The baby was born eight weeks premature. She weighs little more than a kilogram; a tiny bundle in a padded nest battling against death. Her heart flutters.
An alarm sounds, adding to the cacophonous soundtrack of the neonatal intensive-care unit in the Pelonomi Hospital, a sprawling, 44-year-old complex of brown brick buildings southeast of central Bloemfontein. It is typical of many large public hospitals in South Africa: bustling, understaffed and slightly run-down.
"Mamma, kom hier asseblief [Mommy, please come here]," a nurse calls, after silencing the alarm.
The mother gets up from her chair, waddles forward and loosens the straps of her blouse. She tenderly picks up her little one, still connected to electronic monitors, and places the child on her bare bosom. The nurse then secures the child with a kangaroo mother-care wrap. It encircles the mother's chest and the tiny body, and fits beneath her armpits and over her shoulders. It is then tied at her back. Suddenly, everything is calm. The child's heart rate slows. Her frown dissolves.
"Dankie, mamma [Thank you, mommy]," the nurse sings. The child's mother sits back down, cooing to her silent infant.
Early childhood development
Cape Town-based public health physician Nils Bergman says the technique, which imitates the protective environment of a kangaroo's pouch, is an affordable way to ensure the development of premature babies particularly in underresourced facilities where access to incubators is limited. The warmth generated by the skin-to-skin contact between a mother and her baby helps to regulate the baby's body temperature, which is critical for the infant's development.
Bergman says kangaroo mother care is so effective that it should be used "for the care of all newborns, regardless of the resources babies and parents have access to, and whether [or not] infants are premature or underweight".
Research Bergman is working on shows that skin-to-skin contact between a mother and her newborn as soon as possible after birth also helps to develop a baby's emotional and social intelligence because of the warmer body temperature created by kangaroo mother care. Moreover, it produces more consistent heart rates and reduces the risk of a baby developing infections.
According to the health department's maternal and newborn strategic plan for 2012-2016, the government plans to implement kangaroo mother care in all public health facilities that provide newborn care. Underweight babies weighing between one and two kilograms are up to three times more likely to die than heavier babies and, according to the plan, kangaroo mother care can help to gradually reduce the number of neonatal deaths in South Africa in infants who die within the first 28 days of life – from the current 14 deaths per 1 000 births to 12 deaths per 1 000 births by 2014 and 11 by 2016.
Poor provinces can benefit
Largely rural provinces such as the Free State bear the brunt of the inequalities in healthcare delivery. "The further you are away from big cities, the worse the maternal and infant mortality rates. That's because the form of training that most nurses and doctors get these days, mostly in big cities, is often inappropriate for where they are working and what tools they have at their disposal," says David Woods, chairperson of the health education organisation, Perinatal Education Trust.
Free State infant mortality figures are proof of this. According to the province's health department, 48.1 of every 1 000 babies born in the province die before the age of one – more than the national average of 41.7 of 1 000 calculated for 2013 by Statistics South Africa.
Although figures vary greatly according to who collects and calculates them, the Free State's infant mortality rate was as high as 72.1 of a 1 000 live births in 2009, according to Stats SA, compared with a national average of 49.1 at the time.
"The problems in child and maternal health are awful," says Vanessa Booysen, a neonatal nursing specialist at the Free State health department. "This is due to a scarcity of doctors and many facilities heavily relying on nurses, who are overworked and made to feel helpless, to the point of being booked off with depression," she says.
Until two years ago, "most premature and at-risk babies had to be shuttled for hours by road from facility to facility due to a lack of functioning equipment and staff with neonatal skills, thus greatly increasing the risk of fatalities," Booysen says.
At the province's worst-performing hospital, the Mofumahadi Manapo Mopeli Regional Hospital in Phuthaditjhaba, about 12 babies born at the hospital died per month in 2010. "It had a terrible effect on staff," Booysen says.
"Health workers' training wasn't up to scratch and there was little we could do."
But in 2012 a handful of healthcare professionals at five Free State public hospitals, including Manapo and Pelonomi, took a distance-learning course run by the Perinatal Education Trust, in perinatal (before and after birth) care, which includes a strong focus on kangaroo mother care. According to Woods, "studies have shown that, in areas where the education programme is used, skills, knowledge, attitude and the quality of patient care increases".
Booysen says nurses and doctors who have completed the perinatal training have gained "visible confidence" in their work. With skilled healthworkers on board, Manapa especially has focused on noninvasive treatment to save newborns, such as placing special phototherapy blankets (blankets treated with light) and warmers at smaller facilities so only babies needing ventilation or other forms of invasive treatment can be transferred to secondary or tertiary hospitals.
The programme has had dramatic results, with kangaroo mother care being one of the strongest contributors to the success: within three months after implementation, there was a two-thirds reduction in
neonatal mortality at Manapo. The hospital started off with eight kangaroo-care beds and, by October 2012, 288 babies had gone through them without one dying. "These babies gained weight faster than other babies, developed fewer infections and their mothers produced more breast milk than those who didn't do kangaroo care," Booysen says.
The "Manapo plan" will soon be rolled out across the province and the perinatal education programme's mother-and-baby-care modules will become compulsory for all public staff working in maternal and neonatal medicine in the Free State. "Now that it's been seen what we can do, there is a greater need to set up kangaroo mother care wards and getting nurses on the perinatal education programme to save the lives of mothers and babies," says Booysen.
On Wednesday this week at the Pelonomi Hospital music was pumping, patient gospel choirs humming and 16 young mothers in their hospital gowns, with their newborn babies strapped to their chests, took part in a kangaroo mother-care beauty pageant, enthusiastically modelling on a makeshift catwalk.
"All the participants gave birth at the hospital this week and in the audience we had mothers who gave birth earlier this year and those who are about to give birth – all of them singing a special kangaroo mother-care and breast-feeding song they composed," Booysen says.
The competition for the silver kangaroo mother crown, decorated with a pink heart, was tough. Mothers had to answer kangaroo-care questions correctly, hold their babies in the right position and look confident.
One mother breastfed while modelling on the ramp, another had twins tied to her chest and a radiant teenage mom managed to keep her baby asleep for the entire show.
But, in the end, it was 19-year-old Queen Malefu from the Free State farming town Dealesville who walked away with a PEP Stores hamper. When the judges asked her how she would respond to a taxi driver refusing to allow her to enter his vehicle with her baby on her chest, she said: "I'd explain the advantages of kangaroo mother care to him and, if he still says no, I'll walk away and tell him I won't pay for a taxi that doesn't respect my baby's health. He should know better."
Initial close contact has many benefits
A neonatologist at the Rob Ferreira Hospital in Nelspruit, Nelly Maphosa, says the benefits of kangaroo mother care in the facility's small neonatal unit has helped relieve some of the pressure on the referral hospital's limited resources.
"This is a very small neonatal unit, we have only two cubicles and the intensive-care unit is mixed, which means that sick babies don't have their own intensive-care unit," she says. "With kangaroo mother care, we've been able to discharge underweight babies much earlier than we used to, which has helped us to better cope within the context of our limited resources."
Maphosa says that with kangaroo mother care infants as small as 1.65kg can be discharged because they are no longer dependent on incubators. Without it babies would have to weigh between 1.8kg and 2kg before being sent home. She says kangaroo mother care boosts the health of underweight babies (under 2.5kg) and extremely underweight babies (under 1.5kg) and helps with weight gain.
Kangaroo mother care was initially developed in Colombia, in the absence of incubators, to treat premature babies who had no health problems. The technique consists of three parts.
"The first is the emphasis on skin-to-skin contact between a mother and her newborn. This helps with temperature control and the mother acts as an incubator," Maphosa says. "We encourage exclusive breastfeeding during this time because this helps bonding between the mother and the baby and breast milk is optimal for the baby's development.
"The last point is early discharge. Sending the baby home sooner can help protect it from hospital-acquired infections and other illness," she says.
Public health physician Nils Bergman says kangaroo mother care should be used for all newborn infants. "The baby's first hour of life on a mom's chest should not be disturbed. In a birth where there are no complications, there is nothing that has to be done during this time that warrants the separation of a baby from the mother. All nursing and hospital routines can wait," he says.
Kangaroo mother care has been implemented in several state hospitals, including the Pelonomi and Mofumahadi Manapo Mopeli regional hospitals in the Free State, the Rahima Moosa Mother and Child Hospital, Kalafong Hospital and the Dr George Mukhari Hospital in Gauteng, and the Tonga Hospital in Mpumalanga.
But both Bergman and Maphosa warn that the success of kangaroo mother care depends on how well other neonatal health strategies are implemented in combination with it. "Kangaroo mother care is just one of the interventions we have in place to deal with neonatal mortality. Without the resources and healthworkers necessary to implement it in our hospitals we will not be able reap the full benefits of kangaroo mother care," Maphosa says. – Ina Skosana