Evaluation of the implementation of the Kangaroo Mother Care after the DIB project in three health facilities in the central Cameroon region

Evaluation of the implementation of the Kangaroo Mother Care after the DIB project in three health facilities in the central Cameroon region | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluation of the implementation of the Kangaroo Mother Care after the DIB project in three health facilities in the central Cameroon region Marcelle Nina Ehouzou Mandeng, Monique Amor Ndjabo, Lydienne Leslie Bilo'o, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4918406/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background Neonatal mortality remains high in Cameroon and stagnant since 2014 at 28‰ according to DHS 2018. In the strategy to reduce this mortality, the project named “Development Impact Bond” (DIB) was set up in ten health facilities in Cameroon. Our objective was to determine the level of implementation of KMC as well as its effect on neonatal mortality in three health facilities in the central region. Methods We carried out a cross-sectional study using a mixed (quantitative and qualitative) approach with simultaneous triangulation and retrospective data collection. To assess the level of KMC implementation, we chose the progress monitoring model proposed by Bergh et al in 2005. Qualitatively, we used an observation grid and a semi-structured interview guide to collect their verbatims according to the different phases of KMC implementation. Results After the DIB project, our evaluation showed a level of achievement in the institutionalization stage and progress towards sustainable KMC practice, with scores of 24.5, 25 and 27.5 out of 30 points respectively for YGOPH, YUTH and BDH. During the project, there was a 1.6-fold, 2-fold and 4-fold reduction in mortality for YGOPH, YUTH and BDH respectively, followed by a trend towards increased mortality in 2 first-rate facilities, notably YUTH and YGOPH. The causes of this post-project performance appear to be difficulties in involving administrators, in communicating with mothers and in reducing the motivation of caregiver’s staff. Conclusion The level of implementation of the KMC after the DIB project was high, notwithstanding a rebound in mortality that may be explained by continuing managerial, social and technical difficulties. Mother Kangaroo Care implementation mortality DIB project Cameroon Figures Figure 1 Figure 2 Background Neonatal mortality remains high in Cameroon and stagnant since 2014 at 28‰ according to DHS 2018 ( 1 ). To reduce this mortality, in 2017 the country adopted the WHO recommendation of popularizing the Mother Kangaroo care (KMC) in all developing countries ( 2 ). The “Development Impact Bond” (DIB) project was set up in ten health facilities in Cameroon for a period of two years, with a view to implementing quality KMC ( 3 ). Six months after the end of the project, we set out to determine the level of KMC implementation and its effect on neonatal mortality in three health facilities in the central Cameroon region. Methods We carried out a cross-sectional study using a mixed (quantitative and qualitative) approach with simultaneous triangulation and retrospective data collection. Our study site was three health facilities in the Central Cameroon Region involved in the “Cameroon Neonatal DIB” project, namely the Yaoundé University Teaching (YUTH), the Yaoundé Gynaecology, Obstetrics and Pediatrics Hospital (YGOPH) and the Bafia District Hospital (BDH). The first two (YUTH and YGOPH) are 1st category health facilities in Cameroon's health pyramid, while BDH is a 4th category hospital. In terms of health care, YUTH and YGOPH have a highly qualified human resource (neonatologists, pediatricians, specialized nurses, etc.), while the BDH neonatology unit at the time of the study was run by a midwife trained in MMK as part of the project. In terms of infrastructure, all three health facilities had the basic facilities required for the practice of MMK, as one or more incubator rooms, a mother-child room and an outpatient consultation room. Technically, the newborn care protocol was the same, proposed and adapted to local conditions by the Cangaroo fundàcion of Columbia and the “Kangaroo Cameroon Foundation” (KCF) ( 4 ). To assess the level of MMK implementation, we chose the progress monitoring model proposed by Bergh et al in 2005 ( 5 ) ( Fig. 1 ) . The model was conceptualized around three phases: pre-implementation, implementation and institutionalization, and six dimensions that describe progress: awareness, concept adoption, resource mobilization, evidence of practice, evidence of routine and integration, and sustainable practice ( 5 ). This is a validated questionnaire with a number of items for each phase. Each item is assigned a score, the sum of which gives a maximum score of 30 points for each health facility assessed. The scores of each facility are then evaluated according to the progress monitoring model interpretation table, as shown in Table I ( 5 ). With regard to sampling for the qualitative component, we selected staff from the decision-making chain in the three health facilities, both administrative and caregivers (medical and paramedical), with or without MMK training. We used an observation grid and a semi-structured interview guide to collect their verbatims according to the different phases of KMC implementation in their respective health facilities. We obtained a sample of 21 participants at saturation point. The verbatims were transcribed and categorized according to the phases and dimensions of the model. Statistical analysis of quantitative data was carried out with Excel software in MacOs version 16.87 (2020), and was expressed in frequency. From an ethical point of view, we obtained all necessary administrative authorizations and ethical clearance from the Catholic University of Central Africa for the institutions to be evaluated and the persons interviewed. Results and discussion Quantitative component Assessment of the level of KMC implementation in our three health facilities revealed scores of 24.5, 25 and 27.5 out of 30 points for YGOPH, YUTH and BDH respectively (Table II) . These scores enabled us to objectivize on the one hand the achievement of institutionalized KMC practice for YGOPH and on the other hand YUTH and BDH have reached the path of sustainable KMC practice. The scores obtained by YUTH and BDH were the highest of any KMC implementation progress monitoring assessment we have encountered in the literature. Rwanda and Mali are the 2 countries that achieved a maximum of 24.5 points out of 30 at the end of a KMC implementation project in Sub-Saharan Africa (Maternal and Child Health Integrated Program) ( 6 ). Unlike in Mali and Rwanda, where the best-performing health facilities were either University Hospitals or urban hospitals, in our study it was a rural district hospital with a shortage of staff that achieved an advanced level of KMC implementation. The reasons for this performance can be found in the qualitative analysis data, such as the strong involvement of the administration and staff, the fact that KMC care was free of charge even after project, and the practice of ambulatory KMC in the community. Also, in a mixed cross-sectional study in Ethiopia and India involving 3802 newborns under 2000g, Mony et al in 2021 found a high coverage of KMC practices of around 86 and 87% respectively 12 months after the implementation of KMC ( 7 ). With regard to the evolution of neonatal mortality in the three health facilities, Fig. 2 shows an overall downward trend in mortality in all facilities after the start of implementation. This decline was most marked at HDB, with a 1.6-fold, 2-fold and 4-fold decrease for YGOPH, YUTH and BDH respectively. On the other hand, after the project ended, a trend towards increased mortality was observed in 2 first-class health facilities, notably YUTH and YGOPH. The decrease in mortality observed in our study during the implementation of KMC corroborates with data from meta-analyses and systematic reviews by Conde-Agudelo et al and Charpak et al in 2012 and 2021 respectively ( 8 , 9 ). This is the case of the recent work by Esterlita et al in 2021 in the Philippines, which concerned sixteen randomized clinical trials involving 1,738 infants in the KMC group and 1,674 infants in the control group. This team found a 41% reduction in the risk of death in premature and low-birth-weight infants who received KMC compared with conventional medical care (3.6%) ( 10 ). In our review of the literature, we did not find any studies with a similar profile to ours, which evaluated mortality trends during and after the implementation phase. More recently, in 2022 in Bangladesh, Ehtesham Kabir et al, evaluating the implementation of the KMC program, found a drastic drop in hospital neonatal mortality linked to prematurity, from over 50–1.2% at the end of the fourth year of implementation ( 11 ). Mortality trends after implementation have not been studied in this study. Qualitative component Analysis of this section revealed several root causes of the difficulties in implementing KMC, both in the pre-implementation and implementation phases, and in the phase of institutionalizing of KMC. We note that our respondents were a non-homogeneous population, whose perception of certain questions might differ according to level of study and responsibility. In the context of our study, we will raise a number of issues that may explain some of the shortcomings in the implementation of KMC at the end of the DIB project. The involvement of the administrators was on the whole satisfactory and well perceived by most of our respondents, as the respondents from the YUTH and the BDH put it: “(...) That's why we welcomed the hospital's involvement with interest” ; “There was the first administration that adopted and agreed that the project could take place here” . This involvement manifested itself in the enthusiasm and political will without which the project could not have been carried through to completion. However, respondents highlighted several obstacles to involvement, such as the delay in starting up the project, the difficulty of hiring staff and the sudden change of administrators in the decision-making chain. As in our study, Kourouma et al in 2021 in Ivory Coast carried out a qualitative study and found strong involvement of pediatric department heads and hospital directors through staff training, equipment supplies and advocacy to get the KMC vision adopted ( 12 ). In contrast to our study, Bangladesh and South Africa in 2021 maintained a high level of KMC practice after the implementation period with the use of “KMC Champions” and volunteers. The latter continued to maintain a high level of involvement in both decision-making and practical aspects of KMC ( 13 , 14 ). In terms of implementation, many shortcomings or insufficiencies were cited by respondents, and the principal investigator's observation revealed a failure to comply with infrastructural and protocol standards, and difficulties in communicating with mothers. In short, mothers' failure to follow instructions was linked either to language barriers, religious barriers, the patriarchal tendency of the community where only the father makes decisions, or simply to the use of poor communication techniques. As one BDH respondent put it: “Communication is what we do here every day at all hours. It's very important, because first of all, moms are stubborn, they don't understand quickly. You have to talk all the time, you have to explain every minute” ; “ Because we're dealing with a xenophobic, traditionalist people. They have their own way of doing things (...)” . These findings are similar to those of Mehjabeen et al. in 2021, where mothers were not involved in decision-making, with communication sessions taking place in the presence of husbands and/or parents in-laws ( 14 ). Lastly, the decline in staff motivation was a bottleneck raised by several respondents, including one from HGOPY who stated: “(...). Worse still, by the time the project is finished, everyone is no longer receiving bonuses. Knowing that there was a reward, the staff made the effort to note KMC's activities. (...) Today, this work is no longer done” . We have found this loss of motivation in several authors ( 15 ), but the reasons were not financial, but rather in terms of increased workload, insufficient staff and lack of staff upgrading ( 16 ). As study limitations, our sample size was small in the quantitative analysis, but the number of respondents in the quantitative component was sufficient. Nevertheless, the findings of this study at regional level could serve as post-project lessons learned as the country moves towards scaling up KMC, right down to the community level. Conclusion The level of implementation of KMC was at the stage of institutionalization and the path to sustainable practice thanks to good involvement. This performance had an impact on mortality, which fell during the project. After the DIB project, the mortality trend was upwards in 1st category health facilities. The implementation process was marred by a number of shortcomings, including non-compliance with standards, difficulties in communicating with mothers and a decline in staff motivation after the DIB project. Abbreviations BDH Bafia District Hospital DHS Demographic and Health Survey DIB Development Impact Bond KMC Kangaroo Mother Care KFC Kangaroo Foundation Cameroon (KFC) WHO World Health Organization YGOPH Yaoundé Gynaecology, Obstetrics and Pediatrics YUTH Yaoundé University Teaching Declarations Acknowledgments: We would like to thank the health facility managers and caregivers who participated in the realization of this work. We would also like to thank the Kangaroo Cameroon Foundation (KCF), which is continuing its usual support for health facilities despite the end of the DIB project. Authors' contributions: - M.N.E.M, G.C.M.K, L.L.B: made literature review - M.N.E.M, M.A.N, E.K.O, S.N.U.S: took part to Study design - M.N.E.M, G.C.M.K: collected Data in the field - M.N.E.M, E.K.O, M.A.N, L.L.B, S.N.U.S: made statistical analysis - M.N.E.M, S.N.U.S.: wrote the main manuscript - M.N.E.M, G.C.M.K, L.L.B, M.A.N, E.K.O, S.N.U.S.: made reviewing Competing interests: The authors declare that they have not received any funding for this work and therefore have no conflict of interest. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-proft sectors. Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Clinical trial number: not applicable. Clinical trial number : not applicable. Declarations Ethics approval and consent to participate: This study was approved by the Ethics Committee for the analysis of research projects, in particular that of the School of Health Sciences of the Catholic University of Central Africa, under reference N°202/020967/CEIRSH/ESS/MSP. Although this is a mixed cross-sectional study with retrospective data collection, the qualitative aspect of the study required interviews and observations. For these two data collection methods, an information leaflet was presented to each team in the health facilities. Each participant then gave their agreement by signing an informed consent form. References (MINSANTE, Cameroun, INS.), &. Enquête Démographique et de Santé 2018. OMS. Kangaroo mother care: a transformative innovation In health care. Global position paper. ISBN 978-92-4-007265-7. 2023. Fondation Kangourou Cameroun. (FKC). Development Impact Bond (DIB) Néonatal Camerounais. Archives. https://www.fk-c.org/Projets (2020). MINSALUD (Colombia). Actualización de los Lineamientos Técnicos para la implementación de Programas Madre Canguro en Colombia, con énfasis en la nutrición del neonato prematuro o de bajo peso al nacer. 193. 2022. Bergh AM, Arsalo I, Patrick MAF, Pattinson M. Phillips N. Measuring implementation progress in kangaroo mother care. Acta Pædiatrica. 2005;94:1102–8. USAID. Maternal and Child Health Integrated Program (MCHIP). Tracking implementation progress for Kangaroo Mother care. 2012–2014. https://www.mchip.net . Mony PK, Henok T, Abebe GG, Grace JG, Aarti K, Sarmila M, ,Selemawit AB, et al. Scaling up Kangaroo Mother Care in Ethiopia and India: a multi-site implementation research study. BMJ Global Health; 2021. Charpak N, Montealegre-Pomar A, Bohorquez A. Systematic review and meta- analysis suggest that the duration of Kangaroo mother care has a direct impact on neonatal growth. Acta Paediatrica Volume 110, Issue 1 pp. 45–59 ,2021. Conde-Agudelo A, Belizán JM. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Evidence-Based Child Health: Cochrane Rev J. 2012;7(2):760–876. Villanueva-Uy MET, Van Haute MQ, Kasahara ES, De Leon-Mendoza S. A Meta-analysis on the Effect of Kangaroo Mother Care on Preterm Mortality. Acta Med Philipp 2021Dec.21 [cited 2024Jul.20];55(9). https://actamedicaphilippina.upm.edu.ph/index.php/acta/article/view/3745 Ehtesham Kabir A, Afroze S, Amin Z, Biswas A, Lipi SA, Khan M, Islam K, Haque S, et al. Implementation research on kangaroo mother care. Bangladesh Bull World Health Organ. 2022;100(1):10–9. Kourouma KR, Agbré-Yacé ML, Doukouré D, Cissé L, Some-Méazieu C, Ouattara J, Tano-Kamelan A. Konan Kouakou, V. Barriers and facilitators to kangaroo mother care implementation in Cote d’Ivoire: A qualitative study. BMC Health Serv Res. 2021;21:1211. Hailegebriel TD, Bergh A-M, Zaka N, Roh JM, Gohar F, Rizwan S, Asfaw AG, Heidarzadeh M, Zeck W.). Improving the implementation of kangaroo mother care. Bull World Health Organ 2021 99(1), 69–71. Mehjabeen S, Matin M, Gupta RD, et al. Fidelity of kangaroo mother care services in the public health facilities in Bangladesh: a cross-sectional mixed-method study. Implement Sci Commun. 2021;2:115. Chan G, Bergelson I, Smith ER, Skotnes T, Wall S. Barriers and enablers of kangaroo mother care implementation from a health systems perspective: A systematic review. Health Policy Plann, 32(10), 2017. Kinshella M-LW, Hiwa T, Pickerill K, Vidler M, Dube Q, Goldfarb D, et al. Barriers and facilitators of facility-based kangaroo mother care in sub-Saharan Africa: A systematic review. BMC Pregnancy Childbirth. 2021;21:176. Tables Table I: Interpretation table for the KMC implementation progress monitoring model according to Bergh et al 2005 Score obtained Interpretations 0 No implementation of KMC 1 – 2 KMC awareness 3 – 4 Political will to implement the KMC 5 – 9 On the road to appropriation of the KMC concept 10 appropriation of the KMC concept 11 – 16 On the road to practicing KMC 17 Proof of KMC practice 18 – 20 On the road to institutionalizing the practice of KMC 21 – 23 Evidence of institutionalized KMC practice 24 Institutionalized KMC practice 25 – 27 On the road to sustainable KMC practice 28 - 30 Sustainable KMC practice Table II : Overall distribution of points for all phases by health facility Phase Stages YUTH YGOPH BDH Points per stage Pre-implementation Stage 1 Awareness 1,5 1,5 2 2 Stage 2 Adoption of concept 1 2 2 2 Implementation Stage 3 Taking charge 5 4 5 6 Stage 4 Proof of practice 7 6 7 7 Institutionalization Stage 5 Proof of routine and integration 6,5 6,5 7 7 Stage 6 Sustainable practice 4 4,5 4,5 6 Total 25 24,5 27,5 30 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 12 Jun, 2025 Reviews received at journal 29 Apr, 2025 Reviewers agreed at journal 20 Apr, 2025 Reviewers agreed at journal 19 Apr, 2025 Reviews received at journal 25 Sep, 2024 Reviewers agreed at journal 25 Aug, 2024 Reviewers agreed at journal 21 Aug, 2024 Reviewers invited by journal 21 Aug, 2024 Editor assigned by journal 20 Aug, 2024 Submission checks completed at journal 17 Aug, 2024 First submitted to journal 15 Aug, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4918406","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":351226649,"identity":"965cd6d0-2277-463f-96de-f9356035385a","order_by":0,"name":"Marcelle Nina Ehouzou 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1","display":"","copyAsset":false,"role":"figure","size":43319,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eModel for monitoring progress in implementing the Kangaroo Mother Care according to Bergh et al 2005\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4918406/v1/bb60f6b002dec484ea7fd4f1.jpg"},{"id":66548031,"identity":"809dd496-96cd-43f9-b10b-6a5046e25da6","added_by":"auto","created_at":"2024-10-14 08:41:51","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":155007,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eTrends in neonatal mortality before, during and after the Cameroon neonatal ‘DIB’ project\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4918406/v1/398c888d6b1747681449cb9c.jpg"},{"id":66548750,"identity":"8c939b90-9e62-48a9-a09f-3d4dd0239d38","added_by":"auto","created_at":"2024-10-14 08:49:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":627960,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4918406/v1/35a84ed6-efac-4e98-9bfb-f211c41e9f11.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluation of the implementation of the Kangaroo Mother Care after the DIB project in three health facilities in the central Cameroon region","fulltext":[{"header":"Background","content":"\u003cp\u003eNeonatal mortality remains high in Cameroon and stagnant since 2014 at 28\u0026permil; according to DHS 2018 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). To reduce this mortality, in 2017 the country adopted the WHO recommendation of popularizing the Mother Kangaroo care (KMC) in all developing countries (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The \u0026ldquo;Development Impact Bond\u0026rdquo; (DIB) project was set up in ten health facilities in Cameroon for a period of two years, with a view to implementing quality KMC (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Six months after the end of the project, we set out to determine the level of KMC implementation and its effect on neonatal mortality in three health facilities in the central Cameroon region.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe carried out a cross-sectional study using a mixed (quantitative and qualitative) approach with simultaneous triangulation and retrospective data collection. Our study site was three health facilities in the Central Cameroon Region involved in the \u0026ldquo;Cameroon Neonatal DIB\u0026rdquo; project, namely the Yaound\u0026eacute; University Teaching (YUTH), the Yaound\u0026eacute; Gynaecology, Obstetrics and Pediatrics Hospital (YGOPH) and the Bafia District Hospital (BDH). The first two (YUTH and YGOPH) are 1st category health facilities in Cameroon's health pyramid, while BDH is a 4th category hospital. In terms of health care, YUTH and YGOPH have a highly qualified human resource (neonatologists, pediatricians, specialized nurses, etc.), while the BDH neonatology unit at the time of the study was run by a midwife trained in MMK as part of the project. In terms of infrastructure, all three health facilities had the basic facilities required for the practice of MMK, as one or more incubator rooms, a mother-child room and an outpatient consultation room. Technically, the newborn care protocol was the same, proposed and adapted to local conditions by the \u003cem\u003eCangaroo fund\u0026agrave;cion\u003c/em\u003e of Columbia and the \u003cem\u003e\u0026ldquo;Kangaroo Cameroon Foundation\u0026rdquo;\u003c/em\u003e (KCF) (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo assess the level of MMK implementation, we chose the progress monitoring model proposed by Bergh et al in 2005 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. The model was conceptualized around three phases: pre-implementation, implementation and institutionalization, and six dimensions that describe progress: awareness, concept adoption, resource mobilization, evidence of practice, evidence of routine and integration, and sustainable practice (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). This is a validated questionnaire with a number of items for each phase. Each item is assigned a score, the sum of which gives a maximum score of 30 points for each health facility assessed. The scores of each facility are then evaluated according to the progress monitoring model interpretation table, as shown in \u003cb\u003eTable I\u003c/b\u003e (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eWith regard to sampling for the qualitative component, we selected staff from the decision-making chain in the three health facilities, both administrative and caregivers (medical and paramedical), with or without MMK training. We used an observation grid and a semi-structured interview guide to collect their verbatims according to the different phases of KMC implementation in their respective health facilities. We obtained a sample of 21 participants at saturation point. The verbatims were transcribed and categorized according to the phases and dimensions of the model.\u003c/p\u003e \u003cp\u003eStatistical analysis of quantitative data was carried out with Excel software in MacOs version 16.87 (2020), and was expressed in frequency. From an ethical point of view, we obtained all necessary administrative authorizations and ethical clearance from the Catholic University of Central Africa for the institutions to be evaluated and the persons interviewed.\u003c/p\u003e"},{"header":"Results and discussion","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eQuantitative component\u003c/h2\u003e \u003cp\u003eAssessment of the level of KMC implementation in our three health facilities revealed scores of 24.5, 25 and 27.5 out of 30 points for YGOPH, YUTH and BDH respectively \u003cb\u003e(Table II)\u003c/b\u003e. These scores enabled us to objectivize on the one hand the achievement of institutionalized KMC practice for YGOPH and on the other hand YUTH and BDH have reached the path of sustainable KMC practice. The scores obtained by YUTH and BDH were the highest of any KMC implementation progress monitoring assessment we have encountered in the literature. Rwanda and Mali are the 2 countries that achieved a maximum of 24.5 points out of 30 at the end of a KMC implementation project in Sub-Saharan Africa (Maternal and Child Health Integrated Program) (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Unlike in Mali and Rwanda, where the best-performing health facilities were either University Hospitals or urban hospitals, in our study it was a rural district hospital with a shortage of staff that achieved an advanced level of KMC implementation. The reasons for this performance can be found in the qualitative analysis data, such as the strong involvement of the administration and staff, the fact that KMC care was free of charge even after project, and the practice of ambulatory KMC in the community. Also, in a mixed cross-sectional study in Ethiopia and India involving 3802 newborns under 2000g, Mony et al in 2021 found a high coverage of KMC practices of around 86 and 87% respectively 12 months after the implementation of KMC (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWith regard to the evolution of neonatal mortality in the three health facilities, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows an overall downward trend in mortality in all facilities after the start of implementation. This decline was most marked at HDB, with a 1.6-fold, 2-fold and 4-fold decrease for YGOPH, YUTH and BDH respectively. On the other hand, after the project ended, a trend towards increased mortality was observed in 2 first-class health facilities, notably YUTH and YGOPH. The decrease in mortality observed in our study during the implementation of KMC corroborates with data from meta-analyses and systematic reviews by Conde-Agudelo et al and Charpak et al in 2012 and 2021 respectively (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). This is the case of the recent work by Esterlita et al in 2021 in the Philippines, which concerned sixteen randomized clinical trials involving 1,738 infants in the KMC group and 1,674 infants in the control group. This team found a 41% reduction in the risk of death in premature and low-birth-weight infants who received KMC compared with conventional medical care (3.6%) (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn our review of the literature, we did not find any studies with a similar profile to ours, which evaluated mortality trends during and after the implementation phase. More recently, in 2022 in Bangladesh, Ehtesham Kabir et al, evaluating the implementation of the KMC program, found a drastic drop in hospital neonatal mortality linked to prematurity, from over 50\u0026ndash;1.2% at the end of the fourth year of implementation (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Mortality trends after implementation have not been studied in this study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eQualitative component\u003c/h2\u003e \u003cp\u003eAnalysis of this section revealed several root causes of the difficulties in implementing KMC, both in the pre-implementation and implementation phases, and in the phase of institutionalizing of KMC. We note that our respondents were a non-homogeneous population, whose perception of certain questions might differ according to level of study and responsibility. In the context of our study, we will raise a number of issues that may explain some of the shortcomings in the implementation of KMC at the end of the DIB project.\u003c/p\u003e \u003cp\u003eThe involvement of the administrators was on the whole satisfactory and well perceived by most of our respondents, as the respondents from the YUTH and the BDH put it: \u003cem\u003e\u0026ldquo;(...) That's why we welcomed the hospital's involvement with interest\u0026rdquo;\u003c/em\u003e; \u003cem\u003e\u0026ldquo;There was the first administration that adopted and agreed that the project could take place here\u0026rdquo;\u003c/em\u003e. This involvement manifested itself in the enthusiasm and political will without which the project could not have been carried through to completion. However, respondents highlighted several obstacles to involvement, such as the delay in starting up the project, the difficulty of hiring staff and the sudden change of administrators in the decision-making chain. As in our study, Kourouma et al in 2021 in Ivory Coast carried out a qualitative study and found strong involvement of pediatric department heads and hospital directors through staff training, equipment supplies and advocacy to get the KMC vision adopted (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). In contrast to our study, Bangladesh and South Africa in 2021 maintained a high level of KMC practice after the implementation period with the use of \u0026ldquo;KMC Champions\u0026rdquo; and volunteers. The latter continued to maintain a high level of involvement in both decision-making and practical aspects of KMC (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn terms of implementation, many shortcomings or insufficiencies were cited by respondents, and the principal investigator's observation revealed a failure to comply with infrastructural and protocol standards, and difficulties in communicating with mothers. In short, mothers' failure to follow instructions was linked either to language barriers, religious barriers, the patriarchal tendency of the community where only the father makes decisions, or simply to the use of poor communication techniques. As one BDH respondent put it: \u003cem\u003e\u0026ldquo;Communication is what we do here every day at all hours. It's very important, because first of all, moms are stubborn, they don't understand quickly. You have to talk all the time, you have to explain every minute\u0026rdquo;\u003c/em\u003e; \u0026ldquo;\u003cem\u003eBecause we're dealing with a xenophobic, traditionalist people. They have their own way of doing things (...)\u0026rdquo;\u003c/em\u003e. These findings are similar to those of Mehjabeen et al. in 2021, where mothers were not involved in decision-making, with communication sessions taking place in the presence of husbands and/or parents in-laws (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eLastly, the decline in staff motivation was a bottleneck raised by several respondents, including one from HGOPY who stated: \u003cem\u003e\u0026ldquo;(...). Worse still, by the time the project is finished, everyone is no longer receiving bonuses. Knowing that there was a reward, the staff made the effort to note KMC's activities. (...) Today, this work is no longer done\u0026rdquo;\u003c/em\u003e. We have found this loss of motivation in several authors (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), but the reasons were not financial, but rather in terms of increased workload, insufficient staff and lack of staff upgrading (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAs study limitations, our sample size was small in the quantitative analysis, but the number of respondents in the quantitative component was sufficient. Nevertheless, the findings of this study at regional level could serve as post-project lessons learned as the country moves towards scaling up KMC, right down to the community level.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe level of implementation of KMC was at the stage of institutionalization and the path to sustainable practice thanks to good involvement. This performance had an impact on mortality, which fell during the project. After the DIB project, the mortality trend was upwards in 1st category health facilities. The implementation process was marred by a number of shortcomings, including non-compliance with standards, difficulties in communicating with mothers and a decline in staff motivation after the DIB project.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBDH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBafia District Hospital\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDHS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDemographic and Health Survey\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDIB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDevelopment Impact Bond\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eKMC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eKangaroo Mother Care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eKFC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eKangaroo Foundation Cameroon (KFC)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eYGOPH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eYaound\u0026eacute; Gynaecology, Obstetrics and Pediatrics\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eYUTH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eYaound\u0026eacute; University Teaching\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e We would like to thank the health facility managers and caregivers who participated in the realization of this work. We would also like to thank the Kangaroo Cameroon Foundation (KCF), which is continuing its usual support for health facilities despite the end of the DIB project.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions:\u003c/p\u003e\n\u003cp\u003e- M.N.E.M, G.C.M.K, L.L.B: made literature review\u003c/p\u003e\n\u003cp\u003e- M.N.E.M, M.A.N, E.K.O, S.N.U.S: took part to Study design\u003c/p\u003e\n\u003cp\u003e- M.N.E.M, G.C.M.K: collected Data in the field\u003c/p\u003e\n\u003cp\u003e- M.N.E.M, E.K.O, M.A.N, L.L.B, S.N.U.S: made statistical analysis\u003c/p\u003e\n\u003cp\u003e- M.N.E.M, S.N.U.S.: wrote the main manuscript\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e- M.N.E.M, G.C.M.K, L.L.B, M.A.N, E.K.O, S.N.U.S.: made reviewing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have not received any funding for this work and therefore have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-proft sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e: not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclarations Ethics approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee for the analysis of research projects, in particular that of the School of Health Sciences of the Catholic University of Central Africa, under reference N\u0026deg;202/020967/CEIRSH/ESS/MSP.\u003c/p\u003e\n\u003cp\u003eAlthough this is a mixed cross-sectional study with retrospective data collection, the qualitative aspect of the study required interviews and observations. For these two data collection methods, an information leaflet was presented to each team in the health facilities. Each participant then gave their agreement by signing an informed consent form.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e(MINSANTE, Cameroun, INS.), \u0026amp;. Enqu\u0026ecirc;te D\u0026eacute;mographique et de Sant\u0026eacute; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOMS. Kangaroo mother care: a transformative innovation In health care. Global position paper. ISBN 978-92-4-007265-7. 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFondation Kangourou Cameroun. (FKC). Development Impact Bond (DIB) N\u0026eacute;onatal Camerounais. Archives. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.fk-c.org/Projets\u003c/span\u003e\u003cspan address=\"https://www.fk-c.org/Projets\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMINSALUD (Colombia). Actualizaci\u0026oacute;n de los Lineamientos T\u0026eacute;cnicos para la implementaci\u0026oacute;n de Programas Madre Canguro en Colombia, con \u0026eacute;nfasis en la nutrici\u0026oacute;n del neonato prematuro o de bajo peso al nacer. 193. 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBergh AM, Arsalo I, Patrick MAF, Pattinson M. Phillips N. Measuring implementation progress in kangaroo mother care. Acta P\u0026aelig;diatrica. 2005;94:1102\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUSAID. Maternal and Child Health Integrated Program (MCHIP). 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Acta Paediatrica Volume 110, Issue 1 pp. 45\u0026ndash;59\u003c/em\u003e,2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eConde-Agudelo A, Beliz\u0026aacute;n JM. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Evidence-Based Child Health: Cochrane Rev J. 2012;7(2):760\u0026ndash;876.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVillanueva-Uy MET, Van Haute MQ, Kasahara ES, De Leon-Mendoza S. A Meta-analysis on the Effect of Kangaroo Mother Care on Preterm Mortality. Acta Med Philipp 2021Dec.21 [cited 2024Jul.20];55(9). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://actamedicaphilippina.upm.edu.ph/index.php/acta/article/view/3745\u003c/span\u003e\u003cspan address=\"https://actamedicaphilippina.upm.edu.ph/index.php/acta/article/view/3745\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEhtesham Kabir A, Afroze S, Amin Z, Biswas A, Lipi SA, Khan M, Islam K, Haque S, et al. Implementation research on kangaroo mother care. Bangladesh Bull World Health Organ. 2022;100(1):10\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKourouma KR, Agbr\u0026eacute;-Yac\u0026eacute; ML, Doukour\u0026eacute; D, Ciss\u0026eacute; L, Some-M\u0026eacute;azieu C, Ouattara J, Tano-Kamelan A. Konan Kouakou, V. Barriers and facilitators to kangaroo mother care implementation in Cote d\u0026rsquo;Ivoire: A qualitative study. BMC Health Serv Res. 2021;21:1211.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHailegebriel TD, Bergh A-M, Zaka N, Roh JM, Gohar F, Rizwan S, Asfaw AG, Heidarzadeh M, Zeck W.). Improving the implementation of kangaroo mother care. Bull World Health Organ 2021 99(1), 69\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMehjabeen S, Matin M, Gupta RD, et al. Fidelity of kangaroo mother care services in the public health facilities in Bangladesh: a cross-sectional mixed-method study. Implement Sci Commun. 2021;2:115.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChan G, Bergelson I, Smith ER, Skotnes T, Wall S. Barriers and enablers of kangaroo mother care implementation from a health systems perspective: A systematic review. Health Policy Plann, 32(10), 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKinshella M-LW, Hiwa T, Pickerill K, Vidler M, Dube Q, Goldfarb D, et al. Barriers and facilitators of facility-based kangaroo mother care in sub-Saharan Africa: A systematic review. BMC Pregnancy Childbirth. 2021;21:176.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable I:\u0026nbsp;\u003c/strong\u003eInterpretation table for the KMC implementation progress monitoring model according to Bergh et al 2005\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.344370860927153%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eScore obtained\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.65562913907284%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterpretations\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.344370860927153%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.65562913907284%\" valign=\"top\"\u003e\n \u003cp\u003eNo implementation of KMC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.344370860927153%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e1 \u0026ndash; 2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.65562913907284%\" valign=\"top\"\u003e\n \u003cp\u003eKMC awareness\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.344370860927153%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e3 \u0026ndash; 4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.65562913907284%\" valign=\"top\"\u003e\n \u003cp\u003ePolitical will to implement the KMC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.344370860927153%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e5 \u0026ndash; 9\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.65562913907284%\" valign=\"top\"\u003e\n \u003cp\u003eOn the road to appropriation of the KMC concept\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.344370860927153%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e10\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.65562913907284%\" valign=\"top\"\u003e\n \u003cp\u003eappropriation of the KMC concept\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.344370860927153%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e11 \u0026ndash; 16\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.65562913907284%\" valign=\"top\"\u003e\n \u003cp\u003eOn the road to practicing KMC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.344370860927153%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e17\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.65562913907284%\" valign=\"top\"\u003e\n \u003cp\u003eProof of KMC practice\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.344370860927153%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e18 \u0026ndash; 20\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.65562913907284%\" valign=\"top\"\u003e\n \u003cp\u003eOn the road to institutionalizing the practice of KMC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.344370860927153%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e21 \u0026ndash; 23\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.65562913907284%\" valign=\"top\"\u003e\n \u003cp\u003eEvidence of institutionalized KMC practice\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.344370860927153%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e24\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.65562913907284%\" valign=\"top\"\u003e\n \u003cp\u003eInstitutionalized KMC practice\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.344370860927153%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e25 \u0026ndash; 27\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.65562913907284%\" valign=\"top\"\u003e\n \u003cp\u003eOn the road to sustainable KMC practice\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.344370860927153%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e28 - 30\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.65562913907284%\" valign=\"top\"\u003e\n \u003cp\u003eSustainable KMC practice\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable II\u003c/strong\u003e: Overall distribution of points for all phases by health facility\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"699\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.320457796852647%\" valign=\"top\"\u003e\n \u003cp\u003ePhase\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.320457796852647%\" valign=\"top\"\u003e\n \u003cp\u003eStages\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.160228898426324%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;YUTH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.160228898426324%\" valign=\"top\"\u003e\n \u003cp\u003eYGOPH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.872675250357654%\" valign=\"top\"\u003e\n \u003cp\u003eBDH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.165951359084406%\" valign=\"top\"\u003e\n \u003cp\u003ePoints per stage\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.320457796852647%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePre-implementation\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.320457796852647%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u003cstrong\u003e\u003cem\u003eStage 1\u003c/em\u003e\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAwareness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.160228898426324%\" valign=\"top\"\u003e\n \u003cp\u003e1,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.160228898426324%\" valign=\"top\"\u003e\n \u003cp\u003e1,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.872675250357654%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.165951359084406%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.136105860113425%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eStage 2 \u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eAdoption of concept\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.068052930056712%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.068052930056712%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.366729678638942%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.361058601134214%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.320457796852647%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eImplementation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.320457796852647%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003cstrong\u003e\u003cem\u003eStage 3\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eTaking charge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.160228898426324%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.160228898426324%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.872675250357654%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.165951359084406%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.136105860113425%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eStage 4\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eProof of practice\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.068052930056712%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.068052930056712%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.366729678638942%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.361058601134214%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e7\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.320457796852647%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Institutionalization\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.320457796852647%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u003cstrong\u003e\u003cem\u003eStage 5\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eProof of routine and integration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.160228898426324%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;6,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.160228898426324%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; 6,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.872675250357654%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; 7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.165951359084406%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.136105860113425%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eStage 6\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eSustainable practice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.068052930056712%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.068052930056712%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; 4,5\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.366729678638942%\" valign=\"top\"\u003e\n \u003cp\u003e4,5\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.361058601134214%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.320457796852647%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.320457796852647%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.160228898426324%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e25\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.160228898426324%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e24,5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.872675250357654%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e27,5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.165951359084406%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e30\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Mother Kangaroo Care, implementation, mortality, DIB project, Cameroon","lastPublishedDoi":"10.21203/rs.3.rs-4918406/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4918406/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eNeonatal mortality remains high in Cameroon and stagnant since 2014 at 28\u0026permil; according to DHS 2018. In the strategy to reduce this mortality, the project named \u0026ldquo;Development Impact Bond\u0026rdquo; (DIB) was set up in ten health facilities in Cameroon. Our objective was to determine the level of implementation of KMC as well as its effect on neonatal mortality in three health facilities in the central region.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe carried out a cross-sectional study using a mixed (quantitative and qualitative) approach with simultaneous triangulation and retrospective data collection. To assess the level of KMC implementation, we chose the progress monitoring model proposed by Bergh et al in 2005. Qualitatively, we used an observation grid and a semi-structured interview guide to collect their verbatims according to the different phases of KMC implementation.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAfter the DIB project, our evaluation showed a level of achievement in the institutionalization stage and progress towards sustainable KMC practice, with scores of 24.5, 25 and 27.5 out of 30 points respectively for YGOPH, YUTH and BDH. During the project, there was a 1.6-fold, 2-fold and 4-fold reduction in mortality for YGOPH, YUTH and BDH respectively, followed by a trend towards increased mortality in 2 first-rate facilities, notably YUTH and YGOPH. The causes of this post-project performance appear to be difficulties in involving administrators, in communicating with mothers and in reducing the motivation of caregiver\u0026rsquo;s staff.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe level of implementation of the KMC after the DIB project was high, notwithstanding a rebound in mortality that may be explained by continuing managerial, social and technical difficulties.\u003c/p\u003e","manuscriptTitle":"Evaluation of the implementation of the Kangaroo Mother Care after the DIB project in three health facilities in the central Cameroon region","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-14 08:41:46","doi":"10.21203/rs.3.rs-4918406/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-12T11:16:25+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-29T15:44:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"128800506784627351907548808089516764084","date":"2025-04-20T23:00:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"329718692140707575477593238081646885961","date":"2025-04-19T20:26:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-26T02:55:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"204530017916760179856418013573456195906","date":"2024-08-26T03:04:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"249719588576747687677639789990586075407","date":"2024-08-21T09:11:58+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-21T07:41:23+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-20T09:51:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-17T04:01:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2024-08-15T09:25:40+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1837e508-b245-47ae-8717-fdc745830ecf","owner":[],"postedDate":"October 14th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-19T10:08:17+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-14 08:41:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4918406","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4918406","identity":"rs-4918406","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}