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BARRIERS TO AND ENABLERS OF ADHERENCE TO FOLLOW UP AFTER DISCHARGE FROM THE KANGAROO MOTHER CARE UNIT: THE EXPERIENCE OF KENYATTA NATIONAL AND PUMWANI MATERNITY HOSPITALS IN NAIROBI, KENYA Presenter: Lynn Kanyuuru

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  1. BARRIERS TO AND ENABLERS OF ADHERENCE TO FOLLOW UP AFTER DISCHARGE FROM THE KANGAROO MOTHER CARE UNIT: THE EXPERIENCE OF KENYATTA NATIONAL AND PUMWANI MATERNITY HOSPITALS IN NAIROBI, KENYA Presenter: Lynn Kanyuuru Event: USAID FP/RHMNCAH/ Nutrition and WASH Implementing Partners Annual Symposium, at Sarova Woodlands, Nakuru Date: 26th March 2019

  2. Presenter Bio & Picture • Name: Lynn Kanyuuru • Role: Head of Health and Nutrition, • Save the Children Kenya • Education: MBChB, MPH • Work experience: 13 years • Q: If you were an animal, which animal would you be? • A: A snake; they make moving without legs look grateful and effortless. They can be beautiful too. USAID FP/RHMNCAH/ Nutrition and WASH IP Symposium

  3. The Context • In Kenya, while under-age-5 deaths have decreased by 50% since 1990, newborn mortality rates have remained relatively stagnant and currently stand at 22/1,000 live births. • Pre-term birth contributes to 12% of the under-five mortality. USAID FP/RHMNCAH/ Nutrition and WASH IP Symposium

  4. Kangaroo Mother Care (KMC) • Continuous, prolonged skin–to–skin contact between a mother and her preterm/low birth weight new-born with frequent and exclusive breastfeeding, and early discharge from the hospital to continue KMC at home. • Benefits include: • Thermal regulation • Improved bonding • Promotes breast feeding • Infection prevention • Reduces stress • Reduced cost • Additional nursing staff not required KMC requirements: • Wrap (Lesso/Kanga) for the baby • Willing mother or guardian • Can be done at home or hospital • Eligibility: • Stable LBW infant • Moderate and late preterm babies USAID FP/RHMNCAH/ Nutrition and WASH IP Symposium

  5. Background • Nairobi County has the highest neonatal mortality in Kenya estimated at 39/1,000 live births (2014 KDHS) • Most babies who go through KMC are discharged from hospital earlier than those who do not • With early discharge, there is need for strong and effective follow up systems • Studies have shown that approximately 25% of babies discharged to continue KMC at home die within the first two months of discharge and the mortality could be reduced to 2.5% with better follow up systems. USAID FP/RHMNCAH/ Nutrition and WASH IP Symposium

  6. Study Justification and Objectives • Study Objectives: • Main aim: to understand whether mothers/caregivers of preterm and low birth weight babies receive any follow-up after being discharged from hospital KMC units and what factors influence their decision to receive follow-up. Secondary aim: to determine the experience of KMC by mothers once they are discharged, and whether they adhere to the KMC practice while at home. • Study Justification: Number of babies discharged to continue KMC at home vs. those returning for scheduled follow-up USAID FP/RHMNCAH/ Nutrition and WASH IP Symposium

  7. Materials and Methods • Recruitment and Consenting Procedures: • Consent was sought by KMC mothers during these routine follow-up calls • Consent was verified through re-reading the consent form and confirming consent prior to starting the interview by the study team • Sample Size Determination: • Ethical Considerations: • Ethical clearance from the Save the Children Ethical Review Committee (ERC) and the Kenyatta National Hospital/University of Nairobi Ethical Review Board (ERB) • Clearance letter was obtained from the two facilities • Study Design: mixed methods approach • Study Population: asample of mother-baby pairs who had been discharged from the KMC Unit during the October 2017 –June 2018 period • Inclusion criteria: Mothers and their baby who were discharged over the October 2017 - June 2018 period from the KMC Unit at two hospitals: Kenyatta National Hospital and Pumwani Maternity Hospital. • Exclusion criteria: Mothers who cannot be reached over the phone by the KMC unit nurse. • Study Site Description: • Kenyatta National Hospital • Pumwani Hospital USAID FP/RHMNCAH/ Nutrition and WASH IP Symposium

  8. Findings and Discussions 1: Demographic characteristics USAID FP/RHMNCAH/ Nutrition and WASH IP Symposium

  9. Findings and Discussions 2 USAID FP/RHMNCAH/ Nutrition and WASH IP Symposium

  10. Findings and Discussions 3: Experience To assess overall experience at delivery facility for mothers, a composite score for each respondent (n=152) was obtained using five variables. A percentage score was computed based on the maximum attainable score of 5. KNH recorded the higher proportion of mothers reporting experience as unsatisfactory (n=36) at 41% of respondents followed by Pumwani at 23%. USAID FP/RHMNCAH/ Nutrition and WASH IP Symposium

  11. Findings and Discussions 4: Follow up Almost all mothers/ caregivers involved in KMC (96.7%, n= 152) returned to a facility for follow up after discharge. USAID FP/RHMNCAH/ Nutrition and WASH IP Symposium

  12. Findings and Discussions 5: Follow up There was a total of nine services delivered during a KMC follow-up visit. Most mothers reported having received two services (28%), followed by 3 services (24%), then one service (19%); four percent (4%) of the mothers reported that they received no service. The two most reported services were weighing the baby (90%) and performing physical examination of the baby (52%). USAID FP/RHMNCAH/ Nutrition and WASH IP Symposium

  13. Findings and Discussions 6: Reported reasons for follow up USAID FP/RHMNCAH/ Nutrition and WASH IP Symposium

  14. Findings and Discussions 7: Factors influencing the decision for follow up • Bivariate analysis of factors deemed to be influential on follow-up was done • The only associations that were statistically significant was between: making a follow-up visit and number of children the care giver had (χ2=9.942; df=±4; P-value=0.041) discharge weight and interval required to make follow-up (χ2=30.305a; df=±18; P-value=0.035) USAID FP/RHMNCAH/ Nutrition and WASH IP Symposium

  15. Findings and Discussions 8: Reported barriers to follow up USAID FP/RHMNCAH/ Nutrition and WASH IP Symposium

  16. Findings and Discussions 9: Experiences of mothers in providing KMC care at home • Majority of mothers 96.7% practiced KMC at home • The average period recorded by mothers to be practicing KMC at home was a month • Most mothers (74.1%, n = 147) had family help to practice KMC, the most form of aid provided by family members was holding baby on skin to skin position. The family member recorded to have assisted mothers most were their husbands at 67.0% • Most mothers practiced skin to skin contact between 0-6 hours in a day and found daytime as the most convenient time to practice KMC • No relation between baby illness and mother practicing KMC at home USAID FP/RHMNCAH/ Nutrition and WASH IP Symposium

  17. Conclusions • Majority of the mothers (96.7%) discharged from KMC return to facility for at least one follow-up • Choice of health facility for follow up depended largely on advice provided at discharge and distance to the facility • Except for a weak association between number of children a mother had and follow-up visits made, none of the other socio-demographic characteristics produced an association against follow-up • An inconsistency was observed with 67.0% of mothers reporting their husbands had been supportive in KMC practice at home, therefore the nature and adequacy of this support may require further interrogation • There was no adequate data to assess the relationship between mothers who made follow-up and state of wellbeing of their children USAID FP/RHMNCAH/ Nutrition and WASH IP Symposium

  18. Recommendations • Build a post discharge system. This should include the definition of outpatient KMC package of care and building the capacity for lower level health care facilities to integrate KMC and provide services closer home • Proper documentation at facility on follow-up and referral after discharge • Pre-discharge counselling to mothers in advance rather than waiting for the discharge day. A summarized guideline for health workers would aid with this • Have KMC specific follow-up days to avoid stigmatization • Improved and integrated services provided during follow-up USAID FP/RHMNCAH/ Nutrition and WASH IP Symposium

  19. Acknowledgement • Community • Health Care Workers • Ministry of Health (County and National) • Comic Relief USAID FP/RHMNCAH/ Nutrition and WASH IP Symposium

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