The newborn wriggled as she was lowered onto her mother’s chest, minuscule fists clenched, eyes fluttering, chest softly rising and falling. As a nurse wrapped a binding around the pair to steady the tiny body, the baby snuggled into her mother’s skin. The mother began to weep.
“I quickly asked her if she was all right,” says Dr. Sugandha Arya. The infant, born 48 hours earlier, had been immediately separated from her mother and placed in the neonatal intensive care unit (ICU).
The proven power of kangaroo mother care
That poignant scene unfolded in a hospital in India during a clinical trial whose findings could help save the lives of 150,000 premature and low-birthweight babies around the world each year.
Across the globe, one in 10 babies is born preterm, meaning before 37 full weeks of pregnancy. Survival rates of preterm babies vary widely. Prematurity can have a stark effect on overall health, significantly increasing the likelihood of major and chronic illness, disability, and developmental delays.
Preterm babies have many needs, according to Dr. Arya, a pediatric specialist at Safdarjung Hospital in Delhi, India, and one of the clinical trial’s onsite investigators. These include infection prevention, early feeding with breast milk, respiratory support, and thermal care.
The practice of kangaroo mother care (KMC) helps address those needs. Named for the way kangaroo mothers carry and nurse their infants in their pouch, KMC involves prolonged skin-to-skin contact between the mother (or a caregiver) and the baby, as well as breastfeeding when possible. KMC keeps babies warm and stable. It’s also adaptable and can happen in conjunction with oxygen therapy, intravenous fluids, and even more intensive respiratory support.
Early research showed that KMC led to a significant reduction in newborn deaths. The intervention has been recommended for years as important for preterm and low-birthweight babies, but only if they are stable at birth or once they have been stabilized, which could take days or even weeks for very preterm and sick newborns.
Bringing immediacy to kangaroo mother care
New findings from the clinical trial, which was conducted at five hospitals in five countries—including Safdarjung Hospital in India—suggest that a variation of KMC could prove to be even more of a lifesaver. The trial ran from December 2017 to January 2020 in Ghana, India, Malawi, Nigeria, and Tanzania, with funding from the Bill & Melinda Gates Foundation as part of its commitment to help ensure the health of women and their newborns before, during, and after childbirth.
Unstable infants with a birth weight between 1 and 1.799 kilograms were put into one of two groups. One group received immediate KMC, during which the mother or caregiver provided up to 17 hours of skin-to-skin contact per day in a mother-newborn ICU. The other group received conventional care in an incubator or warmer until the baby’s condition stabilized, followed by KMC afterwards.
The clinical trial set out to answer the question of whether KMC could be used for every preterm baby, stable or not, and to compare the benefits of immediate versus standard KMC for all babies, whether stable or not.
“Our question,” says Dr. Harish Chellani, the head of pediatrics at Safdarjung Hospital and a key investigator in the clinical trial, was:
The findings showed a 25% reduction in preterm deaths in the immediate KMC group. The trial was so successful that it was stopped early because everyone involved decided it was unethical to deny other preterm and low-birthweight babies what was clearly lifesaving care.
Using calculations from the trial’s results, a team of trial experts estimated that globally, immediate KMC could save 150,000 more babies every year.
From “standard” to “immediate”
As a result of the clinical trial, the World Health Organization issued new guidelines in November 2022 advising that all preterm and low-birthweight babies have immediate skin-to-skin contact with a caregiver after birth—without any initial time in an incubator, irrespective of the baby’s birth weight, gestational age, or stability.
That marked a significant change from earlier guidance, which called for preterm babies and mothers to be cared for by different departments in separate hospital sections. With immediate KMC, they are kept together in the same area, allowing for continuous skin-to-skin contact and integrated care from an integrated medical team.
“No change comes without challenges,” says Dr. Pratima Mittal, who was involved with the clinical trial when she was the head of the obstetrics department at Safdarjung Hospital. During that time, she oversaw necessary adjustments to the hospital’s physical spaces for women in labor, as well as updates to procedures affecting labor and delivery patients—including infection prevention practices, policies, and personnel.
What made it all work, says Dr. Mittal, was the commitment of hospital leaders as well as good communication and training.
“Strong leadership is very important,” she says. In this case, that meant clear alignment among the heads of the neonatology and obstetrics departments and the medical superintendent.
Despite some initial apprehension as the trial began, the positive results soon became a strong motivating factor, according to Dr. Mittal. Since the trial concluded, the motivation has been even stronger.
A prematurely born baby is given skin to skin contact with the mother at Safdarjung Hospital in New Delhi, India.
Shifting the paradigm of care
Dr. Nitya Wadhwa also notes the importance of evidence. A senior professor at the Translational Health Science and Technology Institute, she supported trial protocols, guidelines, research, and data at the trial site in India. She says the neonatal nurses involved in the trial were initially apprehensive and “talked about how much extra work this would be.” But as the trial progressed, their apprehensions vanished. Immediate KMC did not translate into more work for them—quite the opposite, since mothers and caregivers were now more involved in the babies’ care. And the positive results were extremely motivating.
Dr. Wadhwa also notes the significance of getting extended families and caregivers involved. “We saw whole families coming in with the mother for delivery,” she says. “And so we had surrogates who could provide the skin-to-skin contact, whether a sister or grandmother.” Further, she saw mothers who had experienced immediate KMC become KMC champions, encouraging other new mothers and families. “It was very heartening,” she says.
That aligns with what Aarti Kumar has seen in her decades of work in newborn care and KMC. As the CEO of the Community Empowerment Lab in Uttar Pradesh, India, Kumar helped lead a study of standard KMC in 2004 (also funded by the Gates Foundation) and has been a passionate advocate ever since.
Mothers regularly tell Kumar, “The baby doesn’t startle and is sleeping better. I have more breast milk, earlier.” These positive experiences directly correlate with the likelihood that mothers will continue KMC once they get home, she says.
A few years ago, Kumar led an immediate KMC workshop for nurses. She first had them express their concerns and resistance, and then she shared empirical and anecdotal evidence. She asked these frontline health workers to imagine immediate KMC from the perspective of a newborn that has just come into the world, leaving the womb that kept it safe and nourished.
To Kumar’s astonishment, “many nurses cried during this exercise,” she says. “They had a deep sense of realization that the baby needs to be reunited with its mother.” Some nurses told Kumar that the workshop shifted the way they thought about the babies, especially those with little chance of survival. “That was a transformative moment,” she says.
Moving toward a new standard of care
Many hospitals and clinics already implement standard KMC, but a large percentage need updates to their facilities, as well as staff training to embrace and offer immediate KMC. Those updates include redesigned health systems in the form of mother-newborn ICUs that provide care and medical treatment for both mother and newborn with no separation time or distance between them—even if the baby needs additional medical support.
In this new environment, medical staff involve mothers and caregivers in clinical care. What’s more, mothers and caregivers have dignified spaces for cleaning and bathing, are provided nutritious meals, and are heard and supported. Visitor policies also need updating to enhance the participation of caregivers and family members so immediate KMC is a shared responsibility.
Above all, according to Dr. Arya, what’s needed is space in people’s minds.
“We need to make ourselves open to change. If you change a mindset, you’ll be able to find answers to all obstacles.”
