Paediatrica Indonesiana Mothers' response on

Paediatrica Indonesiana July

VOLUME 49

NUMBER 4

Original Article

Mothers’ response on Kangaroo Mother Care intervention for preterm infants Bernie Endyarni, Rosalina D. Roeslani, Rinawati Rohsiswatmo, Soedjatmiko

Abstract Background The low birth weight still remains the main cause RIQHRQDWDOGHDWKV.DQJDURR0RWKHU&DUH.0& SURJUDPFDQ provide a better care for low birth weight newborn infants through VNLQWRVNLQFRQWDFW Objective The aim of this study was to assess factors and UHVSRQVHVIURPPRWKHUVWKDWZRXOGLQIOXHQFHWKHUHLQWURGXFWLRQ DQG UHLPSOHPHQWDWLRQ RI .0& DW QHRQDWRORJ\ ZDUG &LSWR Mangunkusumo Hospital, Jakarta. Methods This was a prospective preliminary study using questionnaires, to mothers of low birth weight infants who would XQGHUJR.0&LQQHRQDWDOZDUG Results Most mothers felt sad, guilty, worried, afraid and not confident when they first saw their babies, thus, they were initially GRXEWIXODQGDIUDLGLQWKHEHJLQQLQJRI.0&%XWDIWHU.0& was implemented, most of the mothers found positive effects RQPRWKHULQIDQWERQGLQJmaternal affection in love or touch, breastfeeding and mother’s confidence in newborn care. Conclusions.0&SURYLGHVEHQHILWVIRUPRWKHUV0RVWPRWKHUV \LHOGSRVLWLYHUHVSRQVHZKHQLPSOHPHQWLQJ.0&SURJUDPWRWKHLU infants. [Paediatr Indones. 2009;49:224-8].

Keywords: kangaroo mother care, mother’s response, low birth weight

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orld Health Organization (WHO) VWDWHG WKDW VRPH PLOOLRQV ORZ birth weight (LBW) babies are born each year, related to either preterm birth or impaired prenatal growth, and these occur mostly in less developed countries. These LBW babies

224Paediatr Indones, Vol. 49, No. 4, July 2009

contribute a high rate of neonatal mortality. Of the estimated four million neonatal deaths, preterm and LBW babies represent more than a fifth.Indonesia LVOLVWHGDVWKHth country, according to WHO data, of countries with largest number of neonatal deaths worldwide. During the last years, infant mortality UDWH,05 LQ,QGRQHVLDKDVGHFUHDVHGWRSHU OLYHELUWKVLQ²7KHSUHYDOHQFHRI/%: EDELHV LQ ,QGRQHVLD UDQJHV IURP WR DQG LW FRQWULEXWHVRIWKHFDXVHRIQHRQDWDOGHDWK4,5 'DWD LQ QHRQDWDO ZDUG DW &LSWR 0DQJXQNXVXPR +RVSLWDOVKRZHGWKDWSUHYDOHQFHRI/%:LV6 Prematurity as the cause of LBW is associated with various neonatal problems including hypothermia, hypo/hyperglycemia, infections, respiratory distress syndrome and others. .DQJDURR 0RWKHU &DUH .0& SURYLGHV DQ alternative to incubator care for LBW infants, without separation from the mother. Previously, .0&KDGEHHQGHILQHGDVKDYLQJWKUHHFRPSRQHQWV

Presented at the 1st(XURSHDQ&RQIHUHQFHRQWKH.0&PHWKRGDQGth ,QWHUQDWLRQDO:RUNVKRSRQ.0&LQ8SSVDOD6ZHGHQ2FWREHU² )URP WKH 'HSDUWPHQW RI &KLOG +HDOWK 0HGLFDO 6FKRRO 8QLYHUVLW\ RI ,QGRQHVLD&LSWR0DQJXQNXVXPR+RVSLWDO-DNDUWD,QGRQHVLD Reprint request to%HUQLH(QG\DUQL0''HSDUWPHQWRI&KLOG+HDOWK 0HGLFDO6FKRRO8QLYHUVLW\RI,QGRQHVLD&LSWR0DQJXQNXVXPR+RVSLWDO -O'LSRQHJRURQR-DNDUWD3XVDW,QGRQHVLD7HO

Bernie Endyarni et al0RWKHUV·UHVSRQVHRQ.DQJDURR0RWKHU&DUHIRUSUHWHUPLQIDQWV

FRQWLQXRXVVNLQWRVNLQFRQWDFW66& EUHDVWIHHGLQJ preferably exclusively, and support. Recently, DQRWKHUFRPSRQHQWVKDVEHHQDGGHGWR.0&ZKLFK consist of four components: kangaroo position, kangaroo nutrition, kangaroo support and kangaroo discharge. The aim of this study was to assess factors and responses from mothers that would influence the UHLQWURGXFWLRQ DQG UHLPSOHPHQWDWLRQ RI .0& LQ &LSWR0DQJXQNXVXPR+RVSLWDO-DNDUWD

stories”. For mothers who had gemelli, each was interviewed for all babies she had. Questions vary from the data of mothers’ responses at first time seeing their premature infants, mothers’ responses RQ .0& LQWHUYHQWLRQ DQG DOVR WKHLU RSLQLRQ on the program. Written informed consent was required for inclusion. The study was a prospective SUHOLPLQDU\VWXG\UHJDUGLQJWKHUHLPSOHPHQWDWLRQ RI .0& LQWHUYHQWLRQ LQLWLDWHG DW 1,&8 RI &LSWR Mangunkusumo Hospital.

Methods Results This was a descriptive study conducted on the ILUVWWZRPRQWKVRIUHLPSOHPHQWDWLRQRI.0&DW &LSWR 0DQJXQNXVXPR +RVSLWDO IURP -XQH XQWLO -XO\ 'DWD ZHUH FROOHFWHG IURP PRWKHUV of low birth weight infants who would undergo .0& LQWHUYHQWLRQ LQ QHRQDWDO ZDUG DW &LSWR Mangunkusumo Hospital, Jakarta. We recorded data of the LBW infants from the medical record and performed a guided interviewed to the mothers on mothers’ responses using questionnaires. We XVHGVHPLVWUXFWXUHGRSHQHQGHGLQWHUYLHZDVZHOO as close question questionnaires. Some questions were developed to encourage mothers to “tell their

We collected data of the infants and the mothers as well. There were 15 mothers with one teenage PRWKHU \HDUV ROG DQG WKH ROGHVW ZDV \HDUV old. Out of 15 mothers, one had twins and one had triplets, made the total infants included in this study LQIDQWV7KHELUWKZHLJKW%: UDQJHGIURPWKH ORZHVWJXQWLOJ7KHUHZHUHLQIDQWVZLWK ELUWK ZHLJKW OHVV WKDQ J LQIDQWV ZLWK ELUWK ZHLJKW EHWZHHQ ² J DQG WKH RWKHUV ZHUH PRUHWKDQJ7KHORZHVWERG\ZHLJKWRILQIDQWV DWLQLWLDO.0&LQWHUYHQWLRQZDVJZLWKPHDQ 6' JTable 1)

Table 1. Baseline characteristics of mothers and infants Mothers (n=15) Age (yrs) Gestational age(wks) Infants (n=18) Birth weight (g) Body weight at initial KMC (g)

Minimum

Maximum

Mean (SD)

18 28

37 35

27.2 (SD 5.47) 31.6 (SD 2.2)

900

1800

1407.2 (SD 273.02)

1000

1800

1444.8 (SD 230.5)

Figure 1. Mothers’ responses at initiation of KMC

Paediatr Indones, Vol. 49, No. 4, July 2009225

Bernie Endyarni et al0RWKHUV·UHVSRQVHRQ.DQJDURR0RWKHU&DUHIRUSUHWHUPLQIDQWV Table 2. Mothers responses after implementing KMC Responses Mothers’s response after doing KMC (n=15) /QTGEQPſFGPV Would continue KMC at home Follow up: (mothers; n = 15) Continue home KMC Do not continue KMC No data/can’t be reached at follow up Duration home KMC (mothers: n=7) 4 weeks Do not continue KMC

Yes 14/15 14/15 6/15 1/15 8/15 1/7 1/7 4/7 1/7

0RVWRIWKHPRWKHUV ZHUHSULPLSDUDV DQG WKH UHVW ZHUH KDYLQJ WKHLU VHFRQG DQG WKLUG GHOLYHULHV+DOIRIWKHLQIDQWV KDG $3*$5VFRUHOHVVWKDQ7KHUHZHUHRXWRI mothers who underwent caesarean procedures. There were 9 out of 15 mothers who started ‘talking to their babies’ since their pregnancies almost HYHU\ GD\ ZKLOH WKH RWKHUV ¶WDONHG· WLPHVZHHN (4/15), once a week (1/15), and only one that never ‘talked’ to her baby during pregnancy. Most of the PRWKHUV IHOWJXLOW\DQGVWDWHGWKDWWKH\ZHUH the causes of the prematurity of their babies. Only one mother, who had triplets, which thought that the condition was nobody’s fault. 0RUHWKDQKDOI RIWKHLQIDQWVUHFHLYHG combined oral feeding, both formula and breast milk. 7KHUHZHUHRXWRILQIDQWVUHFHLYHGRQO\PRWKHU·V EUHDVW PLON DQG WKH RWKHU LQIDQWV UHFHLYHG RQO\ formula milk. Eight infants were first seen by their PRWKHUDW²GD\VROGDQGRQO\RXWRIZHUH seen at < 1 hour old, with mean age of first seen by WKHLUPRWKHUDWGD\VROG0RUHWKDQKDOI infants) experienced their mothers’ first touch at DJH²GD\VROGDQGRXWRILQIDQWVZHUHILUVW WRXFKHGDWDJH!ZHHNVZLWKPHDQRIILUVWWRXFKDW GD\VROG7KHUHZHUHRXWRILQIDQWVVWDUWHG .0&LQWHUYHQWLRQDWZHHNVRIDJHZKLOHWKHUHVW ZHUHUHFHLYLQJDWGD\VDQG!ZHHNVRIDJHZLWK PHDQRILQLWLDOWLPHRIPRWKHUVSHUIRUPLQJ.0&DQG giving breastfeeding at 15 days old. 5HJDUGLQJ .0& LQWHUYHQWLRQ GXULQJ KRVSLWDO care, at initiation of the program, only 1 out of 15 mother who felt weird, some felt afraid of causing the EDE\WRIDOO VRPH WKRXJKWWKDWWKH.0& intervention was impractical and most felt doubtful

226Paediatr Indones, Vol. 49, No. 4, July 2009

DERXW.0&2QFHVWDUWHG.0&QRRQHVDLGWKHVNLQ WRVNLQFRQWDFWFDXVHGVZHDWLQJDQGDOORIWKHPDJUHHG WKDWDIWHULPSOHPHQWHG.0&WKH\H[SHULHQFHGDQGIHOW EHWWHUPRWKHULQIDQWERQGLQJDQGPDWHUQDODIIHFWLRQ or love to their babies. (Figure 1) Most mother felt that they were more confident in facing and dealing with their babies condition after WKH\VXFFHHGHGGRLQJWKHLUILUVW.0&$WWKHHQGRI the interview, most of mothers (14/15) stated that WKH\ZRXOGFRQWLQXHSHUIRUPLQJ.0&WRWKHLUEDELHV only one mother who could not decide whether she ZRXOGFRQWLQXH.0&DWKRPHRUQRW,QWKHIROORZXS only seven out of 15 mothers that could be reached after discharged. Of those seven mothers, only one PRWKHUZKRGLGQRWFRQWLQXHKRPH.0&ZKLOHWKH UHVWVWRSSHGSHUIRUPLQJ.0&DIWHUPRUHWKDQZHHNV IRXUPRWKHUV ²ZHHNVRQHPRWKHU DQGOHVVWKDQ a week (one mother).

Discussion .0&LVDZD\IRUFDULQJWKHSUHWHUPLQIDQWVZKLFK SURYLGHV VNLQWRVNLQ FRQWDFW EHWZHHQ LQIDQWV DQG their mothers. This care was first created by Ray and 0DUWLQH]LQ%RJRWD&ROXPELDDVDQDOWHUQDWLYHZD\RI care for stable LBW infants who have overcome major DGDSWDWLRQSUREOHPVWRH[WUDXWHULQHOLIH7KLVLVDQ easy method of caring for newborn infants where the mother uses her own body temperature to keep her infant warm. Basically, it is an alternative to minimal care neonatal units. Many studies have shown benefits of the LPSOHPHQWDWLRQRI.0&HVSHFLDOO\WRORZELUWKZHLJKW LQIDQWV .0& VWDELOL]HV LQIDQW WHPSHUDWXUH KHDUW and respiratory rates faster than conventional care using incubator. It also reduces nosocomial infection, promotes breastfeeding, and increases infant growth as ZHOODVGHYHORSPHQW1HZERUQFDUHSURYLGHGE\VNLQ WRVNLQFRQWDFWRQWKHPRWKHU·VFKHVWFDQDOVRUHVXOW LQEHWWHUVXUYLYDODQGSK\VLRORJLFDORXWFRPHV.0& also provides benefits for parents. It facilitates active mother participation, confidence and independence in WKHLQIDQW·VFDUHJLYLQJDVZHOODVEHWWHUPRWKHULQIDQW bonding. 7KLV VWXG\ ZDV FRQGXFWHG GXULQJ WKH UH LQLWLDWLRQRI.0&SURJUDPLQRXUQHRQDWDOZDUG$OO VXEMHFWVLQRXUVWXG\XQGHUZHQWLQWHUPLWWHQW.0&


started at level II and level III care, while neonates were still in incubators. At the time of study, we ZHUHVWLOOHVWDEOLVKLQJRXUFRQWLQXRXV.0&URRP for infants who were discharged from level II and III care and still not be able to be discharged home. ,QWKLVFRQWLQXRXV.0&URRPLQIDQWVZHUHLQWKHLU mothers’ chest almost the whole days, preparing the G\DGUHDG\IRUKRPH.0&7KHUHIRUHRQO\VRPHRI RXUVXEMHFWVZKRH[SHULHQFHGFRQWLQXRXV.0&DW our ward, while others were discharged from level II care. In our study, half of the infants experienced DVSK\[LD :H VWDUWHG WKH LQWHUPLWWHQW .0& ZKLOH the neonates were still in oxygen therapy. We tried WRSURYLGHVXSSRUWLYH1,&8HQYLURQPHQWVIRULQIDQWV as well as parents. This efforts can facilitate active participation in the infant’s care giving, thus providing significant benefits to the developing infant. 7KH ORZHVW ERG\ ZHLJKW WR VWDUW .0& LQ WKLV SUHOLPLQDU\VWXG\ZDVJ7KLVH[DPSOHVKRZHG WKH EHQHILW DQG VWUHQJWK RI .0& LQ UHSODFLQJ conventional therapy using incubator. This condition DOVRDVVXUHVWKDW.0&FDQEHLPSOHPHQWHGLQYHU\ORZ ELUWKZHLJKWLQIDQWV,QPRVWRIUHIHUHQFHV.0&FDQ EHLQLWLDWHGDWJLQIDQWVVKRZLQJWKDWWKHUHLV QROLPLWRIORZHVWERG\ZHLJKWWRVWDUW.0&,QVRPH low income countries with limited, under equipped, DQG XQGHUVWDIIHG KHDOWK IDFLOLWLHV .0& VKRZV LWV important role in providing better LBW care in spite of lack of incubators. Most of mothers started to build their bonding by ‘talking to their babies’ since their pregnancies, vary from almost every day to once a week. Only one who never ‘talked’ to her baby during pregnancy. Most of mothers felt guilty and thought that they were the causes of the prematurity of their babies. Only 1 out of 15 mother who felt weird, some felt afraid and some IHOW.0&ZDVLPSUDFWLFDO$IWHUVHHLQJWKHLUEDELHV and tried to touch them, those feelings disappeared LQ VRPH PRWKHUV $IWHU LPSOHPHQWLQJ .0& PRVW RIPRWKHUVDJUHHGWRFRQWLQXH.0&DWKRPH7KLV is related to the steps of mothers dealing with their premature babies.The initial step is the anticipatory grief, second is facing up, when mothers are strong and brave enough to face their babies, third step is bonding and fourth step is learning stage, when mothers learn about infants’ needs and care. The mothers’ feeling on WKHLULQIDQWV·FRQGLWLRQLVLQIOXHQFHGE\WKHERQGLQJ

that were created between mothers and fetuses during pregnancy, first contact when the infant is born and mother’s previous infant death experience in family. About half of the infants were first seen and WRXFKHGE\WKHLUPRWKHUDW²GD\VROGDQGVRPH VWDUWHG.0&LQWHUYHQWLRQDQGEUHDVWIHHGLQJDW weeks of age. These late starts were due to some reasons, the most common reasons were the infants ZHUH VWLOO LQ 1,&8 DQG VRPH LQIDQWV ZKR ZHUH LQ QHRQDWDO ZDUG FRXOG QRW XQGHUJR .0& EHFDXVH the mothers were already discharged and did not come to visit their babies. These conditions were mostly due to the distance from home to the hospital was considered far and transportation fee was quite expensive. 0RVWPRWKHUVDJUHHGWKDWVNLQWRVNLQFRQWDFW KDGPDGHWKHPRWKHULQIDQWERQGLQJDQGPDWHUQDO affections or love to their babies become better. They also were more confident in facing and dealing with their babies condition after they succeeded GRLQJWKHLUILUVW.0&7KLVFRQGLWLRQZDVVLPLODUWR other studies which revealed that mothers felt that they were seen and considered, which made them feel reassured and gave them a sense of control. Thus, they became more confident in caring their premature babies. Most of neonates in our study received breast milk, only three out of LQIDQWV ZKR UHFHLYHG RQO\ IRUPXOD PLON 0DQ\ VWXGLHV UHSRUWHG WKH EHQHILWV RI .0& LQ LQLWLDWLQJ and increasing breastfeeding. $OPRVWDOORIPRWKHUVDJUHHGWRGRKRPH.0&DQG of seven mothers who could be reached after discharged, four mothers had performed it in more than four weeks. 2QO\RQHPRWKHUZKRGLGQRWFRQWLQXH.0&EHFDXVH there was lack of family support. For some mothers, higher home temperature and humidity were considered WREHDUHDVRQWRVWRSKRPH.0&7KH\GLGQRWKDYHDLU condition at home, therefore the babies were sweating ZKHQ.0&ZHUHSHUIRUPHG7KLVVKRXOGEHDQWLFLSDWHG by health care in educating mothers since Jakarta has pretty high temperature and humidity. However most PRWKHUV VWRSSHG .0& ZKHQ WKH EDELHV WKHPVHOYHV gave signs of uncomfortable feeling, due to the facts that babies were getting bigger and heavier. In conclusions, our preliminary study showed that most mothers gave SRVLWLYHUHVSRQVHRQLPSOHPHQWDWLRQRI.0&SURJUDP to their premature infants.

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