Kangaroo Mother Care

A Way to Reducing Neonatal Mortality

dr. Asri C. Adisasmita, MPH, MPhil, PhD

Seminar Kesehatan Nasional (SKN) Public Health Expo 10

28 Oktober 2017, Universitas Indonesia
 Outline

o Besaran masalah terkini AKN di dunia dan di

Indonesia
o Penyebab AKN di dunia dan di Indonesia
o Menanggulangi AKN di Indonesia (salah satunya
dengan KMC)
o Optimalisasi terobosan program khusus AKN yang
telah ada agar dapat diimplementasikan secara
lebih luas
 Neonatal deaths and the Sustainable
Development Goals 150
Mortality per 1000 births (global av)

Under-5 mortality rate

Early neonatal mortality

Late neonatal mortality

100
50

Target
for
SDG-3
0

1960 1980 2000 2030

Year
Modified from : Lawn JE et al Lancet 2005

By 2030, end preventable deaths of newborns and children under 5 years of age,
with all countries aiming to reduce neonatal mortality to at least as low as 12 per
1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births
Levels and Trends in Child Mortality Report 2017 UNICEF, WHO, World Bank, UN
Levels and Trends in Child Mortality Report 2017
UNICEF, WHO, World Bank, UN
CHILD MORTALITY IN INDONESIA

IDHS, 2012
CHILD MORTALITY IN INDONESIA
Wide disparity of
under-five, infant
and neonatal
mortality rates
across provinces
(UNICEF Indonesia, 2012)
Why?
Causes of
4 million
newborn
deaths
mostly due
to
preventable
conditions
 CHILD MORTALITY IN INDONESIA
Under-5 mortality rate 40 deaths per 1,000 live
births; 80% child death occurred during infancy; and
60% of infant deaths occurred during the first month
of life (neonatal period)1
Diarrhoea
Other
1%
Main causes of neonatal deaths (in Congenital
7%

13%
20102): preterm birth complication
Preterm
(43%), intra-partum related events 43%

(21%), and infection (15%). Infection

15%

Intrapartum
related
21%

1) DHS Indonesia, 2012 Causes of neonatal deaths in Indonesia, 2010

2) Liu et al, 2012, online table (Adapted from Liu et al, 2012, online table)
Integrated packages to reduce newborn deaths
Skilled obstetric and immediate newborn care Emergency newborn care for illness,
(hygiene, warmth, breastfeeding) & resuscitation especially sepsis management and
care of very low birth weight babies
Clinical

Emergency obstetric care to manage including Kangaroo Mother Care

care

complications such as obstructed labour and

hemorrhage

Antibiotics for preterm rupture of membranes#

Corticosteroids for preterm labour#

Folic
Antenatal
Focused 4-visit antenatal
Intrapartum Postnatal
Postnatal
care to support healthy
acid # package including practices
tetanus immunisation,
detection & management of 10 - 30%
Outreach

Family
8% 27 % 29 %
services

syphilis, other infections,

Early detection and referral of
Plann- pre-eclampsia, etc complications NMR
ing
Malaria(6 9%)
intermittent (18 35%) (17 39%) reduction
presumptive therapy*
reduction
Detection and treatment
reduction reduction
of NMR
of bacteriuria #
of NMR of NMR
Counseling and preparation Clean delivery by Healthy home care including
for newborn care and traditional birth breastfeeding promotion, hygienic
community

breastfeeding, emergency attendant (if no skilled cord/skin care, thermal care, promoting
Family-

preparedness attendant is available) demand for quality care 15 - 32%

Simple early NMR
Extra care of low birth weight babies
newborn care reduction
Case management for pneumonia

Pre- pregnancy Pregnancy Neonatal period Infancy

Birth
# For health systems with higher coverage and capacity
Kangaroo Mother Care
Why are we making a case for acceleration of KMC?
Over the past year, it has become increasingly evident that KMC implementation is
something that needs to be explored and acted upon

1 Newborn health is a major global health issue "Born Too Soon" highlighted need
to specifically address preterm mortality

22 KMCiis a critical
i i l iintervention
i h canhhelp
that l address
dd hi
thisi issue

3 Although universal coverage of KMC could avert ~450,000 deaths / year, there has
been very little work on KMC coverage or indicators at the national level

The case for acceleration is clear: we are here together to

examine the options and align on the principles to move forward

2012 Bill & Melinda Gates Foundation | 4

Batasan KMC
Perawatan bayi seperti bayi kanguru di
dalam kantong ibunya
Bayi dalam keadaan telanjang (hanya
memakai popok dan topi) diletakkan
secara vertikal di dada di antara kedua
payudara ibunya (ibu telanjang dada)
kemudian diselimuti
Panas ibunya dialirkan dari kulit ibu ke
kulit bayi secara kontinyu
(STS)
 Komponen KMC
Kangaroo position (Posisi kanguru)

Kangaroo nutrition (Pemberian ASI pd BBLR/prematur)

Kangaroo discharge (Pemulangan, Monitor & Pendidikan
untuk keluarga di RS/fasilitas)
Kangaroo support (dukungan keluarga dan masyarakat)
 Sejarah Penemuan KMC:
Di tahun 1978 dr. Edgar Rey menyarankan KMC
Tahun 1979 dr. Edgar Rey dan dr. Hector Martinez
menerapkan KMC
Dr. Rey dan dr. Martinez bekerja di Bogota, Colombia,
Amerika Latin; KMC menjawab masalah mereka di
pegunungan (2.000 m di atas permukaan laut),
persalinan tinggi, dan inkubator yang terbatas
Ditemukan secara kebetulan
Tahun 1983 UNICEF mulai memperkenalkan KMC
Perkembangan studi KMC
Pertemuan ilmiah KMC
 KMC is not the only public health intervention to have slow
uptake,
uptake but it is time to "bend the curve" for KMC
% coverage of health intervention in low and middle income countries

Coverage (%)
75
Skilled birth attendance
HepB Vaccine
measured starting from
starting from NNRTI ARV's measured
approvalSafe Motherhood
in 1981
Initiative in 19871
measured starting from
ORS measured starting
approval in 19973
50
from Bangladesh rollout
in 19802
Exclusive breastfeeding
measured starting
from BabyFriendly
25 Hospital Initiative in
19921

KMC (illustrative)
Originally introduced in
Colombia in 1978
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

Years from availability of intervention

I Introduction
t d ti fof
intervention

1. Skilled birth attendance and breastfeeding are ancient intervention. Introduction of SBA is measured from 1987, when the Safe Motherhood Initiative was launched. Exclusive breastfeeding measured from 1992, when Baby-
Friendly Hospital Initiative was launched. 2. Average of 49 countries reporting ORS rates 1999-2005, weighted by population under 15 years old 4. NRTIs were first approved in 1987. NNRTIs were approved in 1997 while PIs
were approved in 1995. 2012 Bill & Melinda Gates Foundation | 14
Source: WHO/UNICEF; World Bank; Mahy et al., 2010); BCG analysis
It will take all of us to accelerate implementation of KMC

Programming

Research
Mothers

P li
Policy KMC implementation

Evaluation

Funding

Advocacy

Critical to integrate perspectives while recognizing differing views so KMC implementation

can take off within Every Newborn and country newborn efforts
2012 Bill & Melinda Gates Foundation | 19
 Key Lessons Learned
Most countries have had some limited experience with
KMC it is important to build on that experience
Most Pediatricians and MOH officials are supportive of
scaling-up KMC services
Integration of KMC into other existing training materials
must ensure acquisition of KMC competencies are not
compromised
KMC service establishment is more than
policies and training
 Durasi: 3 tahun (2015 2018)
2015 2016 2017 2018

Baseline Study Intervensi Endline Study

Observasi proses Pelatihan KMC Observasi proses

impelementasi KMC pada
BBLR di RSUD Koja dan
RSUD Karawang
Mengukur Pengetahuan,
Sikap dan Perilaku Nakes
mengenai KMC
impelementasi KMC pada
Pendampingan/ BBLR di RSUD Koja dan
Supportive RSUD Karawang
Supervision
Melakukan pemantauan
KMC di rumah pasca
rawat BBLR di RS

Mengukur Pengetahuan,
Sikap dan Perilaku Nakes
mengenai KMC
Pelatihan KMC di RSUD Koja dan RSUD
Karawang
Pelatihan KMC untuk Puskesmas di wilayah Kotamadya Jakarta Utara dan Kab Karawang
Latihan konseling KMC

Ruang KMC
di RSUD Koja
 KMC di
ruang NICU

KMC di ruang
KMC kontinu di
RSUD Koja
KMC di ruang perinatologi
KMC pada bayi kembar
Study banding ke Da Nang
Women and Children
Hospital, Vietnam
Lembar balik dan buku saku untuk
edukasi dan konseling KMC
Penjemputan Bayi BBLR oleh tim
KPLDH Jakarta Pemantauan pertumbuhan bayi dan KMC di rumah
Pertanyaan
Desi: untuk rating jogja paling rendah, seharusnya jakarta lebih rendah karena fasilitas
lengkap. apakah jogja KMC sudah berjalan daripada jakarta? KMC berhubungan
hipogiklemi?
karena komunitas jogya lebih sedikit dan urbanisasi lebih terkendali serta rihlahnya lebih kecil. KMC di
jogya ialah yang pertama dan sampai sekarang berjalan dengan baik serta konsultasi dgn para dokter.
tersedia KMC unit yang bisa dihuni dengan bayaran 50.000. lulus dengan berat 2500. orang jakarta
tidak semenurut dengan jogyakarta
KMC dapat menurunkan kejadi hipoglikemi, mempercepat pertumbuhan bayi
Diah: 1990-1994 mortalitiy 30, 1993-1997 20. apa yang menyebabkan angka neonatal
menurun signifikan? kenapa tidak dilihat untuk digunakan pada tahun ini?
harus melihat studi yang lain. upaya yg telah dilakukan kemenkes yang membuahkan hasil dengan
penurunan angka neonatal lebih cepat namun stagnan karena cukup sulit dan rentan terhadap
kematian
karena percepatan kualitas pelayanan kesehatan
Roda: apa penyebab kematian neonatal? bagaimana cara menanggulangi?
penyebab: infeksi, terkait persalinan
penurunan: melibatkan keluarga dan rumah sakit. keluarga diikutserta sehingga penurunan kematian
dapat sebesar 32%