Discussion

1. The impact of Kangaroo Mother Care on Neonatal Mortality in BrazilMelo Junior, AVP*; Huttly, SR; Victora, CG; Marshal, TLondon School of Hygiene & Tropical Medicine, United Kingdom (Anisio.Veloso@lshtm.ac.uk) The study aimed to assess the impact of KMC by investigating the association between the level of implementation of KMC and neonatal mortality among children delivered in third level neonatal units in Brazil. An ecological study was conducted with the units of analysis being high-risk pregnancy hospitals in the 27 state capital cities. Aggregated data for each hospital on neonatal deaths and maternal education were compiled by linking birth and death information databases for 2002. Information about the implementation of KMC and other neonatal care facilities were obtained by postal questionnaires. The results of the questionnaire were used to develop various scores for each hospital. The KMC implementation score comprised information on provision and utilization and was calculated as set out in Table 1. Table 1: Computation of the KMC implementation score ________________________________________________________________________________________ Provision 2 Components: A) Number of Kangaroo Care Beds per 1000 low birth weight (LBW) infants born. A score of 1 (low) to 5 (high) was assigned according to the quintile of the distribution of this variable across all hospitals. B) The percentage of maternity unit professionals trained in KMC 80-100%: 5 50-80%: 4 20-50%: 3 10- 20%: 2 <10%: 1 Provision Score = (A + B) 08-10 = 5 06-08 = 4 04-06 = 3 02-04 = 2 < 02 = 1 Utilization C) The percentage of eligible LBW infants who received KMC Utilization Score (C) 80-100% = 5 50-80% = 4 20-50% = 3 10- 20% = 2 <10% = 1 Implementation Implementation Score = (Provision Score + Utilization Score) 2 ________________________________________________________________________________________ A technology score was computed for each hospital which had 16 components as set out in Table 2. This score constituted a potential confounding variable because it might be associated both with KMC implementation and with neonatal mortality. National Birth certificate (SINASC) and National Mortality (SIM) registration information systems was the source of data about neonatal mortality rates. Information on maternal education, measured as years of education, was collected from the SINASC database. In this database this variable is recorded as 0, 1-3 years, 4-7 years, 8-11 years and 12 and more. For this study, these categories were assigned values 0-4 and the mean score per hospital was obtained. The reliability of the two scales (implementation and technology) was assessed through Cronbach’s alpha coefficient. Correlation and regression analyses were used to assess the association between KMC implementation and neonatal mortality, including adjustment for maternal education, availability of technology in the hospital and region of the country. Table 2: Computation of the technology score ________________________________________________________________________________________ 16 components A value of 1 was assigned for the presence of each of the following 1) Human Milk Bank 2) Baby Friendly Hospital 3) Infection committee 4) Paediatrician 24/7 5) Heated cot in labour room 6) Radiology service 7) Laboratory 8) Pathology facilities 9) Pharmacy 10) Teaching Hospital 11) The percentage of professionals trained in neonatal resuscitation: 80-100%: 5 50-80%: 4 20-50%: 3 10- 20%: 2 <10%: 1 A score of 1 (low) to 5 (high) was assigned according to the quintile of the distribution of variables 12-15 across all hospitals. 12) The ratio of LBWI to high-risk obstetric beds 13) The ratio of LBWI infants to incubators 14) The ratio of LBWI to halogen photo therapy units 15) The ratio of LBWI to ventilators 16) Type of person responsible (first on-call basis) for neonatal resuscitation in the labour room Only paediatrician: 5 Any doctor: 4 Any doctor / any nurse: 3 Only nurse: 2 Only students or others: 1 Technology Score (sum of all components score 32-40 = 5 24-32 = 4 16-24 = 3 08-16 = 2 < 08 = 1 ________________________________________________________________________________________ Objective Abstract Results To reduce neonatal mortality and achieve the Millennium Development Goal for Child Survival (MDG-4) poses a challenge for many low and middle-income countries. In 2000, hospital-based Kangaroo Mother Care (KMC) - involving 24-hour skin-to-skin contact between a mother and her stable low birth weight infant - became national policy in Brazilian maternity hospitals. Although promoted as a potential strategy for neonatal survival, there is little evidence for the impact of KMC on mortality. Methods: An ecological study was conducted with the units of analysis being high-risk pregnancy hospitals in the state capital cities. Aggregated data for each hospital on neonatal deaths and maternal education were compiled by linking birth and death information databases for 2002. Information about the implementation of KMC and other neonatal care facilities were obtained by postal questionnaires. Findings: 97 questionnaires were completed (88% response rate). The mean late neonatal mortality rate was 3.75 per 1000 children with birth weight ranging from 1,250-2,000g. The partial correlation coefficient between mortality and KMC final implementation score, adjusted for maternal education, region and technology score, was -0.47 (95% CI: -0.53 to -0.23; p<0.01). The adjusted regression coefficient was -0.42 (95% CI: -0.60 to -0.24; p< 0.01). Interpretation: These results are compatible with an impact of KMC on late neonatal mortality among low birth weight infants in Brazil, and with existing information on the effect of KMC on severe morbidity. It provides evidence in support of this national policy that should encourage other countries considering implementation of KMC to achieve the MDG-4. Methods Figure 1. Linear regression of neonatal mortality on KMC implementation score, with adjustment for technology score. Discussion This study provides some of the first evidence on the potential impact of Kangaroo Mother Care on neonatal mortality. Our results suggest that higher levels of implementation of KMC in Brazilian maternity hospitals in major metropolitan settings are associated with lower mortality. This association persisted after adjustment for three potential confounding variables - maternal education, hospital technology score and region of the country. Trials comparing mortality rates between 24-hour KMC versus conventional care (incubator care) are scarce in the literature. In Ecuador, a trial was stopped after six months because of a highly significant impact on severe morbidity, however no difference in mortality was reported at this stage(4). A trial in Colombia and a multi-centre one in Ethiopia, Indonesia and Mexico also showed no impact on mortality (5,6). In Ethiopia, the effectiveness of early KMC - before stabilization of low birth weight infants – was compared with conventional care. The results suggest better survival of those infants under KMC but comparison with our study is limited as the study population differs (pre-stabilisation infants) (7). A common feature of all these trials is their very limited sample sizes for estimating mortality impact. Data on mortality impact from other types of study are also limited. In a cohort study in Zimbabwe, following the introduction of KMC in a mission hospital, survival of babies born under 1,500g improved from 10% to 50%, whereas that of babies 1,500-1,999g improved from 70% to 90% (8). Facilities in the neonatal unit were scarce and therefore the pre-KMC ‘conventional care’ was not comparable with our study. Also in Zimbabwe, a quasi experimental pilot study found that 0/37 KMC infants died compared to 3/37 in conventional care (9). The existing evidence has been summarised in a Cochrane review (2) and in the Lancet Neonatal Survival Series, both of which that there was evidence of substantial benefit (1). Our study design enabled mortality rates to be based on adequate numbers. The limitations of ecological analyses are well established, but the approach used here makes adjustment for regional differences, a socio-economic factor (maternal education) and technology levels between hospitals. Also, because the units of implementation of KMC under routine conditions are the hospitals, individual level analyses are inappropriate. Although a definitive statement on causality is not possible due to the nature of our study, the evidence is nevertheless quite convincing. The association remained after taking account of differences between hospitals in the availability of other resources which might impact on mortality and was also seen within each region of the country. Although mortality data are not totally reliable, it is unlikely that there is substantial bias in the results, mainly because vital registration in the capital cities is quite uniform within each region. Furthermore, the study achieved a high level of coverage of the study population with complete information on 88% of eligible hospitals. The missing data were not clustered in any particular region nor were of a particular type of hospital. In conclusion this study suggests that Kangaroo Mother Care, implemented under routine conditions, may reduce later neonatal mortality among infants with birth weight of 1,250-2,000g in Brazil. It provides evidence in support of this national policy that should provide encouragement to other countries considering implementation of KMC to achieve the MDG-4. Results Questionnaires were sent to all 115 high-risk pregnancy maternity hospitals in the country. Five of these had not yet received the training on KMC and were thus ineligible for inclusion in the study. Another five hospitals provided incomplete information and seven hospitals did not respond despite repeated attempts. Only one hospital manager refused to participate in the study. Thus the response rate among eligible hospitals was 88% (97/110). The Cronbach’s alpha coefficients for the KMC final implementation and technology scores were 0.81 and 0.79, respectively. The partial correlation coefficient between mortality and KMC final implementation score, adjusted for maternal education, region and technology score, was -0.47 (95% CI: -0.53 to -0.23; p<0.01) Table 3. The adjusted regression coefficient was -0.42 (95% CI: -0.60 to -0.24; p< 0.01) Figure 1. Background . The Millennium Development Goal for child survival (MDG-4) - to reduce childhood mortality by two-thirds by 2015 - will not be met without substantial reductions in neonatal mortality. The World Health Organization estimates that each year four million children die in the first month of life, with three quarters of these deaths occurring in the first week of life and nearly 99% occurring in developing countries. Although the world has witnessed a fall in infant mortality rates, in most developing countries neonatal mortality levels have declined less quickly than post- neonatal rates (1). Since the late 1970s, interest has grown in Kangaroo Mother Care (KMC) as an alternative to incubator care for low birth weight babies. KMC keeps the low birth weight infant in skin-to-skin contact between the mother’s breasts while in the hospital and can continue after discharge. A large proportion of neonatal deaths occur in infants born with low birth weight so KMC has the potential to contribute to the reduction of neonatal mortality. Yet evidence for the effectiveness of KMC is sparse, a Cochrane review by Conde-Agudelo et al. demonstrated the paucity of evidence, particularly for its mortality impact. It concluded that the literature points to a positive impact of KMC on severe morbidity (a reasonable proxy for mortality) with no deleterious effects (2). KMC is a good example of a policy that has a natural appeal to policymakers and that is therefore implemented before it is fully tested in a randomised controlled trial. Brazil is the only country where KMC has become a national health policy for clinically stable low birth-weight infants as a hospital intervention and not at community level (3). The national implementation of KMC in Brazil precluded a randomized controlled trial to evaluate its impact. However, alternative approaches for the evaluation of interventions have been advocated, and in this paper we have explored such approaches to assess the impact of KMC in Brazil. Discussion Table 3: KMC implementation and neonatal mortality ______________________________________________________________________________________________ Implementation Technology Mother’s Mortality rate Pearson’s Partial R-square R-square Score Score education Mean (SD) Coeff. Correlation partial Mean (SD) Mean (SD) Mean (SD) § Coeff.** Correlation** ______________________________________________________________________________________________ National (97 units) 3.01 (1.25) 3.14 (1.23) 1.59 (0.15) 3.75 (1.04) -0.64* -0.47* 0.41 0.22 North (10 units) 1.50 (0.55) 1.82 (0.75) 1.52 (0.83) 4.83 (0.57) -0.25* -0.23* 0.06 0.05 Northeast (31 units) 2.98 (1.21) 3.52 (1.31) 1.58 (0.14) 3.74 (1.11) -0.57* -0.34* 0.33 0.12 Southeast (30 units) 3.53 (1.01) 3.21 (1.04) 1.58 (0.16) 3.30 (0.86) -0.47* -0.37* 0.22 0.14 South (11 units) 3.86 (0.78) 3.63 (1.21) 1.67 (0.18) 3.06 (0.86) -0.60* -0.29* 0.36 0.08 West (15 units) 2.50 (1.30) 2.86 (1.09) 1.57 (0.87) 4.32 (0.66) -0.37* -0.20* 0.14 0.04 ____________________________________________________________________________________________ § 18 (18.6%) cases were missing * Correlation is statistically significant at the 0.01 level (2-tailed) ** Adjusted for technology scores and, for the national score, adjusted for region and maternal education. References References 1. Lawn JE, Cousens S, Zupan J. 4 million neonatal deaths: when? Where? Why? Lancet 2005;365(9462):891-900; 2.Conde-Agudelo A, Diaz-Rossello JL, Belizan JM. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database Syst Rev 2003(2):CD002771; 3.Ministry of Health of Brazil. Humanized Care Assistance To The Low Birth Weight Newborn Baby: Kangaroo Mother Method. Brasilia: MoH, 2004. 282p; 4.Sloan NL, Camacho LW, Rojas EP, Stern C. Kangaroo mother method: randomised controlled trial of an alternative method of care for stabilised low-birthweight infants. Maternidad Isidro Ayora Study Team. Lancet 1994;344(8925):782-5.; 5. Charpak N, Ruiz-Pelaez JG, Figueroa de CZ, Charpak Y. Kangaroo mother versus traditional care for newborn infants </=2000 grams: a randomized, controlled trial. Pediatrics 1997;100(4):682-8; 6. Cattaneo A, Davanzo R, Worku B, et al. Kangaroo mother care for low birthweight infants: a randomized controlled trial in different settings. Acta Paediatr 1998;87(9):976-85; 7. Worku B, Kassie A. Kangaroo mother care: a randomized controlled trial on effectiveness of early kangaroo mother care for low birth weight infants in Addis Ababa, Ethiopia. J Trop Pediatr 2005 Apr;51(2):93-7; 8. Bergman NJ, Jurisoo LA. “The Kangaroo-Method” for treating low birth weight babies in a developing country. Trop Doct 1994; 24(2):57-60; 9. Kambarami RA, Chidede O, Kowo DT. Kangaroo care versus incubator care in the management of well preterm infants- a pilot study. Ann Trop Paediatr 1998 Jun;18(2):81-86. This study was funded by Pan American Health Organization, Brazilian CAPES Foundation and Brazilian Ministry of Health.