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Indian Pediatr 2021;58: 932-935 |
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Evaluating Maternal Discharge Readiness
in Kangaroo Mother Care
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Claire Gooding,1
Tina Lavin,1
Elise van Rooyen,2,3
Anne-Marie Bergh,3
David B Preen1
From 1School of Population and Global Health, University
of Western Australia, Crawley, Western Australia;
2Department of Paediatrics, University of Pretoria and
Kalafong Hospital, Pretoria, South Africa; and 3UP-SAMRC
Unit for Maternal and Infant Health Care Strategies, Faculty
of Health Sciences, University of Pretoria, Pretoria, South
Africa.
Correspondence to: Claire Gooding, School of Population
and Global Health, University of Western Australia, 35
Stirling Highway, Crawley, WA 6009, Australia.
claire.gooding@uwa.edu.au
Received: July 25, 2020;
Initial review: September 14, 2020;
Accepted: December 16, 2020.
Published online: January 28, 2021;
PII:S097475591600285
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Objective: To develop
and apply a tool for measuring hospital discharge readiness of
mothers practicing continuous kangaroo mother care (KMC) in a
tertiary setting. Methods: A 22-item questionnaire was
adapted from an existing tool. After a pilot (n=20), the
survey was administered to 200 mothers in the KMC unit, Kalafong
Hospital, South Africa from 2017-2018. Two items which asked
participants how confident and ready they felt overall were used
to categorize women as ‘ready’ or ‘less ready’ for discharge.
Results: Most women (n=168, 88.0%) were categorized
as ready for discharge. The mean (SD) score for all 22 questions
was 9.4 (0.7). Women categorized as ‘less ready’ scored lower
overall (mean difference: 1.3) and within all four questionnaire
categories compared to women who were discharge ready (P<0.05).
Conclusions: Although most women in this study reported
high levels of discharge readiness, further research is needed
to see if results are comparable across settings.
Keywords: Hospital discharge, Outcome,
Premature neonates, South Africa.
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Kangaroo mother
care (KMC) is one of the ten
key interventions recommended by the World
Health Organization [1] to improve the
survival and health outcomes of premature neonates [2]. The
majority of low birthweight (LBW) infants are born in low-
and middle-income countries (LMICs) [3], where KMC has been
shown to reduce the risk of mortality by 40% compared to
conventional neonatal care [4].
There is a growing recognition of the
importance of maternal self-reported discharge readiness
[5], as research from high-income settings has identified
that inadequate maternal discharge readiness is associated
with increased health service utilization [6,7], low
confidence in provi-ding infant care, and greater difficulty
with stress, recovery, self-care and coping in the early
postnatal period [8,9]. However, there is little evidence
from LMICs of self-reported hospital discharge readiness in
women after giving birth, especially in the context of KMC.
This study aims to address this gap by piloting and
implementing a tool for evaluating self-reported maternal
discharge readiness among women practicing continuous KMC in
a tertiary hospital setting in South Africa.
METHODS
Kalafong Hospital is a public teaching
hospital with approximately 6000 deliveries per year. It
serves women of predominantly low socioeconomic backgrounds,
many of whom live in informal settlements. The KMC unit is
one of the most well-established in the region,
accommodating up to 20 mother baby dyads at any time.
Most LBW and premature babies receive
intermittent KMC in the high-care neonatal unit before being
transferred to the KMC unit for continuous KMC. A
multidisciplinary team of medical and nursing staff,
dieticians, and occupational and speech-language thera-pists
provide extensive discharge preparation to mothers on
feeding, KMC techniques, infant care, hygiene, medications,
and follow-up arrangements. Evaluating correct feeding
techniques for preterm babies and touching and handling are
very important before making a decision on discharge from
hospital. Most babies receiving continuous KMC tend to be
discharged from hospital earlier [10], at a lower weight,
and still on top-up expressed breast milk fed by cup.
The questionnaire used in the current
study was adapted from the Parent Discharge Readiness Survey
[11]. Face validity of the adapted questionnaire was
evaluated by local health professionals and researchers, and
a focus group discussion with five study-eligible women. It
was then piloted with a sample of 20 women who met the study
inclusion criteria. Average inter-item correlation was 0.16
(acceptable level 0.2-0.4) [12] and principal components
analysis (PCA) identified ten components with an Eigen value
>1. As questions were clinically informed, with the intent
of gathering information to improve clinical practice, no
questions were removed. Cronbach’s alpha of the
questionnaire was 0.81 and was not improved if questions
were removed to increase internal consistency.
The study population comprised all
eligible women staying in the KMC unit between 1 November,
2017 and 30 April, 2018. Recruitment was conducted using
conve-nience sampling. Of 212 women who were approached, 200
(94.3%) agreed to participate. Reasons for non-participation
included: depression, previous bad experience with research,
or disinterest.
The included women were aged 18 years or
older who spoke any of the Sotho or Nguni languages,
Afrikaans, or English, staying in the KMC ward for at least
three days with an infant born prior to 37 weeks (preterm)
or under 2500g at birth (LBW). Women with major social
issues (e.g., alcohol or drug addiction), those exclusively
formula feeding (as breastfeeding is a core component of
continuous KMC), and mothers of infants admitted for
palliative care were excluded.
Two trained research assistants
administered the questionnaire on the day of hospital
discharge through face-to-face interview of approximately 30
minutes duration, in the woman’s preferred language. They
recorded responses in English. Hospital records provided
maternal and neonatal clinical information and
socio-demographic data, which were complemented by data
collected upon recruitment. In the case of multiple births,
information from the twin with the poorest clinical
indicators was used (e.g., lowest birth weight) and the twin
pair considered one entity relating to the mother, as the
condition of the poorer twin is the main criterion for
discharge planning according to hospital protocol.
Maternal discharge readiness was treated
as a dichotomous variable (ready/less ready). Two questions
asking about overall discharge readiness were used to
determine overall level of perceived readiness on a 10-point
scale (Q18 and Q22). Women scoring
£8 on
either of these two questions were categorized as ‘less
ready’ while women scoring >8 on both questions were
categorized as discharge ‘ready.’
Statistical analysis: Crude
differences between discharge ‘ready’ and ‘less ready’
groups were evaluated with Pearson chi-square and Fisher
exact test for categorical variables, and independent
samples t-test for continuous variables. Crude
differences between discharge ‘ready’ and ‘less ready’
groups on each item were investigated using independent
samples t-test. All data were analyzed using IBM SPSS
Statistics version 25 statistical software with level of
significance set at P<0.05.
RESULTS
Of the 200 women who agreed to
participate, 190 (95%) women were included in the analysis
of discharge readi-ness. Women were excluded if they were
transferred to another hospital (n=5), discharged
prior to completing the questionnaire (n=4), or did
not complete all questions (n=1).
Descriptive characteristics of the study
participants are presented in Table I. Most
women reported they were of South African citizenship
(78.5%), were multiparous (68.0%) and with a singleton
pregnancy (86.5%). For infants, the mean (SD) gestational
age at birth was 32.8 weeks (2.7), and birthweight was 1703g
(424g). The mean (SD) gestational age at discharge was 36.1
(1.9) week.
Table I Descriptive Characteristics of Study Participants
| Characteristic |
All |
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Discharge readiness
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(N=200) |
Ready |
Less ready |
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(n=168) |
(n=22) |
| Maternal |
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Age, ya,b |
28.8(6.0) |
29.2 (6.2) |
27.0 (4.5) |
| Country of citizenship |
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| South Africa |
157 (78.5) |
130 (77.4) |
18 (81.8) |
| Zimbabwe |
32 (16.0) |
30 (17.9) |
1 (4.5) |
| Malawi |
6 (3.0) |
3 (1.8) |
3 (13.6) |
| Lesotho |
2 (1.0) |
2 (1.2) |
0 |
| DRC |
1 (0.5) |
1 (0.6) |
0 |
| Other |
2 (1.0) |
2 (1.2) |
0 |
| Rural home |
20 (10.0) |
16 (9.5) |
3 (13.6) |
| Married or co-habiting |
106 (53.0) |
92 (54.8) |
10 (45.5) |
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Maternal incomea,c
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3104 (2691) |
3057 (2738) |
3740 (2543) |
| (n=102) |
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Paternal incomea,c
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6401 (6516) |
6645 (6814) |
5398 (5020) |
| (n=97) |
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| Primipara |
64 (32.0) |
51 (30.4) |
10 (45.5) |
| Mode of delivery (n=195) |
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| Vaginal birth |
91 (45.5) |
76 (45.2) |
12 (54.5) |
| Caesarean birth |
104 (52.0) |
87 (51.8) |
10 (45.5) |
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Multiple pregnancyc |
27 (13.5) |
18 (10.7) |
6 (27.3) |
| HIV-positive |
46 (23) |
43 (25.6) |
2 (9.1) |
| Neonatal |
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GA at birth, wka |
32.8 (2.7) |
32.8 (2.7) |
32.7 (2.3) |
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Birthweight, ga |
1703 (424) |
1719 (439) |
1654 (308) |
| 1500-2499 g |
138 (69.0) |
115 (68.5) |
18 (81.8) |
| 1000 to 1499 g |
49 (24.5) |
42 (25.0) |
3 (13.6) |
| £999 g |
13 (6.5) |
11 (6.5) |
1 (4.5) |
| Males |
114 (57.0) |
96 (57.1) |
12 (54.5) |
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Admission weight, ga,c,e |
1769 (330) |
1794 (343) |
1684 (209) |
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Discharge weight, ga,c,e |
2025 (304) |
2059 (307) |
1907 (222) |
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Days in high care prior to KMC unita |
13.2 (12.1) |
13.4 (12.1) |
13.3 (12.0) |
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Days in KMC unita |
10.2 (7.2) |
10.4 (7.6) |
9.6 (3.9) |
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Oxygen therapye
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57 (28.5) |
49 (29.2) |
6 (27.3) |
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Oxygen therapy (d)a,e
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3.2 (6.8) |
3.4 (7.1) |
2.7 (5.0) |
| Breastfeeding |
200 (100) |
168 (100) |
22 (100) |
| Medically complex |
97 (48.5) |
84 (50.0) |
10 (45.5) |
| The sample for
discharge readiness was 190. Values in no. (%)
except amean (SD). GA: gestational age,
DRC-Democratic Republic of the Congo. bP=0.05. cP<0.05.
dincome per month in Rand;ein KMC unit. |
A sensitivity analysis of the outcome
measure (ready/less ready for discharge) was undertaken by
adjusting the cut-off score applied to Q18 and Q22 from 7 to
9 to assess the proportion of women being classified as
ready/less ready. It was determined that a score of
£8 (out
of 10) on Q18 or Q22 allowed for reasonable discrimination
between the two groups, and was also most consistent with
the original tool [11]. In contrast, the mean of all 22
items with the cut-off score
£8
resulted in 95% of participants categorized as ‘ready’ and
therefore did not provide good discrimination between
‘ready’ and ‘less ready’ mothers in our study. The majority
of women were categorized as discharge ready (n=168,
88%). Women who were considered less ready (n=22,
12%) were more likely to be younger, have a multiple
pregnancy, and have an infant who was smaller at both
admission to and discharge from the KMC unit (P<0.05).
The ‘less ready’ group scored lower
overall and in each category of questions compared to women
who were discharge ‘ready’(Table II). Mean
scores for the ‘less ready’ group were 1.2 points (12.6%)
lower across feeding-related questions, 0.9 points (9.5%)
lower across questions related to infant care, 1.3 points
(13.8%) lower across infant health and medications
questions, and 1.0 point (10.1%) lower across questions
related to KMC.
Table II Mean Scores by Question Category
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All |
Discharge readiness groups |
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| (n=190) |
Ready |
Less ready |
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(n=168) |
(n=22) |
| Feeding |
9.3 (0.9) |
9.5 (0.7) |
8.3 (1.1) |
| Infant care |
9.4 (0.9) |
9.5 (0.8) |
8.6 (1.3) |
| Infant health and
medications |
9.3 (0.9) |
9.4 (0.8) |
8.1 (1.1) |
| Practising KMC |
9.8 (0.7) |
9.9 (0.4) |
8.9 (1.3) |
| Overall |
9.4 (0.7) |
9.6 (0.5) |
8.3 (0.9) |
| Values in mean (SD).
For comparison between ‘ready’ and ‘less ready’
groups, P<0.001 for ‘feeding’ and for ‘infant health
and medications’ categories, and P<0.01 for ‘infant
care’ and ‘practicing KMC’ categories. Overall
P<0.001. |
Web Table I shows mean scores for
each discharge readiness questionnaire item. Women who were
‘less ready’ scored significantly lower, on average, than
women who were discharge ‘ready’ on all but four individual
questions (Q4, Q7, Q9, and Q21; P<0.05). The greatest
differences between the ‘ready’ and ‘less ready’ groups were
seen in four questions: Question 18 ‘How confident/sure do
you feel that you are ready for your baby to come home?’
(mean difference: 2.6, P<0.001); Question 22 ‘Please
tell us how ready you feel overall to take your baby home.’
(mean difference: 2.3, P<0.001); Question 14 ‘How
confident/sure do you feel that your baby is strong enough
to go home now?’ (mean difference: 2.3, P<0.001); and
Question 13 ‘How confident/sure do you feel that your baby’s
heart and breathing are stable and it is safe to go home?’
(mean difference: 2.0, P<0.001).
DISCUSSION
To our knowledge, this is the first time
a survey instrument has been used to empirically examine
maternal discharge readiness in a LMIC setting. The
questionnaire developed in the current study builds on an
existing validated tool [11], focusing on those components
appropriate in the context of facility-based continuous KMC.
Although babies in our study were
discharged earlier than higher income settings, most women
(88%) still reported high levels of readiness to return home
with their infant(s) at the time of discharge. This may
reflect the context of facility-based KMC where mothers are
their infant’s primary caregiver, and the strong focus on
discharge preparation and education in the study setting.
Women in the current study scored highly on questions
specifically related to feeding, infant care, infant
health/medications, and ability to practice KMC. Even women
who were categorized as ‘less ready’ for discharge, had a
mean score >8 in each questionnaire category. This may
indicate that although some mothers felt less ready for
discharge in general, the quality of discharge preparation
in the KMC unit ensures mothers have the skills to safely
care for their infants. The high level of self-reported
discharge readiness observed in the current study may also
reflect the fact that the study hospital has one of the most
well established KMC programs in South Africa.
Some limitations exist with this study.
The generalizability of this study is limited by the small
sample size, convenience sampling method, and the
single-center setting characterized by maternity patients of
predomi-nantly low socioeconomic status, as well as early
discharge from the KMC unit.
In conclusion, the maternal discharge
readiness questionnaire is a useful tool for use among
mothers in an established continuous KMC unit in a LMIC
setting. Most women undertaking continuous KMC in the study
setting reported high levels of perceived readiness at the
time of discharge, including preparedness with feeding and
caring for their infants, confidence in their infants’
health, and their ability to continue KMC at home. Further
research is needed in different LMIC contexts to see if
results are comparable across settings.
Acknowledgements: Maryjane Ntima and
Sheila Sono for their assistance with data collection.
Note: Additional material related to
this study is available with the online version at
www.indianpediatrics.net
Ethics clearance: Research Ethics
Committee of the Faculty of Health Sciences, University of
Pretoria (187/2017; 9 June, 2017), the Research Ethics
Committee of Kalafong Hospital (KPTH 34/2017; 13 June,
2017), and the Human Ethics Committee, University of Western
Australia (RA/4/1/9307; 25, July 2017).
Contributions: CG: data analyses and
drafting the manuscript; TL,DBP: conceptualization of the
study design, data analyses, substantial contribution to the
manuscript; EvR, A-MB: conceptualization of the study
design, data collection and preparing the dataset,
substantial contribution to the manuscript. All authors
approved the final manuscript.
Funding: University of Western
Australia Research Collaboration Award; Competing
interests: None stated.
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WHAT THIS STUDY ADDS?
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This study highlights
the importance of quality preparation for mothers
practising continuous kangaroo mother care prior to
discharge from hospital.
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REFERENCES
1. World Health Organization (WHO). WHO
recommendations on interventions to Improve Preterm Birth
Outcomes. Geneva: World Health Organization; 2015. Accessed
April 12, 2020. Available from: https://www.who. int/reproductivehealth/publications/maternal_
perinatal_ health/ preterm-birth-guideline/en/
2. Chawanpaiboon S, Vogel JP, Moller A-B,
et al. Global, regional, and national estimates of levels of
preterm birth in 2014: A systematic review and modelling
analysis. Lancet Glob Health. 2019;7:e37-e46.
3. World Health Organization (WHO).
Guidelines on optimal feeding of Low Birth-Weight Infants in
Low-and Middle-Income Countries. Geneva: World Health
Organization; 2011. Accessed April 12, 2020. Available from
https://www.who.int/maternal_child_adolescent/documents/
9789241548366.pdf
4. Conde-Agudelo A, Diaz-Rossello JL.
Kangaroo mother care to reduce morbidity and mortality in
low birthweight infants. Cochrane Database Syst Rev.
2016:CD002771.
5. Jing L, Bethancourt CN, McDonagh T.
Assessing infant and maternal readiness for newborn
discharge. Curr Opin Pediatr. 2017;29:598-605.
6. Bernstein HH, Spino C, Lalama CM,
Finch SA, Wasserman C, McCormick MC. Unreadiness for
postpartum discharge following healthy term pregnancy:
impact on health care use and outcomes. Acad Pediatr.
2013;13:27-39.
7. Weiss ME, Ryan P, Lokken L. Validity
and reliability of the perceived readiness for Discharge
after birth scale. JOGNN. 2006;35:34-45.
8. Bernstein HH, Spino C, Baker A, Slora
EJ, Touloukian CL, McCormick MC. Postpartum discharge: do
varying perceptions of readiness impact health outcomes?
Ambul Pediatr. 2002;2:388-95.
9. Weiss ME, Lokken L. Predictors and
outcomes of post-partum mothers’ perceptions of readiness
for discharge after birth. J Obstet Gynecol Neonatal Nurs.
2009;38:406-17.
10. Nyqvist K, Anderson C, Bergman N, et
al. State of the Art and Recommendations: Kangaroo Mother
Care: Application in a High-tech Environment. Acta Paediatr.
2010;99:812-9.
11. Smith VC, Young S, Pursley DM,
McCormick MC, Zupancic JA. Are families prepared for
discharge from the NICU? J Perinatol. 2009;29:623-9.
12. Piedmont RL. Inter-item correlations. In:
Michalos A, editor. Encyclopedia of Quality of Life and
Well-being Research. Springer; 2014. p. 3303-04.
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