Effect of Kangaroo Mother Care in Low Birth Weight Infants on Breastfeeding Performance, Gut Function, and Maternal Depressive Symptoms in Low Middle Income Populations in the Indian Subcontinent

Bireshwar Sinha

Research output: Book/ReportDoctoral thesisCollection of Articles


Infants born low birth weight (LBW) have an increased risk of death and illness with many short-term and long-term consequences. As defined by the World Health Organization (WHO), Kangaroo Mother Care (KMC) is an intervention encompassing skin-to-skin-contact between the mother and the infant along with exclusive breastfeeding (1). The WHO recommends practice of KMC in LBW infants. This recommendation is based on the evidence that KMC can substantially reduce deaths and prevent morbidities in LBW infants. Despite the WHO recommendations, there has been reports of resistance towards implementing KMC in developing countries and the estimated coverage of KMC is low. Knowledge on the wide range of benefits of KMC is lacking amongst health care practitioners as well as in the community. Moreover, the potential benefits of KMC to the mothers is unclear, which often presents as a barrier to its promotion and practice.

The PhD studies were therefore designed to assess the effect of promotion and support of KMC on some important biological outcomes i.e., infant breastfeeding performance (Study I), biomarkers of infant gut function (Study II), and maternal postpartum depressive symptoms (Study III). The hypothesis was that KMC can improve infant breastfeeding performance and reduce the risk of maternal postpartum depressive symptoms through enhanced mother-infant bonding and improve infant gut function through reduced pathogen exposure.

The PhD studies were designed as randomized controlled trials embedded within the larger primary KMC trial titled “Impact of Community-initiated Kangaroo Mother Care on Survival of Low Birth Weight Infants” conducted in rural areas of Haryana, North India. Enrolment in the PhD studies were done between April 2017 to March 2018. In the PhD studies, we enrolled stable singleton LBW infants weighing between ≥1500 to ≤2250 grams within 72 hours of birth, born at home, or at hospital with KMC not initiated.

The intervention included promotion and support for early skin-to-skin contact after birth and lactation management to promote exclusive breastfeeding. The intervention delivery team conducted scheduled visits to the homes of the families on 1, 2, 3, 5, 7, 10, 14, 21, and 28 days after birth. During these home visits, practice of skin-to-skin-contact and breastfeeding were observed. The team helped to resolve any difficulties related to KMC practice. Infants in the intervention and control arms of the trial received standard of care i.e., home-based newborn care visits delivered by the health workers of the government health system.

Outcome assessments in the PhD studies were conducted by independent and trained teams. Infant breastfeeding performance was assessed using the validated ‘infant breastfeeding assessment tool’ (IBFAT) at the end of the neonatal period. Effective breastfeeding performance was defined by a IBFAT score of more than or equal to 10. For assessment of gut function, infant stool specimens were collected. Concentration of the fecal biomarkers neopterin, myeloperoxidase, and alpha-1- antitrypsin, were assessed using an automated ELISA system at the end of the neonatal period. The validated ‘Patient Health Questionnaire-9’ (PHQ-9) was used to assess maternal postpartum depressive symptoms at 28 days after birth. Moderate to severe postpartum depressive symptoms was defined by a PHQ-9 score of ≥10.

In Study I, among the 550 enrolled participants, outcome assessments were completed in 98% in the intervention arm and 95% in the control arm. In Study II, among the 200 enrolled participants, assessments of fecal biomarkers were completed in 99% to 100% of the infants in both intervention and control arms. In Study III, among the 1950 enrolled participants, assessments were completed in 93% in the intervention arm, and 94% in the control arm.

In Study I, effective breastfeeding performance was observed in 92% (232/252) of the infants in the intervention arm and 81% (223/276) of the infants in the control arm. The adjusted prevalence ratio (95% CI) for effective breastfeeding performance was 1.24 (1.16 to 1.32), corresponding to an effect of 24% (16 to 32%).

In Study II, between the intervention arm and control arm participants, the adjusted difference in means in the log-transformed concentration of fecal neopterin was 0.03 (95% CI -0.15 to 0.21), myeloperoxidase was 0.28 (95% CI -0.05 to 0.61), and alpha-1-antitrypsin was 0.02 (95% CI -0.30 to 0.34. There was no substantial difference observed in any of the measured fecal biomarkers.

In Study III, moderate-to-severe postpartum depressive symptoms were recorded among 10.8% of the mothers in the intervention arm against 13.6% of the mothers in the control arm. The adjusted relative risk (95% CI) for moderate-to-severe postpartum depressive symptoms was 0.75 (0.59 to 0.96). The corresponding efficacy of the intervention was 25% (4% to 41%).

In conclusion, the findings showed that in low-middle income neighbourhoods in Haryana, North India, promotion and support of KMC in stable LBW infants can substantially improve infant breastfeeding performance, reduce the risk of maternal moderate-to-severe postpartum depressive symptoms, but does not have any substantial effect on the measured fecal biomarkers of infant gut function at the end of the neonatal period. The results support promotion of KMC in public health programs in low-middle income populations in India and in similar South Asian countries. Further research to study the effect of KMC in unstable or very low birth weight infants and its long-term effect on maternal and child health outcomes could be useful.
Original languageEnglish
Place of PublicationTampere
ISBN (Electronic)978-952-03-3125-2
Publication statusPublished - 2023
Publication typeG5 Doctoral dissertation (articles)

Publication series

NameTampere University Dissertations - Tampereen yliopiston väitöskirjat
ISSN (Print)2489-9860
ISSN (Electronic)2490-0028


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