Kangaroo mother care: a systematic review of barriers and enablers
Grace J Chan a, Amy S Labar a, Stephen Wall b & Rifat Atun a
a. Department of Global Health and Population, Harvard TH Chan School of Public Health, 677 Huntington Street, Boston, Massachusetts, 02115, United States of America (USA).
b. Saving Newborn Lives, Save the Children, Washington, USA.
Correspondence to Grace J Chan (email: email@example.com).
(Submitted: 11 May 2015 – Revised version received: 17 October 2015 – Accepted: 23 October 2015 – Published online: 03 December 2015.)
Bulletin of the World Health Organization 2016;94:130-141J. doi: http://dx.doi.org/10.2471/BLT.15.157818
More than 2.7 million newborns die each year, accounting for 44% of children dying before the age of five years worldwide. Complications of preterm birth are the leading cause of death among newborns.1 Kangaroo mother care can include early and continuous skin-to-skin contact, breastfeeding, early discharge from the health-care facility and supportive care.2 The clinical efficacy and health benefits of kangaroo mother care have been demonstrated in multiple settings. In low birthweight newborns (< 2000 g) who are clinically stable, kangaroo mother care reduces mortality and if widely applied could reduce deaths in preterm newborns.3,4 However, in spite of the evidence, country-level adoption and implementation of kangaroo mother care has been limited and global coverage remains low. Few studies have examined the reasons for the poor uptake of kangaroo mother care.
To understand factors influencing adoption of kangaroo mother care in different contexts, we did a systematic review. We created a narrative analysis of the articles and reports identified, guided by a conceptual framework5 with five elements: (i) the problem being addressed – neonatal mortality; (ii) the intervention or innovation aimed at addressing the problem; (iii) the adoption system – those implementing the intervention, those benefiting from it and those affected by it; (iv) the health system – organization, financing and service delivery; and (v) the broad context – demographic, epidemiological, political, economic and sociocultural factors. These five elements interact to influence the extent, pattern and rate of adoption of interventions in health systems.5
We searched PubMed, Embase, Web of Science, Scopus, African Index Medicus (AIM), Latin American and Caribbean Health Sciences Literature (LILACS), Index Medicus for the Eastern Mediterranean Region (IMEMR), Index Medicus for the South-East Asian Region (IMSEAR) and Western Pacific Region Index Medicus (WPRIM) without language restrictions, from 1 January 1960 to 19 August 2015 using the search terms “kangaroo mother care” or “kangaroo care” or “skin-to-skin care.” We excluded studies without human subjects or without primary data collection. We screened studies for inclusion if they discussed barriers to kangaroo mother care implementation or enablers for successful implementation. Our population of interest included mothers, newborns or mother-newborn dyads who had practiced kangaroo mother care, and health-care providers, health facilities, communities and health systems that have implemented such care. We hand-searched the reference lists of published systematic reviews and references of the included articles. To search the grey literature for unpublished studies, we explored programmatic reports and requested data from programmes implementing kangaroo mother care.
Two reviewers independently extracted data from identified articles using standardized forms to identify potential determinants of kangaroo mother care uptake, including data on knowledge, attitudes and practices. Reviewers compared their results to reach consensus and ties were broken by a third party. To assess study quality, we evaluated each study in five quality domains: selection bias, appropriateness of data collection, appropriateness of data analysis, generalizability and ethical considerations.6
A deductive approach was used to fit the outputs of the analysis to the elements of the conceptual framework and explore emerging themes.7 Using the qualitative analytical software NVivo (QSR International, Melbourne, Australia), two researchers indexed and annotated the data through several rounds of coding to analyse themes, viewpoints, ideas and experiences. Once major themes were established, we constructed narratives and categorized the data into matrices by theme. We highlighted quotes that summarized multiple perspectives from the articles. Narratives and matrices were used to define specific concepts and explore associations between themes.
Themes were explored at each level of implementation (mothers, fathers and families; health-care workers; facilities). We examined the interactions between implementers and described health system characteristics that could influence the uptake of kangaroo mother care.
Of the 2875 papers identified, we included 112 studies with qualitative data on barriers to and enablers of kangaroo mother care (Fig. 1). Most of the studies were published between 2010 and 2015 (66; 59%) and had less than 50 participants (67; 60%). Nearly half of the studies were surveys or interviews (50; 45%). Forty studies (36%) were conducted in the WHO Region of the Americas; 29 (26%) in WHO African Region; 64 (57%) in countries with low neonatal mortality, defined as less than 15 deaths per 1000 live births;8 48 (43%) in urban settings; and 67 (60%) at health facilities. Many studies did not include neonatal characteristics such as gestational age (68; 61%) or weight (75; 67%; Table 1). The majority (68; 60%) of the studies appropriately addressed at least four of the five quality domains.
Fig. 1. Flowchart showing the selection of studies on kangaroo mother care (KMC)
The included studies revealed that kangaroo mother care is a complex intervention with several possible components – skin-to-skin contact, breastfeeding, early discharge and follow-up (Table 2). The included components varied across locations and by individual implementer.
The promotion of skin-to-skin contact for as long as possible once the newborn was stabilized emerged as a common theme in several studies.33–35,84–91,116 However, there was limited information on the recommended frequency and duration of skin-to-skin contact and the specific criteria for stopping skin-to-skin contact.31,36–38,89,92,93,117
The complexity of kangaroo mother care and lack of a standardized operational definition makes it challenging to implement. Implementation of kangaroo mother care can be considered at three levels: (i) mothers, fathers and families; (ii) health-care workers; and (iii) facilities. The location of facilities and the resources available determine whether kangaroo mother care takes place in the health facility or at home.18,27,33
Mothers, fathers and families were usually the primary caregivers of preterm newborns and involved in decision-making and practice of care.11,16,94,95,117 Health-care workers were critical for implementation in hospitals or health facilities. Their main role was to educate the parents about kangaroo mother care.
We identified six major themes concerning barriers and enablers for implementation of kangaroo mother care: (i) buy-in and bonding; (ii) social support; (iii) time; (iv) medical concerns; (v) access and (vi) context (Table 3).
Buy-in and bonding
Buy-in and bonding refer to the acceptance of kangaroo mother care, belief in the benefits of such care to mothers and preterm or low birthweight infants and reported perceptions of bonding. Fear, stigma and/or anxiety about having a preterm infant impaired the care process. Mothers felt shame or guilt for having a preterm infant96,97 and some did not want to keep their baby.16
Positive perceptions of the potential benefits of kangaroo mother care for caregivers and for newborns among mothers, fathers and families promoted uptake. Studies used words such as relaxed, calm, happy, natural, instinctive and safe to describe the bonding process that mothers and fathers reported during and after kangaroo mother care.35,39,40,94,95,98 Mothers observed their newborns sleeping longer during skin-to-skin contact; infants were described as less anxious, more restful, more willing to breastfeed and happier than when in an incubator.41,121
A lack of belief in kangaroo mother care and limited knowledge of such care restricted its uptake among health-care workers.39,42–45 In some facilities, there was reluctance by management to allocate dedicated space to kangaroo mother care or to rearrange staffing schedules to allow for supervision of kangaroo mother care.12,16,22,25,29,36,46,82,99,122 Facility leadership had high turnover as leaders trained in kangaroo mother care frequently left for better positions.25,27,29,42,47,82,99,100,123 On the other hand, facilities that had successfully implemented kangaroo mother care reported support from management and good communication among the staff.24,42
Social support refers to assistance received from other people to perform kangaroo mother care. While practicing kangaroo mother care, both mothers and fathers did not feel supported by their families or communities.35,96 Mothers experienced a lack of support from health-care workers. In settings like Zimbabwe, fathers voiced unease about performing kangaroo mother care because of societal norms that childcare should be the role of the mother.79,96 In contrast, among mothers, fathers and families, uptake was promoted by societal acceptance of paternal participation in childcare, by family and community acceptance of kangaroo mother care and by the presence of engaged health-care workers.32,48 In societies where gender roles were more equal (e.g. Scandinavian countries), there were fewer barriers to fathers performing kangaroo mother care.48,49 Paternal involvement played a large role in uptake – either by division of labour or by helping the mother feel comfortable. In Brazil, mothers were grateful to have someone help them during kangaroo mother care, such as grandmothers and sisters, who could take care of housework and help with the newborn.101 Within the maternity ward, peer support from other mothers through sharing their kangaroo mother care experiences also helped promote acceptance.79,102
When institutional leadership did not prioritize kangaroo mother care, health-care workers were less motivated to practice or teach it,42,44 but felt empowered to do so when management allowed for roles in decision-making, promoted kangaroo mother care or mobilized resources for it.24 Staffing shortages and staff turnover created barriers to implementation of kangaroo mother care within a facility.42 By contrast, effective coordination of and communication between staff helped facilitate implementation.82
The time needed to provide kangaroo mother care was a potential barrier for mothers, fathers and families, due to responsibilities at home and work and time needed for commuting, preventing them from devoting the time needed for continuous and extended kangaroo mother care.16,39,41,50,79,91,102 Conversely, practice of such care at home promoted its uptake.92 High workload of health-care workers did not allow sufficient time to dedicate to teaching kangaroo mother care, which further increased workload, especially in facilities with staffing shortages.78,79,103
One study showed that uptake of kangaroo mother care increased with expansion of visiting hours at health facilities.104
Clinical conditions of the mother and/or newborn may prevent kangaroo mother care from occurring. The medical effects of delivery for mothers, including fatigue, depression and postpartum pain, especially after a caesarean section, can reduce uptake of kangaroo mother care.48,51,52,77,98 Particularly for very preterm or unstable infants, concern about potential adverse consequences, such as fear of dislocation of intravenous lines, was an obstacle to kangaroo mother care.38,53,54 Knowledge that kangaroo mother care supported newborns in stabilizing their temperatures, helped with breathing and promoted mother–child bonding, encouraged its use.118
While parents believed that kangaroo mother care was less costly than incubator care,96 lack of money for transportation and the distance to hospital were often reported as the biggest challenges55,81,82,105 as were low resources for newborn-care services.82 Lack of private space for mothers to perform kangaroo mother care and to remain in the hospital with the newborn hindered its uptake,24,25 as did allocation of resources intended for kangaroo mother care to other programmes.24 Uptake improved with transportation for mothers not staying at the hospital, wrappers to hold the baby, furniture/beds where mothers could conduct kangaroo mother care, rooms where mothers could spend the night with the baby,24,48 private spaces and dedicated resources.40,106
Without uniform knowledge and protocols within a facility, health-care workers were uncomfortable promoting kangaroo mother care.16,27,42,99,107 In-service training82,100 of health-care workers enhanced kangaroo mother care implementation.56 Virtual communication and training, often within facilities, allowed more nurses to be trained in kangaroo mother care despite busy schedules and staffing shortages.36 Expanding training to other health-care personnel, such as administrators and interns, also enabled care. Many nurses reported that integration of kangaroo mother care into pre-service and training curricula was beneficial.36,57
Sociocultural context and sociocultural constructs of gender and roles of parents in childcare, men in the household and other family members influenced uptake.79,85,96 Parental and familial adherence to traditional newborn practices was reported as a barrier to kangaroo mother care.105 Traditional practices of early bathing and wrapping infants soon after birth were ingrained behaviours in many cultures that were difficult to change, even after training.16,58 In areas in which carrying the baby on the back was common, it seemed strange to place the baby on the front.23 In some contexts, it was considered unclean to have the mother carry the baby on her chest without a diaper.79
Please refer to the supplementary Table 4 (available at: http://www.who.int/volumes/94/2/15-157818) for full details of the included studies.
The core components of kangaroo mother care are skin-to-skin contact and feeding support. Additional features such as the frequency and location of early-discharge and follow-up depend on the context.57,98 Multiple factors influence the uptake of kangaroo mother care. To support the implementation of kangaroo mother care, context-specific materials such as guidelines, behaviour change materials, training curriculums, and job aids are needed. Simple interventions are more likely to be generalizable to a range of different contexts.5 When designing kangaroo mother care interventions, contextual factors and sociocultural norms need to be taken into account.
The stresses and stigma associated with having a preterm infant can hinder buy-in and support from parents and families for practicing kangaroo mother care. This problem is compounded by a lack of knowledge about kangaroo mother care among parents, families and health-care workers. Clear articulation of the benefits of kangaroo mother care for mothers and for newborns, creation of a community among parents, caregivers and health-care workers and engagement of fathers in childcare can help overcome these barriers. Collaboration among health-care workers, with shared goals and team commitments, partnering inexperienced nurses with nurses experienced in kangaroo mother care can also help.42,106,108
There are substantial barriers to kangaroo mother care within health systems, especially financing and service delivery. Dedicated financing for kangaroo mother care is critical for it to be seriously considered and implemented. Funding should consider creation of suitable environments (beds, wraps, chairs and private spaces), reducing burden of transport costs to mothers, home visits by community health workers and training parents to perform kangaroo mother care as independently as possible. Financing should be augmented with policies, guidelines, role definitions (to enable health-care workers to allocate protected time for kangaroo mother care), education (in service and pre-service) and monitoring systems that are suitably tailored for different settings (including in the community).
Logistic issues, such as time for travel and kangaroo mother care, can be challenging but could be partly overcome by incorporating targeted assistance and support and extension of visiting times. Buy-in from policy-makers is critical to promote kangaroo mother care, especially through policies like maternity and paternity leave.42,107 At the national level, kangaroo mother care should be integrated with essential newborn, maternal and child health guidelines, with appropriate monitoring and evaluation.57
We may not have captured all the programmatic reports and data available. In particular, most of the studies included in our review were published from regions with low neonatal mortality. This limits the generalizability of our findings.
Prolonged skin-to-skin care demands time and energy from mothers recovering from labour and carers who may have other obligations. Many women are not aware of kangaroo mother care; health workers have not been trained or, if trained, do not promote such care. Kangaroo mother care may not be socially acceptable or even conflict with traditional customs. There is lack of standardization on who should receive kangaroo mother care and the presence of admissions criteria in neonatal units.
Kangaroo mother care should be practiced more systematically and consistently to enhance adoption25 and to build trust, with motivated trained staff, education of staff and parents, clear eligibility criteria, improved referral practices and creation of communities among kangaroo mother care participants through support groups. By addressing barriers and by building trust, effective uptake of kangaroo mother care into the health system will increase and this will help to improve neonatal survival.
KMC: kangaroo mother care.
Funding was provided by the Saving Newborn Lives program of Save the Children Federation, Inc. We thank Ellen Boundy, Roya Dastjerdi, Sandhya Kajeepeta, Stacie Constantian, Tobi Skotnes, and Ilana Bergelson for reviewing and abstracting data. Rodrigo Kuromoto and Eduardo Toledo reviewed non-English articles. We acknowledge Kate Lobner for developing and running the search strategy.
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