What influences the implementation of kangaroo mother care? An umbrella review

According to reports from the World Health Organization (WHO), with the development of assisted reproductive technology and the improvement of emergency and critical care technology, the incidence of premature birth is rising, and premature birth has become a global problem [1]. Nearly fifteen million preterm infants are born each year, and more than one million of them unfortunately die each year [2]. According to statistics, complications of preterm birth directly account for more than 35% of all neonatal deaths, while the proportion of deaths indirectly caused by preterm birth is even higher because preterm birth increases the risk of infant death from infection [3]. Many surviving preterm infants encounter plenty of problems due to premature birth, such as sensory impairment and cognitive and language impairment [4‐6]. In addition, the birth of preterm infants may cause a substantial emotional crisis and economic cost to the family, as well as have an impact on public sector services such as education and other social support systems [7, 8]. For mothers, preterm birth may also cause a range of perinatal diseases [5, 9]. Therefore, effective evidence-based interventions that can be implemented at scale are urgently needed to reduce the incidence of preterm birth complications and neonatal mortality.

Kangaroo mother care (KMC) is one such evidence-based life-saving intervention for preterm infants [10]. In KMC, the mother (or father) puts her (his) naked preterm infant on her (his) chest in the same way as kangaroo parenting so that the preterm infant is capable of having early, continuous and long-term skin-to-skin contact with his or her mother (father); in addition, measures such as exclusive breastfeeding or breastfeeding, early discharge, and follow-up after discharge are taken for the preterm infants [11, 12]. Compared with the conventional nursing mode, KMC is not only able to maintain the body temperature of preterm infants but also significantly reduces the risk of death in low-birth-weight infants by 36% while significantly reducing the risk of sepsis, hypoglycaemia, and hypothermia [13]. Numerous studies have shown that KMC is a safe, effective, and multifaceted intervention with many short-term and long-term positive effects for preterm infants, such as stabilizing the neonatal physiological state, enhancing immunity, increasing exclusive breastfeeding rates, and promoting mother-infant bonding [14‐17].

Despite the clear benefits of KMC, this intervention has not yet been fully integrated into health systems around the world [18, 19]. There are many barriers impeding the implementation of the KMC, including but not limited to lack of support from family members, lack of parental information, and lack of tools and resources [20‐23]. Several studies have identified facilitators that may contribute to the implementation of KMC, such as providing KMC training programmes for parents and encouraging physicians to recommend KMC to parents [24‐26]. Undoubtedly, a better understanding of these barriers and facilitators can optimize the implementation of KMC.

Studies on the subject of KMC have developed over many years, with extensive studies from around the world and several systematic reviews on KMC published. These studies spanned different clinical settings, and there are studies that have explored the influencing factors of KMC from different perspectives, such as caregivers (e.g., parents and families) and healthcare workers [27‐29]. A certain number of barriers and facilitators have been identified in these studies. However, the complexity and diversity of conventional studies make KMC difficult to describe and understand and impose challenges for health professionals and administrators who try to apply KMC in health systems [22, 30]. Therefore, it is necessary to robustly summarize the evidence base to identify and elucidate key barriers and facilitators to the implementation of KMC.

One available approach is the umbrella review, which involves the synthesis of existing reviews, enabling researchers to collect evidence from multiple healthcare facilities instead of conducting systematic reviews at each facility. Essentially, an umbrella review is a review of existing reviews to provide an overview of the available evidence on a specific topic and allow comparisons of published reviews [31]. Furthermore, an umbrella review is capable of compiling evidence bases related to specific issues in a relatively short time frame [32]. We adopted this comprehensive assessment approach to outline factors that may facilitate or inhibit KMC implementation and expansion.

Five hundred and thirty one hits retrieved in the initial search were exported into the reference management software Endnote, and 300 of them was left after duplicate records were excluded. A total of 285 references whose subject and theme were not matched were removed after title and abstract screening. Six eligible reviews were included after further full-text screening of the remaining 15 articles, as shown in Fig. 1.

Our umbrella review highlighted different factors, each factor comprising barriers and facilitators, that influence the implementation of KMC, provide decision-makers in healthcare with an overview of the field and provide information for the implementation of KMC. All of the included reviews were published in 2015 or later, which confirms the growth and interest in the field of KMC. However, there is considerable heterogeneity in the evidence base on KMC, which makes translation into practice challenging.

Factors related to facility conditions, mainly including lack of privacy and insufficient space and supplies, were mentioned in all six included reviews, which might be related to the operation characteristics of KMC. Skin-to-skin contact is the most important part of the KMC procedure, which requires parents to undress their upper bodies and put their preterm infants on their chests, which is why a suitable physical environment is of great significance [11, 12]. Studies have reported that mothers felt uncomfortable and exposed due to the continuous coming and going of medical staff during KMC when insufficient KMC private space was provided, which has proved to be a serious barrier affecting the implementation of KMC in many countries around the world [41‐43]. Therefore, medical units should strive to provide enough quiet, comfortable, and private space for NICUs to implement KMC. Apart from physical facility conditions, resources and materials were another factor. Limited by facility space and human resources, some hospitals in China had to perform intermittent KMC instead of continuous KMC [44]. A multicountry analysis of health system bottlenecks from 12 African and Asian countries reported that insufficient essential supplies in facilities to support KMC was a barrier to the implementation of KMC [21].

KMC should be systematically implemented within a facility in accordance with relevant rules and regulations, for example, by adopting standard checklists for mothers and infants to ensure orderly and standardized KMC implementation. In a majority of the hospitals, nurses were required to commit to KMC-related tasks such as KMC recording, assessment, and data monitoring due to the lack of relevant rules and regulations, which meant an extra workload for the nurses [45, 46]. Studies have shown that human resource challenges, record keeping, and data collection are barriers to KMC implementation in countries such as Malawi and Indonesia [28, 47]. Documentation and annotation of KMC implementation were still not common practices in NICUs, while KMC-related information was imported through electronic medical records in most cases [28, 48]. Chan et al. noted that the implementation of KMC was promoted when medical units improved their electronic medical records to allow nurses to record the onset and duration of KMC [28]. Therefore, the Ministry of Health and government agencies should formulate practical KMC implementation guidelines based on local conditions, and medical units should also formulate and standardize KMC implementation guidelines and programs to promote the implementation of KMC.

Lack of proper leadership, insufficient professionalism of personnel, and insufficient training were also obstacles to KMC implementation. A study on the introduction of KMC in Indonesian hospitals found that government support, hospital management, staff acceptance, and training were identified as key facilitators of KMC implementation [47]. In some regions, KMC-specific training programs were provisioned for medical staff by the government [49]. However, the number of staff participating in the training is very limited due to the long distance between the training site and the medical unit and the shortage of personnel in the hospitals, although many medical personnel were willing to participate in the training [42, 50]. In other words, although policymakers and decision-makers tried to provide assistance and intervention programs for healthcare workers, they did not anticipate these barriers to attendance. Of course, the support from hospital administrators and leadership could provide more space and human resources to provision KMC, optimize or update the staffing configuration of neonatal care nurses, strengthen the professionalization of neonatal care by healthcare workers, and improve healthcare staff’s attitudes towards and perceptions of KMC [43, 51].

The attitudes of the health caregivers towards KMC were also a factor influencing the adoption of KMC for parents. If there were staff in the hospital who were familiar with KMC and willing to educate parents on KMC knowledge, it would help parents of preterm infants to acquire KMC-related knowledge, which would promote KMC preferences and the early initiation of KMC [52, 53]. Correspondingly, insufficient awareness of KMC and infant health among parents/family members was a barrier to the practice of KMC [22]. Despite the generally low awareness of KMC, the reviews reported that it was relatively easier to train mothers on KMC practices and that they were more adherent to KMC practices after understanding and accepting KMC [54]. Perceived, observed, and experienced effects of KMC could provide comfort and satisfaction to the parents of preterm infants, which promotes KMC use, whereas KMC is inhibited if parents and/or preterm infants experience KMC-related discomfort.

Lack of assistance is a barrier to KMC practice, whereas support from family, friends, and other mothers is a facilitator to the implementation of KMC. There were many different forms of support. For example, family members took turns embracing the preterm infants to free the mother from this practice [55, 56]. Evidence from the literature has suggested that emotional support, as well as support and help with household chores, is also a facilitator for mothers [57, 58]. Kangaroo nursing can be implemented not only by mothers but also by fathers, grandfathers, grandmothers, and other family members of preterm infants [43, 59], and if family members do not understand this point, preterm infants might lose the opportunity to receive kangaroo care [60]. Therefore, different educational approaches should be adopted to educate families of preterm infants about their roles in KMC, with additional health promotions and activities targeting grandparents and other family members about the benefits of KMC and the significance of supporting mothers, which may increase the number of people receiving KMC.

However, KMC is not suitable for all situations. In some clinical scenarios where mothers of preterm infants have special health conditions, it could be very challenging to train mothers and facilitate KMC implementation. These challenges include the infant being too difficult to embrace, the infant being too heavy, and the mother experiencing chest or back discomfort or pain/fatigue [38]. The reviews showed that mothers’ medical conditions, including postepisiotomy pain repair [61], postcesarean recovery [62], postpartum depression and general maternal illness [48], were another challenge for KMC practice. Additionally, mothers may mentally struggle with KMC practices, including positioning problems (difficulty sleeping on the chest with infants), breast milk expression, and other breastfeeding-related issues [57, 63]. In this case, family support and father involvement make a great difference [64]. Postpartum depression is a barrier to the implementation of KMC, but interestingly, mothers who practised KMC experienced reduced symptoms of postpartum depression [65, 66].

Inviting parents to the NICU to perform KMC could result in extra costs. Studies performed in low-income countries have shown that commuting between home and KMC wards was a barrier to the implementation of KMC, and fees for mothers and babies staying in KMC wards were also considered a barrier [39, 67]. Studies have shown that higher economic status is more conducive to the implementation of KMC [40, 43]. Therefore, accessing financial resources from hospital administration and/or parental health insurance to facilitate KMC would be a necessary part of KMC expansion. Meanwhile, it is necessary to consider how to reduce hospital charges or provide certain transportation subsidies for families with infants whose hospitalization time exceeds the average length of stay. Limited visiting time in the NICU is another obstacle to the implementation of KMC, especially in the case of closed management such as the NICU in China. Extending the visit time could increase the adoption of KMC to some extent [68, 69].

Different cultures, religions, and traditional beliefs in different countries influence perceptions of preterm infants and KMC. In many countries, carrying infants on the chest rather than on the back is considered inappropriate [41], and some cultures believe that skin-to-skin contact between an infant and his or her caregiver is not appropriate [27]. Understanding these culturally specific barriers, it is of great importance to adapt KMC promotion programmes to the needs of the population. In some countries, mothers are ridiculed for giving birth to preterm infants, which results in stigma [55, 70]. Studies have reported that stigma about preterm infants creates anxiety and guilt in mothers, causing them to abandon their infants, which is a factor hindering the implementation of KMC [27, 38]. Muddu et al. [71] found that fondness was an enabler for parents to accept their preterm infants and utilize KMC to support the improvement of their preterm infants’ health. Cultural barriers also encompass the practice of postpartum confinement and traditional resistance to confinement from grandparents and community members. Most mothers are advised to stay home after delivery in China and India [72, 73], which has potential health benefits for mothers and newborns, but it also causes mothers and families to be hesitant to adopt KMC.

Traditional gender role factors were identified as barriers to male participation in neonatal care. KMC was regarded as a breach of social duty or responsibility by mothers in some countries where it is believed that mothers should take care of the family, and when mothers comply with this social duty and gender responsibility, the implementation of KMC becomes a challenge [74]; meanwhile, fathers are not encouraged to participate in KMC implementation in such cultures. Therefore, it is of great significance to develop interventions on how to encourage fathers to participate in KMC and reduce the stigma surrounding this infant care strategy [75]. As Dumbaugh et al. [76] pointed out, the inclusion of males in neonatal care must be done in a way that empowers women. Fathers who are successfully involved in KMC might become peer mentors or examples for others to address the problem of fathers’ reluctance to participate in neonatal care. The name of the intervention, “kangaroo mother care”, could also be modified, e.g., to “kangaroo care”, so that it does not directly imply that the practice is performed only by mothers.

The findings in this manuscript are subject to some limitations. First, due to resource constraints, we only searched for English and Chinese reviews, and there was a possibility of missing some relevant studies. Another limitation of the umbrella review approach was that it could only report on what researchers have investigated and published [32]. For example, some factors might be highly influential, but if they were not adequately investigated in the included studies, they might be reported as less important, or they might not even be included in the review. To mitigate this issue, other key literature not identified in this review was actively referenced. Finally, a potential limitation to the umbrella review approach could be the risk that bias is transmitted upwards from primary studies to the reviews and then to the umbrella review.

KMC implementation issues are likely to differ among different regions, so there remains a need for further research into sustainable development mechanisms in varied settings to promote the adoption of KMC. The generalizability of the findings worldwide and their translation into practice is uncertain. Most of the studies focused at the facility level, such as the NICU, which highlights the lack of community-level studies. Therefore, further research is needed to explore the factors influencing KMC implementation at home and in the community. Male involvement was identified as a facilitator to KMC implementation, but there was no study discussing hindrance factors of father involvement in care specifically. Therefore, further research is also needed to explore the hindrance and/or facilitating factors of male involvement in KMC care from the perspective of fathers. In addition, further research is also needed to test models for addressing barriers and supporting facilitators to promote and implement context-specific health system changes for greater uptake of KMC.

KMC is a complicated intervention that encounters unique barriers and facilitators in different aspects of healthcare systems. Our umbrella review prioritizes the main factors influencing KMC implementation and highlights some key areas that implementers and implementation researchers may need to focus on. KMC should be implemented more systematically and continuously to strengthen and expand its adoption.

The parents of preterm infants and other family members, the medical unit, and the medical staff contribute to a dynamic whole as a triangle, that are closely linked with one another. Support from facility management and leadership and well-trained medical staff are of great significance to the successful integration of KMC into daily medical practice, while the parents of preterm infants and other family members should be educated and encouraged to adopt KMC practice. Effectively integrating KMC into current health systems by addressing barriers and building trust will greatly improve neonatal survival rates.