Kangaroo Mother Care (KMC), a low-tech option for stabilized premature babies where the tiny baby is swaddled skin-to-skin between its mother’s breasts instead of languishing in an incubator, can save many of these babies’ lives and improve their outcomes.
Premature birth is the leading cause of death of babies around the world. Of the 15 million babies born prematurely each year, around one million of them die, according to the World Health Organization (WHO). Of those that survive, many experience cognitive deficits and other problems such as lack of fine motor coordination, attention deficit disorder, poor hearing and vision – problems that often go unnoticed and/or untreated in developing countries.
Yet, despite many studies that point to the benefits of KMC, where the premature baby is swaddled to the mother, father or helper, often in a special stretch cotton or lycra carrier, fed only breast milk where possible, and sent home earlier but with strict year-long follow up, the method has yet to replace more expensive, high-tech options as a mainstream method of care, even – or especially – in places where incubators, baby warmers and other necessary equipment are often in short supply.
The question is why?
Experts point to several reasons why they believe the practice has been slow to catch on, even in poor countries where it could be so beneficial. A quest for hi-tech options, cultural resistance, a lack of scientific understanding and a failure of the imagination, are some of them.
But proponents of KMC are hopeful that recent findings, as well as new evidence on the developing brain, may trigger a sea change.
A recently-released study done in Colombia, where KMC originated 30 years ago due to a shortage of incubators, tracked down individuals 20 years after they were given KMC as premature babies.
According to pediatrician and lead researcher, Dr Nathalie Charpak, director of the Kangaroo Foundation in Bogotá, the findings, published in December 2016 in the journal Pediatrics, show that “Kangaroo Mother Care has significant, long-lasting social and behavioral protective effects 20 years after the intervention”.
The study found that the young adults given KMC were less likely to be aggressive, hyperactive or impulsive, and that they had bigger brains, than those in a comparison group that received traditional incubator care.
When the study was started in 1993, the death rate was twice as great in the comparison group. The study also showed that 20 years later, the KMC-raised babies had more supportive families, had performed better at work and school and were better adjusted socially. Although their IQs were only slightly higher than the comparison group, they had more brain matter in areas important for learning and storing information.
But doctors in hospitals in developing countries sometimes shun KMC as a “third rate” solution compared to the state-of-the-art incubators that wealthier hospitals can offer, says Charpak.
But in Africa, where 60% of women still give birth at home or an informal setting, despite the push to get them to deliver in healthcare facilities, and where incubators in hospitals are often broken and in short supply, premature babies run the risk of infection and death due to these equipment problems according to Dr Nancy Sloan, an epidemiologist who has researched KMC globally. What’s more, delays in getting newborns into hospital increases the risk, as most newborn deaths occur on the first day of life.
Given that KMC does not require expensive drugs or machines, it is no surprise that pharmaceutical or other corporate giants are not queuing up to fund studies. But global development goals in recent decades have galvanized energy around preventing baby deaths and the WHO has promoted and published guidelines on KMC since 2003 as part of a strategy to accomplish this. Many studies, backed by the Bill & Melinda Gates Foundation, the WHO and others, point to the clear benefits of KMC in survival rates and outcomes for premature and low-birth-weight babies.
Charpak is hopeful that the results of her study will help spread the message about the overwhelmingly positive benefits of KMC. Scandinavian countries have been pioneering the practice for years; there are big KMC movements in many other developed countries, including the US and Canada; and the method is being piloted in many developing countries around the world, including in some African countries. In South Africa, there are several successful KMC programs in operation.
But, despite what the studies find, including one in Cameroon shown to almost halve death rates of premature babies, resistance persists. Charpak notes that this is particularly evident in some northern countries on the continent.
“We have failed in countries like Algeria, Morocco and Egypt and I don’t know exactly why.”
She suspects, however, that fathers in these countries may balk at the bigger role that KMC requires of them in nurturing the newborn.
KMC takes human resource dedication to teach mothers and their families exactly how to practice it and to follow up the babies at home for months afterwards. It is not just about putting the baby on the mother and ‘saying bye bye’,” as Charpak puts it. Yet it is less expensive than high-tech interventions. She laments that the intensive, hands-on time required is off-putting to many mothers in countries like the US, for example, where pressure to get back to work as soon as possible is great.
While Charpak believes that KMC should only be started after a premature baby has first been stabilized in an incubator, another group of scientists is keen to show that immediate KMC, directly after birth, could save more babies and improve their outcomes too.
Dr Nils Bergman, a perinatal neuroscientist who has been championing KMC for decades, is heading up a large study in Nigeria, Ghana, Malawi, Tanzania and India, which is set to begin in a few months. Also funded by the Bill & Melinda Gates Foundation, the study on 5,000 premature babies hopes to show that “immediate KMC” directly after birth, even on unstable babies, can improve survival rates.
In Bergman’s view, the reason that KMC hasn’t been taken up more widely, despite clear evidence that shows its benefits, is because there has not been enough scientific knowledge to explain why it works.
His research on 128 Zimbabwean infants 20 years ago using immediate KMC showed not only a dramatic improvement in their survival rate (50% up from 10%), he says, but that the babies behaved differently.
“They suckled well, their skin had a different texture and they grew twice as fast. They opened their eyes and looked at you in a focused way. They were real human beings, not protoplasm lying in a box.”
Now, Bergman says, new studies in neuroscience and epigenetics actually show the toxic effects of stress on the developing brain.
“For all mammals, separation from the mother is the greatest stressor known,” he says. Immediate skin-to-skin contact between mother and baby, whether premature or not, is crucial for the baby’s brain development and bonding, he believes, and in his view, “the incubator is the primary cause of toxic stress”.
“Kangaroo Mother Care is not a Third World fix for infant mortality,” he says. “This is something that all babies around the world could benefit from.”
Bergman would like to show not only that immediate KMC increases the chances of survival but that it improves the quality of that survival. He hopes that more funding will become available for follow-up research on the infants on the study.
Sloan also backs the idea of KMC for all babies, particularly on a continent where most women still give birth at home. In the home or community setting, information crucial to determining whether a baby is premature or not – exactly how old the baby is and how much it weighs – is often not known, even when a baby is admitted to a hospital.
Also, women are sometimes stigmatized for giving birth to premature babies, and KMC for them only could stigmatize them further, she says.
Research shows clear benefits for both stabilized premature babies and for healthy babies, Sloan says, and there is no evidence that it causes harm.
“We need to start promoting universal KMC for every baby,” she says.