(October 2003) Enifa Masangano sits in a ward at the Zomba Central Hospital in Malawi, her 20-day-old twins securely tied to her chest with a piece of cloth. Constant skin-to-skin contact has allowed the mother’s body heat to keep the twins warm since birth. This close contact also ensures that the babies can breastfeed on demand.

By placing her babies in a “pouch” to help them gain weight and feed naturally, Masangano is practicing kangaroo mother care (KMC), a method developed by two doctors in Bogotá, Colombia, in the late 1970s as a response to high numbers of infant deaths, overcrowding, infections, and other problems at health facilities. The method has since grown in acceptance as a way of dealing with inadequate and insufficient incubator care for very small newborns whose only medical problems relate to being born underweight.

Many infants who are delivered before 37 weeks of gestation and weigh less than 2,500 grams (5.5 pounds) at birth require medical care. However, KMC offers a means to provide for warmth, breast milk, protection from infection, stimulation, and safety, according to the World Health Organization (WHO).1 In resource-poor settings, incubators in short supply can be used by infants who have breathing and other life-threatening medical problems.

Though it can be tiring, Masangano is happy to act as an “incubator” for her babies. “They are close to me, and I can see how well they are. If there is something wrong with them or they are not breathing properly, I can tell right away, and I then call the nurse to help me,” says Masangano, who removes the twins from her body only to clean them and change their diapers. Her mother occasionally offers some relief, fastening the babies to her own body.

An Innovative Technique in Malawi

Every year, an estimated 20 million babies are born at low birth weight as a result of either preterm birth or impaired prenatal growth, WHO reports. While underlying causes remain largely unknown, these underweight births contribute to a high rate of infant deaths in the first month of life. Most of these births occur in developing countries, and their distribution corresponds to that of poverty, WHO notes in Kangaroo Mother Care: A Practical Guide.

Programs to save children’s lives are critical in Malawi, an overwhelmingly rural country, where some 65 percent of the population is poor, according to estimates in the country’s Poverty Reduction Strategy Paper.2 With a population of 11 million, the average number of children born to a woman is more than six, but early childhood mortality rates are also high.3 The Malawi Demographic and Health Survey (MDHS) 2000 estimates that one in five children dies before age 5 and that more than 20 percent of these deaths occur during the first month of life. The survey found that newborns perceived by their mothers as “small” or “very small” were much more likely to die before age 1 (154 per 1,000 live births) than those seen as average or larger (91 per 1,000).4

KMC was introduced as a pilot program in 1999 at the Central Hospital in Zomba, an area where children below age 1 die at a higher rate (151 deaths per 1,000 live births), than in the country as a whole (104 per 1,000), by MDHS estimates.

Dr. Georg Herzenstiel, who works in the pediatric/maternity wing of the Zomba hospital, introduced KMC because of the challenges medical staff faced trying to provide incubators for underweight babies. Even when incubators were available, intermittent electricity interruptions created numerous problems in the hospital’s ability to maintain a constant temperature for the infants’ growth and development.

Expansion of the Program

The Zomba hospital is the only hospital in Malawi with a well-established KMC program, but other hospitals in the country are set to start their own with support from the Saving Newborn Lives initiative of Save the Children U.S.5

Recognizing the benefits of KMC for low birth weight babies and the need for additional support to build on the experiences from Zomba, Saving Newborn Lives has facilitated a KMC learning center to prepare for countrywide implementation.

Several hospitals in the country have already been targeted. The country’s largest referral hospital, the Queen Elizabeth Central Hospital in Blantyre, has been preparing for its own KMC unit for underweight babies. Other large mission and government hospitals have also begun preparations to introduce KMC in their maternity wings.

Rosemary Nyirenda of Save the Children U.S., who is responsible for KMC training at the Zomba hospital, notes that getting health workers and traditional birth attendants in the area to recognize when a newborn needs KMC has gone a long way in promoting the survival of underweight infants. “At the moment, we are hoping that the successful KMC unit at this hospital can be used to train medical staff from other hospitals in the country,” she says.

Because of the tradition of carrying the baby on the back in Malawi, the move to carrying the baby in the front has been accepted more easily than health officials like Nyirenda anticipated. Even mothers with babies of normal weight have been known to adopt the practice of carrying their babies in the KMC way because of the easy access to breast milk.

Assistance in carrying the baby by other family members has helped with the quick discharge of mothers and babies from the hospital. Often, the grandmother, the mother’s siblings, the new baby’s older siblings, as well as the father take over KMC when a mother needs time to herself. Support from the wider community also offers some assurance that KMC will continue once the mother is discharged from the hospital.

Saving Newborn Lives program manager Dr. Stella Abwao says even though accurate and substantiated data are not yet available to measure the program’s success, the KMC benefits are already apparent in Malawi. “Although there has not been any research conducted in Malawi on the success of KMC practice, it is evident that this type of care for infants who are not sick but only underweight is good for both baby and mother,” she says.

Pushpa Jamieson is a journalist based in Lilongwe, Malawi.


  1. World Health Organization (WHO), Kangaroo Mother Care: A Practical Guide (Geneva: WHO, 2003).
  2. Government of Malawi, Malawi Poverty Reduction Strategy Paper: Final Draft (Lilongwe: Government of Malawi, April 2002).
  3. United Nations Population Division, World Population Prospects: The 2002 Revision Population Database, accessed online at http://esa.un.org/unpp/, on Sept. 30, 2003.
  4. National Statistical Office (Malawi) and ORC Macro, Malawi Demographic and Health Survey 2000 (Zomba, Malawi and Calverton, MD: National Statistical Office and ORC Macro, 2001).
  5. Save the Children, State of the World’s Newborns: A Report from Saving Newborn Lives (Washington, DC: Save the Children, 2001).