Barriers and facilitators of facility-based kangaroo mother care in sub-Saharan Africa: a systematic review

Globally in 2018, 2.5 million newborns died within the first month of life, equating to approximately 7000 neonatal deaths per day [1]. Preterm birth complications is a leading cause of neonatal mortality, associated with over one in every three (36%) deaths [2]. Hospital-based kangaroo mother care (KMC), including early and continuous skin-to-skin contact of the neonate with the mother’s chest for thermoregulation and bonding, breastfeeding support and early discharge from hospital, has the potential to halve the number of preterm deaths [3]. Although KMC is recommended by the World Health Organization (WHO) for babies weighing 2000 g or less, implementation has been limited [4]. This highlights the need to understand barriers and facilitators to sustainable implementation of KMC, which is especially important in sub-Saharan Africa (sSA) where neonatal mortality rates are the highest in the world (28 per 1000 live births as compared to a global rate of 18 per 1000 live births) [1]. The objective of this review is to understand barriers and facilitators of KMC in health facilities in sSA.

Searches were conducted on MEDLINE Ovid, Web of Science, Cumulative Index to Nursing and Allied Health (CINAHL), African Journals Online (AJOL) and the WHO Regional Database for Africa, African Index Medicus (AIM) from database inception to December 2019, with no limits applied to the year of publication or language. Searches were supplemented by scanning reference lists of papers included for review. Based on the PICOS research framework (Table 1), search included MESH terms Kangaroo-Mother Care Method and “Africa South of the Sahara” and keywords broadly included kangaroo mother care, skin-to-skin care and countries in sub-Saharan Africa (Table 2 for detail on search terms). Results were manually screened for implementation factors, barriers and facilitators and facility-based care to prevent missing relevant studies in the original search that did not include these keywords. A review protocol detailing the research question, search strategy, inclusion and exclusion criteria, quality assessment and strategy for data synthesis was developed in consultation with pediatric clinicians from Malawi (TH, QD, KK) to refine the scope of the review and ensure relevance to sSA contexts. The protocol was registered to Prospero (CRD42020166742).

Two reviewers (MWK, TH) independently screened titles and abstracts according to the eligibility criteria (Table 3). Discrepancies were resolved by discussion and a third reviewer (KP) was asked to adjudicate in the absence of consensus. Full texts were then independently reviewed by the two reviewers (MWK, TH) with the third reviewer (KP) providing an independent assessment in any disputes regarding eligibility. Studies were screened for inclusion if they included mothers and newborns dyads who practiced facility-based KMC in sSA countries as well as if they included health facilities and health workers that implemented KMC in their institutions. Studies that did not specify KMC as a therapeutic practice separate from routine skin-to-skin contact were excluded. Additionally, we excluded studies that explored community-based KMC, such as home visits, outpatient care, and interviews with community health workers or village members. Since our research objective focused on facility-based KMC, studies without primary data collection in health facilities by study authors were excluded, such as review articles and protocols. We evaluated quantitative studies using the study quality assessment tools of the National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH) [5] and qualitative studies using the Critical Appraisal Skills Programme (CASP) Qualitative Checklist [6]. An overall study rating based on critical concerns of internal validity was added to the CASP checklist to consider quality assessment similar to the NIH quality assessment tools. Results reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA) [7].

Details about study country, facility type, rural or urban context, study design, sample size, newborn characteristics, KMC characteristics, onset of skin-to-skin care, barriers and facilitators were extracted into Excel (Microsoft, Redmond, United States). Two reviewers (MWK, KP) independently extracted data and conducted the quality assessment from a sample of eligible studies (three studies, 10%) until agreement was achieved, with the remainder extracted by one reviewer (MWK). The data extraction sheet was imported into NVivo 12 (QSR International, Melbourne, Australia) where thematic analysis was conducted of barriers and facilitators according to health system and facility, health worker and family level factors. Excerpts that did not fit into the specified categories were coded as ‘other’ and reviewed for emergent themes. Illustrative quotes and excerpts from the studies were extracted to highlight key themes.

We identified a total of 761 publications from our database searches (199 from Medline, 151 from Web of Science, 90 from CINAHL, 318 from AIM and 1 from AJOL) and reference lists (2 references). After removal of duplicates and screening against the eligibility criteria, 30 studies were included in the review (Fig. 1). Reasons for exclusion included lack of focus on reporting barriers or facilitators to KMC implementation (n = 12), KMC in community settings rather than in health facilities (n = 3), review or conference proceedings (n = 3), discussed development of evaluation tools but did not report results (n = 1) and not in English (n = 1).

The number of publications discussing barriers and facilitators of implementation of facility-based KMC in sSA has steadily grown over the past two decades from two prior to 2000, nine between 2000 and 2009 and 19 from 2010 to 2019 (Additional file 1 for characteristics of included studies). There were two multi-site studies: one based in Malawi, Mali, Rwanda and Uganda [8], while the other was conducted in Ethiopia, Indonesia and Mexico [9]. For this review focusing on sSA, only the Ethiopian results were included. Of the studies in single sSA countries, five were from West Africa (three from Ghana, two from Nigeria), 17 from Southern Africa (three from Malawi, two from Mozambique, nine from South Africa, one from Zambia, two from Zimbabwe) and six from East Africa (one from Ethiopia, one from Tanzania, four from Uganda). Twenty-one studies, a majority of those included in the review, were conducted in tertiary and secondary level hospitals (70%), while six studies included both hospitals and health centres (21%). Facility level was not clear in three (10%). Tertiary-level hospitals included central, university teaching hospitals and hospitals with specialized maternity and neonatal units while secondary-level hospitals included regional referral, district and rural hospitals. A majority of studies were conducted in urban areas, including 17 (57%) in urban health facilities, 8 (27%) in urban and rural facilities and only one study (3%) in rural settings alone. There were four studies with unclear settings.

Newborn characteristics were not described in ten studies (33%). Of those with newborn data, nine described prematurity and LBW (30%) and seven described LBW alone (23%) as eligibility for KMC. The least frequently described indicator was prematurity alone, which was found in four studies (13%). Cut-offs for LBW varied between below 2500 g to 1800 g for KMC initiation. Five studies (17%) described the use of KMC for stable newborns only, while two studies (7%) included clinically unstable ones. KMC components were not detailed in 13 studies (43%). For nine studies (30%), KMC was synonymous with skin-to-skin care. KMC involved skin-to-skin care and exclusive breastfeeding in three studies (10%). Another three studies (10%) described KMC as skin-to-skin care, exclusive breastfeeding and early discharge, while two studies (7%) added a fourth component of maternal support. Twenty studies did not provide details regarding the onset of skin-to-skin care (67%), though five studies noted KMC initiation immediately after birth with postnatal mothers admitted to KMC units with premature or low birthweight infants (LBWI) (17%) and five studies described initiation of KMC once the newborn was eligible (17%). In the latter, eligible newborns may be identified during ward rounds in the neonatal unit according to clinical stability requirements.

Overall, the majority of studies were considered of good or fair quality, indicating internal validity of reported results (Additional file 2). Those rated poorly were frequently due to limited reporting of methods, which led to unclear assessments of quality. Ten of the 13 qualitative studies were rated good or fair. Those rated poor did not clearly describe their methods of qualitative analysis [10‐13]. The single case series study was rated fair; although the objective, study population, intervention and outcome were clearly described, there was lack of clarity on case characteristics [14]. Seven of the 11 observational cohort and cross-sectional studies were rated good or fair. Among poor studies, lack of clarity existed on refusal rate of eligible participants and ambiguity on methods of data collection and outcome indicators [15‐18]. Among the four controlled intervention studies, two were rated fair. Potential sampling bias, presence of confounders and lack of reporting compliance to treatment increased the risk of bias in the two poor studies [9, 19].

This review focused on facility-based KMC implementation in sSA. At health system level, strong local leadership was essential to overcome barriers of inadequate space, budget, staffing allocation, lack of guidelines and supportive supervision. At health worker level, workload and knowledge gaps compounded with staff skepticism of KMC were barriers to KMC practice. Health worker champions and continued engagement with health workers through mentorship visits were important to build critical mass in KMC practice. Lastly, at mother and family level, mothers required support from their families, peers and health workers while practicing KMC.

A previous review ranking barriers and facilitators from studies in low- and middle-income countries (LMICs) highlighted similar issues [38]. Low awareness of KMC, insufficient facility space, supplies and fears of harming the small infant were important barriers for mothers in LMICs, while workload, lack of clear guidelines, training and belief in its efficacy were barriers to adopt KMC for nurses [38]. Similar findings in our review suggest building momentum for sustainable KMC implementation in sSA continues to be a challenge, perhaps due to the complexity of KMC requiring strong engagement by users and stakeholders [4]. Leadership, governance and health workforce building were reported as significant bottlenecks to scaling up KMC in sSA and Asia [39]. Effective adoption of KMC practice requires synergy of effort and alignment by health policy makers, senior management in health facilities, nurses and other health workers at the front-line and mothers and families who often face challenges in effective communication and sharing of best practices.

Our review adds to the existing literature by highlighting the interaction of health system, health worker and mother levels, particularly in the cross-cutting theme of prioritizing preterm infant health. As a policy maker in Malawi noted, prematurity was not an area of focus until the 2012 ‘Born Too Soon’ report on preterm birth, revealing nine of the 11 countries with preterm birth rates of ≥15% were in sSA, including Malawi with the world’s highest rate of 18% [26]. At health systems level, prioritizing the health of preterm infants includes investment in facilities and policies to integrate education about prematurity into maternal health care. Staffing policies where neonatal care nurses are not rotated, may strengthen health worker specialization with small and sick newborns as some have questioned the sustainability of attempting to continually orient new staff [27]. At health worker level, prioritizing the health of preterm infants highlights the need to address staff attitudes that preterm babies are unlikely to survive. This may be supported through sharing of best practices and success stories with KMC. At mothers and family level, some studies in this review highlighted the shock of parents unprepared for preterm birth and the struggle to cope emotionally with the fear of potentially losing their infants, and cope practically with an extended stay in hospital. This could be supported by sensitization during antenatal care and birth preparedness that highlights potential for prematurity, especially in many sSA countries where rates are high and there may be stigma around preterm birth. In other words, lower prioritization at health systems level relates to less training and specialization for health staff as well as less preparation among families. This reduces capacities for sustainable implementation of KMC as well as other neonatal innovations. Similar barriers of staffing rotation policies, understaffed neonatal units and inadequate support provided to families can be seen with the implementation of bubble continuous positive airway pressure in sSA, an intervention to support care of preterm and LBWI with respiratory distress [40].

Different conceptualizations of what constitutes KMC emerged in our review. Two-thirds of studies were ambiguous on the onset of KMC practice and supporting breastfeeding appeared to be a potentially neglected area. Previous reviews described exclusive breastfeeding as a component of KMC and mentioned that breastfeeding challenges were a barrier to continued KMC practice [4, 38]. Thirty percent of studies in our review only described skin-to-skin care in KMC practice. In Ghana, most health workers agreed that skin-to-skin contact for thermoregulation and bonding was a component of KMC, but less than half included exclusive breastfeeding [10]. Consideration of issues around supporting breastfeeding is important, especially as preterm and LBWI may require expressed breastfeeding, which family members may not be familiar with [41, 42]. Family members may measure progress only in terms of weight gain [37]. Poor weight gain is unhealthy, but also negatively impacts the morale of mothers and health workers [37]. A focus on strengthening breastfeeding also highlights the importance of maternal nutrition and provision of food. Ensuring an adequate and nutritious diet in the hospital would help support health and well-being of the mother, as well as support breastfeeding, which in turn may alleviate tensions arising from dependency on family support.

Lastly, studies from sSA in this review emphasized the complexities of donor-funded KMC programs and challenges of inconsistent local leadership, where external partners propelled momentum. Funding for prenatal and neonatal health has increased substantially [43]. Global health initiatives have led to improvements in health outcomes over the past decade, although coordination with national governments and follow-up continues to be a challenge [44]. For KMC studies, donor-led implementation can lead to extra resources for scale-up, including supporting KMC champions for building momentum in practice, but quality of care may deteriorate as projects end. Continued engagement of health workers through supportive supervision, mentorship and knowledge sharing of best practices and local leadership in prioritization of prenatal and neonatal health is required in the long-term for institutionalization of KMC.

Although KMC is a relatively simple intervention in concept, sustainable implementation requires the combined support of health systems, health workers, mothers and families. In sSA where a heavy burden of neonatal deaths exists, building momentum for KMC involves strengthening health systems and communication, prioritization of preterm infant health in public health strategies and supporting health workers and mothers with their families as partners in care. This is important in supporting KMC, but also in maternal and newborn care in general.