From: What influences the implementation of kangaroo mother care? An umbrella review
Themes | Barriers | Facilitators |
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Environmental Factors | • Facility conditions Lack of privacy Insufficient space and supplies Temperature Issues with clothing / infants’ medical devices Logistical issues related to implementing new practice • Resources and Materials Lack of necessary resources Lack of KMC guidelines or protocols No checklist for KMC admission procedures Lack of electronic medical records for KMC Poor management of resources donated to the hospital KMC was not budgeted for, and resources were mismanaged Facilities did not provide food for mothers • Healthcare system Visitation policies were difficult KMC training not part of a broader healthcare training curriculum Inadequate/inconsistent training Unsupportive staffing policies Poor supportive supervision and record-keeping Inconsistent application of KMC ˙ Inconsistent application of KMC within facilities and among HCWs ˙ Inconsistent knowledge and application of kangaroo mother care Follow-up and discharge procedures not well structured Many facilities reported performing continuous KMC, but few actually practiced it Receiving visitors Only low birthweight infants received kangaroo mother care in some locations | • Facility conditions Access to private space/ privacy screens Sufficient space and supplies Temperature stability KMC ward Quiet and relaxed atmosphere • Resources and Materials Access to structural resources ˙ Use of technology ˙ Use of KMC expert clients ˙ Site assessment tools Use of KMC guidelines or protocols Displayed KMC pictures/posters Reporting and data Management mobilization of resources Breast milk banks provide milk and can be an educational tool among mothers Recreation activities • Healthcare system Integration of kangaroo mother care into health-care curriculum ˙ Expanding training to other healthcare personnel besides nurses Ongoing KMC education Supportive staffing policies Supportive Supervision and dedicated registers KMC policies Follow-up at the facility-based KMC Include KMC in health facility statistics into maternal health services Integrating KMC Use of performance standards and quality improvement measures |
Professional Factors | • Professional perception Lack of belief in efficacy or importance ˙ Nurses believe KMC based on perception and not scientific fact ˙ Nurses fail to have strong belief in importance of kangaroo mother care KMC perceived not safe and causes infection and neck deformity Disagreement over clinical stability ˙ Medical stabilisation of LBWI perceived as restriction to KMC initiation Considered parents or visitors as an obstacle Concerns about other medical conditions / care Belief that KMC causes extra work Concerns about parents’ ability to practice • Professional characteristics Limited communication between HCWs Level of experience Lack of change mindset Unsupportive, loud, uncaring Inadequate knowledge Nurses not given feedback on kangaroo mother care data collected • Professional Management support Lack of leadership and management High staff and leadership turnover Management did not prioritize kangaroo mother care Management reluctance to allocate space for SSC Handoff issues with other nurses Need for high-touch support from staff | • Professional perception Believing KMC benefits ˙ Nurses were more likely to perform KMC if they believed it worked ˙ Nurses more likely to use kangaroo mother care after seeing positive effects • Professional characteristics Good communication Experience with KMC Staff acceptability and enthusiasm Nurses’ willingness to educate PLBWIs • Professional Management Leadership and management support Nurse involvement in care related decision making Multiple health worker support facilitated SSC -- nutrition workers, CHWs and clinical workers Practicing securing catheters lowered nurses’ concerns Mentorship and opportunities to share knowledge Availability of skilled KMC health workers KMC support groups facilitated KMC utilisation Management promotion of kangaroo mother care |
Parents/Family Factors | • Perception and Motivation Experienced and perceived discomforts to the parent and/or LBWI associated with KMC ˙ Discomfort / unease with the situation Were unaware of the benefits of KMC Lack of awareness of KMC Perceived newborn did not enjoy KMC KMC felt forced ˙ Were expected to perform KMC with little or no instruction ˙ Could not see newborn during KMC ˙ Did not feel a bond with the infant ˙ Fears and discomforts with KMC practice Isolation effect ˙ Mothers lonely and depressed in KMC ward Negative impressions of staff attitudes or interactions Fear / anxiety of hurting the infant Felt less of women for having LBWIs Maternal attitude towards KMC PLBWI ridiculed by the family and community • Parenting Capacity Pain / fatigue ˙ Pain hindered KMC, particularly after a C-section Mother’s medical issues / post-partum depression Low self-esteem and lack of confidence Lack of knowledge on KMC Positioning issues (including sleeping) Breastmilk expression and others BF-related issues Demographics of mother or infant • Support and empowerment Lack of family support ˙ Mothers-in-law and grandmothers did not approve ˙ Family attitudes Staffing support (support from medical staff) ˙ Poor support or negative interactions with medical staff ˙ HCWs Did not respect family privacy Disapproval from community P to perform KMCdesireeer pressure negatively influenced Lack of help with KMC practice and other obligations General lack of buy-in / low perceived value Disempowerment in decision-making | • Perception and Motivation Perceived and experienced KMC benefits ˙ Newborns slept longer, less anxious, happier, more willing to feed ˙ KMC was calming, relaxing, comforting, natural, instinctive, secure, logical, healing ˙ Created a family bond, inspired caregiver confidence ˙ Sped emotional and physical recovery of mother ˙ Made caregivers feel useful ˙ Mother-infant attachment ˙ Calming, natural, instinctive, healing for parents and infant Understanding of efficacy / benefits KMC awareness Belief that infant enjoys practice Feelings of confidence / empowerment Ease of practice / preference over traditional care Early discharge as motivator Positive attitudes toward PT survival • Parenting Capacity Health condition ˙ KMC helped mother’s recover from post-partum depression ˙ Managing postpartum pains Maternal confidence/will to practice KMC KMC knowledge Ability to stay with infant Health seeking behaviour • Support and empowerment Family support ˙ Grandmothers, sisters, others helping with chores increased uptake and duration of KMC ˙ Paternal support crucial to success of KMC, they alleviate workload, support, encourage, increase mother’s confidence ˙ Family more likely to understand and respond well if mother explained KMC ˙ Improved family interactions Staffing support (support from medical staff) ˙ Support from staff or community health worker (CHW) ˙ Access to staff and training on KMC ˙ Receiving support from medical staff ˙ Good nurse -- mother relationship Community support with KMC practice Peer support from other mothers Support from government Incorporating mothers in decision making on LBWIs’ care Empowerment in decision-making Continuous training and support ˙ Return demonstration |
Access Factors | • Time / Workload Limited visitation time ˙ Shortage of staff nurses limited parental access and shortened visitation time ˙ The shorter the visitation period was, the more of an interference staff thought parents were Actual increased workload / staff shortages Takes away time from other patients ˙ Training mothers to do SSC would take additional time out of health workers’ schedules, increase their workload, and reduce time with other critical patients ˙ Health-care workers has difficulty finding time for training Caregivers unable to devote time ˙ Time needed to commute from home to hospital was too much ˙ KMC consumes time for house chores ˙ Stresses related to extended hospitalization The season of the year (Season in which the mother delivered) • Location Other responsibilities at home or work interfered Home delivery: late/delayed KMC initiation • Financing Cost associated with travel, food, lodging, parking, clinical fees ˙ Lack of money for transportation, beds and kangaroo mother care wrappers Difficulty accessing facility ˙ Lack of transport and distance to facility | • Time / Workload Unlimited visitation hours at health facility Kangaroo mother care did not increase workload Some nurses reported that KMC did not increase the amount of time they spent on each patient Early KMC initiation • Location Parents preferred to practice KMC at home than at the facility to at tend to other responsibilities ˙ Kangaroo mother care at home allowed parents to perform other duties Hospital delivery: prompt KMC uptake • Financing Lowering hospital costs to families ˙ Belief that KMC cut down hospital bills due to early discharge ˙ Belief that kangaroo mother care was cheaper than incubator care Lower costs for health system Parents more likely to stay if services were free |
Cultural Factors | • Traditional newborn care Traditional bathing, carrying and breastfeeding practices did not always align with kangaroo mother care guidelines ˙ Bathing practices interfered ˙ Infants traditionally carried on back, thus carrying on the front seemed odd If breast feeding not pursued KMC less likely to continue Bathing practices and wrapping infants soon after birth delayed SSC Type of wrap: traditional chitenje • Traditional mindset Country or culture-specific beliefs, practices, or policies ˙ Cultural association of infants skin rash to mother-infant skin contact ˙ Cultural/traditional belief of waiting for the umbilical cord to fall off before KMC started Stigma and shame ˙ Mothers reported shame of having a preterm infant ˙ Fear, guilt doing KMC publically Considered unclean where diapers not used In warm climates staff did not believe hat and socks were necessary KMC hinders social obligations KMC considered as taboo • Gender Roles Felt KMC was role of mother Fathers lack of opportunity to practice ˙ Mothers did not want father to perform KMC ˙ Nurse excluding father from infant care was a cultural norm ˙ The males not allowed in the KMC room Lack of male involvement | • Traditional newborn care Some HCWs advised mothers to delay bathing so infant would not get cold Type of wrap: customised • Traditional mindset Country-specific beliefs or practices Mother-infant confinement • Gender Roles Gender equality Societal acceptance of paternal involvement Normalization of paternal involved in child care Male involvement |