BackgroundPreterm birth is now the leading cause of under-five child deaths worldwide with one million direct deaths plus approximately another million where preterm is a risk factor for neonatal deaths due to other causes. There is strong evidence that kangaroo mother care (KMC) reduces mortality among babies with birth weight <2000 g (mostly preterm). KMC involves continuous skin-to-skin contact, breastfeeding support, and promotion of early hospital discharge with follow-up. The World Health Organization has endorsed KMC for stabilised newborns in health facilities in both high-income and low-resource settings. The objectives of this paper are to: (1) use a 12-country analysis to explore health system bottlenecks affecting the scale-up of KMC; (2) propose solutions to the most significant bottlenecks; and (3) outline priority actions for scale-up.MethodsThe bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops involved technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks", factors that hinder the scale-up, of maternal-newborn intervention packages. We used quantitative and qualitative methods to analyse the bottleneck data, combined with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for KMC.ResultsMarked differences were found in the perceived severity of health system bottlenecks between Asian and African countries, with the former reporting more significant or very major bottlenecks for KMC with respect to all the health system building blocks. Community ownership and health financing bottlenecks were significant or very major bottlenecks for KMC in both low and high mortality contexts, particularly in South Asia. Significant bottlenecks were also reported for leadership and governance and health workforce building blocks.ConclusionsThere are at least a dozen countries worldwide with national KMC programmes, and we identify three pathways to scale: (1) champion-led; (2) project-initiated; and (3) health systems designed. The combination of all three pathways may lead to more rapid scale-up. KMC has the potential to save lives, and change the face of facility-based newborn care, whilst empowering women to care for their preterm newborns.

ObjectiveTo present information on the quality of newborn care services and health facility readiness to provide newborn care in 6 African countries, and to advocate for the improvement of providers' essential newborn care knowledge and skills.DesignCross-sectional observational health facility assessment.SettingEthiopia, Kenya, Madagascar, Mozambique, Rwanda and Tanzania.ParticipantsHealth workers in 643 facilities. 1016 health workers were interviewed, and 2377 babies were observed in the facilities surveyed.Main outcome measuresIndicators of quality of newborn care included (1) provision of immediate essential newborn care: thermal care, hygienic cord care, and early and exclusive initiation of breast feeding; (2) actual and simulated resuscitation of asphyxiated newborn infants; and (3) knowledge of health workers on essential newborn care, including resuscitation.ResultsSterile or clean cord cutting instruments, suction devices, and tables or firm surfaces for resuscitation were commonly available. 80% of newborns were immediately dried after birth and received clean cord care in most of the studied facilities. In all countries assessed, major deficiencies exist for essential newborn care supplies and equipment, as well as for health worker knowledge and performance of key routine newborn care practices, particularly for immediate skin-to-skin contact and breastfeeding initiation. Of newborns who did not cry at birth, 89% either recovered on their own or through active steps taken by the provider through resuscitation with initial stimulation and/or ventilation. 11% of newborns died. Assessment of simulated resuscitation using a NeoNatalie anatomic model showed that less than a third of providers were able to demonstrate ventilation skills correctly.ConclusionsThe findings shared in this paper call attention to the critical need to improve health facility readiness to provide quality newborn care services and to ensure that service providers have the necessary equipment, supplies, knowledge and skills that are critical to save newborn lives.

Swaziland's prevention of mother-to-child transmission (PMTCT) programme is linked to maternal and newborn health (MNH) services, but is mainly focussed on HIV/AIDS. Existing MNH services are inadequate, especially postnatal care (PNC) of mothers and babies, with delayed postnatal visits occurring at 4-6 weeks after delivery. Fifty-seven percent of staff in seven Swazi health facilities were trained in promoting and providing early PNC. A final evaluation showed a 20-fold increase in the number of visits coming for an early postnatal visit (within the first three days after birth). A direct observation of the client-provider interaction showed a significant increase in the competence of the health workers related to postnatal examinations, and care of mothers and babies (p<0.05- < 0.01). The percentage of women breastfeeding within one hour of delivery increased by 41% in HIV-positive mothers and 52% in HIV-negative mothers. Cotrimoxazole prophylaxis for HIV-exposed infants increased by 24%. Although, health workers were observed providing counselling, maternal recall of messages was deficient, suggesting the need for additional strategies for promoting healthy behaviours. High-quality integrated PMTCT programmes and MNH postnatal services are feasible and acceptable, and can result in promoting early postnatal visits and improved care of both HIV-positive and HIV-negative mothers and their babies.

BackgroundAs efforts to scale up the delivery of Kangaroo Mother Care (KMC) in facilities are increasing, a standardized approach to measure implementation and progress towards effective coverage is needed. Here, we describe a consensus–based approach to develop a measurement framework and identify a core set of indicators for monitoring facility–based KMC that would be feasible to measure within existing systems.MethodsThe KMC measurement framework and core list of indicators were developed through: 1) scoping exercise to identify potential indicators through literature review and requests from researchers and program implementers; and 2) face–to–face consultations with KMC and measurement experts working at country and global levels to review candidate indicators and finalize selection and definitions.ResultsThe KMC measurement framework includes two main components: 1) service readiness, based on the WHO building blocks framework; and 2) service delivery action sequence covering identification, service initiation, continuation to discharge, and follow–up to graduation. Consensus was reached on 10 core indicators for KMC, which were organized according to the measurement framework. We identified 4 service readiness indicators, capturing national level policy for KMC, availability of KMC indicators in HMIS, costed operational plans for KMC and availability of KMC services at health facilities with inpatient maternity services. Six indicators were defined for service delivery, including weighing of babies at birth, identification of those ≤2000 g, initiation of facility–based KMC, monitoring the quality of KMC, status of babies at discharge from the facility and levels of follow–up (according to country–specific protocol).ConclusionsThese core KMC indicators, identified with input from a wide range of global and country–level KMC and measurement experts, can aid efforts to strengthen monitoring systems and facilitate global tracking of KMC implementation. As data collection systems advance, we encourage program managers and evaluators to document their experiences using this framework to measure progress and allow indicator refinement, with the overall aim of working towards sustainable, country–led data systems.