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Table 2 Summary of barriers and facilitators

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

Themes

Barriers

Facilitators

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

Ë™ Inconsistent application of KMC within facilities and among HCWs

Ë™ 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

Ë™ Use of technology

Ë™ Use of KMC expert clients

Ë™ 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

Ë™ 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

Ë™ Nurses believe KMC based on perception and not scientific fact

Ë™ 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

Ë™ 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

Ë™ Nurses were more likely to perform KMC if they believed it worked

Ë™ 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

Ë™ 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

Ë™ Were expected to perform KMC with little or no instruction

Ë™ Could not see newborn during KMC

Ë™ Did not feel a bond with the infant

Ë™ Fears and discomforts with KMC practice

Isolation effect

Ë™ 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

Ë™ 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

Ë™ Mothers-in-law and grandmothers did not approve

Ë™ Family attitudes

Staffing support (support from medical staff)

Ë™ Poor support or negative interactions with medical staff

Ë™ 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

Ë™ Newborns slept longer, less anxious, happier, more willing to feed

Ë™ KMC was calming, relaxing, comforting, natural, instinctive, secure, logical, healing

Ë™ Created a family bond, inspired caregiver confidence

Ë™ Sped emotional and physical recovery of mother

Ë™ Made caregivers feel useful

Ë™ Mother-infant attachment

Ë™ 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

Ë™ Managing postpartum pains

Maternal confidence/will to practice KMC

KMC knowledge

Ability to stay with infant

Health seeking behaviour

• Support and empowerment

Family support

Ë™ 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

Ë™ Family more likely to understand and respond well if mother explained KMC

Ë™ Improved family interactions

Staffing support (support from medical staff)

Ë™ Support from staff or community health worker (CHW)

Ë™ Access to staff and training on KMC

Ë™ Receiving support from medical staff

Ë™ 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

Ë™ Return demonstration

Access Factors

• Time / Workload

Limited visitation time

Ë™ Shortage of staff nurses limited parental access and shortened visitation time

Ë™ 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

Ë™ Health-care workers has difficulty finding time for training

Caregivers unable to devote time

Ë™ Time needed to commute from home to hospital was too much

Ë™ KMC consumes time for house chores

Ë™ 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

Ë™ Lack of money for transportation, beds and kangaroo mother care wrappers

Difficulty accessing facility

Ë™ 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

Ë™ Kangaroo mother care at home allowed parents to perform other duties

Hospital delivery: prompt KMC uptake

• Financing

Lowering hospital costs to families

Ë™ Belief that KMC cut down hospital bills due to early discharge

Ë™ 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

Ë™ Bathing practices interfered

Ë™ 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

Ë™ Cultural association of infants skin rash to mother-infant skin contact

Ë™ Cultural/traditional belief of waiting for the umbilical cord to fall off before KMC started

Stigma and shame

Ë™ Mothers reported shame of having a preterm infant

Ë™ 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

Ë™ Mothers did not want father to perform KMC

Ë™ Nurse excluding father from infant care was a cultural norm

Ë™ 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