Many low-resource areas of the world are short on medical technology, including incubators. So why not turn parents into pseudo-incubators? When a baby is born prematurely, a good way to help the baby survive and thrive is simply to hold it close to a parent's naked chest. No technology needed!

That's the essence of kangaroo care.

It's a method of holding the baby, clad only in a diaper, right up against a parent's bare chest for skin-to-skin contact. In 1978, physician researchers Edgar Rey Sanabria and Héctor Martínez-Gómez introduced the technique at the maternity ward of the San Juan de Dios Hospital in Bogota, Colombia. They were hoping to find a way to reduce the country's high death rate for premature infants — approximately 70% at the time.

The name conjures up the way that kangaroo moms hold their offspring in their pouch.

Formerly, these premature babies were placed in incubators — when they were available — to control the infants' temperatures, provide an optimal amount of oxygen and keep them away from disturbing loud noise and bright lights. But resource-poor countries have precious few incubators, and babies were dying for lack of technology.

The Colombian researchers found that parent-child snuggling had benefits similar to incubators.

Kangaroo care works, researchers believe, because the infants pick up heartbeat and breathing rhythms from the parents' bodies, helping to stabilize their own heartbeat and breathing. The body warmth of a parent also helps control the baby's temperature.

The researchers published their results in the 1983 Spanish language journal Curso de Medicina Fetal. They presented their results that year at a UNICEF conference: The babies in kangaroo care sleep more, and cry less, than those in incubators.

UNICEF, recognizing the potential of kangaroo care, began distributing information on the technique worldwide.

According to a study by the World Health Organization, starting kangaroo parental care immediately after birth has the potential to save up to 150,000 infant lives each year.

Since 1983, the practice has slowly spread around the world – for low-weight full-term babies as well as preemies and in wealthy nations as well as resource-poor countries. Fathers are being recruited as well – babies don't care which parent is the kangaroo.

The latest country to encourage this practice is Ivory Coast, where in 2019 the infant mortality rate for children under 12 months was 59 deaths per 1,000 births. By comparison, the average infant mortality rate in industrialized countries was 4 deaths per 1,000 births; the U.S. rate was 6 deaths per 1,000 births.

In 2019 with the help of UNICEF, the University Hospital Medical Center at Treichville in Abidjan, the largest city in the country, opened its first kangaroo care ward. In the ward, referred to by the World Health Organization as a mother-infant ICU, the mother is available to the baby around the clock. This intensive care unit is under the guidance of pediatrician Dr. Some Chantière. It's a pilot program to educate mothers and fathers in a technique not widely known in the country.

"There was a lot of death and lack of knowledge on how to take care of premature babies among the parents we were discharging, so we had to start this," says Chantière. "We knew about the program from its roots in Colombia. Before the program, 60 to 70% of all the premature children that would come out of the NICU boxes [or incubators] would die. Now we are saving over 90%."

The new program is "of critical importance in reducing the mortality of premature babies and can influence hospitals from the public to private sector in Cote d'Ivoire," says Dr. Berthe Evelyne Lasme-Guillao, associate lecturer of pediatrics at the Université Félix Houphouët-Boigny and head of the neonatology department at the CHU hospital in Yopougon.

She believes kangaroo care is a perfect fit for Cote d'Ivoire because of the high infant death rate and the dearth of medical technology, including incubators. "Programs like this can be adapted anywhere with dedicated and trained people," say Lasme-Guillao.

Dads are being trained in the technique, too, according to Mark Vincent, UNICEF representative in Cote d'Ivoire. "The fathers see the importance of the close proximity of the babies to the mother's body," he says. "They realize they can do it as well."

In April, I was able to interview and photograph a number of couples who have participated in the Ivory Coast's pilot program of kangaroo care at the Treichville hospital.

These are the stories of the moms and dads – and babies – I met.

'It was what we had to do and it saved my child's life"

Not all kangaroo care starts in a hospital. Bru Adjen learned the program at home. His wife, Inzuwe Rose, gave birth to twins. The son weighed over 4 pounds but the daughter weighed only 2.7 pounds, making her a strong candidate for kangaroo care. Inzuwe Rose learned the technique in the hospital's ward and brought the knowledge home with her when her daughter had reached 4 pounds and could be released. She taught the technique to her husband.

He had never seen mothers, much less fathers, use kangaroo care. "The start was strange for me, but over time I got used to it," he says. "It was what we had to do and it saved my child's life."

"It creates a link to my child and brings me closer with my wife"

Pastor Kubyes Abuwaka lives in the northern Yopogoon district. His wife, Abuwa Kristien, gave birth to twins. The boy, born weighing 2.6 pounds, died in the incubator. He and his wife feared they would lose their daughter, who weighed 2.7 pounds at birth, as well.

But when mother and daughter were admitted to the hospital's mother-infant ward, their girl gained weight rapidly. By the time she reached 4 pounds, she was discharged to continue the program at home.

"I saw the benefit, and I have been doing kangaroo care with my wife for a month and a half," says Abuwaka. "We both do it. It creates a link to my child and brings me closer with my wife."

The snuggling technique, he says, has made him a better father. "I want other fathers to take part in this. I know fathers have time issues with work, but it is important to get more involved helping mothers."

"I started taking part ... to give the love of a father to my children"

Ablodie Kouwasi, 35, gave birth five weeks prematurely to triplets. Each baby weighed under 4 pounds. Soon after birth, one infant died.

The surviving babies went into two of the hospital's scarce incubators long enough to stabilize their breathing and heart rates before coming out to make room for other infants in need. But Kouwasi and her husband, Yappe Pako, could only take their daughter, Ambo Mari Este, home. Their son, Ambo Crisostome, had contracted malaria and had to stay in the hospital.

But without the support of the incubator, neither infant thrived. Their baby girl lost weight at home, and while their son recovered from malaria, he did not gain weight.

The hospital staff suggested kangaroo care, and mother and her two infants were admitted to the kangaroo care ward. The couple learned the techniques of skin-to-skin care, and mom was on hand around the clock.

It worked quickly. "My wife has been doing it for three weeks, and now my son is healthy, and gaining weight. My daughter gained all her lost weight back, and more,"says Pako. "I started taking part myself to give the love of a father to my children."

"I love it because I can walk with them and have them with me"

I met Day Adeline, 40, when her babies were two weeks old. "My twins were born at 32 weeks, both under 1.3 kilograms (3 pounds)," she says. "The doctors say I cannot walk outside [and risk contracting an illness] to make sure they do not get sick. I have to stay inside this room." But she loves to walk with them. Holding one at a time, bare skin to bare skin, she walks laps in the small ward to pass the time, and to get her own exercise. "The kangaroo experience has been good. I love it because I can walk with them and have them with me, and it encourages growth." When the babies reached 4 pounds, she was able to go home with them. Doctors say it typically takes 2 to 3 weeks of kangaroo care before a newborn can leave the ward.

"I can see my children growing"

Youal Emmnual, 15, is in 9th grade. Her twins, born at 32 weeks, both weighed under 3 pounds. Mother and babies were all admitted to the kangaroo care ward, where Emmnual was happy to be taken under the wings of some older mothers. In addition to the education provided by hospital staff, some of the older mothers in the ward form a kind of impromptu village, passing their knowledge and experiences on to younger mothers. "There is a community in this ward," says Emmnual. "The other mothers are always here for me. I can see my children growing. I will be here for another week or two. I want to go back home to continue school. I will continue to do kangaroo at home."

"I want to be an advocate for the program in my community"

While Aluneumua Kalmel, 40, is taking care of her premature son in the kangaroo ward, her grandmother watches her other three children at home. "In this community that we have formed we do everything together," she says of the ward. "When one person wakes up, we all wake up to help each other. We eat together, and we make sure we are all looking out for each other. We have formed a village. We like it so much, even if we didn't need to be here, we would want to stay. It's safer and healthier for the child. If we were home alone, we would not have this knowledge. When I am out of here, I want to be an advocate for the program in my community. I have seen how it has saved children."

"I need to learn about this [kangaroo care] so I can take care of my child"

Weighing just 2.7 pounds, the baby girl had no name when I met her in April, 2022 in Cote d'Ivoire. Her mother, Diara Subs Aisha, was following a common local practice among parents to put off naming premature babies until they're confident the infants will survive. On her first day in the mother-infant kangaroo ward at the hospital, Aisha waits to take a class, her baby on her chest, as the infant pokes a tiny hand from under a blanket.

Andrew Caballero-Reynolds is a freelance photographer based in Abidjan, Côte d'Ivoire. He was a staff photographer and editor with AFP. He worked as the Reuters chief photographer in Sri Lanka and as a Gulf News staff photographer in Dubai. He has also worked as an emergency logistics coordinator for Doctors Without Borders and a National Forest Service firefighter in Oregon on a hotshot crew.

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