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What is kangaroo mother care? Systematic review of the literature


Background: Kangaroo mother care (KMC), often defined as skin-to-skin contact between a mother and her newborn, frequent or exclusive breastfeeding, and early discharge from the hospital has been effective in reducing the risk of mortality among preterm and low birth weight infants. Research studies and program implementation of KMC have used various definitions.

Objectives: To describe the current definitions of KMC in various settings, analyze the presence or absence of KMC components in each definition, and present a core definition of KMC based on common components that are present in KMC literature.

Methods: We conducted a systematic review and searched PubMed, Embase, Scopus, Web of Science, and the World Health Organization Regional Databases for studies with key words "kangaroo mother care", "kangaroo care" or "skin to skin care" from 1 January 1960 to 24 April 2014. Two independent reviewers screened articles and abstracted data.

Findings: We screened 1035 articles and reports; 299 contained data on KMC and neonatal outcomes or qualitative information on KMC implementation. Eighty-eight of the studies (29%) did not define KMC. Two hundred and eleven studies (71%) included skin-to-skin contact (SSC) in their KMC definition, 49 (16%) included exclusive or nearly exclusive breastfeeding, 22 (7%) included early discharge criteria, and 36 (12%) included follow-up after discharge. One hundred and sixty-seven studies (56%) described the duration of SSC.

Conclusions: There exists significant heterogeneity in the definition of KMC. A large number of studies did not report definitions of KMC. Skin-to-skin contact is the core component of KMC, whereas components such as breastfeeding, early discharge, and follow-up care are context specific. To implement KMC effectively development of a global standardized definition of KMC is needed.

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What is kangaroo mother care? Systematic review of the literature

Grace j chan.

1 Department of Pediatrics, Harvard Medical School, Boston, MA, USA

2 Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA

3 Saving Newborn Lives, Save the Children, Washington, DC, USA

Bina Valsangkar

Sandhya kajeepeta, ellen o boundy, stephen wall, associated data.

Kangaroo mother care (KMC), often defined as skin–to–skin contact between a mother and her newborn, frequent or exclusive breastfeeding, and early discharge from the hospital has been effective in reducing the risk of mortality among preterm and low birth weight infants. Research studies and program implementation of KMC have used various definitions.

To describe the current definitions of KMC in various settings, analyze the presence or absence of KMC components in each definition, and present a core definition of KMC based on common components that are present in KMC literature.

We conducted a systematic review and searched PubMed, Embase, Scopus, Web of Science, and the World Health Organization Regional Databases for studies with key words “kangaroo mother care”, “kangaroo care” or “skin to skin care” from 1 January 1960 to 24 April 2014. Two independent reviewers screened articles and abstracted data.

We screened 1035 articles and reports; 299 contained data on KMC and neonatal outcomes or qualitative information on KMC implementation. Eighty–eight of the studies (29%) did not define KMC. Two hundred and eleven studies (71%) included skin–to–skin contact (SSC) in their KMC definition, 49 (16%) included exclusive or nearly exclusive breastfeeding, 22 (7%) included early discharge criteria, and 36 (12%) included follow–up after discharge. One hundred and sixty–seven studies (56%) described the duration of SSC.


There exists significant heterogeneity in the definition of KMC. A large number of studies did not report definitions of KMC. Skin–to–skin contact is the core component of KMC, whereas components such as breastfeeding, early discharge, and follow–up care are context specific. To implement KMC effectively development of a global standardized definition of KMC is needed.

Globally, 44% of under–five deaths occur during the neonatal period, and the proportion of under–five deaths due to neonatal causes continues to rise [ 1 , 2 ]. Preterm birth (before 37 weeks gestation) accounts for 35% of neonatal deaths. Low birth weight (defined as <2500 g) is commonly used as a surrogate measure of preterm birth [ 3 ]. Preterm and low birth weight infants who survive the neonatal period are more likely to experience neonatal morbidities including acute respiratory, gastrointestinal, immunologic, central nervous system, hearing and vision problems than both term and normal weight infants [ 4 ].

A significant proportion of deaths among preterm and low birth weight infants is preventable. There is evidence that kangaroo mother care (KMC), when compared to conventional neonatal care in resource–limited settings, significantly reduces the risk of mortality in infants born in facilities who are clinically stable and weighing less than 2000 g [ 5 ]. KMC also reduces the risk of hypothermia, severe illness, nosocomial infection, and length of hospital stay, and improves growth, breastfeeding, and maternal–infant attachment [ 5 , 6 ].

Despite strong evidence for mortality and morbidity reduction in low– and middle–income settings and endorsement from the World Health Organization (WHO), country–level adoption and implementation of KMC has been limited. In a systematic assessment of health system bottlenecks among countries with a high burden of neonatal deaths, KMC was identified as an intervention with significant health systems barriers to scale–up including leadership and governance, health financing, health workforce, health service delivery, health information systems, and community ownership and partnership [ 7 ]. Health intervention priority–setting tools, such as the Lives Saved Tool and Child Health and Nutrition Research Initiative methodology, have identified KMC as a high priority intervention based on criteria such as mortality benefit and equity [ 8 , 9 ].

In response to limited global uptake of KMC, in 2013, a group of newborn health stakeholders led by the Bill and Melinda Gates Foundation and Save the Children’s Saving Newborn Lives Program launched a global KMC Acceleration Convening. The goal was to address barriers to implementation, increase uptake of KMC as part of an integrated Reproductive Maternal Newborn and Child Health package, and identify research priorities [ 10 ]. In addition to implementation barriers, a lack of a clear definition of KMC has made effective coverage at scale of KMC challenging. A multi–country study in Africa found variation in KMC implementation across facilities in countries with national commitment to KMC [ 11 ]. Regional, country, and facility differences in health worker capacity, financial resources, leadership, health information systems, and cultural and community structures create challenges to developing and adopting a global definition of KMC.

The WHO has defined KMC as early, continuous, and prolonged skin–to–skin contact (SSC) between the mother and preterm babies; exclusive breastfeeding or breast milk feeding; early discharge after hospital–initiated KMC with continuation at home; and adequate support and follow–up for mothers at home [ 12 ]. While the WHO provides guidance on the components of KMC, guidance on the operationalization and clinical implementation of KMC are needed. There are significant variations in the timing of initiation, duration of SSC, positioning, necessary equipment and supplies, discharge criteria, follow–up frequency, indicators and measurement, and health workforce needs. The variations in these components have differential effects on preterm and low birth weight outcomes. As the global newborn health community begins to accelerate implementation of KMC, a standardized operational definition is needed. We conducted a systematic review of the KMC literature to 1) describe the current definitions of KMC in various settings, 2) analyze the presence or absence of WHO KMC components in each definition, and 3) present a core definition of KMC–common components that are present in at least 70% of all studies and programs–and describe how KMC definitions vary by context. This review provides a basis for development of an operational definition and clinical standards to accelerate the uptake of KMC globally.

We searched PubMed, Embase, Web of Science, Scopus, and WHO regional databases: AIM, LILACS, IMEMR, IMSEAR, and WPRIM using the search terms “kangaroo mother care”, “kangaroo care”, and “skin to skin care” with no language restrictions from 1 January 1960 to 24 April 2014 for original reports including case–control studies, cohort studies, randomized control trials, and case series with 10 or more participants (see Online Supplementary Document (Online Supplementary Document) for the review protocol and full search strategy). Following PRISMA guidelines, studies were included if they contained at least one of the following: the amount of time KMC was practiced, an association between KMC (as an isolated exposure, not part of a larger package) add any outcome, barriers to implementing KMC or factors necessary for successful implementation of KMC. Exclusion criteria were non–human subjects, case series or descriptive studies with fewer than 10 participants, and non–primary data collection or analysis (eg, reviews, meeting abstracts, editorials). Our population of interest included mothers, newborns, or mother–newborn dyads (not restricted to any specific ages) who have practiced KMC as well as health care providers, health facilities, communities, and health systems that have implemented KMC.

We also conducted hand–searches through the reference lists of the articles included in our review and published systematic reviews. Cochrane reviews were searched for relevant articles. To search the “grey literature” for unpublished studies, we explored programmatic reports and requested data from programs implementing KMC to obtain programmatic perspectives in addition to those provided by research studies. Reports were included following the same criteria as above.

Two independent reviewers examined titles, abstracts and full–text articles for inclusion into the review using a screening form based on our inclusion criteria. Using standardized data abstraction forms, two reviewers abstracted data independently from all included articles and reports. At each stage, reviewers compared results to ensure agreement. In the case of disagreement between the two reviewers, a third party acted as a tiebreaker. Native speakers abstracted data from articles in foreign languages. Languages for which a native speaker was not identified (ie, German, Finnish, Korean, Thai and Polish) were translated using an online translation software to assist with data abstraction. If an article or report were missing any information, we contacted the authors to request the data.

Using standardized forms, data were abstracted on study characteristics such as study design, country, sample size, location, and duration of follow–up. We abstracted data on KMC definitions including data on SSC, exclusive breastfeeding, early discharge from the facility, and follow–up and as well as other components [ 12 ]. We generated categorical variables for each component and calculated descriptive frequencies, means, medians and ranges for quantitative data.

Study selection and characteristics

Our search strategy yielded 1035 records of which 299 were included in our review ( Figure 1 ). Details of each included study are found in Table S1 in Online Supplementary Document (Online Supplementary Document) . Summary characteristics of the included studies are presented in Table 1 . In the last five years, as KMC research gaps have gained growing attention, the number of studies conducted has increased. One hundred and thirty–four studies (45%) were published in the last five years between 2010 and 2014, 134 (45%) between 2000 and 2009, and 31 (10%) between 1988 and 1999. Common study types were randomized control trials (n = 85, 28%), surveys or interviews (n = 58, 19%), and cohorts (n = 43, 14%). Other study types included pre–post studies, facility–level evaluations, non–randomized intervention studies, and randomized crossover trials. One hundred and forty–four studies (48%) had less than 50 participants and 47 (16%) had 200 or more participants. Geographically, 115 (38%) of the studies took place in the Americas, 64 (21%) in Europe, 44 (15%) in Africa, 29 (10%) in Southeast Asia, 20 (7%) in Western Pacific, and 16 (5%) in Eastern Mediterranean regions. More studies were in countries with low neonatal mortality rates (NMRs), ie, less than 5 per 100 live births (n = 130, 43%), than in countries with high NMRs, ie, 30 or higher (n = 10, 3%) [ 13 ]. The majority of studies, 192 (64%), were in an urban setting. One hundred and seventy–five studies (59%) took place in health facilities, 107 (36%) in neonatal intensive care units or stepdown units, and 11 (4%) were community or population–based.

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Flow diagram of study selection.

Characteristics of included studies

Most studies included preterm newborns less than 37 weeks gestation (n = 134, 45%), 33 studies (11%) included only full term infants 37 weeks gestation or greater, 28 studies (9%) included newborns of all gestational ages, and 104 studies (35%) did not report gestational ages of the study participants. Similarly, 73 studies (24%) were among low birth weight infants less than 2500 g; 52 studies (17%) included infants less than 2500 g to 1500 g, and 21 (7%) studies were among very low birth weight infants less than 1500 g. Forty–five studies (15%) included a mix of low and very low birth weight newborns. Nine studies (3%) were among newborns weighing 2500 g or greater and 25 studies (8%) included newborns of all birth weights. One hundred forty–six studies (49%) did not describe birth weight characteristics. Forty three studies (14%) reported neither gestational age nor birth weight.

KMC components

The individual components of KMC varied across studies ( Table 2 ). Kangaroo mother care was not defined in 88 studies (29%). All 211 studies (71%) with KMC definitions included SSC as a component. One–hundred forty–eight studies (50%) included SSC only. For the additional components, 49 studies (16%) included SSC and exclusive or near–exclusive breastfeeding, 36 (12%) included SSC and follow–up after discharge from the health facility, and 22 (7%) included early discharge from the health facility.

Description of kangaroo mother care components in studies

Skin–to–skin contact

Among the studies that defined SSC as part of the KMC package, criteria for SSC initiation, SSC ending, and SSC duration were not well described ( Table 3 and Table 4 ). In 43 studies (14%), SSC was initiated after non–stability criteria were met, 27 studies (9%) promoted immediate initiation of SSC within 60 minutes of birth, 76 studies (25%) encouraged SSC after stability criteria were met, 18 studies (6%) encouraged SSC after a painful procedure, and 135 (45%) did not describe SSC initiation criteria. Forty–three studies observed initiation of SSC of which 4 (9%) observed immediate initiation of SSC. Criteria for stability were non–specific including the terms “clinically stable,” “adapted to extra–uterine life,” “can tolerate handling,” and “without serious illness”. More defined criteria included “satisfactory APGAR score,” “stable weight,” and “stable respiratory and hemodynamic parameters.” Criteria to end SSC were largely non–specific with terms “one day or less,” “until baby no longer accepts,” or “until parent no longer accepts.” More specific terms included “until reaches satisfactory weight [2000 grams or 2500 grams]”. We compared descriptions of SSC with observations of SSC to differentiate promotion vs practice. Most studies (>85%) did not include data on observations of SSC practiced ( Table 3 ).

Promoted skin–to–skin contact characteristics compared to observed skin–to–skin contact characteristics

Promoted skin–to–skin contact duration compared to observed skin–to–skin contact duration

Data on the duration of SSC are needed to understand the benefits of SSC as well as the feasibility to scale KMC; however this was missing from most studies ( Table 4 ). One hundred thirty–two studies (44%) did not describe the number of hours per day SSC was promoted. Seventy–eight studies (26%) encouraged SSC for less than two hours per day, 15 of these studies examined the effect of SSC on painful procedures. Otherwise, the most common duration of SSC promoted was 22 hours or more (n = 46, 15%). Only 37 studies (12%) observed duration of SSC practiced, of which six (2%) observed at least 22 hours per day SSC practiced. SSC duration was also categorized inconsistently as continuous, intermittent, number of hours per session, number of sessions per day, and number of days. Definitions of the term continuous included 24 hours per day, continuous within sessions, or one continuous session but less than 24 hours a day.


Breastfeeding habits were reported in 105 (35%) studies: 38 (13%) reported exclusive breastfeeding, 22 (7%) nearly–exclusive breastfeeding, and 35 (12%) breastfeeding and supplemental feeding ( Table 5 ). In most studies, breastfeeding initiation time was not reported (n = 261, 87%). Breastfeeding was started immediately or within one hour of birth in 15 studies (5%), between one and 24 hours after birth in two studies (1%), and 24 hours or longer after birth in five studies (2%). In nine studies (3%) breastfeeding was started at KMC initiation, and seven studies (2%) included physical maturity criteria for initiation of breastfeeding. Seventeen studies (6%) described breastfeeding frequency in their patient population, 13 (4%) studies reported women breastfeeding every two to three hours and four studies (1%) reported women breastfeeding whenever possible.

Description of breastfeeding characteristics

Discharge criteria from facility

Fourteen percent of studies (n = 42) described the criteria used for hospital discharge in their study populations ( Table 6 ). The most common criteria were clinical stability (n = 19, 6%) or meeting a specified weight gain or weight minimum cutoff (n = 15, 5%). Seven studies (2%) required a combination of adequate weight gain and exclusive breastfeeding prior to discharge. Most studies did not report when infants were discharged (n = 285, 95%). Six studies (2%) reported discharge within seven days of life and eight studies (3%) reported discharge after seven days of life.

Description of discharge and follow–up characteristics


Sixty–one studies (20%) described follow–up of infants after discharge, of which 29 studies (48%) followed–up with newborns in health facilities, 22 studies (36%) in homes, and 9 studies (15%) in both facilities and homes ( Table 6 ). Follow–up time varied from one month or less (n = 8, 3%) to six to 18 months (n = 13, 4%). Most studies (n = 270, 90%) did not report compliance with follow–up, 11 (4%) reported 90% or higher compliance.

Other components

Studies also described clothing recommendations, newborn positioning, and temperature monitoring during KMC. In 64 studies (21%) participants were instructed to clothe their infant in only a diaper during kangaroo care, an additional 64 studies (21%) encouraged use of a diaper, cap, and socks, and 17 (6%) promoted having the infant naked during SSC contact ( Table 7 ). The majority of studies (n = 179, 60%) instructed participants to position the infant prone on the care provider’s chest during SSC, while five studies (2%) encouraged a side–lying or breastfeeding position. In 59 studies (20%), the kangaroo care provider was instructed to be in a reclined position, while an upright position was encouraged in 48 studies (16%). Temperature of the infant was monitored during SSC in 71 studies (24%).

Description of clothing and positioning during kangaroo mother care

There is significant heterogeneity in the definition of KMC and a large number of studies did not report a definition of KMC. Of the studies that defined KMC, SSC was present in all studies. Additional KMC components – breastfeeding, early discharge, and follow–up–were missing in the majority of studies. These findings suggest that SSC is accepted in research and programmatic settings as an essential component of KMC, but the other components vary by context, defined as demographic, economic, social, and cultural factors, and newborn characteristics.

The lack of a clear KMC definition and guidance for implementing KMC is a reflection of incomplete evidence. Evidence for KMC is largely based on meta–analyses that combine studies with heterogeneous definitions of KMC and occur in different settings [ 5 , 6 ]. Attempts to stratify the association of KMC on outcomes by KMC components, newborn characteristics (birth weight, gestational age), and high NMR vs low NMR often do not yield statistically significant results because of the limited data available. We do not know the effect of different combinations of KMC components, nor do we understand the feasibility with which each component can be implemented effectively in different contexts. Our study was limited by the lack of data on the duration of SSC. Furthermore, measurement of SSC duration was based on mothers’ report of time with minimal observational data. Studies where SSC duration was measured by an independent observer may be biased by the Hawthorn effect.

To define the optimal duration of SSC, we need additional data on the dose response of SSC duration on mortality and morbidity outcomes. The benefits of SSC are likely dependent on the duration of SSC, however the duration of SSC must also be balanced with the feasibility of practicing SSC for extended periods of time. In most settings promoting SSC 24 hours a day is not feasible. Understanding the minimal duration of SSC that provides the maximal benefits will provide more specific recommendations. Most studies initiated KMC after stabilization of the newborn and the effect of KMC on mortality and morbidity is generalizable to the population of newborns who survive to be stabilized. The effect of KMC immediately after birth before stabilization is unclear due to inconclusive evidence [ 14 – 17 ]. Additional efforts to test the effect of KMC prior to stabilization and to define stability is needed through further studies or by consulting experts at each level of care (primary, secondary, or tertiary care) through a Delphi method.

To operationalize KMC, the simpler the intervention the more likely it is to scale [ 18 ]. A simple and clear operational definition for KMC is needed. Evidence suggests benefits for newborns less than 2000 g, who are stabilized in facilities with SSC as the primary component. More work is needed to improve the measurement of gestational age and improving the recording of birth weights in facilities to better understand the impact of KMC and for whom there are benefits. Our review suggests that skin–to–skin contact is the core minimal component of KMC and variations depend on context and individual clinical needs of the newborn. For example, extremely preterm newborns who are unable to coordinate their suck and swallow will need feeding support such as nasogastric feeding or intravenous fluid. In high resource settings with space and infection precautions, a provider may recommend SSC for a preterm infant but choose not to discharge early from the facility. To operationalize KMC, a simple matrix that lists newborn characteristics in columns and KMC components in rows for different settings, ie, tertiary, secondary, primary or community levels, can take into account the core SSC components with variations based on differences in the newborn and context.

As implementation of KMC begins to accelerate globally, data on the context, individual newborn factors, and KMC components can be collected and harmonized to generate a model that will best define KMC for a set of individual newborn characteristics in specific settings. Research and programmatic agendas to advance KMC should include a standardized set of indicators and measurement tools that document SSC initiation criteria, SSC duration as number of hours per day promoted and ideally observed, feeding protocols, discharge criteria from a facility to community and follow–up standards, and discharge criteria from KMC. To track progress, indicators and standard measurement tools are needed to measure coverage of key newborn interventions including KMC [ 19 ]. The release of the new preterm guidelines by the World Health Organization, where KMC is recommended for all newborns less than 2000 g, will provide an opportunity for programs and researchers to start addressing definition gaps, establish global recommendations of operational definitions and core components of KMC, and accelerate KMC within care of preterm babies.

Developing a standardized operational definition of KMC and employing indicators and measurement tools to measure and evaluate KMC acceleration efforts is needed. More than half of the studies equate KMC with SSC. Moving forward, careful distinction between KMC and SSC is needed. While SSC is beneficial for all newborns, KMC should be clearly defined, at the bare minimum, as a package of interventions including SSC, exclusive breastfeeding, and close monitoring for preterm and/or low birthweight babies. Researchers and program implementers can contribute to building a more solid evidence base for KMC by measuring and reporting how KMC is defined–the components implemented and the feasibility of implementation based on the context–and the outcomes measured. A central and accessible database to share knowledge should contain this data in addition to standardized indicators, such as the proportion of eligible newborns who receive KMC and the barriers and facilitators to implementation of KMC.


We thank Stacie Constantian, Roya Dastjerdi, and Tobi Skotnes for reviewing and abstracting data. Rodrigo Kuromoto and Eduardo Toledo reviewed non–English articles. We acknowledge Kate Lobner for developing and running the search strategy. We would like to thank the mothers and newborns who participated in these studies to better understand how research and programs define KMC.

Funding: Funding for this systematic review was provided by Saving Newborn Lives program of Save the Children Federation, Inc.

Authorship contributions: All authors listed have participated in the concept, design, analysis and interpretation of the data, drafting, or editing of the manuscript. All authors have approved the manuscript as submitted.

Competing interests: The authors completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author). None of the authors has any competing interests to declare. There are no competing interests to disclose.

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How to improve the effectiveness and efficiency of kangaroo mother care: a literature review of equipment supporting continuous kangaroo mother care.

The objective of this study was to provide an overview of the equipment supporting Kangaroo Mother Care (KMC).

The review adopted a five-stage methodological framework that included research question identification, relevant study identification and selection, and data charting, collating, summarizing, and reporting. We conducted reviews to analyze the current research on the design of KMC-supporting devices. Publications were identified from January 2008 to July 2020.

Using the inclusion criteria, 17 relevant studies were identified that concerned the design of supporting equipment for KMC. Five types of equipment improved the comfort of the mothers performing KMC, another five monitored the health and development of the infants, and four served as therapy for the infants. Three equipment types showed no significant effect in supporting KMC.


This study provides information on equipment that effectively and efficiently improves the quality of KMC.

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Peer-review under responsibility of the scientific committee of the 1st International Conference on Safety and Public Health (ICOS-PH 2020). Full-text and the content of it is under responsibility of authors of the article.

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

BMC Pregnancy and Childbirth volume  22 , Article number:  851 ( 2022 ) Cite this article

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

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

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


Support from facility management and leadership and well-trained medical staff are of great significance to the successful integration of KMC into daily medical practice, while the parents of preterm infants and other family members should be educated and encouraged in KMC practice. Further research is needed to propose strategies and develop models for implementing KMC.

Peer Review reports

According to reports from the World Health Organization (WHO), with the development of assisted reproductive technology and the improvement of emergency and critical care technology, the incidence of premature birth is rising, and premature birth has become a global problem [ 1 ]. Nearly fifteen million preterm infants are born each year, and more than one million of them unfortunately die each year [ 2 ]. According to statistics, complications of preterm birth directly account for more than 35% of all neonatal deaths, while the proportion of deaths indirectly caused by preterm birth is even higher because preterm birth increases the risk of infant death from infection [ 3 ]. Many surviving preterm infants encounter plenty of problems due to premature birth, such as sensory impairment and cognitive and language impairment [ 4 , 5 , 6 ]. In addition, the birth of preterm infants may cause a substantial emotional crisis and economic cost to the family, as well as have an impact on public sector services such as education and other social support systems [ 7 , 8 ]. For mothers, preterm birth may also cause a range of perinatal diseases [ 5 , 9 ]. Therefore, effective evidence-based interventions that can be implemented at scale are urgently needed to reduce the incidence of preterm birth complications and neonatal mortality.

Kangaroo mother care (KMC) is one such evidence-based life-saving intervention for preterm infants [ 10 ]. In KMC, the mother (or father) puts her (his) naked preterm infant on her (his) chest in the same way as kangaroo parenting so that the preterm infant is capable of having early, continuous and long-term skin-to-skin contact with his or her mother (father); in addition, measures such as exclusive breastfeeding or breastfeeding, early discharge, and follow-up after discharge are taken for the preterm infants [ 11 , 12 ]. Compared with the conventional nursing mode, KMC is not only able to maintain the body temperature of preterm infants but also significantly reduces the risk of death in low-birth-weight infants by 36% while significantly reducing the risk of sepsis, hypoglycaemia, and hypothermia [ 13 ]. Numerous studies have shown that KMC is a safe, effective, and multifaceted intervention with many short-term and long-term positive effects for preterm infants, such as stabilizing the neonatal physiological state, enhancing immunity, increasing exclusive breastfeeding rates, and promoting mother-infant bonding [ 14 , 15 , 16 , 17 ].

Despite the clear benefits of KMC, this intervention has not yet been fully integrated into health systems around the world [ 18 , 19 ]. There are many barriers impeding the implementation of the KMC, including but not limited to lack of support from family members, lack of parental information, and lack of tools and resources [ 20 , 21 , 22 , 23 ]. Several studies have identified facilitators that may contribute to the implementation of KMC, such as providing KMC training programmes for parents and encouraging physicians to recommend KMC to parents [ 24 , 25 , 26 ]. Undoubtedly, a better understanding of these barriers and facilitators can optimize the implementation of KMC.

Studies on the subject of KMC have developed over many years, with extensive studies from around the world and several systematic reviews on KMC published. These studies spanned different clinical settings, and there are studies that have explored the influencing factors of KMC from different perspectives, such as caregivers (e.g., parents and families) and healthcare workers [ 27 , 28 , 29 ]. A certain number of barriers and facilitators have been identified in these studies. However, the complexity and diversity of conventional studies make KMC difficult to describe and understand and impose challenges for health professionals and administrators who try to apply KMC in health systems [ 22 , 30 ]. Therefore, it is necessary to robustly summarize the evidence base to identify and elucidate key barriers and facilitators to the implementation of KMC.

One available approach is the umbrella review, which involves the synthesis of existing reviews, enabling researchers to collect evidence from multiple healthcare facilities instead of conducting systematic reviews at each facility. Essentially, an umbrella review is a review of existing reviews to provide an overview of the available evidence on a specific topic and allow comparisons of published reviews [ 31 ]. Furthermore, an umbrella review is capable of compiling evidence bases related to specific issues in a relatively short time frame [ 32 ]. We adopted this comprehensive assessment approach to outline factors that may facilitate or inhibit KMC implementation and expansion.

Protocol and registration

A protocol was prospectively developed in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines [ 33 ]. Following current recommendations, the protocol was made openly available through registration with the PROSPERO International Prospective Register of Systematic Reviews platform (registration number CRD42022327994).

Study design

This review was conducted according to the rules for conducting umbrella reviews and published approach [ 32 , 34 ], and was reported following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA 2020) statement [ 35 ]. The PRISMA checklist is shown in Additional file  1 .

Search strategy

Electronic databases, including PubMed, the Cochrane Database of Systematic Reviews, EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the China National Knowledge Infrastructure (CNKI, for Chinese literature), SinoMed (for Chinese literature), and WAN FANG DATA (for Chinese literature), were searched to identify systematic reviews and meta-analyses (published from database inception to 1 July 2022.) of the factors influencing the implementation of KMC in preterm infants. Additionally, we manually searched reference lists from the screened articles to avoid the omission of any related articles. Also, we searched Google Scholar and OpenGrey for grey literature.

The search terms were constructed by combining subject terms and free words, while the language was limited to Chinese or English. The English search terms used were “prematur*/preterm*/premie*/neonat*/infant*/newborn*/low birth weight/LBW/ NICU”, “kangaroo mother care/kangaroo mother method/kangaroo care/kangaroo attachment/kangaroo contact/KMC/KC/skin-to-skin care/skin-to-skin contact/SSC/mother-infant contact”, and “systematic review/meta-analys”, and “早产儿/新生儿/低出生体重儿”“袋鼠护理/袋鼠式护理/皮肤接触”“系统评价/Meta分析/荟萃分析” were adopted as the Chinese search terms. More details of the search strategies are shown in Additional file  2 .

Inclusion criteria

This umbrella review included studies published in peer-reviewed journals and grey literature that addressed the research question. Articles were included if they were published in Chinese, English or in other language with the English version; identified factors impacting KMC implementation, including barriers and facilitators as primary or secondary objectives; and were a systematic review or meta-analysis. Moreover, to retrieve valuable information about the subject under study, we also decided to include scoping reviews, a type of review study that uses a systematic method of searching for information with the aim of accumulating as much evidence as possible and mapping the results. Screening of the searched articles and their subsequent full-text review were carried out based on the following inclusion criteria: (a) studies that used a systematic/scoping review and/or meta-analysis design, (b) studies focused on preterm infants with KMC, and (c) studies that aimed to identify factors associated with KMC implementation. In addition, articles fulfilling the following criteria were excluded: (a) reviews written in any language other than English or Chinese, (b) duplicate publications, and (c) articles or conference abstracts for which the full text was not available.

Study selection

Two researchers independently screened the literature according to the inclusion and exclusion criteria. In case of disagreement, the two researchers first discussed and attempted to resolve the disagreement. If the disagreement could not be resolved, a third researcher was invited to adjudicate. The literature screening process was as follows: (1) Endnote (a literature management software) was used to remove duplicate records; (2) the title and abstract of the articles were read in Endnote, and those that were not related to the subject, population and literature type were removed; (3) the full text of the remaining articles was downloaded, excluding those for which the full text could not be obtained; and (4) the full texts of the articles were read to further exclude literature according to the standard cited in the second step. The study selection process is summarized in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.

Quality assessment

The quality of the included reviews was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklist for systematic reviews and research syntheses [ 36 ]. This assessment tool comprises 11 items, and the evaluation criteria for each item are “yes”, “no”, “unclear” or “not applicable”. Two members independently assessed the retrieved articles. Any disagreement between them was resolved by a third investigator.

Risk of bias assessment

Risk of bias of the included studies was evaluated by two reviewers using the Risk of Bias Assessment Tool for Systematic Reviews (ROBIS) [ 37 ]. In case of disagreement, a third reviewer was consulted until a final decision was made. ROBIS assesses four domains: 1) study eligibility criteria; 2) identification and selection of studies; 3) data collection and study appraisal; and 4) synthesis and findings. Each domain consists of five to six questions with six possible options: Yes, Probably yes, Probably No, No, Not indicated or Not applicable.

Data extraction

Two researchers independently used a unified Excel form that served as a data extraction sheet used to extract variables that were relevant to the scope of the current review, and another researcher verified the accuracy of the data extraction and quality assessment of all the included reviews. The extracted variables included the type of review, years covered, the total number of studies included in the review, country of origin, settings, aims/objectives and participants. As the aim was to provide a broad overview, all barriers and facilitators in all of the reviews were extracted except for those that were infrequently reported (i.e., those reported by only a few studies).

Data synthesis

After the data were extracted, a qualitative content analysis of the factors impacting KMC implementation was undertaken by the researcher. Each review article was read carefully to identify and extract the reported barriers and facilitators, and the researcher prepared the tables to summarize the data of all articles (see Additional file  3 ). The main key factors extracted from the articles were grouped and classified into themes to enhance the comprehension of the results outcomes. This classification of findings was performed based on the identified factors from the studies included in this review. Any uncertainties regarding the thematic categorizations were resolved through discussion and consensus by the reviewers.

Five hundred and thirty one hits retrieved in the initial search were exported into the reference management software Endnote, and 300 of them was left after duplicate records were excluded. A total of 285 references whose subject and theme were not matched were removed after title and abstract screening. Six eligible reviews were included after further full-text screening of the remaining 15 articles, as shown in Fig.  1 .

figure 1

PRISMA flow diagram of barriers and facilitators to implementing KMC

Study characteristics

Table  1 provides an overview of five systematic reviews and one scope review related to KMC implementation as of July 1, 2022, all of which were published in 2015 and later, indicating this topic is relatively fresh. Two of the six articles described barriers and facilitators of KMC implementation from the perspective of caregivers of preterm infants [ 27 , 39 ]; one article explored these influencing factors from the the perspective of healthcare workers [ 28 ]; and the remaining articles discussed the factors affecting KMC implementation from both the perspectives of healthcare workers and parents of preterm infants [ 29 , 38 , 40 ].

The number of studies included in each review varied significantly, which often depended on the inclusion scope of the review [ 27 , 28 , 29 , 38 , 39 , 40 ]. For instance, two most recently published reviews included a smaller number of studies as it defined a specific study area [ 29 , 39 ]. Most of the studies included in the reviews were carried out in low-and middle-income counties and were conducted in health facility.

The methodological quality of the included 6 articles was evaluated by the JBI critical appraisal checklist. The ninth item “Was the likelihood of publication bias assessed” for all the included articles was “No” because publication bias are not assessed in all the included reviews. As the tools for evaluating the quality of the included studies and how to evaluate the quality of the included studies were not described in the two studies conducted by Seidman et al. [ 38 ] and Mathias et al. [ 39 ], so the fifth item “Were the criteria for appraising studies appropriate” and the sixth item “Was critical appraisal conducted by two or more reviewers independently” for these two studied was “No”, and the evaluation results of the remaining items were all “Yes”. The results of the quality appraisal of all the included studies are displayed in Additional file  4 .

After applying the ROBIS tool for risk of bias evaluation, of the six included systematic reviews, four were evaluated to have a high bias risk [ 27 , 28 , 38 , 40 ], and two present an unclear bias risk [ 29 , 39 ] (see Additional file  5 ). Main concerns regarding this aspect were related to (a) limiting searches with language restrictions; (b) lack of risk of bias evaluation; and (c) selection and data extraction not done in duplicate.

Barriers and facilitators of KMC

The five themes identified were environmental factors, professional factors, parent/family factors, access factors, and cultural factors. The subfactors under each theme were divided into barriers or facilitators according to the descriptions provided in the included reviews. A brief summary of the barriers and facilitators identified under each theme is presented in Table  2 . These are described in more detail below.

Environmental factors

This theme comprised facility conditions, resources and materials, and the healthcare system. Facility conditions mainly refer to hardware support in medical institutions, the most common factors being space and privacy. Lack of privacy and insufficient space and supplies directly hinder the implementation of KMC [ 27 , 28 , 29 , 38 , 39 , 40 ], while access to private space/privacy screens and sufficient space and supplies are key facilitators for the implementation of KMC [ 27 , 28 , 29 , 40 ]. In addition, factors such as temperature stability and a quiet and relaxed atmosphere in clinical facilities are conducive to the implementation of KMC [ 27 , 28 , 40 ]. Resources and materials refer to the environmental software support mainly related to resource management and material access. The most common barrier is a lack of KMC guidelines or protocols in the clinical unit [ 27 , 28 , 29 , 38 ], while the implementation of KMC would be enhanced if the clinical unit adopted KMC guidelines or protocols and displayed KMC pictures/posters, etc. [ 28 , 29 , 39 ]. The healthcare system mainly involves educational and policy factors. Inadequate/inconsistent training and unsupportive staffing policies are barriers to KMC implementation [ 28 , 29 , 39 , 40 ], while the integration of KMC into the healthcare curriculum and KMC-related policies are important facilitators for KMC implementation [ 29 , 40 ].

Professional factors

This theme encompassed three subthemes: professional perception, professional characteristics, and professional management. The main barriers under this theme included medical staff’s lack of belief in the efficacy or importance of the KMC [ 38 , 40 ] and their perceptions that KMC is unsafe [ 28 , 39 ] and imposes extra workload on them [ 38 ], the limited level of experience and knowledge of health care workers [ 28 , 29 , 38 ] and lack of communication with each other [ 28 ], high staff and leadership turnover [ 28 , 40 ] and lack of leadership and management support [ 28 , 38 , 40 ]. The main facilitators under this theme included medical staff’s belief in KMC benefits [ 28 , 29 , 40 ] and their sufficient experience, passion, and willingness to implement KMC [ 28 , 29 , 39 ]; leadership and management support [ 29 , 40 ]; and multiple health worker support [ 28 , 39 ].

Parent/family factors

This theme involved parental perception and motivation, parenting capacity, and parental support and empowerment. Experienced and perceived discomfort [ 29 , 39 ], a lack of awareness of the benefits of KMC [ 27 , 29 , 38 , 39 ], and fear/anxiety of hurting the infant [ 38 ] were the most frequently identified barriers to the implementation of KMC. Parenting capacity mainly refers to the health state of the parents of preterm infants. Medical issues such as pain/fatigue [ 27 , 38 , 40 ] and postpartum depression [ 27 , 29 , 38 ] and lack of confidence and knowledge on KMC [ 39 ] were the most common barriers. Support and empowerment refer to the availability of support from family members [ 27 , 29 , 38 , 39 , 40 ], medical staff [ 28 , 29 , 38 , 39 , 40 ], community [ 39 , 40 ], and peers [ 28 , 29 ], which facilitates the implementation of KMC and hinders implementation otherwise.

Access factors

This theme involved time, location, and financing. For medical staff, time was a key barrier; staff perceived that the implementation of KMC would increase their workload [ 28 , 29 , 38 , 40 ] and reduce time with other critical patients [ 28 , 40 ], and they had difficulty finding time for training [ 40 ]. For the parents of preterm infants, commuting from home and the medical unit was another barrier that caregivers were unable to devote sufficient time in KMC practice due to long commutes [ 27 ] or dealing with heavy household chores [ 39 ]. The costs of transportation, accommodation renting, and KMC implementation in the clinical ward were the immediate challenges [ 27 , 38 , 40 ]. Lower hospital costs to family [ 27 , 29 , 40 ], lower cost for health system [ 29 ] and unlimited visitation hours [ 27 , 28 , 40 ] were conducive to the implementation of KMC.

Cultural factors

This theme comprised traditional newborn care, traditional mindset, and gender roles. Traditional newborn care approaches, such as traditional bathing, carrying and breastfeeding practices [ 27 , 28 , 40 ], and the type of wrap [ 39 ] were identified as barriers to the implementation of KMC. However, some aspects of newborn care facilitated the implementation of KMC, i.e., advising mothers to delay bathing [ 28 ]. Some mindsets such as feeling ashamed of having a preterm infant [ 27 , 38 , 40 ], believing that skin-to-skin contact between the preterm infants and their caregivers was inappropriate [ 29 , 38 , 39 ] and considering KMC to be taboo [ 39 ] were identified barriers to the KMC implementation. Additionally, gender inequality existing in the division of labour between fathers and mothers [ 27 , 38 ] was not conducive to the implementation of KMC that KMC was regarded as a role responsibility of the mother, and the father was not allowed to participate in KMC [ 38 , 39 , 40 ] .

Our umbrella review highlighted different factors, each factor comprising barriers and facilitators, that influence the implementation of KMC, provide decision-makers in healthcare with an overview of the field and provide information for the implementation of KMC. All of the included reviews were published in 2015 or later, which confirms the growth and interest in the field of KMC. However, there is considerable heterogeneity in the evidence base on KMC, which makes translation into practice challenging.

Factors related to facility conditions, mainly including lack of privacy and insufficient space and supplies, were mentioned in all six included reviews, which might be related to the operation characteristics of KMC. Skin-to-skin contact is the most important part of the KMC procedure, which requires parents to undress their upper bodies and put their preterm infants on their chests, which is why a suitable physical environment is of great significance [ 11 , 12 ]. Studies have reported that mothers felt uncomfortable and exposed due to the continuous coming and going of medical staff during KMC when insufficient KMC private space was provided, which has proved to be a serious barrier affecting the implementation of KMC in many countries around the world [ 41 , 42 , 43 ]. Therefore, medical units should strive to provide enough quiet, comfortable, and private space for NICUs to implement KMC. Apart from physical facility conditions, resources and materials were another factor. Limited by facility space and human resources, some hospitals in China had to perform intermittent KMC instead of continuous KMC [ 44 ]. A multicountry analysis of health system bottlenecks from 12 African and Asian countries reported that insufficient essential supplies in facilities to support KMC was a barrier to the implementation of KMC [ 21 ].

KMC should be systematically implemented within a facility in accordance with relevant rules and regulations, for example, by adopting standard checklists for mothers and infants to ensure orderly and standardized KMC implementation. In a majority of the hospitals, nurses were required to commit to KMC-related tasks such as KMC recording, assessment, and data monitoring due to the lack of relevant rules and regulations, which meant an extra workload for the nurses [ 45 , 46 ]. Studies have shown that human resource challenges, record keeping, and data collection are barriers to KMC implementation in countries such as Malawi and Indonesia [ 28 , 47 ]. Documentation and annotation of KMC implementation were still not common practices in NICUs, while KMC-related information was imported through electronic medical records in most cases [ 28 , 48 ]. Chan et al. noted that the implementation of KMC was promoted when medical units improved their electronic medical records to allow nurses to record the onset and duration of KMC [ 28 ]. Therefore, the Ministry of Health and government agencies should formulate practical KMC implementation guidelines based on local conditions, and medical units should also formulate and standardize KMC implementation guidelines and programs to promote the implementation of KMC.

Lack of proper leadership, insufficient professionalism of personnel, and insufficient training were also obstacles to KMC implementation. A study on the introduction of KMC in Indonesian hospitals found that government support, hospital management, staff acceptance, and training were identified as key facilitators of KMC implementation [ 47 ]. In some regions, KMC-specific training programs were provisioned for medical staff by the government [ 49 ]. However, the number of staff participating in the training is very limited due to the long distance between the training site and the medical unit and the shortage of personnel in the hospitals, although many medical personnel were willing to participate in the training [ 42 , 50 ]. In other words, although policymakers and decision-makers tried to provide assistance and intervention programs for healthcare workers, they did not anticipate these barriers to attendance. Of course, the support from hospital administrators and leadership could provide more space and human resources to provision KMC, optimize or update the staffing configuration of neonatal care nurses, strengthen the professionalization of neonatal care by healthcare workers, and improve healthcare staff’s attitudes towards and perceptions of KMC [ 43 , 51 ].

The attitudes of the health caregivers towards KMC were also a factor influencing the adoption of KMC for parents. If there were staff in the hospital who were familiar with KMC and willing to educate parents on KMC knowledge, it would help parents of preterm infants to acquire KMC-related knowledge, which would promote KMC preferences and the early initiation of KMC [ 52 , 53 ]. Correspondingly, insufficient awareness of KMC and infant health among parents/family members was a barrier to the practice of KMC [ 22 ]. Despite the generally low awareness of KMC, the reviews reported that it was relatively easier to train mothers on KMC practices and that they were more adherent to KMC practices after understanding and accepting KMC [ 54 ]. Perceived, observed, and experienced effects of KMC could provide comfort and satisfaction to the parents of preterm infants, which promotes KMC use, whereas KMC is inhibited if parents and/or preterm infants experience KMC-related discomfort.

Lack of assistance is a barrier to KMC practice, whereas support from family, friends, and other mothers is a facilitator to the implementation of KMC. There were many different forms of support. For example, family members took turns embracing the preterm infants to free the mother from this practice [ 55 , 56 ]. Evidence from the literature has suggested that emotional support, as well as support and help with household chores, is also a facilitator for mothers [ 57 , 58 ]. Kangaroo nursing can be implemented not only by mothers but also by fathers, grandfathers, grandmothers, and other family members of preterm infants [ 43 , 59 ], and if family members do not understand this point, preterm infants might lose the opportunity to receive kangaroo care [ 60 ]. Therefore, different educational approaches should be adopted to educate families of preterm infants about their roles in KMC, with additional health promotions and activities targeting grandparents and other family members about the benefits of KMC and the significance of supporting mothers, which may increase the number of people receiving KMC.

However, KMC is not suitable for all situations. In some clinical scenarios where mothers of preterm infants have special health conditions, it could be very challenging to train mothers and facilitate KMC implementation. These challenges include the infant being too difficult to embrace, the infant being too heavy, and the mother experiencing chest or back discomfort or pain/fatigue [ 38 ]. The reviews showed that mothers’ medical conditions, including postepisiotomy pain repair [ 61 ], postcesarean recovery [ 62 ], postpartum depression and general maternal illness [ 48 ], were another challenge for KMC practice. Additionally, mothers may mentally struggle with KMC practices, including positioning problems (difficulty sleeping on the chest with infants), breast milk expression, and other breastfeeding-related issues [ 57 , 63 ]. In this case, family support and father involvement make a great difference [ 64 ]. Postpartum depression is a barrier to the implementation of KMC, but interestingly, mothers who practised KMC experienced reduced symptoms of postpartum depression [ 65 , 66 ].

Inviting parents to the NICU to perform KMC could result in extra costs. Studies performed in low-income countries have shown that commuting between home and KMC wards was a barrier to the implementation of KMC, and fees for mothers and babies staying in KMC wards were also considered a barrier [ 39 , 67 ]. Studies have shown that higher economic status is more conducive to the implementation of KMC [ 40 , 43 ]. Therefore, accessing financial resources from hospital administration and/or parental health insurance to facilitate KMC would be a necessary part of KMC expansion. Meanwhile, it is necessary to consider how to reduce hospital charges or provide certain transportation subsidies for families with infants whose hospitalization time exceeds the average length of stay. Limited visiting time in the NICU is another obstacle to the implementation of KMC, especially in the case of closed management such as the NICU in China. Extending the visit time could increase the adoption of KMC to some extent [ 68 , 69 ].

Different cultures, religions, and traditional beliefs in different countries influence perceptions of preterm infants and KMC. In many countries, carrying infants on the chest rather than on the back is considered inappropriate [ 41 ], and some cultures believe that skin-to-skin contact between an infant and his or her caregiver is not appropriate [ 27 ]. Understanding these culturally specific barriers, it is of great importance to adapt KMC promotion programmes to the needs of the population. In some countries, mothers are ridiculed for giving birth to preterm infants, which results in stigma [ 55 , 70 ]. Studies have reported that stigma about preterm infants creates anxiety and guilt in mothers, causing them to abandon their infants, which is a factor hindering the implementation of KMC [ 27 , 38 ]. Muddu et al. [ 71 ] found that fondness was an enabler for parents to accept their preterm infants and utilize KMC to support the improvement of their preterm infants’ health. Cultural barriers also encompass the practice of postpartum confinement and traditional resistance to confinement from grandparents and community members. Most mothers are advised to stay home after delivery in China and India [ 72 , 73 ], which has potential health benefits for mothers and newborns, but it also causes mothers and families to be hesitant to adopt KMC.

Traditional gender role factors were identified as barriers to male participation in neonatal care. KMC was regarded as a breach of social duty or responsibility by mothers in some countries where it is believed that mothers should take care of the family, and when mothers comply with this social duty and gender responsibility, the implementation of KMC becomes a challenge [ 74 ]; meanwhile, fathers are not encouraged to participate in KMC implementation in such cultures. Therefore, it is of great significance to develop interventions on how to encourage fathers to participate in KMC and reduce the stigma surrounding this infant care strategy [ 75 ]. As Dumbaugh et al. [ 76 ] pointed out, the inclusion of males in neonatal care must be done in a way that empowers women. Fathers who are successfully involved in KMC might become peer mentors or examples for others to address the problem of fathers’ reluctance to participate in neonatal care. The name of the intervention, “kangaroo mother care”, could also be modified, e.g., to “kangaroo care”, so that it does not directly imply that the practice is performed only by mothers.


The findings in this manuscript are subject to some limitations. First, due to resource constraints, we only searched for English and Chinese reviews, and there was a possibility of missing some relevant studies. Another limitation of the umbrella review approach was that it could only report on what researchers have investigated and published [ 32 ]. For example, some factors might be highly influential, but if they were not adequately investigated in the included studies, they might be reported as less important, or they might not even be included in the review. To mitigate this issue, other key literature not identified in this review was actively referenced. Finally, a potential limitation to the umbrella review approach could be the risk that bias is transmitted upwards from primary studies to the reviews and then to the umbrella review.

Recommendations for future research

KMC implementation issues are likely to differ among different regions, so there remains a need for further research into sustainable development mechanisms in varied settings to promote the adoption of KMC. The generalizability of the findings worldwide and their translation into practice is uncertain. Most of the studies focused at the facility level, such as the NICU, which highlights the lack of community-level studies. Therefore, further research is needed to explore the factors influencing KMC implementation at home and in the community. Male involvement was identified as a facilitator to KMC implementation, but there was no study discussing hindrance factors of father involvement in care specifically. Therefore, further research is also needed to explore the hindrance and/or facilitating factors of male involvement in KMC care from the perspective of fathers. In addition, further research is also needed to test models for addressing barriers and supporting facilitators to promote and implement context-specific health system changes for greater uptake of KMC.

KMC is a complicated intervention that encounters unique barriers and facilitators in different aspects of healthcare systems. Our umbrella review prioritizes the main factors influencing KMC implementation and highlights some key areas that implementers and implementation researchers may need to focus on. KMC should be implemented more systematically and continuously to strengthen and expand its adoption.

The parents of preterm infants and other family members, the medical unit, and the medical staff contribute to a dynamic whole as a triangle, that are closely linked with one another. Support from facility management and leadership and well-trained medical staff are of great significance to the successful integration of KMC into daily medical practice, while the parents of preterm infants and other family members should be educated and encouraged to adopt KMC practice. Effectively integrating KMC into current health systems by addressing barriers and building trust will greatly improve neonatal survival rates.

Availability of data and materials

The datasets analyzed during the current study are available from the corresponding author on reasonable request. All data were extracted from published systematic reviews and meta-analyses.

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Conceptualization, QC, XFX and HW; Methodology, QC, DQC and YZ; Validation, QC, DQC and RY and YZ; Formal Analysis, QC; Resources, QC, YZ and WLX; Writing – Original Draft Preparation, QC; Writing – Review & Editing, QC, DQC, RY and XFX; Supervision, XFX and HW. All authors have read and agreed to the published version of the manuscript.

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Supplementary Information

Additional file 1..

PRISMA 2020 Checklist.

Additional file 2.

Search strategies for English and Chinese databases.

Additional file 3.

1. Articles presenting barriers to implementing KMC. 2. Articles presenting facilitators to implementing KMC.

Additional file 4.

Result of the quality appraisal of included studies.

Additional file 5.

Risk of Bias analysis using ROBIS tool.

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Cai, Q., Chen, DQ., Wang, H. et al. What influences the implementation of kangaroo mother care? An umbrella review. BMC Pregnancy Childbirth 22 , 851 (2022). https://doi.org/10.1186/s12884-022-05163-3

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Review of kangaroo mother care in the middle east.

review of literature on kangaroo mother care

1. Introduction

2. materials and methods, 2.1. eligibility criteria, 2.2. information sources, 2.3. risk of bias, 4. discussion, 5. conclusions, 6. recommendations, author contributions, conflicts of interest.

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Taha, Z.; Wikkeling-Scott, L. Review of Kangaroo Mother Care in the Middle East. Nutrients 2022 , 14 , 2266. https://doi.org/10.3390/nu14112266

Taha Z, Wikkeling-Scott L. Review of Kangaroo Mother Care in the Middle East. Nutrients . 2022; 14(11):2266. https://doi.org/10.3390/nu14112266

Taha, Zainab, and Ludmilla Wikkeling-Scott. 2022. "Review of Kangaroo Mother Care in the Middle East" Nutrients 14, no. 11: 2266. https://doi.org/10.3390/nu14112266

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