Introduction

More than 2.5 million newborns die each year, accounting for 47% of children dying before the age of five years worldwide [1]. Complications of preterm birth are the leading cause of death among newborns [2]. Of the fifteen million babies born too early each year, more than one million die due to complications related to preterm birth. Low birth weight (newborns weighing < 2,500 grams at birth), due to prematurity and/or restricted growth in utero, is also a major contributor of annual newborn and child deaths worldwide. Pakistan is amongst the ten countries with the greatest number of preterm births and the highest rates of preterm births per 1000 live births, with 860,000 babies born preterm and 75,000 children dying under the age of five due to direct preterm complications annually. Almost one in every three babies born in Pakistan (32%) is a low birth weight (LBW) baby [3]. World Health Organization (WHO) issued recommendations [4] for the care of preterm infants in November 2015, including kangaroo mother care (KMC). An international joint policy statement and endorsement also came from health professional associations (American Academy of Pediatrics, Council of International Neonatal Nurses, International Council of Nurses, American College of Obstetricians and Gynaecologists, International Federation of Gynaecology and Obstetrics, American College of Nurse-Midwives, International Paediatric Association and International Confederation of Midwives) for universal use of KMC for preterm and LBW Infants. The WHO has defined KMC as early, continuous, and prolonged skin–to–skin contact between the mother and 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[5]. KMC has three main components, including: thermal care through continuous skin-to-skin contact by being wrapped with a cloth to the bare chest of the care giver; support for exclusive breastfeeding or other appropriate feeding; and early recognition and response to complications [6]. Neonatal mortality analyses from a 2014 Cochrane review [7] (11 randomized controlled trials) and a 2016 meta-analysis by Boundy [8] (16 studies) found a 33 percent and 23 percent reduction in neonatal mortality, respectively, at the last follow-up when comparing KMC to conventional neonatal care. In both mortality analyses, all but two of the studies included were in resource poor countries. The systematic review conducted by Agudelo & Rosello [9] suggested KMC as an effective and safe alternative for conventional neonatal care for low birth weight (LBW), especially in settings with limited resources. In LBW newborns (< 2000 g) who are clinically stable, practicing KMC can reduce mortality and if widely applied could reduce deaths in preterm newborns [10].

Globally, after the Every Newborn Action Plan (ENAP) has identified KMC as an essential component of newborn health initiatives [11], many agencies have made KMC a priority. In Pakistan as well, policymakers, researchers and key stakeholders in newborn health have recently highlighted KMC as a top preterm intervention agenda as part of the ENAP [12].

United States Agency for International Development (USAID) led a successful initiative in Pakistan through provision of comprehensive maternal newborn child health (MNCH) services to women and children in Sindh Province. Maternal and Child Health Integrated Program (MCHIP) led by Jhpiego and in collaboration with Save the Children, Program for Appropriate Technologies in Health (PATH) and John Snow, Inc. (JSI) implemented this MNCH initiative across 16 districts during 2013–2018 in Sindh province. In addition, Save the Children was also implementing another health project with funding support from the Australian Government, titled Integrated Maternal, Newborn and Child Health (IMNCH) Sindh in Shikarpur and Jacobabad districts. The IMNCH-Sindh project was designed with the objective of complementing MCHIP interventions and activities in these two districts.

MCHIP/USAID and the Australian government supported IMNCH programs facilitated to introduce KMC in two districts (Khairpur and Shikarpur, respectively) in Sindh as a pilot study to introduce KMC first ever in Sindh, Pakistan, in order to make recommendations for scale-up the KMC intervention effectively in other districts of Sindh and to other provinces in the country. To achieve this, it was crucial to understand the key barriers and enablers contributing to the caregiver’s (in)ability to practice KMC and the feasibility of implementing and improving these practices.

In order to enhance successful initiation and implementation of KMC, study by Seidman et al [10] highlighted the importance of understanding the barriers and enablers, within the sociocultural and health systems context, those support uptake and continuity of KMC practice from both supply and demand side aspects.

This pre-implementation study aimed to identify the barriers and enablers prior to introducing KMC in Sindh province at both facility and community level in order to inform policy makers and program planners a way to roll out.

Materials and methods

This study followed a qualitative study design and recruited study participants by employing purposive sampling strategy based on convenience and availability of eligible study participants.

Results

A total of twelve IDIs and fourteen FGDs were conducted across both study sites. The numbers of participants in IDIs and FGDs in study districts are shown in Tables 1 and 2.

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Table 1. Number of in-depth interviews (IDIs) conducted.

https://doi.org/10.1371/journal.pone.0213225.t001

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Table 2. Number of focus group discussion (FGD) sessions conducted.

https://doi.org/10.1371/journal.pone.0213225.t002

We present our study findings in following two sections: A) Enablers and B) Barriers of KMC implementation.

B) Barriers of KMC implementation

Lack of facility readiness to implement KMC.

Managers and health care providers recommended facility strengthening as a prerequisite for implementing KMC at facility level. They pointed out that in-patient ward in the facilities need modifications to ensure privacy for mothers.

“Health facilities need modifications in hospital wards for ensuring privacy to practice KMC and all necessary things required (to practice KMC) should be provided to the patient”(Health care provider, IDI participant).

Lack of training health workers.

In addition to suggesting infrastructure modification at facility, the respondent managers and health service providers also talked about training need for facility staff. None of the health workers (care provider or manager), both at facility and community level, has ever received any training in KMC and they identified staff’s capacity strengthening as one of the basic requirements for implementing KMC at facility level.

“Neither we (managers) nor our staff in this facility received any training on KMC ever. Training at all levels from management, providers and paramedic staff is a prerequisite before introducing KMC at facility” (Health manager, IDI participant).

“First of all we (health care providers) should be trained in conducting KMC and counseling skills to convince mothers to practice” (Health care provider, IDI participant).

In addition to health care facility staff, community based outreach workers (e.g., LHWs) were also identified with lack of knowledge and experience about KMC, though few responses from few LHWs reflected their awareness on need of special and more care for preterm and LBW babies.

“Neither I have ever seen this practice anywhere nor (I have) received any training on this before” (LHW, FGD participant).

Lack of time / workload of LHWs.

With reference to involvement of LHWs in implementation of KMC, a concern was also raised due to their existing workload.

“LHW can play very important role in implementing KMC hence (they) should be trained on KMC. There must be transport facility and other incentives for LHWs…… Having a trustworthy LHW would be the positive factor to encourage KMC at house level” (LHV, IDI participant).

“LHWs are already overburdened in other priority health issues such as polio eradication. Hence their commitment is necessary to support mothers and referral newborn to facility in case of complication” (Health care provider-IDI participant)

Socio-cultural norms and practice.

Study participants also expressed concerns that other female family members may oppose practicing KMC since it will result in shifting of KMC practicing mother’s workload to other female member(s) in the family. It will be challenging for RDW too, who otherwise is expected to contribute to household chores after delivery, particularly if there is no other female in the family to support in the household.

“Our senior family member may not allow me to do KMC at home” (RDW, FGD participant)

“I am only single living with husband in my home, so. I do my all work as sweeping, cleaning etc. at home” (RDW, FGD participant).

Additionally, study respondents raised few other socio-cultural concerns regarding acceptance and support to KMC at household. They were also afraid that they might also face ridicule if mothers spend most of time in caring of their newborns. Culturally they are expected to take care of household chores along with taking care of their newborns.

“I have few concerns …it (practicing KMC) will affect (undertaking) home responsibilities of the household, face taunts of other family members that all the times she held baby with herself”(TBA, FGD participant)

Some RDW participants raised concern regarding potential opposition to the practice of KMC due to prevalent social norms of privacy, given that practicing KMC needs the mother to put the baby on her bare chest, as appeared in the quote below:

“In our culture women are not even permitted to go relatives’ home so, how a woman can practice KMC with half naked dress pattern”? LHW, FGD participants

“Grandfather will not allow practicing KMC because it is against social norms to wear such type of clothes which are designed for KMC” (TBA FGD participant).

The summarized results yielded from facility and community level respondents are listed below, in Table 3.

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Table 3. Summarized results from respondents at health facilities and community.

https://doi.org/10.1371/journal.pone.0213225.t003

Discussion

Our findings are consistent with results from past research on health worker and community members’ perspectives on the feasibility of introducing KMC as well as key barriers and enablers affecting implementation. Health care providers, both at facility and community level, received several newborn care trainings such as Helping Babies to Breathe (HBB), Essential Newborn Care (ENC), neonatal umbilical cord care by using chlorhexidine, and similar other relevant training courses. However, we found that none of the health providers and managers had received any previous training on KMC in the selected study facilities. The respondents at facility level emphasized the critical need for KMC training as a prerequisite of implementing KMC at facility level. Relevant evidence exists in literature and echoes our findings as training opportunities are crucial to provide health care workers with knowledge and skills to facilitate KMC [14]. In a multi country study from Malawi, Mali, Rwanda, and Uganda, researchers found that in service training and including KMC in preservice curricula is a facilitator to implement KMC [15]. Expanding training to other health-care personnel, such as administrators and interns, also enabled KMC acceptance. Another study result also revealed in-service training of health-care workers as enhancer of KMC implementation [16]. Many nurses also found that integration of KMC into pre-service and training curricula was beneficial to accelerate its uptake [17, 18].

Our study results also revealed health care managers and providers at study hospitals are supportive of the idea of implementing KMC, which is a crucial enhancer, and offers opportunity to initiate KMC at facility level and rollout to community level. To establish an effective KMC at the facility level, motivation and enthusiasm of health care provider towards KMC is essential. Evidence in the literature from previously conducted studies are found supporting this finding. The above mentioned multi-country study in Africa on implementing facility-based kangaroo mother care services also found the staff as enthusiastic about KMC services and the support of senior management at the district and facility level played an important role in upholding staff motivation and their ability to continue KMC service [15]. Often, nurses want to practice KMC at their facility, but a lack of managerial support and poor staffing levels impede its practice [19]. Facilities that had successfully implemented kangaroo mother care reported that they received support from their management and had good communication among the staff [20–22].

In a systematic review, researchers identified "issues with facility environment/resources" and "negative impressions of staff attitudes or interactions" as the top two barriers to practice KMC at the facility setting [10].

Strengthening health facilities is an essential prerequisite for introducing KMC implementation at the facility level, as revealed from our study results. This includes infrastructure, equipment and other required logistics and materials for KMC at the facility. Several studies also identified that inadequate resources and logistics (e.g., chairs, beds, linens, curtains, KMC wraps, etc.), insufficient physical space and inadequate privacy (e.g., lacking private space or privacy screen) are major hindering factors to support KMC at the facility level [22–25]. Previous studies have found that when there were adequate logistics (beds, chairs, KMC wrap/binder), as well as physical space with adequate privacy where mothers could practice KMC, the adoption and uptake of KMC were easier at those facilities [22, 26, 27].

Our study respondents emphasized on the need of community level awareness raising and creating links between community and health facilities through LHWs for better implementation at facility as well as continuation of KMC practice at household. The role of LHWs is key factor in improving acceptance and compliance of KMC at facility and community level, respectively. Effective counseling of mothers and their household members is the key for acceptance and successful adherence to the protocol of KMC. As our study respondents suggested, these counseling and awareness raising sessions for community could be facilitated using different media such as video sessions and other information, education and counseling (IEC) materials during household visits by LHWs. At facility level, nursing staff is mainly involved in counseling and at the community level, LHWs are the key player to create awareness and ensure acceptance and adherence. Evidence also supports the value of counseling for mothers about the importance of KMC by community health worker [28]. In a systematic review of studies conducted in lower and middle-income countries, understanding of mothers about the benefits of KMC was found to be among top five facilitators to practice KMC at facility and household level [10]. In rural India, most mothers were found to have a good understanding about KMC after counseling by community health workers, and they could demonstrate the process of KMC correctly [29].

Our study participants at the community level were aware that newborns should be protected against the cold, and skin-to-skin care could be a beneficial way to protect these babies at risk but skin-to-skin contact to provide warmth is not the prevailing norm. Researchers in Ghana also found mothers recognizing that low weight babies could result in serious illness or endanger their life, and they believe skin-to-skin contact care could improve their babies’ health and survival [30].

While our study data revealed the feasibility of KMC initiation at two health facilities and continued use at home within these two study districts, we also found concerns and reservations expressed by study participants related to socio-cultural norms, household work responsibilities and privacy. Researchers also identified social and cultural norms as major issues in the adoption of KMC and found that social support can improve the uptake and duration of KMC [28]. Some elders and uneducated people in the community with a conservative mentality, may be reluctant to accept new methods like KMC as they still believe that traditional methods are safe. Even some people who perceive KMC as a beneficial method, are unwilling to practice this due to the fear of criticism by others [31].

Support from family members is very crucial to continue KMC practice, and it is found to be one of the top ranked enablers for KMC implementation, especially in low and middle-income countries [10]. Specifically, support from mother-in-law and sister-in-law is crucial for the recently delivered mother to practice KMC. Given the joint or extended family structure in Pakistan, it is highly likely that other female family members will be able to support the mother to practice KMC. In Brazil, mothers were grateful to have someone help them during kangaroo mother care, such as grandmothers and sisters, who could take care of housework and help with the newborn [32]. A study in Bangladesh reported where mothers felt resistance from family members, mostly from their mother-in-law and sister-in-law to practice KMC [33]. Participants in another study conducted in Bangladesh expressed that getting help from motivated husbands, sisters-in-law, mothers, and mothers-in-laws in holding the neonates skin-to-skin or doing house hold work would facilitate KMC uptake at community [31].

Husbands, specifically in Pakistan, and in other countries with similar sociocultural norms within the region, are usually not the caregivers of the newborns and less likely to have any active role in practicing KMC. Although, husbands showed willingness to practice KMC for the health and survival of their newborns, but it seems they may have little time to practice given their responsibilities of working outside home or they also may suffer challenges of prevailing customs and socio-cultural norm. Due to societal norms, in some places like Zimbabwe, South Africa, and South Asia, fathers feel uncomfortable to take care of their babies or perform KMC, and they see it as only mother’s responsibility [15, 34–36].

The mother’s obligation to perform household chores is one critical barrier to KMC practice [10, 31, 35] and many mothers found KMC as a burden due to responsibilities at home or work [28] which is quite similar to our study findings. In Maharashtra, India, most of the mothers living in a nuclear family could not continue KMC due to their responsibility to perform various household and agricultural work [29] and similar situation was found in Bangladesh too [31].

While our study is one of the very few studies conducted in Pakistan on KMC, specifically no previous exploratory study is reported in the literature exploring barriers and enablers for introducing KMC in health facilities and continuing KMC practice at household in Pakistan. However, there are few limitations in our study. For organizing the FGD sessions, the sampling strategy included only RDWs having an alive baby and thus the RDWs whose baby died before the FGDs were excluded. These excluded RDWs could be contributors of important other information which we had missed. The interviewers were university graduates and that may have influenced study participants to provide socially desirable responses. In an effort to limit such risk, data collectors were trained to take an informal approach to conduct IDIs and FGDs and to collect data objectively (rather than introducing subjective bias). The other limitation of the study may include collecting only qualitative data and skipping quantitative data (either primary data from RDW about their previous and current delivery, age, parity, family home settings, or secondary data from facilities) those could offer additional strength through triangulation of qualitative and quantitative data.

Conclusion

Our study results revealed feasibility to initiate KMC practice at health facility and to continue practicing at home after returning from facility in rural communities in Pakistan. Ensuring facility readiness to initiate KMC, improving capacity of health providers both at facility and community levels, coupled with focusing on community mobilization strategy, targeting specific audiences, may help policy makers and program planners to initiate KMC at health facility and keep KMC practice continued at household level in similar settings. Further research could help gathering more insights on these issues.

Acknowledgments

We acknowledge guidance and support received from Anna Bauze, former Health Advisor, Health and Nutrition Sector, Save the Children Australia, Emma Williams from Jhpeigo, USA and Shabir Chandio in the Office of Health, Population and Nutrition, USAID Pakistan Mission. We thank the MCHIP team in Pakistan for offering necessary management and administrative support to implement this study. Our grateful appreciation goes to our colleagues in the Ministry of Health (MOH), Pakistan at Sindh provincial level as well as at national level MOH colleagues for their valuable support and advice to conduct this study.