Data analysis and use

The information from the three assessments was evaluated against a 1-4 scale ( Table 3 ) in the six strategic areas to identify progress and trends.

Ethical considerations

The procedures and the semi-structured questionnaire for the midline assessment were submitted to the IRB of George Washington University for review. The IRB issued a waiver of documentation of consent because the research presented no more than minimal risk of harm to participants. A consent statement for exempt research, which explains the purpose of the assessment, was shared with all key participants. All key participants who were interviewed gave verbal consent to participate in the assessment and consented to being audio-recorded. The recordings were not transcribed, but they were used as a reference to confirm notes taken during the interviews.

Software used: MS Word (Microsoft Inc, Seattle WA, USA), MS Excel (Microsoft Inc, Seattle WA, USA), Tableau (Salesforce, Mountain View CA, USA), SAS (Cary North Carolina, USA).

National policy

The MOHs in the six priority countries committed to improve the health outcomes of small babies through different strategies including the integration of KMC into policies that outline newborn care. While countries were at different stages in terms of KMC policies and guideline implementation in 2014, at the time of the last assessment, all six countries had KMC policies in place. The policies included plans for KMC scale-up including resource allocation, coverage and survival targets. For example, the Government of Bangladesh (GOB) in 2013 declared its commitment to introduce and scale up KMC at the facility level and to set a target of reducing under-five mortality to 20 per 1000 live births by 2035 [19]. While the six countries exhibited progress between the first and the last assessment, Nigeria and Ethiopia were the countries with the most progress in this dimension. In 2014, Nigeria did not have a KMC national policy in place, but by 2019, KMC had been integrated into newborn care policies making KMC part of the basic minimum package of health services. Although Ethiopia had a KMC policy drafted in 2014, in 2015, KMC was integrated into the national strategy for newborn care, as well as the health sector transformation plan.

India, Malawi and Rwanda were already ahead in terms of national guidelines at the time of the first assessment. In India, the National Guidelines for KMC and Optimal Feeding of LBW infants were released in 2014 in an effort to implement KMC at the facility level [20]. Later, in the India Newborn Action Plan (INAP), KMC was listed as a specific intervention recommended for small and sick newborns who weigh less than 2000 g [20]. The INAP highlighted the establishment of fully functional KMC unit/wards in health facilities that provide neonatal care services and identified specific coverage targets [21]. Malawi, one of the early adopters of KMC, developed national guidelines in 2005. The guidelines recommended that all babies less than 2500 g be initiated in KMC and be followed up after discharge. Through the ENAP, coverage targets were set at 75% by 2020, 80% by 2025, 85% by 2030, and 90% by 2035. In Rwanda, the MOH included KMC in the National Child Health Policy in 2009, and most recently KMC was included in the MNCH Strategic plan 2018-2024. Including KMC as part of newborn care policies has led to policy-driven actions such as setting measurable time-bound targets, developing KMC guidelines, allocating resources to train staff to provide KMC services, and designating or redesigning KMC space to advance scale-up of facility-based KMC.

Country support/implementation

KMC services are provided at health facilities of different levels in all six priority countries, but there is variability in the coverage, type and quality of services provided and the data quality. In terms of availability of KMC services, India and Bangladesh have greatly increased the number of KMC units in the past few years. In Bangladesh, KMC is being implemented in some tertiary, teaching, and secondary/district health facilities; the number of health facilities offering KMC services increased over four times between 2017 and 2019, from 30 to 167 health facilities according to data from DHIS2 2019. In India, the Ministry of Health and Family Welfare (MOHFW) allotted funds to each state for the adaptation of KMC spaces within the special newborn care units (SNCUs). From 2016 to 2019, the number of KMC units almost tripled, growing from 265 to 782 at district hospitals. However, back in 2017, only 15% of KMC units met the MOHFW recommended number of eight beds per unit. In Nigeria, some general, tertiary and specialist hospitals, as well as some secondary health facilities provide KMC. In an assessment led by Save the Children in 31 states, 202 facilities out of 757 (27%) reported availability of KMC services [22]. However, this might be an overestimation due to different interpretations of what might constitute provision of KMC services. In Rwanda, KMC is implemented in tertiary, teaching, provincial and district hospitals, but data are needed to confirm the number of district hospitals where KMC services are functioning.

KMC coverage estimates in most countries are uncertain, as the numerator (the total of small babies who received KMC) and the denominator (the total population of small babies) are challenging to measure. However, most priority countries are starting to integrate KMC indicators into their national health management information systems (HMIS). In Malawi, it is estimated that fewer than 10% of preterm/LBW newborns receive facility-based KMC, according to data extracted from maternity reports within the District Health Information System 2 (DHIS2). All government-owned tertiary and district hospitals offer facility-based KMC services, although it is difficult to estimate whether KMC is fully operational (staff receiving in-service training on KMC, identified space for KMC and availability of functional infant scale) [18] due to inconsistent reporting through the DHIS2. In Ethiopia, an implementation study, which is expected to inform the strategy of scaling up KMC in Ethiopia, is ongoing. Coverage estimates are presented among the findings. In 2015, a study in six hospitals reported that only 14% of babies who weighed less than 2000 g were initiated in KMC, suggesting low levels of initiation [23]. KMC services are provided in facilities at different levels across the six priority countries, at the tertiary, secondary or primary level, and in some cases in teaching and private hospitals. Even though availability of KMC services has increased in the six countries in terms of number of health facilities with KMC services at different levels, coverage continues to be difficult to estimate.

Research

Similar trends were observed in the themes selected for research over time across the six countries. Generally, by the first assessment, countries had already conducted studies or pilots about the feasibility of KMC implementation. Later, research topics about perceptions, barriers, quality of services and community KMC seemed to be of interest. During the first assessment, Nigeria had already published a study on KMC conventional care in 2004 and later conducted implementation research and studies on perceptions of KMC and attitudes of Nigerian health workers towards KMC. Malawi had conducted multiple studies on KMC service readiness and evaluation of KMC services by 2014. During the 2017 assessment, there were studies on early outcomes, customization of the wrap for skin-to-skin contact, quality of data collection on birthweight, and improving measurements of service readiness. In Bangladesh, a pilot study of KMC had been conducted at the time of the first assessment, KMC operational research was ongoing during the midline assessment, and studies on lessons learned about caring for small babies and implementation research on KMC services had already been published by the last assessment.

Knowledge management

KMC centers of excellence are health facilities that either underwent an accreditation process through the Fundación Canguro (Kangaroo Foundation) based in Bogotá, Colombia or were considered state-of-the-art facilities, having served as training centers and model sites for KMC expansion. The centers of excellence have been building blocks in the adoption and sustainability of KMC, because in most countries, they have pioneered KMC as stand-alone facilities, served as training hubs in their respective countries, and generated evidence of practice. In Rwanda, the Muhima District Hospital was established as a center of excellence in 2007. In Malawi, the Queen Elizabeth Central Hospital and the Thyolo District Hospital are both considered KMC centers of excellence. In the late 1990s, KMC was introduced in Nigeria in the Lagos University Teaching Hospital. This and two other health facilities, the Obafemi Awolowo University Teaching Hospital (Ile-Ife), and the Federal Medical Center (Katsina) are centers of excellence. In India, five centers of excellence were established between 2003 and 2005, and they continue to be centers of excellence. While the number of centers of excellence for KMC has not increased significantly over time, these facilities continue to operate as KMC models and resource centers, contributing to the sustainability of KMC.

Integrating KMC into the curriculum of health professionals and developing KMC manuals and trainings are also important components of scaling up and sustaining KMC. In Bangladesh, KMC has been integrated into the postgraduate curriculum of physicians, as well as the curricula of nurses and midwifes. KMC training in Bangladesh is also done through trainers-of-trainers models where health providers attend trainings in other countries and train KMC teams in multiple hospitals. In India, KMC is highlighted as a strategy to be recommended to families with small babies in the handbook for community health workers (Accredited Social Health Activists, ASHAs). In Rwanda, KMC was integrated into the basic reference manual of emergency obstetrics and newborn care in 2009, into the Essential Newborn Care Reference Manual in 2011, and into maternal community health worker trainings. Continuing to embed KMC in the education process of health professionals and in training materials will facilitate the expansion of KMC.

Monitoring and evaluation

As KMC services are offered more widely in each country, there is a need to collect, review and use KMC data in a systematic way to monitor progress, identify gaps and improve the quality of KMC services. All six priority countries have developed KMC-related indicators, although the interface for and frequency of reporting varies. Five priority countries (Malawi, Nigeria, Rwanda, Bangladesh and Ethiopia) monitor KMC services through their corresponding HMISs. India and Bangladesh achieved the most progress between the first and the last assessment. In India, in 2017, indicators were just being developed; by 2019, 782 facilities were reporting monthly on six KMC indicators through an online tracking system. In Bangladesh, in 2017, KMC indicators were being incorporated into the DHIS2 and a monthly KMC reporting form was implemented. By 2019, the DHIS2 was used to report on seven indicators related to KMC as well as ambulatory KMC follow-up data.

In some countries, the indicators have been modified to better capture the coverage of KMC services and others have been added to record follow-up visits after discharge. Nigeria and Rwanda have changed the data-reporting requirements to calculate the percentage of small babies initiated in KMC. In both countries, the denominator was recently changed to include only babies weighing 2000 g or less. There is a range in the type of KMC indicators being used to track KMC. Rwanda and Bangladesh added an indicator to track up to three KMC follow-up visits after discharge. India tracks KMC indicators through online software for SNCUs. Initially there was only one binary indicator related to KMC, but the government of India (GOI) formed working groups to develop other KMC indicators. Six indicators were developed and integrated into the SNCU online system for monthly reporting. In Bangladesh, to monitor KMC implementation, KMC indicators were incorporated into the national dashboard on DHIS2. The KMC database for DHIS2 has been tested and operationalized but not yet scaled up.

Advocacy

KMC advocacy was assessed in two areas: professional organizations that endorse KMC and the existence of local KMC champions. Overall, there was a trend in the six priority countries for professional organizations – minimally involved in KMC advocacy initially – increasingly to support scale-up of KMC through mentoring, advocating for KMC spaces, publishing evidence-based findings and, in some cases, working at national level to include KMC in curricula, guidelines and policy documents. In Ethiopia, the Ethiopian Paediatric Society had endorsed KMC at the time of the first assessment but had taken no specific action; five years later this organization was supporting the establishment of KMC spaces, equipping them and training health workers to introduce and provide KMC services.

KMC champions, such as professional organizations members, have become instrumental in advocacy efforts. KMC champions have promoted and advocated for KMC. They also exist at different levels at the MOH, as part of the implementing partners or at health facilities. In Rwanda, KMC champions advocated for the inclusion of KMC indicators in the HMIS, increased availability of KMC units in all facilities and referral of all babies in KMC position. In Nigeria, they have supported the development of the KMC operational guidelines, and they have helped to establish KMC centers. It is evident that professional organizations and other local champions have been fundamental for KMC to become a core strategy in newborn care. However, all countries cited a lack of funding and human resources as a recurrent obstacle to expanding KMC working groups and mentoring future KMC champions.

Priority countries compared to the countries of interest

Among the eight countries of interest, four countries (Mali, Philippines, Vietnam, and the Dominican Republic) were in similar stages of scaling up KMC as the priority countries in the strategic areas of national policy, country support and implementation, and monitoring and evaluation. China, Mozambique, and Pakistan were making progress mostly in the areas of national policy, and knowledge management, but in terms of country support and implementation, access to services was limited as KMC was implemented on a small scale. Uganda and Tanzania made some progress in the areas of country support and implementation and knowledge management. There were some facilities that offered KMC services and one or more KMC centers of excellence or state-of-the-art facilities. However, there were challenges in the other strategic areas ( Online Supplementary Document ).