journal of

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global health

Consensus–based approach to develop a

VIEWPOINTS
measurement framework and identify a core

PAPERS
set of indicators to track implementation and
progress towards effective coverage of facility–
based Kangaroo Mother Care
Tanya Guenther1, Sarah Moxon2, Bina
Background As efforts to scale up the delivery of Kangaroo
Valsangkar1, Greta Wetzel1, Juan Ruiz3,4, Mother Care (KMC) in facilities are increasing, a standardized
Kate Kerber1, Hannah Blencowe2, approach to measure implementation and progress towards ef-
Queen Dube5, Shashi N Vani6, Donna fective coverage is needed. Here, we describe a consensus–based
Vivio7, Hema Magge8,9, Socorro De approach to develop a measurement framework and identify a
core set of indicators for monitoring facility–based KMC that
Leon–Mendoza10, Janna Patterson11,
would be feasible to measure within existing systems.
Goldy Mazia12,13
Methods The KMC measurement framework and core list of
1
 ave the Children, Washington, D.C., USA
S indicators were developed through: 1) scoping exercise to iden-
2
London School of Hygiene and Tropical Medicine, tify potential indicators through literature review and requests
London, UK from researchers and program implementers; and 2) face–to–
3
Kangaroo Mother Care Foundation, Bogota, face consultations with KMC and measurement experts working
Colombia at country and global levels to review candidate indicators and
4
Herbert Wertheim College of Medicine, FIU, Miami, finalize selection and definitions.
Florida, USA Results The KMC measurement framework includes two main
5
Queen Elizabeth Central Hospital, Blantyre, Malawi components: 1) service readiness, based on the WHO building
6
Kangaroo Mother Care Foundation, Ahmedabad, blocks framework; and 2) service delivery action sequence cov-
India
ering identification, service initiation, continuation to discharge,
7
USAID, Washington, D.C., USA
and follow–up to graduation. Consensus was reached on 10 core
8
Partners in Health, Kigali, Rwanda
indicators for KMC, which were organized according to the mea-
9
Brigham and Women’s Hospital, Division of Global
surement framework. We identified 4 service readiness indica-
Health Equity, Boston, Massachusetts, USA
tors, capturing national level policy for KMC, availability of KMC
10
Bless–Tetada Kangaroo Mother Care Foundation,
Manila, Philippines indicators in HMIS, costed operational plans for KMC and avail-
11
Bill & Melinda Gates Foundation, Seattle WA, USA ability of KMC services at health facilities with inpatient mater-
12
PATH, Washington, D.C., USA nity services. Six indicators were defined for service delivery,
13
Maternal and Child Survival Programme, including weighing of babies at birth, identification of those
Washington, D.C., USA ≤2000 g, initiation of facility–based KMC, monitoring the qual-
ity of KMC, status of babies at discharge from the facility and
levels of follow–up (according to country–specific protocol).
Conclusions These core KMC indicators, identified with input
from a wide range of global and country–level KMC and mea-
Correspondence to: surement experts, can aid efforts to strengthen monitoring sys-
Tanya Guenther
tems and facilitate global tracking of KMC implementation. As
Save the Children
899 North Capitol Street NE, Suite 900
data collection systems advance, we encourage program manag-
Washington, D.C. 20002 ers and evaluators to document their experiences using this
USA framework to measure progress and allow indicator refinement,
tguenther@savechildren.org with the overall aim of working towards sustainable, country–
led data systems.

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 Guenther et al.

An estimated 15 million babies are born prematurely each year, accounting for about 1 in 10 births world-
wide [1]. Preterm birth, defined as birth before 37 completed weeks of gestation, is the leading direct
cause of newborn mortality and morbidity [2,3]. Complications of prematurity are the primary cause of
child death worldwide and also a risk factor for neonatal deaths from other causes, especially infections
[3]. Globally, preterm birth complications contribute 3% of disability–adjusted life years (DALYs) for all
ages and account for 38% of DALYs attributed to neonatal conditions [4]. The burden of mortality and
morbidity due to preterm birth is heavily concentrated in south Asia and sub–Saharan Africa, where more
VIEWPOINTS

than 60% of preterm births take place and health systems face multiple challenges to deliver high qual-
ity care [1,2,5].
Papers

The Every Newborn Action Plan (ENAP), a global multi–partner movement with the goal of ending pre-
ventable newborn deaths has set national targets of ≤12 neonatal deaths per 1000 live births by 2030 [6].
As the leading cause of newborn deaths, a focus on preterm birth and the associated complications are
essential to achieving these ambitious goals. There are evidence–based, cost–effective interventions to
prevent preterm birth and manage complications. As part of the evidence base for the ENAP, an epide-
miological analysis estimated that up to 70% of preterm deaths could be averted through the provision
of quality inpatient care [7]. Kangaroo Mother Care (KMC) is a critical part of inpatient care for preterm
newborns, and also provides the foundation for improved outpatient and follow–up care of small babies
[5,8]. In July 2015, the World Health Organization (WHO) released guidelines on interventions to im-
prove preterm birth outcomes, which strongly recommend KMC for the routine care of neonates born
weighing ≤2000 g as soon as they are clinically stable [9]. Birthweight is used as an indication for KMC
initiation and a proxy for preterm birth given the challenges of accurate gestational age measurement in
many low–resource settings.
Kangaroo Mother Care is defined by WHO as early, continuous and prolonged skin–to–skin contact be-
tween the mother (or other caregiver) and the baby, and exclusive breastfeeding (ideally) or feeding with
expressed breastmilk [9]. Provision of KMC is embedded within a broader package of inpatient care for
premature babies that involves supportive care (eg, infection prevention and management, respiratory
support, etc.) and requires referral for higher level care when necessary and ongoing follow–up post–dis-
charge [8]. In some more developed settings (eg, certain Latin American countries), KMC may be initi-
ated at the facility and continued on an ambulatory basis with mothers returning to the facility frequent-
ly (as needed). Such an approach is only feasible in settings where health facilities are easily accessible
and the appropriate infrastructure is in place. Studies show that continuous KMC implemented at health
facilities can prevent up to 50% of deaths among babies ≤2000 g [10]. The practice of facility–based KMC
also offers benefits beyond reduced mortality; compared with conventional neonatal care for small babies
(incubator care), KMC reduces infections, hypothermia, and length of hospital stay and improves breast–
feeding, weight gain and maternal–infant bonding [10]. Intermittent KMC, as tolerated, is increasingly
being used for babies that are less stable to support clinical and developmental outcomes [9].
Despite the strong evidence base for KMC, progress in taking KMC implementation to scale has been slow
[5,11,12]. While more than half of the 75 Countdown to 2015 countries report national policies recom-
mending KMC, availability of KMC services is limited to a small number of central or teaching hospitals
in all but a handful of countries ([13] and our unpublished results). A multi–country assessment of health
systems bottlenecks to scale up of KMC in 12 African and Asian countries found that health financing,
community ownership and partnership, health service delivery, leadership and governance and health
workforce were perceived as major or significant barriers by nine or more countries [5]. One of the cross-
cutting challenges underpinning these barriers was effective information systems and data on KMC cov-
erage and quality [5,12].
In an effort to accelerate and support the uptake of KMC, the Bill & Melinda Gates Foundation and part-
ners released a call to action in 2013 for the global adoption of facility–based KMC and formed the KMC
Acceleration Partnership (KAP) [11]. The call to action set an ambitious target of 50% coverage of KMC
among preterm newborns by 2020 and emphasized the importance of measuring progress using robust
metrics and indicators [11]. Similarly, to meet its ambitious goals, ENAP recognized the critical need for
improved data on preterm, small and sick newborns to support the scale up of high impact interventions
[6]. At the time of its launch in 2014, ENAP published a core set of indicators needed for tracking prog-
ress in reaching their goals [6]. Coverage of KMC is one of the core ENAP indicators, and also one of the
indicators with some of the greatest identified data gaps [6,14]. At the time, there was no existing defini-
tion for a KMC coverage indicator. To achieve scale up of KMC, there is a need for consensus on a com-
mon set of indicators to track KMC implementation and progress to effective coverage. The ENAP metrics

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 Tracking implementation and progress towards effective coverage of facility–based Kangaroo Mother Care

stream, therefore, prioritized work on defining and testing a measureable coverage indicator, but also em-
phasized the importance of developing process indicators to track content and quality. In conjunction
with ENAP, the KAP initiated a consensus–based process to identify a core set of standardized indicators
for KMC to facilitate country and global monitoring and evaluation of KMC efforts and inform the inte-
gration of data on KMC into national health management information systems (HMIS). Regular monitor-
ing and reporting of these indicators will strengthen the global evidence base for KMC and inform ap-
proaches to strengthen scale–up of KMC [11,12]. Further, careful facility–level measurement of KMC

VIEWPOINTS
service delivery is important for improving the quality of KMC services and can help avoid the phenom-
enon of “empty” scale–up.

PAPERS
The purpose of this paper is to describe the approach to develop a measurement framework and select
and refine a set of indicators for monitoring implementation of facility–based KMC. The aim was to de-
velop a focused list of indicators that would be relevant across settings and could be measured within ex-
isting health systems at scale. The challenges to establish an appropriate denominator for measuring cov-
erage of KMC and options for testing are also discussed.

METHODS
The KMC measurement framework and core list of indicators were developed through: 1) scoping exer-
cise to identify potential indicators; and 2) face–to–face consultations with measurement and KMC ex-
perts to review candidate indicators and finalize selection (Figure 1).

Scoping exercise to identify potential indicators

An initial list of candidate indicators was developed through a review of the grey literature (program doc-
uments and surveys) and consultations with KMC and measurement experts. We circulated a request for
existing KMC indicators to members of the Newborn Indicators Technical Working Group (NITWG), an
inter–agency working group convened by Saving Newborn Lives, and the KMC Acceleration Partnership.
A total of 79 candidate indicators and data elements were extracted and summarized in an excel spread-
sheet. This list was refined to 55 through sorting and removal of duplicates and organized by a standard
results framework (impact, coverage, access, quality, demand, policy/enabling environment). The main
sources of indicators in this initial list included the Fundacion Cangaru, Maternal and Child Health In-
tegrated Program (MCHIP) KMC implementation Guide, various facility and household surveys conduct-
ed by programs implementing KMC (SNL Malawi Facility Assessment and household survey, Uganda
Newborn Study (UNEST) survey, Ghana Newhints survey, Ethiopia household survey, South Africa Fa-
cility Assessment) and the Malawi HMIS.

Consultations to review and finalize indicator selection

A series of face–to–face meetings were convened with KMC and measurement experts working at coun-
try and global level over a three month period. A full list of participants, their affiliations and area of ex-
pertise (measurement, KMC or both) are included in Table S1 in Online Supplementary Document.

Figure 1. Overview of Kangaroo Mother Care (KMC) framework development and indicator selection process.

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 Guenther et al.

Initial scoring and development of a measurement framework

A small group meeting with 12 members of the KAP and the NITWG was held September 5, 2014 to re-
view and score the raw list of 55 indicators. A focused set of five criterion for initial scoring of the indica-
tors was developed, which reflects commonly applied indicator selection criteria: feasibility (data can be
collected with reasonable and affordable effort in low resource settings), reliability (data can be collected
consistently over time), usefulness for decision–making (data are relevant and will help guide KMC pro-
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gramming), sensitivity (responsive to change), and specificity (focused on specific aspect, not overly broad)
[15–17]. The group broke into smaller groups for in–depth discussion and scored each candidate indi-
cator as high, medium, or low for each of the five criteria. The group recommended that a measurement
Papers

framework specific to KMC should be developed to better organize the indicators and assist with priori-
tizing selection. Following the meeting, a core team representing the KAP, NITWG and ENAP metrics
stream extracted the strongest indicators based on the scoring criteria for further development (prepara-
tion of full definitions, data source, and methods) and drafted a KMC measurement framework. The re-
sulting 18 candidate indicators were then organized according to the draft framework.

Refinement of framework and indicator list

In October, consultations were held with a broader group of newborn programmatic and measurement
experts on October 6–7, 2014 in Washington DC. The 24 attendees, representing implementing agen-
cies, donors and researchers, formed three small groups (national level/service readiness; facility–level/
service delivery; and coverage) to review the KMC framework and each of the 18 candidate indicators in
detail. Groups were provided with a series of questions for each indicator to guide their discussion and
decision–making process. The group made recommendations about which indicators to retain, which to
drop and areas for further research; further details on the discussion and outputs is available in the meet-
ing report [18]. Following the meeting, the core team consolidated feedback and updated the measure-
ment framework and refined the indicator list down to 11 candidate indicators. A smaller task team was
delegated to work specifically on defining a feasible coverage indicator for KMC that could be tested as
part of the ENAP metrics measurement improvement plan. This task team, alongside the core group, also
undertook a preliminary mapping exercise to see what data were available, with a focus on assessing de-
nominator options for generating a potential coverage indicator for KMC that could be tested as part of
the ENAP measurement improvement plan.

Finalization of framework and indicators

The final consultation took place on November 15, 2014 in Kigali, Rwanda as part of the KMC Acceler-
ation meeting and focused on country level input. Eighteen participants, including individuals support-
ing KMC implementation in nine countries (Bangladesh, Malawi, Nigeria, Rwanda, India, Indonesia, Phil-
ippines, Uganda and South Africa) gave feedback on the measurement framework and reviewed each
candidate indicator to assess availability, feasibility and usefulness considering their country context. Par-
ticipants were split into two groups. One group worked specifically on the coverage indicator, and the
other group focused on readiness indicators and facility level data for tracking service delivery and qual-
ity of care. In each group, a presentation was made to provide an overview of progress to date, review
each indicator in detail and identify priority areas for discussion. Participants in the service readiness and
facility data group were asked to use post–it notes to record information on availability/data source, data
users, collection methods, and challenges for each indicator in their setting and then vote whether the
indicator was ready to go, needed more work/unsure or should be dropped. Participants in the coverage
group, reviewed the work carried out by the ENAP metrics KMC task team (Box 1) and discussed a fea-
sible a measurable coverage indicator. In view of the challenges in measuring a denominator, the group
reached consensus through placing individual votes between use of <2500 g, total facility births or esti-
mated live births. Based on the feedback, the core team finalized the framework and list of indicators.

RESULTS
KMC measurement framework
Figure 2 shows the KMC measurement framework, which was developed to guide the identification and
prioritization of core indicators. The framework includes two main components: 1) KMC service readiness
and 2) action sequence of KMC service delivery. The seven service readiness elements are based on the WHO

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 Tracking implementation and progress towards effective coverage of facility–based Kangaroo Mother Care

Box 1. The challenge of measuring KMC coverage

What is coverage measurement and why is it challenging for KMC?

A coverage indicator aims to measure the number of individuals that receive a specific intervention or treatment
within a given population in need of the intervention. The numerator is measured as the total number of indi-
viduals that received the intervention and the denominator is the total population, usually those that could have
benefitted from that specific intervention or treatment. For KMC, neither the numerator nor the denominator
are easy to define or measure. KMC is not a one–off contact with the health system; many of the components

VIEWPOINTS
of KMC are processes (eg, continuous skin–to–skin contact, follow up care). And measurement of specific in-
terventions is a challenge when only by a small group or sub population benefit from that intervention. Defin-

PAPERS
ing whether or not an infant could benefit from KMC requires a level of clinical judgement and more precise
metrics than those reported by most routine information systems in LMIC.
The ENAP metrics KMC task team
ENAP metrics assembled a KMC task team with experts in measurement and programme implementation draw-
ing on expertise from the KMC acceleration partnership and wider groups. Different numerators and denomi-
nators were proposed and discussed based on their definition and the feasibility of measurement.
Numerator challenges
The evidence base for mortality impact of KMC is currently for infants weighing 2000 g or less. However, in some
low and middle income countries where programmes have been extended, eligibility criteria for entry to KMC may
be for babies up to 2500 g. Coverage of most maternal and newborn interventions in many settings is still mea-
sured through household surveys and relies on maternal recall up to five years after the birth in question. Even
though mothers can accurately recall KMC, even years after the event, the sample size needed to gather represen-
tative data through a household survey may be prohibitively large15. Typically, facility based assessments capture
information on infrastructure, processes and service readiness, and are best suited to measure the number of fa-
cilities that are prepared to provide components of the service (eg, sufficient trained staff, space, and equipment).
In most settings, the number of newborns initiated on facility–based KMC is measured either through hospital
admission or care records, but currently these data are rarely reported into national health information systems.
Denominator challenges
The denominator was the most technically challenging and a list of options were proposed. A large proportion
of newborns do not have their weight recorded at birth and even where birthweight is recorded, there is a known
tendency for “heaping” of data, especially at measures of 2500 g and 2000 g. Given the difficulty in accurately
capturing all those babies in need of KMC, especially through existing data collection systems, using total live
births as the denominator to give a proxy was considered. This has been done with other interventions where
the aim is not for 100% coverage, such as C–section, to generate a rate that is benchmarked against a target thresh-
old. Recent estimates suggest a variation in preterm birth rates of between 4–18% of total lives births in different
countries. This means that the KMC rate in each country may indicate a different unmet need and target thresh-
olds would need to vary between settings to reflect these differences as well as variation in numbers of full–term
LBW and pre–term babies. As an important limitation, if total live births is used as a denominator, it does not
reflect whether the babies that received it were drawn from the population that could have benefitted from KMC.
Proposed indicator
The ENAP KMC task team established that it is not possible to capture all of the components of KMC in one
coverage indicator as many of these refer to processes that happen over a period of time. Household surveys are
unlikely to be a feasible approach to measure KMC coverage and increasingly, health facility assessments are
starting to measure key components of KMC care. Of all the available options, the number of newborns initi-
ated on facility based KMC gives a representation of the number of newborns initiating the care. Task teams
agreed the indicators would need rigorous testing for validity and feasibility with a variety of different denomi-
nator options including, live births in the facility, estimated live births and eventually target population
for coverage (total number of newborns ≤2000 g).
As a preliminary exercise, the task team approached a select few LMIC countries for data on the KMC numera-
tor, which is available through a limited number of HMIS and many hospital registration systems. To demon-
strate the numerator with different denominator options, task teams present three graphs showing the proposed
numerator over total reported live births, total reported live births <2500 g and estimated live births for two
countries, Malawi and Dominican Republic (Figure 4).
What are the next steps?
As national facility based data and health information systems become more advanced, the ideal is to develop
more precise indicators, but these are not currently available in most of the countries where the unmet need for
KMC is arguably the greatest and there are the most data gaps. It is critical to improve the recording and report-
ing of birth weight in facilities. Given the importance of prematurity as a direct cause of death and as a risk fac-
tor for morbidities and death from other causes (eg, infections), developing simplified tools for measuring ges-
tational age is critical to plan for programmes, to improve the evidence base and to develop more precise
indicators of unmet need. If such data were available in more settings, indicators based on specific weight or
gestational age criteria could be measured. Existing data sets from countries with established KMC programmes
and accurate assessment of gestational age and birthweight could be used for testing the denominators and pro-
posed numerators. The ENAP metrics measurement improvement plan has a five year plan set out to test the
validity and feasibility of a number of numerator and denominator options for all the ENAP core indicators with
the objective of institutionalizing a KMC coverage indicator in global accountability mechanisms by 2020.

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VIEWPOINTS
Papers Guenther et al.

Figure 2. Measurement framework for Kangaroo Mother Care (KMC).

building blocks framework, and specify what minimum elements should be in place to support national–
level implementation of KMC [19]. The action sequence of service delivery outlines four main steps neces-
sary for provision of KMC at health facilities: identification of small babies; KMC initiation per protocol;
KMC continuation to discharge; and follow–up to KMC graduation. Essential actions for health service pro-
viders and for caregivers and families are outlined in broad terms for each step in the action sequence.

KMC core indicators

The 10 KMC core indicators are summarized in Figure 3 according to the framework and defined in Ta-
ble 1. Table S2 in Online Supplementary Document provides further information on the limitations
and additional data collection considerations for each indicator.

Service readiness indicators

Consensus was reached on four indicators of service readiness, namely national level policy for KMC,
availability of KMC indicators in HMIS, costed operational plans for KMC and availability of KMC ser-
vices meeting national minimum standards at facilities with inpatient maternity services. The service
readiness indicators are qualitative milestones or benchmark indicators, which build on existing indica-
tors and data collection efforts at national/global level, such as the Countdown to 2015 policy indicators.
Primary data sources are Ministry of Health and implementing partners and the data can be aggregated
at global level to track progress across countries. Availability of data are mixed. The indicator on national
level policy for KMC was added in 2014 to the set of policy indicators tracked in Countdown to 2015
and data are available for two years (2014 and 2015), but there are no clear plans for tracking post 2015
[14]. The other three indicators are not currently tracked and would need to be collected in coordination
with countries. Limited data on the availability of KMC services at health facilities are currently captured
through several large facility assessment tools, including the Demographic and Health Survey Program’s
(ICF International) Service Provision Assessment (SPA) and the WHO’s Service Availability and Readiness
Assessment (SARA) and the revised Emergency Obstetrics and Newborn Care (EmONC) assessment tools
[20]. However, these assessments are conducted infrequently, and countries investing in scaling up KMC
services may need to establish other more frequent mechanisms to track KMC service availability, such
as supervision or periodic audits. Further work is also needed to define ‘operational’ KMC, but at mini-
mum it should specify availability of trained staff, space, and supplies. Defining these minimum compo-
nents was also considered critical to the ENAP metrics measurement improvement plan, which recom-
mended tracking the availability of KMC services as a process indicator [14].

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 Tracking implementation and progress towards effective coverage of facility–based Kangaroo Mother Care

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PAPERS
Figure 3. Summary of core Kangaroo Mother Care (KMC) indicators according to framework.

Service delivery indicators

Six indicators were identified for service delivery, including weighing of babies at birth, identification of
those ≤2000 g, initiation of facility–based KMC (coverage indicator), monitoring of KMC for quality, sta-
tus of babies at discharge from KMC and level of follow–up according to national protocol. The service
delivery indicators focus on capturing service utilization and elements of quality (both process and out-
comes) and are intended for use primarily at the facility and district level for assessing KMC implemen-
tation and identifying program improvement needs. As such, the primary data sources are routine facil-
ity records and the list of recommended indicators was kept as short as possible to minimize burden on
health staff.
Two indicators focus on identification of babies eligible for KMC. The percentage of newborns weighed
at birth is captured by both the Demographic Health Survey (DHS) and the Multiple Indicator Cluster
Survey (MICS), but only every few years. Weighing of babies at birth can also be estimated on a more
routine basis using facility labour and delivery (L&D) records, although in most cases only facility births
would be included and quality of recording is often poor. The DHS and MICS household surveys also
estimate the percentage of low birth–weight babies, defined as birth weight <2500 g. However, as the
evidence base for KMC is for babies weighing ≤2000 g at birth, the recommended indicator reinforces
this cut–off and encourages routine data collection through facility L&D records. Most countries have
space to record actual birth weight, but to our knowledge very few high burden countries currently col-
late and report on the number of live births weighing ≤2000 g. In addition to improving measurement of
birth weight, investment in approaches to strengthen assessment of gestational age during antenatal care
and at delivery are necessary to better target KMC interventions towards who would benefit most as the
proportion of LBW babies that are pre–term will vary by setting.
The percentage of babies initiated on facility–based KMC was identified as a coverage indicator. Defining
the denominator for a KMC coverage indicator proved especially challenging. The ideal denominator
would be the number of babies born weighing less or equal to 2000 g. Yet as noted earlier, few if any
low–income countries currently reliably capture such data for all births. Even for those births occurring
in facilities, weight is not always recorded and if recorded, not always accurate and reliable. In the inter-
im, several denominators are recommended for further testing. The preliminary mapping exercise sug-
gested that using the expected number of live births may be the preferred denominator until measure-
ment of birth weight improves (see Box 1). In this scenario, a benchmark value or range would need to
be established for interpretation, similar to that used for C–section rates.

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 Guenther et al.

Table 1. KMC indicator definitions and data sources

Indicator Metric Main purpose Data source(s) and methods of collection Frequency
KMC in national policy: Yes = national policy recommends KMC National reporting/ National policy documents – re- Annually or less
National policy recommends No = national policy does not recom- monitoring cord review; Key informants
KMC mend KMC through interview
KMC indicator in HMIS: Yes = national HMIS includes the National reporting/ HMIS documents – record review; Annually or less
National HMIS includes the number of newborns who received monitoring Key informants through interview
number of newborns who facility–based KMC
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received facility–based KMC No = national HMIS does not include the

care number of newborns who received
facility–based KMC
Papers

Costed plan includes Yes = costed plan or plans to scale up National reporting/ Costed plans – record review; Key Annually or less
KMC: Costed national maternal, newborn and child health monitoring informants through interview
implementation plans for intervention includes KMC components
maternal newborn health No = no costed implementation plan OR
include KMC costed implementation plan does not
include KMC components
KMC service availability: Numerator: Number of health facilities National reporting/ Facility assessments and MOH Annually or less
Percentage of facilities with in which KMC is operational* monitoring records (collected through
in–patient maternity services Denominator: Number of health supervision or periodic audits)
with operational KMC facilities with inpatient maternity
services
Weighed at birth: Numerator: Number of newborns Facility monitoring Interviews with mothers + child Periodic for
Percentage of newborns weighed at birth† health card review – collected household
weighed at birth Denominator: Number of live births through household surveys; L&D surveys; routinely
registers – collected through (monthly/
record review as part of facility quarterly)
assessment or supervision depending on
need
Identification of newborns Numerator: Number of newborns Facility monitoring L&D registers – collected through Routinely
≤2000 g: Percentage of live identified as ≤2000 g HMIS (see notes) or through (monthly/
births identified as ≤2000 g Denominator: Number of live births register review as part of quarterly)
supervision or facility assessment
KMC coverage‡: Percentage Numerator: Number of newborns Facility monitoring KMC registers – reported through Annually
of newborns initiated on initiated on facility–based KMC§ & National HMIS or collected through register
facility–based KMC reporting/ review as part of facility assess-
Denominator: Expected number of live monitoring ment; Denominator available
births OR expected number of LBW through national and global
babies estimates updated annually
KMC monitoring: Numerator: Number of newborns Facility monitoring KMC patient charts – collected Quarterly or less;
Percentage of KMC admitted to KMC who are monitored by through record review as part of to be determined
newborns who are health facility staff according to protocol facility assessment/supervision at country level
monitored by health facility (includes at minimum: assessing visits
staff according to protocol feeding, STS duration, weight, tempera-
ture, breathing, heart rate, urine/stools)
Denominator: Number of newborns
initiated on facility–based KMC
Status at discharge from Numerator: Number of newborns Facility monitoring KMC registers – reported through Routinely
KMC facility: Percentage of discharged from facility–based KMC HMIS or collected through register (monthly/
newborns discharged from who: 1) met facility criteria for weight review as part of facility assessment quarterly)
KMC facility who: met facility gain, health status, feeding, thermal
criteria for weight gain/health regulation, family competency, etc; 2) left
status; left against medical ad- against medical advice; 3) referred out for
vice; referred out; or died be- higher level care; 4) died before discharge
fore discharge Denominator: Number of newborns
discharged from facility–based KMC
KMC follow–up: Percentage Numerator: Number of newborns Facility monitoring KMC registers/records – reported Routinely
of newborns discharged from discharged from facility–based KMC that through HMIS or collected through (monthly/
facility–based KMC that re- received follow–up per protocol register review as part of facility as- quarterly)
ceived follow–up per protocol Denominator: Number of newborns sessment and/or) Interviews with
discharged alive who received facility– caregivers/mothers of newborns
based KMC¶ discharged from KMC
KMC – Kangaroo Mother Care; HMIS – Health Management Information System; MOH – Ministry of Health; LBW – low birth weight; L&D – Labour
and Delivery; STS – skin–to–skin
*KMC elements already collected through Service Provision Assessments (SPA) include: staff receiving in-service training on KMC; identified space for
KMC; and availability of functional infant scale. This indicator has been prioritized for further testing by the KMC Acceleration and ENAP metrics group,
with particular focus on identifying and testing additional KMC elements for inclusion in future harmonized facility assessments, supervision checklists
and MOH audits.
†Countries will need to define a timeframe for ‘weighed at birth’. In some settings, this may include babies weighed at admission to the health care fa-
cility within a certain timeframe after delivery and babies weighed at home by a trained provider with weight documented on a maternal held record.
‡Indicator recommended as priority for inclusion in national HMIS.
§This may include facility–initiated ambulatory KMC as in Latin America (eg, Colombia); this indicator has been prioritized for further testing by the
KMC Acceleration and ENAP metrics group, with particular focus on establishing the most feasible, valid, and reliable denominator and benchmarks
for interpretation.
¶Countries should define their own denominator based on the national protocol for follow–up care of small and sick newborns, with an ideal denomi-
nator that captures all those infants discharged alive that were potential candidates for KMC.

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 Tracking implementation and progress towards effective coverage of facility–based Kangaroo Mother Care

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PAPERS
Figure 4. Analysis of denominator options for Kangaroo Mother Care (KMC) coverage indicator in
Malawi and Dominican Republic.

Three of the recommended service delivery indicators serve as proxies for quality of care processes and
outcomes. While in facility, KMC babies require daily monitoring to assess and record their positioning,
feeding, and weight gain and to check for signs of illness or other complications. One core indicator tracks
the percentage of KMC babies who are monitored according to the national protocol by reviewing patient
charts or other relevant facility records, through supervision visits or periodic assessments (monitoring
adherence with recommended processes). The status of babies at the time of discharge from KMC is also
an important proxy measure of quality of care, monitoring overall performance through a critical outcome
indicator. Status at discharge should be captured in a KMC or postnatal register and include the follow-
ing categories: met facility criteria for weight gain, health status, feeding, thermal regulation, and family
competency with KMC (the ideal); died before discharge; left against medical advice (defaulters); and re-
ferred out for higher level care. These categories are similar to those used for community management of
acute malnutrition (CMAM) programs for performance monitoring; however unlike CMAM, protocols
differ substantially by country and there is insufficient data and experience to establish international min-
imum performance standards for KMC [21]. The third proxy indicator for quality relates to the level of
follow–up post–discharge from facility KMC, which can be regarded as both a process and intermediate
outcome. It is common for low birth weight and preterm babies to be discharged at 1500–1800 g to re-
duce exposure to nosocomial infections and allow space for other patients. Adherence to regular follow–
up care that involves tracking growth and addressing other complications of prematurity is critical for
improved outcomes of these still vulnerable preterm babies. Improving measurement of gestational age
during pregnancy and/or by clinical assessment of the baby is essential for better targeting of clinical in-
terventions and identification of infants who will require long–term and specialized care and follow–up.
As discharge criteria and follow–up schedules vary by country, the indicator definition for follow–up will
need to be tailored in each country accordingly. Assessing follow–up through routine sources can be com-
plicated if babies receive follow–up care at different facility than where they received KMC, in which case
periodic assessments may be required to supplement routine data.

DISCUSSION
To the best of our knowledge, this is the first attempt to use a global consultation process to identify a
prioritized set of core indicators to track country progress towards scaling up KMC. Both ENAP and the
KMC Acceleration Partnership have set ambitious goals for reducing newborn morbidity and mortality
through improved coverage of high impact interventions, including KMC [6,11]. Better quality data and
measurement of KMC will be critical in accelerating progress of implementation and supporting scale up
of the intervention. As has been seen with child health programs (eg, vaccinations) good quality, compa-

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 Guenther et al.

rable data allows for informed planning, decision–making and targeting of programs. As direct complica-
tions of prematurity are now the leading cause of child death, comparable data are critical to foster glob-
al visibility, policy attention and accountability structures within the Sustainable Development Goals for
child health. This requires a consistent approach to measurement of KMC with standardized indicators
and data collection methodologies that can be captured in sustainable, country–driven health informa-
tion systems. We employed a consensus–based process to develop a measurement framework and iden-
tify a set of 10 core indicators for measuring progress of KMC implementation. The resulting framework
VIEWPOINTS

can be used to help program managers at the country level plan and set milestones that will be compa-
rable between different settings. At a facility level, program implementers can use the service delivery in-
Papers

dicators to identify areas for quality improvement.

The indicator selection and refinement process had several strengths. We engaged a broad range of KMC
and measurement experts representing global and country level perspectives and diverse technical and
methodological expertise. The candidate indicators were selected through a literature review, including
peer reviewed and grey literature (surveys and program documents), and canvasing of KMC researchers
and implementers to ground the work in experience with existing measures. We conducted a preliminary
mapping exercise to look at availability of data for some of the most critical indicators and we consulted
with country–based KMC implementers to assess the feasibility and relevance of the proposed indicators.
To avoid overburdening health systems and frontline workers with unnecessary data collection require-
ments, we intentionally kept the list to a minimum set and focused on indicators with potential to be col-
lected within existing, sustainable systems. Finally, the overlap between members of the ENAP metrics
stream and the KMC Acceleration Partnership facilitated close collaboration and alignment of the recom-
mended process and coverage indicators. This collaboration also allowed for wide consultation and shared
learning with other groups facing similar challenges to measure interventions for newborns requiring ex-
tra care (eg, neonatal resuscitation, treatment of neonatal infections) [14].
The development of a measurement framework specific to KMC played a critical role in guiding the pro-
cess of selecting and refining the indicators. Inclusion of the WHO building blocks helped ensure a health
systems approach and the action sequence identified the major steps that need to take place to deliver
high quality KMC services. Use of the framework allowed us to ensure indicators were evenly spread
along the continuum of care from service readiness to service delivery. The framework also provides a
useful reference point for program implementers, evaluators and researchers to identify additional indi-
cators on aspects of readiness and service delivery. The intent was not to create a rigid framework, but to
prioritize indicators that are relevant to implementation across a wide range of settings. The expectation
is that individual programs will identify additional indicators that are program specific and adapt the
framework to fit their context and data collection capacity.
As mentioned in the results, data availability is limited for most of the recommended KMC indicators.
For countries in early stages of introducing KMC, the focus should be on tracking progress against the
service readiness indicators. Once KMC is integrated within packages of care for preterm babies, coun-
tries can design and test data collection systems to capture more of the service delivery indicators. For
countries with more established KMC services, efforts should be made to review their existing health in-
formation systems to determine the best way to integrate the recommended indicators such that select
indicators are reported up to the national level. While nearly all service delivery indicators could be ag-
gregated and reported through a national HMIS, given system constraints in most settings, priority should
be given to capturing KMC initiation for tracking coverage. Countries will need to tailor some of the in-
dicator definitions, particularly for KMC service availability, KMC monitoring, and KMC follow–up, to
align with national protocols and clinical guidelines.
The core list of KMC indicators should be considered in light of the limitations of the process and of the
indicators themselves. First, due to time constraints we were unable to undertake a formal systematic re-
view of the literature and may have missed some relevant information. However, we did reach out to re-
nowned KMC experts to share their experiences and materials and the majority of candidate indicators
were extracted from these grey sources. Second, while we convened a series of consultations with a wide
range of experts including representatives directly involved in country implementation, we were not able
to sufficiently involve the principal end–users of the service delivery indicators – namely managers and
service providers at district and facility levels. Third, given the aim was to develop a focused list of indi-
cators suitable for routine systems, several aspects central to quality implementation of KMC are not re-
flected in the set of core indicators. Approaches to capture aspects such as timely initiation of KMC, ex-

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 Tracking implementation and progress towards effective coverage of facility–based Kangaroo Mother Care

tent of skin–to–skin and feeding practices, referral completion and health outcomes were discussed
in–depth and considered only feasible within the context of research settings or special studies for the
time being. In 2016, the WHO released a set of standards for improving quality of maternal and newborn
care in health facilities and recommended two indicators for facilities to use to evaluate quality of KMC
care; these draw attention to and have the potential to reinforce facility–level quality improvement efforts.
However, measuring these quality of care indicators would require detailed information captured through
daily patient charts and may not be feasible for routine monitoring and national aggregation in most set-

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tings [22].
Future work will include developing guidance for the indicators such as detailed reference sheets outlin-

PAPERS
ing how to collect and use the data effectively and supporting country–level partners to adapt and use
the indicators. Both the KAP and ENAP metrics offer platforms for disseminating such materials to a wide
audience and to collate and share additional resources and experiences gathered through collecting the
indicators. The KAP regional communities of practice in Africa and Asia will convene meetings in 2016
and 2017 and provide an important opportunity to engage country–level partners to further refine the
indicators. A critical next step is initiating special studies to test and validate the recommended KMC cov-
erage indicators as outlined in the ENAP measurement improvement roadmap (see Box 1) [14]. This will
be embedded in work to test all of the core ENAP coverage indicators for newborns with complications
requiring extra care (antenatal corticosteroids, neonatal resuscitation and treatment of neonatal infection)
that face similar measurement challenges. Data collection is under way to test a range of numerator and
denominator options for validity (eg, sensitivity and specificity of the indicators), feasibility of measure-
ment and usefulness through country hubs in Bangladesh and Tanzania. Another important area of future
work is to establish a coordinated mechanism for global tracking of a sub–set of the core indicators to as-
sess progress towards the KAP and ENAP goals. This will require harmonized investments in strengthen-
ing country health information systems, prioritizing capture of data to generate coverage estimates fol-
lowing validation efforts, as well as a system for global reporting.

CONCLUSIONS
As KMC accelerates globally, a standardized approach to measuring implementation and progress towards
effective coverage is needed. The indicators presented in this paper, identified with input from a wide
range of global and country–level KMC and measurement experts, can aid efforts to strengthen monitor-
ing 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
inform further progress and indicator refinement with the overall aim of working towards sustainable,
country–led data systems.

Acknowledgements: We acknowledge the contributions of the following individuals who participated in one or
more of the meetings to conceptualize, review, and provide inputs into the framework and indicator development
process: Stella Abwao, Asri Adisamita, Rajiv Bahl, Jennifer Callaghan, Grace Chan, Nathalie Charpak, Ruth Da-
vidge, Kim Dickson, Mary Drake, Cyril Engmann, Sabine Gabrysch, John Grove, Eni Gustina, Zelee Hill, Erin
Hunter, Steve Hodgins, Lily Kak, Neena Khadka, Joy Lawn, Jim Litch, Rachel Makunde, Liz Mason, Suleiman
Mohammed, Winnie Mwebesa, Harriot Nambuya, Silvia Nurdin, Magdalena Sherpa, Lara Vaz, Brendan Wacken-
reuter, Peter Waiswa and Evelyn Zimba.
Disclaimer: The opinions expressed are those of the authors and do not necessarily reflect the views of Save the
Children.
Funding: Funding for this work was provided by Save the Children – Saving Newborn Lives.
Authorship declaration: TG, SM, BV and GW formed the core team leading the development of the measure-
ment framework and indicators and consolidating participant inputs. All co–authors participated in one or more
of the consultations. TG and SM wrote the manuscript and all authors reviewed the manuscript drafts and pro-
vided inputs.
Competing interests: The authors have completed the Unified Competing Interest form at www.icmje.org/coi_
disclosure.pdf (available on request from the corresponding author) and declare no conflict of interest.

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 Guenther et al.

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