Background
Conceptual framework
Method
Study setting
Study design
Participants and sampling
Data collection
COVID-19 precautions
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At the KMC unit level: only five beds were left open to maintain physical distancing between mothers, in addition to the other measures to prevent COVID-19 infection, renewal of awareness and hand washing demonstration posters, compliance with barrier measures
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At the mother’s level: free distribution of 40 face masks to each mother per month, regular hand washing or use of hand sanitizer, respect of physical distancing with the other parents and visitors, reception of visitors in the courtyard, restriction of visits to the strict minimum and when necessary.
Data analysis
Data rigor and trustworthiness
Results
Characteristics of the participants
Interview number | Age (year) | Sexe | Qualifications | years’ experience in KMC (in year) |
---|---|---|---|---|
Interview 1 | 41 | F | pediatrician | 1 ─2 |
Interview 2 | 43 | F | midwife | 1 ─2 |
Interview 3 | 46 | F | midwife | 1 ─2 |
Interview 4 | 48 | F | nurse aid | 1 ─2 |
Interview 5 | 40 | F | nurse aid | 1 ─2 |
Interview 6 | 39 | F | childcare worker | 1 ─2 |
Interview 7 | 35 | F | volunteer staff | 1 ─2 |
Interview 8 | 36 | F | volunteer staff | 1 ─2 |
Interview 9 | 46 | F | pediatrician | 1 ─2 |
Interview 10 | 44 | M | pediatrician | 1 ─2 |
Interview 11 | 50 | M | pediatrician | 1 ─2 |
Interview 12 | 47 | F | pediatrician | 1 ─2 |
Age (year) | Education level | Occupation | Marital status | Parity | |
---|---|---|---|---|---|
Interview 1 | 39 | University | Civil servant | Married | 2 |
Interview 2 | 25 | Secondary | Housewife | Married | 1 |
Interview 3 | 34 | Secondary | Housewife | Married | 3 |
Interview 4 | 47 | Secondary | Housewife | Married | 8 |
Interview 5 | 21 | Secondary | Housewife | Single/engaged | 1 |
Interview 6 | 35 | Secondary | Self-employed | Married | 2 |
Interview 7 | 32 | Secondary | Self-employed | Married | 4 |
Interview 8 | 18 | High school | Student | Single/engaged | 1 |
Interview 9 | 28 | High school | Housewife | Single/engaged | 2 |
Interview 10 | 19 | University | Student | Single/engaged | 1 |
Interview 11 | 32 | University | Self-employed | Single/engaged | 4 |
Interview 12 | 40 | University | Self-employed | Married | 5 |
Interview 13 | 30 | High school | Self-employed | Married | 1 |
Interview 14 | 22 | Secondary | Self-employed | Single/engaged | 2 |
Interview 15 | 34 | University | Civil servant | Married | 3 |
Interview 16 | 36 | Secondary | Self-employed | Single/engaged | 1 |
Interview 17 | 25 | University | Student | Married | 2 |
Interview 18 | 29 | High school | Housewife | Married | 1 |
Interview 19 | 30 | Secondary | Housewife | Married | 3 |
Interview 20 | 27 | University | Self-employed | Married | 1 |
Interview 21 | 32 | Secondary | Housewife | Married | 3 |
Interview 22 | 38 | Secondary | Self-employed | Married | 3 |
Interview 23 | 23 | University | Student | Single/engaged | 1 |
Interview 24 | 26 | Secondary | Self-employed | Married | 2 |
Interview 25 | 37 | High school | Civil servant | Married | 1 |
Interview 26 | 31 | Primary school | Housewife | Single/engaged | 2 |
Interview 27 | 23 | Secondary | Self-employed | Single/engaged | 1 |
Interview 28 | 33 | Secondary | Housewife | Married | 3 |
Interview 29 | 20 | University | Student | Single/engaged | 2 |
Interview 30 | 31 | Secondary | Housewife | Married | 3 |
Interview 31 | 33 | Secondary | Self-employed | Single/engaged | 2 |
Interview 32 | 36 | University | Civil servant | Married | 3 |
Identified barriers and facilitators by CFIR domains
CFIR domain | Construct | Barrier | Facilitator |
---|---|---|---|
Intervention characteristics | cost of the intervention | Barrier did not emerged from data | Low cost of the intervention |
Outer Setting | Patient needs and resources | Lack of community awareness | Facilitator did not emerged from data |
Beliefs about carrying a newborn on the chest | |||
Father’s resistance | |||
Cosmopolitanism | Barrier did not emerged from data | Partnership and networking with other organizations | |
Inner setting | Tension for change | Increased workload | Facilitator did not emerged from data |
Leadership engagement | Barrier did not emerged from data | Strong leadership | |
Available resources | Lack of food for admitted mothers | Training of healthcare providers | |
Lack of space for admission | |||
Lack of supplies | |||
Insufficiency of human resources | |||
Characteristics of individuals | Knowledge & Beliefs about the Intervention | Barrier did not emerged from data | Healthcare providers’ perceived value of KMC |
Mothers’adherence to KMC | |||
Other Personal Attributes | Barrier did not emerged from data | Good relationship between mothers and healthcare providers | |
Process | Executing | Lack of collaboration between service involved in newborn care | Facilitator did not emerged from data |
Lack of home visits | |||
Low rate of exclusive breastfeeding |
Intervention characteristics
“It is a practice that does not require too much financial means…my sister has given birth to a premature baby, it is currently in an incubator and it is really expensive” (M20, 27 years old).
“In Cote d'Ivoire, a newborn dies every hour due to prematurity because there are not enough incubators. In Abidjan, the capital city with more than 5 million inhabitants, there are less than 50 incubators in public hospitals. For preterm and low birth weight babies, a place in a public hospital is therefore rare. In addition, in the private sector, it is expensive: between 50,000 and 100,000 CFA francs [90 to 180 USD] for a day in an incubator with oxygen. When we know that the minimum salary is 65,000 CFA francs [117 USD], the incubator is not affordable to everyone. At the KMC unit, apart from the food that the patients have to pay for, everything is practically free.” (HP1, pediatrician)
Outer setting
Cosmopolitanism
“With the help of this association, we were able to provide food for mothers for a month” (HP3, midwife).
“Through this tripartite partnership we were trained in research methodology, qualitative and quantitative data analysis, scientific article writing and monitoring and evaluation.” (HP2, midwife).
Patient needs and resources
"Unfortunately, we are sometimes confronted with mothers who are reluctant to use the method because of their beliefs about carrying the child on their chest…According to these women, in case of danger, if the child is on the chest, it will be the most exposed ". (HP8, volunteer staff)
“Community awareness is a component of this intervention…unfortunately we were not able to realize it... A good sensitization of the community would have made it possible to provide adequate information on KMC and to act on the community's adherence to this practice... ” (HP1, pediatrician)
“ It was only when my child was admitted here that I learned about kangaroo mother care ...I had never heard about it before...that's why the beginning was difficult for me...If it was something I knew before maybe I wouldn't be so worried about my child ... ” (M30, 31 years old)
“At the beginning, I was doing intermittent Kangaroo because the baby was in the incubator... but since the baby went down to the unit for continuous Kangaroo.... my husband's behavior has changed; for him the fact that the baby is no longer in the incubator means that it is getting better and that we can be discharged…. ” (M7, 32 years old)
Inner setting
Tension for change
"At the general hospital of Port-Bouët, I am the only one who has been trained in kangaroo mother care, we have a lot of births here...it is not easy to manage everything. I am in a process of training a nurse aid to help me with this activity.... Given the number of eligible babies that we refer to the KMC unit of CHUT, we are advocating for the opening of a unit in our hospital" (HP11, pediatrician)
Leadership engagement
“We have started slowly....but look at what level we are today…..we are committed to the implementation of KMC thanks to the leadership of our head of pediatric service who really boosted us and made us adhere to his vision of KMC” (HP1, pediatrician)
Available resources
"At this time, the unit does not have a budget to provide food to the mothers. They are therefore obliged to prepare the food themselves in turn… When one of them is cooking, the other mothers or the nurse aids look after her child. We are currently advocating with the national nutrition program and some implementing partners to find a solution to this issue…" (HP1, pediatrician)
"Hum...when I have to leave my child to go to cook, I am always worried... the times when my sister brings the food, it is still expenses for the transport because we live far away…" (M2, 25 years old)
"We do not have enough space to hospitalize premature babies eligible for kangaroo mother care. From March 2019 to July 2020, out of 319 newborns hospitalized in neonatology and eligible for SMK, 209 were admitted to the SMK unit. We did not take the other eligible newborns due to lack of beds" (HP2, midwife)
"I sincerely wish we could have our own aspirator in the unit. When the babies swallow the wrong way, we go upstairs with them in the NICU to use their aspirator with all the risks that this may entail ". (HP4, nurse aid)
"We really need supplies, all the supplies you see here have been provided by an external partner ". (HP3, midwife)
" We really need more staff in the unit….Because of the lack of human resources we can’t take our time to do other important activities such as mother’s counselling, which requires time, we are obliged to rush" (HP5, volunteer staff)
“…We participated in a very interesting training which gave us the knowledge and skills to provide KMC. This training was also a good refresher training for us…..we could go back to the basics such as newborn care with a focus on preterm and low birth weight ” (HP12, pediatrician)
Characteristics of individuals
Knowledge and belief about the intervention
“KMC are a blessing!!!!!....this method will save many premature and low birth weight newborns. I find that KMC are humanized and the mother also participates in these cares which allows her to better assess the evolution of her child than when the child is in an incubator… ” (HP11, pediatrician)
“The majority of the mothers we received here, recognized the value of this practice for their child...this is what allowed us to carry out our activities without much resistance from them” (HP7, volunteer staff)
“When I first came at the KMC unit...I was afraid to carry my child on my chest and I was not sure that it would help my child develop….but little by little, with what the midwives taught me, I have started to see my child grow up and to have confidence in this method.” (M15, 34 years)
Other personal attributes
“At the very beginning I was really anxious, I was afraid to hurt my baby, but the health staff was great, the midwives were patient with me, they supported me and gradually I was able to take care of my child without any problem… ” (M13, 30 years old)
Process
Executing
"There is a lack of collaboration between perinatal specialists .... Pediatricians, midwives and obstetricians for instance. The organization of meetings, common staffs between us could really improve outcomes for newborn especially preterm and low birth weight"(HP12, pediatrician)
"Unfortunately, we do not yet make home visits, which does not allow us to appreciate the continuity of KMC within the community" (HP1, pediatrician)
“Normally KMC is supposed to increase exclusive breastfeeding, but here when you look at the numbers the breastfeeding rate is low, mixed feeding is what women do most....we really need to address this …. ” (HP4, nurse aid)
Proposed solutions to improve KMC implementation
Volunteer staff motivation
“Volunteer staff is a great help in the implementation of SMK given the shortage staff and they need to be motivated. As far as I’m concerned their participation in training is not enough to motivate. If we want to retain this staff we need to give them financial incentives.... ” (HP3, midwife).
Intensifying mothers and families education and counselling
“ I think that we need more time, more information and education tools to obtain the adherence of mothers and their relatives.... ” (HP5, nurse aid)
The recruitment of a psychologist
“ We need a psychologist in the unit ....we have had cases of young mothers who could not practice the method because it was their first pregnancy with a preterm newborn. Most of these young mothers do not necessarily have the support of their families or the child's father, which puts them in a stressful situation that does not facilitate the production of milk.” (HP2, midwife)
Involvement of all stakeholders
“ For KMC implementation to be successful, we need the commitment of all stakeholders. For example, structures such as the National Nutrition Program and the World Food Program can help us provide food to mothers in a sustainable way.” (HP11, pediatrician)