO/Blink
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Considerations for designing a
KMC implementation strategy
This section summarizes the findings from two systematic syntheses of literature for programmatic
actions and health system interventions that could promote high coverage, which guided the design of
the implementation strategy for KMC scale-up.
The first synthesis of grey literature identified reports of programmatic implementation of KMC, with
an objective to understand the population-based coverage of KMC, availability of KMC services at
national and subnational levels, programmatic approaches to scale, and health system actions that
may influence KMC scale-up (14) (Box 1). The findings of this review were supplemented with additional
structured searches of both grey and published literature to cover sources beyond the scope of this
review. The second review documented the findings from research studies evaluating health system
intervention strategies for KMC implementation that increase its coverage among preterm or LBW


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intervention strategies for KMC implementation that increase its coverage among preterm or LBW
infants conducted at various scales (16).
Lessons learned from national efforts to scale up KMC
Summary of lessons learned from programmatic implementation
Box 1.
of KMC at national or subnational levels
Eighteen countries (Bangladesh, Brazil, Colombia, Ethiopia, Ghana, India, Indonesia, Islamic
Republic of Iran, Malawi, Mali, Nepal, Nigeria, the Philippines, Rwanda, South Africa, Uganda,
the United Republic of Tanzania and Viet Nam) had information about the implementation
of KMC at national or subnational levels. National-level population-based KMC coverage was
available from only seven countries (Colombia, 63%; the Philippines, 53%; Ethiopia, 46%;
Bangladesh, 22%; Malawi, 22%; India, 13%; Viet Nam, 8%) and subnational-level coverage from
two countries (Rwanda, 58%; Mali, 41%). Information on the availability of KMC services was
scarce and fragmented, with no information on their quality.


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scarce and fragmented, with no information on their quality.
Countries for which information on KMC implementation was available shared common
health systems actions such as: KMC being part of national policy; recognition of KMC as a
priority newborn health intervention; strong advocacy by champions at all levels; dedicated
investments for KMC, in some cases covered by insurance; capacity-building and
motivation among health workers; dedicated space for KMC with equipment and
supplies; support for practising KMC; and data collection and use (14).
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Only a few countries have implemented KMC at a national or subnational scale. Until around 2012,
there was little movement towards implementing KMC on a large scale in most countries. While 28
countries that provided data for ENAP reported having an updated national policy or guideline on KMC
in 2019 (3), only a few have implemented it in programme settings. The grey literature synthesis found
information suggesting that only 18 countries implemented KMC at a national or subnational level (see
Box 1). There were few data on the programmatic implementation of KMC in high-income countries.
Information on the availability of KMC services is scarce and fragmented. There was little information
on the availability of KMC services at national or subnational levels, and the availability of services
closely reflect coverage. For example, KMC is provided in all departments of Colombia (2021) and


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closely reflect coverage. For example, KMC is provided in all departments of Colombia (2021) and
across 43% of national, regional and provincial hospitals in the Philippines (2019), both of which report
high coverage. In other countries that are expanding KMC services (e.g. Bangladesh, where KMC was
available across 108 sub-district health complexes and higher-level facilities in both urban and rural
areas in 2021), the coverage of KMC is increasing (34). However, it is also important to note that facilities
and hospitals reporting the provision of KMC services may not be ready to provide and sustain the
service due to a lack of staffing, guidelines, equipment and infrastructure, and other constraints. For
example, a 2014 assessment covering all 87 hospitals in the 22 districts of Malawi reported that, while
79% reported providing inpatient KMC service, only 67% met the basic readiness parameters in terms of
staff, space for KMC and a functional infant weighing scale (35).


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staff, space for KMC and a functional infant weighing scale (35).
There was little information on KMC scale-up in high-income countries. A policy survey around 2012 on
family involvement from eight European countries showed that even among the units offering so-called
kangaroo care (either skin-to-skin or not), not all responding units were offering skin-to-skin contact by
mothers or fathers or partners. While 90% of units in the Kingdom of the Netherlands and 89% of units
in Spain offered skin-to-skin contact by mothers, the figure was 78% for Denmark, 66% for Italy, 40%
for Belgium, 36% for France and 31% for the United Kingdom (36). Other reports from national surveys
in Italy and Spain provide slightly different figures for the proportion of level-3 neonatal intensive
care units that offer KMC: 71% in Spain (2018) (37) and 94% in Italy (2021) (38). This could be due to
differences in the responding units, definitions used for reporting, or the reporting period. However,


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even in these settings, restrictions to implementation were reported; for example, in most units in Italy,
KMC was limited to specific times.
KMC coverage estimates are lacking in most countries. Data on KMC coverage are lacking even from
countries that have implemented KMC at a national or subnational scale. National-level population-
based data on KMC coverage were available from only seven countries, as follows.
• In the Philippines, 53% of preterm or LBW infants (< 36 weeks or < 2000 g) received KMC in 2019,
based on 478 postpartum maternal interviews from a sample of 45 national and subnational
hospitals (6).
• In Colombia, KMC coverage data available from 24 cities/departments covering approximately 80%
of the population suggest KMC coverage is close to 60% for all surviving preterm or LBW infants (10).
• In Ethiopia, 46% of all LBW infants born in the 3804 health-care facilities providing delivery care
services in Ethiopia were initiated on KMC in 2016 (39).


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services in Ethiopia were initiated on KMC in 2016 (39).
• In Bangladesh, 6410 of the 64 426 (i.e. 10% of) infants weighing under 2000 g born over four years
(2016–2020) received KMC; the KMC coverage was approximately 22% in 2020 (34).
• In Malawi, 16 000 cases nationally were initiated on KMC in health-care facilities in 2017, an
estimated 21% of expected cases, assuming that 10% of all live births would need KMC (8,40).
However, a recent report suggests that fewer than 10% of preterm or LBW infants in Malawi received
facility-based KMC in 2021, according to data extracted from maternity reports within the DHIS2 (4).
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• In India, 50 959 of the 800 000 infants treated in special newborn care units (13.2%) received KMC
between 1 January 2015 and 31 July 2017, with the proportion varying from 0 to 31% between
states (41).
• In Viet Nam, according to routine national data from 2015, 5050 of 61 825 LBW infants received
KMC (8%), while data from 7 provincial hospitals implementing KMC showed that 2013 of 9153 LBW
infants received KMC (22%) in the same year (42).
Subnational (i.e. regional-, state- or district-level) data on KMC coverage were available from Mali and
Rwanda. In Mali, 41% of infants < 2500 g were initiated on KMC in three regions in October 2018 to
September 2019 (43). In Rwanda, facility-level KMC admission rates of LBW infants in 10 districts were
55%, 68%, 61% and 46%, respectively, for the four quarters in 2016 (44).
Only a handful of countries have included KMC indicators in their national health management


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Only a handful of countries have included KMC indicators in their national health management
information systems (HMIS), but the information collected is inadequate, and the reporting is
inconsistent. Even where the availability of KMC services has increased in terms of the number of
health-care facilities providing KMC services, such as in Malawi, coverage continues to be difficult to
estimate (4).
Programmatic actions for KMC implementation at scale. Table 1 presents the main programmatic
actions for KMC implementation in seven countries for which sufficient information was available on
large-scale KMC implementation efforts. The actions could have occurred at national or subnational
levels and are classified by health system building blocks. Countries for which information on KMC
implementation was available shared common health systems actions, such as: KMC being part of
national policy; recognition of KMC as a priority newborn health intervention and strong advocacy by


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champions at all levels; dedicated investments for KMC, in some cases covered by insurance; capacity-
building and motivation among health workers; dedicated space for KMC with equipment and supplies;
support for practising KMC; and data collection and use (14).
Considerations for designing a KMC implementation strategy 13
©WHO/PAHO.
Country:
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Table 1. Programmatic actions taken by countries that have made efforts towards
KMC implementation at scale classified by health system building blocks
Country
Health system Programmatic actions for
building block KMC implementation
Ban Bra Col Ind Mal Phil SA
Policy, governance Adoption of KMC in national or subnational
+ + + + + + +
and leadership policy and guidelines
Advocacy by champions (e.g. professional
organizations and political leaders) at national
+ + + + + +
and subnational levels and linkage with
international KMC networks
Recognition of the value of KMC as a priority
+ + + +
newborn health intervention
Utilization of service readiness surveys or
situational analyses to inform the planning + +
of scale-up
Target setting for KMC coverage + +a
Health system Dedicated funding/investments for KMC from
+ + + + + + +
financing government and/or donors
Inclusion of KMC as an essential maternal
and newborn health service covered under + + + + +
insurance (partially or fully)


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and newborn health service covered under + + + + +
insurance (partially or fully)
Health workforce Capacity-building of health workforce
including pre-service and in-service training + + + + + + +
and sensitization on KMC
Motivation of staff and creating a network of
+ + + +
health-care professionals
Facility staff serving as champions and
+ + +
motivators
Health service Integration of KMC into small and/or sick
delivery newborn care, comprehensive newborn care, + + + + +
and/or maternal and newborn care packages
Provision of family-centred care + + + + + +
Clarity about KMC and its practice (e.g.
protocols, counselling board, tools, job aids) + + + + +
at each levels of care
Centres of excellence and/or champions for
KMC in tertiary and secondary level facilities + + + + +
(i.e. coaches to train others)
Continuity of care within the health system
and between the facility and community + + +
(including referral system)
Post-discharge follow-up at a health facility or
+ + + + +


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(including referral system)
Post-discharge follow-up at a health facility or
+ + + + +
in the community
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Country
Health system Programmatic actions for
building block KMC implementation
Ban Bra Col Ind Mal Phil SA
Health infrastructure Dedicated space for KMC with equipment and
+ + + + + +
and supplies supplies
Health management Monitoring KMC through HMIS using specific
+ + + +
information systems indicators
Creation of a data collection platform (not
national level) with specific indicators for + +
access and outcomes
Putting in place data management systems
for data use and sharing to ensure data quality + + +
and utilization of data for action
Capacity-building on data collection, analysis
+ +
and interpretation
Community Social and behaviour change communication
ownership and initiatives and community awareness building + + + +
partnership
Use and orientation of existing community
health workers and support groups for referral + +
and post-discharge follow-up
Engagement of community structures and
community health workers for community- +
based provision of KMC


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community health workers for community- +
based provision of KMC
Countries: Ban: Bangladesh; Bra: Brazil; Col: Colombia; Ind: India; Mal: Malawi; Phil: Philippines;
SA: South Africa.
Abbreviations: HMIS: health management information system; KMC: kangaroo mother care.
No information found in the documents
+ Found in a least one document
available for review
Source: Berg et al. (2023) (14); a Sumita Ghosh, Ministry of Health and Family Welfare, Government of India,
personal communication.
Considerations for designing a KMC implementation strategy 15


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It is of note that, in the same country, implementation success at subnational levels may vary,
depending on the prioritization of small and/or sick newborn care and various contextual,
geographical, social, economic and political factors beyond the health system building blocks.
India has advanced very rapidly with the programmatic implementation of KMC. Figure 1 shows the
key programmatic milestones that led to the scale-up of KMC as part of facility-based small and/or sick
newborn care in India.
Figure 1. KMC in India: programmatic milestones
KMC included in
India Newborn
Action Plan with National guidelines
coverage targets of on family All functional SNCU/
KMC Network of 75% by 2025 and participatory care NICUs are providing
India established 90% by 2030 released KMC services
1994 2003 2011 2014 2017 2018 2022
Guidelines to revise
existing SNCU
KMC included in layout to create
Operational
national guidelines additional space
guidelines for KMC


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Operational
national guidelines additional space
guidelines for KMC
KMC introduced for facility-based to accommodate
released
newborn care mother and baby
together
KMC: kangeroo mother care; NICU: neonatal intensive care unit; SNCU: special newborn care unit.
Source: developed in collaboration with the Government of India.
16
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Evidence from implementation research
The second review synthesizes evidence from research on health system intervention strategies for
KMC implementation that increase its coverage, irrespective of country income, facility or community
setting (16). Sixteen studies evaluated 15 health system intervention strategies for KMC implementation
applied in one or more building blocks and reported KMC coverage. Two studies implemented and
evaluated the same intervention package in two countries (Nepal and Uganda), resulting in two
publications. Two were community-based cluster randomized controlled trials, one was a mixed-
methods study done across the facility–community continuum, two were quality-improvement studies
(one facility- and one community-based), nine were uncontrolled before–after facility-based studies,
and two were national-level programmatic scale-ups. Thirteen studies were from lower-middle- or low-


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income country settings (Bangladesh, India, Ethiopia, Ghana, Nepal, Philippines, Uganda), and three
were from a high-income setting (United States of America).
Eight of the 16 studies achieved increased coverage, defined as an increase in KMC coverage by at
least 25% from baseline and final coverage of more than 50%, of which four also achieved skin-to-skin
contact of at least 8 h/day. On analysing the health system interventions applied by studies that did
or did not achieve high coverage (increase in KMC coverage by < 25% from baseline or final coverage
< 50%), the main lessons were as follows.
Breadth of health system interventions (i.e. number of health system building blocks in which
interventions were delivered). A higher proportion of studies that applied interventions across
more health system building blocks achieved increased coverage, with some variability. Of the 16
included studies:


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included studies:
• all three studies (100%) that applied interventions across five to six building blocks achieved
increased coverage;
• two of the four studies (50%) that applied interventions across three to four building blocks achieved
increased coverage;
• three of the nine studies (33%) that had interventions across one to two building blocks attained
increased coverage.
The studies that did not achieve increased coverage had interventions primarily focused on the health
workforce and service delivery, and were weak on leadership and governance, financing and health
information systems.
Intensity of health system interventions (i.e. how much and how well the interventions were
applied). Studies that included high-intensity intervention in at least one health system building block
were more likely to achieve increased KMC coverage than those that did not.
• All three studies (100%) that achieved increased KMC coverage along with mean skin-to-skin contact


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for at least 8 h/day had high-intensity interventions in at least one health system building block.
• Three of the five studies (60%) that achieved increased KMC coverage but where mean skin-to-skin
contact was fewer than 8 h/day or not reported had high-intensity interventions in at least one health
system building block.
• Three of the eight studies (38%) studies that did not achieve increased KMC coverage had high-
intensity interventions in at least one health system building block.
The review findings suggest that high-intensity interventions across multiple health system building
blocks should be used for equitable scale-up of KMC that achieves skin-to-skin contact for at least
8 h/day. The interventions should be integrated into small and/or sick newborn care and adapted to the
local context.
Considerations for designing a KMC implementation strategy 17


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Types of health system interventions (i.e. what interventions were applied). The types of interventions
implemented by the studies that achieved increased KMC coverage are summarized in Table 2 along
with some important barriers.
Table 2. Health systems barriers identified and interventions that were effective in
improving KMC coverage (16)
Health system Key interventions that were
Important barriers identified
building block effective in improving KMC coverage
Leadership and • Lack of priority and leadership support • High-level leadership engagement
governance or within the health system. (national/provincial/district policy-
policy • Policy changes not accompanied makers and programme managers
by system-based efforts to secure and facility leadership).
hospital introduction of KMC. KMC was • KMC-supportive policies (create
recommended in national guidelines conditions to enable mothers to be
but not practised in district and with their infants [i.e. by providing


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but not practised in district and with their infants [i.e. by providing
lower-level facilities. a bed, food, water, toilet, etc.];
• Male family members are not allowed allow the family to support the
inside wards to practise or support KMC. mother in providing KMC), and
regulations (incorporate KMC in
licensing standards for health-care
facilities and pre-service education
of doctors and nurses).
Health financing • No specifically allocated financial • Costs for establishing KMC wards,
resources to cover implementation costs human resources and running
of expanding infant care to include KMC costs are included in national and
for preterm or LBW infants within health- subnational plans and budgets.
care facilities; costs not included in local • Expanded health insurance to cover
government planning. care for small and/or sick infants.
Health workforce • Shortage of nursing staff leading to an • Adequate nursing staff with


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Health workforce • Shortage of nursing staff leading to an • Adequate nursing staff with
increased workload for the existing nurses; strengthened competency and
no dedicated KMC nurses and counsellors; motivation to support KMC.
resident doctors, interns and nurses not • Engagement of professional
oriented on practical aspects of KMC. organizations, KMC
• Nurses unable to spend time on KMC champions, maternal–neonatal
counselling due to frequent rotations and staff collaboration.
multiple tasks.
• Resource-limited setting with low doctor-
to-patient and nurse-to-patient ratios;
double the resources required in case
of twins; lack of confidence and training
of staff.
• Health-care staff, including nurses,
consider KMC inferior to incubator care;
staff reluctance to change old practices;
concerns about the safety of preterm or
LBW infants; fear of complications; and
fears about giving care responsibilities to
mothers and other caregivers.
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Health system Key interventions that were
Important barriers identified
building block effective in improving KMC coverage
Service delivery • Lack of counselling of mothers and • KMC wards with a conducive
relatives in labour wards, postnatal wards; environment (infrastructure,
consequently, no early initiation of KMC. support and counselling).
• Lack of interest from mothers and • Community engagement to
poor support from family; early promote KMC.
discharge demands. • Early identification and facilitated
referral of LBW infants.
Health • No documentation of KMC, lack of regular • Recording KMC (clinical registers)
information audit of KMC practices and documentation using KMC-specific indicators in
systems in registers. routine data systems.
• KMC registers not well maintained, data
entry not consistent.
Supplies • Non-availability of KMC bags and binders, • KMC beds, chairs and
shortage of KMC chairs and beds. garments/binders.
KMC: kangeroo mother care; LBW: low birth weight.


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KMC: kangeroo mother care; LBW: low birth weight.
Father providing KMC in Da Nang Hospital for
Women and Children, Da Nang, Viet Nam.
Considerations for designing a KMC implementation strategy 19
©WHO/Gato
Borrero


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Adebowale Seun, 32, providing skin-to-skin care to her preterm baby in the combined
maternal–newborn care unit, Obafemi Awolowo University Teaching Hospital, Ile-ife, Nigeria.
2200
©LD
Photography/Idowu
Olamide
4


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Guiding principles for KMC
implementation
Recognize the mother’s role as primary caregiver
Respecting, empowering and supporting mothers as primary caregivers is critical for successful KMC
implementation. Respectful maternity care is an essential prerequisite for quality infant care. Mothers’
trust in health-care providers and engagement in the care of their infants is often dependent on how
they are treated in the health-care facility after birth (26,27). A key component of respectful maternal
care is creating the best possible conditions for mothers to stay with their newborns, which is essential
for implementing immediate KMC. This involves keeping the mother and the infant together from
birth until facility discharge, even when the infant is preterm or LBW and sick or the mother herself
is sick, unless either the mother or infant is in a critical condition. It requires close collaboration and
coordination between maternal and infant health-care providers (45,46).


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coordination between maternal and infant health-care providers (45,46).
The WHO Immediate KMC Study Group has shown that it is possible to keep LBW infants (weighing at
least 1.0 kg, but less than 1.799 kg, requiring admission to the newborn care unit) with their mothers
immediately after birth, regardless of gestational age, type of delivery, or singleton or twin status. The
study started skin-to-skin contact for these infants at a median of 1.3 hours after birth, which decreased
infant mortality by 25% compared with conventional KMC (i.e. care in an incubator or by a radiant
warmer until their condition stabilized and KMC thereafter) (46). This was achieved by integrating
maternal and infant care starting in the labour room. A paediatrician remained in the delivery room
with the obstetrics team, particularly when a preterm or LBW infant was expected. If the preterm or LBW
infant required admission to the special or intensive care unit, skin-to-skin contact with the mother


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or surrogate was maintained during transfer, whenever possible. Mothers were asked to identify one
or two adult women who could act as surrogate providers of KMC immediately after birth for a few
hours until the mother could take over. The mother had a bed inside the infant care unit beside the
radiant warmer/incubator so she could stay with her infant on a 24 hours a day, seven days a week
(24/7) basis. The study called this new infrastructure a mother–newborn care unit, which would be a
place of combined care for both the mother and the infant. KMC (skin-to-skin contact and support for
breastfeeding or breast-milk feeding) was started within two hours after birth, and the mother–infant
dyad was cared for together in the mother–newborn care unit through close collaboration between
infant and maternal care providers.
Besides the infrastructural redesign to provide combined maternal–newborn care, health-care


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Besides the infrastructural redesign to provide combined maternal–newborn care, health-care
providers have a pivotal role in empowering and enabling mothers and families to be at the centre of
their infant’s care. It is critical that health-care providers gradually transfer the responsibility for the
care of the infant to the parent and do not take over. Health-care providers should take time to listen,
provide support respectfully and sensitively, and be cognizant of the existing power dynamic between
them and the mother, realizing the vulnerability of new mothers in the difficult first days of a preterm
or LBW infant’s life. As a result, mothers will gain the confidence and self-reliance needed to care for
their infants. KMC establishes parents as change agents for their infant’s care. However, they need an
enabling facility environment and resources, favourable staff attitudes and interactions, support with


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practising KMC, and information about KMC and their infant’s health to be able to practise it (47–50).
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Meet the needs of the mother
The mother is at the centre of KMC provision, so addressing her needs is critical. While mothers stay
with their preterm or LBW infants to practise KMC, they need adequate support to meet their own
physical and mental health needs within a conducive service delivery model. The mothers should
have access to basic amenities such as a toilet, bathroom, clean drinking water and hygienic food.
They should receive routine postnatal or necessary medical care for any special needs, counselling
and support for their mental well-being, and training and supervision to care for their infants and to
practise KMC.
Involving the father or partner and other family members in the mother’s and infant’s care with
adequate counselling and support is also crucial. Support from family members and friends facilitates
KMC practice. Support from family during their active participation in infant care will allow the


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KMC practice. Support from family during their active participation in infant care will allow the
mothers time for self-care and adequate rest while the infant can continue to receive continuous and
prolonged skin-to-skin contact. Peer support (e.g. information, motivation and mentorship on KMC to
new mothers from other community members) also facilitates maternal confidence, acceptance and
provision of KMC (47–50).
KMC benefits maternal mental health, however, mothers should have access to support services if they
face any issues, especially as the global prevalence of postpartum depression among mothers is high
(51–53). Many low- and middle-income countries will need to develop such support systems for effective
maternal–newborn care.
Implement KMC as the foundation of small and/or sick
newborn care
KMC is recommended for all preterm or LBW infants, whether they are well or are sick (1). It should be


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implemented as part of small and/or sick newborn care within maternal, newborn and child health
programmes rather than as a stand-alone intervention or programme. Thus, KMC adoption and
implementation must be scaled-up alongside other essential interventions for preterm or LBW infants.
KMC is recommended for all preterm or LBW infants whether
they are well or are sick. It should be provided at all levels
of facility care starting immediately after birth and in the
community for preterm or LBW newborns who do not need
admission to a newborn care unit (1).
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Stable preterm or LBW infants can readily be kept with their mothers in the maternity/postnatal wards
and receive immediate KMC. However, the risk of separation increases when either the infant or the
mother is sick and needs special or intensive care. For every preterm or LBW infant to receive KMC
immediately after birth, even when sick, it is imperative to first make sure that mothers and infants
are able to remain together after birth, even when one of them is sick. The current scenario in most
settings is that if the infant requires admission to the newborn care unit, the mother can only visit the
infant intermittently, for example for breastfeeding and KMC. The Immediate KMC study showed that
having the mother stay inside the newborn special or intensive care unit 24/7 achieved earlier initiation
and longer duration of skin-to-skin contact per day, unlike the approach in which the mother is merely


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a visitor to the newborn special or intensive care unit. Countries can use this or other innovative
arrangements to keep mothers and infants together. For example, if the mother is sick, especially if she
requires intensive care, the infant can be cared for and provided KMC by the father, partner or other
family members in the maternity ward or at home, until the mother recovers. If both infant and mother
are sick, the location and arrangements for care can be adapted to the specific setting/context to keep
the mother and infant together as much as possible. Several innovations in service design and delivery
to provide combined medical care to mothers and infants may be feasible and effective, for example
level-2 newborn care units with beds for mothers of admitted preterm or LBW infants, or common
special care areas for maternal and newborn care.
ENAP (2020–2025) has set a specific target for the availability of small and/or sick newborn care in at


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least 80% of districts in each country (18). Some low- and middle-income countries have already started
setting up new units at the district level, alongside strengthening small and/or sick newborn care,
while others are at an early stage of developing national plans and strategies. This offers a tremendous
opportunity to set up new units with the infrastructure and service delivery organized around the
combined care of mother and infant right from the start.
The integrated maternal–newborn service delivery model with increased participation of mothers,
fathers or partners and families might require a potentially higher investment at the start for building
new units or redesigning existing units. In the long run, however, it will increase the efficiency of care,
improve the quality and experience of care, improve long-term outcomes, and reduce health-care costs.
Elsa Samuelsson, born via caesarean section, received immediate


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Elsa Samuelsson, born via caesarean section, received immediate
skin-to-skin contact with the father until her mother arrived in the NICU,
when the mother took over. Lund-Malmö NIDCAP Center, Stockholm.
Guiding principles for KMC implementation 23
©Lund-Malmö
NIDCAP
Center/Stina
Klemming


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Deliver KMC at all levels of facility care and in the community
KMC should be provided at all levels of facility care and in the community for all preterm or LBW
infants, both well and sick. Figure 2 illustrates how to operationalize KMC within existing newborn care
packages at different levels of facility care and in the community. It also suggests when and where to
start KMC for preterm or LBW infants requiring different levels of care.
Figure 2. Guidance on KMC within ENAP levels of care and newborn care packages (19)
Preterm or LBW infants who need intensive care*
• Intensive newborn Initiate KMC immediately after birth and continue in newborn
care
intensive care unit, where the mother can stay with the • Special newborn care
newborn on a 24/7 basis.**
• Essential newborn care
(Plus provide KMC to other preterm or LBW infants who do not
• Postnatal care
need intensive care)
24
dna
larrefeR
level-yraitret
ytilicaf
Preterm or LBW infants who need special newborn care*


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24
dna
larrefeR
level-yraitret
ytilicaf
Preterm or LBW infants who need special newborn care*
Initiate KMC immediately after birth and continue in newborn
special care unit, where the mother can stay with the newborn
on a 24/7 basis.**
(Plus provide KMC to other preterm or LBW infants who do not
need special care)
ytilicaf
level-dnoceS
• Special newborn care
• Essential newborn care
• Postnatal care
KMC: kangaroo mother care; LBW: low birth weight.
* Unless the newborn is unable to breathe spontaneously even after resuscitation, is in shock, or requires
mechanical ventilation.
** If the mother is sick, father or partner or other family member could stay with the newborn on 24/7 basis till mother recovers.
There must be a functional referral system in place connecting care at various levels, as well as strong
linkages between the facility and the community, to ensure continuity of care. KMC could also be


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linkages between the facility and the community, to ensure continuity of care. KMC could also be
provided during transfer from home to newborn care unit, from one level of care to another, and from
newborn care unit to home after discharge.
level-tsriF
ytinummoC
ytilicaf
Preterm or LBW infants who do not need special newborn
• Essential newborn care care
• Postnatal care Initiate KMC immediately after birth in delivery room/postnatal
ward.**
Home births: preterm or LBW infants
Initiate KMC immediately after birth and refer those with
danger signs or below country threshold for low birth weight
• Essential newborn care
to hospital.
for home births
• Postnatal home visits
for mothers and
newborns Facility births: preterm or LBW infants after discharge
Continue KMC at home for all infants who received KMC in the
facility; initiate KMC if not already started in the facility.
In either case with close monitoring and follow up.
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Adapt implementation by country-income settings and
health system contexts
Countries may tailor this KMC implementation strategy to their health system contexts based on their
needs, priorities, service delivery models and available resources. The main implementation challenges
appear similar in low- and high-resource settings. A recent systematic review reported the main
limitations for KMC adoption in the United Kingdom to be a lack of national guidance and guidelines,
lack of coherent policies, and lack of routine training for health-care professionals and families to
improve their knowledge and confidence in practising KMC. Many neonatal care units are not fit for KMC
implementation owing to a lack of private spaces, reclining chairs, beds and other infrastructure that
facilitates KMC (54). Studies on KMC scale-up in low-resource settings in Ethiopia and India highlighted
the same limitations (15), and hence similar solutions may apply across countries or contexts.


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the same limitations (15), and hence similar solutions may apply across countries or contexts.
Even so, the service delivery models might differ by setting according to the health system’s structure
and capacity, both between countries and within the same country. In lower-resource settings, a higher
proportion of preterm or LBW infants may be delivered at home or discharged early after a facility birth;
community-initiated KMC might therefore need equal focus as immediate facility-initiated KMC. In
higher-resource settings – where it is exceptional for women to deliver in settings other than hospitals
– with the capacity to provide highly specialized care, greater focus will be required on post-discharge
follow up, with continued support for KMC at home alongside immediate initiation of KMC in facilities
with continued KMC till discharge.
Apart from the programmatic aspects, health-care providers in high-income settings have raised


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Apart from the programmatic aspects, health-care providers in high-income settings have raised
some practical considerations for KMC implementation. These include KMC practice by mothers after
caesarean section, difficult delivery, under the effect of anaesthetics or drugs or during sleep, and
ensuring a patent airway for preterm or LBW newborns. All the providers practicing KMC have faced
and easily addressed these issues by using a surrogate to provide KMC until the mother’s condition
improves or when she needs to rest, and by using a binder to secure the infant to the mother’s chest
and maintain a patent airway. None of the providers report an event of the infant falling out of bed or of
smothering (55).
The other issue raised by experts from high-income settings is a potential contradiction with safe
sleeping recommendations. Robust randomized controlled trials show that overall mortality is lower


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sleeping recommendations. Robust randomized controlled trials show that overall mortality is lower
among preterm or LBW infants who receive KMC compared with those who receive conventional care
(12,22). Moreover, in a recent large randomized controlled trial on immediate KMC, the proportion of
sudden deaths was lower among LBW infants who received immediate KMC compared with those who
received conventional care (1.0% versus 1.3%; relative risk 0.80, 95% CI 0.41–1.53) (46). The protective
effect of KMC for sudden deaths did not reach statistical significance due to low numbers, but it
provides assurance that KMC is unlikely to increase the baseline risk of sudden deaths.
The implementation strategy may be tailored to different
country-income settings and health system contexts based
on their needs, priorities and service-delivery models.
Guiding principles for KMC implementation 25


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26
©WHO/PAHO.
Country:
Colombia
Align with World Health Organization guidelines
Countries should provide KMC as part of a comprehensive package of essential, evidence-based
interventions or services for small and/or sick newborns.
The relevant guidelines that may be considered when planning KMC implementation include WHO
guidelines for the care of preterm or LBW infants (1), postnatal care of mothers and infants (56),
hospital care for children (57) and antenatal steroids (58). Other relevant guidelines for programmatic
implementation include WHO guidelines on health promotion interventions for maternal and infant
health (59). These include the involvement of fathers or partners and other family members, which is
critical for KMC because it allows the mother time to rest and for her own care, while allowing the father
or partner and other family members to participate in the care of the infant. Another recommendation


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is to allow a companion of choice during labour. The labour companion could support the mother in
initiating KMC in the labour room and continue it until after discharge. Similarly, the recommendation
on partnership with traditional birth attendants provides an opportunity to start KMC immediately
after birth for preterm or LBW infants born at home who do not require admission to a newborn unit
(59). Community participation in quality-improvement processes and programme planning and
implementation could increase buy-in at the community level for KMC initiation and continuation, and
help remove the stigma around preterm birth.
Additionally, WHO’s human resource strategies to improve newborn care in health-care facilities
in low- and middle-income countries include guidelines for improving and standardizing neonatal
care training for existing health workers, of which KMC is a part (60). Additionally, role optimization


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guidelines recommend that lay health workers can promote KMC for LBW infants, while auxiliary
nurses and midwives may support the initiation and maintenance of KMC (61). However, new evidence
suggests that if provided with proper training, community health workers can successfully educate and
support mothers in initiating and practicing KMC at home (62,63).
We urge countries to constantly update their maternal–newborn care packages in line with the latest
evidence-based guidelines and provide KMC as part of these packages for optimal outcomes.
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General programmatic principles
Equity and access. Countries should consider approaches to ensure that all mothers and infants have
access to essential health services, including KMC. Some strategies that may improve service access
or utilization, especially among the poor, include: free medical care or health insurance for pregnant
women and their preterm or LBW infants through national health programmes (64,65); no or reduced
user charges (66); additional days of leave from work and additional financial payments to address the
special needs of mothers, fathers or partners and other primary caregivers of preterm or LBW infants
(1), improving geographical access to maternal and newborn care units, including rural and hard-to-
reach areas (67–69); and community-based health worker programmes in which these workers are
part of the care delivery team, have been recruited, paid and supported to ensure long-term retention,


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are adequately trained, linked to the health system and have a manageable scope of work (70–72).
Policy-makers should consider quantifying inequalities in service coverage as a function of several risk
factors to identify left-behind populations who might benefit from targeted policy or programmatic
interventions (73).
Fragility and emergencies. The Roadmap to accelerate progress for every newborn in humanitarian
settings 2020–2024 outlines the delivery of appropriate care for small and/or sick newborns and
the strengthening of care for the mother–infant dyad by expanding access to dignified and quality
care during pregnancy, delivery, and postpartum as two of the 10 key action areas (74). The existing
humanitarian health service delivery guidelines and minimum standards in humanitarian response
could incorporate guidance on operationalizing KMC as part of small and/or sick newborn care in
such settings (75,76). Besides these approaches, specific interventions such as multistakeholder


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such settings (75,76). Besides these approaches, specific interventions such as multistakeholder
collaboration, introducing new technology or systems innovations, and staff training can also facilitate
the implementation of KMC as part of small and/or sick newborn care in such settings (77).
Value and ownership. Promoting and ensuring ownership of KMC at national and subnational levels
in public and private facilities and in the community is a complex process that needs contextualization.
The process is likely to be facilitated by enabling health systems to routinely track health outcomes,
including quality and patient-reported outcomes in relation to costs. Patients may perceive increased
value in health services if they are engaged in the service design, delivery and monitoring, and
perceive that these focus on their preferences, comfort and convenience (78). Health-care providers
can be encouraged to strive towards patient-centred service provision through educational activities,


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behaviour change communication and service delivery innovations that improve efficiency and reduce
workload. Private sector engagement will require strategic planning, particularly in settings where it
caters substantially to health care. Some options could be to include KMC promotion for all preterm
or LBW infants as part of small and/or sick newborn care as a licensing standard and/or accreditation
criterion for health-care facilities (79) and include KMC in the health insurance reimbursement packages
for newborn care.
Sustainability and accountability. Essential health interventions and services for preterm or LBW
infants, including KMC, should have separate, non-negotiable budget heads in the financial planning
and budgeting for health at national, subnational and facility levels. Governments and administrators
should earmark these services as critical to the population’s health so that their budget is not diverted


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to other services in emergencies such as the coronavirus disease 2019 (COVID-19) pandemic (80).
Bringing such services under universal health coverage will help ensure long-term sustainability. There
is little evidence on how to ensure accountability in health systems. Stakeholders at different levels
can foster a culture of accountability by making learning and development a continuous process,
increasing collaboration and coordination across all levels of care, and leveraging regular monitoring
for improving performance, with supportive supervision and feedback mechanisms.
Guiding principles for KMC implementation 27


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Father practices skin-to-skin contact with his LBW newborn in the KMC
ward of Dr Jose Fabella Memorial Hospital, Manila, the Philippines.
Broad partnerships. A commitment to work together to support country-led implementation efforts
by diverse partners through existing and new alliances can maximize the programmatic impact of
KMC. The many successful examples of such partnerships include: private–public partnerships for
primary health care to facilitate access to health services, especially in remote areas (81); integration
of services across different levels and types of care (82); collaborations between in-country research
institutions; coordination between local health departments and implementing partners, such as
the global small and/or sick newborn care Community of Practice and Every Newborn network; and
scale-up of initiatives such as the Baby Friendly Hospital Initiative and respectful maternity care. As a


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core component of family-centred care, partnerships between professional organizations in obstetrics,
paediatrics, nursing and midwifery, and collaborations between these professional cadres, and mothers
and families are instrumental in KMC implementation (83,84).
Systems and integration. Health services should respond to the needs of all mothers and infants and
deliver quality essential maternal and newborn care services, including KMC, at all levels of facility care
and in the community. The broad framework of implementing KMC at different levels of care
(see Fig. 2, under “Considerations for designing a KMC implementation strategy”) serves as the basis
for designing integrated systems and services. Health systems should be easy for parents and families
to navigate and should strive towards standardized care delivery at different levels. This can be done by
clearly identifying the roles and responsibilities in interprofessional teams (e.g. for infant and maternal


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health teams within a facility), defining care pathways (e.g. to which facility a community health worker
should refer a preterm or LBW infant born at home), and using shared protocols and decision-making
tools for a smooth transition of patients with continuity of care (e.g. for a referral from a lower- to a
higher-level facility) (85,86).
The health information system should also be designed so that patient information (clinical,
registration and scheduling, etc.) is accessible across the different health-system levels to facilitate
seamless communication between care providers (e.g. through recording of community KMC in
home-based records).
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Evidence-based and data-driven. Governments should undertake a situation analysis of small and/
or sick newborn care in their country and use existing data and evidence to decide changes to the
infrastructure and service design and delivery for programmatic implementation of KMC within
maternal, newborn and child health programmes. Implementation research with social and behavioural
components can generate the necessary evidence to drive continual improvement in national
implementation and scale-up with quality (87). Governments should actively support, strengthen and
utilize a network of local researchers who can examine the programme data and highlight the gaps,
know about the evidence-based informed approaches for improvement, and may undertake research
to address local context-specific issues where required.
Research and innovation. Implementation research can identify and address context-specific


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Research and innovation. Implementation research can identify and address context-specific
challenges and fill the know-do gap in real-world settings to improve maternal and infant health,
inform policy design and implementation, strengthen health service delivery, and empower
communities and beneficiaries (88). Innovations in the design and delivery of services can improve the
care for preterm or LBW infants and their mothers at various levels of care to meet their health and care
needs, enhance the experience of care for parents and families, and achieve better outcomes in diverse
contexts. Such innovations facilitate the creation of new value propositions that expand the previous
technology-driven focus towards a human-centred and co-creative one (89–91). Ongoing research
efforts – such as service readiness, quality- and experience-of-care surveys, situational analyses,
priority-setting discussions, stakeholder workshops and community acceptability studies – can help


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priority-setting discussions, stakeholder workshops and community acceptability studies – can help
refine implementation and allow for sociocultural adaptations, and should be part of the routine health
systems evaluation.
Tsehayensh, 25, holds her LBW baby wrapped closely to her chest to provide skin-to-
skin contact, an integral part of KMC, at Felege Hiwot Hospital in Bahir Dar, Ethiopia.
Guiding principles for KMC implementation 29
©WHO/Blink
Media
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Hilina
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Twins Hertzberg, born just over eight weeks preterm, in immediate
and continuous KMC, Lund-Malmö NIDCAP Center, Stockholm.
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Implementation strategy to
achieve scale-up
Engage political leadership and develop KMC-supportive
policies with a national KMC implementation plan
National political leaderships' commitment and engagement, supportive policies, legal or regulatory
framework, and a national plan or strategy for implementing KMC alongside the scale-up and
strengthening of small and/or sick newborn care are critical to the successful implementation and
scaling up of KMC.
The political leadership should recognize KMC as an instrument to restructure health systems and
reorganize maternal–newborn service delivery to enhance efficiency and improve survival, health,
well-being, and long-term human capital – yielding a high return on investment and benefitting the
overall economy. They should include KMC as part of universal health coverage and create a supportive
policy and regulatory environment for implementing KMC at national and subnational levels in both


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policy and regulatory environment for implementing KMC at national and subnational levels in both
public and private health sectors. Maternal–newborn care policies should be updated to include KMC in
the pre-service curricula of all health-care providers, national licensure examinations, health insurance
packages for maternal–newborn care, and licensing standards for health-care facilities. Governments
should develop a national plan for implementing KMC at all levels of facility care and in the community,
with provision for combined, respectful care of the mother–infant dyad and active participation of
families, even when the infant is preterm or LBW and sick.
The plan should include KMC for all preterm or LBW infants as a fundamental intervention during the
scale-up and strengthening of small and/or sick newborn care. The plan should also set achievable and
time-bound goals and targets for coverage and quality of KMC implementation and scale-up as part of


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time-bound goals and targets for coverage and quality of KMC implementation and scale-up as part of
small and/or sick newborn care at national and subnational levels.
Political leadership should recognize KMC as an instrument to
restructure health systems and reorganize maternal–newborn
service delivery for improved maternal and newborn health
outcomes, and provide long-term benefits for the economy and
human capital.
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Ensure adequate and sustainable financing
Political leaderships' commitment to KMC implementation must accompany financial commitment
reflected in national and subnational budgets for maternal, newborn and child health programmes
through dedicated provisions for the implementation and scale-up of KMC as the foundation of small
and/or sick newborn care. The finance ministry or departments should be involved in the planning,
along with maternal, newborn and child health programme managers from the ministry of health.
The main budget item will be the costs for infrastructure redesign for combined respectful care of the
mother–infant dyad with the involvement of families, and essential care interventions for all preterm
or LBW infants (e.g. infection prevention and continuous positive airway pressure for those with
respiratory distress).
KMC for preterm or LBW infants who are sick will require infrastructure arrangements in the newborn


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KMC for preterm or LBW infants who are sick will require infrastructure arrangements in the newborn
care units to allow the mother, if she is well, to stay with the infant. These will include a bed beside the
newborn warmer/incubator, a toilet and bathroom attached to the unit, and other basic amenities such
as clean drinking water, and food. Spaces for boiling utensils used for expressed breast-milk feeding
(e.g. paladai, cup/spoon) and maternal examination for postnatal problems may also be required. KMC
for preterm or LBW infants will require arrangements for the mother’s privacy, expressing breast-milk,
KMC beds and chairs, and other amenities specified above.
Other budget items include human resources and costs for in-service training, running costs for
maintenance and consumables, and regular programme monitoring for quality and coverage.
Governments should allocate resources for KMC implementation at all levels of facility care and in the


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community, and use appropriate tracking mechanisms to ensure accountability.
Budgetary considerations should also include removing the financial barriers to access, especially for
the poor, and covering families’ expenditures on care, especially in settings where the private sector is
dominant. Governments could consider different health finance and protection schemes and insurance
mechanisms to cover the costs (expense) of care by the family. For example, the Philippines expanded
the benefits under the existing packages for mothers and infants to cover comprehensive services for
preterm or LBW infants, including KMC (92). Many countries, such as Austria, Colombia, Germany, Haiti,
India and Luxembourg also provide extended maternity and paternity leave in case of preterm or LBW
birth, and other countries may consider adopting this policy too (1).
Governments should commit dedicated financial resources for
the implementation of KMC including immediate KMC as the


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the implementation of KMC including immediate KMC as the
foundation of small and/or sick newborn care within national
and subnational budgets for maternal, newborn and child health
programmes. Appropriate monitoring and tracking mechanisms
should be used to ensure accountability.
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Domestic financial support for KMC implementation will be crucial to its sustainability. However,
most low- and lower-middle-income countries may achieve adequate financing for KMC only through
combined government funds and external investments by donors and partners. Governments in
resource-restricted settings should reach out to donors, development and implementation partners,
and United Nations agencies, and seek investment to support the domestic efforts to establish,
strengthen and scale up small and/or sick newborn care services with KMC. The sources and amounts
of funds may vary by context. For example, Grand Challenges Canada supported the Government of
Cameroon in scaling up KMC across five regions through a development impact bond (93), and the
Global Financing Facility in collaboration with Laerdal Global Health, a Norwegian non-profit-making
company, supported the scale-up of KMC in four regions of Ethiopia (94). While sources and amounts


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company, supported the scale-up of KMC in four regions of Ethiopia (94). While sources and amounts
of funds may vary, sustainable financing for KMC will require countries to mobilize and effectively
manage resources to support and develop priority interventions around special newborn care, while
demonstrating accountability and quality results.
Increase availability, capacity and motivation of
health-care providers
Health-care providers are key to implementing KMC in all settings. The national KMC implementation
plan and budget must provide for sufficient numbers of health workers of different cadres (e.g. doctors,
nurses, midwives and community health workers) to achieve high coverage of KMC in health-care
facilities and communities. Governments should plan for adequate capacity-strengthening of all health-
care providers in small and/or sick newborn care with KMC for all preterm or LBW infants by including


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it in pre-service education and in-service training and by providing on-the-job support and supportive
supervision. The education and training should encompass: counselling and communication skills to
support mothers, fathers or partners and families; lactation support; promoting family participation;
ensuring smooth discharge planning and transition to home, including follow-up home visits, and
supporting maternal mental health as core components alongside KMC practice and quality preterm or
LBW infant care.
Besides having adequate numbers of health workers who are well educated and trained in KMC, it
is vital that they accept, promote and practise KMC as the standard of care for all preterm or LBW
infants, both well and sick. Governments should engage professional organizations to accept, endorse,
promote and implement a policy to keep and care for the mother and infant together after birth, with


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immediate, continuous and prolonged KMC as the standard of care for all preterm or LBW infants,
both well and sick. Specialists (paediatricians, neonatologists, obstetrician–gynaecologists), general
practitioners, nurses and midwives should lead by example by demonstrating a change in practice.
They can be KMC champions and work to develop and sustain the motivation and momentum of the
health workforce through evidence sharing, continuous medical education and other mechanisms.
At the facility level, it is essential to have an interprofessional team engaged in ongoing educational
activities with hands-on training, regular refresher courses and supportive supervision. Facility
administrators should avoid rotating KMC-skilled staff to other areas. In the community, the outreach
or community health workers will require intensive training in skin-to-skin contact and lactation
counselling with hands-on practice in health-care facilities that implement KMC to support mothers,


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counselling with hands-on practice in health-care facilities that implement KMC to support mothers,
fathers or partners and families in initiating and continuing KMC at home. A network of health-care
professionals and community health workers can promote capacity-building and cross-learning.
The human resource strategy should align with the need for
operationalizing KMC at all levels of health care in facilities and
in the community, including plans for capacity-building in small
and/or sick newborn care and KMC.
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Reorganize service delivery to fulfil the needs of mothers and
infants simultaneously
Currently, in many countries, if a preterm or LBW infant does not require admission to a newborn care
unit,b the mother–infant dyad stays together in the postnatal ward. On the other hand, if the preterm
or LBW infant is below the country-specific gestational age or birth weight cut-off for admission to a
newborn care unit, or is sick, the infant is separated from the mother and kept in a special or intensive
care unit until the infant's clinical condition improves. The mother stays in the postnatal ward (or is
discharged) and visits the infant intermittently when advised. Fathers or partners and other family
members also visit the infant during limited, specified hours. Mothers, fathers or partners and families
are also usually not involved in the infant’s care. This service-delivery model is not in the best interests


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of either the infant or the mother. Mothers’, fathers’ or partners’, and families’ involvement in the routine
care of their infants is essential, as it improves their short- and long-term health and development
outcomes, and the overall care experience.
The services for mothers and infants should be combined at every level of care in the health system,
starting in the antenatal period. There is some evidence to show that breastfeeding counselling
interventions provided during both antenatal and postnatal periods are more effective in improving
breastfeeding outcomes than those provided during either of these periods alone (95). Similarly,
KMC could be introduced during antenatal counselling alongside nutrition, contraception, birth
preparedness, obstetric warning signs, etc. Now that WHO recommends that all preterm and LBW
infants receive KMC immediately after birth, more than 10% of all pregnant women are likely to benefit


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from antenatal counselling on KMC. It may also serve to increase overall provider and community
awareness and may help in generating demand and uptake. Integrated maternal and infant service
delivery should continue during labour, childbirth and in the postnatal period, including referral
transport, in-facility care or post-discharge follow-up.
National policies should call for collaboration between maternal and infant care providers and the
provision of all postnatal maternal and newborn services together in the same place. Programmes
should align maternal and infant health services even during post-discharge follow-up to ensure that
the mother receives support for her physical and mental health along with KMC at home. Guidance
for the delivery of services at various levels of care should be clear and consistent. Ensuring high-
quality service delivery through continuous improvement activities is paramount to enhancing parent


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quality service delivery through continuous improvement activities is paramount to enhancing parent
satisfaction and ensuring a positive experience for all involved.
b For example, if the newborn is above the country cut-off of gestational age or birth weight for admission to a newborn care unit
and does not have any clinical complications.
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©WHO/PAHO.
Country:
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Mothers and newborns should be kept together after birth, even
when the infant is sick and requires care inside the newborn
care unit. Both mother and newborn should receive respectful
care, together as a unit, in one place (17).
Upgrade infrastructure and design of maternal–newborn
care to create a conducive environment for KMC
A fundamental health system requirement for implementing KMC is to keep and care for the mother
and infant together after birth and allow the mother to take a central role in newborn care, supported
by the father or partner and other family members. National policies and implementation plans for
KMC should clearly and emphatically state this principle, and facility policies should be conducive for
its implementation. Facility policies, infrastructure, environment and services should enable mothers
and infants to remain together starting immediately after birth, irrespective of their clinical condition,


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unless critically ill. This necessitates a shared space where mothers and infants can be kept and cared
for together even when preterm or LBW infants require admission to a special or intensive care unit,
with all the facilities and equipment for their care. The maternal and newborn health-care providers
should collaborate to care for the mother and the infant together. This dedicated space should also
meet all the medical and other needs of the mother, including food, water and hygiene, alongside
the infant.
For a preterm or LBW infant who is otherwise well, countries could consider having a separate area in all
postnatal wards or assigning separate wards for these mother–infant dyads. For preterm or LBW infants
who require special or intensive care, countries will need to put some thought and work into deciding
the arrangements that may work in their contexts. A recent study that had mothers reside 24/7 with


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the arrangements that may work in their contexts. A recent study that had mothers reside 24/7 with
their LBW infants by placing their beds inside the newborn intensive care unit achieved early initiation
and longer duration of KMC (see Box 2). This or other innovative arrangements may be used when a
preterm or LBW infant requires special or intensive care.
Countries can set up new units that allow for combined maternal–newborn care with KMC, or redesign
existing units to do the same. Design innovations will be required to convert existing newborn units to
accommodate mothers inside the newborn care units while ensuring respectful medical and supportive
care for her; many designs and adaptations are possible in different settings. For example, maternal
waiting rooms adjacent to the newborn units may be combined into one large room with bed spaces
for mothers alongside radiant warmers/incubators with a central nursing station and attached toilet,


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bathroom and maternal examination area. Alternatively, when the mother requires medical care,
accommodation can be made to practise KMC in the maternal wards and provide newborn care with
KMC in those wards with provisions to accommodate family members as surrogates to support the
mother in doing KMC.
Once operationalized, keeping mothers and infants together may simplify infrastructure and service
delivery. In deciding to renovate existing structures or build new facilities, governments should
consider incorporating innovative design features that are environmentally sustainable, energy-
efficient, easy to use, comfortable and promote the well-being of mothers, families and health workers.
The commodities (including KMC beds, chairs and garments) for KMC care are low cost and can be
purchased locally or using bulk purchasing contracts. All items should be of good quality to ensure
the mother’s comfort and the infant’s safety, and adequate supplies should be available to ensure


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the mother’s comfort and the infant’s safety, and adequate supplies should be available to ensure
uninterrupted care.
Implementation strategy to achieve scale-up 35


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How were mothers and infants kept together in the
Box 2.
Immediate KMC study?
• A new newborn intensive care unit was designed with space for mother’s bed with
each infant; this space was called a mother–newborn care unit.
• Additional infrastructure included a toilet, bathing area, kitchenette and clinical examination
cubicle attached to the unit, for mothers.
• All other equipment and care for the infant was as in conventional newborn intensive
care units.
• Infants were moved from the labour room or operating theatre to the mother–newborn care
unit in the KMC position with the mother or a surrogate.
• Mother or surrogate provided continuous KMC until the mother was moved to the unit.
• Neonatal nurses provided essential maternal postnatal care after receiving training.
• Obstetricians took daily rounds for mothers in the mother–newborn care unit.
Source: WHO Immediate KMC Study Group et al. (2021) (46).
Develop robust data systems and use data for
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Develop robust data systems and use data for
quality improvement
Recording KMC and small and/or sick newborn care delivery and practices using specific indicators as
part of national routine health management information systems is vital for tracking and improving the
coverage and quality of these practices.
Facility-level data collection (e.g. paper-based, digital or a combination) and use are fundamental
to identifying problems early, triggering corrective actions, and supporting decision-making for
improving implementation. Home-based records and community-level data collection and use can help
monitor community-initiated KMC or the continuation of KMC after facility discharge.
Countries should develop a national-level monitoring and evaluation framework and incorporate a few
priority KMC indicators into their national health management information systems alongside other
indicators for small and/or sick newborn care. WHO has recently refined the KMC coverage indicator in


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line with the updated WHO guidelines for care of preterm or LBW infants; it is easily measurable from
registers and tally sheets, and validated in the Every Newborn Birth Indicators Research Tracking in
Hospitals (EN-BIRTH) multicountry validation study (96, 97). The numerator is the number of newborns
< 2500 g who are initiated on KMC (placed in skin-to-skin contact or kangaroo position) anywhere in
the facility, and the denominator is the number of admitted newborns (born in a hospital or referred
from elsewhere) with birth weight < 2500 g (Box 3). A few quality parameters – duration of KMC (daily
duration and the number of days), appropriate breast-milk feeding, and post-discharge care and follow-
up – have also been agreed upon (97).
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WHO/ENAP proposed indicator for measuring KMC coverage
Box 3.
at the facility level*
No. newborns < 2500 g initiated on kangaroo position
anywhere in the facility
KMC coverage =
No. admitted newborns with birth weight < 2500 g
* While simple and easy to measure in routine health systems, it may be confused with skin-to-skin contact
in first hour after birth, which is recommended for all newborns
Indicators related to other high-impact, evidence-based newborn care interventions were proposed
by the ENAP in 2014 (Table 3). Of the ten core indicators proposed to achieve the mortality and
coverage targets to end preventable newborn deaths and stillbirths, seven are relevant to small and/
or sick newborn care and KMC. However, only a few are currently being tracked as part of routine
health systems.
Table 3. ENAP core indicators of relevance for national monitoring for kangaroo mother
care and small and/or sick newborn care
Current status Type of indicator Core ENAP indicators


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care and small and/or sick newborn care
Current status Type of indicator Core ENAP indicators
Definitions are clear, Impact 1. Stillbirth rate
but quantity and 2. Maternal mortality ratio
consistency of data 3. Neonatal mortality rate*
are lacking
Contact point Coverage: 4. Skilled attendant at birth*
definitions clear, but care for all mothers 5. Early postnatal care for mothers and infants*
data on content of and infants 6. Essential newborn care (tracer is
care are lacking early breastfeeding)*
Gaps in coverage Coverage: 7. Antenatal corticosteroids use
definitions, and complications 8. Newborn resuscitation
requiring validation and extra care
9. Kangaroo mother care
and feasibility testing
for HMIS use • Coverage indicator has been defined
following validation work (2021)
• Service readiness indicator defined and
incorporated in health-care facility
assessment tools (2015)
10. Treatment of severe neonatal infections
* Already being measured.


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assessment tools (2015)
10. Treatment of severe neonatal infections
* Already being measured.
Indicators in purple are relevant to small and/or sick newborn care and KMC.
Source: Adapted from Moxon et al. (2014) (98).
Implementation strategy to achieve scale-up 37


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In 2015, the ENAP proposed an indicator for measuring service readiness for KMC at the national level,
defined as the number of facilities with a designated space for KMC and at least one staff member
who has received KMC training within the last two years (98). It is now incorporated into the relevant
large health-care facility assessment tools such as the Service Availability and Readiness Assessment,
Harmonized Health Facility Assessment (99,100), Service Provision Assessment Survey (101) and
Harmonized Health Facility Assessment (100,102). A KMC measurement framework has since been
developed with core indicators to track implementation and progress towards effective coverage of
facility-based KMC through a global consultative process (103). We have adapted these indicators to
align with the current recommendations (see Fig. 3).
Figure 3. Indicators for measuring facility-based KMC
National-level
Facility-level measurement
measurement
Identification KMC coverage Follow-up


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National-level
Facility-level measurement
measurement
Identification KMC coverage Follow-up
KMC service readiness of small in health-care support for
newborns facilities KMC at home
1. National policy 4. Percentage of infants 5. Percentage of 6. Percentage of
recommends KMC weighed at birth newborns weighing infants who received
2. Costed national < 2500 g initiated support for KMC in
implementation on KMC anywhere the community
plans for maternal– in the facility (WHO/
newborn health ENAP coverage
include KMC indicator, see Box 3)
3. Number and
percentage of
facilities with
operational
KMC (ENAP
process indicator)
ENAP: Every Newborn Action Plan; KMC: kangaroo mother care.
Source: Adapted from Guenther et al. (2017) (103).
Further work is required to agree on a clear framework with specific indicators aligned to the existing
recommendations on KMC and its measurement at national and subnational levels.


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recommendations on KMC and its measurement at national and subnational levels.
National coverage data are an essential step, but in due course these need to be linked to more detailed
data on quality of care, which is likely to require the development of a neonatal individually linked
data set covering KMC and also other small and/or sick newborn care parameters such as continuous
positive airway pressure, safe oxygen use, infection management, and enabling follow-up tracking.
Governments may also consider putting programme learning and quality assurance mechanisms in
place to identify issues with implementation and provide insights for actions to improve programme
implementation and performance.
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Create a functional network of care and improve
referral transport
Governments should not implement KMC in isolation. Optimal outcomes for preterm or LBW infants
require that essential small and/or sick newborn care services are available at all levels of care, with
functional linkages between them. Networks of care with a functional referral system can facilitate care
seeking and provision at the right level of care with reduced stress on the health system, health workers
and patients, decreased costs of care, and improved outcomes.
Emergency transportation support offered as part of a broader multicomponent intervention package
that included financial incentives, improved communication and community mobilization has been
shown to increase facility deliveries and reduce newborn mortality (104). Programmes could consider
such mechanisms to facilitate the timely transfer of small and/or sick newborns from a lower- to a


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such mechanisms to facilitate the timely transfer of small and/or sick newborns from a lower- to a
higher-level facility, while ensuring early initiation and continuation of KMC at different levels of care.
Follow-up linkages between facilities and communities also need to be strengthened for adequate
follow-up and support for KMC at home after discharge of the mother–infant dyad from the health-
care facility. Some approaches to promote these linkages could include community-based transport
initiatives (105,106), continuity of care (107,108) and mobile-health interventions (109).
KMC cannot be implemented in isolation and optimal outcomes
for preterm or LBW infants require that essential services for
small and/or sick newborn care are available at all levels of care,
with functional linkages between different levels of care.
Adebisi Adejoke, 41, with her baby in KMC position and the assisting nurses in the mother–


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Adebisi Adejoke, 41, with her baby in KMC position and the assisting nurses in the mother–
newborn care unit, Obafemi Awolowo University Teaching Hospital, Ile-ife, Nigeria.
Implementation strategy to achieve scale-up 39
©LD
Photography/Idowu
Olamide


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A father provides KMC for his premature baby at Setthathirath
Hospital, Vientiane, Lao Peopleʼs Democratic Republic.
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©WHO/Yoshi
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Operationalizing the
implementation strategy
National planning and coordination of KMC implementation
Governments should constitute a national technical advisory group to carry out national-level
planning and coordination of KMC implementation, ensuring broad stakeholder participation. This
advisory group should include programme leadership at national and subnational levels; professional
organizations and health-care professionals in paediatrics, obstetrics–gynaecology, nursing and
midwifery from public and private sectors; public health and research organizations; academia;
parent organizations and civil society representatives; and multilateral and bilateral development
partners such as WHO, UNICEF and USAID. This advisory committee will help countries to conduct
situation analyses of small and/or sick newborn care, including KMC for all preterm or LBW infants, and
contextualize implementation planning to the country. This process will include setting achievable


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contextualize implementation planning to the country. This process will include setting achievable
goals and timelines, developing or refining national and subnational implementation strategies
and operational plans and guidelines (including standards and protocols), and regular monitoring
and evaluation.
Besides establishing the national technical advisory group, governments should set up strategic
partnerships and collaborations with key stakeholders at national and subnational levels to create buy-
in for implementation and scale-up at all levels. Additionally, centres of excellence can be instrumental
in training and motivating staff and promoting the integration of KMC within existing initiatives and
programmes. A national resource centre can develop strategic, clinical and operational guidelines
and protocols and oversee the coordination, training and monitoring of KMC activities at national and


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subnational levels. Governments can mobilize resources for implementation by creating memoranda
of understanding with partners and donors, and combining global and private sector investments to
support local implementation efforts.
Governments will need to develop a human resource strategy to align with the need for
operationalizing KMC at all levels of health care in facilities and in the community, including plans for
capacity-building and training of both maternal and newborn health-care providers in small and/or
sick newborn care, including KMC. KMC should be included in the pre-service education curricula and
in-service education and training of health-care providers working in maternal and newborn health
areas. For existing health cadres, a KMC training plan will be required to create master trainers at
national and subnational levels to support continued training and refreshers. Professional associations


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in paediatrics, obstetrics–gynaecology, nursing and midwifery could facilitate continued in-service
training and hands-on practice of relevant health workers. Governments should also use different types
of mass communication approaches to create public awareness about KMC practice and its benefits.
Another critical action for governments is to operationalize a monitoring and evaluation system for
small and/or sick newborn care and KMC, including indicator(s) related to KMC as part of the routine
facility and community health information systems (HMIS, District Health Information Software,
and national surveys such as Demographic Health Surveys or Multiple Indicator Cluster Surveys).
Programme leadership should review the data regularly with the national technical advisory group and
provide feedback to the implementing teams and partners for mid-course corrections. Additionally,
they should work towards building and/or strengthening the capacity at the subnational and facility


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they should work towards building and/or strengthening the capacity at the subnational and facility
levels to use data to analyse gaps and make continuous quality improvements at the local level.
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Subnational-level planning and implementation
Subnational leadership plays a crucial role in the planning and implementation of KMC as the
foundation of small and/or sick newborn care, especially in a federal system of governance. Successful
implementation at the subnational level relies on: (1) proper use and allocation of regional/state
budgets; (2) development of standard operating procedures for operationalizing the implementation
strategy; (3) strengthening of service delivery at both facility and community levels; (4) ensuring
functional referral links between different levels of care and the community to facilitate timely referrals
and follow-up; (5) maintenance of a trained, multidisciplinary health workforce and capacity-building;
and (6) regular monitoring of implementation across all districts with follow-up action in areas
requiring improvement.
Subnational programme teams should be part of the national planning process. This involvement will


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Subnational programme teams should be part of the national planning process. This involvement will
help them understand the principles of implementing a service delivery model of maternal–newborn
care that ensures that mothers and their infants are kept and cared for together after birth in the same
place with KMC practice for all preterm and LBW infants, both well and sick. They must include a budget
for KMC activities in the district-level activity plans. They should provide strong leadership and engage
with facility administration and community processes to ensure commitment and buy-in by all local
stakeholders. Some facilities may be designated as centres of excellence for practising, training and
promotion of family-centred care, and can also serve as demonstration sites for best practices in small
and/or sick newborn care, including KMC for all preterm or LBW infants. The subsequent actions at the


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subnational level should focus on enabling health-care facilities to initiate KMC for all preterm or LBW
infants even when sick, and strengthening services across the continuum of care to support the early or
immediate initiation and continuation of KMC. These actions are summarized below.
Timely identification of preterm or low-birth-weight infants
Timely identification of preterm or LBW infants in facilities at all levels of care and in the community
is important for early initiation of KMC. This requires properly functioning digital weighing scales in
facilities for institutional births and with the community health workers for home births, training of
health workers for examining infants for the presence of any danger signs, and facilitating the referral of
preterm or LBW infants to an appropriate facility as per the country’s birth weight and gestational age
cut-off and other criteria (e.g. presence of specified danger signs) for admission to special or intensive


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newborn care units. KMC can be used during transport. Preterm or LBW infants born at home who do
not require admission to the newborn care unit may be initiated on KMC at home. Additionally, preterm
or LBW infants who could not be initiated on KMC in the facility after birth can also be initiated on KMC
at home after discharge.
Timely identification of preterm or LBW
infants in the facility and community is
important for early initiation of KMC.
42
Kangaroo
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Johnson Tolulope, 41, a surrogate KMC-mother providing KMC to her sisterʼs preterm baby in
the mother–newborn care unit, Obafemi Awolowo University Teaching Hospital, Ile-ife, Nigeria.
Facility-level actions
• Policies: The facility management should establish policies that facilitate keeping the mother and
infant together after birth and caring for them together as a unit in the same place, with means
for ensuring respectful care (medical care, beds, food and water, bathing, toilet, etc.) and KMC.
Additionally, fathers or partners and other family members should be allowed to visit the infant at
any time and be supported in practising KMC along with the mother.
• Infrastructure: Preterm or LBW infants requiring KMC may be well or sick. Those who are otherwise
well are usually cared for in the postnatal wards and arrangements can be made in these wards to
keep the mother and infant together, for example having a dedicated area for these mother–infant


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keep the mother and infant together, for example having a dedicated area for these mother–infant
dyads in the postnatal wards. For preterm or LBW infants who are sick and need to be cared for inside
a special or intensive care unit, a common limitation is that many units only allow mothers to visit
their infants intermittently to provide KMC. However, a recent study provided a bed for the mother
inside the special or intensive newborn care unit so that she could reside with the infant on a 24/7
basis and was no longer a visitor (46). This strategy achieved early initiation (more than two thirds of
infants put in skin-to-skin contact within two hours after birth) and a longer duration of KMC (almost
17 hours per day). This or other innovative arrangements should be used to ensure immediate,
prolonged and continuous KMC for all preterm or LBW infants, even when sick.
• Services: The maternal and newborn health service providers in the health-care facility should


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• Services: The maternal and newborn health service providers in the health-care facility should
collaborate to provide care to the mother–infant dyad together as a unit from birth to enable them
to remain together even when the infant is preterm or LBW and sick, and practise immediate KMC.
Additionally, the mother should be provided the required medical care, counselling and support
for her own and her infant’s care, with food and clean water, bathing and toilet facilities, etc., for
respectful care.
Operationalizing the implementation strategy 43
©LD
Photography/Idowu
Olamide


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• Health-care providers: It is important that health-care providers at all levels of the facility are
convinced of the advantages of keeping the mother and infant together from birth and caring for
them together in the same place with KMC as the standard of care, even when the infant is preterm
or LBW and sick. They should be trained to counsel and demonstrate KMC to the mother, father or
partner and other family members throughout the hospital stay; support them in carrying out KMC;
and monitor their progress. Similarly, community-based health-care providers should understand
the importance of initiating KMC at home for preterm or LBW infants who do not need referral to a
facility, and continuing KMC in the post-discharge period for infants born in and initiated on KMC
in facilities. They should also have adequate skills and confidence to support the mothers, fathers
or partners and other family members in doing KMC and timely identification of any danger signs


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or partners and other family members in doing KMC and timely identification of any danger signs
requiring referral to the hospital.
• Follow-up linkages: Appropriate follow-up linkages between lower- and higher-level facilities and
between hospital and home should be established or strengthened for early initiation of KMC and
continued KMC practice post-discharge. Health-care providers should ensure that mothers and
families are confident in taking care of their preterm or LBW infant, including providing KMC at
home, before they are discharged from the hospital. Adequate support should be provided for the
mother–infant dyad, father or partner and other family members in the community after discharge
to continue KMC; follow-up can be provided through telehealth, phone calls, home visits and/or
community-based health programmes or special high-risk programmes (if they already exist in the
country) depending on the country context.


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country) depending on the country context.
• Monitoring and continuous quality improvement: The delivery and uptake of KMC should be
regularly monitored to ensure accountability and to promote the delivery of effective KMC as a part
of ongoing quality improvement initiatives.
Measurement and monitoring of KMC implementation
To put the KMC indicator into practice in routine health systems, it is essential to ensure that
appropriate data elements are included in patient notes, registers and tally sheets in the facility or
hospital, for accurate and complete data availability. Home-based records are needed to document
KMC in the community.
High coverage of KMC can be achieved at the district level using context-adapted service-delivery
models based on a mechanism to identify challenges and test solutions across the facility–community
continuum (15). Optimizing implementation will also require planning and costing tools, including floor
plans and other aids at the district level.
44


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Figure 4. Theory of change
Mission statement: Global scale-up of KMC as foundation of small and/or sick newborn care under
universal health coverage (UHC)
Immediate KMC after birth with other life-saving interventions for all mothers and their preterm or
low-birth-weight infants globally
Global Position Paper and Implementation Strategy published with wide dissemination
Multistakeholder discussions at regional and country levels
Partnerships between government
and partners for implementation at
national and subnational levels
Activities Outputs Outcomes Impact
High-level national KMC in national Increased KMC Increased newborn
leadership engaged policy and coverage in facilities survival: newborn
programmes for preterm or LBW mortality rate ≤ 12
newborns per 1000 live births in
KMC budgeted in
all countries by 2030
national plans as part
achieved
of UHC
KMC provided in
postnatal wards and
Establish small and/or in small and/or sick
sick newborn care unit newborn care units


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Establish small and/or in small and/or sick
sick newborn care unit newborn care units
in every district with
policies and provisions
for mother to stay with
newborn on 24/7 basis
and immediate KMC
Include initiation and KMC initiated and High population-
continuation of KMC at continued at home based coverage of
home in community- KMC
based health
programmes or special
high-risk programmes
if they already exist in
the country
Include KMC indicators Data on KMC
in routine health implementation and
information systems quality is available
Continuously monitor
KMC coverage and
quality and take
corrective actions
Operationalizing the implementation strategy 45


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7
Mother doing KMC in the neonatal care unit of Da Nang
Hospital for Women and Children, Da Nang, Viet Nam.
4466
©WHO/Gato
Borrero


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Path forward
Implementation of KMC is central to achievement of the SDGs for the survival, health and well-being of
preterm or LBW infants, both well and sick, through its successful scale-up at all levels of facility care
and in the community. Based on the new evidence on successful scale-up of KMC in programmatic
settings from several countries, complemented by the joint wisdom and experience of global
stakeholders, this implementation strategy is intended to guide the way forward for universal coverage
of KMC for all preterm or LBW infants, both well and sick. This implementation strategy is meant to
inspire a renewed vision in which mothers and infants are kept and cared for together from birth, and
where parents and families play a central role in the care of their infants, thus humanizing health care
(Fig. 4).
KMC has been shown to be an essential intervention superior to standard radiant warmer/incubator


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KMC has been shown to be an essential intervention superior to standard radiant warmer/incubator
care in all settings. We hope that all countries, irrespective of their income setting and resource
availability, will adapt this strategy to their health system contexts to realize the full impact of KMC in
improving the survival, health and well-being of mothers and preterm or LBW infants alike.
KMC provides for humanized and cost-effective, yet high-quality
maternal and newborn care regardless of technological or
resource gaps. It empowers mothers to lead the physical and
emotional care of their infants, thus improving the health and
well-being of infants and mothers alike (1).
Girl Samuelsson, born almost 10 weeks preterm, in KMC
with her mother, Lund-Malmö NIDCAP Center, Stockholm.
47
©Lund-Malmö
NIDCAP
Center/Stina
Klemming


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Kangaroo
mother
care:
Implementation
strategy


