Temporal and spatial trends of low birth weight and Kangaroo Mother Care initiation in Uganda, 2015–2023

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Kangaroo Mother Care (KMC) is a low-cost, effective intervention for the survival of LBW babies in low-resource settings, including Uganda. However, the distribution of LBW births and their KMC initiation is not well documented in Uganda. We assessed trends and spatial distribution of LBW births and their KMC initiation, Uganda, 2015–2023. Methods We abstracted data on LBW, total deliveries, and LBW babies initiated on KMC during 2015–2023 from the District Health Information Software Version 2. We calculated LBW prevalence as the proportion of LBW births among total deliveries. Kangaroo Mother Care initiation coverage was computed as the proportion of LBW babies started on KMC. We stratified LBW and KMC initiation data by region, and health facility level. We used the Mann-Kendall test to assess the significance of trends. Results During 2015–2023, 605,876 of 10,952,463 births (5.5%) were LBW, with no significant change in the prevalence (p = 0.8). The highest prevalence of LBW was observed in Karamoja and West Nile (7.4%) in northern Uganda, with no trend (p = 0.14). Bukedi (p = 0.05) and Busoga (p = 0.003) subregions in eastern Uganda, had an increasing trend, whereas, Kigezi subregion in western Uganda, had a declining trend (p = 0.003). Among the 296,421 live LBW births during 2020–2023, 188,519 (64%) received KMC. Its coverage increased from 60% in 2020 to 68% in 2023 (p = 0.01). Ankole (p = 0.005), Bunyoro (p = 0.017), and West Nile subregions had increasing trends whereas Bukedi (p = 0.024) and Kampala (p < 0.001) had declining trends. Karamoja had low KMC coverage (60%) with no trend (p = 0.96). KMC initiation increased at Health Centre IIIs (sub-county level) (p = 0.006), but declined at national referral hospitals (p < 0.01). Conclusion There were regional disparities in trends of LBW births. While KMC initiation improved in certain regions and at lower-level health facilities, challenges persist in Karamoja and national referral hospitals. Further studies are needed to understand the determinants of LBW births, and initiation to KMC, to better guide region-specific interventions. Low birthweight Kangaroo Mother Care Method Uganda Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction The world Health Organization (WHO) estimates that about 15–20% of all births in the world are LBW and this proportion is even higher in sub-Saharan Africa (SSA) ( 1 , 2 ). Low birthweight (LBW) refers to babies who are born with < 2500 grams of body weight regardless of their gestational age at birth. These comprise preterm births (< 37 weeks of completed gestation) and term births (≥ 37 weeks of gestation) born with < 2500 grams of body weight ( 3 , 4 ). It is a derivative of both gestational age and fetal growth ( 5 ). Low birth weight is a key determinant of neonatal mortality and morbidity, with LBW babies having the highest risk of death during pregnancy, infancy, and early childhood. Over 80% of all newborn deaths occur among LBW babies in Southern Asia and SSA ( 2 ). According to the Uganda Demographic and Health Survey (UDHS), 2022, 10% of all babies born in Uganda had LBW. In Uganda, deaths related to LBW related complications contribute to > 50% of perinatal mortality ( 6 ). Additionally, LBW babies are at an increased risk of long term complications and chronic diseases such as cognitive impairments, neurodevelopmental disorders, cardiovascular diseases, diabetes and others ( 7 ). Kangaroo mother care (KMC) is an affordable and highly effective method for LBW babies, especially in resource limited settings. It involves prolonged skin-to-skin contact, promotion of exclusive breastfeeding, and allowing early discharge from health facilities. It enhances growth and reduction of complications such as hypothermia, hypoglycemia, and sepsis, but also fosters maternal bonding and stimulation ( 8 ). Furthermore, KMC improves outcomes among LBW babies, reducing neonatal mortality by 32% and six-month mortality by 25%. It also decreases hypothermia by 68%, reduces sepsis by 15%, and increases exclusive breastfeeding duration by 48%. Beyond that, KMC promotes better growth and development among LBW infants ( 8 ). KMC can contribute towards Uganda’s achievement of the Sustainable Development Goal (SDG) target 3.2, which aims to reduce the neonatal mortality rate (NMR) to < 12 deaths per 1,000 live births by 2030. Uganda’s NMR stands at 22 deaths per 1,000 live births, indicating that progress towards this goal has been slow ( 6 , 9 ). KMC is part of the WHO level 2 care for sick and small newborns (SSN), which recommends that at least 80% of districts in a country offer this level of care ( 10 ). Uganda is currently in early phase III of the NMR transition framework, a stage for countries with NMR ranging between 30 and 16 deaths per 1000 live births ( 11 ). Currently, KMC is included in the essential maternal and newborn care guidelines of Uganda and is recommended for LBW babies ( 12 ). Despite KMC being a low-cost and high-impact innovation, its use and distribution across Uganda are not well documented ( 13 ). We described the trends and spatial distribution of LBW babies and the application of KMC in Uganda during 2015–2023. Methods Study setting This was a national study in Uganda, with a population of approximately 45.9 million people in 2024 ( 14 ). It is one of the countries with a high fertility rate and poor maternal and neonatal health indices in the world ( 15 ). The country is divided into 15 non-administrative sub-regions each comprising of nine to thirteen districts ( 6 ). Health care services are organized from national referral level to health centre IIs; maternal and child health services are provided from health center III level to national referral level. The health care package increases with the level of care, with higher level health facilities managing more referrals and complicated cases. Study design and data source We conducted a nationwide descriptive analysis of LBW babies and KMC in terms of person, time, and place reported through the electronic district health information software version 2 (DHIS2), a computer-based national health information system. Data on LBW babies and LBW babies initiated on KMC are routinely generated at registered health facilities (all public health facilities and most private health facilities) that offer delivery services, aggregated at the district level, and then forwarded to the national database, the DHIS2, to make decisions and plan interventions on reproductive and infant health. Study variables, data abstraction and analysis We abstracted monthly data for each health facility in the country, all the districts, and at the national level for the analysis period of 2015–2023. We calculated national annual reporting rates of LBW prevalence by dividing the available monthly reports per year for all districts by the expected monthly reports for all districts per year. We also calculated national quarterly reporting rates of KMC coverage by dividing the available monthly reports per quarter for all regions by the expected monthly reports for all districts per quarter. Monthly data was abstracted using pivot tables in DHIS2 on LBW babies, LBW babies initiated on KMC, and total deliveries, 2015–2023. We disaggregated the data into national, regional and district levels data. We obtained data on LBW babies, LBW babies initiated on KMC, and total deliveries. We described the prevalence of LBW babies as a proportion of total deliveries in Uganda, 2015–2023. Additionally, we described the spatial distribution of the LBW prevalence in all districts across the country. We described the initiation of KMC as a proportion of total live LBW babies that were initiated on KMC, 2020–2023. We plotted the annual LBW prevalence against the study period in years to present the trend in prevalence at national level, 2015–2023. We also plotted the quarterly KMC coverage against the study period in years to demonstrate the trend in the coverage at national level and at health facility level, 2015–2023. Choropleth maps for LBW babies and their initiation on KMC were generated using Quantum Geographic Information System (QGIS) to show the distribution in Uganda. We analyzed for trends using Man Kendall test and Sen’s slope test for the direction of the trend. Results Trend of proportion of low birthweight babies at the national level, Uganda, 2015–2023 During the study period, a total of 605,876 LBW babies were recorded out of 10,952,463 babies (5.5%). The proportion increased from 4.5% in 2015 to 5.4% in 2023 with a peak of 7.1% in 2019 (p = 0.8). The reporting rate were good from 72% in 2015 to 98% in 2023 (average of 85%) (Fig. 1 a). Trend of low birthweight babies initiated on Kangaroo Mother Care at national and regional levels, Uganda, 2020–2023 Of the 296,421 LBW babies born during the four-year analysis period, 188,596 (64%) babies were initiated on KMC. The proportion of LBW babies initiated on KMC increased from 60% in January–March 2020 to 68% in October–December 2023 with a trend (p = 0.01) (Fig. 1 b). The reporting rates were good and stable from 95% in 2020 to 91% in 2023 (average of 98%). At regional level; 5 regions had a trend. In Ankole subregion, KMC coverage improved from 53% in January–March 2020 to 70% in October–December 2023, average of 70% (p = 0.005). In Bunyoro, the coverage improved from 45% in January–March 2020 to 70% in October–December 2023, average of 60% (p = 0.017). In West Nile subregion, the coverage improved from 80% in January–March 2020 to 88% in October–December 2023, average of 73% (p = 0.024). The coverage declined in Bukedi subregion from 80% in January–March 2020 to 71% in October–December 2023, average of 66% (p = 0.024). Similarly, the coverage declined in Kampala from 74% in January–March 2020 to 49% in October–December 2023, average of 71% (p < 0.001). The remaining 10 regions had no trend. Acholi region (54%), followed by North central (58%), Bunyoro (60%) and Karamoja (60%) region had the lowest KMC coverage (Fig. 2 ). Distribution of and trend of the proportion of low birthweight babies initiated on Kangaroo Mother Care by health facility level, Uganda, 2015–2023 Of the 2,536,064 babies delivered at HC IIIs, 99, 648 (3.9%) were LBW, and 58,161(58%) were initiated on KMC from 2020–2023. Out of the 1,127,754 babies delivered at HC IVs, 58,251 (5.2%) were LBW, and 38,126 (65%) of these were initiated on KMC. At general hospitals, out of the 938,473 babies delivered, 72,344(7.7%) were LBW and out of these, 54,546 (75%) were initiated on KMC. At RRH level, out of 323,880 babies that were delivered, 28,972 (8.9%) were LBW and out of these, 18,232 (63%) were initiated on KMC. At NRH level, out of the 127,508 babies delivered, 14,817 (11.6%) were LBW, and 11,176 (75%) were initiated on KMC (Fig. 3 ). There was a significant increase in KMC initiation coverage at HC III from January–March 2020 at 50–68% in October–December 2023 period (p = 0.006) with an average of 59%, a non-significant increase in coverage at HC IV level from 66% in January–March 2020 to 64% in October–December 2023 with an average of 65% (p = 0.9). At general hospital level, KMC coverage increased from 66% in January–March 2020 to 85% in October–December 2023, with an average of 75% with no trend (p = 0.16). At RRH level, KMC initiation coverage declined from 90% in January–March 2020 to 69% in October–December 2023 with an average of 64% (p = 0.9). At NRH level, the coverage declined from 91% in January–March 2020 to 39% in October–December 2023 with an average of 79% with a declining trend (p < 0.001) (Fig. 3 ). Distribution of low birthweight babies in Uganda, 2015–2023 The distribution of LBW babies was unequal all over the country with gross variations across different regions of the country. Karamoja and West Nile subregions, located in northeastern and northwestern Uganda respectively, had the highest prevalence (7.2%) with no trend (p = 1) (Fig. 4 ). Acholi, in northern Uganda, had a prevalence of 7.2% and no trend (p = 0.11), while Lango, also in northern Uganda, had 6.4% with no trend (p = 0.2). Kampala, in central Uganda, had a similar average prevalence of 6.4% (p = 0.08). Bukedi, in eastern Uganda, and Busoga, also in the east, showed increasing trends, with Bukedi rising from 3.4–5.1% (p = 0.05) and Busoga from 3.3–5.6% (p = 0.003) (Fig. 5 ). Kigezi, located in the southwestern region, exhibited a slight decline from 4.4% in 2015 to 4.6% in 2023 (p = 0.003). Discussion The LBW births stagnated during the study period, 2015–2023, with substantial regional heterogeneity. Karamoja and West Nile subregions in northern part of the country consistently reported the highest prevalence, whereas regions such as Bukedi and Busoga in eastern Uganda experienced increasing rates. There was a decline in some districts in Kigezi and Ankole subregions. Although there was an increase in KMC uptake, especially at lower-level health centers, there was low coverage in Karamoja and a significant decline at national referral hospitals. Overall, these trends highlight the importance of additional studies to understand the local determinants of LBW births and barriers to KMC uptake for better targeted interventions for each region. We found a lower prevalence of low birthweight (LBW) compared to the 10% reported by the 2022 Uganda Demographic and Health Survey (UDHS), as well as a study on LBW prevalence and its association with maternal body weight status in selected African countries, including Uganda. Additionally, the prevalence was lower than the estimated 13% observed in sub-Saharan Africa( 3 , 9 ). Although the reasons for the stagnation in LBW prevalence during the study period remain unclear, the high prevalence in sub-Saharan Africa may be attributed to factors such as increasing food insecurity, exacerbated by climate change ( 16 , 17 ). We observed variations in the prevalence of LBW and KMC initiation coverage across the country, with the highest prevalence found in the Karamoja and West Nile subregions. These regional differences could be linked to variations in maternal nutritional intake, which directly affect newborn birthweight ( 18 ). Additionally, high levels of food insecurity in these regions may contribute to the elevated LBW prevalence, as they are among the most food-insecure areas in the country ( 19 , 18 , 20 ). The disparities in KMC coverage across regions are likely due to differences in access to newborn care, particularly in districts without general district hospitals, which typically offer better resources for newborn care than lower-level health facilities( 21 ). To improve KMC coverage, it is essential to involve leaders at all administrative levels, provide targeted training for health workers, allocate dedicated spaces for KMC, manage mothers and babies as pairs, and implement robust education and counseling programs for mothers on the benefits and practice of KMC ( 22 ). We observed low average KMC coverage compared to the near-100% target, despite the recent OMWANA trial recommending KMC for all LBW babies, irrespective of clinical stability ( 23 ). However, the increasing trend suggests that Uganda is on track to meet the WHO’s target of at least 75% KMC initiation coverage by 2025. Achieving this target is crucial for reducing the neonatal mortality rate (NMR) to 12 deaths per 1,000 live births by 2025, from the current 22 deaths per 1,000 live births( 24 ). To meet this goal, scaling up KMC coverage will require stronger political and leadership commitment, allocation of human and financial resources, training of health workers, integration of KMC guidelines into curricula, reorganization of space for KMC, provision of basic equipment, and leveraging locally generated data. Furthermore, the use of KMC champions among health workers has been shown to accelerate coverage improvements in similar settings ( 25 ). We found differing KMC coverage trends at different health facility levels observed in this study. This could be due to the country’s focus on empowering lower-level health facilities to offer more service packages to the populations within their catchment area. This could explain the increasing trend of KMC coverage at the HC III level. The declining coverage at NRH could be due to managing more complicated LBW babies that require neonatal intensive care ( 26 ). Furthermore, higher-level facilities often face overcrowding and high workloads, which can hinder effective KMC implementation ( 27 ). Additionally, the higher cesarean section rates at these facilities, which limit KMC uptake, could also contribute to the observed decline( 28 ). However, evidence suggests that improving KMC coverage in tertiary settings can be achieved through the provision of adequate supplies, routine coaching and mentorship of health workers, and effective data quality management ( 29 ). Our study has some limitations that should be considered. Firstly, the reliance on secondary data restricted the analysis to the available variables related to LBW and KMC in Uganda. This may limit the depth of understanding regarding the underlying factors influencing LBW prevalence. Future studies utilizing primary data would be more effective in exploring these factors and providing a more robust estimate of LBW prevalence. Additionally, it is important to recognize that some deliveries occur outside health facilities, which suggests that the reported LBW prevalence and KMC coverage in this study may be underreported. Conclusion Our study found disparities in trends of LBW births in the different regions of the country with no trend at the national level. Whereas KMC initiation improved in certain regions and at lower-level health facilities, coverage was low in Karamoja and national referral hospitals had a declining trend. The low KMC coverage in some regions, yet with a high prevalence of LBW, and the declining trend at NRH reveal opportunities to strengthen KMC implementation. Further studies are also needed to understand the determinants of LBW births and initiation of KMC to better guide region-specific interventions. Abbreviations DHIS2 District Health Information System-version 2 LBW low birthweight KMC Kangaroo Mother Care MoH Ministry of Health QGIS Quantum Geographic Information System WHO World Health Organization Declarations Ethical considerations Our study utilized routinely aggregated surveillance data with no personal identifiers in health facility outpatient and in-patient monthly reports, obtained from the DHIS2. The Uganda Public Health Fellowship Program is part of the National Rapid Response Team and has been granted permission to access and analyze surveillance data in the DHIS-2 and other data such as survey and field investigation data to inform decision-making in the control and prevention of outbreaks and public health programming. Additionally, the Ministry of Health (MoH) has also granted the Program permission to disseminate the information through scientific publications. We stored the abstracted dataset in a password-protected computer and only shared it with the investigation team. In addition, the Office of the Associate Director for Science, U.S. 144 Centers for Disease Control and Prevention, determined that this study was not a human subjects research with the primary intent of improving the use of surveillance data to guide public health planning and practice. This activity was reviewed by the CDC and was conducted consistent with applicable federal law and CDC policy. § 149 §See e.g., 45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. §241(d); 5 U.S.C. §552a; 44 U.S.C. §3501 et seq. Consent for publication Not applicable Availability of data and materials The data upon which our findings are based belongs to the government of Uganda, Ministry of Health and cannot be shared publicly. However, the data can be availed by the corresponding author with permission from the Ministry of Health Uganda, Division of Health Information. Competing interest The authors declare no competing interests, be it financial or personal. Funding This study was supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) through the United States Centers for Disease Control and Prevention Cooperative Agreement number GH001353-01 through Makerere University School of Public Health to the Uganda Public Health Fellowship Program, Ministry of Health. The contents of this manuscript are solely the responsibility of the authors and do not necessarily represent the official views of the US Centers for Disease Control and Prevention and the Department of Health and Human Services, Makerere University School of Public Health, or the Uganda Ministry of Health. Authors’ contributions EM, RM, and JOK were involved in the design and implementation of this study. EM, JOK, and RM were involved in data analysis. RM, HTN, DM, CE, RM, LB, BK, and ARA had primary responsibility for final content. All authors participated in the writing, reading, editing and approving the final manuscript. Acknowledgements We would like to thank the Ministry of Health for the permission to access the data. We thank the US-CDC for funding the Uganda Public Health Fellowship Program (UPHFP) activities. Finally, we thank the UPHFP secretariat for the technical support from the inception of the study to final product. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6888421","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":473154289,"identity":"2f06411b-f6a5-4b6f-8f98-c68d77e7e3f6","order_by":0,"name":"Emmanuel 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Health","correspondingAuthor":false,"prefix":"","firstName":"Richard","middleName":"","lastName":"Migisha","suffix":""},{"id":473154291,"identity":"a5c2b172-2099-492d-8ac8-4ddc926561a0","order_by":2,"name":"Joyce Owens Kobusingye","email":"","orcid":"","institution":"Uganda Public Health Fellowship Program, Uganda National Institute of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Joyce","middleName":"Owens","lastName":"Kobusingye","suffix":""},{"id":473154292,"identity":"eb6a6e87-48ec-4a73-96f4-5453a332c096","order_by":3,"name":"Benon Kwesiga","email":"","orcid":"","institution":"Uganda Public Health Fellowship Program, Uganda National Institute of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Benon","middleName":"","lastName":"Kwesiga","suffix":""},{"id":473154293,"identity":"db57f872-15bc-48ff-97a7-cb5f5e2e749f","order_by":4,"name":"Hildah Tendo Nansikombi","email":"","orcid":"","institution":"Uganda Public Health Fellowship Program, Uganda National Institute of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Hildah","middleName":"Tendo","lastName":"Nansikombi","suffix":""},{"id":473154294,"identity":"c7ddfc45-b7b4-450c-86fd-c830878ff97d","order_by":5,"name":"Lilian Bulage","email":"","orcid":"","institution":"Uganda Public Health Fellowship Program, Uganda National Institute of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Lilian","middleName":"","lastName":"Bulage","suffix":""},{"id":473154295,"identity":"7fb2d420-8464-4dac-b747-d47a06260ce9","order_by":6,"name":"Deo Migadde","email":"","orcid":"","institution":"Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Deo","middleName":"","lastName":"Migadde","suffix":""},{"id":473154296,"identity":"3322bd2a-6419-4b01-b6f9-42a97398d2c2","order_by":7,"name":"Chris Ebong","email":"","orcid":"","institution":"Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Chris","middleName":"","lastName":"Ebong","suffix":""},{"id":473154297,"identity":"f3d7ca85-52aa-42c5-a6ee-dc6aa4e9f07e","order_by":8,"name":"Richard Mugahi","email":"","orcid":"","institution":"Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Richard","middleName":"","lastName":"Mugahi","suffix":""},{"id":473154298,"identity":"ea19cdbc-3af8-4b0e-93bd-032f9c96aecc","order_by":9,"name":"Alex Riolexus Ario","email":"","orcid":"","institution":"Uganda Public Health Fellowship Program, Uganda National Institute of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Alex","middleName":"Riolexus","lastName":"Ario","suffix":""}],"badges":[],"createdAt":"2025-06-13 12:54:17","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6888421/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6888421/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85173165,"identity":"5a059413-64d2-4a5e-b3c4-41b216bfdccd","added_by":"auto","created_at":"2025-06-23 05:56:11","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":52159,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e1a: Trends in the prevalence of low birthweight (LBW) infants at the national level in Uganda from 2015 to 2023; \u0026nbsp;1b: Proportion of low birthweight babies receiving Kangaroo Mother Care (KMC) at the national level in Uganda, covering the years 2020 to 2023\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6888421/v1/4a1529d05dde8c75c7db974c.png"},{"id":85171929,"identity":"5a63709d-cab3-46e1-90a8-7358edb0baea","added_by":"auto","created_at":"2025-06-23 05:48:11","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":170291,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of Kangaroo Mother Care coverage by region by year, 2020–2023, Uganda.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6888421/v1/8e31b23e50248ba98853486e.png"},{"id":85171923,"identity":"5553e26a-6e80-4e72-9118-8282572d364a","added_by":"auto","created_at":"2025-06-23 05:48:11","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":37798,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCoverage of Kangaroo Mother Care (KMC) across different health facility levels in Uganda, 2020–2023. LLHF represents data combined from Health Centers IV and III. Abbreviations: LLHF - Lower-Level Health Facility, HC - Health Center, RRH - Regional Referral Hospital, NRH - National Referral Hospital, KMC - Kangaroo Mother Care.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6888421/v1/15d2032ec54cf0d11729cbd8.png"},{"id":85171931,"identity":"e1ffc07a-b5d8-41db-8917-1e7d49009d7a","added_by":"auto","created_at":"2025-06-23 05:48:11","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":117609,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of average low birthweight (LBW) prevalence by region (2015–2023) and Kangaroo Mother Care (KMC) initiation coverage (2020–2023) in Uganda. Figure labels with white background represent KMC coverage, while labels with green background indicate LBW prevalence.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-6888421/v1/16c45e638544e8922c1528e9.png"},{"id":85171926,"identity":"26830449-e7fb-45d4-b0ee-13f76efd3b8c","added_by":"auto","created_at":"2025-06-23 05:48:11","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":148651,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of low birthweight prevalence by region by year, 2015–2023, Uganda.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage414.png","url":"https://assets-eu.researchsquare.com/files/rs-6888421/v1/22928aff4242a75547588fa6.png"},{"id":90819519,"identity":"5d5d664b-2dff-4f27-8922-9c639c5458b1","added_by":"auto","created_at":"2025-09-08 13:53:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1396948,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6888421/v1/4ac794f4-c59e-429a-acd7-a5739f530b9b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Temporal and spatial trends of low birth weight and Kangaroo Mother Care initiation in Uganda, 2015–2023","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe world Health Organization (WHO) estimates that about 15\u0026ndash;20% of all births in the world are LBW and this proportion is even higher in sub-Saharan Africa (SSA) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Low birthweight (LBW) refers to babies who are born with \u0026lt;\u0026thinsp;2500 grams of body weight regardless of their gestational age at birth. These comprise preterm births (\u0026lt;\u0026thinsp;37 weeks of completed gestation) and term births (\u0026ge;\u0026thinsp;37 weeks of gestation) born with \u0026lt;\u0026thinsp;2500 grams of body weight (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). It is a derivative of both gestational age and fetal growth (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Low birth weight is a key determinant of neonatal mortality and morbidity, with LBW babies having the highest risk of death during pregnancy, infancy, and early childhood. Over 80% of all newborn deaths occur among LBW babies in Southern Asia and SSA (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAccording to the Uganda Demographic and Health Survey (UDHS), 2022, 10% of all babies born in Uganda had LBW. In Uganda, deaths related to LBW related complications contribute to \u0026gt;\u0026thinsp;50% of perinatal mortality (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Additionally, LBW babies are at an increased risk of long term complications and chronic diseases such as cognitive impairments, neurodevelopmental disorders, cardiovascular diseases, diabetes and others (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eKangaroo mother care (KMC) is an affordable and highly effective method for LBW babies, especially in resource limited settings. It involves prolonged skin-to-skin contact, promotion of exclusive breastfeeding, and allowing early discharge from health facilities. It enhances growth and reduction of complications such as hypothermia, hypoglycemia, and sepsis, but also fosters maternal bonding and stimulation (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Furthermore, KMC improves outcomes among LBW babies, reducing neonatal mortality by 32% and six-month mortality by 25%. It also decreases hypothermia by 68%, reduces sepsis by 15%, and increases exclusive breastfeeding duration by 48%. Beyond that, KMC promotes better growth and development among LBW infants (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). KMC can contribute towards Uganda\u0026rsquo;s achievement of the Sustainable Development Goal (SDG) target 3.2, which aims to reduce the neonatal mortality rate (NMR) to \u0026lt;\u0026thinsp;12 deaths per 1,000 live births by 2030. Uganda\u0026rsquo;s NMR stands at 22 deaths per 1,000 live births, indicating that progress towards this goal has been slow (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eKMC is part of the WHO level 2 care for sick and small newborns (SSN), which recommends that at least 80% of districts in a country offer this level of care (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Uganda is currently in early phase III of the NMR transition framework, a stage for countries with NMR ranging between 30 and 16 deaths per 1000 live births (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Currently, KMC is included in the essential maternal and newborn care guidelines of Uganda and is recommended for LBW babies (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Despite KMC being a low-cost and high-impact innovation, its use and distribution across Uganda are not well documented (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). We described the trends and spatial distribution of LBW babies and the application of KMC in Uganda during 2015\u0026ndash;2023.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy setting\u003c/h2\u003e \u003cp\u003eThis was a national study in Uganda, with a population of approximately 45.9\u0026nbsp;million people in 2024 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). It is one of the countries with a high fertility rate and poor maternal and neonatal health indices in the world (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The country is divided into 15 non-administrative sub-regions each comprising of nine to thirteen districts (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Health care services are organized from national referral level to health centre IIs; maternal and child health services are provided from health center III level to national referral level. The health care package increases with the level of care, with higher level health facilities managing more referrals and complicated cases.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy design and data source\u003c/h3\u003e\n\u003cp\u003eWe conducted a nationwide descriptive analysis of LBW babies and KMC in terms of person, time, and place reported through the electronic district health information software version 2 (DHIS2), a computer-based national health information system. Data on LBW babies and LBW babies initiated on KMC are routinely generated at registered health facilities (all public health facilities and most private health facilities) that offer delivery services, aggregated at the district level, and then forwarded to the national database, the DHIS2, to make decisions and plan interventions on reproductive and infant health.\u003c/p\u003e\n\u003ch3\u003eStudy variables, data abstraction and analysis\u003c/h3\u003e\n\u003cp\u003eWe abstracted monthly data for each health facility in the country, all the districts, and at the national level for the analysis period of 2015\u0026ndash;2023. We calculated national annual reporting rates of LBW prevalence by dividing the available monthly reports per year for all districts by the expected monthly reports for all districts per year. We also calculated national quarterly reporting rates of KMC coverage by dividing the available monthly reports per quarter for all regions by the expected monthly reports for all districts per quarter.\u003c/p\u003e \u003cp\u003eMonthly data was abstracted using pivot tables in DHIS2 on LBW babies, LBW babies initiated on KMC, and total deliveries, 2015\u0026ndash;2023. We disaggregated the data into national, regional and district levels data. We obtained data on LBW babies, LBW babies initiated on KMC, and total deliveries.\u003c/p\u003e \u003cp\u003eWe described the prevalence of LBW babies as a proportion of total deliveries in Uganda, 2015\u0026ndash;2023. Additionally, we described the spatial distribution of the LBW prevalence in all districts across the country. We described the initiation of KMC as a proportion of total live LBW babies that were initiated on KMC, 2020\u0026ndash;2023. We plotted the annual LBW prevalence against the study period in years to present the trend in prevalence at national level, 2015\u0026ndash;2023. We also plotted the quarterly KMC coverage against the study period in years to demonstrate the trend in the coverage at national level and at health facility level, 2015\u0026ndash;2023. Choropleth maps for LBW babies and their initiation on KMC were generated using Quantum Geographic Information System (QGIS) to show the distribution in Uganda. We analyzed for trends using Man Kendall test and Sen\u0026rsquo;s slope test for the direction of the trend.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eTrend of proportion of low birthweight babies at the national level, Uganda, 2015\u0026ndash;2023\u003c/h2\u003e \u003cp\u003eDuring the study period, a total of 605,876 LBW babies were recorded out of 10,952,463 babies (5.5%). The proportion increased from 4.5% in 2015 to 5.4% in 2023 with a peak of 7.1% in 2019 (p\u0026thinsp;=\u0026thinsp;0.8). The reporting rate were good from 72% in 2015 to 98% in 2023 (average of 85%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eTrend of low birthweight babies initiated on Kangaroo Mother Care at national and regional levels, Uganda, 2020\u0026ndash;2023\u003c/b\u003e \u003c/p\u003e \u003cp\u003eOf the 296,421 LBW babies born during the four-year analysis period, 188,596 (64%) babies were initiated on KMC. The proportion of LBW babies initiated on KMC increased from 60% in January\u0026ndash;March 2020 to 68% in October\u0026ndash;December 2023 with a trend (p\u0026thinsp;=\u0026thinsp;0.01) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eb). The reporting rates were good and stable from 95% in 2020 to 91% in 2023 (average of 98%).\u003c/p\u003e \u003cp\u003eAt regional level; 5 regions had a trend. In Ankole subregion, KMC coverage improved from 53% in January\u0026ndash;March 2020 to 70% in October\u0026ndash;December 2023, average of 70% (p\u0026thinsp;=\u0026thinsp;0.005). In Bunyoro, the coverage improved from 45% in January\u0026ndash;March 2020 to 70% in October\u0026ndash;December 2023, average of 60% (p\u0026thinsp;=\u0026thinsp;0.017). In West Nile subregion, the coverage improved from 80% in January\u0026ndash;March 2020 to 88% in October\u0026ndash;December 2023, average of 73% (p\u0026thinsp;=\u0026thinsp;0.024). The coverage declined in Bukedi subregion from 80% in January\u0026ndash;March 2020 to 71% in October\u0026ndash;December 2023, average of 66% (p\u0026thinsp;=\u0026thinsp;0.024). Similarly, the coverage declined in Kampala from 74% in January\u0026ndash;March 2020 to 49% in October\u0026ndash;December 2023, average of 71% (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The remaining 10 regions had no trend. Acholi region (54%), followed by North central (58%), Bunyoro (60%) and Karamoja (60%) region had the lowest KMC coverage (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eDistribution of and trend of the proportion of low birthweight babies initiated on Kangaroo Mother Care by health facility level, Uganda, 2015\u0026ndash;2023\u003c/b\u003e \u003c/p\u003e \u003cp\u003eOf the 2,536,064 babies delivered at HC IIIs, 99, 648 (3.9%) were LBW, and 58,161(58%) were initiated on KMC from 2020\u0026ndash;2023. Out of the 1,127,754 babies delivered at HC IVs, 58,251 (5.2%) were LBW, and 38,126 (65%) of these were initiated on KMC. At general hospitals, out of the 938,473 babies delivered, 72,344(7.7%) were LBW and out of these, 54,546 (75%) were initiated on KMC. At RRH level, out of 323,880 babies that were delivered, 28,972 (8.9%) were LBW and out of these, 18,232 (63%) were initiated on KMC. At NRH level, out of the 127,508 babies delivered, 14,817 (11.6%) were LBW, and 11,176 (75%) were initiated on KMC (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere was a significant increase in KMC initiation coverage at HC III from January\u0026ndash;March 2020 at 50\u0026ndash;68% in October\u0026ndash;December 2023 period (p\u0026thinsp;=\u0026thinsp;0.006) with an average of 59%, a non-significant increase in coverage at HC IV level from 66% in January\u0026ndash;March 2020 to 64% in October\u0026ndash;December 2023 with an average of 65% (p\u0026thinsp;=\u0026thinsp;0.9). At general hospital level, KMC coverage increased from 66% in January\u0026ndash;March 2020 to 85% in October\u0026ndash;December 2023, with an average of 75% with no trend (p\u0026thinsp;=\u0026thinsp;0.16). At RRH level, KMC initiation coverage declined from 90% in January\u0026ndash;March 2020 to 69% in October\u0026ndash;December 2023 with an average of 64% (p\u0026thinsp;=\u0026thinsp;0.9). At NRH level, the coverage declined from 91% in January\u0026ndash;March 2020 to 39% in October\u0026ndash;December 2023 with an average of 79% with a declining trend (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eDistribution of low birthweight babies in Uganda, 2015\u0026ndash;2023\u003c/h2\u003e \u003cp\u003eThe distribution of LBW babies was unequal all over the country with gross variations across different regions of the country. Karamoja and West Nile subregions, located in northeastern and northwestern Uganda respectively, had the highest prevalence (7.2%) with no trend (p\u0026thinsp;=\u0026thinsp;1) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAcholi, in northern Uganda, had a prevalence of 7.2% and no trend (p\u0026thinsp;=\u0026thinsp;0.11), while Lango, also in northern Uganda, had 6.4% with no trend (p\u0026thinsp;=\u0026thinsp;0.2). Kampala, in central Uganda, had a similar average prevalence of 6.4% (p\u0026thinsp;=\u0026thinsp;0.08). Bukedi, in eastern Uganda, and Busoga, also in the east, showed increasing trends, with Bukedi rising from 3.4\u0026ndash;5.1% (p\u0026thinsp;=\u0026thinsp;0.05) and Busoga from 3.3\u0026ndash;5.6% (p\u0026thinsp;=\u0026thinsp;0.003) (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Kigezi, located in the southwestern region, exhibited a slight decline from 4.4% in 2015 to 4.6% in 2023 (p\u0026thinsp;=\u0026thinsp;0.003).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe LBW births stagnated during the study period, 2015\u0026ndash;2023, with substantial regional heterogeneity. Karamoja and West Nile subregions in northern part of the country consistently reported the highest prevalence, whereas regions such as Bukedi and Busoga in eastern Uganda experienced increasing rates. There was a decline in some districts in Kigezi and Ankole subregions. Although there was an increase in KMC uptake, especially at lower-level health centers, there was low coverage in Karamoja and a significant decline at national referral hospitals. Overall, these trends highlight the importance of additional studies to understand the local determinants of LBW births and barriers to KMC uptake for better targeted interventions for each region.\u003c/p\u003e \u003cp\u003eWe found a lower prevalence of low birthweight (LBW) compared to the 10% reported by the 2022 Uganda Demographic and Health Survey (UDHS), as well as a study on LBW prevalence and its association with maternal body weight status in selected African countries, including Uganda. Additionally, the prevalence was lower than the estimated 13% observed in sub-Saharan Africa(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Although the reasons for the stagnation in LBW prevalence during the study period remain unclear, the high prevalence in sub-Saharan Africa may be attributed to factors such as increasing food insecurity, exacerbated by climate change (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe observed variations in the prevalence of LBW and KMC initiation coverage across the country, with the highest prevalence found in the Karamoja and West Nile subregions. These regional differences could be linked to variations in maternal nutritional intake, which directly affect newborn birthweight (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Additionally, high levels of food insecurity in these regions may contribute to the elevated LBW prevalence, as they are among the most food-insecure areas in the country (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The disparities in KMC coverage across regions are likely due to differences in access to newborn care, particularly in districts without general district hospitals, which typically offer better resources for newborn care than lower-level health facilities(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). To improve KMC coverage, it is essential to involve leaders at all administrative levels, provide targeted training for health workers, allocate dedicated spaces for KMC, manage mothers and babies as pairs, and implement robust education and counseling programs for mothers on the benefits and practice of KMC (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe observed low average KMC coverage compared to the near-100% target, despite the recent OMWANA trial recommending KMC for all LBW babies, irrespective of clinical stability (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). However, the increasing trend suggests that Uganda is on track to meet the WHO\u0026rsquo;s target of at least 75% KMC initiation coverage by 2025. Achieving this target is crucial for reducing the neonatal mortality rate (NMR) to 12 deaths per 1,000 live births by 2025, from the current 22 deaths per 1,000 live births(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). To meet this goal, scaling up KMC coverage will require stronger political and leadership commitment, allocation of human and financial resources, training of health workers, integration of KMC guidelines into curricula, reorganization of space for KMC, provision of basic equipment, and leveraging locally generated data. Furthermore, the use of KMC champions among health workers has been shown to accelerate coverage improvements in similar settings (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe found differing KMC coverage trends at different health facility levels observed in this study. This could be due to the country\u0026rsquo;s focus on empowering lower-level health facilities to offer more service packages to the populations within their catchment area. This could explain the increasing trend of KMC coverage at the HC III level. The declining coverage at NRH could be due to managing more complicated LBW babies that require neonatal intensive care (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Furthermore, higher-level facilities often face overcrowding and high workloads, which can hinder effective KMC implementation (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Additionally, the higher cesarean section rates at these facilities, which limit KMC uptake, could also contribute to the observed decline(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). However, evidence suggests that improving KMC coverage in tertiary settings can be achieved through the provision of adequate supplies, routine coaching and mentorship of health workers, and effective data quality management (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur study has some limitations that should be considered. Firstly, the reliance on secondary data restricted the analysis to the available variables related to LBW and KMC in Uganda. This may limit the depth of understanding regarding the underlying factors influencing LBW prevalence. Future studies utilizing primary data would be more effective in exploring these factors and providing a more robust estimate of LBW prevalence. Additionally, it is important to recognize that some deliveries occur outside health facilities, which suggests that the reported LBW prevalence and KMC coverage in this study may be underreported.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study found disparities in trends of LBW births in the different regions of the country with no trend at the national level. Whereas KMC initiation improved in certain regions and at lower-level health facilities, coverage was low in Karamoja and national referral hospitals had a declining trend. The low KMC coverage in some regions, yet with a high prevalence of LBW, and the declining trend at NRH reveal opportunities to strengthen KMC implementation. Further studies are also needed to understand the determinants of LBW births and initiation of KMC to better guide region-specific interventions.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDHIS2\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDistrict Health Information System-version 2\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLBW\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003elow birthweight\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eKMC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eKangaroo Mother Care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMoH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMinistry of Health\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eQGIS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eQuantum Geographic Information System\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur study utilized routinely aggregated surveillance data with no personal identifiers in health facility outpatient and in-patient monthly reports, obtained from the DHIS2. The Uganda Public Health Fellowship Program is part of the National Rapid Response Team and has been granted permission to access and analyze surveillance data in the DHIS-2 and other data such as survey and field investigation data to inform decision-making in the control and prevention of outbreaks and public health programming. Additionally, the Ministry of Health (MoH) has also granted the Program permission to disseminate the information through scientific publications. We stored the abstracted dataset in a password-protected computer and only shared it with the investigation team. In addition, the Office of the Associate Director for Science, U.S. 144 Centers for Disease Control and Prevention, determined that this study was not a human subjects research with the primary intent of improving the use of surveillance data to guide public health planning and practice. This activity was reviewed by the CDC and was conducted consistent with applicable federal law and CDC policy. \u0026sect; 149 \u0026sect;See e.g., 45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. \u0026sect;241(d); 5 U.S.C. \u0026sect;552a; 44 U.S.C. \u0026sect;3501 et seq.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data upon which our findings are based belongs to the government of Uganda, Ministry of Health and cannot be shared publicly. However, the data can be availed by the corresponding author with permission from the Ministry of Health Uganda, Division of Health Information.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests, be it financial or personal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the President\u0026rsquo;s Emergency Plan for AIDS Relief (PEPFAR) through the United States Centers for Disease Control and Prevention Cooperative Agreement number GH001353-01 through Makerere University School of Public Health to the Uganda Public Health Fellowship Program, Ministry of Health. The contents of this manuscript are solely the responsibility of the authors and do not necessarily represent the official views of the US Centers for Disease Control and Prevention and the Department of Health and Human Services, Makerere University School of Public Health, or the Uganda Ministry of Health.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEM, RM, and JOK were involved in the design and implementation of this study. EM, JOK, and RM were involved in data analysis. RM, HTN, DM, CE, RM, LB, BK, and ARA had primary responsibility for final content. All authors participated in the writing, reading, editing and approving the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the Ministry of Health for the permission to access the data. We thank the US-CDC for funding the Uganda Public Health Fellowship Program (UPHFP) activities. Finally, we thank the UPHFP secretariat for the technical support from the inception of the study to final product.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Global Nutrition Targets 2025: Low birth weight policy brief. 2014. Global Nutrition Targets. 2015;2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlencowe H, Krasevec J, de Onis M, Black RE, An X, Stevens GA, et al. National, regional, and worldwide estimates of low birthweight in 2015, with trends from 2000: a systematic analysis. Lancet Global Health. 2019;7(7):e849\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO W. 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Kangaroo mother care: a multi-country analysis of health system bottlenecks and potential solutions. BMC Pregnancy Childbirth. 2015;15(2):1\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChan GJ, Labar AS, Wall S, Atun R. Kangaroo mother care: a systematic review of barriers and enablers. Bull World Health Organ. 2016;94(2):130\u0026ndash;J141.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuttau N, Mwendafilumba M, Lewis B, Kasprzyk K, Travers C, Menon JA, et al. Strengthening Kangaroo Mother Care at a tertiary level hospital in Zambia: A prospective descriptive study. PLoS ONE. 2022;17(9):e0272444.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Low birthweight, Kangaroo Mother Care Method, Uganda","lastPublishedDoi":"10.21203/rs.3.rs-6888421/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6888421/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eLow birth weight (LBW) births account for \u0026gt;\u0026thinsp;80% of global neonatal deaths, with the highest prevalence in low-and middle-income countries. Kangaroo Mother Care (KMC) is a low-cost, effective intervention for the survival of LBW babies in low-resource settings, including Uganda. However, the distribution of LBW births and their KMC initiation is not well documented in Uganda. We assessed trends and spatial distribution of LBW births and their KMC initiation, Uganda, 2015\u0026ndash;2023.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe abstracted data on LBW, total deliveries, and LBW babies initiated on KMC during 2015\u0026ndash;2023 from the District Health Information Software Version 2. We calculated LBW prevalence as the proportion of LBW births among total deliveries. Kangaroo Mother Care initiation coverage was computed as the proportion of LBW babies started on KMC. We stratified LBW and KMC initiation data by region, and health facility level. We used the Mann-Kendall test to assess the significance of trends.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eDuring 2015\u0026ndash;2023, 605,876 of 10,952,463 births (5.5%) were LBW, with no significant change in the prevalence (p\u0026thinsp;=\u0026thinsp;0.8). The highest prevalence of LBW was observed in Karamoja and West Nile (7.4%) in northern Uganda, with no trend (p\u0026thinsp;=\u0026thinsp;0.14). Bukedi (p\u0026thinsp;=\u0026thinsp;0.05) and Busoga (p\u0026thinsp;=\u0026thinsp;0.003) subregions in eastern Uganda, had an increasing trend, whereas, Kigezi subregion in western Uganda, had a declining trend (p\u0026thinsp;=\u0026thinsp;0.003). Among the 296,421 live LBW births during 2020\u0026ndash;2023, 188,519 (64%) received KMC. Its coverage increased from 60% in 2020 to 68% in 2023 (p\u0026thinsp;=\u0026thinsp;0.01). Ankole (p\u0026thinsp;=\u0026thinsp;0.005), Bunyoro (p\u0026thinsp;=\u0026thinsp;0.017), and West Nile subregions had increasing trends whereas Bukedi (p\u0026thinsp;=\u0026thinsp;0.024) and Kampala (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) had declining trends. Karamoja had low KMC coverage (60%) with no trend (p\u0026thinsp;=\u0026thinsp;0.96). KMC initiation increased at Health Centre IIIs (sub-county level) (p\u0026thinsp;=\u0026thinsp;0.006), but declined at national referral hospitals (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThere were regional disparities in trends of LBW births. While KMC initiation improved in certain regions and at lower-level health facilities, challenges persist in Karamoja and national referral hospitals. Further studies are needed to understand the determinants of LBW births, and initiation to KMC, to better guide region-specific interventions.\u003c/p\u003e","manuscriptTitle":"Temporal and spatial trends of low birth weight and Kangaroo Mother Care initiation in Uganda, 2015–2023","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-23 05:48:06","doi":"10.21203/rs.3.rs-6888421/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f89e0ee5-23e0-40b9-98f2-9f8b9d08c796","owner":[],"postedDate":"June 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-08T13:53:24+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-23 05:48:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6888421","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6888421","identity":"rs-6888421","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}