Original Article

Rolling Out of Kangaroo Mother Care in Secondary Level Facilities

in Bihar-Some Experiences
Sutapa B. Neogi1, Monika Chauhan2, Jyoti Sharma3, Preeti Negandhi3, Ghanshyam Sethy4
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1
Additional Professor, 2Project Associate, 3Associate Professor, Indian Institute of Public Health-Delhi, Public Health Foundation of India,
4
Health Specialist, UNICEF, Bihar, India
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Abstract
Background: Preterm birth is one of the leading causes of under-five child deaths worldwide and in India. Kangaroo mother
care (KMC) is a powerful and easy-to-use method to promote health and well-being and reduce morbidity and mortality in
preterm/low birth weight (LBW) babies. Objective: As the part of the roll-out of India Newborn Action Plan interventions, we
implemented KMC in select facilities with an objective to assess the responsiveness of public health system to roll out KMC.
Methods: KMC intervention was implemented in two select high priority districts, Gaya and Purnea in Bihar over the duration
of 8 months from August 2015 to March 2016. The implementation of intervention was phased out into; situation analysis,
implementation of intervention, and interim assessment. KMC model, as envisaged keeping in mind the building blocks of
health system, was established in 6 identified health-care facilities. A pretested simple checklist was used to assess the
awareness, knowledge, skills, and practice of KMC during baseline situational analysis and interim assessment phases for
comparison. Results: The intervention clearly seemed to improve the awareness among auxiliary nurse midwives/nurses
about KMC. Improvements were also observed in the availability of infrastructure required for KMC and support logistics like
facility for manual expression of breast milk, cups/suitable devices such as paladi cups for feeding small babies and digital
weighing scale. Although the recording of information regarding LBW babies and KMC practice improved, still there is scope
for much improvement. Conclusion: There is a commitment at the national level to promote KMC in every facility. The present
experience shows the possibility of rolling out KMC in secondary level facilities with support from government functionaries.

Keywords: Kangaroo mother care, low birth weight, preterm, skin-to-skin contact

Introduction
The health sector has been seeing momentous changes over
the past decade in all aspects of healthcare. India contributes
to 42% of global burden of low birth weight (LBW) babies
and about a quarter of preterms births. Nearly, 30% of
neonates – 7.5 million are born with LBW, that is, birth
weight <2500 g in India.1 About 60% of the LBW infants
Corresponding Author: Dr. Sutapa B. Neogi,
Indian Institute of Public Health-Delhi, Public
Health Foundation of India, Plot No. 47,
Sector 44, Gurgaon, NCR, Haryana, India.
E-mail: sutapa.bneogi@iiphd.org
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are born at term, whereas the remaining 40% (around 3.5
million) are born preterm (before 37 weeks of gestation).2
LBW is a major contributor to infant mortality accounting
for 60%–80% of neonatal deaths3 and two-thirds of infant
deaths.4 LBW infants are at 11–13 times increased risk
Special Contribution in this Study
*KMC implementation team
*Rashid Ahmed Khan (PHFI), Shirish Tiwari (PHFI),
Siddharth Reddy (UNICEF),
Syed Hubbe Ali (UNICEF)
This is an open access article distributed under the terms of the
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License, which allows others to remix, tweak, and build upon the
work non-commercially, as long as the author is credited and the
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For reprints contact: reprints@medknow.com

DOI: 10.4103/0019-557X.195864
Cite this article as: Neogi SB, Chauhan M, Sharma J, Negandhi P, Sethy G.
Rolling out of kangaroo mother care in secondary level facilities in Bihar-Some
PMID: ***
experiences. Indian J Public Health 2016;60:302-8.

© 2016 Indian Journal of Public Health | Published by Wolters Kluwer - Medknow

 Neogi, et al.: Implementation of Kangaroo mother care at public health facilities
of dying than normal weight infants.5 Any reduction in
mortality in India will influence the global rates.
Kangaroo mother care as a strategy
Interventions to improve care during childbirth and the
postnatal period, as well as feeding, are likely to improve
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the immediate and long-term health and well-being of
the individual infant and have a significant impact on
reduction in neonatal and infant mortality at a population
level. This is even more relevant for preterm and LBW
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infants, who often require consistent care and support
until they are stabilized. Kangaroo mother care (KMC),
defined as skin-to-skin contact between a mother and
her newborn, frequent and exclusive or nearly exclusive
breast milk feeding and early discharge from hospital
has proven to be an alternative to conventional neonatal
care for LBW babies.6 Recent evidence indicates that
KMC is closely associated with a significant reduction
in the risk of overall mortality (relative risk [RR]: 0.60;
95% confidence interval [CI]: 0.39–0.93); nosocomial
infections or sepsis (RR: 0.42; 95% CI: 0.24–0.73);
hypothermia (RR: 0.23; 95% CI: 0.10–0.55). There is
a reduction in the mean duration of hospital stay by 2.4
days. The long-term impact includes improvement in the
average daily weight gain (3.9 g; 95% CI: 1.9–5.8 g) and
breastfeeding (RR: 1.25; 95% CI: 1.06–1.47).7 In the low-
and middle-income countries, where financial and human
resources for neonatal care are restricted, and hospital
wards for LBW infants are over-crowded, this approach is
feasible and seems to be an acceptable strategy. KMC also
allows for continued care at home, even after discharge
from the hospital. Both continuous and intermittent KMC
have been associated with decreased risk of infection,
hypothermia, and reduced duration of hospital stay.7
Global experiences
Experiences from community-based studies indicate that
after discharge from hospitals, a continuation of KMC
varies from 3.4% in Africa8 to 75% in Bangladesh,9
thereby emphasizing the significance of continuation
of KMC at home. Continuing KMC at home is likely to
increase the benefits of KMC manifolds.
Experiences from India
In India, the focus of NRHM on newborn care in recent
years has been on child health-care strategies that are
implementable not only at the facility but also within the
community. The proportion of institutional deliveries has
more than doubled since the launch of Janani Suraksha
Yojana scheme.10 Access to services and their utilization
Indian Journal of Public Health, Volume 60, Issue 4, October-December, 2016
303
in facilities have increased manifold. Essential newborn
care and care of sick babies have gained considerable
attention and currently several guidelines are in place
for the same.11 Despite skin-to-skin contact traditionally
being a part of child survival intervention packages,
focused attention was a critical gap. Its implementation
has not been satisfactory since KMC guidelines and
policies were not in place until September 2014.12
Given the known benefits and challenges of KMC as a
model of care for LBW babies, there is a felt need to create
scientific evidence to address the feasibility of adaptation
and scale-up of this model for LBW and preterm babies
at the health facilities. In addition, there is also need to
extend the implementation of KMC to the community,
thereby increasing the coverage. It is pertinent to tailor
the strategies for implementation of KMC according
to the diverse socio-cultural needs and resources of the
settings. There is evidence to show that context-specific
strategies are more successful and should be focused
in regions where the burden of neonatal morbidity and
mortality and more specifically LBW is high.
The objective of this study was to roll out India Newborn
Action Plan (INAP) interventions of which KMC was a
key component. We implemented KMC in select facilities
with an objective to assess the responsiveness of public
health system to roll out KMC.
Materials and Methods
As part of the rollout of INAP in Bihar, the KMC
intervention was implemented in two select high priority
districts, Gaya and Purnea. The intervention was divided
into three phases; situation analysis, implementation of
intervention, and interim assessment of the responsiveness
of the public health system in the two districts. The initial
assessment of all the health facilities in both the districts
having a delivery load of more than 200 was conducted.
The target facilities were assessed for infrastructure and
logistics; care providers (nurses/ auxiliary nurse midwives
[ANMs] on duty on the day of assessment) were assessed
for awareness, knowledge, skills and practice of KMC
using a pretested simple checklist. Based on the initial
assessment, two sub-divisional hospitals (SDH) in Gaya,
3 referral hospitals (RH) and 1 Primary Health Centre
(PHC) in Purnea district were identified for setting up KMC
Corners. A KMC Corner would be a dedicated space in
the postnatal ward of the hospital, with two or more beds
earmarked for mothers who need to practice KMC for their
 304 Neogi, et al.: Implementation of Kangaroo mother care at public health facilities

babies until discharge from the hospital. This space would
have all the requisite facilities for the implementation of
KMC (such as a screen for privacy, beds to help the mother
recline during KMC, cloths to wrap baby in KMC position).
During the implementation phase, efforts were put in to
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were interviewed regarding their knowledge, skills, and
practices regarding KMC as well as the infrastructure
available for KMC and the status of recording and
reporting the practice of KMC. During the interim
assessment, nurses and ANMs across the 6 facilities,
where KMC set up was established, and the intervention

equip the identified facilities and health-care staff therein
with required logistics and skills to facilitate the delivery
of KMC services. The implementation phase lasted for
8 months from August 2015 to March 2016. Interim
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was implemented over the preceding 8 months, were
interviewed and observations were made to draw the
results.

assessment was conducted in April 2016 to assess the
improvement in awareness, knowledge, skills, and practice
about KMC in the identified facilities of both the districts.
The INAP project was approved by Institutional Ethics
Committee of Indian Institute of Public Health Delhi
at the outset, and assessment of the implementation of
KMC in the two districts of Bihar was part of the project
activities. The data for the interim assessment were
collected from the health-care facilities by talking to the
staff as well as through observations. For the purpose
of maintaining confidentiality, the names of the staff
members have not been revealed anywhere in the paper.
Results
The baseline situational analysis was conducted in 22
facilities in both the districts, wherein nurses and ANMs
In the baseline assessment it was found that although
a considerable number of ANMs/nurses (17, 77.3%)
knew about KMC as an intervention, only 5 (23%)
were aware about recommending KMC for LBW
babies. Their knowledge on correct time to initiate
breastfeeding was relatively poor (72.7%). Digital
weighing machines were used to measure weight, but
most of them (68%) referred all babies with LBW to
newborn care corners (NBCCs), and the practice of
KMC was not common. Adequate infrastructure was not
made available to manage LBW babies. Furthermore,
the system of recording and reporting though existed
was not optimum to capture basic information on LBW
babies [Table 1].
Kangaroo mother care intervention model
A KMC model was envisaged keeping in mind the building
blocks of health system that was finalized in consultation

Table 1: A comparison between baseline and Interim assessment of key indicators pertaining to kangaroo mother care
Domain
Level of awareness
Availability of infrastructure,
and logistics
Recording and reporting
KMC = Kangaroo mother care, ANMs = Auxiliary nurse midwifes, LBW = Low birth weight
Indicators Baseline assessment, Interim assessment,
n=22 facilities (%) n=6 facilities (%)
Proportion of ANMs/nurses who knew about right time to 17 (77.3) 6 (100)
initiate KMC (look for answer: within 1 h of birth)
Proportion of ANM/nurses who recorded birth weight of 20 (90.9) 6 (100)
every baby
Proportion of care providers who would recommend KMC if 5 (22.7) 5 (83.3)
the birth weight is <2500 g
Proportion of health care facilities having separate room/ 2 (9.5) 6 (100)
space for mothers to practice KMC
Proportion of health care facilities having facility for 4 (18.2) 4 (66.7)
expression of breast milk
Proportion of health care facilities having digital baby 20 (90.9) 6 (100)
weighing scales
Proportion of health care facilities having room heaters for - -
centers in areas requiring room heating
Proportion of health care facilities having cups/suitable 5 (22.7) 3 (50)
devices for feeding small babies
Proportion of healthcare facilities having separate register to 4 (18.2) 3 (50)
record information about KMC
Proportion of healthcare facilities reporting LBW/preterm 22 (100) 4 (66.7)
babies
Proportion of healthcare facilities reporting LBW/preterm - 3 (50)
babies receiving KMC

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 Neogi, et al.: Implementation of Kangaroo mother care at public health facilities
with the district authorities. The implementation of
intervention phase started with apprising the service
providers and managers at district level about the KMC
intervention as part of the INAP roll out and its importance
for managing LBW babies. Official letters were issued for
roll out of KMC intervention and assurance for providing
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all the necessary support toward its implementation by
district level authorities was given.
In consultation with the respective district authorities
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and feasibility of implementation, a total of six health
facilities were identified for setting up KMC Corners in
both the districts two SDH in Gaya district and three RH
and one PHC in Purnea district.
The names of the identified facilities are listed below:
• In Gaya district-SDH Tekari and SDH Sherghati
• In Purnea district-RH Damdaha, RH Rupauli, RHB
anmankhi, and PHC Amour.
In both the districts separately, the medical officers-
in-charge and block health managers of the selected
facilities were sensitized about the importance of KMC.
Not only the availability of suitable space was a hurdle
for this intervention but also the availability of funds was
a concern. The field team comprising of members from
UNICEF and Public Health Foundation of India provided
technical support to designate separate space/room in the
facilities with basic amenities to practice KMC. Since
no funds were earmarked for this activity in the Program
Implementation Plan (PIP), Rogi Kalyan Samitis (RKS)
provided the requisite financial support. The team
facilitated the preparation of District-level newborn
action plan where separate funds could be allocated to
KMC. Information education and communication (IEC)
departments of the districts were requested to display
the necessary visual materials in all the KMC Corners.
The staff from labor room/postnatal ward were identified
and given charge of KMC Corners and their duty
schedules were rotated so as to have at least one staff
dedicated to KMC Corners round the clock. The KMC
component was discussed during monthly meetings,
and its implementation was emphasized during trainings
on Navjaat Shishu Suraksha Karyakram conducted for
ANMs during the intervention period. Besides, on-site
training and demonstrations were provided by the field
team to the ANMs, nurses as well as the MAMTA workers
(contract health workers based in the facilities for care
of newborn babies and their mothers). In addition, KMC
Indian Journal of Public Health, Volume 60, Issue 4, October-December, 2016
305
practice was emphasized in other overlapping trainings
that the staff were exposed to.
The activities in KMC Corners of all the identified health
facilities were closely monitored and supervised by the
field team. It was also advocated to the government
through District Health Society that KMC related
indicators must be included in the existing Health
Management and Information System.
The key points included in the intervention model are
summarized in Table 2.
The activities toward implementation of the model
continued for 8 months after which an assessment was
performed. The results [Table 2] demonstrated a definite
improvement in the awareness among ANMs/nurses
about KMC. Care providers were adept to providing
KMC in the same facilities instead of referring every
LBW baby to NBCC as was happening previously.
The intervention clearly seemed to impact the availability of
infrastructure required for KMC as provision was made for
separate space/room/beds for providing KMC in the selected
facilities. Provisions such as the presence of curtains/
separators/partitions were made to maintain the privacy of
the mother-baby duo while practicing KMC. Facilities for
manual expression of breast milk were also made available
at four of the six health-care facilities. Although availability
of digital weighing scale and cups/suitable devices like
paladi cups for feeding small babies improved (100% and
50%, respectively) with efforts, yet the presence of room
heaters and feeding tubes remained a concern.
Over a period of 8 months of intervention, the recording,
and reporting of KMC improved a little. Though the
availability of separate register to record the information
about LBW babies increased to 50% and LBW babies
receiving KMC started getting reported in half of the
facilities, there is a lot of scope for further improvement.
Discussion
An intervention model was developed and rolled out
in select facilities in Bihar to institutionalize KMC. Its
success can be noted in terms of increased awareness
and knowledge about KMC among the care providers,
significant improvement in terms of infrastructure,
logistics, and ownership of the health-care providers
over 8 months.
 306 Neogi, et al.: Implementation of Kangaroo mother care at public health facilities

Table 2: Components of kangaroo mother care implementation model with respect to WHO health systems framework
Health system building block Challenges Actual activities done during implementation
Leadership and governance Lack of awareness on benefits of KMC among Conducted workshops and involved MOICs, BHMs, senior
hospital staff and their commitment officers from state and district in designing a roadmap of
Lack of knowledge among district level managers DNAP
on allocation of resources and budget for KMC A separate space was identified in consultation with hospital
implementation staff in selected facilities and developed as KMC corners
Emphasis was given to identify dedicated staff for managing
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KMC corners
Health financing Separate budget for KMC implementation not BHMs were requested to utilize RKS fund to setup KMC
specified corner
A separate budget line item was include in DNAP for KMC
implementation
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Health workforce Shortage and poor distribution of well trained staff A comprehensive training (NSSK) was imparted to health
workers giving due emphasis on KMC
On‑site training and mentoring of ANMs/nurses
Essential medical products Lack of awareness on list and budget for Meeting with MOICs and BHMs for essential requirements
and technologies equipment to implement KMC for KMC setup and inclusion of the same in the PIP
The requirements for setting up KMC corners such as
screen for privacy, IEC displays, weighing machine,
wrapping towels, covering blankets were provided
Other requirements like recumbent chairs and recumbent
beds were requested for inclusion in DNAP
Health information systems Lack of records and reporting Developed a separate register to record details on LBW
Poor quality of data babies requiring and receiving KMC
Initiated recording of details related to KMC
Health service delivery Lack of institutionalization of KMC Sensitization of staff members on national guidelines for
Poor quality of services KMC implementation
Community ownership and partnership Regular monitoring and supportive supervision by the PHFI/
UNICEF staff
Developed follow up of LBW and preterm newborn babies
after discharge through follow up by SNCU staff
Requested District Program Managers to issue official
letter regarding community follow up of LBW and preterm
newborn babies by ASHA and AWW
LBW = Low birth weight, MOICs = Medical Officers in‑charge, BHMs = Block health managers, DNAP = District‑level Newborn Action Plan, RKS = Rogi Kalyan Samitis, NSSK
= Navjaat Shishu Suraksha Karyakram, PIP = Program Implementation Plan, IEC = Information education and communication, UNICEF = United Nations Children's Fund,
PHFI = Public Health Foundation of India, SNCU = Special Newborn Care Units, ASHA = American Speech‑Language‑Hearing Association, AWW = Anganwadi Worker

Our findings are similar to the experiences reported
from other countries. Reports on KMC in four regions
in Ghana indicated that after implementation of the
program, 50% of total hospitals had a separate KMC
ward and other 34% had been using beds in the postnatal
ward for this purpose.13 The practice of providing KMC
to LBW babies was seen as a significant change, similar
to our findings. Research from Africa and Asia highlights
the success of KMC as a vertical, donor-driven strategy
in tertiary care hospitals; however, dissemination at
tertiary level hospitals was limited and cascading
the strategy to lower health-care levels remained a
challenge.14-17 Experience from South Africa revealed
reluctance of hospital management to allocate dedicated
space for mothers to practice KMC round-the-clock.18
Besides training, innovation and improvization on other
aspects of the health system, including infrastructure,
human resource, community mobilization, behavior
change, family support to facilitate and continue KMC
implementation also deserve due importance.17,19-21 In
our intervention model, we considered every aspect of
health system strengthening so as to have a sustainable
model in place.
Continuous supervision by a senior professional or
other cadre is crucial, given the specialization required
to care for vulnerable LBW and preterm babies. The
current intervention utilized the existing workforce for
the purpose of managing the LBW babies with the help
of KMC, further burdening the already overburdened
health-care workers. To manage the crunch of staff, at
one major hospital in Malawi, in the absence of qualified
staff, patient attendants were trained to run KMC ward
under nursing and medical supervision.22
Facility-based studies conducted in India on KMC show
significant benefits in terms of acceptability, feasibility,
improved growth and reduced infections among
newborns.23-25 However, around 50% mothers go home
within 48 h of delivery.26 For ensuring optimum benefit;

Indian Journal of Public Health, Volume 60, Issue 4, October-December, 2016

 Neogi, et al.: Implementation of Kangaroo mother care at public health facilities
it is important to ensure that the mothers initiating KMC
in the hospitals continue it even after discharge. There is,
therefore, a need to link facility with community-based
practice. Community-based research carried out by
Indian Council of Medical Research (ICMR) covering
diverse population groups (urban, rural, tribal) suggests
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that the method is acceptable to mothers and family
members. The intervention package in the ICMR study
included providing information on the benefits of KMC
to mothers during the antenatal check-ups through IEC
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material, films on KMC and posters. Over 50% mothers
initiated KMC within 72 h after delivery and 80% did so
within a week, average duration being 5 h.27 Nevertheless,
this model had its challenges and barriers in terms of
awareness and knowledge of KMC, continuation of KMC
after discharge from the facility, support from family at
home21 and time that can be allocated to provide KMC,
given other household chores.
Similar issues were reported in a multi-country analysis
of 12 Asian and African countries and were rated as
very major bottlenecks.28 There was an overall lack of
prioritization of KMC by regulatory bodies and lack
of institutionalization of KMC. Financial barriers were
also very prominently emphasized. Inadequate space
for performing and monitoring KMC, poor referral and
transport system, poor quality of KMC delivery and weak
quality improvement measures were reported. Health
information challenges were also acknowledged as one
of the barriers for scaling up of KMC.28
Our model could address some of these challenges
with the help of district authorities and the health-
care staff. Every aspect of the intervention was owned
by the district. With minimal investment, we could
mobilize some funds from RKS for the intervention.
Staff members were imparted training and mentoring on
KMC implementation. Despite issues with availability
of space and logistics, six facilities succeeded in setting
up KMC corners and initiated implementation of KMC
in 8 months’ time.
However, the limited duration of the intervention was
a relatively short time to assess the impact of any
intervention. Moreover, the number of facilities where the
model could be implemented was small. We, therefore,
conducted an interim assessment to gauge the progress
related to the implementation of the model and the
challenges thereof. With these limitations, it is difficult to
determine the sustainability and scalability of the model.
Indian Journal of Public Health, Volume 60, Issue 4, October-December, 2016
307
Experiences have shown that the pathway for KMC
scale-up in low-income countries like for many other
interventions has been donor-driven and has resulted
in countries being dependent on this funding.29 There
is a need to integrate the budgetary allocation for KMC
implementation in PIP to maintain the continuous influx
of money to initiate and sustain this intervention. In India,
there is a political commitment to promote KMC as a
part of INAP and RMNCH+A.30 However, the budget
allocated for KMC is subsumed within the broad head
of newborn health and hence does not catch the attention
of district managers.
Conclusion
To conclude, there is a commitment at the national level
to promote KMC in every facility. Our experiences
have shown that it is possible to roll-out KMC in
secondary level facilities with support from government
functionaries. With an intervention that lasted for less
than a year in limited facilities, and initial success in the
uptake of the program, we are yet to see how sustainable
the efforts are in the long run.
Financial support and sponsorship
UNICEF, Bihar.
Conflicts of interest
Ghanshyam Sethy, Syed Hubbe Ali and Siddharth Reddy
are affiliated to UNICEF Bihar (sponsor of the study
and supplement). The views expressed in the paper are
those of the individuals and not of the organizations they
represent.
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