BMJ Open Qual: first published as 10.1136/bmjoq-2021-001775 on 11 May 2022. Downloaded from http://bmjopenquality.bmj.

com/ on February 9, 2023 at Yonsei University (Medical Library

Open access Quality improvement report

Quality improvement initiative to

improve the duration of Kangaroo
Mother Care in tertiary care neonatal
unit of South India
Sathya Jegannathan, Muthukumaran Natarajan, Manikumar Solaiappan,
Ramya Shanmugam, Sandeep Ajit Tilwani

To cite: Jegannathan S, ABSTRACT implementation is not satisfactory and

Natarajan M, Solaiappan M, Background India has the highest number of preterm average institutional duration of KMC in all
et al. Quality improvement
births and maximum number of deaths due to prematurity. Indian studies is very low as compared with
initiative to improve the duration
of Kangaroo Mother Care in
Chengalpattu Government Medical College had 11 593 recommended standards.3 4
tertiary care neonatal unit of deliveries annually in 2020, of which 2252 of neonates There are almost 12 000 live births annu-
South India. BMJ Open Quality were low birth weight. 2016 Cochrane review concluded ally in Chengalpattu Medical College, with
2022;11:e001775. doi:10.1136/ that Kangaroo Mother Care (KMC) reduces the morbidity
around 1500 babies born less than 2 kg weight
bmjoq-2021-001775 and mortality in low birthweight infants. The average
every year. We have a 66-­bed neonatal unit,
duration of KMC in our unit was around 4.6 hours/baby/
day. with 16-­ bed level 3 NICU, 20-­ bed level 2

and Hospital). Protected by copyright.

Received 7 December 2021
Accepted 18 April 2022 Objective To improve the duration of KMC in stable low NICU and 30-­bed level 1 NICU. In a prelim-
birthweight babies from short duration to continuous inary survey conducted prior to discharge in
duration (>12 hours) over 8 weeks. our unit, our KMC duration was 4.6 hours/
Methods The implementation phase was conducted baby/day. So, this study was implemented as
during January 2021 and February 2021. All babies with first QI project in our unit.
birth weight <2 kg and who were haemodynamically Cochrane meta analysis published in
stable were enrolled. QI (Qualitympovement) team included 2016 showed that KMC was associated with
staff nurses, nursing in charge, resident doctors and mortality reduction at 40 weeks post menstrual
consultants. Potential barriers were listed using fishbone
age (40%); reduced late onset sepsis (LOS)
analysis. Various possible interventions were identified
(65%); reduced hypoglycaemia (80%);
and a priority matrix was formed to decide the sequence
of introduction of changes. The following measures were reduced hypothermia (72%); increased rates
subsequently tested by multiple PDSA (Plan Do Study Act) of exclusive breast feeding; increased weight
cycles: ensuring the availability of KMC charts, combining gain,head circumference and length; and
KMC chart with individualised weight chart, documentation decreased readmission rates.5
of KMC duration in case sheets, increasing number of KMC
chairs, opening of mother–neonatal ICU (M-­NICU), KMC
slings for mothers, education videos in local language and METHODS
rewards for mothers. This study was conducted in Department
Outcome indicator Duration of KMC, recorded by bedside of Neonatology at Chengalpattu Medical
nurses on daily basis. College during January–August 2021. All
Results A total of 86 newborns were enrolled. At the end babies weighing less than 2 kg, who were
of 8 weeks, average duration of KMC increased to 16.6 haemodynamically stable and not on invasive
hours/baby/day. The intervention which was most useful in mechanical ventilation or phototherapy, were
increasing KMC duration was opening of M-­NICU. We were
© Author(s) (or their included in the study. Each eligible mother
able to sustain the improvement at the end of 6 months.
employer(s)) 2022. Re-­use baby dyad was taken as one participant.
permitted under CC BY-­NC. No
Conclusion Sequential measures taken as a part of QI
initiative, helped to increase the average duration of KMC QI team consisting of faculty members, resi-
commercial re-­use. See rights
and permissions. Published by from 4.6 hours/day to 16.6 hours/day, without much dent doctors, staff nurses, lactation counsellor
BMJ. additional resources. and research nurse was formed and head
Department of Neonatology, nurse of NICU was chosen as a team leader,
Government Chengalpattu since she would act as a link between doctors
Medical College, Chengalpattu, BACKGROUND and staff nurses implementing the changes in
Tamil Nadu, India Kangaroo Mother Care (KMC) is an evidence-­ PDSA cycles and communicate the problems
Correspondence to based low-­cost initiative, which is expected to faced by the QI team.
Dr Sandeep Ajit Tilwani; prevent around 4.5 lakh deaths annually.1 2 Baseline data collection was done in the
​sandeep.​tilwani92@g​ mail.​com However, despite all its known benefits, the end of December 2020. Based on 24-­ hour

Jegannathan S, et al. BMJ Open Quality 2022;11:e001775. doi:10.1136/bmjoq-2021-001775 1

 BMJ Open Qual: first published as 10.1136/bmjoq-2021-001775 on 11 May 2022. Downloaded from http://bmjopenquality.bmj.com/ on February 9, 2023 at Yonsei University (Medical Library
Open access

Table 1 Demographic details of participants in

implementation phase
Parameter Numbers
Mean gestational age 32.6
weeks
Mean birth weight 1483.2 g
Males 39
Females 47
VLBW 36
ELBW 5
Term babies 9
Preterm babies 77
Figure 1 Fishbone analysis for causes of less KMC. KMC,
Kangaroo mother care.
were given to all mothers practicing KMC. This was an
easy to use chart, which required daily marking the hours
recall from the mothers putting KMC, the average KMC
of KMC by mothers. Data was then compiled by research
duration was 4.6 hours/baby/day. So, we made a SMART
nurse on daily basis. Process indicator was percentage of
aim—‘To improve the duration of KMC in our unit from
mothers having KMC charts. Duration of KMC increased
baseline of 4.6 hours/baby/day to 12 hours/baby/day
to 8.5 hours/baby/day at the end of PDSA 2.
over a period of 8 weeks in all stable babies with birth
As a part of the third PDSA cycle, to improve motiva-
weight of less than 2 kg’.

and Hospital). Protected by copyright.

tion among the mothers putting KMC, customised weight
In the first QI meet, we discussed the potential barriers
chart was printed at the back of KMC chart. This would
to prolonged KMC in our unit, and a fishbone diagram
help to track the weight of the baby on a daily basis and
was constructed to enlist them. Figure 1 shows the fish-
reinforce to mothers that prolonged KMC duration will
bone diagram.
help to achieve better weight gain for the baby. We used
Based on this analysis, we listed out possible interven-
Ehrenkranz weight chart customised to nearest 100 g of
tions. Priority matrix was constructed to decide the order
baby’s birth weight for babies with weight between 800 g to
of testing changes on weekly basis.
1500 g. Beyond 1.5 kg birthweight babies, we constructed
QI team decided to have one intervention per week
two charts using Dancis weight charts, although Dancis
with weekly meetings to discuss the effects of interven-
weight charts are no longer used as a standard.
tion. The primary outcome indicator was duration of
Average KMC duration increased to 9.5 hours/baby/
KMC expressed in hours per baby per day. A research
day. This practice of combining KMC charts with weight
nurse working in our unit was assigned the task of daily
charts is now a routine in our unit.
collection of data.
In the fourth PDSA cycle, in order to identify the non-­
For sustaining the improvement, QI team met on
compliance among mothers, daily KMC duration was
monthly basis in post-­ implementation phase, relevant
documented in baby case sheet during morning rounds.
data were reviewed and continuous feedback was to given
This drew the attention of doctors and nurses toward
to all staffs. The duration of KMC was plotted on run
the mothers who were not practising KMC for adequate
chart. Informed consent was taken from mothers prior to
duration and helped to provide more attention and coun-
enrolment in study.
selling to such mothers to further motivate them. KMC
duration increased to 10.3 hours/baby/day. All the KMC
RESULTS eligible babies in the unit now have KMC duration docu-
A total of 86 mother infant dyads participated in the mented in case sheet.
implementation phase of 2 months. Demographic details During the fifth PDSA cycle, as a part of quality assur-
of the participants are mentioned in table 1. ance measure, the number of KMC chairs in the unit
Lack of privacy was one of the main barriers, so this was increased. Process indicator used was percentage
addressed in the first PDSA cycle. In the first PDSA cycle, of mothers practising KMC without a KMC chair. This
a separate area was marked out in each ward to segregate helped to increase the KMC duration to 11.1 hours/
the mothers putting KMC in unit. Process indicator used baby/day.
for this was number of mothers putting KMC outside In the sixth PDSA cycle, in order to promote the policy
this segregated area. The mean duration increased to of ‘zero separation’ of mother baby dyad and to improve
6.9 hours/baby/day. We continue to segregate mothers family centred care in our unit, ‘mother–neonatal ICU’
putting KMC in each ward to ensure privacy. was opened in our hospital. This is only second of its
As a part of the second PDSA cycle, plan was to ensure kind unit in entire country. In this 10-­bedded unit, babies
objective documentation of KMC duration. KMC charts requiring level 2 care are kept in warmers, with mother’s

2 Jegannathan S, et al. BMJ Open Quality 2022;11:e001775. doi:10.1136/bmjoq-2021-001775

 BMJ Open Qual: first published as 10.1136/bmjoq-2021-001775 on 11 May 2022. Downloaded from http://bmjopenquality.bmj.com/ on February 9, 2023 at Yonsei University (Medical Library
Open access

Table 2 Summary of PDSA cycles in implementation phase

PDSA cycle
number Plan Do Study Act
1 Ensuring privacy for Segregation of mothers Total average KMC Separate areas marked out
mothers putting KMC to a separate duration=6.9 hours/ in each ward for mothers
area in each ward baby/day putting KMC
2 Documentation of KMC Ensuring that all mothers Total average KMC KMC chart routinely given to
duration have KMC chart duration= all mothers
8.5 hours/baby/day
3 Motivation of mothers for Combining KMC chart Total average KMC KMC chart routinely
KMC with weight chart duration= combined with weight chart
9.5 hours/baby/day for all mothers
4 Identifying non-­ Documentation of KMC Total average KMC Documentation of KMC
compliance duration in case sheet duration= duration in case sheets
10.3 hours/baby/day adopted as a routine
5 Quality assurance Ensuring availability of Total average KMC KMC chairs are made
KMC chairs duration= available to all mothers
11.1 hours/baby/day putting KMC in our unit
6 Ensuring comfort to Opening of M-­NICU and Total average KMC Postnatal mothers who are
mothers and decreasing family centred care unit duration= not very sick, are admitted
stress 13.1 hours/baby/day in M-­NICU and routine
obstetric care is provided

and Hospital). Protected by copyright.

7 Ensuring KMC education KMC education videos in Total average KMC KMC education videos are
to mothers local language duration= shown routinely to mothers
15.2 hours/baby/day of all LBW babies.
8 Ensuring maternal KMC slings for mothers Total average KMC We educated the mothers
comfort during prolonged duration= about benefits of using slings
KMC 16.6 hours/baby/day for prolonged KMC
KMC, Kangaroo mother care; M-­NICU, mother–neonatal ICU.

cot being next to her baby. Routine obstetric postnatal During the post-­ implementation phase, most of the
care is provided to mothers round the clock by the changes introduced in the implementation phase were
obstetric team. At the end of this PDSA cycle, KMC dura- well sustained. Data collection was done fortnightly.
tion increased to 13.1 hours/ baby/day. Additionally, to improve motivation among mothers,
In the seventh PDSA cycle, to increase KMC-­related the concept of weekly KMC champions was introduced,
education among mothers and our healthcare staff, wherein the mothers practicing maximum duration
we prepared KMC education videos inocal language. of KMC were awarded with certificates of appreciation
These videos were displayed in the department daily every week. Figure 3 shows the run chart of the KMC
for educating the mothers. These videos also helped duration during entire study period, including post-­
in clearing doubts among many healthcare workers implementation phase.
regarding ideal KMC practices. The average KMC dura- Though we faced challenge of second wave of COVID-­19
tion increased to 15.2 hours/baby/day.
pandemic, during which manpower constraints caused the
In the last PDSA cycle, to ensure maternal comfort
total KMC duration to decline to 13.7 hours/baby/day,
during prolonged KMC, KMC slings were used in our
it was above our target of 12 hours/baby/day. One more
unit. This change was, however, not well accepted in our
challenge faced was ensuring father KMC in night time.
unit despite educating mothers about its benefits. Some of
the prime reasons we found were the hot climate causing Though we segregated an area for father KMC in our unit,
more sweating among mothers and making it uncomfort- practising father KMC at night is still a challenge due to
able and use of front open gowns by mothers, making use staff constraints in night time for continuous monitoring.
of KMC slings a less prevalent practice in unit. Though One thing which needs to be highlighted here is the role of
at the end of week 8 average KMC duration increased to hospital administration in supporting this study. Our team
16.6 hours/baby/day, it was probably due to better imple- was able to convince the administrators regarding benefits
mentation of changes introduced in previous PDSA cycles of KMC and its impact on improving survival of LBW babies.
and not due to KMC slings. Table 2 provides a summary As a result, a lot of quality assurance steps like increasing the
of all PDSA cycles. Figure 2 shows the run chart during number of KMC chairs, opening of M-­NICU and KMC slings
implementation phase. for mothers could be ensured.

Jegannathan S, et al. BMJ Open Quality 2022;11:e001775. doi:10.1136/bmjoq-2021-001775 3

 BMJ Open Qual: first published as 10.1136/bmjoq-2021-001775 on 11 May 2022. Downloaded from http://bmjopenquality.bmj.com/ on February 9, 2023 at Yonsei University (Medical Library
Open access

and Hospital). Protected by copyright.

Figure 2 Run chart showing average KMC duration during implementation phase. M-­NICU, mother–neonatal ICU; KMC,
Kangaroo mother care.

Figure 3 Run chart showing average KMC duration in hours/baby/day throughout the duration of study. KMC, Kangaroo
mother care.

4 Jegannathan S, et al. BMJ Open Quality 2022;11:e001775. doi:10.1136/bmjoq-2021-001775

 BMJ Open Qual: first published as 10.1136/bmjoq-2021-001775 on 11 May 2022. Downloaded from http://bmjopenquality.bmj.com/ on February 9, 2023 at Yonsei University (Medical Library
Open access

DISCUSSION and India, with help of local administrative bodies.

KMC is proven to reduce hypothermia, hypoglycaemia They were able to ensure good rates of KMC initiation
and sepsis among LBW babies, but also has a direct role in in hospital and were able to sustain them post discharge
reducing neonatal mortality significantly.6 Despite these, from hospital.14
full integration of KMC in routine care of LBW world- KMC has the components, namely, skin-­to-­skin contact,
wide is facing challenges. Lack of involvement of family exclusive breast feeding and early discharge from hospital.
members in providing KMC and less family support is This study mainly focused on improving duration of
identified as a significant barrier to prolonged KMC.7 So, skin-­to-­skin contact. Impact on rates of exclusive breast
to tackle this, M-­NICU and family centred care ward was feeding were, however, not studied. Also, the impact of
established in our unit, wherein mother and one more prolonged KMC duration on length of hospital stay was
relative is allowed to stay with baby, and asked to provide not studied. Some of the other limitations of the study
KMC as soon as baby is haemodynamically stable. were that we did not study the morbidity of the partic-
A similar study was conducted by Joshi et al at AIIMS, ipants and its effect on KMC duration, anthropometric
New Delhi. However, in the current study, the number of data of babies on prolonged KMC was not studied and
mother baby dyads included is more and also the number we did not follow-­up duration of KMC in these babies in
of PDSA cycles to achieve the target is more.8 community post discharge.
Quasem et al had reported that lack of knowledge
among mothers and family members regarding benefits
of KMC is one of the main reasons for less KMC dura- CONCLUSION
tion.9 To address this issue, we had prepared educational Simple steps taken as a part of quality improvement initi-
videos for mothers in local language. This did help in ative with more education of mothers and involvement
increasing KMC duration. of family members can help to increase duration of KMC
Brimdyr et al had reported that one of the barriers was significantly and help in the improvement.

and Hospital). Protected by copyright.

hot climate leading to irritation and sweating among
Contributors SAT, SJ, MN, MS and RS all made significant contributions to
mothers, thereby decreasing KMC duration.10 Though designing of the study and in acquisition and analysis of data. SJ and MS gave
most of the mothers did not complain the same routinely, important inputs in conduction of study and writing of the manuscript. MN and RS
but they felt that use of KMC slings was causing more provided administrative support. This study was conducted under supervision of MN
sweating and so use of slings is less accepted practice in and MS and they made sure that all the data provided are correct, as a guarantor.
our unit. To achieve prolonged KMC duration, mother Funding The authors have not declared a specific grant for this research from any
and baby bonding is very important. Kambarami et al had funding agency in the public, commercial or not-­for-­profit sectors. Publication of
this article is made Open Access with funding from the Nationwide Quality of Care
reported that lack of bonding leads to less KMC dura- Network.
tion.11 So, the concept of M-­NICU was introduced, which Competing interests None declared.
ensured that mother stays next to baby and spends more
Patient and public involvement Patients and/or the public were not involved in
time with baby. the design, or conduct, or reporting, or dissemination plans of this research.
Although appointment of extra nurses and manpower
Patient consent for publication Not applicable.
will improve KMC duration, but such change cannot be
Ethics approval This study involves human participants. This work is exempt from
sustained and will revert back to older ways once addi-
institutional ethics committee approval since it involves use of existing data and
tional manpower is withdrawn, as reported by Seidman et records. Sources are publicly available. Information is collected by investigators
al and Jayaraman et al.4 12 Hence, we did not employ addi- in such a way that identity of subjects is not revealed. Participants gave informed
tional manpower during this study. Available manpower consent to participate in the study before taking part.
was used to introduce and sustain changes. Auditing and Provenance and peer review Not commissioned; externally peer reviewed.
feedback are considered as backbone of QI project, so Data availability statement All data relevant to the study are included in the
we conducted weekly audits to review our performance article or uploaded as supplemental information.
in various change ideas introduced and to review overall Open access This is an open access article distributed in accordance with the
KMC duration. After the discussion, necessary modifica- Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-­commercially,
tions were implemented, so as to sustain the change intro-
and license their derivative works on different terms, provided the original work is
duced. Some of the other strengths of our study were a properly cited, appropriate credit is given, any changes made indicated, and the use
higher set target of 12 hours/baby/day as compared is non-­commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
with previous studies, combining KMC chart with weight
chart customised to that baby, opening of M-­NICU and
strengthening concept of family centred care.
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