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
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BackgroundKangaroo Mother Care (KMC) is a method of caring for newborn infants that was introduced in 1979 in Bogotá, Colombia. It is particularly beneficial for nursing low birth weight (LBW) and preterm infants. In KMC the infant is placed skin-to-skin on the mother’s chest, between her breasts and secured with a wrap. This method of care was developed as an alternative to inadequate and insufficient incubator care for those preterm and or LBW newborn infants who had adapted to the extra-uterine environment, who were stable and only required to feed and grow. (Whitelaw & Sleath, 1985:1206-1208). The KMC method requires a paradigm shift from conventional health care practices, where the health care workers are the primary caretakers of the infants, to supportive roles where the mothers are supported in becoming the primary caretakers of their infants. (Affonso D, Wahlberg V, Persoon B, 1989, 43-51) The support includes information about KMC and its benefits, general health care education and teaching the mothers the specific skills that would enable them to feed and take care of their infants (Cattaneo; Davanzo; Uxa & Tamburlini, 1998:442; Victor & Persoon, 1994: 891-895; Kirsten & Bergman, 2001). The relatively simple and novel method of KMC was considered to be the best method of resolving the demand for LBW infant care at Kalafong Hospital. A 20-bedded KMC unit was established and opened on 6 July 1999. LBW infants who were stable, did not need intravenous treatment and were on oral feeds, were admitted to the KMC unit. Most of these infants were cared for either by continuous or intermittent KMC, depending on whether they were receiving oxygen or not. On discharge, the infants were followed up on a weekly basis until they reached a normal birth weight. (Van Rooyen et al. 2002:6-8). Adequate and accurate information should be provided to the mother to enable her to make an informed decision about the health care of her infant and whether to participate in KMC (Patients' rights charter, 1999; Cattaneo; Davanzo; Uxa & Tamburlini, 1998:442). To address this issue an information leaflet was developed in simple English to inform mothers about the practice of KMC at Kalafong hospital.KMC-practice guidelines and protocols were developed after the unit was established. These were developed in order to set a high standard of care in the unit and to provide the necessary information for all health care personnel working in the KMC unit. This was to ensure that the mothers would receive the necessary support from all staff members involved in the care of the infants in the KMC unit. “KMC should not be a mere unsupported entrustment of the tiny infant to its mother.” (Kirsten & Bergman; 2001) The guidelines and protocols are regularly updated and adjusted.After the KMC unit was established, intermittent KMC was introduced in the HCU where mothers would sit with their infants in the skin-to-skin position. This intermittent practice took place at feeding times. The mother would feed her infant in this position and sit with the infant for about an hour at a time. Mothers were usually assisted by a lay health care worker, and shown how to take their infants out of the incubator and position their babies on the chest. She would also tell the mothers about KMC and why it is important to do KMC. This information was endorsed by the medical and nursing staff working in the HCU. Problem Setting: In spite of excellent mortality and morbidity figures from an ongoing audit in the KMC unit, (Van Rooyen et al; 2002) it was observed that knowledge about the KMC method, as well as support and education to the mothers in rendering optimal care to their infants, might be insufficient. It appeared questionable whether mothers were always fully informed about the practice and benefits of KMC before their participation in KMC. Mothers often lacked knowledge and skills about keeping their infants in the kangaroo position and feeding them, using the correct techniques. They did not always fully comprehend their roles in being the primary care givers when they were discharged home with their infants. This problem developed in spite of all the measures set in place to prevent a lack of knowledge and support from the staff. According to the nursing staff mothers were informed about KMC but they lacked knowledge because they were unwilling to practice KMC and were uninterested in learning about KMC. From the above issues emerged the need to investigate which factors or scenarios were responsible for the poor practice and knowledge of KMC. Aim of the Research Firstly the aim was to investigate the mother’s knowledge and understanding of the Kangaroo Mother Care method with the focus on the different components of the KMC method of care. Secondly the aim was to establish the mother’s perceptions of the medical and nursing care practices, support and information provided in the neonatal and KMC units at Kalafong Hospital.
The researcher was unable to participate in the in-depth interviews, because the interviews took place during the KMC follow-up clinic. An experienced research assistant who is a retired professional nurse and able to speak SePedi and SeTswana, the languages that are most commonly spoken by the majority of mothers in the ward, conducted the in-depth interviews. The interviews took place in the KMC ward in a separate room ensuring privacy and confidentiality. Mothers already discharged from the KMC unit were interviewed. The research assistant explained the aims of the study to each participant striving to do it in their mother tongue or in a language that the participant understood and spoke well. Written informed consent were obtained from each participant. The interviews took the form of the participants telling their stories about their experience and understanding of the KMC method of care as well as their experiences in the unit. The interviews were guided by means of an interview guide.
These were held with mothers that were in the KMC unit. The discussions were held in a separate building to ensure privacy and confidentiality. The same research assistant who conducted the in-depth interviews, also conducted the focus group discussions. The researcher attended all the focus group discussions as an observer and took field notes. The interviewer acted as interpreter whenever the mothers spoke in their mother tongues. The research assistant explained the aims of the study to each participant striving to do it in their mother tongue or in a language that the participants spoke well. A written informed consent was obtained from each participant. The discussions were taped on an audiocassette recorder which was transcribed by the researcher. Results Care Before Admission to KMC unit In the high care unit most of the mothers were shown how to hold their infants in the KMC position. Little information on the benefits of KMC was provided. There was inadequate preparation of mothers in anticipation of transfer to the KMC unit and uncertainty of what to expect in the KMC unit by the mothers. One mother’s comment on her attempt to obtain information: “When I ask for something they do not give answers, or they just look at you like this, as if your are dead. They don’t want to take care of you.”
The mothers understood the following components and benefits of KMC: KMC provides warmth to the baby: “Kangaroo mother care protects the baby from getting cold” “It is important for the baby to be kept here on the chest to be kept warm”
“Babies grow faster and easily” The physical closeness of the baby to the mother helps with the bonding process: “When we do KMC you know the baby and the baby knows you.” Mixed Perceptions of Care “The staff in the ward is very supportive. They are always there for you. It depends on the staff’s personality whether they are friendly. Some of the staff is not always friendly. Some of the staff is good……. “The nursing staff welcomed me and introduced themselves. They explained when the time of feeding was – the same as in ward 27 [High Care Unit]. They told us the procedure of how to feed our babies. We had to wash our hands and change the nappy before feeding the baby. These mixed perceptions of care were due to the fact that there was a new nursing sister who were conscientious, hard working and introduced good nursing practices to the unit. Unfortunately she left after a few months when her contract with the hospital expired. The focus group interviews were held just before and after she left the unit. Negative Experiences of Care Staff attitudes and behaviour: “When I arrived in the KMC ward …the staff did not have welcome faces. They do not talk smartly.” “No-one showed me around when I arrived in KMC. I was scared to ask the nurses, they shout or are nasty with me.” “There are not quick reaction to a problem” Lack of orientation, information and explanation: “I had to look at other mothers and learnt from them what to do” “Some doctors come to our babies and they take blood but they don’t tell us the results or what they are doing or why the procedure is done.” Despite experiences of poor support mothers remained positive about KMC: Feelings of well-being: “KMC makes me feel well “ “I was so happy cause I was going to see my baby next to me”
“… it gives me time to grow with my child and have knowledge of my child ” “We know our babies’ hearts are beating”
“While doing KMC I can also wash dishes and do other tasks” Conclusion Mothers were not adequately informed on and prepared for KMC during pregnancy and the perinatal period. There was a lack of information about KMC in the high care unit as well as the KMC unit. Nursing support was experienced as insufficient in both units. In general mothers had positive perceptions of other health care role players like the doctors, physiotherapists, dieticians, occupational therapists and speech-language therapists. An enthusiastic and dedicated nurse made a big difference in mothers’ experiences of their treatment in the KMC unit. Despite shortcomings in the support of mothers, KMC was well accepted and practised in the unit and at home Recommendations A more concerted effort to include KMC in health education and promotion at antenatal clinics is needed in order to prepare and inform the mother better about the practice of KMC. Innovative strategies to improve nursing staff morale and attitudes are urgently needed!
Bahl R et al, Bulletin of WHO 2005; 83: 418-426
Edmond KM, et al Paediatrics 117; 380-386B
Dept of International Dev; Published in the American Journal Paediatrics
The potential costs implications in the absence of breastmilk: In the USA costs increase by $186,200 when treating an infant with NEC. Should the infant need surgery it spirals to $R259,700
NICU R5,720 per day High Care R1,658 per day Nursery R 634 per day In other words to treat a single case of NEC at a secondary state hospital costs the department of health in excess of R80.000 This figures excludes surgery, often required for these infants. How can we avoid NEC in the NICU:
The reasons why mothers milk is not always available to susceptible infants vary, most often due to maternal illness, living far away and unaffordable travelling expenses. In the Western Cape, Milk Matters attempt to provide milk to babies who have limited access to their own mothers milk. To this end Milk Matters has assisted in the setting up of 4 milk banks. Three of which were supplied with essential equipment. In addition, 9 hospitals have been supplied with donor milk - all for less than R150,000. All in all hundreds of babies in the Western Cape have received Bank Milk or Donor Expressed Breastmilk. Our Recipients Micro prems, babies weighing less that 1,500gr, whose mothers are not in a position to provide ‘own mothers milk’ for their infants An outline of what milk banking entails: DONORS
Moms of prems with excess milk, Breastfeeding moms who specifically express to donate Working moms who express for their own babies and extra to donate MARKETING At Hospitals Clinics
By word of Mouth Radio Talks, Very importantly, identify potential donors within your institution FORMS
Indemnity, Information, Screening, Recipient, HIV test referral letters METHOD
Sterile glass jars are provided to donors Donor moms cool & freeze the expressed milk The milk bank receives the frozen milk Defrosts to Pasteurise using the Holder Method Rapidly Cools and Freezes the milk Defrost for use Refrigerate for up to 24 hrs Syringe Driver for 4 hrs FUNDING Private and Corporate EXPENDITURE Pasteurisers and freezers, Pamphlets and posters, Co-ordinator Results Decrease in the incidence of NEC Increase in motivated staff, both doctors and nurses 9 Hospitals presently participating in the Western Cape 4 Pasteurisers in use, More donors always needed!! Ultimately Breastfeeding is being promoted. The options remain in order of priority;
Conclusion Skin to skin care, Developmental Care, Breastfeeding and Bank Milk belong in every NICU. Find out how to source Bank Milk for your NICU www.milkmartters.org (Cape Town) www.ithembalethu.org.za (Durban) www.sabr.org Johannesburg) www.hmbana.org (North America) www.ukamb.org ( United Kingdom) SESSION 6: PAPER 4 A CASE FOR A HUMAN MILK BANKING ASSOCIATION OF SOUTH AFRICA P Reimers Coordinator iThemba Lethu Breastmilk Bank What is donor Milk Banking? Donor human milk banking is the collection, pasteurisation, storage, and distribution of human milk that has been donated by healthy lactating women. All donor mothers are screened and the milk is pasteurised according to international standards laid down by Human Milk Banking Associations. Holder pasteurization reliably inactivates HIV and Cytomegalovirus and will eliminate titers of most other viruses (Lawrence, 1999). Most bioactive properties remain viable after pasteurization. What are the benefits of Donor Milk? Donor human milk plays an important role in reducing mortality and morbidity in critically ill or premature infants and so is vitally important to improve child survival in industrialized and developing countries. Research has shown that human milk is exceptionally suited to infants and contains many nutritional and immunological factors that have never been manufactured. It especially benefits the preterm and immune compromised infant. Benefits for preterm infants:
How does Donor Milk Banking fit into Health Policies? Every effort should be made to feed fresh breast milk to a mother’s own infant; where this is not possible, donor human milk is recommended as the first alternative by both the World Health Organization and UNICEF. Milk Banking should be part of a comprehensive breastfeeding programme that protects, supports and promotes breastfeeding. The Baby Friendly Hospital Initiative has numerous opportunities within 10 steps to successful breastfeeding for the implementation of donor milk banking. The Global Strategy for Infant and Young Child Feeding’s (WHO/UNICEF 2003) aim is to improve the survival of infants through optimal feeding. Donor milk banking will also help achieve the Millennium Development Goals (2000) of reducing under- five mortality by two-thirds. What is the situation in South Africa? iThemba Lethu Community based Milk Bank in Durban was the first to be established in South Africa by Professor Anna Coutsoudis in 2001 to meet the needs of babies in the transition home who have been abandoned or orphaned as a result of HIV/AIDS. Milk Matters was then established in the Western Cape and they operate in a number of hospitals providing milk for preterm infants. This was followed by the South African Breastmilk Reserve in Gauteng, they have a public private partnership where private hospitals collect donor milk and share with the public hospitals. What are international trends?
What is the role of the Human Milk Banking Association of South Africa? (HMBASA)
Management Committee of HMBASA The Management Committee will consist of 10 – 20 people with a representative from each of the following constituencies.
Conclusion There is a long history of safe operation of donor milk banking internationally, it can save lives, reduce morbidity and save health care costs while ensuring optimal physical and neurological development. Milk Banking and breastfeeding are intimately linked and the up scaling of donor milk banking will also improve breastfeeding rates. HMBASA was constituted at the Priorities Perinatal Conference in March 2008 and will be another step towards establishing recognition for Milk Banking in South Africa and help ensure the provision of the gold standard for safe handling of human milk. SESSION 6: PAPER 5 THE USE OF DONOR BREAST MILK IN A NEONATAL UNIT LG Lloyd, SD Delport Department of Paediatrics and the University of Pretoria Introduction The use of own mother’s milk in low birth weight (LBW) infants prevents nosocomial sepsis and necrotising enterocolitis (NEC) - two potentially lethal conditions - which occur commonly when formula feeds is administered to LBW infants. At Kalafong Hospital the exclusive use of breastmilk became a reality in September 2006 when donor breastmilk (DBM) was accessed from the South African Breastmilk Reserve (SABR). Informed written consent is obtained from mothers before DBM is administered and measures is initiated to stimulate lactation. An audit was done to determine the indications for the use of DBM, the duration of use and the incidence of feeding intolerance. Patients and methods Clinical and feeding records of infants (birth weight ≤2000g) admitted over a one year period were reviewed. The following variables were documented: Age of infant, indication for DBM, duration of administration, volume received per infant, feeding intolerance (aspirates, vomiting, abdominal distension, omission of feeds), NEC, HIV exposure and total volume utilised. Yüklə 1,33 Mb. Dostları ilə paylaş:
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