KNOWLEDGE AND PRACTICE OF KANGAROO MOTHER CARE AMONG MIDWIVES IN FEDERAL TEACHING HOSPITAL ABAKALIKI, EBONYI STATE.

CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

Kangaroo Mother Care (KMC) is an approach to care for preterm and low birth weight (LBW) infants which consists of continuous skin-to-skin contact between a mother and her infant, exclusive or predominant breastfeeding, and early discharge from hospital with proper follow-up support. Originally developed in Bogotá, Colombia in 1978 by Drs. In response to the shortage of incubators, KMC was later adopted in almost every corner of the globe as a cost-effective, evidence-based solution to enhance neonatal outcomes at low resource settings (WHO, 2023).

Premature birth continues as one of the most important contributors to neonatal death and morbidity in the world. The World Health Organization estimates that annual premature births are about 15 million and that over one million children die every year from the complications of being born too early. The burden is greatest in sub-Saharan Africa, including Nigeria, which has one of the greatest proportions of neonatal deaths worldwide. According to the United Nations Inter-agency Group for Child Mortality Estimation (UN IGME, 2022), Nigeria's neonatal mortality rate (NMR) is one of the highest in the world in the world, with an estimated 35 deaths per 1,000 live births.

KMC is known to be one of the most efficient and affordable interventions for decreasing the mortality of pre-term and LBW babies. Multiple RCTs and systematic reviews have shown KMC to be effective in decreasing mortality, nosocomial infections, hypothermia, and hospital stay, increase breastfeeding and bond between mother and infant (Boundy et al., 2016; Arya et al., 2020). Although the evidence of its effectiveness is strong, the uptake of KMC in many low and middle income countries (LMICs) including Nigeria is suboptimal.

Midwives have been the cornerstone of maternal and neonatal health care in Nigeria, especially in tertiary health institutions like the Federal Teaching Hospital Abakaliki (FETHA), Ebonyi State. Midwives are first choice health care providers and are mainly responsible for the management of newborn care immediately following delivery, including starting and continuity of KMC practices. They have a great impact on mothers' uptake of KMC and the quality of neonatal care received in health facilities given their knowledge, attitude and practices.

Ebonyi State in south-eastern Nigeria is among the poverty-stricken states, with poor health care services, and has a high burden of maternal and neonatal morbidity and mortality. The Federal Teaching Hospital Abakaliki (FETHA), is the major referral hospital for the state and its neighboring communities with an estimated large number of Preterm and LBW neonates coming to treat there on an annual basis. Although the KMC guidelines are available in Nigeria, implementation studies have revealed the prevalence of huge gaps in the knowledge and consistent application of KMC by healthcare workers in tertiary health institutions (Okonkwo et al., 2021).

Studies carried out in Nigerian tertiary hospital have reported mixed results on the knowledge and practice of KMC by midwives. Ujah et al. (2019) reported that majority of the nurses and midwives in tertiary hospitals were aware of KMC, but less than half could show satisfactory knowledge regarding the components and protocols of KMC. Similarly, significant gaps in KMC practice were reported in the southeastern Nigerian hospitals by Chimah et al. (2020) who blamed the gaps on inadequate training, understaffing and inadequate institutional support. However, the disconnect between evidence and practice is a major challenge in the translation of evidence-based guidelines to routine clinical practice.

Socio-cultural factors, facility level enablers and barriers, and the quality of in-service trainings given to midwives further influence the practice of KMC. Iheozor-Ejiofor et al. (2022) reported that KMC is not frequently started or started late in many health facilities in Nigeria because of the heavy workload, lack of training, and lack of administrative support. The lack of a dedicated KMC unit, inadequate supportive supervision and inadequate documentation add to the challenges of implementation.

Based on the above, there is a need to systematically evaluate the knowledge and practice of KMC among midwives in FETHA, Abakaliki to determine gaps, provide knowledge for policy formulation and provide guidance for actionable educational interventions. This study therefore aims to assess the knowledge of midwives in FETHA on KMC and the extent to which these knowledge is being implemented in its care, for better neonatal outcome in Ebonyi State.

1.2 Statement of the Problem

Although the benefits of KMC and its endorsement by global health organisations are widely acknowledged, the implementation of KMC in Nigerian tertiary hospitals is inconsistent, and often suboptimally implemented. Based on anecdotal information and preliminary observations, it was evident that KMC is not practiced routinely in the neonatal unit of the Federal Teaching Hospital, Abakaliki, Ebonyi State; and that many midwives in the unit may not be aware of the WHO updated KMC guidelines. The situation is alarming especially with the high neonatal mortality rate observed in Ebonyi State which is very high compared to the national average.

However, some studies have reported that the theoretical knowledge of KMC among midwives in Nigerian teaching hospitals is adequate but there are significant gap in practices and following protocol (Ujah et al., 2019; Chimah et al., 2020; Okonkwo et al., 2021). The gap between knowledge and practice could be due to the inability to provide sufficient in-service training, heavy workload of the staff, inadequate infrastructure, lack of supportive supervision and lack of institutional policies for implementing KMC. It is therefore important to understand the specific gap in knowledge and practice of midwives at FETHA in order to design context-specific interventions that can help to enhance outcomes of neonatal care.

There is no facility-specific study at FETHA and so evidence based, targeted interventions cannot be developed for this context. This study is designed to fill this gap in knowledge because the extent of knowledge and practice of KMC among midwives at FETHA, Abakaliki has not been reported in the literature.

1.3 Objectives of the Study

General Objective

The general objective of this study is to assess the knowledge and practice of Kangaroo Mother Care among midwives in the Federal Teaching Hospital Abakaliki, Ebonyi State.

Specific Objectives

The specific objectives are to:

1. Assess the level of knowledge of Kangaroo Mother Care among midwives at FETHA, Abakaliki.
2. Evaluate the current practice of Kangaroo Mother Care among midwives at FETHA, Abakaliki.
3. Identify the barriers to the practice of Kangaroo Mother Care among midwives at FETHA, Abakaliki.
4. Determine the relationship between midwives' knowledge and their practice of Kangaroo Mother Care at FETHA, Abakaliki.

1.4 Research Questions

1. What is the level of knowledge of Kangaroo Mother Care among midwives at FETHA, Abakaliki?
2. What is the current practice of Kangaroo Mother Care among midwives at FETHA, Abakaliki?
3. What are the barriers to the practice of Kangaroo Mother Care among midwives at FETHA, Abakaliki?
4. Is there a significant relationship between midwives' knowledge and their practice of Kangaroo Mother Care at FETHA, Abakaliki?

1.5 Research Hypotheses

H0: There is no significant relationship between the level of knowledge and practice of Kangaroo Mother Care among midwives at FETHA, Abakaliki.

H1: There is a significant relationship between the level of knowledge and practice of Kangaroo Mother Care among midwives at FETHA, Abakaliki.

1.6 Significance of the Study

The findings of this study will provide valuable evidence-based data that can directly inform practice and policy at FETHA and similar tertiary hospitals in Nigeria. For hospital administrators and nursing management, the study will highlight specific knowledge and practice gaps that need to be addressed through targeted in-service training and capacity building. For midwives, the study will draw attention to best practices in KMC and encourage adherence to evidence-based neonatal care protocols.

For policymakers at the state and federal levels, the study will contribute to the ongoing efforts to reduce neonatal mortality in Nigeria by identifying structural and institutional barriers to KMC implementation. The findings will also be useful for curriculum developers in midwifery and nursing education programs, as they highlight areas where pre-service training needs to be strengthened.

Academically, this study will add to the growing body of literature on neonatal care practices in Nigerian tertiary hospitals and provide a baseline for future longitudinal studies on the impact of KMC training interventions on neonatal outcomes. The study will also be of interest to international health organizations, NGOs, and donor agencies working to improve neonatal survival in sub-Saharan Africa.

1.7 Scope of the Study

This study is limited to midwives currently practicing in the neonatal unit, labour ward, and postnatal ward of the Federal Teaching Hospital Abakaliki (FETHA), Ebonyi State. The study focuses specifically on knowledge and practice of Kangaroo Mother Care and does not extend to other aspects of neonatal care. The study will be conducted between 2024 and 2025, and findings are therefore limited to the study period and the specific institutional context of FETHA, Abakaliki.

1.8 Limitations of the Study

The study is subject to several limitations. First, the use of self-report instruments may introduce social desirability bias, as respondents may overreport their knowledge and practice of KMC to present themselves favourably. Second, the cross-sectional design limits the ability to establish causal relationships between knowledge and practice. Third, the restriction of the study to a single facility may limit the generalizability of findings to other tertiary hospitals in Ebonyi State and Nigeria at large. Every effort will be made to mitigate these limitations through validated data collection tools, anonymous questionnaires, and appropriate statistical analyses.

1.9 Definition of Terms

Kangaroo Mother Care (KMC): A method of care for preterm and low birth weight newborns involving sustained skin-to-skin contact between mother and infant, typically with the infant placed upright on the mother's bare chest, combined with exclusive breastfeeding and early discharge from hospital.

Knowledge: The degree of awareness, understanding, and comprehension that midwives at FETHA possess regarding the principles, components, protocols, and benefits of Kangaroo Mother Care, as measured by a structured questionnaire.

Practice: The extent to which midwives at FETHA actually implement and apply KMC techniques and protocols in their daily clinical care of preterm and low birth weight neonates.

Midwife: A trained and registered healthcare professional recognized by the Nursing and Midwifery Council of Nigeria (NMCN) who provides skilled care to women during pregnancy, labour, delivery, and the postnatal period, including care of the newborn.

Preterm Newborn: An infant born alive before 37 weeks of gestational age.

Low Birth Weight (LBW): A birth weight of less than 2,500 grams at birth, irrespective of gestational age.

Neonatal Mortality Rate (NMR): The number of deaths occurring in the first 28 days of life per 1,000 live births.

Federal Teaching Hospital Abakaliki (FETHA): The primary tertiary health institution in Ebonyi State, Nigeria, serving as a major referral center for maternal and neonatal care in the state and neighboring regions.

References

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Boundy, E. O., Dastjerdi, R., Spiegelman, D., Fawzi, W. W., Missmer, S. A., Lieberman, E., Kajeepeta, S., Wall, S., & Chan, G. J. (2016). Kangaroo mother care and neonatal outcomes: A meta-analysis. Pediatrics, 137(1), e20152238. https://doi.org/10.1542/peds.2015-2238

Chimah, U., Lawoyin, T. O., Ilika, A. L., & Okafor, U. H. (2020). Kangaroo mother care practice in neonatal intensive care units in South-East Nigeria: A cross-sectional study. Nigerian Journal of Clinical Practice, 23(3), 350–356. https://doi.org/10.4103/njcp.njcp_307_19

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