Quantitative analysis
All 752 women who provided KMC to their newborns agreed to take part in the study, data from all these women were included in the analysis (Table 1). Nearly half of the mothers had an educational attainment of university level and above, 63.6% of the mothers were primiparous and 61.6% delivered through caesarean section. Most premature infants admitted to the postnatal ward had a gestational age between 36 weeks and 36 weeks and six days and a birth weight of 2500g or above.
Table 1. Basic socio-demographic of mothers who performed kangaroo mother care
|
Number
(N=752)
|
Percentage
|
Age
|
|
|
< 30
|
254
|
33.8%
|
30-34
|
294
|
39.1%
|
>=35
|
204
|
27.1%
|
Education attainment
|
|
|
High school
|
222
|
29.5%
|
College
|
191
|
25.4%
|
University & above
|
339
|
45.1%
|
Parity
|
|
|
Primipara
|
478
|
63.6%
|
Multipara
|
274
|
36.4%
|
Delivery mode
|
|
|
Vaginal delivery
|
289
|
38.4%
|
C-section
|
463
|
61.6%
|
Pregnancy-related complications
|
|
|
No
|
327
|
43.5%
|
Yes
|
425
|
56.5%
|
Birth weight
|
|
|
Normal (>= 2500 g)
|
656
|
87.2%
|
Low weight (< 2500 g)
|
96
|
12.8%
|
Gestational age
|
|
|
34 – 34 + 6 weeks
|
2
|
0.3%
|
35 – 35 + 6 weeks
|
108
|
14.4%
|
36 – 36 + 6 weeks
|
642
|
85.4%
|
Note: Values are n and %
Table 2. KMC experience during hospital stay
|
Vaginal delivery
(N=289)
|
C-section
(N=463)
|
Total
(N=752)
|
Length of hospital stay (day, mean±SD)
|
2.42 (1.25)
|
4.35 (2.08)
|
3.60 (2.04)
|
KMC total frequency (times, mean±SD)
|
2.73 (1.54)
|
3.98 (1.61)
|
3.50 (1.70)
|
KMC total duration (min, mean±SD)
|
198.93 (180.22)
|
274.33 (213.98)
|
241.12 (205.89)
|
KMC frequency per day (times, mean±SD)
|
1.26 (0.79)
|
0.99 (0.42)
|
1.09 (0.61)
|
KMC average duration per session (min, mean±SD)
|
68.93 (83.27)
|
66.64 (36.48)
|
67.52 (58.99)
|
< 1 hour
|
92 (31.8%)
|
208 (44.9%)
|
300 (39.9%)
|
1-2 hours
|
142 (49.1%)
|
201 (43.3%)
|
343 (45.6%)
|
2-4 hours
|
39 (13.5%)
|
32 (6.9%)
|
71 (9.4%)
|
4-6 hours
|
7 (2.4%)
|
1 (0.2%)
|
8 (1.1%)
|
6-8 hours
|
0
|
5 (1.1%)
|
5 (0.7%)
|
>8 hours
|
9 (3.1%)
|
16 (3.5%)
|
25 (3.3%)
|
Heard of KMC before
|
55 (19.0%)
|
86 (18.6%)
|
141 (18.8%)
|
Source of KMC knowledge (multiple choice, among those heard of KMC before)
|
|
|
|
Medical staff
|
33 (60.0%)
|
53 (61.6%)
|
86 (61.0%)
|
People with KMC experience
|
4 (7.3%)
|
4 (4.7%)
|
8 (5.7%)
|
Family and friend
|
9 (16.4%)
|
9 (10.5%)
|
18 (12.8%)
|
Media
|
13 (23.6%)
|
17 (19.8%)
|
30 (21.3%)
|
Internet
|
11 (20.0%)
|
19 (22.1%)
|
30 (21.3%)
|
Experienced difficulty during KMC
|
23 (8.0%)
|
60 (13.0%)
|
83 (11.0%)
|
Reasons to discontinue KMC (multiple choice)
|
|
|
|
Pre-arranged time limitation
|
81 (28.0%)
|
118 (25.5%)
|
199 (26.5%)
|
Break
|
52 (18.0%)
|
89 (19.2%)
|
141 (18.8%)
|
Restroom use
|
139 (48.1%)
|
199 (43.0%)
|
338 (45.0%)
|
Feeding
|
59 (20.4%)
|
102 (22.0%)
|
161 (21.4%)
|
Sleeping
|
50 (17.3%)
|
75 (16.2%)
|
125 (16.6%)
|
Infant crying
|
111 (38.4%)
|
161 (34.8%)
|
272 (36.2%)
|
Did not pause
|
23 (8.0%)
|
31 (6.7%)
|
54 (7.2%)
|
Received family support for KMC
|
276 (95.5%)
|
442 (95.5%)
|
718 (95.5%)
|
Received medical staff support for KMC
|
278 (96.2%)
|
437 (94.4%)
|
715 (95.1%)
|
Type of support received (multiple choice, among those received support)
|
|
|
|
Expressing breast milk
|
74 (26.6%)
|
125 (28.6%)
|
199 (27.8%)
|
Feeding posture adjustment
|
191 (68.7%)
|
279 (63.8%)
|
470 (65.7%)
|
Feeding reminder
|
115 (41.4%)
|
187 (42.8%)
|
302 (42.2%)
|
KMC posture adjustment
|
253 (91.0%)
|
391 (89.5%)
|
644 (90.1%)
|
Consolation
|
120 (43.2%)
|
191 (43.7%)
|
311 (43.5%)
|
Infant condition observation guidance
|
219 (78.8%)
|
335 (76.7%)
|
554 (77.5%)
|
Intention to continue KMC post discharge
|
271 (93.8%)
|
431 (93.1%)
|
702 (93.4%)
|
Note: Values are n(%).
Table 2 shows mothers’ experience of KMC during their hospital stay, stratified by mode of delivery. On average, mothers and newborns stayed on postnatal wards for 3.6 days and during this time mothers provided an average of 3.5 sessions of KMC, an average of 1.1 sessions a day. The average length of each KMC session was 68 minutes, however there was much variation between mothers. Most mothers provided KMC for between one and two hours (45.6%) or less than one hour (39.9%). Compared with those who gave birth vaginally, mothers who delivered through caesarean section had a longer average hospital stay (4.35 vs. 2.42 days), on a daily basis they provided KMC less frequently (0.99 vs. 1.26 sessions) but provided more sessions of KMC during their hospital stay (3.98 vs. 2.73 sessions). Common reasons mentioned for stopping a session of KMC included restroom use (45% of mothers), infant crying (36.2%) and a perceived pre-arranged time limitation (26.5%). Most mothers received family support for KMC, and support from medical and nursing staff, this included adjusting the infants’ position for KMC (mentioned by 90.1% of mothers who received KMC support), provision of guidance on how to observe the infants condition (77.5%), and feeding posture adjustment (65.7%). Only 18.8% of mothers had heard of KMC before arriving on the postnatal ward. Those who had heard of KMC had heard from medical staff, media, or the internet. Most mothers did not experience any difficulty performing KMC (89.0%)
Table 3 shows mothers’ preference for length of KMC sessions and the time of day when they preferred to provide KMC. Over half of the mothers preferred to provide KMC for between one to two hours (55.5%) while approximately a quarter (26.7%) preferred a duration of less than one hour. Morning (34.4%) and afternoon (35.9%) were the times when most mothers preferred to provide KMC to their newborns.
Table 3. Preferred KMC session duration and time of day
|
N=252
|
Preferred KMC duration
|
|
< 1 hour
|
201 (26.7%)
|
1-2 hours
|
417 (55.5%)
|
2-4 hours
|
77 (10.2%)
|
4-6 hours
|
25 (3.3%)
|
6-8 hours
|
8 (1.1%)
|
>8 hours
|
2 (0.3%)
|
Others
|
22 (2.9%)
|
Preferred time of day
|
|
Morning
|
259 (34.3%)
|
Noon
|
93 (12.4%)
|
Afternoon
|
270 (35.9%)
|
Evening
|
106 (14.1%)
|
Others
|
24 (3.2%)
|
Note: Values are n (%).
At hospital discharge the majority of mothers (93.4%) intended to continue providing intermittent KMC. Of those mothers who were successfully followed up (n=627) on the 42nd day after birth 69.5% (n=436) reported that they had continued to provide intermittent KMC. The mean average frequency of KMC provision was 1.9 times a day additional file 2 (eTable 1).
Qualitative analysis
A total of ten semi-structured interviews were conducted during August and September 2018 in two of the participating postnatal wards. Six out of the ten interviewees were nurses involved in the provision of KMC on the ward, two were mothers providing intermittent KMC to their newborns and two were obstetricians – one of whom had recently given birth to a preterm newborn and provided intermittent KMC. Detailed characteristics of the ten interviewees are presented in additional file 3 (eTable 2). Four main themes emerged from the interviews and these are presented below.
Introducing and initiating KMC
The two hospitals operated differently in terms of when and how they introduce KMC to mothers. One hospital informed women about KMC after birth and on admission to the postnatal ward, the other identified women at risk of preterm birth and informed them about KMC during antenatal care. Information focused on the benefits of KMC including maintenance of body temperature, benefits for digestion and breastfeeding and alleviation of postnatal depression. After informing mothers’ about KMC on the postnatal ward, consent for providing KMC was sought, some mothers preferred to discuss KMC with their family before deciding whether to provide it. Nurses emphasized that instead of directly introducing KMC and “forcing” mothers to provide KMC, they would start by discussing the babies’ prematurity, prompting mothers to ask about ways in which they could improve their babies’ condition. Most mothers agreed to provide KMC, a few refused due to pain associated with a caesarean delivery. After mothers agreed to perform KMC, nurses would prepare the mother and infant, this included reminding mothers to use the restroom, to clean their bodies and prepare them for KMC positions.
“You just tell them what the benefits are, not too deep as they might not understand, just simple words. When they know that it’s good for the infant, help maintaining their vital signs, they are quite happy that it can help the infant and promote breast milk secretion, they are quite happy and like to try KMC.” – 01 (nurse)
“If the infant turns out to be premature, I would definitely not say you need KMC. I would ask you how’re you feeling and your condition as a mother…then if your baby is a premature baby - if yes what’s your worry or concern. She might say that I am worried about feeding the baby and its growth. And then I would say that besides regular neonatal care, there’s something called KMC, it’s a care strategy like a kangaroo…. They usually accept it well if I tell them step by step. If I just come and say that I am going to perform KMC on your infant, she might find it hard to accept.” – 03 (nurse)
Health workers support during KMC
During each KMC session, nurses usually provided support for mothers and their infants, this included taking temperatures before each session, adjusting an infants’ posture, and observing for any abnormalities. Interviewed nurses reported that when mothers were providing KMC, they would spend time with them, supporting them and explaining about newborn care. This prompted more communication and interaction between nurses and mothers and contributed to better nurse mother relationships.
“Also, when the parents are performing KMC, we definitely will provide them some new-born care guidance, and spend more time than average mothers. They will learn more professional knowledge.” – 05 (nurse)
“Sometimes, sometimes I think that the posture is not very comfortable, and then sometimes I will ask the nurse to help me and adjust the posture, the baby will also feel more comfortable.” – 06 (mother)
Length of KMC and discontinuing KMC
Mothers usually attempted to provide KMC for one hour per session, some mothers provided KMC for 20 to 30 minutes as they felt uncomfortable. Other common reasons mentioned for discontinuing a KMC session included mothers needing to use the restroom or having to eat, the baby crying, family visits or hospital procedures such as hearing tests interrupting KMC provision. Nurses mentioned that mothers were instructed to try KMC for at least one hour each session, and therefore most would only attempt to provide one hour of KMC at a time. Nurses tried to encourage mothers to gradually increase the length of KMC provision although it was challenging as mothers and newborns did not stay on the postnatal ward for very long.
“Sometimes KMC is discontinued, why? Because after the nurse set it up, the doctor may come and do some procedure on the baby, or people from child development department may come and test the baby’s hearing, then KMC is discontinued. Without those procedures, parents may persist longer.” – 03 (nurse)
“There’s rarely any that could persist for three or four hours, mostly one to two hours. Mostly due to parental factors. Also likely because we first promoted and introduced KMC to be one hour session each, at least one hour, parents will then feel that one hour is enough…They feel like they have accomplished the task, the nurse told me one hour and I just need to do it for one hour.” – 04 (nurse)
“…They would ask when I should finish, we would say at least one hour, and then they would just aim for one hour. Also people’s perception has not changed, the grandparents heard baby crying, and thought the baby must be feeling unformattable or painful. The grandparents would be nervous and say let me hold the baby and discontinued the KMC.”– 06 (nurse)
Mother’s perception of KMC benefits and challenges.
While there were many benefits mentioned by nurses, there were not many observed benefits primarily due to the limited length of hospital stay. Nurses claimed that babies receiving KMC cried less, grew faster, and fed better, they also said that parents seemed to be happier. When we asked nurses to recall what mothers said about the benefits of KMC most mentioned better feeding and better emotional bonding.
“…Frankly speaking it’s impossible to have an extremely significant difference…I think (the benefits) will show up when the infant grows up later but it’s hard to see a huge change in the short period.”– 02 (obstetrician)
“(The mother) said that when put in the trolley, the baby did not suck well and might sleep for three to five hours without waking up. As long as you put it on your skin for skin-to-skin contact, the baby shook its head and looked for food.”– 04 (nurse)
“I went through a C-section and when I tried KMC for the first time, I felt very warm as the baby stayed on me, I felt an emotional bonding and the baby felt safer. I also fed him my breast milk, stimulate the secretion is very important and the baby could eat well and grow faster.”– 09 (mother)
There were several challenges mentioned including lack of privacy during KMC and continuation of KMC after hospital discharge.
“It is best to have something covering (me), because there are too many people in the wards, there are also men, the children are naked, and my upper body is almost naked, which is not convenient.” – 10 (mother)
“(Parents) definitely think KMC is good, but the challenge is after discharge. When performing KMC during hospital stay there’s health workers prompting, some people might not adhere to it after they go back home.”– 08 (nurse)