Nurses' Kangaroo Mother Care practice implementation and future challenges: an integrative review

Kangaroo mother care prior to clinical stabilisation: Implementation barriers and facilitators reported by caregivers and healthcare providers in Uganda

Kangaroo mother care (KMC) is an evidence-based method to improve newborn survival. However, scale-up even for stable newborns has been slow, with reported barriers to implementation. We examined facilitators and barriers to initiating KMC before stabilisation amongst neonates recruited to the OMWaNA study in Uganda. The OMWaNA study was a randomised controlled trial that examined the mortality effect of KMC prior to stabilisation amongst newborns weighing ≤2000 grams. At the four trial hospitals, we conducted focus group discussions (FGD) separately with caregivers and healthcare providers, in-depth interviews (IDI) with caregivers and key informant interviews (KII) with hospital administrators and healthcare providers. The World Health Organisation (WHO) Health Systems Building Blocks were used to guide thematic analysis. Eight FGDs (4 caregivers, 4 healthcare providers), 41 caregiver IDIs (26 mothers, 8 grandmothers, 7 fathers), and 23 KIIs were conducted. Key themes based on the building blocks were; family and community support/ involvement, health workforce, medical supplies and commodities, infrastructure and design, financing, and health facility leadership. We found that the presence of a family member in the hospital, adequate provision of healthcare workers knowledgeable in supporting KMC prior to stability, and adequate space for KMC beds where neonatal care is being delivered, can enable implementation of KMC before stability. Implementation barriers included fear of inadvertently causing harm to the newborn, inadequate space to practice KMC in the neonatal unit, and a limited number of trained healthcare workers coupled with insufficient medical supplies.

Healthcare providers' perceptions and experiences of kangaroo mother care for preterm infants in four neonatal intensive care units in China: a qualitative descriptive study

Background

Kangaroo mother care (KMC) is an evidence-based intervention that can effectively reduce morbidity and mortality in preterm infants, but it has yet to be widely implemented in health systems in China. Most qualitative studies on KMC for preterm infants focused on the experiences and influencing factors from the perspective of preterm infant parents, while neglecting the perspective of healthcare providers, who played a critical role in guiding KMC practice. Therefore, this study aimed to explore the perceptions and experiences of healthcare providers regarding their involvement in KMC implementation for preterm infants to promote the contextualized implementation of KMC.

Methods

A descriptive qualitative approach was adopted. A purposive sampling was used to select healthcare providers involved in KMC implementation in the neonatal intensive care units (NICUs) as participants from four tertiary hospitals across four cities in Zhejiang Province, China. Face-to-face semi-structured interviews were conducted to collect information. Thematic analysis was employed to analyze the data.

Results

Seventeen healthcare professionals were recruited, including thirteen nurses and four doctors in the NICUs. Four themes and twelve subthemes emerged: different cognitions based on different perspectives (acknowledged effects and benefits, not profitable economically), ambivalent emotions regarding KMC implementation (gaining understanding, gratitude and trust from parents, not used to working under parental presence, and concerning nursing safety issues), barriers to KMC implementation (lack of unified norms and standards, lack of systematic training and communication platform, insufficient human resources, and inadequate parental compliance) and suggestions for KMC implementation (improving equipment and environment, strengthening collaboration between nurses and doctors, and support from hospital managers).

Conclusions

Despite acknowledging the clinical benefits of KMC, the lack of economic incentives, concerns about potential risks, and various barriers hindered healthcare providers' intrinsic motivation to implement KMC in NICUs in China. To facilitate the effective implementation of KMC, hospital managers should provide bonuses and training programs for healthcare providers, while giving them recognition and encouragement to enhance their motivation to implement KMC.

Feasibility and acceptability of a novel biomedical device to prevent neonatal hypothermia and augment Kangaroo Mother Care in Kenya: Qualitative analysis of focus group discussions and key Informant Interviews

Hypothermia is a leading newborn complication, especially among premature and/or low birth weight infants. Within low/middle-income countries where incubators and radiant warmers are often in short supply, leading to gaps in the thermal care chain, neonatal hypothermia underlies high rates of newborn morbidity and mortality. Kangaroo Mother Care/Skin-to-skin care is an effective method for prevention of hypothermia in premature and low birthweight babies but can be very burdensome for families and healthcare providers. Our international multidisciplinary team has developed a prototype for a wearable biomedical device ("NeoWarm") to provide continuous thermal care and augment kangaroo mother care practices in low-resource settings. The objective of this study was to assess the feasibility and acceptability of NeoWarm and to obtain user design feedback for an early prototype from among adult end-users in Western Kenya. We performed key informant interviews (n = 17) among healthcare providers and 5 focus group discussions (FGDs) among 3 groups of adult stakeholders of premature babies, including: (1) parents/family members of premature babies aged 6 weeks or less (3 FGDs); (2) healthcare providers of newborns (e.g., nurses; physicians; 1 FGD); (3) community opinion leaders and stakeholders (e.g., traditional birth attendants; pastors; village elders; 1 FGD). Content and thematic analyses of transcripts indicate that NeoWarm is acceptable and feasible in promoting facility-based kangaroo mother care in the Kenyan setting. Novel findings derived from respondents include (1) the ability of the device to potentially overcome several barriers to traditional kangaroo mother care methods and (2) user-driven encouragement to expand the use case of the device to potentially include community-based kangaroo mother care and neonatal transport. User design feedback obtained during the interviews informed several key design iterations for subsequent prototypes of the device.

Essential components of an educational program for implementing skin-to-skin contact for preterm infants in intensive care units: an integrative literature review

BACKGROUND

Globally, prematurity is the primary factor behind the mortality of children under the age of 5 years, resulting in approximately 1 million children dying annually. The World Health Organization (WHO) recommends Skin-to-Skin Contact (SSC) as part of routine care for preterm infants. Evidence shows that SSC reduces mortality, possibly by improving thermoregulation, facilitating the earlier initiation of breastfeeding and reducing the risk of nosocomial infection. An educational program for implementing SSC has been demonstrated to enhance the knowledge and practice of parents and nurses in intensive care units. This study, the first of its kind in the North West Province (NWP), aims to identify the essential components of an educational program for implementing SSC for premature infants in intensive care units.

OBJECTIVE

This paper presents an integrative literature review that critically synthesizes research-based literature on essential components of an educational program for implementing SSC for preterm infants in intensive care units.

METHODS

A comprehensive search of electronic databases, such as CINAHL, MEDLINE, PsycINFO, ProQuest and Health Source: Nursing/Academic Edition and Health Source-Consumer Edition, was conducted using different keywords and references lists from the bibliography.

RESULTS

Twelve articles relevant to this review were identified, read and synthesized to answer the research question. Three essential components emerged from the findings of this review, namely (1) the necessity of policy and role players for implementing SSC, (2) the availability of education and training, and (3) counseling and support for parents of preterm infants.

CONCLUSIONS

The outcomes of this study have the potential to facilitate the implementation and expansion of SSC in intensive care units. This could aid program implementers, policymakers, and researchers to implement and scale up this important tool in intensive care units.

Preclinical validation of NeoWarm, a low-cost infant warmer and carrier device, to ameliorate induced hypothermia in newborn piglets as models for human neonates

Introduction

Approximately 1.5 million neonatal deaths occur among premature and small (low birthweight or small-for gestational age) neonates annually, with a disproportionate amount of this mortality occurring in low- and middle-income countries (LMICs). Hypothermia, the inability of newborns to regulate their body temperature, is common among prematurely born and small babies, and often underlies high rates of mortality in this population. In high-resource settings, incubators and radiant warmers are the gold standard for hypothermia, but this equipment is often scarce in LMICs. Kangaroo Mother Care/Skin-to-skin care (KMC/STS) is an evidence-based intervention that has been targeted for scale-up among premature and small neonates. However, KMC/STS requires hours of daily contact between a neonate and an able adult caregiver, leaving little time for the caregiver to care for themselves. To address this, we created a novel self-warming biomedical device, NeoWarm, to augment KMC/STS. The present study aimed to validate the safety and efficacy of NeoWarm.

Methods

Sixteen, 0-to-5-day-old piglets were used as an animal model due to similarities in their thermoregulatory capabilities, circulatory systems, and approximate skin composition to human neonates. The piglets were placed in an engineered cooling box to drop their core temperature below 36.5°C, the World Health Organizations definition of hypothermia for human neonates. The piglets were then warmed in NeoWarm (n = 6) or placed in the ambient 17.8°C ± 0.6°C lab environment (n = 5) as a control to assess the efficacy of NeoWarm in regulating their core body temperature.

Results

All 6 piglets placed in NeoWarm recovered from hypothermia, while none of the 5 piglets in the ambient environment recovered. The piglets warmed in NeoWarm reached a significantly higher core body temperature (39.2°C ± 0.4°C, n = 6) than the piglets that were warmed in the ambient environment (37.9°C ± 0.4°C, n = 5) (p < 0.001). No piglet in the NeoWarm group suffered signs of burns or skin abrasions.

Discussion

Our results in this pilot study indicate that NeoWarm can safely and effectively warm hypothermic piglets to a normal core body temperature and, with additional validation, shows promise for potential use among human premature and small neonates.

The NeoRoo mobile app: Initial design and prototyping of an Android-based digital health tool to support Kangaroo Mother Care in low/middle-income countries (LMICs)

Premature birth and neonatal mortality are significant global health challenges, with 15 million premature births annually and an estimated 2.5 million neonatal deaths. Approximately 90% of preterm births occur in low/middle income countries, particularly within the global regions of sub-Saharan Africa and South Asia. Neonatal hypothermia is a common and significant cause of morbidity and mortality among premature and low birth weight infants, particularly in low/middle-income countries where rates of premature delivery are high, and access to health workers, medical commodities, and other resources is limited. Kangaroo Mother Care/Skin-to-Skin care has been shown to significantly reduce the incidence of neonatal hypothermia and improve survival rates among premature infants, but there are significant barriers to its implementation, especially in low/middle-income countries (LMICs). The paper proposes the use of a multidisciplinary approach to develop an integrated mHealth solution to overcome the barriers and challenges to the implementation of Kangaroo Mother Care/Skin-to-skin care (KMC/STS) in LMICs. The innovation is an integrated mHealth platform that features a wearable biomedical device (NeoWarm) and an Android-based mobile application (NeoRoo) with customized user interfaces that are targeted specifically to parents/family stakeholders and healthcare providers, respectively. This publication describes the iterative, human-centered design and participatory development of a high-fidelity prototype of the NeoRoo mobile application. The aim of this study was to design and develop an initial ("A") version of the Android-based NeoRoo mobile app specifically to support the use case of KMC/STS in health facilities in Kenya. Key functions and features are highlighted. The proposed solution leverages the promise of digital health to overcome identified barriers and challenges to the implementation of KMC/STS in LMICs and aims to equip parents and healthcare providers of prematurely born infants with the tools and resources needed to improve the care provided to premature and low birthweight babies. It is hoped that, when implemented and scaled as part of a thoughtful, strategic, cross-disciplinary approach to reduction of global rates of neonatal mortality, NeoRoo will prove to be a useful tool within the toolkit of parents, health workers, and program implementors.

The effect of kangaroo mother care or skin-to-skin contact on infant vital signs: A systematic review and meta-analysis

BACKGROUND

It has been reported that kangaroo mother care/skin-to-skin contact immediately after birth facilitates the newborn's physiological and psychological adaptation to extrauterine life.

OBJECTIVE

To examine the effect of kangaroo mother care/skin-to-skin contact on infants' body temperature, oxygen saturation, respiratory rate and heart rate.

DESIGN

Systematic review and meta-analysis.

METHODS

PubMed, ScienceDirect, SpringerLink, Wiley Online Library and Taylor & Francis Online were searched for the period 1 January 2015 to 30 November 2021 for studies published in the English language. The methodological quality of articles was assessed using the modified Jadad scale and the Newcastle-Ottawa scale. Effect size calculations were made using the fixed effects and random effects models.

FINDINGS

This meta-analysis included 13 studies, with a total of 891 infants. Kangaroo mother care/skin-to-skin contact was effective for maintaining infants' body temperature (p = 0.000). Infants' heart rate decreased (p = 0.015) and oxygen saturation was higher (p = 0.040) following kangaroo mother care/skin-to-skin contact. Kangaroo mother care/skin-to-skin contact did not affect infants' respiratory rate (p = 0.896), but infants' respiratory rate decreased after kangaroo mother care/skin-to-skin contact (p = 0.047).

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Kangaroo mother care/skin-to-skin contact is effective for improving the vital signs of newborns. Kangaroo mother care/skin-to-skin contact is recommended for all neonates, and standardization of this approach would be beneficial.

The effects of kangaroo mother care on physiological parameters of premature neonates in neonatal intensive care unit: A systematic review

PURPOSE

The effects of Kangaroo mother care (KMC) on physiological parameters in preterm infants have been reported in the literature by experimental and quasi-experimental studies, and varying findings have been presented. The present study was conducted to determine the effects of KMC on the physiological parameters of premature newborns in the Neonatal Intensive Care Unit.

DESIGN AND METHOD

The review was conducted according to the specified keywords by scanning the EBSCO-host, Cochrane Library, Medline, PubMed, ScienceDirect, Web of Science, and TR index databases using the keywords "kangaroo care AND preterm AND vital signs." The pool mean differences (MDs) were calculated, adopting a 95% confidence interval (CIs) using the Stata 16 software for the meta-analysis [PROSPERO: CRD42021283475].

RESULTS

Eleven studies for systematic review and nine studies for meta-analysis, including 634 participants, were found eligible for inclusion. It was determined that the "temperature" (z = 3.21; p = 0.000) and "oxygen saturation" (z = 2.49; p = 0.000) values created a positive effect in general in the kangaroo care group; however, there was no sufficient evidence to state that it affected the "heart rate" (z = -0.60; p = 0.55) and "respiratory rate" (z = -1.45; p = 0.15) values. In the present study, the duration of KMC application had statistically different effects on temperature and oxygen saturation (SpO₂) (p < 0.05). One-hour or shorter applications of KMC had a higher effect on the temperature and oxygen saturation values (1.83; 1.62, respectively).

CONCLUSION

Our results provided references for clinical implications, and the "temperature" and "oxygen saturation (SpO₂)" values created a positive effect in general in the KMC group. However, there was no sufficient evidence to state that it affected the "heart rate" and "respiratory rate" values. The duration of KMC application had statistically different effects on temperature and oxygen saturation. One-hour or shorter applications of KMC had a higher effect on the temperature and SpO₂ values. Longitudinal, randomized, controlled studies examining the effects of KMC on vital signs in premature newborns with vital parameters outside the normal reference range are recommended.

PRACTICE IMPLICATIONS

The goal of the NICU nurse is to improve the infant's well-being. The application of KMC is a unique care for the nurse in maintaining the newborn's well-being. The vital signs of newborns hospitalized in the NICU with critical problems may be out of normal limits. KMC is an essential developmental care practice that ensures that the neonate's vital signs are kept within normal limits by relaxing the neonate, reducing stress, increasing comfort, and supporting interventions and treatments. KMC application is unique for each mother‑neonate pair. Depending on the tolerance of the mother and infant in terms of duration, it is recommended to perform KMC in the NICU under the supervision of a nurse. Neonatal nurses should support mothers in giving KMC in the NICU since KMC has ameliorative effects on the vital signs of premature neonates.

Study on the value of KMC combined with blue light irradiation in improving the therapeutic effect of neonatal jaundice

Neonatal jaundice is a common problem that affects newborns. We aim to investigate the effect of Kangaroo Mother Care (KMC) combined with blue-light irradiation on enhancing the therapeutic effect in the treatment of neonatal jaundice. From May 2020 to August 2022, 89 neonates with pathological jaundice and their mothers were selected as participants. All neonates received blue-light irradiation. The participants were divided into two groups: 46 neonates cared for by KMC as the research group (RG) and 43 neonates receiving routine nursing as the control group (CG). The first lactation time, first breastfeeding duration, and scores of Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS) before and after nursing were recorded and compared between the groups. Pre- and post-interventional total bilirubin (TBIL), direct bilirubin (DBIL), and indirect bilirubin (IBIL) levels of both groups of newborns were measured, and the time of jaundice resolution, first defecation, and meconium yellowing were recorded. Neonatal adverse reactions (ARs) during treatment were counted, and a nursing satisfaction survey was conducted at discharge. KMC group mothers had earlier lactation and longer first breastfeeding durations (P < 0.05). Both groups' SAS and SDS scores decreased post-nursing, with greater improvement in the KMC group (P < 0.05). KMC group newborns had lower bilirubin levels and faster resolution of jaundice and meconium yellowing, with fewer adverse reactions and higher nursing satisfaction (P < 0.05). KMC can effectively improve the efficacy of blue light irradiation in the treatment of neonatal jaundice, and promote the healthy development of newborns and the efficiency of maternal breastfeeding.

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

Background

Kangaroo mother care (KMC) is an evidence-based intervention that reduces morbidity and mortality in preterm infants. However, it has not yet been fully integrated into health systems around the world. The aim of this study is to provide a cogent summary of the evidence base of the key barriers and facilitators to implementing KMC.

Methods

An umbrella review of existing reviews on KMC was adopted to identify systematic and scoping reviews that analysed data from primary studies. Electronic English databases, including PubMed, Embase, CINAHL and Cochrane Library, and three Chinese databases were searched from inception to 1 July 2022. Studies were included if they performed a review of barriers and facilitators to KMC. Quality assessment of the retrieved reviews was performed by at least two reviewers independently using the Joanna Briggs Institute (JBI) critical appraisal checklist and risk of bias was assessed with the Risk of Bias Assessment Tool for Systematic Reviews (ROBIS) tool. This umbrella review protocol was documented in the PROSPERO registry (CRD42022327994).

Results

We generated 531 studies, and after the removal of duplicates and ineligible studies, six eligible reviews were included in the analysis. The five themes identified were environmental factors, professional factors, parent/family factors, access factors, and cultural factors, and the factors under each theme were divided into barriers or facilitators depending on the specific features of a given scenario.

Conclusions

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 in KMC practice. Further research is needed to propose strategies and develop models for implementing KMC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05163-3.

Postpartum Experiences of Early Skin-to-Skin Contact and the Traditional Separation Approach After a Very Preterm Birth: A Qualitative Study Among Mothers

Traditional care immediately after very preterm birth separates the mother and child by the transfer of the infant to the neonatal intensive care unit. A nonseparation approach is currently being considered, allowing early skin-to-skin contact in the delivery room/postoperative care unit. This study aimed to explore mothers’ experiences of early skin-to-skin contact and traditional care. A qualitative study using individual semi-structured interviews with five mothers from each of the two groups was conducted. Content analysis revealed that both groups’ experiences were characterized by (i) mothers’ need to be affirmed of their infants’ vitality, (ii) bonding challenges, and (iii) benefits of skin-to-skin contact. We suggest that early skin-to-skin contact after very preterm births is crucial for the bonding process and mothers’ feelings of safety and well-being. When early skin-to-skin contact is infeasible, our findings reveal the significance of photos, information, and the father’s presence at the time of postpartum separation.

Increasing Skin-to-Skin in a Level IV NICU: A Quality Improvement Project

PURPOSE

To evaluate the effect of a bundled intervention on the number of skin-to-skin ("kangaroo care") events occurring in a level IV NICU.

DESIGN

A quality improvement effort centering around the introduction of an intervention bundle intended to safely increase the rate of skin-to-skin holding. Rates of unplanned extubations were recorded as a balancing measure to estimate safety.

SAMPLE

All infants admitted to the NICU from December 2017 through September 2019 were included. The "preintervention" period was the 6 months prior to the initiation of the intervention bundle (December 2017-May 2018).

RESULTS

The absolute number of skin-to-skin holds increased from the preintervention phase (range 7-28 holds/month, median 11 holds/month) to the postintervention phase (range 16-100 holds/month, median 55 holds/month). The total unplanned extubations showed no significant change between the preintervention and postintervention periods.

Barriers and Facilitators to Conducting Kangaroo Mother Care in Italian Neonatal Intensive Care Units

PURPOSE

This work aimed to investigate obstacles and facilitators for carrying out Kangaroo Mother Care (KMC) across Italian NICUs.

DESIGN AND METHODS

A survey that investigated Unit's characteristics, policies toward parents and KMC practice and policies was carried out. Data from 86 NICUs (80.4%) was collected. Descriptive statistics and Multiple Regression Models were computed.

RESULTS

Eighty-one NICUs provided KMC. These NICUs had a less restricted parental access policies (chi² = 7.373, p = .007). More than the 70% of the units did not have adequate facilities for parents. KMC daily length was positively predicted (R² = 0.18, F = 7.91, p = .001) by repeated sessions and documentation of KMC.

CONCLUSION

The implementation of KMC is characterized by different barriers and facilitators that determine the parent's possibility to provide KMC. Structural factors (e.g., adequate space and facilities) can support families in providing KMC. A unique result of this survey is that KMC documentation on medical records appears critical for improving its practice.

PRACTICE IMPLICATIONS

Although most of the Italian units provide KMC as a routine practice, improving its practical support would be beneficial to its implementation. A more formalized approach to KMC may strengthen staff habits to consider KMC like a standard care treatment.