The 26th Conference on Priorities in Perinatal Care in South Africa was held under the auspices of the Priorities in Perinatal Care Association and sponsored by Abbott Laboratories sa (Pty) Ltd

Purpose of the evaluation

In 2007 a retrospective evaluation of KMC practices at the seven hospitals was done in collaboration with the South African MRC Unit for Maternal and Infant Health Care Strategies. The aim was to identify the strengths and weaknesses of KMC implementation in these facilities and to find out to what kind of approaches and strategies had worked and what had not worked. Other questions were

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  Can KMC be scaled up to all district hospitals?
  
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  What links exist between communities and health facilities?
  
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  How should the lack of human resources be dealt?
  
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  What should the length of off-site training be?
  

Methods

There were 10 hospitals in the study. Six of the project hospitals were visited and a telephone conference was held with the seventh hospital. Three health facilities of which no knowledge of KMC implementation was available were visited for comparison purposes. Table 1 gives an overview of the level and types of facilities included in the study:

Table 1 Facilities included in the study

Type of facility	Project facilities	Additional facilities
Central hospital	3
District hospital	1
Mission hospital	3	1
Community hospital		1
Heath centre		1

Qualitative data were collected through discussions with key informants. The South African standardised progress-monitoring tool⁸ was used to get a sense of the nature of quality of KMC practice.

Results

Of the project hospitals, five of the seven managed to implement continuous KMC successfully and sustainably. Three of these were central hospitals and two mission hospitals. The other two hospitals had KMC wards, but appeared to have problems sustaining services, partly related to human resource challenges. Three hospitals indicated that they had also trained providers from other sites. In two of the facilities that were not part of the project, there was a high awareness of KMC, as well as evidence of attempts to implement KMC. It appears as if lack of sufficient information and confidence hampered efforts to sustain the practice.
Three recommendations for immediate attention were identified:

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  Intermittent KMC should be introduced for stable infants in neonatal units, even before they are transferred to continuous KMC in a KMC unit.
  
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  Current feeding practices should be strengthened for all babies in KMC, with scheduled feeding time and adequate nursing supervision.
  
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  All infants should be transported in the skin-to-skin position between home and health facilities or between facilities.
  

Many of the informants expressed the perception that newborn care was not a priority in the health system. There are also two other broad challenges for KMC implementation and sustainability, namely human resources and specific perceptions and practices in individual facilities:

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  The wide-scale practice of staff rotations leads to the loss of staff with skills in KMC and jeopardises sustainability in some instances. Dire staff shortages hamper nursing and clinical supervision of infants in KMC, prevent staff from attending essential further training and lead to insufficient orientation of new health care staff in KMC. There is also resistance from staff to undergo on-site training from colleagues who have trained off-site.
  
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  A widespread perception was that KMC could not be implemented without a special unit, special beds and heaters. In some facilities the quality of record keeping, especially with regard to feeding, was poor and there was also a variation in the discharge criteria between hospitals. The lack of appropriate follow-up systems after discharge also leads to the loss of babies.
  

The following factors were identified as crucial for sustainability:

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  Advocacy and sensitisation: Appropriate communication and collaboration with community health structures and local leaders are essential.
  
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  Management at all levels: There is a need for active support and leadership, as well as good communication and consultative participation.
  
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  Implementation: Experienced persons need to drive the process and the right persons, who would receive ongoing support afterwards, should be sent for training.
  
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  Service delivery: KMC should be integrated into current services to avoid a “project mentality” and the establishment of a community follow-up system was essential.
  

Conclusion

There is strong support from the MoH in Malawi for KMC, as well as awareness of the benefits of KMC among health workers, even in hospitals and health centres not practising it. Health workers at all facilities in the study were positive about KMC and saw potential for scaling it up to all district hospitals. Although the design and implementation of a scale-up programme for Malawi is possible, a new training system may be needed, with shorter, integrated off-site training in the form of one-day workshops for district officials and two-day workshops for key implementers at district hospitals, combined with continuous on-site facilitation and support. Leadership and enough personnel are other crucial elements. Given the extreme lack of clinical staff, novel approaches to appropriate care will be required, including the use of other health cadres such patient attendants. Furthermore, a solid monitoring and evaluation system for tracking practices and quality will be important.

SESSION 6: PAPER 2
THE UNDERSTANDING AND PERCEPTIONS OF MOTHERS PRACTICING KANGAROO MOTHER CARE AT KALAFONG HOSPITAL

Elise van Rooyen, Rachel Mokhondo, Anne-Marie Bergh

MRC Unit for Maternal and Infant Health Care Strategies

Department of Paediatrics, Kalafong hospital and University of Pretoria