Impact of Kangaroo Mother Care on infant mortality may depend on duration of skin-to-skin contact in the first 2 days of life

Reviews of past studies have concluded that Kangaroo Mother Care (KMC) reduces the incidence of diseases among preterm and low birth weight infants. However, there is insufficient evidence to conclude that KMC reduces infant mortality. The authors of this study suggest that traditional KMC may not reduce infant mortality because it is only applied to clinically stabilized newborns, and most newborn deaths occur in the first few days of life, before many preterm babies are stabilized.

To determine whether KMC provided immediately after birth in settings with little access to neonatal care could reduce mortality, traditional KMC was adapted for community-based application in rural Bangladesh and called community-based KMC (CKMC). CKMC is similar to traditional KMC in that it teaches that skin-to-skin should be provided continuously to ensure thermal regulation. However, CKMC differs from KMC because it is initiated immediately after birth, without being limited to clinically stabilized babies. A randomized controlled trial, which involved following 4,165 live-born infants during the first 28 days after birth, was conducted to determine the effects of CKMC on newborn and infant health and survival.

The initial results of the trial were published in 2008 and showed no difference in overall newborn mortality between CKMC and control groups. The authors propose that the lack of effect was most likely due to insufficient skin-to-skin time between mothers and infants in the CKMC group. The objectives of this follow-up paper were to 1) present new data regarding the relationship between skin-to-skin time and infant morbidity and mortality, and 2) highlight factors that need to be addressed to increase the effectiveness of KMC and CKMC interventions.

In the Bangladesh study, most neonatal mortality (deaths during the first month of life) occurred in the first 2 days: 56% on the day of birth and an additional 5% on the following day. In the CKMC group, there was a significant inverse relationship between the length of time spent in skin-to-skin contact during the first 2 days of life and neonatal mortality. The neonatal death rate was as high as 8.4% for babies who were held less than 1 hour and as low as 0.9% for babies held 7 or more hours per day (one quarter of the national neonatal death rate in rural areas).

An important limitation of the study is that it does not rule out the possibility of “reverse causation”, i.e. that sick babies, particularly those dying in the first days of life, were less likely to be held skin-to-skin than healthy babies. It is unclear whether short duration of skin-to-skin contact is simply a marker of poor infant health or actually contributes to greater mortality.

The factor that appeared to most influence the length of time spent in skin-to-skin contact was community worker interaction with women during pregnancy. While almost 19 out of every 20 mothers who held their infant for 7 or more hours had contact with a community worker in the last month of pregnancy, only about half of mothers who held their baby for less than one hour had contact with a health worker during this period.

The authors conclude that the lack of methodologically sound evidence demonstrating that KMC and CKMC improve survival is probably due to improper implementation. They suggest that promoting skin-to-skin contact for at least 7 hours is important to increase the likelihood of impact. They advocate for more research to confirm whether and to what extent CKMC and early KMC can prevent newborn mortality in resource-poor settings. Before scaling up, identification of barriers to sufficient skin-to-skin contact and improvement of CKMC training are needed.

Community Kangaroo Mother Care: implementation and potential for neonatal survival and health in very low-income settings. Ahmed S, Mitra SN, Chowdhury AM, Camacho LL, Winikoff B, Sloan NL. J Perinatol. 2011 May;31(5):361-7. Epub 2011 Feb 10. PMID: 21311502 [PubMed - indexed for MEDLINE]

Summary written by A&T to highlight key infant and young child feeding findings as well as program implications.

To read author's abstract, visit PubMed.