SystematicSystematic reviews reviews

Kangaroo mother care: a systematic review of barriers and enablers Grace J Chan,a Amy S Labar,a Stephen Wallb & Rifat Atuna

Objective To investigate factors influencing the adoption of kangaroo mother care in different contexts. Methods We searched PubMed, Embase, Scopus, Web of Science and the World Health Organization’s regional databases, for studies on “kangaroo mother care” or “kangaroo care” or “skin-to-skin care” from 1 January 1960 to 19 August 2015, without language restrictions. We included programmatic reports and hand-searched references of published reviews and articles. Two independent reviewers screened articles and extracted data on carers, health system characteristics and contextual factors. We developed a conceptual model to analyse the integration of kangaroo mother care in health systems. Findings We screened 2875 studies and included 112 studies that contained qualitative data on implementation. Kangaroo mother care was applied in different ways in different contexts. The studies show that there are several barriers to implementing kangaroo mother care, including the need for time, social support, medical care and family acceptance. Barriers within health systems included organization, financing and service delivery. In the broad context, cultural norms influenced perceptions and the success of adoption. Conclusion Kangaroo mother care is a complex intervention that is behaviour driven and includes multiple elements. Success of implementation requires high user engagement and stakeholder involvement. Future research includes designing and testing models of specific interventions to improve uptake.

Introduction Methods More than 2.7 million newborns die each year, accounting for We searched PubMed, Embase, Web of Science, Scopus, Af- 44% of children dying before the age of five years worldwide. rican Index Medicus (AIM), Latin American and Caribbean Complications of are the leading cause of death Health Sciences Literature (LILACS), Index Medicus for the among newborns.1 Kangaroo mother care can include early Eastern Mediterranean Region (IMEMR), Index Medicus for and continuous skin-to-skin contact, , early the South-East Asian Region (IMSEAR) and Western Pacific discharge from the health-care facility and supportive care.2 Region Index Medicus (WPRIM) without language restric- The clinical efficacy and health benefits of kangaroo mother tions, from 1 January 1960 to 19 August 2015 using the search care have been demonstrated in multiple settings. In low terms “kangaroo mother care” or “kangaroo care” or “skin- birthweight newborns (< 2000 g) who are clinically stable, to-skin care.” We excluded studies without human subjects kangaroo mother care reduces mortality and if widely applied or without primary data collection. We screened studies for could reduce deaths in preterm newborns.3,4 However, in spite inclusion if they discussed barriers to kangaroo mother care of the evidence, country-level adoption and implementation implementation or enablers for successful implementation. of kangaroo mother care has been limited and global coverage Our population of interest included mothers, newborns or remains low. Few studies have examined the reasons for the mother-newborn dyads who had practiced kangaroo mother poor uptake of kangaroo mother care. care, and health-care providers, health facilities, communities To understand factors influencing adoption of kangaroo and health systems that have implemented such care. We hand- mother care in different contexts, we did a systematic review. searched the reference lists of published systematic reviews We created a narrative analysis of the articles and reports and references of the included articles. To search the grey identified, guided by a conceptual framework5 with five ele- literature for unpublished studies, we explored programmatic ments: (i) the problem being addressed – neonatal mortality; reports and requested data from programmes implementing (ii) the intervention or innovation aimed at addressing the kangaroo mother care. problem; (iii) the adoption system – those implementing the Two reviewers independently extracted data from iden- intervention, those benefiting from it and those affected by it; tified articles using standardized forms to identify potential (iv) the health system – organization, financing and service determinants of kangaroo mother care uptake, including data delivery; and (v) the broad context – demographic, epidemio- on knowledge, attitudes and practices. Reviewers compared logical, political, economic and sociocultural factors. These five their results to reach consensus and ties were broken by a third elements interact to influence the extent, pattern and rate of party. To assess study quality, we evaluated each study in five adoption of interventions in health systems.5 quality domains: selection bias, appropriateness of data col- lection, appropriateness of data analysis, generalizability and ethical considerations.6 A deductive approach was used to fit the outputs of the analysis to the elements of the conceptual framework and

a Department of Global Health and Population, Harvard TH Chan School of Public Health, 677 Huntington Street, Boston, Massachusetts, 02115, United States of America (USA). b Saving Newborn Lives, Save the Children, Washington, USA. Correspondence to Grace J Chan (email: [email protected]). (Submitted: 11 May 2015 – Revised version received: 17 October 2015 – Accepted: 23 October 2015 – Published online: 3 December 2015 )

130 Bull World Health Organ 2016;94:130–141J | doi: http://dx.doi.org/10.2471/BLT.15.157818 Systematic reviews Grace J Chan et al. Kangaroo mother care

7 explore emerging themes. Using the Fig. 1. Flowchart showing the selection of studies on kangaroo mother care (KMC) qualitative analytical software NVivo (QSR International, Melbourne, Aus- tralia), two researchers indexed and annotated the data through several 2846 records identified through database search: • 379 from WHO’s Regional databases rounds of coding to analyse themes, • 748 from EMBASE viewpoints, ideas and experiences. • 556 from PubMed Once major themes were established, we • 645 from Scopus constructed narratives and categorized • 518 from Web of Science the data into matrices by theme. We highlighted quotes that summarized 29 records identified through other sources multiple perspectives from the articles. Narratives and matrices were used to define specific concepts and explore 2875 records screened associations between themes. 1515 duplicates removed Themes were explored at each level of implementation (mothers, fathers and families; health-care workers; facilities). 1360 abstracts assessed for eligibility 716 records excluded: We examined the interactions between • 364 not primary data collection or analysis implementers and described health sys- • 304 KMC not individual exposure tem characteristics that could influence • 34 case series ≤ 10 participants • 8 non-human subjects the uptake of kangaroo mother care. • 6 outcomes measured unrelated to our purpose 644 full-text articles assessed for eligibility Results 532 full-text articles excluded: • 265 barriers and facilitator not discussed Of the 2875 papers identified, we in- • 117 not primary data collection or analysis cluded 112 studies with qualitative data • 92 full-text article not found • 44 KMC not individual exposure on barriers to and enablers of kangaroo 112 articles included in qualitative analysis • 7 outcomes measured unrelated to our purpose mother care (Fig. 1). Most of the stud- • 6 case series ≤ 10 participants ies were published between 2010 and • 1 duplicate publication of data 2015 (66; 59%) and had less than 50 participants (67; 60%). Nearly half of the studies were surveys or interviews (50; 45%). Forty studies (36%) were varied across locations and by individual critical for implementation in hospitals conducted in the WHO Region of the implementer. or health facilities. Their main role was Americas; 29 (26%) in WHO African The promotion of skin-to-skin to educate the parents about kangaroo Region; 64 (57%) in countries with contact for as long as possible once mother care. low neonatal mortality, defined as less the newborn was stabilized emerged We identified six major themes than 15 deaths per 1000 live births;8 48 as a common theme in several stud- concerning barriers and enablers for (43%) in urban settings; and 67 (60%) ies.33–35,84–91,116 However, there was lim- implementation of kangaroo mother at health facilities. Many studies did not ited information on the recommended care: (i) buy-in and bonding; (ii) so- include neonatal characteristics such as frequency and duration of skin-to-skin cial support; (iii) time; (iv) medical gestational age (68; 61%) or weight (75; contact and the specific criteria for stop- concerns; (v) access and (vi) context 67%; Table 1). The majority (68; 60%) ping skin-to-skin contact.31,36–38,89,92,93,117 (Table 3). of the studies appropriately addressed Implementation Buy-in and bonding at least four of the five quality domains. The complexity of kangaroo mother care Buy-in and bonding refer to the accep- Conceptual framework and lack of a standardized operational tance of kangaroo mother care, belief Problem definition makes it challenging to imple- in the benefits of such care to mothers ment. Implementation of kangaroo and preterm or low birthweight The narrative synthesis of the studies mother care can be considered at three and reported perceptions of bonding. showed that the burden of death and dis- levels: (i) mothers, fathers and families; Fear, stigma and/or anxiety about hav- ability of newborns was acknowledged (ii) health-care workers; and (iii) fa- ing a preterm impaired the care as an important problem.9–11,16–32,76–83 cilities. The location of facilities and the process. Mothers felt shame or guilt for 96,97 Intervention resources available determine whether having a preterm infant and some did kangaroo mother care takes place in the not want to keep their baby.16 The included studies revealed that health facility or at home.18,27,33 Positive perceptions of the potential kangaroo mother care is a complex Mothers, fathers and families benefits of kangaroo mother care for intervention with several possible com- were usually the primary caregivers caregivers and for newborns among ponents – skin-to-skin contact, breast- of preterm newborns and involved mothers, fathers and families promoted feeding, early discharge and follow-up in decision-making and practice of uptake. Studies used words such as re- (Table 2). The included components care.11,16,94,95,117 Health-care workers were laxed, calm, happy, natural, instinctive

Bull World Health Organ 2016;94:130–141J| doi: http://dx.doi.org/10.2471/BLT.15.157818 131 Systematic reviews Kangaroo mother care Grace J Chan et al.

Table 1. Characteristics of included studies in the systematic review on kangaroo mother care

Study characteristic No. (%) of studies (n = 112) Year 20159–15 7 (6) 2010 to 201416–75 59 (53) 2000 to 200976–115 40 (36) 1988 to 1999116–120 5 (5) No. of participants < 5010–12,14,15,17,22,24–26,28–31,33,35,36,39–41,45,47,50,52,53,55–57,59,60,63,64,67,69,72,74,77,79,80,83–87,89–97,99–103,106,108,110–112,114,115,117 66 (59) 50 to < 10013,16,20,21,27,32,37,42–44,51,66,68,71,118,120 15 (13) 100 to < 20023,46,48,54,61,65,73,78,82,88,104,105,107,109 15 (13) ≥ 2009,18,19,34,38,49,58,62,70,75,76,81,98,113,116,119 16 (14) Study type Survey or interview11–14,16,18,21,28,29,32,33,35,39–45,48–52,58,63,64,66,69,72,74,75,77,79,87,89–91,94–97,101,102,106,107,111,114,115,117 50 (45) Facilities’ evaluation24,25,27,31,34,47,53–55,57,59,60,67,80,82,83,100,108,113 19 (17) Randomized control trial9,10,37,61,68,76,99,103,105,110,112,119 12 (11) Cohort study23,56,81,92,116 5 (4) Other (chart review, case control, surveillance)15,17,19,20,22,26,30,36,38,46,62,65,70,71,78,84–86,88,98,104,109,118,120 24 (21) Pre-post73 1 (1) Interventional trial93 1 (1) WHO region Americas12,21,28,33–37,42–44,50,52,56,63,65,71–75,84–91,94,97,101,106,108,112–115,119,120 40 (36) African9–11,16,17,20,23–26,29,47,51,55,58–60,68,80–83,92,96,99,100,102,110,116 29 (26) European13–15,38–41,45,48,49,53,54,64,66,70,95,104,107,118 19 (17) South-East Asia18,19,22,30,32,67,76,77,93,98,103,109 12 (11) Eastern Mediterranean46,61,62,69 4 (3) Western Pacific31,78,105,111 4 (3) Multiple regions27,57,79 3 (3) Missing117 1 (1) Country-level neonatal mortality rate (deaths per 1000 ) < 514,15,36–45,48,49,52–54,56,63–66,70,71,82,94,95,104–108,111–113,120 36 (32) 5 to < 1512,21,28,33–35,46,50,58,59,61,62,69,74,75,84–91,97,101,114,115,119 28 (25) 15 to < 309–11,16–19,22–26,29,30,32,47,51,57–60,68,76–78,80–83,93,98–100,102,103,109,110 37 (33) ≥ 30 50, 57, 88 4 (4) Missing13,20,27,31,73,79,117 7 (6) Setting Urban17,23,28,33,35,36,38,39,41,43,44,49,50,52,56,60,61,63,65–67,72,77,78,80,81,87,89–92,96,97,100–102,105,106,108,109,111,114–120 48 (43) Urban and rural19,34,42,58,62,70,75,79,84,85,88,99,104,110,113 15 (13) Rural16,21,51,68,76,98 6 (5) Missing9–15,18,20,22,24–27,29–32,37,40,45–48,53–55,57,59,64,69,71,73,74,82,83,86,93–95,103,107,112 43 (38) Population source Health facility10,11,13,14,16,17,23–30,33–36,41,46,47,49,50,52,55–57,59–61,64,67,69–71,75,76,78–92,94,96,97,99,100,102,106,108,110,113–116,118,119 67 (60) Neonatal intensive care unit or stepdown unit12,15,22,31,37–40,42–45,48,53,54,63,65,66,72–74,93,95,103–105,107,109,111,112,117,120 32 (28) Community or population-based surveillance9,18,19,21,32,51,58,62,68,77,98,101 12 (11) Missing20 1 (1) Gestational age Preterm 34 to < 37 weeks15,16,35,50,72,84,87,97,102,114,117,118,120 13 (12) All gestational ages9,10,19,36,38,39,58,62,68,76,77,98 12 (11) Very preterm < 34 weeks40,48,63–65,70,95,101,112 9 (8) Mixed preterm and very preterm < 37 weeks33,37,89,90,94,109 6 (5) Full term ≥ 37 weeks41,49,61,71 4 (3) Missing11–14,17,18,20–32,34,42–47,51–57,59,60,66,67,69,73–75,78–83,85,86,88,91–93,96,99,100,103–108,110,111,113,115,116,119 68 (61) Birthweight Low birthweight 1500 to < 2500 g33,50,51,72,80,81,85,88,91,93,96,116,119 13 (12) All birthweights9,10,19,36,38,39,48,58,62,68,76,77,98 13 (12) Mixed low and very low birthweight < 2500 g17,23,90,92,101,109,120 7 (6) Very low birthweight < 1500 g78,89,103,105 4 (3) Missing11–16,18,20–22,24–32,34,35,37,40–47,49,52–57,59–61,63–67,69–71,73–75,79,82–84,86,87,94,95,97,99,100,102,104,106–108,110–115,117,118 75 (67) WHO: World Health Organization. Note: Inconsistencies arise in some values due to rounding.

132 Bull World Health Organ 2016;94:130–141J| doi: http://dx.doi.org/10.2471/BLT.15.157818 Systematic reviews Grace J Chan et al. Kangaroo mother care

Table 2. Descriptions of kangaroo mother care in studies included in the systematic review

Characteristic Common theme Less common theme Quotation Duration skin- As long as possible During breastfeeding “Kangaroo mother care is defined as to-skin contact 24 hours/day Less than 24 hours/day early, prolonged and continuous (or as Early/prolonged/continuous To begin immediately after birth far as circumstances permit) skin-to- 2 hours or more per day To begin 24 hours after birth skin care between the low birthweight To begin once newborn had stabilized infant and mother.”39 Extended As long as possible First month of life “Mothers were instructed to continue duration skin- As long as circumstances permit Until 24 hours after birth kangaroo position at least until the baby to-skin contact Until newborn weight of 2500 g Until 37 weeks post menstrual age reached 2500 g.”116 Breastfeeding Exclusive Kangaroo mother care integrated as “Exclusive breastfeeding wherever On demand part of a larger breastfeeding package possible and early discharge from the Breastfeeding encouraged Discharge after breastfeeding health facility when breastfeeding has Breastfeeding would begin only established been established.”88 after skin-to-skin contact had been Breastfeeding only after suturing completed for a given period of time and skin-to-skin contact had been completed Newborn Blanket cover Cap “Undressed except for a diaper and was clothing Naked Booties covered with the mother’s gown and a Diaper baby sheet.”93 Newborn Sleeping upright Upright “The baby is kept upright, close to the position Vertical against chest On adult’s chest chest of the adult.”84 Between mother’s breasts skin-to-skin On mother’s or father’s chest contact Vertical under clothes Held after being removed from Prone position incubator Against mother’s chest Prone Bathing Clean baby with damp or dry cloth Dry infant after birth “The routines included quickly drying the newborn immediately after birth and then placing it naked (skin-to-skin) on the mother’s chest.”41 Caregiver Open gown Dupatta “Held in position by using innovations clothing Wrap (cloth or blanket) Specialized kangaroo mother care bra like dupatta (stole), sports bra, loose blouse or a specially designed sling.”109 Caregiver Upright Seated in chair “Skin-to-skin contact prone or semi- position Prone Walking around upright position.”101 Inclined Early discharge Early discharge (undefined) Skin-to-skin contact encouraged before “Discharge when the mother shows Early discharge based on clinical discharge an appropriate level of infant-handling conditions Discharge after breastfeeding competency and the infant is gaining Infant weight gain, mother competency established weight.”33 in kangaroo mother care Follow-up Follow up (undefined) As part of Brazilian Ministry of Health “With a proper follow-up system in Adequate follow-up guidelines: place for regular review of the infant.”90 Within the facility at: Week 1: 3 times (home) 1−2 weeks Week 2: 2 times (home) 1–6 months Week 3: 1 time (home) 1 year Note: The quotes were concise examples of common themes found across many articles. and safe to describe the bonding pro- workers.39,42–45 In some facilities, there management and good communication cess that mothers and fathers reported was reluctance by management to allo- among the staff.24,42 during and after kangaroo mother cate dedicated space to kangaroo mother Social support care.35,39,40,94,95,98 Mothers observed their care or to rearrange staffing schedules to newborns sleeping longer during skin- allow for supervision of kangaroo mother Social support refers to assistance re- to-skin contact; infants were described care.12,16,22,25,29,36,46,82,99,122 Facility leader- ceived from other people to perform as less anxious, more restful, more will- ship had high turnover as leaders trained kangaroo mother care. While practic- ing to breastfeed and happier than when in kangaroo mother care frequently left ing kangaroo mother care, both moth- in an incubator.41,121 for better positions.25,27,29,42,47,82,99,100,123 ers and fathers did not feel supported A lack of belief in kangaroo mother On the other hand, facilities that had by their families or communities.35,96 care and limited knowledge of such care successfully implemented kangaroo Mothers experienced a lack of support restricted its uptake among health-care mother care reported support from from health-care workers. In settings

Bull World Health Organ 2016;94:130–141J| doi: http://dx.doi.org/10.2471/BLT.15.157818 133 Systematic reviews Kangaroo mother care Grace J Chan et al. like Zimbabwe, fathers voiced unease expansion of visiting hours at health Context about performing kangaroo mother facilities.104 Sociocultural context and sociocultural care because of societal norms that Medical concerns constructs of gender and roles of parents childcare should be the role of the in childcare, men in the household and mother.79,96 In contrast, among moth- Clinical conditions of the mother and/or other family members influenced up- ers, fathers and families, uptake was newborn may prevent kangaroo mother take.79,85,96 Parental and familial adher- promoted by societal acceptance of care from occurring. The medical effects ence to traditional newborn practices paternal participation in childcare, of delivery for mothers, including fa- was reported as a barrier to kangaroo by family and community acceptance tigue, depression and postpartum pain, mother care.105 Traditional practices of of kangaroo mother care and by the especially after a , early bathing and wrapping infants soon presence of engaged health-care work- can reduce uptake of kangaroo mother after birth were ingrained behaviours ers.32,48 In societies where gender roles care.48,51,52,77,98 Particularly for very pre- in many cultures that were difficult to were more equal (e.g. Scandinavian term or unstable infants, concern about change, even after training.16,58 In areas countries), there were fewer barriers potential adverse consequences, such as in which carrying the baby on the back to fathers performing kangaroo mother fear of dislocation of intravenous lines, was common, it seemed strange to care.48,49 Paternal involvement played a was an obstacle to kangaroo mother place the baby on the front.23 In some large role in uptake – either by division care.38,53,54 Knowledge that kangaroo contexts, it was considered unclean to of labour or by helping the mother feel mother care supported newborns in sta- have the mother carry the baby on her comfortable. In Brazil, mothers were bilizing their temperatures, helped with chest without a diaper.79 grateful to have someone help them breathing and promoted mother–child Please refer to the supplementary during kangaroo mother care, such as bonding, encouraged its use.118 Table 4 (available at: http://www.who. grandmothers and sisters, who could Access int/volumes/94/2/15-157818) for full take care of housework and help with details of the included studies. the newborn.101 Within the maternity While parents believed that kanga- ward, peer support from other mothers roo mother care was less costly than Discussion through sharing their kangaroo mother incubator care,96 lack of money for care experiences also helped promote transportation and the distance to hos- The core components of kangaroo acceptance.79,102 pital were often reported as the biggest mother care are skin-to-skin contact When institutional leadership did challenges55,81,82,105 as were low resources and feeding support. Additional features not prioritize kangaroo mother care, for newborn-care services.82 Lack of such as the frequency and location of health-care workers were less moti- private space for mothers to perform early-discharge and follow-up depend vated to practice or teach it,42,44 but felt kangaroo mother care and to remain on the context.57,98 Multiple factors in- empowered to do so when management in the hospital with the newborn hin- fluence the uptake of kangaroo mother allowed for roles in decision-making, dered its uptake,24,25 as did allocation care. To support the implementation of promoted kangaroo mother care or of resources intended for kangaroo kangaroo mother care, context-specific mobilized resources for it.24 Staffing mother care to other programmes.24 materials such as guidelines, behaviour shortages and staff turnover created Uptake improved with transportation change materials, training curriculums, barriers to implementation of kanga- for mothers not staying at the hospital, and job aids are needed. Simple inter- roo mother care within a facility.42 By wrappers to hold the baby, furniture/ ventions are more likely to be general- contrast, effective coordination of and beds where mothers could conduct izable to a range of different contexts.5 communication between staff helped kangaroo mother care, rooms where When designing kangaroo mother care facilitate implementation.82 mothers could spend the night with the interventions, contextual factors and 24,48 Time baby, private spaces and dedicated sociocultural norms need to be taken resources.40,106 into account. The time needed to provide kangaroo Without uniform knowledge and The stresses and stigma associated mother care was a potential barrier for protocols within a facility, health-care with having a preterm infant can hinder mothers, fathers and families, due to workers were uncomfortable promot- buy-in and support from parents and responsibilities at home and work and ing kangaroo mother care.16,27,42,99,107 families for practicing kangaroo mother time needed for commuting, preventing In-service training82,100 of health-care care. This problem is compounded by them from devoting the time needed workers enhanced kangaroo mother a lack of knowledge about kangaroo for continuous and extended kangaroo care implementation.56 Virtual com- mother care among parents, families and mother care.16,39,41,50,79,91,102 Conversely, munication and training, often within health-care workers. Clear articulation practice of such care at home promoted facilities, allowed more nurses to be of the benefits of kangaroo mother care its uptake.92 High workload of health- trained in kangaroo mother care despite for mothers and for newborns, creation care workers did not allow sufficient busy schedules and staffing shortages.36 of a community among parents, caregiv- time to dedicate to teaching kangaroo Expanding training to other health-care ers and health-care workers and engage- mother care, which further increased personnel, such as administrators and ment of fathers in childcare can help workload, especially in facilities with interns, also enabled care. Many nurses overcome these barriers. Collaboration staffing shortages.78,79,103 reported that integration of kangaroo among health-care workers, with shared One study showed that uptake of mother care into pre-service and train- goals and team commitments, partner- kangaroo mother care increased with ing curricula was beneficial.36,57 ing inexperienced nurses with nurses

134 Bull World Health Organ 2016;94:130–141J| doi: http://dx.doi.org/10.2471/BLT.15.157818 Systematic reviews Grace J Chan et al. Kangaroo mother care Context, cultural norms Context, Reporting and data of data Collection of performanceUse and standards measures quality improvement tools assessment Site skin- document to of use data Lack to-skin contact practised on electronic medical record on feedback Nurses not given collected data kangaroo mother care policies sometimes Visitation performing mothers from prevented skin-to-skin contact continuously. way. get in the found visitors Staff Mother preferred kangaroo mother Mother preferred confidence inspired incubator, to care Gender equality carrying bathing, and Traditional, practices did not always breastfeeding with kangaroo mother care align guidelines None interfered protocols Traditional carrying)(bathing, infant from father Nurse excluding norm a cultural was care Health systems access systems Health resources structural to Access within facilities allows Quiet atmosphere rest mothers to milk and can be an milk banks provide Breast among mothers tool educational of moneythe facility mother’s Lack at for transportation mothers without the hospital for to Distance transportation hospital-provided and privacy do of space Lack mothers to for kangaroo mother care transportation, of money Lack for beds and wrappers kangaroo mother care to donated of resources management Poor the hospital costs Associated Transport Virtual and training. communication into of kangaroo mother care Integration health-care curriculum training Difficulty for finding time training Inadequate/inconsistent Belief that kangaroo mother care was was Belief kangaroo that mother care care cheaper than incubator Medical concerns encouraged throughout throughout encouraged the hospital clinical over Disagreement stability did not provide Facilities mothers for food birthweight Only low kangaroo received infants in some mother care locations Maternal fatigue and pain fatigue Maternal stability. Temperature Experienced nurses comfortable with more kangaroo mother care Nurses did not feel kangaroo mother care infants for appropriate too were who they felt small/young/ill space private to Access including family rooms or privacy Higher screen. rates milk feeding breast when breast discharge at and allowed was feeding Helped mothers recover Helped mothers recover emotionally Access There was limited limited was There time due to visitation staff shortages Caregivers were unable were Caregivers time devote to Mothers lonely in kangaroo mother care ward Kangaroo mother did not increase care workload Extra workload time from away Takes other patients visitation Unlimited preferred Kangaroo mother home allowed at care perform to parents other duties Adoption systems Adoption Social support Staffing shortages,Staffing high staff and leadership turnover changing resisted Staff protocols Fear, guilt, discomfort guilt, of Fear, participatefamily members to kangaroo or condone mother in public care Privacy of Management promotion kangaroo mother care and other Role of parents health-care workers Management did not kangarooprioritize mother care serve could as a Parents health-care to hindrance worker Staffing support Good communication to of committees Use kangaroo mother for advocate care Father, health-care worker, health-care worker, Father, family and community support mothers and for success crucial to was fathers of kangaroo mother care Buy-in and bonding Leadership lack of buy-in Leadership lack of adequate led to resources Stigma, shame, kangaroo shame, Stigma, forced felt mother care likely to Nurses more use kangaroo mother after seeing positive care effects. Support more from experienced nurses buy-in improved strong have Nurses fail to belief in importance of kangaroo mother care knowledgeInconsistent of and application kangaroo mother care Leadership Management support Calming, natural, natural, Calming, healing for instinctive, and infant parents - Summary of kangaroo mother care implementation of enablers and barriers to

Table 3. Table Barriers Barriers Health-care workers Enablers Barriers Facilities Enablers Level of imple Level mentation Parents Enablers

Bull World Health Organ 2016;94:130–141J| doi: http://dx.doi.org/10.2471/BLT.15.157818 135 Systematic reviews Kangaroo mother care Grace J Chan et al.

experienced in kangaroo mother care mother care, especially through policies Kangaroo mother care should can also help.42,106,108 like maternity and paternity leave.42,107 be practiced more systematically and There are substantial barriers to At the national level, kangaroo mother consistently to enhance adoption25 and kangaroo mother care within health care should be integrated with essential to build trust, with motivated trained systems, especially financing and service newborn, maternal and child health staff, education of staff and parents, delivery. Dedicated financing for kan- guidelines, with appropriate monitoring clear eligibility criteria, improved garoo mother care is critical for it to be and evaluation.57 referral practices and creation of com- seriously considered and implemented. We may not have captured all the munities among kangaroo mother care Funding should consider creation of programmatic reports and data avail- participants through support groups. suitable environments (beds, wraps, able. In particular, most of the studies By addressing barriers and by build- chairs and private spaces), reducing bur- included in our review were published ing trust, effective uptake of kangaroo den of transport costs to mothers, home from regions with low neonatal mortal- mother care into the health system will visits by community health workers and ity. This limits the generalizability of our increase and this will help to improve training parents to perform kangaroo findings. neonatal survival. mother care as independently as pos- KMC: kangaroo mother care. ■ sible. Financing should be augmented Conclusion with policies, guidelines, role defini- Acknowledgements tions (to enable health-care workers to Prolonged skin-to-skin care demands Funding was provided by the Saving allocate protected time for kangaroo time and energy from mothers recov- Newborn Lives program of Save the mother care), education (in service and ering from labour and carers who may Children Federation, Inc. We thank pre-service) and monitoring systems have other obligations. Many women Ellen Boundy, Roya Dastjerdi, Sandhya that are suitably tailored for different are not aware of kangaroo mother care; Kajeepeta, Stacie Constantian, Tobi settings (including in the community). health workers have not been trained Skotnes, and Ilana Bergelson for review- Logistic issues, such as time for or, if trained, do not promote such ing and abstracting data. Rodrigo Ku- travel and kangaroo mother care, can care. Kangaroo mother care may not romoto and Eduardo Toledo reviewed be challenging but could be partly be socially acceptable or even conflict non-English articles. We acknowledge overcome by incorporating targeted with traditional customs. There is lack of Kate Lobner for developing and running assistance and support and extension standardization on who should receive the search strategy. of visiting times. Buy-in from policy- kangaroo mother care and the presence makers is critical to promote kangaroo of admissions criteria in neonatal units. Competing interests: None declared.

ملخص رعاية األم لوليدها عىل طريقة الكنغر: مراجعة منهجية للعوائق والعوامل املساعدة بتضمني 112 دراسة اشتملت عىل بيانات نوعية حول التنفيذ. اهلدفالنظر يف العوامل التي تؤثر عىل تبني طريقة رعاية األمهات كانت رعاية األم لوليدها عىل طريقة الكنغر قد تم تطبيقها بطرق ملواليدهن عىل طريقة الكنغر يف سياقات خمتلفة. خمتلفة يف سياقات خمتلفة. وتكشف الدراسات عن وجود العديد الطريقةلقد بحثنا يف قواعد بيانات PubMed و Embase من العوائق يف طريق تطبيق رعاية األم لوليدها عىل طريقة الكنغر، و Scopus و Web of Science وقواعد البيانات اإلقليمية من بينها احلاجة إىل الوقت، والدعم االجتامعي، والرعاية الصحية، التابعة ملنظمة الصحة العاملية إلجياد دراسات حول “رعاية األم وتقبل الرعاية من جانب األرسة. ومن بني العوائق الكامنة يف لوليدها عىل طريقة الكنغر” أو “الرعاية عىل طريقة الكنغر” ” “ النظم الصحية كانت هناك النواحي التنظيمية، والتمويل، وتقديم أو رعاية الوليد بمالمسة برشة األم ًبدءا من 1 يناير/كانون اخلدمة. ويف السياق األعم، أثرت املعايري الثقافية عىل التصورات الثاين 1960 وحتى 19 أغسطس/آب 2015 من دون القيود املحيطة هبذا النوع من الرعاية ومدى نجاح تطبيقه. اللغوية. وقمنا بتضمني التقارير الصادرة عن الربامج ومراجع االستنتاج متثل رعاية األم لوليدها عىل طريقة الكنغر وسيلة معقدة املقاالت واملراجعات التي تم إجراء البحث بشأهنا بشكل يدوي. للتدخل تعتمد عىل السلوك، وتتضمن عدة عنارص. وحيتاج نجاح ثمقام اثنان من املراجعني املستقلني بتصفح املقاالت واستخالص تطبيقها إىل مشاركة كبرية من جانب املستفيدين ًفضال عن إدراج البيانات حول مقدمي الرعاية، وخصائص النظام الصحي، جهود اجلهات املعنية. وتتضمن البحوث املستقبلية نامذج لتصميم والعوامل السياقية. كام قمنا بوضع نموذج تصوري لتحليل عملية واختبار عمليات تدخل حمددة بغرض زيادة تبني هذا النوع من إدماج رعاية األم لوليدها عىل طريقة الكنغر يف األنظمة الصحية. الرعاية. النتائج قمنا بفحص دراسات بلغ عددها 2875 دراسة، كام قمنا

摘要 袋鼠妈妈式护理：障碍和促进因素的系统评价 目的 旨在调查不同环境下采用袋鼠妈妈式护理的影响 找 1960 年 1 月 1 日到 2015 年 8 月 19 日期间关于“袋 因素。 鼠妈妈式护理”或“袋鼠式护理”或“肌肤接触护理” 方法 我们搜索了 PubMed、Embase、Scopus、 的研究。我们包括了项目报告以及手工检索到已发表 Web of Science 以及世界卫生组织的区域数据库，以查 的评论与文章等参考资料。两个独立的评论员分别筛

136 Bull World Health Organ 2016;94:130–141J| doi: http://dx.doi.org/10.2471/BLT.15.157818 Systematic reviews Grace J Chan et al. Kangaroo mother care

选出关于护理人员、卫生系统特征和环境因素的文章 资和提供服务。在大环境中，文化规范影响人们对采 并提取了数据。我们开发了一个概念模型，以分析袋 用该护理方式的看法和成功率。 鼠妈妈式护理在卫生系统中的整合。 结论 袋鼠妈妈式护理是一种复杂的干预措施，受行为 结果 我们筛选出 2875 项研究，其中 112 项研究中包 驱动且涵盖多种因素。 成功的实施要求用户的高度参 含实施方面的定性数据。 袋鼠妈妈式护理以各种方式 与以及其他利益相关者的参与。未来的研究包括具体 应用于不同的环境中。该研究表明实施袋鼠妈妈式护 干预措施的设计和测试模型，以提高该护理方式的接 理存在几个障碍，包括需要时间、社会支持、医疗护 受率。 理和家庭的接受。卫生系统内部的障碍包括组织、筹

Résumé La méthode «mère kangourou»: examen systématique des obstacles et des aides Objectif Étudier les facteurs qui influencent l’adoption de la méthode of Science et les bases de données régionales de l’Organisation mondiale de la mère «kangourou» dans différents contextes. de la Santé des études sur la méthode de la mère «kangourou», les Méthodes Nous avons recherché dans PubMed, Embase, Scopus, Web soins «kangourou» ou les soins peau contre peau du 1er janvier 1960 au 19 août 2015, sans restrictions de langues. Nous avons inclus des rapports du temps et un soutien social, et suppose des soins médicaux et une programmatiques et des références, recherchées manuellement, acceptation par les familles. Les obstacles inhérents aux systèmes de d’études et d’articles publiés. Deux réviseurs indépendants ont examiné santé résidaient notamment dans l’organisation, le financement et les articles et extrait des données sur les aidants, les caractéristiques la prestation de services. Dans l’ensemble, les normes culturelles ont des systèmes de santé et les facteurs contextuels. Nous avons élaboré influencé les perceptions et le succès de l’adoption de cette méthode. un modèle conceptuel pour analyser l’intégration de la méthode de la Conclusion La méthode de la mère «kangourou» est une intervention mère «kangourou» dans les systèmes de santé. complexe axée sur le comportement qui inclut de multiples éléments. Le Résultats Nous avons examiné 2875 études et inclus 112 études succès de sa mise en œuvre exige un engagement fort des utilisateurs et contenant des données qualitatives sur la mise en œuvre. La méthode une mobilisation des parties intéressées. De futurs travaux de recherche de la mère «kangourou» a été appliquée de différentes façons selon incluent la conception et l’essai de modèles d’interventions spécifiques les contextes. Les études démontrent qu’il existe plusieurs obstacles à pour favoriser l’adoption de cette méthode. la mise en œuvre de la méthode de la mère «kangourou»: elle requiert

Резюме Метод «кенгуру»: систематический обзор барьеров и способствующих факторов Цель Изучить факторы, влияющие на применение метода контекстах способы осуществления ухода по методу «кенгуру» «кенгуру» в различных контекстах. были различными. Исследования показали, что существует Методы Нами был проведен поиск по базам данных PubMed, несколько препятствий на пути осуществления ухода методом Embase, Scopus, Web of Science, а также по региональным базам «кенгуру», включая потребность во времени, социальной данных Всемирной организации здравоохранения; целью поиска поддержке, медицинском уходе, а также в принятии со стороны были исследования по теме «метод “кенгуру”», или «принцип семьи. Препятствия со стороны системы здравоохранения “кенгуру”», или «метод телесного контакта» в период с 1 января включают организационные аспекты, финансирование и 1960 г. по 19 августа 2015 г. без ограничений по языку. Мы предоставление услуг. В широком контексте культурные нормы включили в рассмотрение отчеты о программах и найденные оказывали влияние на восприятие и успех осуществления метода. вручную ссылки на опубликованные обзоры и статьи. Два Вывод Уход по методу «кенгуру» представляет собой комплексное независимых эксперта просматривали статьи и извлекали из вмешательство, в основе которого лежат поведенческие них данные о лицах, осуществляющих уход, о характеристиках факторы и которое включает множество элементов. Для систем здравоохранения и факторах, определяющих контекст. успешного осуществления необходима высокая степень Мы разработали концептуальную модель для анализа интеграции заинтересованности участников, а также привлечение партнеров. метода «кенгуру» в системы здравоохранения. В будущих исследованиях планируется уделить время разработке Результаты Мы проверили 2875 исследований и включили в и тестированию моделей конкретных вмешательств с целью обзор 112 исследований, которые содержали количественные улучшения усвоения метода. данные, касающиеся осуществления метода. В различных

Resumen El método madre canguro: una revisión sistemática de barreras y facilitadores Objetivo Investigar los factores que influencian la adopción del método 19 de agosto de 2015, sin limitación de idiomas. Se incluyeron informes madre canguro en diferentes contextos. sistemáticos y búsquedas manuales de referencias de revisiones Métodos Se realizaron búsquedas en las bases de datos PubMed, y artículos publicados. Dos revisores independientes revisaron los Embase, Scopus, Web of Science y la Organización Mundial de la Salud artículos y extrajeron datos sobre los cuidadores, las características del sobre estudios relacionados con el “método madre canguro”, “cuidado sistema sanitario y los factores contextuales. Se desarrolló un modelo canguro” o “contacto directo de la piel” desde el 1 de enero de 1960 al conceptual para analizar la integración del método madre canguro en

Bull World Health Organ 2016;94:130–141J| doi: http://dx.doi.org/10.2471/BLT.15.157818 137 Systematic reviews Kangaroo mother care Grace J Chan et al. los sistemas sanitarios. y el suministro de servicios. En el contexto general, las normas culturales Resultados Se revisaron 2 875 estudios y se incluyeron 112 estudios influenciaron las percepciones y el éxito de la adopción. que contenían datos cualitativos sobre la implementación. El método Conclusión El método madre canguro es una intervención compleja madre canguro se aplicó de formas diferentes en contextos diferentes. impulsada por el comportamiento e incluye múltiples elementos. El Los estudios muestran que existen diversas barreras a la hora de éxito de la implementación requiere una participación elevada del implementar el método madre canguro, incluyendo la necesidad de usuario y la involucración del interesado. Las futuras investigaciones tiempo, apoyo social, asistencia médica y aceptación familiar. Las barreras incluyen diseñar y probar modelos de intervenciones específicas para dentro de los sistemas sanitarios incluían la organización, la financiación mejorar la aceptación.

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Bull World Health Organ 2016;94:130–141J| doi: http://dx.doi.org/10.2471/BLT.15.157818 141 Systematic reviews Grace J Chan et al. Kangaroo mother care . .) a X X X – – – – – – – – – – and Policies Policies guidelines ( continues X X X X X X X X – – – – – Facilities X X X X X X X X X – – – – care Health- workers Barriers and facilitators - a X X X X X X X X X X – – X Care givers N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Days roo mother careroo 5–6 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Hours Hours Provision of kanga - Provision per day per day care Onset of skin-to-skin N/A N/A N/A after Immediately birth N/A N/A N/A N/A N/A N/A Once eligible: N/A eligible: Once definition N/A Once eligible: N/A eligible: Once definition Kangaroo mother care components Skin-to-skin care Skin-to-skin care Skin-to-skin care Skin-to-skin exclusive care, breastfeeding, N/A N/A N/A N/A N/A N/A N/A Skin-to-skin care N/A 2000

teristics Newborn charac - Newborn N/A N/A birthweight; Low N/A cut-off N/A N/A N/A N/A N/A N/A N/A Premature, Premature, ≥ g All ages Premature; N/A Premature; cut-off Sample size 11 facilities 30 parents 13 mothers 23 9 mothers, health-care workers 38 facilities 2 facilities 10 facilities 36 facilities 38 facilities (out 4 regions of 10) 14 facilities 1052 mothers 33 dyads Study design Facility Facility focus evaluation, group/interview group/ Focus interview group/ Focus interview group/ Focus interview Facility evaluation Facility evaluation Facility evaluation Randomized trial controlled based Pop surveillance, facility evaluation Facility evaluation Facility evaluation Pop based Pop surveillance, facility evaluation Chart review, Chart review, group/ focus interview urban Rural or Mixed Urban Urban Rural N/A Urban Urban Mixed N/A N/A N/A Mixed Mixed Country Uganda Brazil Brazil Ghana Ghana South Africa Indonesia South Africa Ghana Ghana Malawi Egypt Brazil

59 67 99 26 83 25 84 Description of studies included in the systematic review on kangaroo mother care review Description of studies included in the systematic

62 29 33 28 51 100 Table 4. Table Author, year Author, Abul-Fadl, 2012 Aliganyira, 2014 2009 Bergh, Arivabene, Arivabene, 2010 Bazzano, Bazzano, 2012 2013 Bergh, Bergh, 2003 2008 Bergh, 2012 Bergh, 2012 Bergh, Alves, 2007 Alves, 2012 Bergh, de Araújo, de Araújo, 2010

Bull World Health Organ 2016;94:130–141I| doi: http://dx.doi.org/10.2471/BLT.15.157818 141A Systematic reviews Kangaroo mother care Grace J Chan et al.

. .) X X X X – – – – – – – – and Policies Policies guidelines ( continues X X X X X X X X X X – – Facilities X X X X X X X X X – – – care Health- workers Barriers and facilitators - X X X X X X X X X X X X Care givers 1 10 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Days 1 1 roo mother careroo N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Hours Hours Provision of kanga - Provision per day per day care Onset of skin-to-skin Once eligible: N/A eligible: Once definition N/A N/A eligible: Once definition N/A N/A N/A N/A N/A N/A N/A after Immediately birth after Immediately birth Kangaroo mother care components N/A Skin-to-skin exclusive care, breastfeeding, discharge, follow-up Skin-to-skin care Skin-to-skin exclusive care, breastfeeding, discharge, follow-up N/A N/A N/A Skin-to-skin care Skin-to-skin care Skin-to-skin exclusive care, breastfeeding Skin-to-skin care Skin-to-skin discharge, care, follow-up teristics 2000 g 2000 g 1501 g

Newborn charac - Newborn N/A N/A N/A N/A N/A 28–33 weeks, 740–2920 g All ages N/A term Full < < < Sample size 7 facilities 6 facilities 7 facilities 11 facilities 39 facilities 272 newborns 1 facility 74 76 mothers, fathers 23 dyads 126 dyads 40 nurses and health-care workers 117 mothers, 107 fathers Study design Facility Facility evaluation Facility evaluation Facility evaluation Facility evaluation Facility Focus evaluation, group/interview Prospective cohort Facility evaluation group/ Focus interview group/ Focus interview Randomized trial controlled group/ Focus interview group/ Focus interview urban Rural or N/A N/A N/A N/A Urban Urban Urban N/A Urban Urban N/A Urban Country Mali Malawi Rwanda Uganda Mali,Malawi, Rwanda, and Uganda Malawi Malawi Sweden Sweden Malaysia Egypt Sweden, Norway ) 55 82 47 24 27 49 105 81 80 48 39 69 Author, year Author, 2012 Bergh, Brimdyr, Brimdyr, 2012 Blencowe, Blencowe, 2005 Blomqvist, 2013 Bergh, 2007 Bergh, 2012 Bergh, 2012 Bergh, 2014 Bergh, Blencowe, 2009 Blomqvist, 2011 2007 Boo, 2010 Calais, (. . continued

141B Bull World Health Organ 2016;94:130–141I| doi: http://dx.doi.org/10.2471/BLT.15.157818 Systematic reviews Grace J Chan et al. Kangaroo mother care

. .) X X X – – – – – – – – – – – – – and Policies Policies guidelines ( continues X X X X X X X X X X X – – – – – Facilities X X X X X X X X X X – – – – – – care Health- workers Barriers and facilitators - X X X X X X X X X X X X X X – – Care givers 1 38 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Days roo mother careroo N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Hours Hours Provision of kanga - Provision per day per day care 2 mins after birth

Onset of skin-to-skin N/A N/A Immediately after Immediately birth N/A N/A N/A eligible: Once definition N/A N/A after Immediately birth N/A N/A N/A N/A N/A N/A ≤ Kangaroo mother care components N/A N/A Skin-to-skin discharge, care, follow-up Skin-to-skin care N/A N/A Skin-to-skin care Skin-to-skin care N/A Skin-to-skin care Skin-to-skin care N/A Skin-to-skin care N/A N/A Skin-to-skin care teristics 36 weeks, 2320 g 36 weeks,

Newborn charac - Newborn N/A N/A N/A N/A birthweight; Low N/A cut-off N/A term Full N/A term Full All ages N/A N/A Premature; cut-off N/A N/A Premature; cut-off N/A < Sample size 537 facilities 8 mothers 17 kangaroo mother care co-ordinators, 15 facilities 34 nurses 113 mothers 28 facilities 48 nurses and 101 parents 261 dyads 145 HCPs 20 mothers 2063 mothers 109 facilities 1 mother 1 facility 9 mothers 14 15 mothers, nurses Study design Facility Facility evaluation Focus group/ group/ Focus interview group/ Focus interview group/ Focus interview group/ Focus interview sectional Cross Pre-post Descriptive sectional Cross group/ Focus interview Intervention based Pop surveillance group/ Focus interview Facility evaluation group/ Focus interview group/ Focus interview urban Rural or Urban Mixed Urban Urban Mixed Mixed N/A Mixed Urban Rural Mixed Urban Urban Urban Mixed Urban Country Colombia 15 developing countries Australia Malawi Brazil States United of America States United of America India Sweden, Norway India Italy Brazil States United of America Brazil States United of America States United of America ) 50 30 111 79 11 85 73 71 41 98 104 97 108 114 113 52 Author, year Author, Castiblanco 2011 López, Dalal, 2014 Dalal, Charpak, 2006 Ferrarello, Ferrarello, 2014 Chia, 2006 Chia, Chisenga, 2015 Colameo, 2006 Cooper, 2014 Crenshaw, 2012 Dalbye, 2011 Darmstadt, 2006 De Vonderweid, 2003 Eichel, 2001 Eleutério, 2008 Engler, 2002 Duarte, 2001 (. . continued

Bull World Health Organ 2016;94:130–141I| doi: http://dx.doi.org/10.2471/BLT.15.157818 141C Systematic reviews Kangaroo mother care Grace J Chan et al.

. .) X X X – – – – – – – – – – – and Policies Policies guidelines ( continues X X X X X X X – – – – – – – Facilities X X X X X X X – – – – – – – care Health- workers Barriers and facilitators - X X X X X X X X X X X – – – Care givers 1 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Days 3 10; roo mother careroo N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A mean Hours Hours Provision of kanga - Provision per day per day care Onset of skin-to-skin N/A N/A N/A N/A N/A N/A eligible: Once definition N/A eligible: Once definition N/A one hour after Within birth N/A N/A stable Clinical N/A N/A Kangaroo mother care components Skin-to-skin care Skin-to-skin care N/A N/A N/A Skin-to-skin care Skin-to-skin exclusive care, breastfeeding N/A Skin-to-skin exclusive care, breastfeeding Skin-to-skin care Skin-to-skin care N/A N/A Skin-to-skin care teristics 27 weeks 27 weeks 34 weeks

Newborn charac - Newborn N/A N/A N/A Premature; cut-off N/A N/A All ages N/A N/A birthweight; Low N/A cut-off N/A All ages < < < Sample size 62 health-care workers 22 newborns 10 parents 293 facilities 293 facilities 32 mothers 30 mothers 6 7 mothers, fathers 59 nurses 143 mothers, 42 health-care workers 30 nurses 148 doctors 11 and nurses, facilities 6 nurses and 51 clinicians 635 mothers, 14 villages Study design Focus group/ group/ Focus interview Prospective cohort, descriptive group/ Focus interview Facility evaluation group/ Focus interview group/ Focus interview Intervention, qualitative group/ Focus interview group/ Focus interview group/ Focus interview Prospective cohort sectional Cross group/ Focus interview group/ Focus interview urban Rural or Urban N/A Urban Mixed Mixed Urban Urban N/A Urban Urban Urban Mixed Urban Mixed Country Ireland Brazil Brazil Brazil Brazil States United of America States United of America Sweden States United of America States United of America States United of America Brazil England Ghana ) 63 86 87 66 58 34 75 36 40 44 65 56 88 13 Author, year Author, 2010 Flynn, Haxton, 2012 Hendricks- Muñoz, 2010 Hendricks- Muñoz, 2014 Freitas, 2007 Freitas, 2003 Furlan, Gontijo, 2010 Gontijo, 2012 2013 Gonya, Heinemann, 2013 Hennig, 2006 Higman, 2015 2010 Hill, Hendricks- Muñoz, 2013 (. . continued

141D Bull World Health Organ 2016;94:130–141I| doi: http://dx.doi.org/10.2471/BLT.15.157818 Systematic reviews Grace J Chan et al. Kangaroo mother care

. .) – – – – – – – – – – – – and Policies Policies guidelines ( continues X X X – – – – – – – – – Facilities X X X X X X – – – – – – care Health- workers Barriers and facilitators - X X X X X X X X X X X – Care givers 1 2 1 N/A N/A N/A N/A N/A N/A N/A N/A N/A Days 1

3 12 0.5 ≤ roo mother careroo N/A N/A N/A N/A N/A N/A N/A 0.83 Hours Hours Provision of kanga - Provision per day per day care 15 minute before before 15 minute hours after

Onset of skin-to-skin Once eligible: N/A eligible: Once definition N/A enrolment After N/A N/A heel before 30 minute stick N/A N/A N/A N/A ≥ heel lance 2 caesarean Kangaroo mother care components Skin-to-skin care N/A Skin-to-skin care N/A Skin-to-skin care N/A Skin-to-skin care Skin-to-skin care Skin-to-skin care Skin-to-skin care Skin-to-skin care N/A teristics g

Newborn charac - Newborn N/A 1200–1999 g N/A 28–36 weeks birthweight: Low N/A cut-off term Full 30–32 weeks N/A N/A N/A Premature: cut-off 1000– 24–35 weeks N/A Premature: cut-off 1800 Sample size 121 participants 13 newborns, 11 mothers and female relatives 17 nurses 62 newborns N/A mothers 160 dyads 10 newborns 18 nurses 69 health-care 11 providers, facilities 61 dyads 12 families 6 parents Study design Focus group/ group/ Focus interview Crossover group/ Focus interview Randomized trial controlled crossover group/ Focus interview Randomized trial controlled Randomized trial controlled crossover group/ Focus interview group/ Focus interview Randomized controlled pre-post, trial, crossover group/ Focus interview group/ Focus interview urban Rural or Rural Urban Peri- urban/ slum N/A Urban Urban N/A N/A Mixed Urban N/A Urban Country Bangladesh Nigeria States United of America Canada Zimbabwe Islamic Republic of Iran States United of America Sweden, Norway, Denmark States United of America Canada Sweden South Africa ) 45 42 92 32 106 37 96 61 112 120 64 102 Author, year Author, Hunter, 2014 Johnson, 2007 Kymre, 2013 Kymre, Kambarami, 2002 Lemmen, Lemmen, 2013 Ibe, 2004 Johnston, 2011 Keshavarz, 2010 2012 Lee, Legault, 1995 Leonard, 2008 Kostandy, Kostandy, 2008 (. . continued

Bull World Health Organ 2016;94:130–141I| doi: http://dx.doi.org/10.2471/BLT.15.157818 141E Systematic reviews Kangaroo mother care Grace J Chan et al.

. .) – – – – – – – – – and Policies Policies guidelines ( continues X X – – – – – – – Facilities X X X X X – – – – care Health- workers Barriers and facilitators - X X X X X X X X – Care givers N/A N/A N/A N/A N/A N/A N/A N/A N/A Days 20

roo mother careroo N/A N/A N/A N/A N/A N/A N/A N/A > Hours Hours Provision of kanga - Provision per day per day care Onset of skin-to-skin Stabilized health Stabilized presence condition, of a sucking reflex, thermoregulation, condition mother’s enabling her to the low for care birthweight infant, of the cessation IV need for infant’s oxygen, therapy, or photo-therapy NG tube by feeding N/A N/A eligible: Once definition N/A 18 out of 19 within 24 hour postpartum for infant stable preterm N/A N/A N/A N/A Kangaroo mother care components Skin-to-skin exclusive care, breastfeeding, discharge, follow-up Skin-to-skin care Skin-to-skin care Skin-to-skin care Skin-to-skin care N/A N/A N/A N/A g g

teristics 2000 g 1500 2000 27 weeks

Newborn charac - Newborn N/A N/A N/A 30–32 weeks, All newborns N/A < < < < Sample size 246 newborns 19 facilities 121 doctors and paramedical staff 5 mothers 109 newborns 8 mothers 129 nurses 520 newborns 292 midwives Study design Prospective Prospective cohort Facility evaluation group/ Focus interview group/ Focus interview Chart review, facility evaluation group/ Focus interview Survey based Pop surveillance Questionnaire urban Rural or Urban N/A N/A Urban Urban Urban Urban Mixed Urban Country Mozambique Denmark France Brazil New Papua Guinea Brazil Sweden Sweden Islamic Republic of Iran ) 116 53 107 115 78 101 15 70 46 Author, year Author, Lincetto, 1998 Maastrup, Maastrup, 2012 Moreira, Moreira, 2009 Mörelius, 2015 Nahidi, 2014 Mallet, 2007 Martins, 2008 McMaster, 2000 Mörelius, 2012 (. . continued

141F Bull World Health Organ 2016;94:130–141I| doi: http://dx.doi.org/10.2471/BLT.15.157818 Systematic reviews Grace J Chan et al. Kangaroo mother care

. .) X X – – – – – – – – – – – and Policies Policies guidelines ( continues X X X X X X X – – – – – – Facilities X X X X X X X X – – – – – care Health- workers Barriers and facilitators - X X X X X X X X X X X – – Care givers 2 2 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Days 4

1 2 ≥ roo mother careroo N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Hours Hours Provision of kanga - Provision per day per day care Onset of skin-to-skin N/A N/A eligible: Once definition N/A N/A admission in After hospital and if mother willing was after Immediately birth N/A N/A N/A was care routine After observed and data collected were N/A N/A N/A Kangaroo mother care components Skin-to-skin discharge, care, follow-up N/A Skin-to-skin care Skin-to-skin care Skin-to-skin exclusive care, breastfeeding, follow-up N/A N/A Skin-to-skin care N/A Skin-to-skin care Skin-to-skin care Skin-to-skin care N/A g

teristics 32 weeks 1500

Newborn charac - Newborn All newborns N/A Premature; cut-off 1000–2000 g All NICU newborns N/A 26–37 weeks, 550–2500 g N/A birthweight; Low N/A cut-off All ages 32–37 weeks N/A Premature; cut-off < < Sample size 13 mothers 20 health facilities 1 8 mothers, father 195 dyads 170 mothers, 381 staff 52 paediatricians 135 newborns 34 facilities 30 dyads 35 mothers 28 newborns 10 mothers 10 mothers, 7 health-care providers Study design Randomized trial controlled group/ Focus interview Prospective cohort Prospective cohort, qualitative Questionnaire group/ Focus interview Retrospective cohort Randomized trial controlled Crossover group/ Focus interview Randomized trial controlled group/ Focus interview group/ Focus interview urban Rural or Rural Urban Urban Urban Urban N/A Urban Mixed N/A Urban N/A N/A Urban Country Uganda N/A Ghana Finland India Sweden India South Africa India Bangladesh India States United of America Brazil ) 94 93 117 35 10 23 38 22 95 109 110 77 103 Author, year Author, Namazzi, 2015 Roller, 2005 Roller, Parmar, Parmar, 2009 Neu, 1999 Neu, Nguah, 2011 Niela–Vilén, 2013 Nimbalkar, 2014 Pattinson, 2005 2004 Priya, Quasem, 2003 Ramanathan 2001 Sá, 2010 Nyqvist, Nyqvist, 2008 (. . continued

Bull World Health Organ 2016;94:130–141I| doi: http://dx.doi.org/10.2471/BLT.15.157818 141G Systematic reviews Kangaroo mother care Grace J Chan et al.

. .) X – – – – – – – and Policies Policies guidelines ( continues X – – – – – – – Facilities X X X X – – – – care Health- workers Barriers and facilitators - X X X X X X – – Care givers on stay N/A N/A N/A N/A N/A N/A N/A Days mothers length of Depended 24

roo mother careroo N/A N/A N/A N/A N/A N/A N/A ≤ Hours Hours Provision of kanga - Provision per day per day care Onset of skin-to-skin Once eligible: N/A eligible: Once definition N/A N/A N/A N/A N/A N/A N/A Kangaroo mother care components Skin-to-skin care N/A N/A Skin-to-skin care N/A N/A N/A Skin-to-skin exclusive care, breastfeeding 1000–

teristics g

Newborn charac - Newborn All ages Premature: N/A Premature: N/A low Premature, birthweight; N/A cut-off N/A N/A N/A N/A cut-off, < 1550 662 204

Sample size 145 newborns, 810 mothers 5 dyads 48–72 traditional birthing (6 attendant groups focus with 8–12 participants per group) 12 mothers 57 mothers and 14 traditional birthing attendants 20 nursing technicians 8 nurses 320 mothers, 61 accredited social health 19 activists, home visits Study design Focus group/ group/ Focus interview Focus group/ group/ Focus interview group/ Focus interview group/ Focus interview group/ Focus interview group/ Focus interview control Case group/ Focus interview urban Rural or Rural Urban Mixed Urban Urban Urban Mixed Rural Country Honduras Brazil United Republic of Tanzania Brazil Brazil Brazil India India ) 19 18 21 74 12 89 72 20 Author, year Author, 2013 Sacks, Sinha, 2014 Santos, Santos, 2013 Shamba, 2014 2014 Silva, 2015 Silva, Silva, 2008 Silva, Singh, 2012 (. . continued

141H Bull World Health Organ 2016;94:130–141I| doi: http://dx.doi.org/10.2471/BLT.15.157818 Systematic reviews Grace J Chan et al. Kangaroo mother care

. .) X X – – – – – – – – and Policies Policies guidelines ( continues X X X X X X – – – – Facilities X X X X X X – – – – care Health- workers Barriers and facilitators - X X X X X X X X X – Care givers life N/A N/A N/A N/A N/A N/A N/A N/A N/A Days days of days

2; data 2; data for first for available available 2 roo mother careroo N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Hours Hours Provision of kanga - Provision per day per day care Onset of skin-to-skin N/A extra- to Adapted and able life uterine breastfeed to 39 3 to Ranged from of life days of life Mean 18 days N/A N/A N/A N/A N/A N/A Kangaroo mother care components N/A Skin-to-skin discharge, care, follow-up N/A N/A Skin-to-skin care Skin-to-skin care N/A N/A Skin-to-skin care Skin-to-skin care g

teristics g

2500 2001 g 2000 g

Newborn charac - Newborn All ages N/A N/A N/A All ages N/A Premature; cut-off < < N/A Premature: 1150– cut-off, 2300 < 888

fathers Sample size

39 mothers 7 30 mothers, 15 30 mothers, nurses 56 nurses 126 staff 488 newborns 14 mothers, 41 mothers 12 countries 98 zones 66 dyads Study design Cluster Cluster randomized trial controlled sectional Cross group/ Focus interview Facility evaluation Randomized trial controlled group/ Focus interview group/ Focus interview Facility evaluation Cluster randomized trial controlled Retrospective cohort urban Rural or Rural Urban Urban N/A Urban Urban Urban N/A Rural Urban Country Bangladesh South Africa States United of America Sweden Colombia Brazil Brazil Ethiopia, Mali,Malawi, Mozambique, Nigeria, United Republic of Tanzania, Uganda, Bolivia, Indonesia, Viet Nepal, Nam Ghana Sweden ) 43 76 90 91 68 17 54 119 57 118 Author, year Author, Sloan, 2008 Solomons, Solomons, 2012 Stikes, 2013 Stikes, 2003 Toma, 2007 Toma, Undefined author: Save the Children, 2011 Strand, Strand, 2014 Tessier, 1998 2013 Vesel, Wahlberg, 1992 (. . continued

Bull World Health Organ 2016;94:130–141I| doi: http://dx.doi.org/10.2471/BLT.15.157818 141I Systematic reviews Kangaroo mother care Grace J Chan et al.

– – – – – and Policies Policies guidelines X X X – – Facilities X X X – – care Health- workers Barriers and facilitators - X X X X X Care givers N/A N/A N/A N/A N/A Days hour roo mother careroo N/A N/A N/A N/A

times Hours Hours 1 several several Provision of kanga - Provision At least At per day per day per day care Onset of skin-to-skin Once eligible: stable eligible: Once or low preterm birthweight babies, infants excluding with poor respiratory lines, invasive status, who are or parents not willing depressed, do kangaroo to having mother care, infectious skin disease unfit on chest, or with flu- physically, like symptoms. N/A N/A N/A N/A Kangaroo mother care components Skin-to-skin care N/A Skin-to-skin exclusive care, breastfeeding N/A N/A teristics g

Newborn charac - Newborn Premature; N/A Premature; cut-off All newborns N/A than 34 Less than Less weeks; N/A 1500 Sample size 30 health-care and workers 16 mothers, facilities 395 women 2 facilities 1 ICU 8 midwives Study design Focus group/ group/ Focus interview Cluster randomized trial controlled Facility evaluation Facility evaluation group/ Focus interview means not included in the study. urban Rural or Rural Rural Urban Urban Urban Country Uganda Uganda Ghana Singapore Sweden ) 31 60 16 9 14 X means included in the study and ‘–’ X means included in the study and

a ‘ ICU: intensive care unit; N/A: not available; NICU: neonatal intensive care unit. care intensive NICU: neonatal unit; N/A: not available; care ICU: intensive Author, year Author, Waiswa, 2010 Zwedberg, Zwedberg, 2015 Waiswa, Waiswa, 2015 2010 Wobil, 2014 Zhang, (. . continued

141J Bull World Health Organ 2016;94:130–141I| doi: http://dx.doi.org/10.2471/BLT.15.157818