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Background Kangaroo mother care (KMC) is an evidence-based intervention with large protective effects on neonatal mortality and morbidity, especially among small babies. Despite the available evidence, KMC adoption, implementation and scale-up has lagged. The purpose of this paper is to inform current and future KMC implementation by identifying achievements and challenges in countries that are in the process of scaling up KMC. Methods We collected and analyzed information to track the status of facility-based KMC in countries identified by the KMC Acceleration Partnership. We assessed the status of the scale-up in six priority countries (Ethiopia, Malawi, Nigeria and Rwanda in Africa, and Bangladesh and India in Asia) for three periods: 2014 and prior, 2015-2017 and 2017-2019 across six strategic areas: national policy, country implementation, research, knowledge management, monitoring and evaluation and advocacy. We collected information through in-depth interviews with key participants, quantitative data extraction from the Demographic Health Survey and secondary data extraction from policies, briefs, program reports and other documents. Results Progress in terms of national policy and advocacy appeared to occur quite quickly and evenly across the six priority countries, despite being at different stages during the first assessment. In the areas of country implementation support and research, progress occurred more slowly and results were more variable across countries. It was noted that the number of health facilities offering KMC services increased in all six priority countries, but coverage of KMC was difficult to estimate, demonstrating the ongoing challenges in the area of monitoring and evaluation despite progress made in integrating KMC indicators into national health information systems in five countries. Among the six priority countries - Malawi and Bangladesh had fully achieved at least four the first time six conditions were introduced. Conclusions We documented notable achievements in the dimensions of policy and country implementation across the six countries, which were likely driven by government engagement to prioritize newborn care services and the promotion of KMC as a core intervention for small babies. We noted challenges in critical areas such as ambulatory KMC, follow-up, and monitoring and evaluation. Addressing these gaps while securing funding to allocate human resources adequately, promoting acceptance of KMC for demand creation and facilitating the use of data for decision making will be vital to ensure effective coverage at scale.

Background Responding to stagnating neonatal mortality rates in Ghana, a five-year collaboration called Making Every Baby Count Initiative (MEBCI) was undertaken to improve the quality of newborn care provided around the time of birth. A multi-pronged approach was used to build health worker (HW) capacity in resuscitation, essential newborn care, and infection prevention using a curriculum built on the American Academy of Pediatric’s (AAP) Helping Babies Breathe (HBB) and Essential Care for Every Baby (ECEB) modules with an added section on infection prevention (IP). Methods MEBCI used a training of trainer’s approach to train 3688 health workers from district-level facilities in four regions in Ghana between June 2015 and July 2017. Prior to training, HWs familiarized themselves with the learning materials. Concurrently, MEBCI worked to improve enabling environments that would sustain the increased capacity of trained health workers. Knowledge and skills gained were tested using AAP’s Knowledge checklist and validated single-scenario Objective Structured Clinical Examinations (OSCEs) tools. Findings: Majority of HWs trained were midwives (58.8%) and came from district-level hospitals (88.4%). Most HWs passed the HBB OSCE (99.9%, 3436/3440). Age of doctors was negatively associated with HBB scores (r = − 0.16, p = 0.0312). Similarly, older midwives had lower HBB scores (r = − 0.33, p value Initiating ventilation within the Golden Minute was challenging for HWs (78.5% passed) across all regions. Overall, the pass rate for ECEB OSCEs was 99.9% in all regions. Classify newborn for further care and communicate plan to family were frequent challenges observed in Volta Region (69.5% and 72.0% pass rate respectively). HWs less than 40 years of age performed significantly better than health workers older than 40 years (p = 0.023). Age of only paediatricians was positively associated with ECEB scores (r = 0.77, p r = − 0.08, p Conclusion MEBCI’s integrated HBB-ECEB-IP training resulted in significant mastery of the clinical knowledge and skills of HWs. Harmonization and standardization of the course delivery by trainers and having a core team to ensure training fidelity are essential to maintaining high quality while scaling a program nationally. Funding Children’s Investment Fund Foundation (CIFF).

Objective To validate a novel objective structured clinical examination (OSCE) tool for assessing neonatal care skills among delivery attendants trained as part of the Essential Care for Every Baby (ECEB) program and to assess ECEB training effectiveness. Methods Between August 1 and September 30, 2015, a cross-sectional study enrolled ECEB-trained healthcare providers who attended deliveries from the Brong Ahafo and Eastern regions of Ghana. Participants completed a previously developed 21-item OSCE tool that assessed neonatal-care competency. Participant performance was scored independently by regional trainers and national master trainers. The inter-rater scoring reliability was assessed using the Cohen kappa coefficient and performance was compared across participant characteristics. Results The study enrolled 57 trained delivery attendants from 12 district hospitals. Inter-rater agreement was perfect (kappa 1.00) or almost perfect (kappa 0.81–0.99) for nine OSCE items, substantial (kappa 0.61–0.80) or moderate (kappa 0.41–0.60) for 11 items, and fair (kappa 0.21–0.40) for one item. Differences in OSCE-item performance were recorded based on participants’ regions, facility type, age, and education level ( P Conclusions In a resource-limited setting, the OSCE tool demonstrated substantial reliability and ECEB-trained healthcare practitioners exhibited satisfactory performance. The OSCE tool could be useful in similar settings and could have potential for up-scaled use in assessing neonatal-management skills.

Background As efforts to scale up the delivery of Kangaroo Mother Care (KMC) in facilities are increasing, a standardized approach to measure implementation and progress towards effective coverage is needed. Here, we describe a consensus–based approach to develop a measurement framework and identify a core set of indicators for monitoring facility–based KMC that would be feasible to measure within existing systems. Methods The KMC measurement framework and core list of indicators were developed through: 1) scoping exercise to identify potential indicators through literature review and requests from researchers and program implementers; and 2) face–to–face consultations with KMC and measurement experts working at country and global levels to review candidate indicators and finalize selection and definitions. Results The KMC measurement framework includes two main components: 1) service readiness, based on the WHO building blocks framework; and 2) service delivery action sequence covering identification, service initiation, continuation to discharge, and follow–up to graduation. Consensus was reached on 10 core indicators for KMC, which were organized according to the measurement framework. We identified 4 service readiness indicators, capturing national level policy for KMC, availability of KMC indicators in HMIS, costed operational plans for KMC and availability of KMC services at health facilities with inpatient maternity services. Six indicators were defined for service delivery, including weighing of babies at birth, identification of those ≤2000 g, initiation of facility–based KMC, monitoring the quality 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 measurement experts, can aid efforts to strengthen monitoring 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 measure progress and allow indicator refinement, with the overall aim of working towards sustainable, country–led data systems.

Objective To present information on the quality of newborn care services and health facility readiness to provide newborn care in 6 African countries, and to advocate for the improvement of providers9 essential newborn care knowledge and skills. Design Cross-sectional observational health facility assessment. Setting Ethiopia, Kenya, Madagascar, Mozambique, Rwanda and Tanzania. Participants Health workers in 643 facilities. 1016 health workers were interviewed, and 2377 babies were observed in the facilities surveyed. Main outcome measures Indicators of quality of newborn care included (1) provision of immediate essential newborn care: thermal care, hygienic cord care, and early and exclusive initiation of breast feeding; (2) actual and simulated resuscitation of asphyxiated newborn infants; and (3) knowledge of health workers on essential newborn care, including resuscitation. Results Sterile or clean cord cutting instruments, suction devices, and tables or firm surfaces for resuscitation were commonly available. 80% of newborns were immediately dried after birth and received clean cord care in most of the studied facilities. In all countries assessed, major deficiencies exist for essential newborn care supplies and equipment, as well as for health worker knowledge and performance of key routine newborn care practices, particularly for immediate skin-to-skin contact and breastfeeding initiation. Of newborns who did not cry at birth, 89% either recovered on their own or through active steps taken by the provider through resuscitation with initial stimulation and/or ventilation. 11% of newborns died. Assessment of simulated resuscitation using a NeoNatalie anatomic model showed that less than a third of providers were able to demonstrate ventilation skills correctly. Conclusions The findings shared in this paper call attention to the critical need to improve health facility readiness to provide quality newborn care services and to ensure that service providers have the necessary equipment, supplies, knowledge and skills that are critical to save newborn lives.

The regional Latin American and Caribbean (LAC) Neonatal Alliance and national neonatal alliances in Bolivia, El Salvador, and Peru were studied through in-depth interviews and a review of publications. Findings were analyzed to distill successful strategies, structures, and tools for improving neonatal health by working through alliances that can be replicated at the regional or national level. The studies found the following factors were the most critical for successful outcomes from alliance work: inclusion of the Ministry of Health as a leader or primary stakeholder; a committed, diverse, technically expert, and horizontal membership; the presence of champions for neonatal health at the national level; development of a shared work plan based on feasible objectives; the use of shared financing mechanisms; the use of informal and dynamic organizational structures; and a commitment to scientific evidence-based programming. The relationship between the regional and national alliances was found to be mutually beneficial.

Swaziland's prevention of mother-to-child transmission (PMTCT) programme is linked to maternal and newborn health (MNH) services, but is mainly focussed on HIV/AIDS. Existing MNH services are inadequate, especially postnatal care (PNC) of mothers and babies, with delayed postnatal visits occurring at 4-6 weeks after delivery. Fifty-seven percent of staff in seven Swazi health facilities were trained in promoting and providing early PNC. A final evaluation showed a 20-fold increase in the number of visits coming for an early postnatal visit (within the first three days after birth). A direct observation of the client-provider interaction showed a significant increase in the competence of the health workers related to postnatal examinations, and care of mothers and babies (p0.05-0.01). The percentage of women breastfeeding within one hour of delivery increased by 41% in HIV-positive mothers and 52% in HIV-negative mothers. Cotrimoxazole prophylaxis for HIV-exposed infants increased by 24%. Although, health workers were observed providing counselling, maternal recall of messages was deficient, suggesting the need for additional strategies for promoting healthy behaviours. High-quality integrated PMTCT programmes and MNH postnatal services are feasible and acceptable, and can result in promoting early postnatal visits and improved care of both HIV-positive and HIV-negative mothers and their babies.

Recognizing the need to improve the care and follow up of mothers and infants in the postnatal period the Swaziland Ministry of Health and Social Welfare (MOHSW) with support from the Horizons Program of Population Council the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) Basics Support for Institutionalising Child Survival (BASICS) and the Central Statistics Office (CSO) carried out an operations research project to reposition postnatal care (PNC) within the context of a high HIV environment. The objectives of the study were to determine if changes to the sexual and reproductive health guidelines on postnatal care would result in the timely and quality provision of key components of essential maternal and newborn care in the postnatal period increase utilization of postnatal care services among all postpartum (PP) women and improve the care and follow up of HIV-positive postpartum women and their infants. The study confirms that the introduction of an improved postnatal package with revised timing and content provides key components of maternal newborn and HIV care and increases the utilization of services among postpartum women and their infants. Postpartum women were three times more likely to attend PNC within one week of delivery post-intervention. An assessment of the quality of care during client-provider interactions for all postpartum women demonstrated a fourfold increase in the proportion that included all aspects of care: maternal and newborn health counseling for HIV family planning and improved provider-client relationships. Facilities are prepared to provide new postnatal care package. Health provider knowledge increased in several areas. More information was given to pregnant women during late pregnancy about the postnatal period. Women and their babies received better postnatal care. A higher proportion of postpartum women were breastfeeding post-intervention. The strong PMTCT program maintained a high proportion of women testing for HIV and receiving ART. More women?s partners were testing for HIV and sharing their results. There was an increased use of care and support services by HIV-positive postpartum women and their infants. More women were asked about family planning by health care providers. The new postnatal package was well received by clients. Providers were receptive to new postnatal package. Sustaining new PNC package requires addressing barriers. (Excerpts)

Background Preterm birth is now the leading cause of under-five child deaths worldwide with one million direct deaths plus approximately another million where preterm is a risk factor for neonatal deaths due to other causes. There is strong evidence that kangaroo mother care (KMC) reduces mortality among babies with birth weight