Enablers and Barriers to Kangaroo Mother Care in Decentralized African District

Background: Since its creation in the 1970s, Kangaroo Mother Care (KMC) has proven many benefits, particularly in reducing mortality of premature or LBW new-borns in low resources settings. Unfortunately, its expansion, especially in Africa, remains insufficient. A KMC project set up over 2 years in the district hospital of Bonassama in Cameroon with a grant of the Geneva University Hospitals (HUG). After more than five years, its sustainability remained uncertain without external funds. We therefore thought to determine enablers and barriers to KMC in this health structure of a low resources African district. Method: Qualitative research by semi-structured interviews with 22 families and 6 caregivers who directly participated in the KMC program. Data analysis was based on a pre-established evaluation grid. Results: The main barriers to KMC parents were communitarian, based on prejudice against prematurity and LBW, direct costs for families


Introduction
Prematurity and low birthweight (LBW) is considered the first cause of mortality in new-borns worldwide [1]. Fifteen million premature births occur each year [2], of which one million die due to its complications [3]. The WHO's seven recommendations to improve survival and health of new-borns recommend Kangaroo Mother Care (KMC) for premature or LBW new-borns since 2015 [4]. KMC was developed in the 1970s due to a lack of incubators [5]. It has showed improved survival and neurocognitive outcome [5][6][7].
Today, broadly supported by WHO, UNICEF and large NGOs, KMC is recommended for basic neonatal care based on its positive cost-benefit balance. However, expansion of KMC, particularly in sub-Saharan Africa, remains low. Since 60% of the world's prematurity occurs in sub-Saharan Africa and South Asia [1], it is essential to understand barriers to KMC, its sustainability and expansion, specifically in these regions.
A systematic review of enablers and barriers to KMC [8] identified the days spent in hospital practicing the method, social and medical support, family acceptance and organization, and finally financing and performance of the health structures as supporting elements. According to this review including 29 studies with 9 from the African continent, the adoption of KMC was predominantly influenced by cultural norms and perceptions. Mothers played a central role in acceptance or refusal of KMC, strongly influenced by family stigmatization and pressure, lack of willingness, tiredness, and post-partum depression [9]. Only three studies concerned rural settings or decentralized structures [10,11]. As KMC may be most relevant to such decentralized healthcare facilities of lower level, understanding their enablers and barriers appears essential.
Descriptive data of a small neonatal unit in a decentralized sub-urban district hospital of Bonassama in Cameroon showed the highest association of mortality with hypothermia [12] and led subsequently to the development of a KMC program supported by a 2-year cooperation fund from the University Hospitals of Geneva.

Method Objectives
The aim was to understand enablers and barriers to KMC and its sustainability in a decentralized sub-Saharan healthcare structure. We collected the experience of caregivers and families who were directly involved in the KMC program, to uncover critical barriers and infer levers for autonomy, propagation, and sustainability of KMC.

Study type
Qualitative observational study through semi-structured interviews.

Population
We included KMC families and healthcare staff. Inclusion criteria for families were personal experience in continuous KMC, the possibility of contact for the interview, and an informed signed consent. Travel fees to the interview site were provided (3.6 U$). Inclusion criteria for healthcare staff was direct experience in KMC support and follow-up of at least 10 mother-child dyads.

Setting
Interviews were conducted at the District Hospital of Bonassama by the two primary authors (LM, KB) of the Geneva University (Switzerland) with training and supervision of two senior neonatologist (DKK, REP).
Bonassama is a suburban, decentralized, low resources district of the port city of Douala. Its district hospital possesses a small neonatology unit, which is the only one in the district. It provides care for a large radius, with some requiring up to 4 hours travel time. Sanitation was rudimentary with only cold running water. Paediatric patients and parents were not provided food during hospitalization. Hospitalization fees in the unit were about 15 U$/hospital day.
In late 2012, a three bedded KMC room was set up. For two years, all parents of low birthweight new-borns (< 2500g) were offered to practice KMC as soon as their baby was considered stable. Upon acceptance they received two Lycra® pouches for carrying and in-hospital support through a dedicated paediatrician or KMC-nurse. Participants practiced KMC on average 18 hours per day. Parents were encouraged to pursue KMC at home. At least one home visit by the KMC-nurse was provided. Regular followup for weight, height and immunization were also offered.

Ethics Consent
The Kangaroo Mother Care project at Bonassama, including its evaluation, was approved in 2012 by the Ethics Committee of Cameroon. The hospital direction of Bonassama gave written consent for the evaluation and each interviewee gave informed written consent for the interview. Analyses were anonymous.

Interviews
A qualitative semi-structured questionnaire (see additional material) was composed around seven themes (demography, 4 Volume 06; Issue 02

Demographics of Participating Mothers/Families
General knowledge and first contact with KMC ( Figure 1) Only two (9.1%) of the mothers/families had heard about KMC before the current pregnancy. Their most difficult experience was unanimously the first contact with prematurity or low birth weight, much more than KMC. All interviewees thought it necessary to receive information on KMC before giving birth. However, most recalled having understood and accepted the method when presented to them. Directly learning the KMC practice from a dedicated KMCnurse or paediatrician was considered optimal by all families. Caregivers reported the same perception. Healthcare staff had received a specific theoretical education, followed by applied training. KMC training itself was remembered very positively.
When asked how comfortable they were with the concepts of KMC, families and caregivers felt capable and motivated to safely teach and pass on the KMC method. Half of the parents had already spread their knowledge to other parents in the community or within the health care facility and most families and caregivers (89.3%) had explained KMC to their relatives. Caregivers and parents felt it was important to broaden knowledge within the community and considered the knowledge transfer efficient, comprehensive, and with a positive long-term impact.

In-hospital KMC (Figure 3)
Particularly during early practice of KMC, mothers recalled a feeling of tiredness and stress. Despite the absence of distractions in hospital, boredom and solitude were not considered relevant. Support by caregivers and interaction with other KMC-families in the unit were appreciated. The general atmosphere within the unit was felt to be comforting due to the open discussions with caregivers. KMC-mothers received regular external visits, but very few had a second carrier to free some of their time.
All considered their participation in the KMC program as a personal choice without external constraints. For mothers and families, prematurity and LBW were the main source of anxiety and fear, but without feelings of shame or guilt. Anxiety and fear were mainly fueled by the community, family, and own prejudices. In the community, although KMC was perceived positively, hospitalization and prematurity were seen negatively. Concerning identification with the mostly unknown Australian kangaroo, neither mothers nor staff reported negative perceptions. For relatives, in-hospital KMC was complicated due to the prolonged absence of the mother from home. The principal reported maternal difficulty of home-KMC was tiredness, exacerbated by household work and the care of other siblings. Despite tiredness, interviewees reported that their good practical aptitude acquired in hospital made them feel confident and facilitated home-KMC. Returning home was remembered pleasantly and parents did not report excessive stress for too early or too late hospital dismissal. However, outpatient hospital followup was preferred to the home visit, by parents and caregivers alike.

Barriers to KMC (Figure 4)
Significant general barriers to KMC were, in order of reported relevance, (1) insufficient knowledge on KMC, (2) direct costs (hospital) and indirect costs (work interruption, travel costs) and (3) prejudice against KMC. However, KMC was not considered against local traditions and thought to find social acceptance in Cameroon.
For global logistical barriers to KMC, (1) transportation fees and equipment costs, (2) constraints arising from KMC such as fatigue from continuous carrying and heat discomfort, and (3) travel duration or distance from home to hospital were put forward. However, in personal matters, these barriers, including social pressure and duration of hospitalization, have not been retained as significant hindrances.
Carrying pouches and disposable diapers were two accessories unanimously considered essential for KMC, as reusable diapers reported uncomfortable by mothers. Although recommended by WHO [5] in certain temperatures, hats, socks, and open sleeveless shirt for the baby were not considered essential. The availability of these accessories was reported as complicated and stressful by caregivers only.
Direct hospital costs associated with KMC were considered a limiting factor by caregivers and parents. Caregivers only, strongly felt a negative financial impact of KMC on the healthcare facility. Despite the high personal motivation put forward, caregivers expressed a low likelihood of KMC becoming autonomous and sustainable in their district hospital. The possibility for parents to pay off part of the direct hospital costs with some short-term handwork at the facility was welcomed by most parents, but frankly refused by caregivers.

Discussion
The discussion is structured according to the 7 interview sections followed by illustrating quotes.

Demography
It was easier to interview families than anticipated, contrasting with the difficulty to access caregivers, due to their lack of time, but also reluctance. We therefore feel the caregivers' answers should be interpreted carefully, but staff reluctance points to a main barrier.
Most of the 22 mothers were around thirty years old with secondary level education, and primiparous. We considered the high proportion of first-time mothers compared to the country's average a positive selection bias for KMC due to lower family duties, rather than just availability for interviews.
Only 34% of parents had accepted KMC. Despite comparable weight and pathologies, in-hospital mortality was considerably lower in the KMC (4%) compared to the standard care (18%) group [17]. It has not been possible to interview refusing families as contact details were not recorded in the KMC register for confidentiality reasons, and parents still in hospital refused the interview. As all interviewees had surviving babies, a selection bias putting forward more optimistic views is likely.

First contact with KMC
The first contact with KMC was associated with negative emotions. However, parents were unable to distinctly separate these feelings from those associated with prematurity and LBW. Some form of parental education on these subjects appears essential. Information, Educations, Communication (IEC) is a common educational practice in Cameroon during hospital waiting periods, but prematurity and LBW are not covered, despite concerning up to 20% of new-borns [12]. In addition to public awareness campaigns, personnel involved in antenatal care need more education on KMC [18] to inform mothers at risk early. This may include a visit to the KMC unit or contact with KMC mothers.

QUOTES:
Mother #5 : […] The main barrier is, according to me, that parents do not accept their babies and their realities. At the beginning, I had a lot of hardship myself. I cried a lot because I

Learning/Teaching KMC
In general, teaching and learning KMC was considered effective by healthcare providers and parents alike. Particularly peer-to-peer parent education was perceived as very effective. In contrast, access to structured KMC training for caregivers was felt insufficient, as also reported by Engler & al [19]. Broader training opportunities and institutional encouragement were desired.
All interviewees felt at ease with KMC and communicated willingly with others about it. Parents who had personally practiced KMC were particularly knowledgeable and keen advocates of the method in the community [18,20].

In-hospital KMC
When practicing KMC, especially at the beginning, fear for the child's death, weariness and stress were the predominant emotions reported. These feelings may be attenuated by anticipation, that is, better general knowledge on prematurity, LBW and KMC in the childbearing population. To reduce maternal exhaustion, more active encouragement or second KMC carriers should be considered [5].

QUOTES:
Mother #12 : […] My hospital stay went well even though I was scared at first. I was stressed because I did not know how to proceed. I did not know that it was possible for a baby this small to survive. Many people told me that it was a waste of time, that my baby would die anyway since it was this small. One day, a KMC mother showed me her son, all grown up and fat, even though he had been smaller than mine. This gave me the courage to continue. […] Mother #14 : […] My husband tried to hold our baby [in KMC] once during our hospital stay but he did not wish to do it again afterwards. I am not sure why he did not wish to do it, maybe he found it tiring. […] For families, the parents', particularly the mother's, absence from home was considered a main difficulty. In addition, the close community criticized hospitalizations with costs deemed unreasonable. Arguments that traditional methods to care for small babies were as efficient but less expensive were common.
Several lines of evidence suggested poor reputation of healthcare structures in general; elements put forward were corruption and fraud, but also the high hospital mortality. In this respect, KMC appears an effective intervention to promote respectful and participatory care, and possibly rebuild community trust. Using advocacy of KMC-mothers and families, and including traditional chieftaincy, may therefore not only leverage promotion of KMC but more broadly paediatric healthcare in the African society [8].

Home-KMC
A precautious return home on KMC with proper follow-up is recommended by the WHO [5]. However, home follow-up in remote or inaccessible areas was complex. After in-hospital KMC, parents felt competent and confident with home-KMC and praised the teaching and encouragement by the dedicated KMC-nurse. The main complaint at home was tiredness. 10 Volume 06; Issue 02 Despite some considerable travel distances of up to several hours to reach the hospital, out-patient follow-up was preferred to home follow-up by parents. Their arguments were availability of anthropometric equipment and emergency services. We may infer that KMC made the healthcare structure more trustworthy. Caregivers preferred hospital follow-up too for reduced travel cost and logistics. However, home visits may have a promotional role in sensitizing remote communities with KMC, as reported in Ghana [21], thus supporting competent KMC-families within the community [8,9].

Barriers to KMC
The main general barrier reported was the lack of knowledge about KMC. Once the method understood, accepted and above all practiced, few barriers discourage parents, even when at first reluctant. Awareness campaigns, particularly during antenatal care, may therefore encourage broader use of KMC. Mothers were more easily convinced through concrete examples, other practicing mothers, and as reported elsewhere, rapid initiation of KMC at birth [17].
Other reported barriers, such as frequent changes in hospital management, corruption, and cultural prejudice in the community [8,9] were also reported by our interviews. The distance from home to hospital was not put forward as a significant logistic barrier, although frequently mentioned. We assume that the distance barrier was overcome by the acceptance of the method, as reported by others [8,9,22].
The main cultural barriers to KMC put forward by families were the bad reputation of hospital structures and community pressure to use cheaper "traditional" care of LBW babies. Although KMC itself was generally not considered against local habits, practicing KMC mothers strongly remembered negative social pressure from the extended family and relatives. Main concerns of the broader family were delayed return home, and a fatalist opinion on viability of the LBW baby. We hypothesize that parents who refused KMC may have experienced the impact of this social pressures and prejudices even stronger.

QUOTES:
Mother #18 : […] My uncle told me my baby should die… Even my uncle criticized us ! He said we should already prepare the burial, given that my baby was too small. He came back to visit us after a month and apologized because he saw that in the end all was well. […] Mother #12 : […] My mother, who is also the village mother, did not want me to participate [KMC program] because I could not get out of the hospital and that there were too many trips from and to the hospital. She said it was a waste of money, and that it would be better for me to come back to the village. Infrastructure, such as a dedicated KMC room as well as toilets/showers accessible to parents specifically set in place for the program were considered as provided but are seldom available in peripheral healthcare structures in the sub-Saharan context. Provision of equipment and consumables may be resumed to financial barriers. For caregivers, the carrying pouches were considered the most essential consumable. During the KMC project, two pouches were gifted to each participant for hygiene reasons. After external financing stopped, the healthcare structure was unable/unwilling to finance these pouches, temporarily leading the nurses to acquire them privately. Locally produced pouches costed 1'450 CFA (around 2.6 USD), close to one third of a nurse's daily salary. This supports the view that healthcare staff was very supportive to KMC and that limitations were more at a hospital management level.
For parents and caregivers, financial capacity was spontaneously mentioned as the most important condition for KMC. However, upon direct interrogation, financial barriers were not considered the most important, although a selection bias is likely to downplay this barrier. Free governmental new-born care in Cameroon, including KMC [23], may mitigate these direct financial limitations to KMC.

QUOTES:
Mother  [KMC] is. Until people have not tried, there remains doubt, they are unsure of the benefits. It is not a question of religion or culture. We often encounter people who initially refuse or are reluctant, but once they try, they continue. […] Like in most African district hospitals, patients had to acquire and pay for the necessary medical consumables. This included syringes, nasogastric tubes, saline solutions, oxygen, phototherapy, antibiotics, blood tests, and even hot water. Up to 30'000 CFA (54 USD) per day may thus add up to the regular hospital fees (particularly on oxygen therapy). For relatives and friends of our interviewees these additional expenses were regarded as means of profitmaking by hospitals. Consequently, KMC was associated to such practices.
Globally, work insecurity and unstable salaries were frequently recounted. With more than one third of Cameroon's population living under the poverty threshold, and with a GDP of 3'600 USD [24,25], the financial strain of treatment costs was evident and easily understandable. Several parents had to take loans in their community to pay hospital bills. To mitigate the financial burden, most parents would have gladly accepted simple work such as cleaning or gardening for the hospital. Caregivers were reluctant as they feared an additional workload for setting it up, and the potential risk for their own job.
Despite recommendation of reusable diapers by WHO [5] to reduce costs, disposables were largely preferred by our KMC mothers based on diverse arguments such as hygiene, religious believes and other personal reasons. Although a washing facility had been made available for the KMC program, easy access to a public water point is not always available at decentralized healthcare structures.

Sustainability of the Project
Given the numerous advantages [6] and its broad recommendation by WHO, KMC should be the standard of care for LBW babies. The motivated KMC-nurse had maintained close contact with families and promoted KMC in addition to her primary role of in-hospital facilitator and data manager within the externally financed program. She played a key role for keeping the program alive. Transition from acute neonatal care to KMC needs close integration within the neonatal unit. Appropriate premises and adapted infrastructures for maternal comfort [5] appear essential since dyads are initially concealed within the unit, often sitting, or lying for hours [17,18]. However, mothers did not complain of boredom. Idle time was and may be further used for IEC sessions on neonatal and paediatric health care.

Conclusion
Our report focuses on facilitators and the main barriers to KMC put forth by parents and healthcare staff in a decentralized regional hospital of Cameroon serving a large and inaccessible catchment area.
Sequential interviews foremost revealed poor general knowledge of prematurity, LBW and KMC in the general population and a strong prejudice against healthcare structures.
General feedback from KMC-parents and caregivers on the method was always very positive. Although parents who personally had practiced KMC refuted direct costs as a significant barrier, their reports on societal prejudice, particularly arguments on the reputation of healthcare in general, clearly put forward these direct economic barriers. Hopefully, government support to newborn care, including KMC, will reduce some of these barriers. To improve KMC practice and possibly healthcare reputation, the best advocates are KMC-families as they hold a central role in society to integrate the method and reduce discrimination. We believe that KMC has not only the potential to directly reduce neonatal mortality, but also to break the negative emotional spiral towards healthcare structures that suffer from bad reputation in general, in part unjustly due to late referrals of the sickest with high mortality rates.
Secondary costs, such as for travel and loss of income during work interruption, have been less reported during our interviews. This limitation may have been underestimated in our evaluation due to the selection bias of interviewees, all of whom had accepted and practiced KMC.
Supporting decentralized KMC infrastructures require education of dedicated staff but can count on high acceptance and motivation of caregivers. However, the viability and sustainability of a KMC program require an institutional and governmental commitment.
Based on our findings, we believe that using mothers as ambassadors promoting KMC, a conceptual support from the local healthcare management, and free government care for new-borns including direct in-hospital KMC costs, are the key components for sustainability in decentralised and rural low-and middle-income areas. However, indirect costs to families in remote regions should not be underestimated.