Exploring community Kangaroo Mother Care practices among NICU graduates: a prospective cohort study in South India

doi:10.21203/rs.3.rs-3556938/v1

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Research Article

Exploring community Kangaroo Mother Care practices among NICU graduates: a prospective cohort study in South India

https://doi.org/10.21203/rs.3.rs-3556938/v1

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Aim

To describe KMC practice in the community (cKMC) after discharge from the Neonatal Intensive Care Unit (NICU) in South Indian mother-LBW infants.

Method

A prospective study enrolling 420 dyads at discharge from the NICU with follow-up on cKMC practice two months after discharge. Factors associated with cKMC were explored using logistic regression.

Result

Among the 420 enrolled, 2 (0.5%) infants died, and 12 (2.9%) were lost to follow-up. Of the remaining families, 25% (101) never practiced cKMC, and effective practice was done by 25% (77). Infant birth weight ≥ 1.5 kg (OR: 3.1, 95% CI 1.8, 5.3) was associated with higher odds of practicing cKMC, while infant born at term (OR: 0.5, 95% CI 0.3, 0.8) and mothers’ weight > 45 kg (OR: 0.3, 95% CI 0.1–0.7) was associated with lower odds of practicing cKMC. Continued KMC practice 48 hours before discharge was associated with higher odds (OR: 3.4, 95% CI 1.8–6.2), while absence of father's support was associated with lower odds (OR: 0.6, 95% CI 0.3, 1.0) of effective cKMC.

Conclusion

The continuum of cKMC after discharge from the NICU was inadequate. Factors associated with cKMC practice should be considered when planning interventions to improve cKMC practices.

Low birth weight infant

community Kangaroo Mother Care (cKMC)

NICU graduates

Over 20 million babies are born with low birth weight (LBW) each year. (1). The World Health Organization (WHO) has defined LBW as, “the weight at birth less than 2,500 grams which can be a consequence of preterm birth, being small for gestational age, or both” (1). As per the National Family Health Survey data-5 from 2019 to 2021 (2), the infant mortality rate in India is 35.2 per 1000 live births. LBW contributes significantly to infant mortality, emphasizing the importance of care of LBW infants in health and social systems (3).

There are many strategies to improve the survival of LBW babies, such as providing standard thermal care with incubators, antenatal steroids and Continuous Positive Airway Pressure (CPAP) for respiratory distress (3, 4). WHO has recommended Kangaroo Mother Care (KMC) as a cost-effective, evidence-based, high impact intervention for the care of preterm and LBW new-borns at high risk of neonatal mortality and morbidity (3).

KMC was developed by Dr. Edgar Ray in 1978 with the aim to provide efficient thermal care for LBW infants (5). In addition, KMC facilitates breastfeeding, infection control, and bonding, promoting the health and well-being of LBW new-borns. Most published literature concerning KMC comes from health facilities where care was taught and given under the supervision of skilled health workers (6–8). Cochrane Studies from this field suggest that KMC decreases mortality by 40% post discharge and reduce severe infection, nosocomial sepsis, hypothermia and length of hospital stay (9, 10). A systematic review and meta-analysis in 2022 mentions community-based studies that enrolled infants at home, showing benefits on mortality in LBW infants after initiation of KMC (4, 11, 12). There are few studies from India, that have documented the challenges of KMC implementation in the health care delivery settings and the continuum of KMC practice at home including the duration of community KMC practice (cKMC) (13, 14).

The objectives of the present study were to assess current cKMC practice among families with new-borns who have been discharged from the Neonatal Intensive Care Unit (NICU) at Chengalpattu Medical College Hospital (CMCH), and to identify factors associated with cKMC practice after discharge.

Study setting and population

Study participants were identified at CMCH, one of the largest perinatal care centres in the state of Tamil Nadu, South India with 10,000–12,000 deliveries per year. All mothers with high-risk pregnancies from Chengalpattu and neighbouring districts are referred to CMCH. The NICU of this facility has 2,000–3,000 admissions every year, and 40% of the admissions are due to LBW. The health team provides guidance to KMC practice under the supervision of nurses, in addition, there are a KMC ward and a father Kangaroo ward adjacent to the NICU with comfortable reclining cots and chairs to facilitate family KMC practice. Caretakers are encouraged to follow the practice at home. The continuum of KMC practice for LBW in the health system (both in the facility and the community) is depicted in Fig. 1.

Study design and study sample

The study employed a prospective follow up design, enrolling families of LBW new-borns at discharge from the NICU, from January 2020 to December 2020. All neonates born alive at CMCH with a birthweight of less than 2,500g were invited to participate and included after obtaining written consent from the mother/caregiver. LBW neonates delivered outside CMCH and referred from the community and those born from multiple pregnancies were also invited to the study. Neonates with the following criteria were excluded: (1) neonates born with life-threatening congenital malformations, (2) neonates of mothers with absolute contraindication to breastfeeding like carcinoma, (3) neonates abandoned by the family and discharged to child helpline services, and (4) neonates currently participating in other clinical trials. Mothers intending to stay away from the study area (18.5%) and who did not give consent (9.2%) were also excluded. Of a total 596 mothers invited to participate in the study, 420 mother-baby dyads were enrolled (70.5%).

Data collection

Baseline data were obtained at discharge from the NICU by a team of two trained nurses and one social worker using the mobile application Epicollect 5 (data capture tool developed by CGPS). Socio-demographic details and mothers’ weight at first visit were obtained from the Pregnancy and Infant Cohort Monitoring and Evaluation (PICME) card and delivery details from hospital records. A pretested questionnaire, designed in a user-friendly manner, was used to collect information on the KMC practices in the hospital and at home after discharge. During pretesting, a small group of participants not included in the main study responded to the questionnaire. Their feedback was scrutinized and incorporated to refine the instrument. The team received comprehensive training in interviewing techniques and efficient data documentation methods before data collection, ensuring the accuracy and reliability of the gathered data.

Baseline data included questions regarding hospital KMC practices, namely the time of initiation of KMC after delivery and the average KMC duration per day by the mother/family members 48 hours before discharge.

Two months after discharge, the families were interviewed at home on their KMC practice, facilities and support and challenges faced. CKMC practice was defined as any KMC practice in the community (yes/no).

The questionnaire included questions on: cKMC practices: the frequency and duration of cKMC practices at home, as well as the position adopted by the mothers for KMC practice such as sitting, reclining and both positions. Facilities in home environment: essential amenities fostering KMC practice such as availability of a private room and a separate bed. Family Type: Nuclear family was defined as consisting of a married couple and their children living together in one household. A joint family was defined as including multiple generations living together in the same household. Father participation: whether other family members, such as fathers, participated in KMC. Challenges faced: questions concerning difficulties faced by the mothers.

Statistical analysis

Following a thorough process of revision and validation, the data was exported to SPSS version 29 for subsequent analysis. The data set was subjected to a process of data cleaning that involved identifying the duplicate, incomplete entries, outliers and missing values. The data was checked for inconsistencies, reviewed, and rectified if possible.

As per the operational guidelines of the Government of India on KMC for service care providers, we categorized the duration of KMC as per the cumulative completed hours of skin-to-skin contact in a 24-hour period to short (4 hours daily), extended (5–8 hours daily), long (9–12 hours daily) and continuous (more than 12 hours daily) (15). The protocol from KMC multicentric Study Group suggests that the recommended duration for practicing KMC is eight hours or more (16), The systematic review and meta-analysis for KMC suggest that KMC should be provided for at least 8 hours a day for greater benefit (11). Hence, effective KMC practice was defined as at least 8 hours per day in the current study.

Descriptive statistics such as frequencies, proportions and means were calculated to summarize the characteristics of KMC practices. Logistic regression analysis was used to identify factors associated with practicing cKMC or not, and effective cKMC or not. Families (n = 101) who did not practice cKMC at the follow-up were excluded from the analysis on effective cKMC or not.

For both outcomes, several potential independent variables were initially assessed, i.e., gestational age (< 37 vs ≥ 37 weeks), birth weight (< 1.5 vs ≥ 1.5 kgs), mother’s age (< 25 vs ≥ 25 years), mother’s weight (< 45 vs ≥ 45 kg), mode of delivery (normal vs caesarean section), delivery type (twin vs singleton), initiation of KMC after birth in the hospital (before vs after 3 days), family type (nuclear vs joint), father support for KMC (yes vs no), KMC at discharge (effective/≥8 hours vs ineffective/<8 hours), and monthly family income (< 8,000 INR, 8000-12,999 INR, ≥ 13,000 INR). The statistical analysis utilized a stepwise approach to select variables, following the recommendations of Hosmer and Lemeshow (17). Initially, the relationship between each independent variable and the chosen outcomes (cKMC practice or not, and effective cKMC or not) was evaluated using univariate logistic regression models. Variables that demonstrated statistical significance at a p-value of less than 0.2 were retained in multivariate logistic regression models, while those that did not show statistical significance in the initial assessment were reintroduced individually later into multiple models. Only variables that remained significant (p < 0.05) after this process were included in the final multiple models presented in the paper.

Ethical considerations

A total of 420 mother-baby dyads were recruited at the time of discharge, and 406 of these were followed up in the community two months later. Two infants died before follow-up, and twelve families had moved out of the community and could not be contacted. Table 1 provides the baseline characteristics of the mother-baby dyads. Among the mothers, 25% (102) had term deliveries. The majority of the infants were first-born (73% (295)), delivered in the tertiary care medical college (94% (380)) and 294 (72%) of the mothers lived in joint family systems.

Table 2 presents information on cKMC practice two months after discharge. A quarter of the families (101) did not engage in cKMC practice after discharge, of the remaining families who practiced cKMC, 19% (77) practiced cKMC effectively for more than eight hours per day and 9% (35) practiced for more than 12 hours (continuous).

Among those who practiced cKMC, 56% (172) usually opted for a sitting position, 20% (61) chose a reclined position, and 24% (72) practiced using both sitting and reclining positions. Regarding living arrangements, 75% (229) of households provided a private room and 89% (271) had a separate bed for the mother and baby.

Factors associated with practicing cKMC or not two months after discharge from NICU are shown in Table 3. In the multivariate model, the odds of practicing cKMC were lower among mothers with a weight of 45kg and above (OR=0.3 (95% CI 0.1, 0.7)) and in mothers who had delivered at term (OR=0.4 (95% CI 0.3, 0.8)) compared to mothers with weight less than 45kg and who had delivered preterm. The odds of practicing cKMC were higher when the baby was born with a birth weight of 1.5kg or above (OR=3.1 (95% CI 1.8, 5.3)) and if the mother initiated KMC after 72 hours of birth (OR=2.8 (95% CI 1.4, 5.4)), compared to babies born with weight less than 1.5kg and compared to initiating KMC earlier.

Father’s support of cKMC was a crucial determinant of cKMC practice after discharge. There was no support from the fathers among the mother-baby dyads that did not practice cKMC. Mode and type of delivery, mother’s age, family type at discharge were not associated with cKMC two months after discharge.

Factors associated with effective practice of cKMC are summarized in Table 4. Mothers who continued to practice KMC in the hospital for at least 48 hours before discharge had higher odds of practicing effective cKMC at home (OR=3.4 (95% CI,1.8,6.2)). Among the families without paternal support, the odds of practicing cKMC were lower compared to families with paternal support (OR=0.6 (95% CI,0.3,1). None of the other factors assessed was significantly associated with effective cKMC.

Supplement table 1 describes family characteristics and duration of KMC practice in hospital and in the community. Supplement table 2 reports barriers to cKMC practice. Around 40% (123) of the mothers reported pain as a barrier to practicing cKMC, while only a small percentage (3.5% (11)) expressed discomforts such as sweating and feeling hot as barriers to practice KMC.

This study represents one of few studies conducted in South India delineating the practice of KMC for LBW new-borns discharged from a government NICU health facility. Among the larger states of India, Tamil Nadu (TN) has the second-lowest neonatal mortality rate (18), but to the best of our knowledge, there is no published literature from TN describing the continuum of KMC for new-borns discharged to the community. Our findings underscore a significant inadequacy in the implementation of cKMC within the community setting. Approximately a quarter of families failed to engage in cKMC practice post-discharge, and 75% exhibited inadequate adherence. Only 19% adhered effectively to cKMC practices, and a mere 9% followed the continuous practice of cKMC (> 12 hours a day). Moreover, our analysis revealed that the weight of the infant at birth, as well as the mother's weight, were factors linked to the practice of cKMC. Furthermore, the provision of support from the father, coupled with the hospital practice of continuation of KMC up-to 48 hours prior to discharge, were associated with effective cKMC practice.

There are few studies regarding the duration of cKMC practice and factors that support the practice at home. The KMC uptake study for small babies in Karnataka, India, have shown that almost three quarters of mothers continued KMC 30 ± 8 days after discharge (19).

A study in Ghana documented nearly ubiquitous home-based cKMC practice; one week post discharge, 99.5% were still practising KMC and majority of them cKMC continued cKMC practice over four weeks of life (19). It is noteworthy that the current study deviates from the observed prevalent trends, revealing that a substantial proportion of families refrained from cKMC post-discharge.

A high-risk pregnancy is defined as "a pregnancy wherein the presence of any medical factor, either related to the mother or the foetus, has the potential to negatively influence the course of the pregnancy and its outcomes" (20). In the context of our study, we also considered familial and maternal characteristics, factors such as parity, mother's age, and family structure which did not exhibit a significant impact on the adoption of cKMC, but maternal weight was associated with cKMC practice. Intriguingly, we observed a higher chance of cKMC practice among mothers with a weight below 45 kg as retrieved from the PICME card documented at the first visit to the health facility. It is important to note that mothers with lower body weights are more susceptible to adverse birth outcomes, such as preterm delivery, stillbirth, and LBW. A study from China regarding per-pregnancy maternal weight and pregnancy outcomes found that underweight mothers delivered more LBW high-risk infants (21). Essentially, this signifies the challenge of delivering a high-risk infant by mothers who themselves are at a higher risk due to their weight, a scenario where the mother's inherent risk intersects with that of the new-born. Remarkably, we found that these high-risk mothers demonstrated a more successful continuation of cKMC practices at home. It is of significance to underscore that those mothers who delivered preterm infants also had higher odds of practicing cKMC.

In the current study, families with VLBW infants (< 1.5kg) practiced less cKMC hours in a day at home. Similar findings were observed in the KMC uptake study in Karnataka, India, where the babies less than 1.5 kg received less KMC. However, the study setting differed to ours as there was no intensive care available. In contrast, the CMCH has a targeted intervention strategy in the NICU, having facilities for intensifying KMC exposure for families in both the intensive and step-down units, with infrastructure for KMC and Father KMC wards. There is a standard institute protocol to discharge infants after gaining the target weight of 1.8 kg. Despite these efforts in the facility, the continuity of KMC practice was inadequate among LBW infants.

Similar to CMCH, a study conducted within Malaysia demonstrated a shorter hour of cKMC practices within the NICU cohort after discharge (22). We hypothesise that this could be due to the adequate weight gain and stabilisation before discharge and therefore less motivation among the families to practice KMC. However, further research is needed to confirm this.

The study examined how the initiation of KMC and the practice of KMC before discharge affected the continued practice of cKMC at home. At CMCH, nearly three fourth of the families initiated to KMC within the first three days, but this did not necessarily lead to a positive impact on the continuity of practice at home. Cochrane review mentions that multi-country and community-based trials investigating the initiation of KMC at the health facility and its impact on neonatal survival revealed that the time of KMC initiation in various studies ranged from 3 to 24 days after birth (4, 11, 12). A study conducted in Haryana, India, emphasized the initiation of KMC within the first 72 hours of life and highlighted its positive influence on survival(12). While there is ample literature on the immediate benefits of KMC and its impact on neonatal survival, there is lack of information regarding how early initiation KMC affects duration of practice of KMC in the community. Further research is necessary to explore the effect of immediate KMC on community KMC practice, ensuring a seamless transition from healthcare facilities to the community setting.

The present study shows that families with paternal support practiced longer duration of KMC daily. Similar critical roles by family members to enhance KMC was documented in African and Scandinavian studies (23, 24). Similar findings were found in other studies where structured care educational programs for families at NICU have shown benefits (22).Our results in conjunction with previous results, support the importance of availability of health facilities, and the policy of allowing family members in the NICU for KMC practice. Among the difficulties expressed, body pain was reported by approximately 40% of the mothers. Similar findings were reported in other published studies, in which postpartum pain, depression and fatigue in the mothers can reduce the practice of KMC (23, 25–27).

Limitations

The main limitation of the present study is its focus on the regional context, which may limit the generalizability. In the purview of the COVID-19 pandemic at the time of data collection, the families had to change the usual pattern of family functioning during the lockdowns. Also, the Integrated Child Development Scheme (ICDS) centres were closed, and the village health nurses were diverted to COVID related activities. Hence the continuum of care at the home may have been compromised due to the altered socioeconomic pattern and altered work pattern of health care workers during the pandemic. This study focused only on the mother-baby dyad discharged from the government NICU health facility. The status of babies delivered in private and other government care settings are not known.

To conclude, the practice of KMC in the community was inadequate. Hospital-based interventions like initiation of KMC, effective practice up to discharge and training the spouse and other family members to assist in KMC could help to improve the continuum of KMC in the community. Further implementation and quality improvement studies are needed to strengthen the continuum of care of LBW infants.

Ethics approval and consent to participate

This study acquired ethical committee approval from the Chengalpattu Medical College Institutional Ethics Committee and the Norwegian Regional Committee for Medical and Health Research Ethics (32413). We confirm that all interviews were performed following the relevant guidelines and regulations. We confirm that informed consent was obtained from all mothers and caregivers and the records were de-identified before analysis.

Availability of data and materials

The dataset used and analysed during the current study are available from the

corresponding author on reasonable request.

Materials Consent for Publication

Not applicable

Funding

Ekam Foundation, Chennai, India.

Competing interests

All the authors declare no competing interests.

Authors’ contributions

The authors’ responsibilities were as follows—SJ, IK, CS and TS: designed the research; SJ had primary responsibility for patient screening, enrolment and outcome assessment. IK, CS, TS supervised and periodically reviewed the progress of the research; JS, IK, CS, RV: analysed the data, performed the statistical analysis. SJ, IK, CS wrote the manuscript; TS reviewed the manuscript and suggested final modifications: SJ, IK, CS, TS, RV had primary responsibility for the final content; all authors: read and approved the final manuscript.

Acknowledgements

We acknowledge the support and contribution of the mothers and families of babies who participated in the study. We thank the Directorate of Medical Education and Directorate of Public Health & Preventive Medicine, government of Tamil Nādu for the permission of the research work. We thank the Dean of CMCH, Professor of Dept. of Neonatology Dr. Muthukumaran, the Nodal officer, SNCU Dr. Manikumar, Professor of Paediatrics Dr. Ravikumar, Professor in-charge of District Early Intervention Centre (DEIC) Dr. Murali, Ms. Reeta Mary Staff Nurse, follow up nurse of SNCU, all the nurses of NICU and staffs of DEIC. We thank Dr. Muniyandi Scientist (Statistician), ICMR who supported the preliminary data analysis. We thank Ms. Shenbagam, SNCU data operator, ICDS staffs and village health nurses of Primary Health Centres who helped to track the children. We thank Dr. S.Seethalakshmi Director Gandhigram Institute of Rural health for her support and Mr.Lingesh Artist cum Draftsman for designing the schematic flow diagram and Mr. Saravanan for secretarial assistance.

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Table 1: Baseline characteristics in a cohort of 406 low birthweight children discharge from the Neonatal Intensive Care Unit in South India

		N	%
Maternal and socio-economic characteristics
Mothers age	≤21 Years	79	19
	22-30 Years	288	71
	>30 Years	39	10
Mothers weight	Less than 45 Kg	56	14
	45Kg and above	350	86
Family Type	Nuclear – Married couple and children in one household	112	28
	Joint Family- multiple generations living together in the same household	294	72
Family Income /Month	< Rs.8000	99	24
	Rs.8000- Rs.12999	174	43
	≥Rs.13000	133	33
Birth and new born characteristics
Parity	Primigravida	295	72.6
	Second gravida	86	21.1
	Third gravida	22	5.4
	Fourth Gravida	3	0.73
Gestational Age
Extreme Preterm	< 28 weeks completed	2	0.4
Very Preterm	<32 weeks	59	14.5
Moderate Preterm	32 to <34 weeks	90	22.1
Late Preterm	34 to <37weeks	153	37.7
Term	37 to 42 weeks	102	24.9
Twin birth		110	27.1
Place of birth	Medical College1	38 0	94
	Others2	26	6
Mode of delivery	Caesarean	197	49
New-born sex	Male	220	54.1
		Mean	SD
Weight at Birth, g		1567	200
Weight at Discharge, g		2072	180

¹Tertiary care, 2 Referral from Primary Health Centre, District Hospital and Private Hospital.

Table 2: Community Kangaroo Mother Care (cKMC) practice in 406 Mother - LBW infants dyads two months after discharge from the Neonatal Intensive Care Unit in South India.

		N	%
Duration of Practice of cKMC after discharge (Months)	Not practiced	101	24.9
	Less than a month	137	33.7
	More than one month	168	41.4
Frequency of cKMC in a week	Not Practiced	101	24.9
	Daily	266	65.5
	4-5 times in a week	10	2.5
	Less than three times in a week	29	7.1
Frequency of cKMC in a day	Not Practiced	101	24.9
	Once	35	8.6
	Twice	77	19.0
	Thrice	88	21.7
	Four times and above	105	25.9
Hours of cKMC in a day	Not Practiced	101	24.9
	Short; <4hrs	134	33.0
	Extended; 5-8hrs	94	23.2
	Long; 8-12hrs	42	10.3
	Continuous; >12hrs	35	8.6
Home facilities for the 305 (75%) of families who practiced KMC
a) Separate Bed availability at home	Yes	271	88.9
a) Separate Bed availability at home	No	34	11.1
b) Private Room	Yes	229	75.1
b) Private Room	No	76	24.9
c) KMC Position	Sitting in chair or floor	172	56.4
	In Sleeping position	61	20.0
	Both	72	23.6

Table 3. Factors for practicing cKMC after discharge from NICU in 406 South Indian mother-infant dyad s
		No cKMC practice after discharge N=101	cKMC practice after discharge N=305	Univariate logistic regression			Multivariable logistic regression§
		N (%)	N (%)	OR	95%CI	p-value	OR	95%CI	p-value
Gestational age	<37 Months	60 (14.8%)	244 (60.1%)	ref.			ref.
	≥37 Months	41 (10.1%)	61 (15.0%)	0.4	0.2, 0.6	<0.001	0.5	0.3, 0.8	0.007
Birth weight	<1.5Kg	48 (11.8%)	97 (23.9%)	ref.			ref.
	≥1.5Kg	53 (13.1%)	208 (51.2%)	1.9	1.2, 3.1	0.005	3.1	1.8, 5.3	<0.001
Mode of delivery	Normal	53 (13.1%)	156 (38.4%)	ref.
	Caesarion	48 (11.8%)	149 (36.7%)	1.1	0.7, 1.7	0.817
Delivery type	Singleton	81 (20.0%)	215 (53.0%)	ref.
	Multiple	20 (4.9%)	90 (22.2%)	1.7	1.0, 2.9	0.059
Mothers age	<25	44 (10.8%)	149 (36.7%)	ref.
	≥25	57 (14.0%)	156 (38.4%)	0.9	0,7, 1.1	0.444
Mothers weight	<45kg	7 (1.7%)	49 (12.1%)	ref.			ref.
	≥45 kg	94 (23.2%)	256 (63.1%)	0.4	0.2, 0.9	0.025	0.3	0.1, 0.7	0.008
Family income	<Rs.8000, ref	19 (4.7%)	80 (19.7%)	ref
	Rs.8000-13000	53 (13.1%)	121 (29.8%)	0.5	0.3, 1.0	0.044
	≥Rs.13000	29 (7.1%)	104 (25.6%)	0.9	0.4, 1.6	0.627
Family living	Nuclear	26 (6.4%)	86 (21.2%)	ref.
	Joint	75 (18.5%)	219 (53.9%)	0.9	0.5, 1.5	0.633
Initiation of KMC after birth	before 3 days	88 (21.7%)	210(51.7%)	ref.			ref.
	after 3 days	13 (3.2%)	95 (23.4%)	3.1	1.6, 5.8	0.001	2.8	1.4, 5.4	0.003
KMC at discharge-	Ineffective(<8Hrs)	87 (21.4%)	235 (57.9%)	ref.
	Effective (≥8 Hrs)	14 (3.4%)	70(17.2%)	1.9	1.0, 3.5	0.053
Father support of KMC*	Yes	0	109(26.8%)	ref
	No	101(24.9%)	196(48.3%)	-	-	-
§ r^=0.11 (11 %), *no father support in those not practicing cKMC; father support predicts the outcome perfectly

Table 4. Factors for Effective cKMC after discharge from NICU in 305 South Indian Mother-infant dyad s practicing cKMC
		Ineffective <8 Hrs N=228	Effective >8 Hrs N=77	Uni variate logistic regression			Multivariate logistic regression*
		N (%)	N (%)	OR	95%CI	p-value	OR	95%CI	p-value
Gestational age	<37 Months	180(59.0%)	64(21.0%)	ref
	≥37 Months	48(15.7%)	13(4.3%)	0.8	0.4, 1.5	0.430
Birth weight	<1.5 Kg	68(22.3%)	29(9.5%)	ref
	≥ 1.5Kg	160(52.5%)	48(15.7%)	0.7	0.4, 1.2	0.203
Mode of delivery	Normal	118(38.7%)	38(12.5%)	ref
	Caesarean	110(36.1%)	39(12.8%)	1.1	0.7, 1.8	0.715
Delivery Type	Single	158(51.8%)	57(18.7%)	ref
	Multiple birth	70(23.0%)	20(6.6%)	0.8	0.4, 1.4	0.432
Mothers age	<25Yrs	110(36.1%)	39(12.8%)	ref
	≥25 Yrs	118(38.7%)	38(12.5%)	1.0	0.7, 1.2	0.715
Mothers weight	<45kg	30(9.8%)	19(6.2%)	ref
	≥45 kg	198(64.9%)	58(19.0%)	0.5	0.2, 0.9	0.019
Family Income	< Rs.8000	57(18.7%)	23(7.5%)	ref
	Rs. 8000-13000	95(31.1%)	26(8.5%)	0.7	0.4, 1.3	0.242
	>Rs. 13000	76(24.9%)	28(9.2%)	0.9	0.5, 1.7	0.784
Family Type	Nuclear	66(21.6%)	20(6.6%)	ref
	Joint	162(53.1%)	57(18.7%)	1.1	0.6, 2.1	0.616
Initiation of KMC after birth	before 3 days	165(54.1%)	45(14.8%)	ref
	after 3 days	63(20.7%)	32(10.5%)	1.9	1.1, 3.2	0.024
KMC at discharge	Ineffective (<8 Hours)	191(62.6%)	44(14.4%)	ref			ref.
	Effective (≥8 Hours)	37(12.1%)	33(10.8%)	3.9	2.2, 6.9	<0.001	3.4	1.8, 6.2	<0.001
Father support of KMC	Yes	75(24.6%)	34(11.1%)	ref			ref.
	No	153(50.2%)	43(14.1%)	0.6	0.4, 1.1	0.076	0.6	0.3, 1.0	0.047
r^=0.07 (7%)

No competing interests reported.

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Exploring community Kangaroo Mother Care practices among NICU graduates: a prospective cohort study in South India

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