Article Text

Scaling up Kangaroo Mother Care in Ethiopia and India: a multi-site implementation research study
  1. Prem K Mony1,
  2. Henok Tadele2,3,
  3. Abebe Gebremariam Gobezayehu4,
  4. Grace J Chan5,6,
  5. Aarti Kumar7,
  6. Sarmila Mazumder8,
  7. Selemawit Asfaw Beyene9,
  8. Krishnamurthy Jayanna10,11,
  9. Dejene Hailu Kassa12,
  10. Hajira Amin Mohammed4,
  11. Abiy Seifu Estifanos13,
  12. Pankaj Kumar14,
  13. Arun Singh Jadaun8,
  14. Tedros Hailu Abay15,
  15. Maryann Washington16,
  16. Fitsum W/Gebriel3,
  17. Lamesgin Alamineh17,
  18. Addisalem Fikre18,
  19. Alok Kumar19,
  20. Sonia Trikha20,
  21. Fisseha Ashebir Gebregizabher21,
  22. Arin Kar22,
  23. Selamawit Mengesha Bilal23,
  24. Mulusew Lijalem Belew17,
  25. Mesfin Kote Debere13,
  26. Raghav Krishna7,
  27. Suresh Kumar Dalpath20,
  28. Samson Yohannes Amare24,
  29. H L Mohan22,
  30. Thomas Brune25,
  31. Lynn M Sibley26,
  32. Abraham Tariku27,
  33. Arti Sahu7,
  34. Tarun Kumar8,
  35. Marta Yemane Hadush15,
  36. Prabhu Deva Gowda28,
  37. Khalid Aziz29,
  38. Dereje Duguma30,
  39. Pramod Kumar Singh7,
  40. Gary L Darmstadt31,
  41. Ramesh Agarwal32,
  42. Dawit Seyoum Gebremariam15,
  43. Jose Martines33,
  44. Anayda Portela33,
  45. Harsh Vardhan Jaiswal8,
  46. Rajiv Bahl33,
  47. Suman Rao PN34,
  48. Birkneh Tilahun Tadesse3,
  49. John N Cranmer26,
  50. Damen Hailemariam35,
  51. Vishwajeet Kumar7,
  52. Nita Bhandari8,
  53. Araya Abrha Medhanyie9,36
  54. On behalf of KMC Scale-Up Study Group
  1. 1Division of Epidemiology & Population Health, St John's Medical College and Research Institute, Bangalore, India
  2. 2College of Health Sciences, Department of Paediatrics and Child Health, Addis Ababa University, Addis Ababa, Ethiopia
  3. 3Department of Pediatrics and Child Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
  4. 4Emory Ethiopia-Country Office, Addis Ababa, Ethiopia
  5. 5Boston Children’s Hospital, Boston, Massachusetts, USA
  6. 6Department of Pediatrics, Department of Epidemiology, Harvard Medical School, Boston, Massachusetts, USA
  7. 7Community Empowerment Lab, Lucknow, Uttar Pradesh, India
  8. 8Center for Health Research and Development, Society for Applied Studies, New Delhi, India
  9. 9School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
  10. 10Karnataka Health Promotion Trust, Bangalore, India
  11. 11Ramaiah University of Applied Sciences, Bangalore, India
  12. 12College of Medicine and Health Sciences, School of Public Health, Hawassa University, Hawassa, Ethiopia
  13. 13School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
  14. 14National Health Mission, Government of Uttar Pradesh, Lucknow, Uttar Pradesh, India
  15. 15Department of Pediatrics and Child Health, School of Medicine, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
  16. 16St John’s Research Institute, St John’s Medical College, Bangalore, India
  17. 17Emory Ethiopia-Amhara Regional Office, Bahir Dar, Ethiopia
  18. 18St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
  19. 19Governent of Uttar Pradesh, Lucknow, Uttar Pradesh, India
  20. 20State Health Systems Resource Center, Panchkula, Haryana, India
  21. 21Tigray Regional Health Bureau, Mekelle, Ethiopia
  22. 22Karnataka Health Promotion Trust, Rajajinagar, India
  23. 23School of Public Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
  24. 24Department of Software Engineering, School of Computing, College of Science and Technology, Mekelle University, Mekelle, Ethiopia
  25. 25Sachs’ Children and Youth Hospital, Stockholm, Sweden
  26. 26Emory University, Atlanta, Georgia, USA
  27. 27Maternal & Child Health Department, Federal Ministry of Health, Addis Ababa, Ethiopia
  28. 28Directorate of Health & Family Welfare Services, Government of Karnataka, Bangalore, India
  29. 29Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
  30. 30Federal Ministry of Health, Addis Ababa, Ethiopia
  31. 31Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
  32. 32Pediatrics, All India Institute of Medical Sciences, New Delhi, India
  33. 33Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
  34. 34Department of Neonatology, St John's Medical College Hospital, Bangalore, India
  35. 35Addis Ababa University, Addis Ababa, Ethiopia
  36. 36School of Public Health, Mekelle University College of Health Sciences, Mekelle, Ethiopia
  1. Correspondence to Dr Rajiv Bahl; bahlr{at}


Objectives Kangaroo Mother Care (KMC), prolonged skin-to-skin care of the low birth weight baby with the mother plus exclusive breastfeeding reduces neonatal mortality. Global KMC coverage is low. This study was conducted to develop and evaluate context-adapted implementation models to achieve improved coverage.

Design This study used mixed-methods applying implementation science to develop an adaptable strategy to improve implementation. Formative research informed the initial model which was refined in three iterative cycles. The models included three components: (1) maximising access to KMC-implementing facilities, (2) ensuring KMC initiation and maintenance in facilities and (3) supporting continuation at home postdischarge.

Participants 3804 infants of birth weight under 2000 g who survived the first 3 days, were available in the study area and whose mother resided in the study area.

Main outcome measures The primary outcomes were coverage of KMC during the 24 hours prior to discharge and at 7 days postdischarge.

Results Key barriers and solutions were identified for scaling up KMC. The resulting implementation model achieved high population-based coverage. KMC initiation reached 68%–86% of infants in Ethiopian sites and 87% in Indian sites. At discharge, KMC was provided to 68% of infants in Ethiopia and 55% in India. At 7 days postdischarge, KMC was provided to 53%–65% of infants in all sites, except Oromia (38%) and Karnataka (36%).

Conclusions This study shows how high coverage of KMC can be achieved using context-adapted models based on implementation science. They were supported by government leadership, health workers’ conviction that KMC is the standard of care, women’s and families’ acceptance of KMC, and changes in infrastructure, policy, skills and practice.

Trial registration numbers ISRCTN12286667; CTRI/2017/07/008988; NCT03098069; NCT03419416; NCT03506698.

  • paediatrics
  • health systems
  • other study design

Data availability statement

Data are available upon reasonable request. Data are available upon reasonable request from the principal investigator of each site and/or the corresponding author.

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

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Data availability statement

Data are available upon reasonable request. Data are available upon reasonable request from the principal investigator of each site and/or the corresponding author.

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  • Handling editor Valery Ridde

  • Twitter @gdarmsta, @anagportela

  • Contributors All authors contributed to the conceptualization of the study, the preparation of the first draft of the manuscript and its subsequent revisions. All authors read and approved the final manuscript. The list of authors follows a random order, as decided in consultation with the investigators. The corresponding author and the principal investigators of each site had full access to all the data in the study and had final responsibility for the decision to submit for publication.

  • Funding The study was funded by a grant from the Bill and Melinda Gates Foundation to the WHO (Global Development Grant OPP1136804).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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