Kangaroo mother care: a systematic review of barriers and enablers

Abstract Objective To investigate factors influencing the adoption of kangaroo mother care in different contexts. Methods We searched PubMed, Embase, Scopus, Web of Science and the World Health Organization’s regional databases, for studies on “kangaroo mother care” or “kangaroo care” or “skin-to-skin care” from 1 January 1960 to 19 August 2015, without language restrictions. We included programmatic reports and hand-searched references of published reviews and articles. Two independent reviewers screened articles and extracted data on carers, health system characteristics and contextual factors. We developed a conceptual model to analyse the integration of kangaroo mother care in health systems. Findings We screened 2875 studies and included 112 studies that contained qualitative data on implementation. Kangaroo mother care was applied in different ways in different contexts. The studies show that there are several barriers to implementing kangaroo mother care, including the need for time, social support, medical care and family acceptance. Barriers within health systems included organization, financing and service delivery. In the broad context, cultural norms influenced perceptions and the success of adoption. Conclusion Kangaroo mother care is a complex intervention that is behaviour driven and includes multiple elements. Success of implementation requires high user engagement and stakeholder involvement. Future research includes designing and testing models of specific interventions to improve uptake.


Introduction
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 framework 5 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

Methods
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 "skinto-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 handsearched 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 Objective To investigate factors influencing the adoption of kangaroo mother care in different contexts. Methods We searched PubMed, Embase, Scopus, Web of Science and the World Health Organization's regional databases, for studies on "kangaroo mother care" or "kangaroo care" or "skin-to-skin care" from 1 January 1960 to 19 August 2015, without language restrictions. We included programmatic reports and hand-searched references of published reviews and articles. Two independent reviewers screened articles and extracted data on carers, health system characteristics and contextual factors. We developed a conceptual model to analyse the integration of kangaroo mother care in health systems. Findings We screened 2875 studies and included 112 studies that contained qualitative data on implementation. Kangaroo mother care was applied in different ways in different contexts. The studies show that there are several barriers to implementing kangaroo mother care, including the need for time, social support, medical care and family acceptance. Barriers within health systems included organization, financing and service delivery. In the broad context, cultural norms influenced perceptions and the success of adoption. Conclusion Kangaroo mother care is a complex intervention that is behaviour driven and includes multiple elements. Success of implementation requires high user engagement and stakeholder involvement. Future research includes designing and testing models of specific interventions to improve uptake. 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.

Results
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.

Intervention
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][34][35][84][85][86][87][88][89][90][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][37][38]89,92,93,117 Implementation 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).

Social support
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

Bathing
Clean baby with damp or dry cloth Dry infant after birth "The routines included quickly drying the newborn immediately after birth and then placing it naked (skin-to-skin) on the mother's chest. " 41 Caregiver clothing Open gown Wrap (cloth or blanket) Dupatta Specialized kangaroo mother care bra "Held in position by using innovations like dupatta (stole), sports bra, loose blouse or a specially designed sling. " 109  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

Time
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 healthcare 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

Medical concerns
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

Access
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 challenges 55,81,82,105 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 training 82,100 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 Context 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

Discussion
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 Systematic reviews Kangaroo mother care Grace J Chan et al. Lack of use of data to document skinto-skin contact practised on electronic medical record Nurses not given feedback on kangaroo mother care data collected Visitation policies sometimes prevented mothers from performing skin-to-skin contact continuously.
Staff found visitors get in the way.
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 policymakers 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.

Conclusion
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 adoption 25 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. ■