Barriers and enablers for practicing kangaroo mother care in South Wollo Zone public hospitals East Amhara, Northeast Ethiopia

Barriers and enablers for practicing kangaroo mother care in South Wollo Zone public hospitals East Amhara, Northeast Ethiopia | 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 Barriers and enablers for practicing kangaroo mother care in South Wollo Zone public hospitals East Amhara, Northeast Ethiopia Setegn Mihret Tarekegn, Gebeyaw Biset Wagaw, Asnakew Molla Mekonen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3072715/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Every year, an estimated 13 million premature babies are delivered in the world, making it the largest cause of newborn mortality due to infections and hypothermia. Kangaroo mother care is a low-cost treatment strategy for reducing hypothermia-related death. However, it has a low coverage rate in Ethiopia. Objective The aim of this study was to assess the barriers and enablers for practicing kangaroo mother care. Study Design: Facility based study design was conducted in South Wollo zone public hospitals on a total of 12 IDIs and 10 FGDs from November 2021 to December 2021. After informed consent was obtained; Pediatrician, Obstetrician/gynecologist, mothers, neonatal nurses, and midwives were participated in FGDs and IDIs. The results have been summarized after data has been transcribed, themed, preliminarily analyzed, and quoted the participants' opinions. Result Community/maternal related, health care provider related, and hospital related barriers and enablers for practicing KMC in the study hospitals were identified. The investigated barriers included maternal fear that the baby would suffocate during KMC, maternal illness, poor maternal hygiene, being a rural mother, poor maternal economy, lack of trained health care providers (HCP), lack of continuous supervision, long hospital stays, and lack of full KMC infrastructures, to name a few. The listed enablers for KMC practice included getting support from other mothers and community leaders, mothers' faith in medical professionals, births other than cesarean sections, urban mothers, proximity to the hospital, families' positive attitudes toward KMC, the availability of KMC infrastructures, hospital services (KMC), and food costs being covered by the hospital. Conclusion and recommendation: To begin and maintain KMC in the hospital, hospital infrastructures, community/maternal initiation, and health care provider initiation must all be addressed. As a result, everyone involved in the study area works to remove constraints on KMC practice and foster enablers. Pediatrics KMC practice barriers enablers South Wollo zone Northeast Ethiopia Background Around 13 million babies are born each year in the world before they reach 37 weeks of pregnancy ( 1 , 2 ). The highest rates of preterm birth have been observed in Sub-Saharan Africa, South Asia, and North America, while the lowest rates have been reported in European countries. ( 2 ). The major causes of newborn morbidity and mortality are preterm complications. Each year, preterm death accounts for more than 27% of all neonatal deaths ( 1 , 3 ). From 3 million global neonatal deaths to about 1.1 million deaths owing to preterm and accompanying problems such as hypothermia, which may be avoided if kangaroo mother care was provided ( 4 ). Ethiopia is one of the world's top neonatal mortality countries, with 30 neonatal deaths per 1000 births ( 5 ). KMC is suggested as a helpful and cost-effective intervention for improving short- and long-term preterm birth outcomes, with the potential to avert up to half of all preterm infant fatalities. ( 6 , 7 ). Kangaroo mother care should begin early and continue for as long as the mother and the infant are together ( 3 ). KMC entails three major elements in a supportive environment: skin-to-skin contact with the mother, exclusive breastfeeding when possible, and early discharge from the health facility with proper follow-up measures. KMC can be done constantly throughout the day or on a regular basis for a set number of days ( 8 , 9 ). KMC lowers mortality, infection, and hypothermia among babies in hospitals by 40%, 65%, and 72%, respectively ( 3 ). Furthermore, KMC may aid in the improvement of preterm children' growth and development, as well as their mother-child bond. It is also a cost-effective alternative to conventional neonatal care. ( 3 , 10 ). In low-resource nations, kangaroo mother care is the only option for preventing hypothermia and its implications in preterm and low-birth-weight newborns ( 3 ). Despite the fact that kangaroo mother care is critical for preventing newborn morbidity and mortality, it is underutilized in poorer countries such as Ethiopia; Only about a quarter of mothers use kangaroo mother care ( 11 ). According to studies, there are a variety of challenges that prevent KMC adoption in hospitals and communities ( 12 ). Gaps in training, mentoring, and support, a notion that there are no costs associated, and a perception of KMC as a lesser alternative to incubators, were the identified barriers ( 12 ). In addition, KMC's earlier recognized impediments to practicing at the hospital or community level were leadership and governance, health care financing, health workforce, and socio-cultural barriers ( 4 , 13 , 14 ). On the other hand, social support from family members, understanding of the efficacy of KMC, the belief that infants enjoy KMC, remaining with the infant in hospital and access to KMC knowledge are enablers of KMC practices ( 6 ). The barriers and enablers of practicing KMC in Ethiopia are poorly understood. Hence to promote KMC at home/health facility without an understanding of its barriers and enabling factors may lead to limited success ( 3 ). To ease this, a study aimed to assess the barriers and enablers for practicing kangaroo mother care is conducted. Methods and materials Study setting and study populations From November 2021 to December 2021, a qualitative approach will be used in south Wollo public hospitals, with a community-based cross-sectional study design and phenomenological study design. In focus group discussions and interviews, health care experts such as pediatricians, obstetricians/gynecologists, neonatal intensive care unit (NICU) nurses, midwives, and mothers were participated Sampling frame and participants’ selection By lottery, we chose three hospitals (Dessie Referral Hospital, Akesta General Hospital, and Mekane Selam district Hospital) at random from 11 institutions that offer NICU services. Participants were chosen for the study based on their relationship to the issue. To investigate system-level challenges, the leaders of each study hospital's neonatal intensive care unit and maternity ward were chosen to participate in the study. In addition, all human resources involved in maternity and neonatal nursing services in the study hospitals [doctors, neonatal nurses, and midwives] are invited to participate. Data was collected from health care professionals (one from each group) at selected hospitals based on their availability and consent status. We randomly pick 4–6 (mothers, neonatal nurses, and midwives) among available consenting participants for a minimum of three FGD/IDIs (maternity head, NICU head, and one mother) in each hospital. Each FGD session had one moderator, one note taker, and one recorder. The FGD moderator gave a quick overview of the KMC approach and demonstrated how to use vignettes to practice it. The participants were questioned about the advantages of practicing KMC, their ability to perform KMC, family support or opposition, and impediments to practicing KMC. Participants who were very unwell and were unable to participate in the study were excluded. Study procedure and data collection To gather the necessary information, one-on-one in-depth interviews (IDIs) and focus group discussions (FGDs) were done. To fulfill the study's goals, open-ended questions and possible probes were used. All data collection tools were translated from English to Amharic for interview and FGD and then back again to ensure that the translation was accurate. The IDIs and FGDs were conducted in the field by nine trained interviewers and three supervisors. All team members are proficient in the local language (Amharic) and have the requisite skills and experience in qualitative data collection. Over the course of five days, all interviewers and supervisors were taught on the study protocol, the concept of KMC, the fundamentals of qualitative research methodology, and how to conduct IDIs and FGDs efficiently. Three teams (each with three interviewers and one supervisor) were constituted, with one interviewer serving as moderator and the other as note taker/recorder during the FGD session. In addition to taking notes, a digital voice recorder was used with participants' consent to collect as much information as possible with minimal chance of data loss. Data was collected until saturation was reached and no new information was discovered. Supervisors and primary investigators evaluated the data for completeness and clarity on a daily basis. Patient and Public Involvement No patient involved in the study design Data processing and analysis The recorded data was first transcribed into Amharic and then translated into English. It was structured (theme-wise), sorted, documented, and coded, and preliminary analysis was conducted to edit the data in order to prepare it for further analysis, define the data's major features, and summarize the findings. It was studied, synthesized, and integrated, and the information was interpreted accordingly. Finally, the findings were presented in the form of tables and texts, with quotations from interviews and focus groups used to illustrate the participants' points of view. Result The aim of this study was to determine the barriers and enablers of kangaroo mother care in public hospitals in South Wollo zone, East Amhara region, Northeast Ethiopia. A total of 12 IDIs and 10 FGDs were conducted in the study hospitals. From the ten focus groups, four were held at the Dessie referral hospital and six were held at the other two hospitals (Akesta general (3FGD) and Mekane Selam district hospitals (3 FGD). Neonatal nurses, midwives, and mothers held four focus groups, three focus groups, and three focus groups, respectively. Pediatrician, Obstetrician/Gynecologist, Neonatal nurse, Midwife, and Mother are all members of IDI. Barriers for practicing KMC Community and maternal related barriers Maternal unwillingness to practice KMC, maternal concern that the baby may suffocate during KMC, mothers' lack of experience with or knowledge of a child who has survived this treatment (by KMC), maternal work overload, and family unwillingness to support mothers during workload were all identified as barriers to KMC practice in this study. Furthermore, rural moms' common practice is to carry their babies on their backs rather than their fronts, which is new to them and a hurdle to KMC. “I think it is a challenge for moms to not know how to do it, I think that the professional should not give enough education to moms, what to use, moms think that baby will be suffocated, we have to train someone else (father, grandmother, sister) because it is not suitable for work”. (Pediatrician IDI participant) “Because most mothers are rural, they carry it in front and think it is unsuitable for work and lack of awareness”. (Neonatal nurse FGD participant) “ More culturally, we (mothers) may be influenced by our neighbors and the local people who say she has something special when she is in contact”. (Mother FGD participant) Another community/maternal barriers were lack of family support, poor economy (to buy: diapers, carrying clothes, food), poor maternal hygiene, maternal fear of disease transmission from mother to baby, maternal illness (due to: cesarean delivery, presence of episiotomy, and other disease), and maternal discomfort were some of the barriers to KMC implementation at the health facility and home. “Excessive workload after childbirth, during this workload other people refusal to do skin-to-skin contact”. (Obstetrician/Gynecologist IDI participant) “Mothers' health problems, economic problems (Mothers have trouble buying diapers; mothers with shortage of food), mothers who may have a disease that can be passed on mother to child, and Mothers may not feel comfortable (overcrowding, if the baby is sick), and other people are unwilling when mothers are sick are the barriers for practicing KMC” (Midwife FGD participant) “When birth is due to cesarean section, when there is an episiotomy tear, and not being able to sit much” (Midwife IDI participant) “Mothers discontinued KMC: when there is long stay at hospital, left against because they feel a child is better when they come out of breathing problems, when there is an economic and social problem, when rural mothers due to food problem” (Mother IDI participant) Health care providers (HCP) related barriers Poor health care provider comprehension of KMC implementation, lack of continuous supervision, despair about mothers' KMC practice, and a lack of KMC education for mothers were identified as health care provider-related KMC practice barriers. “The more challenging for skin-to-skin contact; lack of health care provider awareness, lack of follow-up, health care provider despair mother’s poor practice, and did not give mothers enough education (how to carry, and what to use)” (Neonatal nurse FGD participant) Hospital related barriers The study hospitals' most frequently reported challenges to KMC implementation were a lack of full infrastructure (e.g., rooms, beds, bags) and protracted hospital stays. "KMC practice was hampered (barriered) by institutional classroom constraints and a lack of KMC beds." (Neonatal FGD participants) “Even though KMC services are exempt, the hospital did not give food for the moms, and our hospital had difficulty in providing KMC services due to classroom limits and KMC carrying bags." (Neonatal IDI participant) Enablers of KMC implementation Community and maternal related barriers The availability of mother-to-mother (experienced mothers to new mothers) support and counseling, being educated from influential community leaders, the availability of other people and attendant support, maternal training, if mothers trust the health professionals, births other than cesarean section, availability of maternal initiation/volunteerism, active maternal listening to professional advice, being urban mothers, being near the hospital, were all mentioned by the study participants. “If previous working mothers are shown the new ones, and if mothers communicate and support one another" (Neonatal FGD participants) “If they (mothers) have learnt about the benefits and drawbacks of KMC from a professional, if they (mothers) have been trained by Health Care Providers and influential persons in the kebele, and if other people are supporting them, skin-to-skin contact will be enhanced." (Midwife FGD participants ) “If ladies (Mothers) listened to and trusted the professionals (HCP) and didn't give delivery by cesarean section, our hospital would have a highly implemented KMC." (Obstetrician/Gynecologist IDI participant) “If moms are willing, if an expert is around, and if they (mothers) follow expert advice, skin-to-skin contact can be properly implemented." (Pediatrician IDI participant) “Mothers who live in the city, are accessible to the hospital, and have relatives who support them and have a good opinion of KMC are all important elements in kangaroo mother care at our institution." (Neonatal IDI participant) Health care provider related enablers HCP related KMC practice enablers in the study areas included the availability of health care advice, the presence of good HCP approaches to mothers, routine staff support, close HCP supervision, the presence of a trained neonatal nurse, good awareness of KMC, the availability of HCP support, the availability of HCP initiation, and the presence of HCP training to mothers. “When health care providers treat moms with respect and provide ongoing teaching, they are implementing KMC practice." (Pediatrician IDI participant) "To give kangaroo mother care, it was required that staff (HCP) assists mothers, that they (HCP) help and discuss one another, and that they (HCP) are willing and knowledgeable." (Mother FGD participants) “The presence of a Neonatal Nurse and professional (HCP) particular training in kangaroo mother care are essential factors in facilitating kangaroo mother care in our hospital.” (Neonatal FGD participant) Hospital related barriers The availability of hospital infrastructures such as enough, comfortable, and separate KMC rooms, availability of KMC carrying bags, beds, and hitters, availability of shower, hospital services (KMC), and food costs are covered by the hospital, and availability of continuous KMC educations to mothers in the hospital were described as enablers of KMC practice by the study participants. “We can implement skin-to-skin contact if hospitals provide enough, pleasant, and distinct (private) rooms, KMC bags, KMC beds, and hitters.” (Mothers FGD participant) “If KMC equipment such as separate (private) rooms, showers, other KMC facilities, and maternity lodging are available, skin-to-skin contact can begin." (Neonatal nurse FGD participant) “Because the hosting hospital covered our hospital costs and food, we were able to stay for an extended amount of time while providing skin-to-skin contact with the little infant” (Mother IDI participant) Discussion The aims of this facility-based qualitative study in Northeast Ethiopia’s South Wollo Zone were to look at the barriers and enablers of practicing KMC. In this study the barriers and enablers to KMC practice were divided into three themes: 1. Community/maternal related, 2. Health Care Provider related, and 3. Hospital related barriers and enablers. In this study, community and maternal-related factors for practicing KMC were found to have a significant negative and positive impact on KMC practice; specifically, maternal unwillingness, maternal concern that the baby may suffocate during KMC, mothers' inexperience with or knowledge of a child who has survived this treatment (by KMC), maternal work overload, and family unwillingness to support mothers during workload were identified as barriers to practice KMC. Two systematic reviews concluded that social unsupported and maternal unwillingness are the common obstacles to practice KMC ( 15 , 16 ). In the current study, poor maternal cleanliness, poor economy (to buy diaper, and food), maternal fear of disease transmission from mother to baby, maternal illness (cesarean birth, episiotomy tear, and maternal discomfort) were all also identified as barriers which is supported by study in Pakistan and a systematic review ( 12 , 16 ); conversely, the availability of mother-to-mother support and counseling, maternal training, maternal trust on HCP, give birth other than cesarean section, maternal initiation/volunteerism, active maternal listening to professional's advice, and being close to the hospital, if educated from influential people, presence of attendant support, families have a positive view of KMC were community/maternal related enablers of KMC practice. Studies in India and Ethiopia support this finding ( 3 , 17 ). The current study's unique findings are that rural parents commonly hold their newborns on their backs rather than their fronts, which is new to them and a challenge for KMC. Urban mothers, on the other hand, prefer to hold their newborns on their fronts rather than their backs. However, we couldn't locate any proof to back up these claims. Poor health care provider comprehension of KMC implementation, lack of continuous supervision, health care providers in despair about mothers' KMC practice, and a lack of KMC education for mothers were identified as health care provider-related barriers to KMC practice in this study ( 18 ). Whereas, providing: advice, good approaches to mothers, support and supervision, presence of trained neonatal nurse, having good awareness of KMC, availability of supporting each other, availability of HCP initiation, and providing training to mothers were the HCP enablers of KMC. The outcomes of a multi-country study and feedback from international workshops support our findings ( 18 , 19 ). Small, inadequate, and congested KMC rooms were recognized in this study as barriers to KMC practice, which is consistent with a comprehensive assessment that identified a shortage of hospital space as a barrier to KMC practice ( 20 ). Furthermore, long hospital stay, insufficient KMC infrastructure (beds, bags) all had a negative impact on KMC practice. This conclusion is consistent with a KMC report on an international workshop ( 18 ) while the availability of full KMC facilities/infrastructures (enough, pleasant, and separate rooms, bags, hitters, and showers), if hospital services (KMC) and food costs are paid by the hospital, and the provision of ongoing KMC educations to mothers were all enablers of KMC practice. Different previous literatures conducted in rural Pakistan and south India supported with these conclusions ( 12 , 21 ). Strength and limitation of the study The strength of the study is it explored the barriers and enablers for practicing kangaroo mother care with the repeated data collection method. However, this study didn’t address kangaroo mother care practice in community level. Conclusion and recommendation Community/maternal initiation, health care provider initiation, and hospital infrastructures must all be met in order to start and continue KMC in the hospital. As a result, all stakeholders in the research region work to eliminate barriers and promote enablers to KMC practice. Abbreviations FDG - Focus Group Discussion HCP- Health Care Provider IDI- In-Depth-Interview KMC- Kangaroo Mother Care Declarations Contributors: SMT, GBW, and AMM conceived the study idea and designed the study. SMT sampled the participants. SMT and GBW reviewed and analyzed the data. SMT, AMM, and AWT interpreted and wrote the draft. All authors critically revised and approved the final version. Competing interests: The authors no has competing interest Funding: no funding Data Sharing Statement: No additional data available. Ethical approval: Wollo University's Institutional Review Committee issued an ethical clearance letter with the IRB number CMHS114/13/21. Permission letters and informed consent from participants were received from the South Wollo Zone health authorities. Following that, data gathering began. References Lawn JE, Gravett MG, Nunes TM, Rubens CE, Stanton C, Group tGR. Global report on preterm birth and stillbirth (1 of 7): defi nitions, description of the burden and opportunities to improve data. BMC pregnancy and childbirth. 2010;10(Suppl 1):S1. Lawn JE, Gravett MG, Nunes TM, Rubens CE, Stanton C, the GRG. Global report on preterm birth and stillbirth (1 of 7): definitions, description of the burden and opportunities to improve data. BMC Pregnancy and Childbirth. 2010;10(1):S1. Mazumder S, Upadhyay RP, Hill Z, Taneja S, Dube B, Kaur J, et al. 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Report on an international workshop on kangaroo mother care: lessons learned and a vision for the future. BMC pregnancy and childbirth. 2018;18(1):170-. Bergh A-M, de Graft-Johnson J, Khadka N, Om’Iniabohs A, Udani R, Pratomo H, et al. The three waves in implementation of facility-based kangaroo mother care: a multi-country case study from Asia. BMC International Health and Human Rights. 2016;16(1):4. Smith ER, Bergelson I, Constantian S, Valsangkar B, Chan GJ. Barriers and enablers of health system adoption of kangaroo mother care: a systematic review of caregiver perspectives. BMC pediatrics. 2017;17(1):35. Raajashri R, Adhisivam B, Vishnu Bhat B, Palanivel C. Maternal perceptions and factors affecting Kangaroo Mother Care continuum at home: A descriptive study. The Journal of Maternal-Fetal & Neonatal Medicine. 2017. 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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-3072715","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":210554086,"identity":"94331006-e817-409c-82c4-ba1f5aab62c0","order_by":0,"name":"Setegn Mihret Tarekegn","email":"","orcid":"","institution":"Wollo University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Setegn","middleName":"Mihret","lastName":"Tarekegn","suffix":""},{"id":210554087,"identity":"e2973376-f659-4486-8cef-391b08f9e552","order_by":1,"name":"Gebeyaw Biset Wagaw","email":"","orcid":"","institution":"Wollo University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Gebeyaw","middleName":"Biset","lastName":"Wagaw","suffix":""},{"id":210554088,"identity":"5a8ee54f-ebe2-40b7-b9b7-901774a83155","order_by":2,"name":"Asnakew Molla Mekonen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+klEQVRIiWNgGAWjYHACAyCWYOBnZmz/8QHIZGMnVotke/MByRkgLczEaQGSZ44lSPOAWIS08E87vPHhjz8Wcgw3cgyMbX5tk+djZmD88DEHtxaJ22nFxrxtEsaMM3IMknP7bhu2MTMwS87chsea2zlm0owNEonNEjkGh3N7bjMCtbAx8+LRIn87x/znjz8S9W0SOYbNlj237QlqMQDawsDDJpHAw3MsmZnhx+1EgloMgX6RBvrFcAZ78zHG3obbyW3MjM14/SJ3O3njxx9/6uTtDzO2Mfz4c9t2fnvzwQ8f8XkfBQB1gcgGYtWDwB9SFI+CUTAKRsFIAQCONE95kqe3pQAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0001-7573-1594","institution":"Wollo University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Asnakew","middleName":"Molla","lastName":"Mekonen","suffix":""}],"badges":[],"createdAt":"2023-06-16 13:46:26","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":true,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false,"coiExplicitlySet":false},"doi":"10.21203/rs.3.rs-3072715/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3072715/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":38757624,"identity":"b88c8337-e32f-4379-9649-f1798978df1b","added_by":"auto","created_at":"2023-06-19 10:29:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":340382,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3072715/v1/224d98ca-abda-4e29-93e0-06fec1fb188a.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eBarriers and enablers for practicing kangaroo mother care in South Wollo Zone public hospitals East Amhara, Northeast Ethiopia\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eAround 13\u0026nbsp;million babies are born each year in the world before they reach 37 weeks of pregnancy (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The highest rates of preterm birth have been observed in Sub-Saharan Africa, South Asia, and North America, while the lowest rates have been reported in European countries. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The major causes of newborn morbidity and mortality are preterm complications. Each year, preterm death accounts for more than 27% of all neonatal deaths (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). From 3\u0026nbsp;million global neonatal deaths to about 1.1\u0026nbsp;million deaths owing to preterm and accompanying problems such as hypothermia, which may be avoided if kangaroo mother care was provided (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Ethiopia is one of the world's top neonatal mortality countries, with 30 neonatal deaths per 1000 births (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eKMC is suggested as a helpful and cost-effective intervention for improving short- and long-term preterm birth outcomes, with the potential to avert up to half of all preterm infant fatalities. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Kangaroo mother care should begin early and continue for as long as the mother and the infant are together (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). KMC entails three major elements in a supportive environment: skin-to-skin contact with the mother, exclusive breastfeeding when possible, and early discharge from the health facility with proper follow-up measures. KMC can be done constantly throughout the day or on a regular basis for a set number of days (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). KMC lowers mortality, infection, and hypothermia among babies in hospitals by 40%, 65%, and 72%, respectively (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Furthermore, KMC may aid in the improvement of preterm children' growth and development, as well as their mother-child bond. It is also a cost-effective alternative to conventional neonatal care. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). In low-resource nations, kangaroo mother care is the only option for preventing hypothermia and its implications in preterm and low-birth-weight newborns (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite the fact that kangaroo mother care is critical for preventing newborn morbidity and mortality, it is underutilized in poorer countries such as Ethiopia; Only about a quarter of mothers use kangaroo mother care (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). According to studies, there are a variety of challenges that prevent KMC adoption in hospitals and communities (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Gaps in training, mentoring, and support, a notion that there are no costs associated, and a perception of KMC as a lesser alternative to incubators, were the identified barriers (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). In addition, KMC's earlier recognized impediments to practicing at the hospital or community level were leadership and governance, health care financing, health workforce, and socio-cultural barriers (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). On the other hand, social support from family members, understanding of the efficacy of KMC, the belief that infants enjoy KMC, remaining with the infant in hospital and access to KMC knowledge are enablers of KMC practices (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The barriers and enablers of practicing KMC in Ethiopia are poorly understood. Hence to promote KMC at home/health facility without an understanding of its barriers and enabling factors may lead to limited success (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). To ease this, a study aimed to assess the barriers and enablers for practicing kangaroo mother care is conducted.\u003c/p\u003e"},{"header":"Methods and materials","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy setting and study populations\u003c/h2\u003e \u003cp\u003eFrom November 2021 to December 2021, a qualitative approach will be used in south Wollo public hospitals, with a community-based cross-sectional study design and phenomenological study design. In focus group discussions and interviews, health care experts such as pediatricians, obstetricians/gynecologists, neonatal intensive care unit (NICU) nurses, midwives, and mothers were participated\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSampling frame and participants\u0026rsquo; selection\u003c/h2\u003e \u003cp\u003eBy lottery, we chose three hospitals (Dessie Referral Hospital, Akesta General Hospital, and Mekane Selam district Hospital) at random from 11 institutions that offer NICU services. Participants were chosen for the study based on their relationship to the issue. To investigate system-level challenges, the leaders of each study hospital's neonatal intensive care unit and maternity ward were chosen to participate in the study.\u003c/p\u003e \u003cp\u003eIn addition, all human resources involved in maternity and neonatal nursing services in the study hospitals [doctors, neonatal nurses, and midwives] are invited to participate. Data was collected from health care professionals (one from each group) at selected hospitals based on their availability and consent status. We randomly pick 4\u0026ndash;6 (mothers, neonatal nurses, and midwives) among available consenting participants for a minimum of three FGD/IDIs (maternity head, NICU head, and one mother) in each hospital. Each FGD session had one moderator, one note taker, and one recorder. The FGD moderator gave a quick overview of the KMC approach and demonstrated how to use vignettes to practice it. The participants were questioned about the advantages of practicing KMC, their ability to perform KMC, family support or opposition, and impediments to practicing KMC. Participants who were very unwell and were unable to participate in the study were excluded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStudy procedure and data collection\u003c/h2\u003e \u003cp\u003eTo gather the necessary information, one-on-one in-depth interviews (IDIs) and focus group discussions (FGDs) were done. To fulfill the study's goals, open-ended questions and possible probes were used. All data collection tools were translated from English to Amharic for interview and FGD and then back again to ensure that the translation was accurate. The IDIs and FGDs were conducted in the field by nine trained interviewers and three supervisors. All team members are proficient in the local language (Amharic) and have the requisite skills and experience in qualitative data collection. Over the course of five days, all interviewers and supervisors were taught on the study protocol, the concept of KMC, the fundamentals of qualitative research methodology, and how to conduct IDIs and FGDs efficiently. Three teams (each with three interviewers and one supervisor) were constituted, with one interviewer serving as moderator and the other as note taker/recorder during the FGD session. In addition to taking notes, a digital voice recorder was used with participants' consent to collect as much information as possible with minimal chance of data loss. Data was collected until saturation was reached and no new information was discovered. Supervisors and primary investigators evaluated the data for completeness and clarity on a daily basis.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePatient and Public Involvement\u003c/strong\u003e \u003cp\u003eNo patient involved in the study design\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData processing and analysis\u003c/h2\u003e \u003cp\u003eThe recorded data was first transcribed into Amharic and then translated into English. It was structured (theme-wise), sorted, documented, and coded, and preliminary analysis was conducted to edit the data in order to prepare it for further analysis, define the data's major features, and summarize the findings. It was studied, synthesized, and integrated, and the information was interpreted accordingly. Finally, the findings were presented in the form of tables and texts, with quotations from interviews and focus groups used to illustrate the participants' points of view.\u003c/p\u003e \u003c/div\u003e"},{"header":"Result","content":"\u003cp\u003eThe aim of this study was to determine the barriers and enablers of kangaroo mother care in public hospitals in South Wollo zone, East Amhara region, Northeast Ethiopia. A total of 12 IDIs and 10 FGDs were conducted in the study hospitals. From the ten focus groups, four were held at the Dessie referral hospital and six were held at the other two hospitals (Akesta general (3FGD) and Mekane Selam district hospitals (3 FGD). Neonatal nurses, midwives, and mothers held four focus groups, three focus groups, and three focus groups, respectively. Pediatrician, Obstetrician/Gynecologist, Neonatal nurse, Midwife, and Mother are all members of IDI.\u003c/p\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eBarriers for practicing KMC\u003c/h2\u003e\n \u003cp\u003e\u003cstrong\u003eCommunity and maternal related barriers\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMaternal unwillingness to practice KMC, maternal concern that the baby may suffocate during KMC, mothers\u0026apos; lack of experience with or knowledge of a child who has survived this treatment (by KMC), maternal work overload, and family unwillingness to support mothers during workload were all identified as barriers to KMC practice in this study. Furthermore, rural moms\u0026apos; common practice is to carry their babies on their backs rather than their fronts, which is new to them and a hurdle to KMC.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I think it is a challenge for moms to not know how to do it, I think that the professional should not give enough education to moms, what to use, moms think that baby will be suffocated, we have to train someone else (father, grandmother, sister) because it is not suitable for work\u0026rdquo;. (Pediatrician IDI participant)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Because most mothers are rural, they carry it in front and think it is unsuitable for work and lack of awareness\u0026rdquo;. (Neonatal nurse FGD participant)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;\u003cem\u003eMore culturally, we (mothers) may be influenced by our neighbors and the local people who say she has something special when she is in contact\u0026rdquo;. (Mother FGD participant)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eAnother community/maternal barriers were lack of family support, poor economy (to buy: diapers, carrying clothes, food), poor maternal hygiene, maternal fear of disease transmission from mother to baby, maternal illness (due to: cesarean delivery, presence of episiotomy, and other disease), and maternal discomfort were some of the barriers to KMC implementation at the health facility and home.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Excessive workload after childbirth, during this workload other people refusal to do skin-to-skin contact\u0026rdquo;. (Obstetrician/Gynecologist IDI participant)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Mothers\u0026apos; health problems, economic problems (Mothers have trouble buying diapers; mothers with shortage of food), mothers who may have a disease that can be passed on mother to child, and Mothers may not feel comfortable (overcrowding, if the baby is sick), and other people are unwilling when mothers are sick are the barriers for practicing KMC\u0026rdquo; (Midwife FGD participant)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;When birth is due to cesarean section, when there is an episiotomy tear, and not being able to sit much\u0026rdquo; (Midwife IDI participant)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Mothers discontinued KMC: when there is long stay at hospital, left against because they feel a child is better when they come out of breathing problems, when there is an economic and social problem, when rural mothers due to food problem\u0026rdquo; (Mother IDI participant)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eHealth care providers (HCP) related barriers\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003ePoor health care provider comprehension of KMC implementation, lack of continuous supervision, despair about mothers\u0026apos; KMC practice, and a lack of KMC education for mothers were identified as health care provider-related KMC practice barriers.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The more challenging for skin-to-skin contact; lack of health care provider awareness, lack of follow-up, health care provider despair mother\u0026rsquo;s poor practice, and did not give mothers enough education (how to carry, and what to use)\u0026rdquo; (Neonatal nurse FGD participant)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eHospital related barriers\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThe study hospitals\u0026apos; most frequently reported challenges to KMC implementation were a lack of full infrastructure (e.g., rooms, beds, bags) and protracted hospital stays. \u003cem\u003e\u0026quot;KMC practice was hampered (barriered) by institutional classroom constraints and a lack of KMC beds.\u0026quot; (Neonatal FGD participants)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Even though KMC services are exempt, the hospital did not give food for the moms, and our hospital had difficulty in providing KMC services due to classroom limits and KMC carrying bags.\u0026quot; (Neonatal IDI participant)\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003eEnablers of KMC implementation\u003c/h2\u003e\n \u003cp\u003e\u003cstrong\u003eCommunity and maternal related barriers\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThe availability of mother-to-mother (experienced mothers to new mothers) support and counseling, being educated from influential community leaders, the availability of other people and attendant support, maternal training, if mothers trust the health professionals, births other than cesarean section, availability of maternal initiation/volunteerism, active maternal listening to professional advice, being urban mothers, being near the hospital, were all mentioned by the study participants. \u003cem\u003e\u0026ldquo;If previous working mothers are shown the new ones, and if mothers communicate and support one another\u0026quot; (Neonatal FGD participants)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;If they (mothers) have learnt about the benefits and drawbacks of KMC from a professional, if they (mothers) have been trained by Health Care Providers and influential persons in the kebele, and if other people are supporting them, skin-to-skin contact will be enhanced.\u0026quot; (Midwife FGD participants\u003c/em\u003e)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;If ladies (Mothers) listened to and trusted the professionals (HCP) and didn\u0026apos;t give delivery by cesarean section, our hospital would have a highly implemented KMC.\u0026quot; (Obstetrician/Gynecologist IDI participant)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;If moms are willing, if an expert is around, and if they (mothers) follow expert advice, skin-to-skin contact can be properly implemented.\u0026quot; (Pediatrician IDI participant)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Mothers who live in the city, are accessible to the hospital, and have relatives who support them and have a good opinion of KMC are all important elements in kangaroo mother care at our institution.\u0026quot; (Neonatal IDI participant)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eHealth care provider related enablers\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eHCP related KMC practice enablers in the study areas included the availability of health care advice, the presence of good HCP approaches to mothers, routine staff support, close HCP supervision, the presence of a trained neonatal nurse, good awareness of KMC, the availability of HCP support, the availability of HCP initiation, and the presence of HCP training to mothers. \u003cem\u003e\u0026nbsp;\u0026ldquo;When health care providers treat moms with respect and provide ongoing teaching, they are implementing KMC practice.\u0026quot; (Pediatrician IDI participant)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;To give kangaroo mother care, it was required that staff (HCP) assists mothers, that they (HCP) help and discuss one another, and that they (HCP) are willing and knowledgeable.\u0026quot; (Mother FGD participants)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The presence of a Neonatal Nurse and professional (HCP) particular training in kangaroo mother care are essential factors in facilitating kangaroo mother care in our hospital.\u0026rdquo; (Neonatal FGD participant)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eHospital related barriers\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThe availability of hospital infrastructures such as enough, comfortable, and separate KMC rooms, availability of KMC carrying bags, beds, and hitters, availability of shower, hospital services (KMC), and food costs are covered by the hospital, and availability of continuous KMC educations to mothers in the hospital were described as enablers of KMC practice by the study participants. \u003cem\u003e\u0026ldquo;We can implement skin-to-skin contact if hospitals provide enough, pleasant, and distinct (private) rooms, KMC bags, KMC beds, and hitters.\u0026rdquo; (Mothers FGD participant)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;If KMC equipment such as separate (private) rooms, showers, other KMC facilities, and maternity lodging are available, skin-to-skin contact can begin.\u0026quot; (Neonatal nurse FGD participant)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Because the hosting hospital covered our hospital costs and food, we were able to stay for an extended amount of time while providing skin-to-skin contact with the little infant\u0026rdquo; (Mother IDI participant)\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe aims of this facility-based qualitative study in Northeast Ethiopia\u0026rsquo;s South Wollo Zone were to look at the barriers and enablers of practicing KMC. In this study the barriers and enablers to KMC practice were divided into three themes: 1. Community/maternal related, 2. Health Care Provider related, and 3. Hospital related barriers and enablers.\u003c/p\u003e\n\u003cp\u003eIn this study, community and maternal-related factors for practicing KMC were found to have a significant negative and positive impact on KMC practice; specifically, maternal unwillingness, maternal concern that the baby may suffocate during KMC, mothers\u0026apos; inexperience with or knowledge of a child who has survived this treatment (by KMC), maternal work overload, and family unwillingness to support mothers during workload were identified as barriers to practice KMC. Two systematic reviews concluded that social unsupported and maternal unwillingness are the common obstacles to practice KMC (\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e). In the current study, poor maternal cleanliness, poor economy (to buy diaper, and food), maternal fear of disease transmission from mother to baby, maternal illness (cesarean birth, episiotomy tear, and maternal discomfort) were all also identified as barriers which is supported by study in Pakistan and a systematic review (\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e); conversely, the availability of mother-to-mother support and counseling, maternal training, maternal trust on HCP, give birth other than cesarean section, maternal initiation/volunteerism, active maternal listening to professional\u0026apos;s advice, and being close to the hospital, if educated from influential people, presence of attendant support, families have a positive view of KMC were community/maternal related enablers of KMC practice. Studies in India and Ethiopia support this finding (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe current study\u0026apos;s unique findings are that rural parents commonly hold their newborns on their backs rather than their fronts, which is new to them and a challenge for KMC. Urban mothers, on the other hand, prefer to hold their newborns on their fronts rather than their backs. However, we couldn\u0026apos;t locate any proof to back up these claims.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePoor health care provider comprehension of KMC implementation, lack of continuous supervision, health care providers in despair about mothers\u0026apos; KMC practice, and a lack of KMC education for mothers were identified as health care provider-related barriers to KMC practice in this study (\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e). Whereas, providing: advice, good approaches to mothers, support and supervision, presence of trained neonatal nurse, having good awareness of KMC, availability of supporting each other, availability of HCP initiation, and providing training to mothers were the HCP enablers of KMC. The outcomes of a multi-country study and feedback from international workshops support our findings (\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eSmall, inadequate, and congested KMC rooms were recognized in this study as barriers to KMC practice, which is consistent with a comprehensive assessment that identified a shortage of hospital space as a barrier to KMC practice (\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e). Furthermore, long hospital stay, insufficient KMC infrastructure (beds, bags) all had a negative impact on KMC practice. This conclusion is consistent with a KMC report on an international workshop (\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e) while the availability of full KMC facilities/infrastructures (enough, pleasant, and separate rooms, bags, hitters, and showers), if hospital services (KMC) and food costs are paid by the hospital, and the provision of ongoing KMC educations to mothers were all enablers of KMC practice. Different previous literatures conducted in rural Pakistan and south India supported with these conclusions (\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrength and limitation of the study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe strength of the study is it explored the barriers and enablers for practicing kangaroo mother care with the repeated data collection method. However, this study didn\u0026rsquo;t address kangaroo mother care practice in community level.\u003c/p\u003e"},{"header":"Conclusion and recommendation","content":"\u003cp\u003eCommunity/maternal initiation, health care provider initiation, and hospital infrastructures must all be met in order to start and continue KMC in the hospital. As a result, all stakeholders in the research region work to eliminate barriers and promote enablers to KMC practice.\u003c/p\u003e"},{"header":"Abbreviations ","content":"\u003cp\u003eFDG - Focus Group Discussion\u003c/p\u003e\n\u003cp\u003eHCP- Health Care Provider\u003c/p\u003e\n\u003cp\u003eIDI- In-Depth-Interview\u003c/p\u003e\n\u003cp\u003eKMC- Kangaroo Mother Care\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eContributors:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eSMT, GBW, and AMM conceived the study idea and designed the study. SMT sampled the participants. SMT and GBW reviewed and analyzed the data. SMT, AMM, and AWT interpreted and wrote the draft. All authors critically revised and approved the final version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors no has competing interest\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e no funding\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Sharing Statement:\u0026nbsp;\u003c/strong\u003eNo additional data available.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval:\u0026nbsp;\u003c/strong\u003eWollo University\u0026apos;s Institutional Review Committee issued an ethical clearance letter with the IRB number CMHS114/13/21. Permission letters and informed consent from participants were received from the South Wollo Zone health authorities. Following that, data gathering began.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLawn JE, Gravett MG, Nunes TM, Rubens CE, Stanton C, Group tGR. Global report on preterm birth and stillbirth (1 of 7): defi nitions, description of the burden and opportunities to improve data. BMC pregnancy and childbirth. 2010;10(Suppl 1):S1.\u003c/li\u003e\n\u003cli\u003eLawn JE, Gravett MG, Nunes TM, Rubens CE, Stanton C, the GRG. Global report on preterm birth and stillbirth (1 of 7): definitions, description of the burden and opportunities to improve data. BMC Pregnancy and Childbirth. 2010;10(1):S1.\u003c/li\u003e\n\u003cli\u003eMazumder S, Upadhyay RP, Hill Z, Taneja S, Dube B, Kaur J, et al. Kangaroo mother care: using formative research to design an acceptable community intervention. BMC public health. 2018;18(1):307.\u003c/li\u003e\n\u003cli\u003eJamali QZ, Shah R, Shahid F, Fatima A, Khalsa S, Spacek J, et al. Barriers and enablers for practicing kangaroo mother care (KMC) in rural Sindh, Pakistan. PloS one. 2019;14(6):e0213225.\u003c/li\u003e\n\u003cli\u003eHug L, Sharrow D, Danzhen. Levels \u0026amp; Trends in Child Mortality. NEW YORK, USA: United Nations Inter-agency Group for Child Mortality Estimation (UN IGME), 2017.\u003c/li\u003e\n\u003cli\u003eCattaneo A, Amani A, Charpak N, De Leon-Mendoza S, Moxon S, Nimbalkar S, et al. Report on an international workshop on kangaroo mother care: lessons learned and a vision for the future. BMC pregnancy and childbirth. 2018;18(1):170.\u003c/li\u003e\n\u003cli\u003eBergh AM, de Graft-Johnson J, Khadka N, Om\u0026apos;Iniabohs A, Udani R, Pratomo H, et al. The three waves in implementation of facility-based kangaroo mother care: a multi-country case study from Asia. BMC international health and human rights. 2016;16:4.\u003c/li\u003e\n\u003cli\u003eCharpak N, JG R-P. Resistance to implementing Kangaroo Mother Care in developing countries, and proposed solutions. Acta Paediatr 2006;95:529-34.\u003c/li\u003e\n\u003cli\u003eMaternal and Child Health Integrated Program (MCHIP): Kangaroo Mother Care Implementation Guide. Washington, DC: MCHIP; 2012.\u003c/li\u003e\n\u003cli\u003eConde-Agudelo A, Diaz-Rossello JL. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. The Cochrane database of systematic reviews. 2016(8):CD002771.\u003c/li\u003e\n\u003cli\u003eMOH. KANGAROO MOTHER CARE IN ETHIOPIA. ADDIS ABABA ETHIOPIA. SAVE THE CHILDREN. 2018.\u003c/li\u003e\n\u003cli\u003eJamali QZ, Shah R, Shahid F, Fatima A, Khalsa S, Spacek J, et al. Barriers and enablers for practicing kangaroo mother care (KMC) in rural Sindh,Pakistan. PLoSONE. 2019;14(6):e0213225.\u003c/li\u003e\n\u003cli\u003eVesel L, Bergh AM, Kerber KJ, Valsangkar B, Mazia G, Moxon SG, et al. Kangaroo mother care: a multi-country analysis of health system bottlenecks and potential solutions. BMC pregnancy and childbirth. 2015;15 Suppl 2:S5.\u003c/li\u003e\n\u003cli\u003eGamlath G.G.A.W., Wijayarathne P.G.S.S., Gunadasa P.A.C.R. , Sakalasooriya S.S.N.D., Kuruppu N.R., Cooray k, et al. Barriers to Implement Kangaroo Mother Care among Post- Natal Mothers with Premature Low Birth Weight Babies. OPENING MINDS: RESEARCH FOR SUSTAINABLE DEVELOPMENT. 2017.\u003c/li\u003e\n\u003cli\u003eChan GJ, Labar AS, Wall S, Atun R. Kangaroo mother care: a systematic review of barriers and enablers. Bull World Health Organ. 2016;94(2):130-41J.\u003c/li\u003e\n\u003cli\u003eSeidman G, Unnikrishnan S, Kenny E, Myslinski S, Cairns-Smith S, Mulligan B, et al. Barriers and Enablers of Kangaroo Mother Care Practice: A Systematic Review. PLoS ONE 2015;10(5):e0125643.\u003c/li\u003e\n\u003cli\u003eYusuf E, Fiseha F, Dulla D, kassahun G. Utilization of Kangaroo Mother Care (KMC) and Influencing Factors Among Mothers and Care Takers of Preterm/Low Birth Weight Babies in Yirgalem Town, Southern, Ethiopia. Diversity and Equality in Health and Care. 2018;15(2):87-92.\u003c/li\u003e\n\u003cli\u003eCattaneo A, Amani A, Charpak N, De Leon-Mendoza S, Moxon S, Nimbalkar S, et al. Report on an international workshop on kangaroo mother care: lessons learned and a vision for the future. BMC pregnancy and childbirth. 2018;18(1):170-.\u003c/li\u003e\n\u003cli\u003eBergh A-M, de Graft-Johnson J, Khadka N, Om\u0026rsquo;Iniabohs A, Udani R, Pratomo H, et al. The three waves in implementation of facility-based kangaroo mother care: a multi-country case study from Asia. BMC International Health and Human Rights. 2016;16(1):4.\u003c/li\u003e\n\u003cli\u003eSmith ER, Bergelson I, Constantian S, Valsangkar B, Chan GJ. Barriers and enablers of health system adoption of kangaroo mother care: a systematic review of caregiver perspectives. BMC pediatrics. 2017;17(1):35.\u003c/li\u003e\n\u003cli\u003eRaajashri R, Adhisivam B, Vishnu Bhat B, Palanivel C. Maternal perceptions and factors affecting Kangaroo Mother Care continuum at home: A descriptive study. The Journal of Maternal-Fetal \u0026amp; Neonatal Medicine. 2017.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Wollo University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"KMC practice, barriers, enablers, South Wollo zone, Northeast Ethiopia","lastPublishedDoi":"10.21203/rs.3.rs-3072715/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3072715/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eEvery year, an estimated 13\u0026nbsp;million premature babies are delivered in the world, making it the largest cause of newborn mortality due to infections and hypothermia. Kangaroo mother care is a low-cost treatment strategy for reducing hypothermia-related death. However, it has a low coverage rate in Ethiopia.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThe aim of this study was to assess the barriers and enablers for practicing kangaroo mother care.\u003c/p\u003e\u003ch2\u003eStudy Design:\u003c/h2\u003e \u003cp\u003eFacility based study design was conducted in South Wollo zone public hospitals on a total of 12 IDIs and 10 FGDs from November 2021 to December 2021. After informed consent was obtained; Pediatrician, Obstetrician/gynecologist, mothers, neonatal nurses, and midwives were participated in FGDs and IDIs. The results have been summarized after data has been transcribed, themed, preliminarily analyzed, and quoted the participants' opinions.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e \u003cp\u003e Community/maternal related, health care provider related, and hospital related barriers and enablers for practicing KMC in the study hospitals were identified. The investigated barriers included maternal fear that the baby would suffocate during KMC, maternal illness, poor maternal hygiene, being a rural mother, poor maternal economy, lack of trained health care providers (HCP), lack of continuous supervision, long hospital stays, and lack of full KMC infrastructures, to name a few. The listed enablers for KMC practice included getting support from other mothers and community leaders, mothers' faith in medical professionals, births other than cesarean sections, urban mothers, proximity to the hospital, families' positive attitudes toward KMC, the availability of KMC infrastructures, hospital services (KMC), and food costs being covered by the hospital.\u003c/p\u003e\u003ch2\u003eConclusion and recommendation:\u003c/h2\u003e \u003cp\u003eTo begin and maintain KMC in the hospital, hospital infrastructures, community/maternal initiation, and health care provider initiation must all be addressed. As a result, everyone involved in the study area works to remove constraints on KMC practice and foster enablers.\u003c/p\u003e","manuscriptTitle":"Barriers and enablers for practicing kangaroo mother care in South Wollo Zone public hospitals East Amhara, Northeast Ethiopia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-06-19 10:28:50","doi":"10.21203/rs.3.rs-3072715/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3d4feb18-c085-4c5b-a76e-ac9ae6a2df59","owner":[],"postedDate":"June 19th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":22469253,"name":"Pediatrics"}],"tags":[],"updatedAt":"2023-06-19T10:28:50+00:00","versionOfRecord":[],"versionCreatedAt":"2023-06-19 10:28:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3072715","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3072715","identity":"rs-3072715","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}