INTRODUCTION:

“Children are the wealth of the nation, Take care of them If you wish to have a strong India - NEHRU

Kangaroo mother care is special way of caring of low birth weight babies. It foster their health and well being by promoting effective control, breast feeding, infection prevention and bonding. Kangaroo Mother Care is a type of care for preterm infants and their parents that provide early skin- to -skin between the baby and the parents. This method enables parent to provide primary care and comfort to the child during their time in hospital.¹

Kangaroo mother care is universally available and biologically sound method of care for all new born but in particular for pre mature babies with the three component, skin to skin, exclusive breast feeding, support to mother infant dyad.²

Skin to skin thermal protection (kangaroo mother care) fosters greater involvement of in the care of Low Birth Weight babies and reduces reliance on equipment evidence indicates that using Kangaroo Mother Care for preterm babies results in stability of cardiac and respiratory function lower rate of severe infection, increased breast milk supply, higher rate of exclusive breast feeding and better weight gain Kangaroo Mother Care is gentle. Effective method that leads to shorter stay and early discharge for hospitalized babies, encourages frequent. Observation of the baby by the mother and fosters bonding.³

One in 12 babies (8.3% of live births) was low birth weight in 2005 in India. Between 1995 and 2005, the number of infants born low birth weight infants born in India increased to 11%. Because of the poor care and resources, this rate was increasing steadily.⁴

The benefits for all babies on Kangaroo Mother Care are that they stabilize faster on skin to skin care than in the incubator. They do not stabilize in the incubator in the first six hour of life. then KMC babies have stable oxygen rates and breathing. The heart rate is stable. The temperature is most stable on the mother in skin to skin care the mothers chest automatically warms a cold baby, and the mothers core temperature can drop if her baby has a temperature. Another of the essential factors of Kangaroo Mother Care is breast feeding, breast milk production is stimulated by skin to skin care so baby gets all the benefits of breast milk including the correct milk for human.⁵

The mother should be explained how to breastfeed while the baby is in Kangaroo Mother Care position. Holding the baby near the breast stimulates milk production. She may express milk while the baby is still in Kangaroo Mother Care position. The baby could be fed with paladai; spoon or tube, depending on the condition of the baby Kangaroo Mother Care unavoidably requires some exposure on the part of the mother. This can make her nervous and could be de-activating. The staff must respect mother’s sensitivities in this regard and ensure culturally acceptable privacy standards in the nursery and the wards where Kangaroo Mother Care is practiced.⁶

Kangaroo Mother Care can be started as soon as the baby is stable. Babies with severe illnesses or requiring special treatment should be managed according to the unit protocol: short Kangaroo Mother Care sessions can be initiated during recovery with ongoing medical treatment (intravenous fluids, oxygen therapy).Kangaroo Mother Care can be provided while the baby is being fed via orogastric tube or on oxygen therapy.⁷

A study reveals that kangaroo Mother care also helps to improve the sleep pattern of infants and may be a good intervention for colic.⁸

When the mother and baby are comfortable, Kangaroo Mother Care is continued for as long as possible, at the institution and then at home. Often this is desirable until the baby’s gestation reaches term or the weight is around 2500 gms. She starts wriggling to show that she is comfortable, pulls her limbs out, cries and fusses every time the mother tries to put her back skin to skin. This is the time to wean the baby from Kangaroo Mother Care. Mothers can provide skin to skin contact occasionally after giving the baby a bath and during cold nights.⁹

Globally it is estimated that 17% of live birth infant born are low birth weight. It focused only in South Asia 37% and India 33% of birth, are preterm or low birth weight infants constitute 1/6^th of the total annual global live birth in the ratio of preterm to small for date infants. According to annual report of ICMR, New Delhi in 2002-2003 among 16, 611 deliveries recorded in 10 centuries 18.5% were preterm and in 2003-2004 among 18, 074 neonates 22.5% were low birth weight 7.2% preterm 0.3% hypothermia and primary cause of death is 45%asphyxia, 30% prematurity, 12% malformation and infection out of 14.7% preterm babies half were appropriate for gestational age and remaining were small for gestational age babies 31% were full term and 69% were preterm. Globally each year 25 million babies are born with Low BirthWeight.¹⁰

Kangaroo mother care is a method of holding an infant with skin contact, prove and upright on the chest of the parent. It promotes better maintenance of temperature, better maintenance of regular heart rate, respiration and oxygen saturation, low oxygen requirement, less apnea, improved pulmonary function reduced crying, improved pulmonary function reduced crying, improved sleep weight gain, reduction in gastric reflux, reduction in hospital stay, improved bonding between baby and parent. Lactation for longer period, more milk production, promotion of self confidence, increased self esteem and decreased maternal stress. Infants given kangaroo care gained weight more quickly than babies not given, weight can often leads to shorter hospital stays. Mother are able to control the infants temperature better than an incubator. Nurses working in neonatal care units play a vital role in providing an individual comprehensive care for high risk Low birth weight babies based on their need¹⁰

NEED FOR THE STUDY:

A study has shown that the babies receiving Kangaroo Mother Care have more regular breathing and fewer predispositions to apnea and it protects against nosocomial infections. Even after discharge from the hospital, the morbidity amongst babies managed by Kangaroo Mother Care is less. Kangaroo Mother Care is associated with reduced incidence of severe illness including pneumonia during infancy¹¹

A randomized controlled trail was performed over one year period in which 89 neonates were randomized into two groups kangaroo mother care and conventional method of care. The result of the study was forty four babies were randomized in to Kangaroo Mother Care group and forty five to CMC. There was significant reduction in Kangaroo Mother Care vs. Conventional Method Care group of hypothermia (10/44 vs. 21/45, p-value<0.01), higher oxygen saturation (95.7 vs. 94.8, p-<0.01) and decrease in respiratory rates (36.2 vs. 40.7, p-<0.01). 79% of mothers felt comfortable during the Kangaroo Mother Care and 73% felt they would be able to give KangarooMother Care at home. Kangaroo Mother Care is feasible, as mothers are already admitted in hospital and are involved in the care of new born.¹²

A study stated that birth weight of <1200 grms babies frequently develop serious prematurity –related morbidity often starting soon after birth. They benefit the most from in-utero transfer to the institutions with neonatal intensive care facilities. It may take days to weeks before baby’s condition allows initiation of Kangaroo Mother Care.¹³

A study shown that, infant responses to pain during heel lance procedure were compared using kangaroo holding with the neonate held upright at a 60-degree angle between the mother’s breasts for maximal skin-to-skin contact. The pain score were significantly lower in kangaroo-held infants.¹⁴

A study revealed that 62 low birth weight babies were given Kangaroo Mother Care. Of these 19 (31%) were <1000gms, 32(52%) 1001-1500gms and rest between 1501- and 2500gms. (Smallest 548 grams). Kangaroo Mother Care was initiated within first week in 50% and by 2^nd week in 27.4%. Mean duration of Kangaroo Mother Care was 7 days (range1-48). No significant variation in heart rate, respiratory rate was noticed. Babies who received Kangaroo Mother Care had fewer complications and their survival rate was better. An increase in expressed breast milk in mothers was reported. Mothers accepted Kangaroo MC well, were more confident in handling their LBW babies. Their milk yield increased and they felt that they are contributing positively in the care of their tiny babies.¹⁵

A study was concluded that the KMC babies had better average weight gain per day (KMC: 23.99g vs. CMC: 15.58g, p<0.0001).The weekly increments in head circumference (KMC: 0.75 cm vs. CMC: 0.49 cm, p=0.02) and length (KMC: 0.99 cm vs. CMC: 0.7 cm, p=0.008) were higher in the KMC group suffered from hypothermia, hypoglycemia and sepsis. There was no effect on time to discharge. More Kangaroo Mother Care babies were exclusively breastfed at the end of the study (98% vs. 76%). Kangaroo Mother Care was acceptable to most mother and families at home.¹⁶

A study introduced a method to alleviate the shortage of care givers and lack of resources. Kangaroo care was early discharge in the kangaroo position despite prematurity. It has proven successful in improving survival rates of premature, low birth weight newborn, lowering the risk of nosocomial infection severe illness and lower respiratory tract disease. It also increased exclusive breast-feeding and for a longer duration and improved maternal satisfaction and confidence.¹⁷

A review examined 15 studies in low- and middle- income countries, including three randomized control trials, and found a 51% reduction in newborn mortality when stabilized babies weighting less than four pounds (2, 000gm) received warmth and breast milk through continues skin-to-skin contact on the chest of their mothers. The findings suggest that up to half a million newborn death due to preterm birth complications could be prevented each year if kangaroo mother care were available for all preterm babies, particularly in low-income countries, where newborn mortality rates are highest.¹⁸

A study was conducted in NICU of two places showed that kangaroo group infants showed significantly higher mean daily weight gain from the time of enrollment till 40 weeks of post conceptional age. There was a significantly higher episode of hypothermia, hyperthermia and apnea seen in the control group Kangaroo Mother Care group infants showed significantly higher episodes of upper respiratory tract infections at 3 months post conceptional age. Episodes of serious infections were found to be significantly more in control group. Exclusive breast feeding were found to be significantly more in Kangaroo Mother Carer group at discharge and at follow up.¹⁹

The researcher’s has observed the complications of hypothermia during the posting in neonatal ward.The researcher to conduct the study to assess the knowledge and attitude regarding the kangaroo mother care among B.sc Nursing 3^rd year students.²⁰

REVIEW OF LITERATURE:

Literature review is defined as a broad, comprehensive, in depth, systematic and critical review of scholarly publication, unpublished printed or audio visual material and personal communications.³⁶

A thorough literature review helps to lay the foundation for a study and can inspire new research ideas. Review of literature is arranged under the following headings:

1. Reviews related to low birth weight and physiological changes of neonates in kangaroo mother care

2. Studies related to neurobehavioral changes of neonates in kangaroo mother care

3. Studies on various medical personnel and their involvement in kangaroo mother care.

1) Reviews related to low birth weight and physiological changes of neonate in kangaroo mother care :

Low birth weight is one of the most serious challenges in maternal and child health in both developed and developing countries. Its public health, significance may be described to numerous factors its high incidence, its association with mental retardation and a high risk of perinatal and infant mortality and morbidity (half of all perinatal and one-third of all infant deaths are due to low birth weight), human wastage and suffering, the very high cost of special care and intensive care units. Many of them die during their first year. The infant mortality rate is about 20 times greater for all low birth weight babies than for other babies. The lower the birth weight, the lower the survival chance. ²¹

The set goal of government of India in health for all by 2000 with regard to low birth weight is to reduce its incidence to 10% level. A birth weight of less than 2500 grams is considered less favorable for the survival and well-being of a newborn and hence the weight of 2500 grams is being used as a cut off point. But in India the cut off point for low birth weight babies occur in babies with birth weight below 2000 grams. There are two main groups of low birth weight babies. Those born prematurely (before 37 weeks of gestation) and babies born with fetal growth retardation are referred as term, small for gestational age (TSGA).²²

A randomized control trial to compare the effect of Kangaroo Mother Care (KMC) and Conventional Methods of Care (CMC) on growth in low birth weight babies. The subjects were 206 neonates with birth weight less than 2000 grams. The findings of the study revealed that the KMC babies had better average weight gain per day (KMC: 23.99g Vs CMC: 15.58g, P<0.0001). The weekly increment in the head circumference (KMC: 0.75cm Vs CMC: 0.49cm, P=0.02) and length (KMC: 0.99cm VS CMC: 0.7cm, P=0.0008) were higher in the KMC group. Therefore, the study revealed that babies under kangaroo care were started earlier on breast feeds (98% Vs 76%). The study concluded that KMC is a simple and acceptable method for the mother can be continued at home and thereby improves the infant growth and reduces morbidity.²³

A descriptive study to explore the supportive behavior of nurses as experienced by mothers of premature infants. A convenience sampling of 37 mothers in a neonatal intensive care unit were recruited. These findings demonstrated that parents desired more nursing support than they received particularly in the area of supportive communication and health information. Thus the nurses should be aware of the importance of tailoring nursing support to meet the needs of parents with premature infants. ²⁴

A study to find out the various beneficial effects of kangaroo mother care in low birth weight babies. The sample size was 50 low birth weight infants, weighing less than 2000 grams. The mean birth weight was 1.487-0.175 kg. The mean age at discharge was 23.6-3.52 days and mean duration of hospital stay was 15.5-11.3 days. The study concluded that KMC is effective than traditional care with incubators is safe on stable preterm infants. KMC because of its simplicity would be preferred in home care of low birth weight babies.²⁵

A study to introduce community-based skin-to-skin care in low birth weight babies. The study findings revealed that the incidence of hypothermia was significantly reduced in (36.5 degrees C) both low birth weight and normal birth weight infants (49.2%, [361/733] and 43% [418/971], respectively). Acceptance of skin-to-skin contact (STSC) was nearly universal. No adverse events from STSC were reported. The study revealed that mother perceived STSC as a way of preventing newborn hypothermia, enhancing mother’s capability to protect her baby from evil spirits, and make the baby more content. The STSC is said to be highly acceptable in rural India when introduced through appropriate cultural paradigms. STSC may be of benefit for all newborns and for many mothers as well. New approaches are needed for introduction of STSC in the community compared to the hospital.²⁶

A randomized control trial to compare the effectiveness of using early Kangaroo care for extra uterine temperature adaptation against that of using radiant warmers. Trial subjects included 78 consecutive cesarean newborn infants with hypothermia problems. The Kangaroo care group received skin-to-skin contact with their mothers in the post-operative room. While infants in the control group received routine care under radiant warmers. The mean temperature of the Kangaroo care group was slightly higher than that of the control group (36.29 degrees C vs. 36.22 degrees C, p=0.044). After four hours, 97.43% of kangaroo care group infants had reached normal body temperatures, compared with 82.05% in the radian warmer group. Results demonstrated the positive effects of kangaroo care for extra uterine temperature adaptation in hypothermia infants. In the course of evidence-based practice, kangaroo care could be incorporated into the standard care regimen of low birth weight infants in order to improve hypothermia care against that of using radiant warmers.²⁷

Two case studies to determine the temperatures of Breast and infant temperature with twins during shared kangaroo care. Twins were being simultaneously kangarooed and the temperatures of maternal breasts during shared kangaroo care. Two sets of premature twins were held in shared kangaroo care for 1.5 hours. Infant temperatures were recorded from those on incubators and on breast. Infant temperatures remained warm and increased during kangaroo care and each breast appeared to respond to the thermal needs of the infant on that breast. Physiological explanations for thermal synchrony exist. These data suggested because each breast responds individually to the infants thermal needs.²⁸

A retrospective study to evaluate the efficacy of Kangaroo method on thermoregulation and weight gain of a cohort of preterm. It covers 56 preterm babies. The mean gestational age was 33+/-, 6 weeks and mean birth weight was, 1488+/-277, 6g (median=1500g). Mean temperature was satisfactory during follow up and was stable around 37+/-, 5 degrees C at discharge of program with mean daily weight gain of 33+/-7, 6g. The results of this study pointed out the efficacy of kangaroo method on thermoregulation, weight gain and survival of preterm babies. Thus the group advocates Kangaroo care for developing countries because of its low cost. ²⁹

2) Studies Related To Neurobehavioral Changes In Kangaroo Care:

A randomized control trial to evaluate the effect of Kangaroo Care (KC), used shortly after delivery, on the neurobehavioral responses of the healthy newborn. The subjects included were 47 healthy mother-infant pairs. KC began at 15 to 20 minutes after delivery and lasted for one hour. Control infants and KC infants were brought to the nursery 15 to 20 and 75 to 80 minutes after birth, respectively. During a one hour long observation, starting at 4 hours postnatal, the KC infants slept longer, were mostly in a quiet sleep state, exhibited more flexor movements and postures and showed less extensor movements. KC seems to influence state organization and motor system modulation of the newborn infant shortly after delivery. The significance of our findings for supportive transition from the womb to the extra uterine environment is discussed. Medical and nursing staff may be well advised to provide this care shortly after birth.³⁰

A study about the history of the Kangaroo Mother Care and present scientific evidence about benefits of this practice on morbidity and mortality, psychological and neurological development and breastfeeding of low birth weight infants. Sources of data were papers about Kangaroo Mother Care published from 1993 to 2004 were consulted, selected in Medline and lilacs as well as books, thesis and technical publications from the Brazilian Health Department. The findings were since its first description; Kangaroo Mother Care has been extensively studied. The method was always associated with reduced risks like nosocomial infection, severe illness and lower respiratory tract disease at six months and better gain of weight per day. There was no evidence of a difference in infant’s mortality. The investigators concluded that positive impact of KMC on breastfeeding was found. The method appears to reduce severe infant morbidity. ³¹

An exploratory descriptive analysis to explore relationships among physiological stress, behavioral stress and motor activity cues in preterm infants when they were not being handled or disturbed. The convenience sample included 42 preterm infants who had been 27 to 33 weeks gestational age at birth and were from 6 to 19 days old at the time of data collection in the neonatal intensive care unit. In each 10 minute observation, heart rate and oxygen saturation levels were recorded every 5 seconds and observational measures of behavioral distress and motor activity were recorded twice a minute. The physiological data were coded to reflect the percentage of each 10 minute period during which heart rate levels were less than 100bpm or more than 200bpm or oxygenation saturation levels were abnormally low (less than 90 mg%). Data were analyzed with correlation and general linear mixed models procedures. Stress cues and motor activity were more often related to low levels of Oxygen saturation than to low or high heart rate. Physiological status was more often related to motor activity than to stress cues. Few differences in the relationships were observed between younger and older preterm infants. Although these results are preliminary, they suggest that neonatal nurses should monitor preterm infants, behavioral stress and motor activity cues in response to care giving and minimize stimuli that evoke stress responses linked to physiological instability.³²

3) Studies on Various Medical Personnel and Their Involvement in Kangaroo Care:

A study to assess the nurses understanding about the delivery of Family Centered Care (FCC) in the neonatal unit. A qualitative approach was used. Audio taped interviews were conducted with seven nurses with varied experience of delivering FCC. They also described a lack of confidence, associated with less experience, as having an impact on the capacity to provide it. None of the nurses interviewed had received specific training with regard to this area of practice and all felt more could be done to improve nursing education in this area. This study highlighted the deficiencies in the training and experience of nurses in the delivery of FCC. Further research and development within this field is required with the aim of improving educational opportunities and resources for both juniors and seniors.³³

A descriptive survey to describe factors identified by nurses that promote Kangaroo holding in the special care nursery environment. 67 experienced registered nurses completed a survey to identify factors that support the implementation of kangaroo mother care holding. The primary factor for implementing Kangaroo holding was the assessed physiologic stability of the infant (stated by 98.5% of nurses). The other factors identified as integral components included adequate staffing patterns, maternal readiness and encouragement from the institution. To institute effective Kangaroo care, the factors to be ensured are educational programs, adequate staffing and encouragement.³⁴

A study to assess knowledge and practice of midwives regarding neonatal care. In seven hospitals of Mount Lebanon, 44 midwives taking care of 204 term neonates were addressed. Questionnaires and checklists were constructed to evaluate knowledge of midwives and their practice with respective neonates regarding neonatal care. They found out that midwives had acceptable knowledge regarding neonatal care, but the application of this knowledge in practice measures was limited. Neonates were thus at risk of hypothermia, physical pain and psychological distress.³⁵

A survey on the attitudes and practices of neonatal nurses in the use of Kangaroo care and identifies possible concerns with promoting kangaroo care in the neonatal intensive care unit. The sample size was thirty four nurses working in the NICU of a large public hospital in Melbourne completed a survey questionnaire. Four respondents were subsequently selected for follow-up interview to explore in greater depth issues associated with promoting kangaroo care in the NICU. The nurse’s attitudes, practices and role of the neonatal nurse in promoting kangaroo care were analyzed. This study confirms neonatal nurses strongly support the use of kangaroo care in the NICU. Although the majority of nurses reported positive attitudes and practices, they did identify a number of educational and practical concerns that need to be addressed to ensure kangaroo care with low birth weight infants is safe and effective.³⁵

STATEMENT OF PROBLEM:

“A Pre-Experimental Study to assess the Effectiveness of Structured Teaching Programme and Demonstration Method on knowledge of Kangaroo Mother Care among B.sc Nursing 3^rd year students of Royal Institute of Nursing Gurdaspur, Punjab.”

OBJECTIVES:

1. To assess the level of knowledge regarding Kangaroo Mother Care among B.sc Nursing 3^rd year students.

2. To assess the effectiveness of demonstration method and STP on knowledge regarding Kangaroo Mother Care.

3. To determine the association between pre-test and post-test score of level of knowledge regarding Kangaroo Mother Care among B.sc Nsg 3^rd year

NULL HYPOTHESIS:

· H_1:There will be no significant association between the knowledge regarding Kangaroo Mother Care with the selected socio-demographic variables of bsc nursing 3^rd year students at level of significance <0.01

· H₂: There will be no significant co-relation between pre- test and post- test knowledge score of Kangaroo Mother Care among b.sc (N) 3^rd year students at score of level of knowledge regarding Kangaroo Mother Care at level of significance <0.01

MATERIAL AND METHODS:

Pre- Experimental approach was used to assess the knowledge of B.Sc (n) 3^rd year Student studying in Royal Institute Of Nursing College. The Pre-experimental research design is adopted in this study.The pre-experimental research design is design in which Researcher has very little control over the experiment and it is very simple and convenient. The study setting for the present study was in Royal Institute of nursing of Jatio Sarja, District Gurdaspur, Punjab situated 3 km away from Batala. The population for this study comprises of B.sc (N) 3^rd year Student of Royal Institute of Nursing. District Gurdaspur, Punjab. The sample size

Figure 4: Percentage distribution of selected students according to level of pre test and post test knowledge.

DISCUSSION:

Objective 1: To assess the level of knowledge regarding kangaroo Mother Care among B.sc(n) 3^rd year students.

A quasi experimental study to assess the knowledge of mothers of preterm babies regarding kangaroo mother care and to evaluate the effectiveness of structured teaching programme on kangaroo care among the mothers of preterm babies. A total of 35 mothers were selected for the study. Findings of the study revealed that, the pre-test knowledge of the Kangaroo Care was Nil. After the structured teaching programme post test knowledge of the mother regarding Kangaroo Care was increased. 6 (17.10%) mothers had inadequate knowledge on Kangaroo Care, 25 (71.4%) mothers had moderately adequate knowledge and 4 (11.5%) mothers had adequate knowledge on Kangaroo Care. Kangaroo Mother Care is a simple low cost and highly effective intervention for low birth weight babies. And also teaching programmes can improve the knowledge of mothers on Kangaroo Care. So, educational programme on Kangaroo Care can be provided to Mothers, which in turn will improve the preterm and low birth care.³⁶

In the present research study the knowledge score reveals that out of 40 student of B.sc Nursing 3^rd year 80% have average knowledge, 17.5 % have good knowledge and 2.5% have poor knowledge.

Objective 2: To assess the effectiveness of demonstration and STP method on knowledge regarding Kangaroo Mother Care.

The study was conducted to assess effectiveness of video assisted teaching on kangaroo mother care shows and improvement of knowledge score with pre-test and post-test the using paired ‘t’test.The t value is 9.6429 at29 degree of freedom. It show highly positive researcher hypothesis (H₂) is accepted and null hypothesis is rejected.The video assisted teaching on kangaroo mother care shows highly significance, it shows video assisted teaching was more effective.³⁷

The present study reveals the effectiveness of STP and demonstration method on the knowledge of student of B.sc Nursing 3^rd year in pre-test and post- test by using t-value 10.007.

Objective 3: To determine the association between pre-test and post-test score of knowledge regarding Kangaroo Mother Care among B.sc 3^rd year students.

The present study reveals that the knowledge regarding the Kangaroo Mother Care. To assess the knowledge of student of Bsc. Nursing 3^rd year. The findings of the study reveals that Pre - test knowledge 80% have a average knowledge, 17.5 % is good knowledge, 2.5 % is poor knowledge. Post test knowledge 87.5% have good knowledge, 12.5% is average knowledge, 0% is a poor knowledge.

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Received on 25.07.2016 Modified on 20.08.2016

Int. J. Nur. Edu. and Research. 2016; 4(4): 465-473.

DOI: 10.5958/2454-2660.2016.00085.5