Kangaroo mother care: a systematic review of barriers and enablers.

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. Kangaroo mother care can include early and continuous skin-to-skin contact, breastfeeding, early discharge from the health-care facility and supportive care. 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., 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 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.

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 “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.

A deductive approach was used to fit the outputs of the analysis to the elements of the conceptual framework and explore emerging themes. 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; 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)

Table 1

Characteristics of included studies in the systematic review on kangaroo mother care

Study characteristic	No. (%) of studies (n = 112)
Year
20159–15	7 (6)
2010 to 201416–75	59 (53)
2000 to 200976–115	40 (36)
1988 to 1999116–120	5 (5)
No. of participants
< 5010–12,14,15,17,22,24–26,28–31,33,35,36,39–41,45,47,50,52,53,55–57,59,60,63,64,67,69,72,74,77,79,80,83–87,89–97,99–103,106,108,110–112,114,115,117	66 (59)
50 to < 10013,16,20,21,27,32,37,42–44,51,66,68,71,118,120	15 (13)
100 to < 20023,46,48,54,61,65,73,78,82,88,104,105,107,109	15 (13)
≥ 2009,18,19,34,38,49,58,62,70,75,76,81,98,113,116,119	16 (14)
Study type
Survey or interview11–14,16,18,21,28,29,32,33,35,39–45,48–52,58,63,64,66,69,72,74,75,77,79,87,89–91,94–97,101,102,106,107,111,114,115,117	50 (45)
Facilities’ evaluation24,25,27,31,34,47,53–55,57,59,60,67,80,82,83,100,108,113	19 (17)
Randomized control trial9,10,37,61,68,76,99,103,105,110,112,119	12 (11)
Cohort study23,56,81,92,116	5 (4)
Other (chart review, case control, surveillance)15,17,19,20,22,26,30,36,38,46,62,65,70,71,78,84–86,88,98,104,109,118,120	24 (21)
Pre-post73	1 (1)
Interventional trial93	1 (1)
WHO region
Americas12,21,28,33–37,42–44,50,52,56,63,65,71–75,84–91,94,97,101,106,108,112–115,119,120	40 (36)
African9–11,16,17,20,23–26,29,47,51,55,58–60,68,80–83,92,96,99,100,102,110,116	29 (26)
European13–15,38–41,45,48,49,53,54,64,66,70,95,104,107,118	19 (17)
South-East Asia18,19,22,30,32,67,76,77,93,98,103,109	12 (11)
Eastern Mediterranean46,61,62,69	4 (3)
Western Pacific31,78,105,111	4 (3)
Multiple regions27,57,79	3 (3)
Missing117	1 (1)
Country-level neonatal mortality rate (deaths per 1000 live birth)
< 514,15,36–45,48,49,52–54,56,63–66,70,71,82,94,95,104–108,111–113,120	36 (32)
5 to < 1512,21,28,33–35,46,50,58,59,61,62,69,74,75,84–91,97,101,114,115,119	28 (25)
15 to < 309–11,16–19,22–26,29,30,32,47,51,57–60,68,76–78,80–83,93,98–100,102,103,109,110	37 (33)
≥ 30 50, 57, 88	4 (4)
Missing13,20,27,31,73,79,117	7 (6)
Setting
Urban17,23,28,33,35,36,38,39,41,43,44,49,50,52,56,60,61,63,65–67,72,77,78,80,81,87,89–92,96,97,100–102,105,106,108,109,111,114–120	48 (43)
Urban and rural19,34,42,58,62,70,75,79,84,85,88,99,104,110,113	15 (13)
Rural16,21,51,68,76,98	6 (5)
Missing9–15,18,20,22,24–27,29–32,37,40,45–48,53–55,57,59,64,69,71,73,74,82,83,86,93–95,103,107,112	43 (38)
Population source
Health facility10,11,13,14,16,17,23–30,33–36,41,46,47,49,50,52,55–57,59–61,64,67,69–71,75,76,78–92,94,96,97,99,100,102,106,108,110,113–116,118,119	67 (60)
Neonatal intensive care unit or stepdown unit12,15,22,31,37–40,42–45,48,53,54,63,65,66,72–74,93,95,103–105,107,109,111,112,117,120	32 (28)
Community or population-based surveillance9,18,19,21,32,51,58,62,68,77,98,101	12 (11)
Missing20	1 (1)
Gestational age
Preterm 34 to < 37 weeks15,16,35,50,72,84,87,97,102,114,117,118,120	13 (12)
All gestational ages9,10,19,36,38,39,58,62,68,76,77,98	12 (11)
Very preterm < 34 weeks40,48,63–65,70,95,101,112	9 (8)
Mixed preterm and very preterm < 37 weeks33,37,89,90,94,109	6 (5)
Full term ≥ 37 weeks41,49,61,71	4 (3)
Missing11–14,17,18,20–32,34,42–47,51–57,59,60,66,67,69,73–75,78–83,85,86,88,91–93,96,99,100,103–108,110,111,113,115,116,119	68 (61)
Birthweight
Low birthweight 1500 to < 2500 g33,50,51,72,80,81,85,88,91,93,96,116,119	13 (12)
All birthweights9,10,19,36,38,39,48,58,62,68,76,77,98	13 (12)
Mixed low and very low birthweight < 2500 g17,23,90,92,101,109,120	7 (6)
Very low birthweight < 1500 g78,89,103,105	4 (3)
Missing11–16,18,20–22,24–32,34,35,37,40–47,49,52–57,59–61,63–67,69–71,73–75,79,82–84,86,87,94,95,97,99,100,102,104,106–108,110–115,117,118	75 (67)

WHO: World Health Organization.

Note: Inconsistencies arise in some values due to rounding.

Conceptual framework

Problem

The narrative synthesis of the studies showed that the burden of death and disability of newborns was acknowledged as an important problem.–,–,–

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.

Table 2

Descriptions of kangaroo mother care in studies included in the systematic review

Characteristic	Common theme	Less common theme	Quotation
Duration skin-to-skin contact	As long as possible24 hours/dayEarly/prolonged/continuous2 hours or more per dayTo begin once newborn had stabilized	During breastfeedingLess than 24 hours/dayTo begin immediately after birthTo begin 24 hours after birth	“Kangaroo mother care is defined as early, prolonged and continuous (or as far as circumstances permit) skin-to-skin care between the low birthweight infant and mother.”39
Extended duration skin-to-skin contact	As long as possibleAs long as circumstances permitUntil newborn weight of 2500 g	First month of lifeUntil 24 hours after birthUntil 37 weeks post menstrual age	“Mothers were instructed to continue kangaroo position at least until the baby reached 2500 g.”116
Breastfeeding	ExclusiveOn demandBreastfeeding encouragedBreastfeeding would begin only after skin-to-skin contact had been completed for a given period of time	Kangaroo mother care integrated as part of a larger breastfeeding packageDischarge after breastfeeding establishedBreastfeeding only after suturing and skin-to-skin contact had been completed	“Exclusive breastfeeding wherever possible and early discharge from the health facility when breastfeeding has been established.”88
Newborn clothing	Blanket coverNakedDiaper	CapBooties	“Undressed except for a diaper and was covered with the mother’s gown and a baby sheet.”93
Newborn position	Sleeping uprightVertical against chestBetween mother’s breasts skin-to-skin contactHeld after being removed from incubatorProne	UprightOn adult’s chestOn mother’s or father’s chestVertical under clothesProne positionAgainst mother’s chest	“The baby is kept upright, close to the chest of the adult.”84
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 gownWrap (cloth or blanket)	DupattaSpecialized kangaroo mother care bra	“Held in position by using innovations like dupatta (stole), sports bra, loose blouse or a specially designed sling.”109
Caregiver position	UprightProneInclined	Seated in chairWalking around	“Skin-to-skin contact prone or semi-upright position.”101
Early discharge	Early discharge (undefined)Early discharge based on clinical conditionsInfant weight gain, mother competency in kangaroo mother care	Skin-to-skin contact encouraged before dischargeDischarge after breastfeeding established	“Discharge when the mother shows an appropriate level of infant-handling competency and the infant is gaining weight.”33
Follow-up	Follow up (undefined)Adequate follow-upWithin the facility at:1−2 weeks1–6 months1 year	As part of Brazilian Ministry of Health guidelines:Week 1: 3 times (home)Week 2: 2 times (home)Week 3: 1 time (home)	“With a proper follow-up system in place for regular review of the infant.”90

Note: The quotes were concise examples of common themes found across many articles.

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.–,–, 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.,–,,,,

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.,,

Mothers, fathers and families were usually the primary caregivers of preterm newborns and involved in decision-making and practice of care.,,,, 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).

Table 3

Summary of enablers and barriers to implementation of kangaroo mother care

Level of implementation	Adoption systems				Health systems access	Context, cultural norms
	Buy-in and bonding	Social support	Access	Medical concerns
Parents
Enablers	Calming, natural, instinctive, healing for parents and infant	Father, health-care worker, family and community support for mothers and fathers was crucial to success of kangaroo mother care	Kangaroo mother care at home allowed parents to perform other duties	Helped mothers recover emotionally	Belief that kangaroo mother care was cheaper than incubator care	Mother preferred kangaroo mother care to incubator, inspired confidenceGender equality
Barriers	Stigma, shame, kangaroo mother care felt forced	Fear, guilt, discomfort of family members to participate or condone kangaroo mother care in publicPrivacy	Caregivers were unable to devote timeMothers lonely in kangaroo mother care ward	Maternal fatigue and pain	Associated costsTransport	Traditional, bathing, carrying and breastfeeding practices did not always align with kangaroo mother care guidelines
Health-care workers
Enablers	Nurses more likely to use kangaroo mother care after seeing positive effects.Support from more experienced nurses improved buy-in	Management promotion of kangaroo mother care Role of parents and other health-care workers	Kangaroo mother care did not increase workload	Temperature stability.Experienced nurses more comfortable with kangaroo mother care	Virtual communication and training.Integration of kangaroo mother care into health-care curriculum	None
Barriers	Nurses fail to have strong belief in importance of kangaroo mother careInconsistent knowledge and application of kangaroo mother care	Management did not prioritize kangaroo mother careParents could serve as a hindrance to health-care worker	Extra workloadTakes away time from other patients	Nurses did not feel kangaroo mother care appropriate for infants who they felt were too small/young/ill	Difficulty finding time for trainingInadequate/inconsistent training	Traditional protocols interfered (bathing, carrying)Nurse excluding father from infant care was a cultural norm
Facilities
Enablers	LeadershipManagement support	Staffing supportGood communicationUse of committees to advocate for kangaroo mother care	Unlimited visitation preferred	Access to private space including family rooms or privacy screen. Higher breast milk feeding rates at discharge when breast feeding was allowed and encouraged throughout the hospital	Access to structural resourcesQuiet atmosphere within facilities allows mothers to restBreast milk banks provide milk and can be an educational tool among mothers	Reporting and dataCollection of dataUse of performance standards and quality improvement measuresSite assessment tools
Barriers	Leadership lack of buy-in led to lack of adequate resources	Staffing shortages, high staff and leadership turnoverStaff resisted changing protocols	There was limited visitation time due to staff shortages	Disagreement over clinical stabilityFacilities did not provide food for mothersOnly low birthweight infants received kangaroo mother care in some locations	Lack of money at the facility for mother’s transportationDistance to the hospital for mothers without hospital-provided transportationLack of space and privacy for mothers to do kangaroo mother careLack of money for transportation, beds and kangaroo mother care wrappersPoor management of resources donated to the hospital	Lack of use of data to document skin-to-skin contact practised on electronic medical recordNurses not given feedback on kangaroo mother care data collectedVisitation policies sometimes prevented mothers from performing skin-to-skin contact continuously. Staff found visitors get in the way.

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 infant, and some did not want to keep their baby.

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.,,,,, 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.,

A lack of belief in kangaroo mother care and limited knowledge of such care restricted its uptake among health-care workers.,– 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.,,,,,,,,, Facility leadership had high turnover as leaders trained in kangaroo mother care frequently left for better positions.,,,,,,,, On the other hand, facilities that had successfully implemented kangaroo mother care reported support from management and good communication among the staff.,

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., 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., 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., In societies where gender roles were more equal (e.g. Scandinavian countries), there were fewer barriers to fathers performing kangaroo mother care., 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. Within the maternity ward, peer support from other mothers through sharing their kangaroo mother care experiences also helped promote acceptance.,

When institutional leadership did not prioritize kangaroo mother care, health-care workers were less motivated to practice or teach it,, but felt empowered to do so when management allowed for roles in decision-making, promoted kangaroo mother care or mobilized resources for it. Staffing shortages and staff turnover created barriers to implementation of kangaroo mother care within a facility. By contrast, effective coordination of and communication between staff helped facilitate implementation.

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.,,,,,, Conversely, practice of such care at home promoted its uptake. 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.,,

One study showed that uptake of kangaroo mother care increased with expansion of visiting hours at health facilities.

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.,,,, 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.,, Knowledge that kangaroo mother care supported newborns in stabilizing their temperatures, helped with breathing and promoted mother–child bonding, encouraged its use.

Access

While parents believed that kangaroo mother care was less costly than incubator care, lack of money for transportation and the distance to hospital were often reported as the biggest challenges,,, as were low resources for newborn-care services. Lack of private space for mothers to perform kangaroo mother care and to remain in the hospital with the newborn hindered its uptake,, as did allocation of resources intended for kangaroo mother care to other programmes. 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,, private spaces and dedicated resources.,

Without uniform knowledge and protocols within a facility, health-care workers were uncomfortable promoting kangaroo mother care.,,,, In-service training, of health-care workers enhanced kangaroo mother care implementation. Virtual communication and training, often within facilities, allowed more nurses to be trained in kangaroo mother care despite busy schedules and staffing shortages. 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.,

Context

Sociocultural context and sociocultural constructs of gender and roles of parents in childcare, men in the household and other family members influenced uptake.,, Parental and familial adherence to traditional newborn practices was reported as a barrier to kangaroo mother care. 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., In areas in which carrying the baby on the back was common, it seemed strange to place the baby on the front. In some contexts, it was considered unclean to have the mother carry the baby on her chest without a diaper.

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.

Table 4

Description of studies included in the systematic review on kangaroo mother care

Author, year	Country	Rural or urban	Study design	Sample size	Newborn characteristics	Kangaroo mother care components	Onset of skin-to-skin care	Provision of kangaroo mother care			Barriers and facilitators
								Hours per day	Days		Caregivers	Health-care workers	Facilities	Policies and guidelines
Abul-Fadl, 201262	Egypt	Mixed	Pop based surveillance, facility evaluation	1052 mothers	All ages	Skin-to-skin care	N/A	N/A	N/A		Xa	X	X	–a
Aliganyira, 201429	Uganda	Mixed	Facility evaluation, focus group/interview	11 facilities	N/A	Skin-to-skin care	N/A	N/A	N/A		–	X	X	–
Alves, 200784	Brazil	Mixed	Chart review, focus group/ interview	33 dyads	Premature; N/A cut-off	N/A	Once eligible: N/A definition	N/A	N/A		X	–	–	–
de Araújo, 201033	Brazil	Urban	Focus group/ interview	30 parents	Premature, ≥ 2000 g	N/A	Once eligible: N/A definition	5–6	N/A		X	X	X	–
Arivabene, 201028	Brazil	Urban	Focus group/ interview	13 mothers	N/A	Skin-to-skin care	N/A	N/A	N/A		X	–	–	–
Bazzano, 201251	Ghana	Rural	Focus group/ interview	9 mothers, 23 health-care workers	Low birthweight; N/A cut-off	Skin-to-skin care	N/A	N/A	N/A		X	–	–	–
Bergh, 201359	Ghana	N/A	Facility evaluation	38 facilities	N/A	Skin-to-skin care, exclusive breastfeeding,	Immediately after birth	N/A	N/A		X	X	X	X
Bergh, 2003100	South Africa	Urban	Facility evaluation	2 facilities	N/A	N/A	N/A	N/A	N/A		–	X	X	–
Bergh, 201267	Indonesia	Urban	Facility evaluation	10 facilities	N/A	N/A	N/A	N/A	N/A		X	–	–	–
Bergh, 200899	South Africa	Mixed	Randomized controlled trial	36 facilities	N/A	N/A	N/A	N/A	N/A		X	X	X	–
Bergh, 201226	Ghana	N/A	Pop based surveillance, facility evaluation	38 facilities	N/A	N/A	N/A	N/A	N/A		X	X	–	X
Bergh, 200983	Ghana	N/A	Facility evaluation	4 regions (out of 10)	N/A	N/A	N/A	N/A	N/A		X	X	X	–
Bergh, 201225	Malawi	N/A	Facility evaluation	14 facilities	N/A	N/A	N/A	N/A	N/A		X	X	X	X
Bergh, 201255	Mali	N/A	Facility evaluation	7 facilities	N/A	Skin-to-skin care, exclusive breastfeeding, discharge, follow-up	N/A	N/A	N/A		X	X	X	X
Bergh, 200782	Malawi	N/A	Facility evaluation	6 facilities	N/A	N/A	N/A	N/A	N/A		X	X	X	–
Bergh, 201247	Rwanda	N/A	Facility evaluation	7 facilities	N/A	N/A	N/A	N/A	N/A		X	X	X	–
Bergh, 201224	Uganda	N/A	Facility evaluation	11 facilities	N/A	N/A	N/A	N/A	N/A		X	X	X	X
Bergh, 201427	Malawi, Mali, Rwanda, and Uganda	Urban	Facility evaluation, Focus group/interview	39 facilities	N/A	Skin-to-skin care	N/A	N/A	N/A		X	X	X	X
Blencowe, 200981	Malawi	Urban	Prospective cohort	272 newborns	< 2000 g	N/A	Once eligible: N/A definition	N/A	N/A		X	–	X	–
Blencowe, 200580	Malawi	Urban	Facility evaluation	1 facility	< 2000 g	Skin-to-skin care, exclusive breastfeeding, discharge, follow-up	N/A	N/A	N/A		X	–	–	–
Blomqvist, 201348	Sweden	N/A	Focus group/ interview	76 mothers, 74 fathers	28–33 weeks, 740–2920 g	Skin-to-skin care	N/A	N/A	N/A		X	X	X	–
Blomqvist, 201139	Sweden	Urban	Focus group/ interview	23 dyads	All ages	Skin-to-skin care, exclusive breastfeeding	N/A	N/A	N/A		X	X	X	–
Boo, 2007105	Malaysia	Urban	Randomized controlled trial	126 dyads	< 1501 g	Skin-to-skin care	Once eligible: N/A definition	1	10		X	X	X	–
Brimdyr, 201269	Egypt	N/A	Focus group/ interview	40 nurses and health-care workers	N/A	Skin-to-skin care	Immediately after birth	1	1		X	X	X	–
Calais, 201049	Sweden, Norway	Urban	Focus group/ interview	117 mothers, 107 fathers	Full term	Skin-to-skin care, discharge, follow-up	Immediately after birth	N/A	N/A		X	–	–	X
Castiblanco López, 201150	Colombia	Urban	Focus group/ interview	8 mothers	< 36 weeks, 2320 g	N/A	N/A	N/A	N/A		X	–	X	–
Charpak, 200679	15 developing countries	Mixed	Focus group/ interview	17 kangaroo mother care co-ordinators, 15 facilities	N/A	Skin-to-skin care, discharge, follow-up	Immediately after birth	N/A	N/A		X	X	X	–
Chia, 2006111	Australia	Urban	Focus group/ interview	34 nurses	N/A	Skin-to-skin care	N/A	N/A	N/A		X	X	X	–
Chisenga, 201511	Malawi	Urban	Focus group/ interview	113 mothers	N/A	N/A	N/A	N/A	N/A		X	–	–	–
Colameo, 200685	Brazil	Mixed	Cross sectional	28 facilities	Low birthweight; N/A cut-off	N/A	Once eligible: N/A definition	N/A	N/A		X	X	X	–
Cooper, 201473	United States of America	Mixed	Pre-post	48 nurses and 101 parents	N/A	Skin-to-skin care	N/A	N/A	N/A		X	X	–	–
Crenshaw, 201271	United States of America	N/A	Descriptive	261 dyads	Full term	Skin-to-skin care	≤ 2 mins after birth	N/A	1		X	X	X	–
Dalal, 201430	India	Mixed	Cross sectional	145 HCPs	N/A	N/A	N/A	N/A	N/A		X	X	–	–
Dalbye, 201141	Sweden, Norway	Urban	Focus group/ interview	20 mothers	Full term	Skin-to-skin care	Immediately after birth	N/A	N/A		X	X	–	–
Darmstadt, 200698	India	Rural	Intervention	2063 mothers	All ages	Skin-to-skin care	N/A	N/A	N/A		X	–	X	–
De Vonderweid, 2003104	Italy	Mixed	Pop based surveillance	109 facilities	N/A	N/A	N/A	N/A	N/A		–	X	X	X
Duarte, 200197	Brazil	Urban	Focus group/ interview	1 mother	Premature; N/A cut-off	Skin-to-skin care	N/A	N/A	38		X	–	X	–
Eichel, 2001108	United States of America	Urban	Facility evaluation	1 facility	N/A	N/A	N/A	N/A	N/A		X	X	X	X
Eleutério, 2008114	Brazil	Urban	Focus group/ interview	9 mothers	Premature; N/A cut-off	N/A	N/A	N/A	N/A		–	–	X	–
Engler, 2002113	United States of America	Mixed	Facility evaluation	537 facilities	N/A	N/A	N/A	N/A	N/A		X	X	X	–
Ferrarello, 201452	United States of America	Urban	Focus group/ interview	15 mothers, 14 nurses	N/A	Skin-to-skin care	N/A	N/A	N/A		X	–	–	X
Flynn, 201066	Ireland	Urban	Focus group/ interview	62 health-care workers	N/A	N/A	N/A	N/A	N/A		X	X	–	–
Freitas, 200786	Brazil	N/A	Prospective cohort, descriptive	22 newborns	N/A	N/A	N/A	N/A	N/A		–	–	X	–
Furlan, 200387	Brazil	Urban	Focus group/ interview	10 parents	Premature; N/A cut-off	Skin-to-skin care	Once eligible: N/A definition	10; mean	N/A		X	–	X	X
Gontijo, 201034	Brazil	Mixed	Facility evaluation	293 facilities	N/A	Skin-to-skin care, exclusive breastfeeding	Once eligible: N/A definition	N/A	N/A		X	–	–	–
Gontijo, 201275	Brazil	Mixed	Focus group/ interview	293 facilities	N/A	N/A	N/A	N/A	N/A		–	–	X	–
Gonya, 201363	United States of America	Urban	Focus group/ interview	32 mothers	< 27 weeks	Skin-to-skin care	N/A	N/A	N/A		X	–	X	X
Haxton, 201236	United States of America	Urban	Intervention, qualitative	30 mothers	All ages	Skin-to-skin care, exclusive breastfeeding	Within one hour after birth	3	1		X	X	X	X
Heinemann, 201340	Sweden	N/A	Focus group/ interview	7 mothers, 6 fathers	< 27 weeks	Skin-to-skin care	N/A	N/A	N/A		X	–	X	–
Hendricks-Muñoz, 201044	United States of America	Urban	Focus group/ interview	59 nurses	N/A	Skin-to-skin care	N/A	N/A	N/A		–	X	–	–
Hendricks-Muñoz, 201365	United States of America	Urban	Focus group/ interview	143 mothers, 42 health-care workers	< 34 weeks	N/A	N/A	N/A	N/A		X	X	–	–
Hendricks-Muñoz, 201456	United States of America	Urban	Prospective cohort	30 nurses	N/A	Skin-to-skin care	N/A	N/A	N/A		X	–	–	–
Hennig, 200688	Brazil	Mixed	Cross sectional	148 doctors and nurses, 11 facilities	Low birthweight; N/A cut-off	N/A	Clinical stable	N/A	N/A		X	X	X	–
Higman, 201513	England	Urban	Focus group/ interview	6 nurses and 51 clinicians	N/A	N/A	N/A	N/A	N/A		X	X	–	–
Hill, 201058	Ghana	Mixed	Focus group/ interview	635 mothers, 14 villages	All ages	Skin-to-skin care	N/A	N/A	N/A		X	X	–	–
Hunter, 201432	Bangladesh	Rural	Focus group/ interview	121 participants	N/A	N/A	N/A	N/A	N/A		X	X	–	–
Ibe, 200492	Nigeria	Urban	Crossover	13 newborns, 11 mothers and female relatives	1200–1999 g	Skin-to-skin care	After enrolment	12	N/A		X	–	–	–
Johnson, 2007106	United States of America	Peri-urban/slum	Focus group/ interview	17 nurses	N/A	N/A	N/A	N/A	N/A		X	X	X	–
Johnston, 201137	Canada	N/A	Randomized controlled trial crossover	62 newborns	28–36 weeks	Skin-to-skin care	≥ 15 minute before heel lance	≤ 1	2		X	–	–	–
Kambarami, 200296	Zimbabwe	Urban	Focus group/ interview	N/A mothers	Low birthweight: N/A cut-off	N/A	N/A	N/A	N/A		X	–	X	–
Keshavarz, 201061	Islamic Republic of Iran	Urban	Randomized controlled trial	160 dyads	Full term	Skin-to-skin care	2 hours after caesarean	3	N/A		X	–	–	–
Kostandy, 2008112	United States of America	N/A	Randomized controlled trial crossover	10 newborns	30–32 weeks	Skin-to-skin care	30 minute before heel stick	0.83	1		–	X	–	–
Kymre, 201345	Sweden, Norway, Denmark	N/A	Focus group/ interview	18 nurses	N/A	Skin-to-skin care	N/A	N/A	N/A		X	X	–	–
Lee, 201242	United States of America	Mixed	Focus group/ interview	69 health-care providers, 11 facilities	N/A	Skin-to-skin care	N/A	N/A	N/A		X	X	X	–
Legault, 1995120	Canada	Urban	Randomized controlled trial, pre-post, crossover	61 dyads	Premature: N/A cut-off 1000–1800 g	Skin-to-skin care	Once eligible: N/A definition	0.5	1		X	–	–	–
Lemmen, 201364	Sweden	N/A	Focus group/ interview	12 families	24–35 weeks	Skin-to-skin care	N/A	N/A	N/A		X	X	–	–
Leonard, 2008102	South Africa	Urban	Focus group/ interview	6 parents	Premature: N/A cut-off	N/A	N/A	N/A	N/A		X	–	–	–
Lincetto, 1998116	Mozambique	Urban	Prospective cohort	246 newborns	< 2000 g	Skin-to-skin care, exclusive breastfeeding, discharge, follow-up	Stabilized health condition, presence of a sucking reflex, thermoregulation, mother's condition enabling her to care for the low birthweight infant, cessation of the infant's need for IV therapy, oxygen, photo-therapy or feeding by NG tube	> 20	N/A		X	X	X	–
Maastrup, 201253	Denmark	N/A	Facility evaluation	19 facilities	N/A	Skin-to-skin care	18 out of 19 within 24 hour postpartum for stable preterm infant	N/A	N/A		X	–	–	–
Mallet, 2007107	France	N/A	Focus group/ interview	121 doctors and paramedical staff	N/A	N/A	N/A	N/A	N/A		X	X	X	–
Martins, 2008115	Brazil	Urban	Focus group/ interview	5 mothers	N/A	N/A	N/A	N/A	N/A		X	–	–	–
McMaster, 200078	Papua New Guinea	Urban	Chart review, facility evaluation	109 newborns	< 1500 g	Skin-to-skin care	N/A	N/A	N/A		X	–	–	–
Moreira, 2009101	Brazil	Urban	Focus group/ interview	8 mothers	30–32 weeks, < 2000 g	Skin-to-skin care	Once eligible: N/A definition	N/A	N/A		X	–	–	–
Mörelius, 201515	Sweden	Urban	Survey	129 nurses	All newborns	N/A	N/A	N/A	N/A		X	X	–	–
Mörelius, 201270	Sweden	Mixed	Pop based surveillance	520 newborns	< 27 weeks	Skin-to-skin care	N/A	N/A	N/A		–	X	–	–
Nahidi, 201446	Islamic Republic of Iran	Urban	Questionnaire	292 midwives	N/A	N/A	N/A	N/A	N/A		X	X	–	–
Namazzi, 201510	Uganda	Rural	Randomized controlled trial	20 health facilities	All newborns	Skin-to-skin care	N/A	N/A	N/A		X	X	X	–
Neu, 1999117	N/A	Urban	Focus group/ interview	8 mothers, 1 father	Premature; N/A cut-off	Skin-to-skin care	N/A	1	2		X	X	X	–
Nguah, 201123	Ghana	Urban	Prospective cohort	195 dyads	1000–2000 g	Skin-to-skin care, exclusive breastfeeding, follow-up	After admission in hospital and if mother was willing	N/A	N/A		X	–	–	–
Niela–Vilén, 201338	Finland	Urban	Prospective cohort, qualitative	170 mothers, 381 staff	All NICU newborns	N/A	Immediately after birth	N/A	N/A		X	X	–	–
Nimbalkar, 201422	India	Urban	Questionnaire	52 paediatricians	N/A	N/A	N/A	N/A	N/A		–	X	–	–
Nyqvist, 200895	Sweden	N/A	Focus group/ interview	13 mothers	< 32 weeks	Skin-to-skin care, discharge, follow-up	N/A	N/A	N/A		X	X	X	X
Parmar, 2009109	India	Urban	Retrospective cohort	135 newborns	26–37 weeks, 550–2500 g	Skin-to-skin care	N/A	N/A	N/A		X	X	X	–
Pattinson, 2005110	South Africa	Mixed	Randomized controlled trial	34 facilities	N/A	N/A	N/A	N/A	N/A		–	–	X	–
Priya, 200493	India	N/A	Crossover	30 dyads	Low birthweight; N/A cut-off	Skin-to-skin care	After routine care was observed and data were collected	2	2		X	–	–	–
Quasem, 200377	Bangladesh	Urban	Focus group/ interview	35 mothers	All ages	Skin-to-skin care	N/A	N/A	N/A		X	–	X	–
Ramanathan 2001103	India	N/A	Randomized controlled trial	28 newborns	< 1500 g	N/A	Once eligible: N/A definition	≥ 4	N/A		X	X	–	–
Roller, 200594	United States of America	N/A	Focus group/ interview	10 mothers	32–37 weeks	Skin-to-skin care	N/A	N/A	N/A		X	X	X	X
Sá, 201035	Brazil	Urban	Focus group/ interview	10 mothers, 7 health-care providers	Premature; N/A cut-off	N/A	N/A	N/A	N/A		X	–	–	–
Sacks, 201321	Honduras	Rural	Focus group/ interview	48–72 traditional birthing attendant (6 focus groups with 8–12 participants per group)	N/A	N/A	N/A	N/A	N/A		X	X	–	–
Santos, 201372	Brazil	Urban	Focus group/ interview	12 mothers	Premature, low birthweight; N/A cut-off	Skin-to-skin care	N/A	N/A	N/A		X	–	X	–
Shamba, 201420	United Republic of Tanzania	Mixed	Focus group/ interview	57 mothers and 14 traditional birthing attendants	N/A	N/A	N/A	N/A	N/A		X	–	–	–
Silva, 201474	Brazil	Urban	Focus group/ interview	20 nursing technicians	N/A	N/A	N/A	N/A	N/A		X	X	–	–
Silva, 201512	Brazil	Urban	Focus group/ interview	8 nurses	N/A	N/A	N/A	N/A	N/A		–	X	–	–
Silva, 200889	Brazil	Urban	Focus group/ interview	5 dyads	Premature: N/A cut-off, < 1000–1550 g	Skin-to-skin care	Once eligible: N/A definition	≤ 24	Depended on mothers length of stay		X	–	–	–
Singh, 201219	India	Mixed	Case control	145 662 newborns, 810 204 mothers	All ages	N/A	N/A	N/A	N/A		–	–	–	X
Sinha, 201418	India	Rural	Focus group/ interview	320 mothers, 61 accredited social health activists, 19 home visits	N/A	Skin-to-skin care, exclusive breastfeeding	N/A	N/A	N/A		X	X	–	–
Sloan, 200876	Bangladesh	Rural	Cluster randomized controlled trial	39 888 mothers	All ages	Skin-to-skin care	N/A	N/A	2; data available for first 2 days of life		X	X	–	–
Solomons, 201217	South Africa	Urban	Cross sectional	30 mothers, 15 nurses	< 2500 g	N/A	N/A	N/A	N/A		X	X	X	–
Stikes, 201343	United States of America	Urban	Focus group/ interview	56 nurses	N/A	Skin-to-skin care	N/A	N/A	N/A		X	X	X	X
Strand, 201454	Sweden	N/A	Facility evaluation	126 staff	N/A	N/A	N/A	N/A	N/A		X	X	X	–
Tessier, 1998119	Colombia	Urban	Randomized controlled trial	488 newborns	< 2001 g	Skin-to-skin care, discharge, follow-up	Adapted to extra-uterine life and able to breastfeed	N/A	N/A		X	–	–	–
Toma, 200390	Brazil	Urban	Focus group/ interview	14 mothers, 7 fathers	Premature: N/A cut-off, 1150–2300 g	N/A	Ranged from 3 to 39 days of life	N/A	N/A		X	–	–	–
Toma, 200791	Brazil	Urban	Focus group/ interview	41 mothers	< 2000 g	N/A	Mean 18 days of life	N/A	N/A		X	–	X	–
Undefined author: Save the Children, 201157	Ethiopia, Malawi, Mali, Mozambique, Nigeria, United Republic of Tanzania, Uganda, Bolivia, Indonesia, Nepal, Viet Nam	N/A	Facility evaluation	12 countries	N/A	N/A	N/A	N/A	N/A		X	X	X	X
Vesel, 201368	Ghana	Rural	Cluster randomized controlled trial	98 zones	All ages	Skin-to-skin care	N/A	N/A	N/A		X	–	–	–
Wahlberg, 1992118	Sweden	Urban	Retrospective cohort	66 dyads	Premature; N/A cut-off	Skin-to-skin care	N/A	N/A	N/A		–	X	X	–
Waiswa, 201016	Uganda	Rural	Focus group/ interview	30 health-care workers and mothers, 16 facilities	Premature; N/A cut-off	N/A	N/A	N/A	N/A		X	X	X	–
Waiswa, 20159	Uganda	Rural	Cluster randomized controlled trial	395 women	All newborns	Skin-to-skin care, exclusive breastfeeding	N/A	N/A	N/A		X	–	–	–
Wobil, 201060	Ghana	Urban	Facility evaluation	2 facilities	N/A	N/A	N/A	N/A	N/A		X	–	X	–
Zhang, 201431	Singapore	Urban	Facility evaluation	1 ICU	Less than 34 weeks; Less than 1500 g	Skin-to-skin care	Once eligible: stable preterm or low birthweight babies, excluding infants with poor respiratory status, invasive lines, or parents who are depressed, not willing to do kangaroo mother care, having infectious skin disease on chest, unfit physically, or with flu-like symptoms.	At least 1 hour several times per day	N/A		X	X	X	–
Zwedberg, 201514	Sweden	Urban	Focus group/ interview	8 midwives	N/A	N/A	N/A	N/A	N/A		X	X	–	–

a ‘X means included in the study and ‘–’ means not included in the study.

ICU: intensive care unit; N/A: not available; NICU: neonatal intensive care unit.

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., 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. 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.,,

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., At the national level, kangaroo mother care should be integrated with essential newborn, maternal and child health guidelines, with appropriate monitoring and evaluation.

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 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.