Key messages
Background
Methods
Conceptual framework considered for achieving high uptake of KMC
Study setting and population characteristics
Study team
Data collection
Household trials and developing a prototype intervention
Procedures for household trials
Barriers Reported | Feasible Solution(s) |
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For exclusive breastfeeding | |
Baby too weak to suck | Mothers counseled and demonstrated with hands on practice on feeding expressed breast milk |
Colostrum discarded; pre-lacteal feeds given; feel that baby needs water during summer | Counseled about benefits of feeding colostrum; exclusive breastfeeding and disadvantages of pre-lacteal feeding. Also counseled about adequacy of water content for the baby in breast milk |
Scanty milk flow soon after birth; inadequacy of breast milk, feels that baby should be given top milk | Explained to mothers that baby does not need milk in large volumes during the initial few days after birth and that frequent breastfeeding increases milk flow |
Inverted, small or cracked nipples; engorged breasts, breast abscess | Demonstration on use of syringe to pull out nipple; feed expressed breast milk till cracked nipple heals; mothers taught to practice hot fomentation and express breast milk; facilitated referral for treatment of breast abscess |
No milk secretion, mother severely ill | Lactation support provided. If mother severely ill, option of breast feeding by wet nurse suggested to the family. If not available, top milk advised with appropriate hygiene and preparation methods |
For continued skin-to-skin contact | |
Heat and humidity, especially during summers | Family counseled to use fan or cooler without exposing baby directly or use hand fans during power cuts. Water sprinkled on floor, floor mopped with cold water to reduce room temperature |
Lack of privacy | For single room homes, partition with cloth, plastic curtain or a vertically placed jute cot was used for privacy. In households with more than one room, mother moved to a separate room. |
Abdominal pain post delivery, postpartum fatigue, mother ill or too weak | Mother assisted to sit comfortably using pillow or soft clothes and change positions often (semi-reclining, supine) or give KMC while moving around. Family members counseled to help mother and to give adequate food to the mother. Mothers referred to health facility if unwell. If other family members not available, encouraged to call relatives or neighbours to help. |
Reluctance to wear front open clothes either due to cultural reasons or shyness | Long binders similar to shirts worn in the setting that cover the mother’s body, designed. Alternatively, mothers advised to wear husband’s shirts or night gown. |
Heat from mother’s abdomen gets transmitted to baby causing diarrhea or vomiting, concern that baby’s stomach would get pressed and cause vomiting | Counseled that heat from mother’s body is essential for a LBW baby who is unable to maintain own body temperature. Baby feels comfortable and secure when placed on mother’s body and the stomach does not get pressed in this position |
Concern regarding possibility of injuring umbilical stump and bleeding in SSC due to friction with mother’s skin | Family counseled and reassured that SSC position does not cause friction or injury to umbilical stump. |
Fear of neck deformity in baby if kept with head turned on one side, in the same position for long; difficulty in placing baby in SSC due to lack of neck control | Counseled that KMC position, if followed correctly, does not cause deformity; and baby’s neck is well supported and rests on mother’s breasts; |
SSC would be interrupted as the baby needs to be removed from SSC frequently to clean stool | Mothers demonstrated on how to clean the baby without removing from SSC position |
Concern that baby would not allow the mother to resume routine work after the period of rest is over due to excessive attachment | Counseled about the importance of doing KMC and its long term effect on baby’s growth and development. Also that KMC promotes healthy bonding rather than dependency. |
Fear that mother’s infections could pass on to the baby through sweat | Family counseled and assured that infections are not transmitted through sweat |
Refusal to undress the baby for KMC in winter; feared that the baby will catch cold | Family advised to keep doors and windows shut and use room heater, whenever possible. Mother demonstrated on how to undress baby after placing in SSC position; use of sleeveless front open woolen sweaters promoted for the baby in families who insisted on woolen clothing |
Apprehensions about giving SSC at night: fear of suffocating or smothering the baby if she falls asleep and turns to her side crushing the baby | Demonstrated how to lie down with support on either side with pillows or blankets, or rolled up old clothes (if pillows not available) to prevent her from turning on her side. This way they could avoid smothering the baby while asleep |
Inability to practice SSC while moving around | Mother encouraged to use binders |
Refusal to use tube top elastic binders: fear of suffocating the baby | Mothers demonstrated on placing baby in SSC in regular clothes. Tube tops given to women who felt comfortable |
Difficulty in doing KMC for twins | Mother assisted in placing both babies in SSC simultaneously; family members requested for help |
Time | |
Lack of time due to household responsibilities | Mother-in-law and other family members counseled and encouraged to share household chores. |
Limited family support, particularly in nuclear families | Mother encouraged to call relatives or neighbors or practice KMC for longer hours at night |
Data analysis
Results
Characteristics of the participants
Findings
Perception of babies born small or before time and need for special care
“Such babies sleep most of the time, do not wake up even if they are hungry, and cry very less. They are very fragile and therefore require to be treated in a special way, even at home” (Mother)
Reactions to photographs showing mothers practicing KMC
A fourth of the mothers and grandmothers however, felt it was not a good practice to keep baby on the chest because babies would get used to mothers’ smell and closeness and not leave the mother later when she has to do household chores after the initial period of rest. Only a tenth of the mothers and grandmothers had heard about SSC, either from a health worker or hospital and they described it as placing the baby on mother’s chest because it helps in starting breast feeding, reduces need of incubator and promotes weight gain. However, none of them mentioned that it is for small babies or babies born before time. Only one mother had practiced SSC for her older child. She was advised to do so by a doctor from a primary health centre (http://nhm.gov.in/nrhm-components/health-systems-strengthening/infrastructure.html) to give SSC for 1 to 2 h each day after her baby was born. She had therefore practiced for 1 month, for an hour or two each day.“The baby is kept close to the heart. He is covered with clothes so that he remains warm. The baby is sleeping and after breastfeeding, babies usually sleep comfortably in this position” (Mother)
Views on whether it would be possible for mothers to practice KMC at home
However, all grandmothers agreed that since mothers do not do any household chores for some time after delivery, practising KMC should be possible at least during this time.“The mother can keep the baby in this position for one-and-half hours only, she cannot sit for long. A longer period for more than 2 hours at a stretch is possible only while lying down. She can do like this for 3-4 times a day. If mother falls asleep, the baby will be smothered” (Grandmother)
Availability of family support for practising KMC at home
A few mothers said that since child care is the responsibility of the mother alone, no one in the family would help; however, the father may agree to help for a male baby. Mothers and grandmothers were unsure whether mothers in urban areas would be able to practice KMC as most families in the urban areas are nuclear with no additional family members. Mothers in nuclear families had to resume household chores soon after delivery, as early as the next day. In such cases, they suggested that relatives could be called to help.“The male members work outside home and return late at night and are tired. They will not like the smell of urine and stool of the baby but some fathers may keep the baby on their chest before sleeping” (Mother)
Views of community health workers (ASHAs and ANMs)
Quite unlike the mothers and grandmothers, the health workers believed that disposable diapers were necessary and that all families would like to use them except those who could not afford to buy them.“Mothers don’t sit on chairs; elders, male members, children and guests have right to chairs. Women are on the floor or jute cot (charpai). With everyone around, mother will be reluctant to undress. KMC in summer will not be possible because of the heat and frequent power cuts.” (ANM)
Recognition of KMC
Household environment
Key findings of the household trials
Factors motivating mothers to practice KMC
Lessons for the design of the randomized controlled trial
Issues | Role of formative Research in Shaping Intervention Package for the RCT |
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How long to practice KMC and for how many days | Scientific guidance on optimal duration of practicing KMC per day (in hours) and the total duration (in days) was lacking. We advised mothers to give KMC, preferably for 24 h in a day and continue giving till 28 days of infant age or till the baby wriggles out (whichever was earlier). Both these suggestions emerged feasible and acceptable in the formative research. These findings served as an input in the main RCT |
Position of mother in SSC | Supine and semi-reclining positions were most comfortable and preferred. The same were advised in the main trial |
Use of Binders | Women were not comfortable or confident moving around or doing household chores, with baby in SSC supported by binders, feared that baby will fall. Binders therefore, were decided to be provided to only those who ask for them |
Use of Diapers | Diapers were considered unhygienic and thought to cause skin rash. Also, it was believed that they increase the gap between baby’s legs leading to deformity. Therefore, it was planned to offer only to those who asked for. |
Personnel to deliver the intervention | SSC initiation and support for initial few days required skilled counselling, effective demonstration, persistent encouragement, empathy and problem solving ability to bring about behaviour change activation. ANM like workers, with higher education and skills were considered appropriate for initiation; ASHAs were able to support mothers during follow up visits |
Frequency of visit | Frequent visits needed initially, could be reduced later. Substantial support and encouragement needed during first 3 to 4 days. Less frequent visits needed subsequently once the mother was comfortable doing KMC. |
Weight cut off for enrolment | Babies with birth weight ≥ 1500 to ≤2250 g were planned to be included in the study, as babies weighing > 2250 g did not stay in SSC for more than 4 to 5 days (wriggled out earlier) and those weighing < 1500 g required hospital care. |
Age cut off for enrolment | Very early enrolment would not be feasible for facility births. A window period of 72 h of birth was considered feasible to initiate KMC at home |
Involvement of male members in providing KMC to the baby | Male family members participated enthusiastically in providing SSC; they were planned to be involved from the outset in the RCT |