Continuation of Kangaroo Mother Care when transitioning from Facility to Community: Maternal and Familial perspectives from South India

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Despite its success, many families struggle to implement KMC effectively post-discharge. Method: This qualitative study explored the experiences of mothers and families practicing KMC after discharge from the hospital in South India. In-depth, semi-structured interviews were conducted with eight mothers, fathers, and grandmothers, focusing on their experiences with community KMC (cKMC) and their challenges in maintaining cKMC at home. Results: Analysis resulted in the construction of three main themes: 1) Breast Feeding - Persevering Despite Initial Difficulties; 2) Kangaroo Mother Care - Seeing benefits but struggling to practice; and 3) Family Boon or Bane - Family as a crucial context for cKMC practice. Participants expressed a strong commitment to breastfeeding despite encountering challenges. KMC was adopted positively and benefitted from support by healthcare team and infrastructure during hospital stay, but continuation at home was difficult due to inadequate counselling, lack of community follow-up and challenging home environment. Family emerged both as a support system and a source of a tension to KMC practice. While fathers and grandmothers actively supported KMC in hospital settings, post-discharge traditional gender norms and domestic responsibilities hindered continuity at home. Conclusion: To promote sustained family-inclusive cKMC practices, there is a need for structured education to empower all caregivers, including grandmothers and fathers. Adoption of gender inclusive terminology such as “Kangaroo Family Care” can help to dismantle gender-oriented perceptions and encourage participation of all family members. Engaging grandparents as champions of KMC can promote intergenerational support for families and improve the outcome of LBW newborns. Community health teams should strengthen through tailored training on antenatal counselling and post-discharge support. Kangaroo Mother Care low-birth-weight infants family support breastfeeding challenges community health workers gender-inclusive practices Introduction Kangaroo Mother Care (KMC) is an evidence-based intervention that significantly reduces neonatal morbidity and mortality, particularly among low-birth-weight (LBW) and preterm infants [1]. Globally, LBW remains a pressing concern. In 2020, 14.7% of all babies were born with LBW [2]. Over half of preterm births worldwide occurred in just eight countries, with India accounting for 3.02 million preterm births annually, constituting 20% of the global total [3]. Extensive research has established a strong association between preterm birth and developmental disorders, including cerebral palsy [4–6], intellectual disabilities [7], attention deficit hyperactivity disorders (ADHD) [8], and developmental delays [9]. Premature and LBW infants constitute 70% of all neonatal deaths worldwide [10]. These alarming statistics highlight the urgent need to address neonatal care to meet the Sustainable Development Goal (SDG 3.2), which aims to reduce neonatal mortality to 12 per 1,000 live births by 2030 [11]. Developed in 1978 in South America, Kangaroo Mother Care (KMC) is an essential modality of treatment for low-birth-weight babies. KMC comprises of essential components such as continuous skin-to-skin contact, exclusive breastfeeding, early discharge, and sustained follow-up care [12]. These practices have demonstrated effectiveness in reducing the incidence of neonatal infections, hypothermia, pain responses, and overall mortality [13, 14]. In India, where neonatal care remains a challenge due to the high prevalence of LBW and preterm births, the implementation of KMC was integrated into hospital settings with relative success [15]. However, the transition from hospital-based KMC to community-based care could represent several challenges that impede its effectiveness and sustainability as shown in previous studies [16, 17]. This could be particularly relevant in South India, where social, cultural, and systemic factors play a significant role in determining health outcomes. The India Newborn Action Plan (INAP) established ambitious targets for KMC coverage, aiming for 35% by 2017, 50% by 2020, 75% by 2025, and 90% by 2030. To achieve these targets, the Indian government has established 894 Sick Newborn Care Units (SNCUs) nationwide, which provide specialized care for small and sick newborns. Tamil Nadu, a southern state with comparatively robust health infrastructure in an Indian context, has ensured the availability of new born care facilities in all districts [15, 18]. Specifically, Chengalpattu Medical College Hospital (CMCH) has implemented quality improvement interventions in its neonatal intensive care unit (NICU) to increase the duration of KMC to over 16 hours per day before discharge [19]. Despite these efforts, little is known about the transition of KMC from hospital to home settings. This qualitative study explores the factors that enable or hinder the practice of community-based KMC in South India. Specifically, it examines caregivers’ experiences with KMC at the place of birth, the challenges they face in maintaining KMC practices at home, and their successes or struggles in sustaining the key KMC components, particularly breastfeeding and skin-to-skin contact. By understanding these dynamics, this study seeks to inform interventions that can bridge the gap between the hospital and home care, ensuring that the benefits of KMC reach the most vulnerable populations. Effective community-based KMC has the potential to significantly reduce neonatal mortality and improve health outcomes for LBW and preterm infants, contributing to the broader goal of enhancing new born survival in South India and beyond. Methods Study context and background This study was motivated by the experiences of the primary author, working in the Paediatric department Intensive Care Unit (ICU) and the District Early Intervention Centre (DEIC) at the tertiary care hospital in Chengalpattu district. It was observed that many LBW infants discharged from the Neonatal Intensive Care Unit (NICU) frequently got readmitted in critical conditions. Interestingly, despite having received instructions on KMC during their NICU stay, many families encountered difficulties to practice KMC once they returned home. This study was designed to explore the enabling factors, difficulties and challenges from the caregiver’s perspective and gain a deeper understanding of the enablers and barriers to continue KMC post-discharge. Study setting The study was conducted in the Kancheepuram and Chengalpattu districts of South India. Chengalpattu Medical College Hospital (CMCH) serves as a tertiary care centre, offering free medical services to residents of both districts, where approximately 60% of deliveries occur. High-risk mothers are routinely referred to CMCH, and both LBW and preterm infants born at CMCH or referred from outside are admitted to the NICU. At CMCH, the protocol mandates the initiation of KMC in the NICU, with continued KMC practice in the step-down wards. The medical team emphasizes KMC throughout the hospital stay, supported by visual displays and daily counselling sessions, including guidance at the time of discharge. Notably, CMCH features a father KMC ward, equipped with semi-reclining cots to facilitate KMC for fathers, an amenity available only in select centres across the state. Infants are discharged from CMCH upon reaching a weight of 1.6 kg and demonstrating consistent weight gain over three consecutive days. In the community, neonatal health services follow an interdisciplinary model. Primary Health Care (PHC) staff and Integrated Child Development Scheme (ICDS) personnel conduct home follow-ups to monitor the growth and development of discharged infants. These healthcare providers are trained in KMC and are responsible for assisting and monitoring KMC practices at the community level. Study Design This study adopted a constructivist paradigm to explore the subjective experiences of participants with KMC, acknowledging that their perceptions are shaped by their social and cultural contexts. A phenomenological approach was chosen because it is well-suited to exploring the lived experiences of mothers and families, aligning with the study's aim to deeply understand their perceptions and experiences of KMC after hospital discharge [20]. In-depth, semi-structured interviews were conducted within participants' homes to capture authentic family perspectives on practicing KMC at home. The home setting was chosen to promote openness, comfort, and flexibility, enabling participants to share their experiences freely. Mothers could pause or continue the interviews according to their needs and the comfort of the mother-baby dyad. Each participant was assigned a unique code, and interviews were audio-recorded to ensure accurate transcription and facilitate cross-checking. Recruitment and Participants Collaboration was established with the discharge nurse/data entry operator in the NICU and the village health nurse (VHN) at the community level, ensuring that participants informed consent and their voluntary participation were secured before inclusion in the study. A comprehensive list of discharged neonates from the NICU was compiled, and purposive sampling ensured representation from rural, urban, and tribal communities. Mothers of LBW infants were eligible to participate. A total of eight mothers, aged 20 to 30, whose infants had been treated in the NICU and discharged, volunteered to participate after the project was explained to them. In some cases, fathers and grandmothers, who were caretakers or present during the interviews, also participated, providing additional insights into the caregiving dynamics and family support systems. In this region, it is customary for women to stay at their mother’s house for their first delivery, typically spanning 3 to 6 months post-delivery. From the second child onwards, mothers usually reside with their husband’s family. The VHN was contacted to determine whether each mother was at her maternal or marital home. Before traveling to the participants’ homes, the interview team confirmed each mother’s willingness to participate in the study. Data Collection The primary author (SJ) did the interview, and she was assisted by a field researcher to create a safe and confidential environment where mothers felt comfortable sharing their childcare experiences. During data collection, special attention was paid to ensure participant comfort and ethical standards. All participants provided informed consent before each interview, and they were assured that their responses would be treated with confidentiality and respect. Audio recordings and transcriptions were securely stored on encrypted devices, and identifying information was removed during transcription to maintain confidentiality. The in-depth interviews with mothers and family members lasted between 60 and 90 minutes, with an average duration of 70 minutes. Various techniques such as open-ended questions, active listening, probing, and other facilitative methods were used. The semi-structured interview guide adapted from Lydon et al. [21] was reviewed after initial interviews and adjusted slightly to explore emerging themes more deeply. The interviews were designed to prioritize the mothers' narratives and life experiences. They guided the participants through their journey of care before childbirth, the experience of preterm delivery, the family’s experience immediately after birth, the transition to the NICU, and the KMC provided within the healthcare facility. The second part of the interview focused on the discharge process, the care provided at home, and the support received from family and the community. These interviews aimed to provide researchers insights into the challenges of KMC and to explore the behaviours and strategies families adopted to care for their LBW new-borns. The interviews were conducted in Tamil, the participants' native language, and were audio-recorded. Additionally, the primary author took visual documentation of the physical surroundings in the homes where children were cared for. This included detailed notes on the space available for KMC and other relevant environmental factors. Data Analysis The in-depth interviews were transcribed verbatim to maintain accuracy. To ensure precision and fidelity, these transcriptions were cross-checked against the audio recordings by two researchers, safeguarding the accuracy and integrity of the collected data. Trustworthiness was enhanced through peer debriefing, maintaining an audit trail, and engaging in reflexive discussions to ensure credibility and confirmability. To protect anonymity and confidentiality, participants’ identities were concealed throughout the transcription and analysis phases. Precautionary measures were taken to protect the participants’ privacy and the sensitive information shared. For effective data management and organization, NVivo 12, a qualitative research software, was employed. The methodological approach grounded in the phenomenological tradition [20] emphasizes a deep alignment with participants’ experiences. This commitment to understanding participants' lived realities informed the entire analysis process. The analytical process was guided by reflexive thematic analysis (22, 23), and began with a thorough review of the individual interview transcripts by all authors. This initial phase was exploratory and focused on identifying topics within the data that were of significant interest and aligned with the study’s aim. The emphasis was on capturing the lived experiences of mothers and families shared during the interviews. The primary author (SJ) conducted the initial data analysis under the supervision of SH and IK. As the analysis progressed, researchers engaged in extensive reading and discussion of the data, leading to the development of an initial framework. This framework mapped the process of acquiring KMC knowledge within hospital settings and the obstacles faced in practicing community-based KMC (cKMC). In the subsequent phase, the team further dissected the data into three distinct themes, developing a nuanced understanding of the diverse experiences and challenges encountered. The research team collaborated to achieve a consensus on descriptions of the challenges presented in each interview, reflecting on the varied experiences of participants. Each phase was documented to ensure a high level of transparency, allowing readers to critically evaluate the applicability and credibility of the findings. Reflexivity With extensive experience in neonatal care, the primary author (SJ) acknowledges that clinical perspectives might influence interpretations. The primary author, who worked in the hospital, visited the homes of families and played the dual role of caregiver in the hospital and researcher in the field. Although the families treated the researcher (SJ) with respect (addressed as “Madam”), the impression is that they were not hesitant to narrate the real issues. Reflexive journaling was employed to critically evaluate how the author’s professional background, assumptions, and positionality influenced data collection and analysis, ensuring participants' voices remained central. This research also adopted the reflective thematic analysis approach, emphasizing the researcher’s role in generating knowledge. The framework proposed by Braun and Clarke [22, 23] was utilized for its flexibility and systematic approach to identifying themes within qualitative data. After the initial reading phase, the authors convened for a reflective discussion on the first day of analysis. These discussions incorporated elements of both analysis and reflection, drawing on the researchers’ diverse backgrounds in child health, clinical psychology, and sociology. This interdisciplinary approach enriched the analysis and provided multiple perspectives. Ethical considerations The study adhered to ethical principles outlined in the Declaration of Helsinki [24]. The research was approved by the Norwegian Regional Committee for Medical and Health Research Ethics (32413) and the Institutional Ethical Committee of Chengalpattu Medical College (ECR/774/INST/TN). All participants were fully informed about the project and provided their signed informed consent before participating. Ethical handling of participants' interviews and data was prioritized, ensuring confidentiality, respect, and integrity throughout the research process. Findings The analysis resulted in the construction of the following themes, detailing mothers' experiences with breastfeeding and the practice of skin-to-skin contact in KMC: Theme 1: Breast Feeding – Persevering Despite Initial Difficulties -Despite encountering various physical and emotional hurdles, many mothers demonstrated remarkable perseverance, motivated by the health benefits for their new-borns. Theme 2: Kangaroo Mother Care (KMC) – Seeing benefits but struggling to practice - The barriers they face in consistent practice, such as physical discomfort, time constraints, cultural influence, lack of family and community support, were examined. Theme 3: Family Boon or Bane (trouble) - Family as a crucial context for Community Kangaroo Mother Care (KMC) practice - Examined the dual role of family as either facilitators or obstacles in the successful implementation of KMC. Theme 1: Breast Feeding – Persevering Despite Initial Difficulties Analysis of the participants’ experience with breastfeeding showed that all of them intended to breastfeed their baby for an extensive period after birth. However, all participants also reported facing several obstacles to breastfeeding during the postpartum period, particularly in the beginning when many were separated from their baby at the hospital. Breastfeeding was seen as health promoting for their babies for most participants, with bottle feeds being associated with health risks. This understanding was often linked to advice given by health professionals: “At the time of discharge doctor advised me, ‘Babies health is on your hand, you should continue KMC at home with breast feeding and the breast milk is the only nutrition that gives the energy to the baby.’ So, doctor informed me to continue breast milk for six months.” (Participant 1) However, most participants faced difficulties initiating breastfeeding during initial stages in NICU. Mothers were upset to see the tiny babies surrounded by lifesaving equipment but tried their best to give breast milk. The options available to the mothers were to strive hard for breast milk or switch to bottle feeds. Many participants were unable to give direct breastfeeding initially, since the baby was taken to intensive care: “Baby was there inside, and I was in the caesarean ward room. I was not giving milk for the first 10 days.” (Participant 2) Soon after birth many participants were expressing milk, and family members were delivering the milk at ICU, so that milk could be given through the nasogastric tubes: Grandmother: “We were expressing milk from my daughter, and we were taking into the glass room. It was given to the baby through tube." (Participant 2) In addition to the initial separation, many participants experienced inadequacy of milk initially, with the infant’s premature status complicating breastfeeding due to weak sucking. When failing to produce sufficient milk initially, five participants resorted to borrowing milk from others: “Sometimes I was not getting adequate milk. I used to have breast engorgement. Then I used to get milk from mothers who were lying on nearby cots and give it to the baby. Later I started to give my own breast milk.” (Participant 3) Though inadequate milk was a challenge, few mothers reported increased milk secretion when they practiced skin-to-skin contact: “Breast milk secreted well, while on KMC, it was good” (participant 6). Some participants were also getting milk from the milk bank when experiencing inadequacy of milk, or when having excess milk. However, few participants were unaware of the milk bank: “There are sisters who take care of the milk bank. She collects milk and donates to others.” (Participant 6) “We don’t know about milk bank and they also not given milk from milk bank.” (Participant 5) Physical discomfort due to the C-section restricted movement, and some mothers expressed the inability to breastfeed, due to the pain: “I had stitches on my body. I was not able to sit. It was very painful.” (Participant 1) Participants also expressed an understanding of how the milk secretion is depending on mother’s emotions and food intake. When the milk was perceived as inadequate, the mother and her families tried many methods to increase the secretion especially through supplementing through additional foods. The families took special efforts to prepare foods believed to be galactagogues such as special fish (paal Sura/ Sura putu), garlic, homemade nutritious mix etc: “In my family, they ask me to eat the special fish and I was adding the fish in the hospital. Special sea food called ‘paalsura’. It is available in special fish market.” (Participant 8) In contrast to the common belief that good food assists adequate milk secretion for the baby, two mothers expressed concern about adverse consequence of more food, paving way for more milk which will choke the baby: “Eat more food, then there’ll be more milk. And when more milk comes through my breast, it will choke the baby’s breath.” (Participant 2) During the hospital stay as the babies’ condition improved, they were shifted from ICU to stepdown unit, then to family centred care unit before discharge to home. The families tried their best to adopt the feeding practice, from tube feeds to expressed milk to direct breast-feeding: “The baby was always tube-feed, finally I came to the room with a screen, the tube was removed and paladai feed (cup feed) was given. The baby got the food through tube, through paladai (cup feed) and also tried breast milk.” (Participant 6) From the hospital the babies were discharged to home. The cultural practice in Tamil Nādu is for the first pregnancy, the mother goes to her parental home soon after discharge, she gets adequate support for rest and childcare. Some mother felt milk secretion increased after arriving home. On the contrary few felt the milk secretion decreased after going home – overwhelmed by the household responsibilities: “When I was in the hospital milk secretion was not good and after reaching home, it was good.” (Participant 5) “Milk secretion was not good after coming home.” (Participant 5) Being able to breastfeed was felt important to many mothers, exemplified with how they persevered in their efforts despite challenges. Not being able to produce sufficient milk therefore felt uncomfortable, even shameful to some participants. A mother who had delivered twin babies had switched to bottle feeds, lowered her head in guilt while narrating the change to bottle feeds after advice from a private doctor: “I don’t take enough food due to fever for the past two days so I don’t get good milk. Then I took the babies to private clinic, there the Doctor said, the powder milk is not good for the baby’s health but now you are sick, so for time being you can give powder milk.” (Participant 1) Theme 2: Kangaroo Mother Care (KMC) – Seeing benefits but struggling to practice Even though the practice of KMC was new and unfamiliar to the families, they expressed positive attitudes towards KMC. Most families found the environment within the healthcare facility, not only in step down wards but also in intensive care units, to be helpful and a support in learning and initiating KMC as part of their care for their children. This included both support and advice given by the doctors and nurses in why and how to do KMC, as well as information materials about KMC at display around the premises. As a result, most participants practiced KMC while at the healthcare facility: “The sister will ask me to sit on the chair and she used to keep the baby on the chest. The sister in the ICU helps me to perform KMC, she removes the tubes and places the baby over my chest. There I have been provided with the chair. The doctor has advised to keep the baby in KMC for maximum 18hrs minimum 12hrs; then only the baby will gain weight.” (Participant 3) The mothers also frequently highlighted the importance of having adequate infrastructure facilities to support KMC, like KMC beds, opportunities for privacy and the inclusion of fathers in the care: “There is a bed for the mother, baby cot, and each bed is covered with a screen to do KMC.” (Participant 4) However, it was apparent that for some participants verbal guidance alone was not sufficient. They expressed a desire for instructional videos to enhance their understanding to implement these KMC more confidently and effectively: “They advise only by talking. If more video shown regarding baby care, it will be good for my family members to see and practice.” (Participant 8) Some fathers also raised concerns regarding the restrictions on men’s access into the NICU. This limitation hindered their ability to practice, which made them feel unable to contribute to this important caregiving practice for the low weight new-born: “There are lots of deliveries and less discharges. Because of the overcrowding father KMC place was given to mothers. Father ward was given to mother.” (Participant 1). The engagement of fathers in the practice of KMC during their stay at the health facility also influenced the fathers’ confidence in practicing KMC with their child: “Father: If I had been trained, it will be easier for me to hold now. It needs special skill to handle new-born baby, if we are not holding the neck properly baby will get nerve pain (sprain).” (Participant 5) Overall, mothers and caregivers articulated several advantages that babies would gain from adoption of KMC. Many of the participants had given birth prematurely, and they likened KMC to provide womb-like environment for their infants emphasizing the nurturing qualities of the practice: “This method will help the low birth baby to grow normal like mother’s womb.” (Participant 5) However, although the mothers and their families had received extensive training and counselling on KMC in the health facility and integrated KMC as part of their care in NICU and step-down wards, and also expressed benefits of KMC, many participants did not continue to practice KMC after being discharged: “(Mother smiled shyly): No, we did not practice such thing at my Home. The doctor said to do KMC, but we never did.” (Participant 4) The seamless flow of healthcare services from the hospital to the community is intricately linked to the knowledge and advice imparted to their families when they are discharged. Family members recounted the valuable guidance, they received from the healthcare team at the time of discharge process. This guidance acts as a pivotal role between the care at the facility and the ongoing care and support the child will receive in the community: “At the time of discharge, they said I should do KMC, wash hands before taking baby, to give breast milk and to take the baby every week to the hospital.” (Participant 6) However, there were also families who expressed dissatisfaction with the discharge process. They voiced their concern regarding the lack of guidance or counselling regarding KMC during the discharge. Instead, they felt they were given only a discharge card without advice regarding the crucial practice of KMC: “I did not get any counselling and there was no advice. At the time of discharge there was no advice. I got the discharge card from a lady sitting in computer room and came home.” (Participant 4) Though the families received support in the hospital, after discharge they had to manage alone. They expressed the community workers were involved in routine activities and they felt dissatisfied with regards to KMC support in the community: “The Balwadi (ICDs- Integrated Child Development Scheme) people they give the nutritional mix, the village health nurse from the primary centre, she's more involved with a vaccination. But we don't get information about the KMC from anybody.” (Participant 2) In addition, many mothers, especially those who had undergone caesarean sections or who had given birth to twins, encountered difficulties in practicing KMC due to post-delivery pain: “When I practice KMC I had headache. Pain over the head and I had especially pain over the neck, it was radiating, and it was pulling my neck. So, because of that I was not able to sit.” (Participant 1) Some mothers of LBW infants were also worried practicing KMC might cause harm or discomfort to their babies: “I was scared to carry the baby; I was afraid it was a small baby to keep it close to the chest; I was worried that breathing may stop.” (Participant 8) Balancing household duties with KMC also proved to be a daunting task. Many families found it hard to simultaneously engage in KMC while managing their household responsibilities: “Morning I am not able to do. I have work in the morning. I have to do all the household jobs.” (Participant 6) Finally, the region in Southern India where this study was carried out is characterized by a hot climatic condition, particularly during summer. Families residing in the region expressed various challenges related to the sweltering heat they encountered. “It is hot. We have only a roof- tile roof. It radiates heat inside and it's very difficult to keep the baby on the chest when it's very hot. And my baby also not keeping quiet.” (Participant 2) Theme 3: Family Boon or Bane (Trouble) - Family as a crucial context for Community KMC practice. The mothers identified themselves as a part of large family network and the collective responsibility of shared household activities and childcare practices were expressed by them. In respect of maternal and new-born health, the families played a pivotal role in care of the child. As we have seen above, the family took active part during the hospital stay and assisted for KMC in the intensive care unit, after being trained by the health team. The findings from the in-depth interviews suggest that grandmothers played a significant role for the practice of KMC. They were a source of support for both the mother and the infant, serving as important caregivers and decisionmakers. However, the degree of involvement varied among the grandmothers. While some of them actively participated in KMC, care giving activities and emotional support to the mothers, a few of them played a more passive role, deferring decision making to other family members. The dynamics within the family and the mother's relationship with her own mother (the grandmother) emerged as a critical factor influencing the acceptance and implementation of KMC. Open communication, shared understanding, and a positive relationship between the mother and grandmother were reported to foster a collaborative approach towards KMC: “My mother assisted in the hospital to hold; my mother had always cared for the baby! (Grandma approves and smiles).” (Participant 2) Some grandmothers also took on a leadership role after staying for more than a fortnight in NICU, teaching KMC to new mothers and grandmothers: “In the hospital when the baby was there for long time, I used to talk to other mothers and grandmothers and I teach them the position of KMC, whatever I learnt from doctors and sisters, I will tell others". (Participant 7) Next to the grandmothers, it was the fathers who took the most active role for KMC in NICU. During the hospital stay where the mothers were convalescing in the post operative ward or intensive care unit, the fathers took active part in doing KMC in NICU: Father: “I go in the morning between 11 am to 5 pm, give kangaroo care.” (Participant 3) The hospital had the practice of allowing the men for particular periods of the day and some fathers expressed a wish for more KMC hours in the hospital. Some fathers were emotional to have the baby on the chest and expressed the feelings for KMC: "She had the opportunity to carry the baby in womb. But by KMC I too had the chance. (The father felt emotional his eyes were tearing. He brought the hands to the chest as a gesture of gratefulness).” (Participant1) The mothers also narrated the experience of the other family members in NICU supporting KMC in the hospital: “Two of my sisters came to hospital to do KMC, my elder sister and younger one. Five of our family members came to the hospital and they all did KMC.” (Participant 1) Though the families were supporting in terms of KMC care and breastfeeding in the hospital, after discharge the dynamics of many families changed. Conflicts or differing opinions for allowing the family members to do KMC posed challenges to the successful practice of KMC. Moreover, during interviews, views were expressed mirroring cultural expectations that the baby care is the mothers' responsibility. Traditional gender roles with men being breadwinners and the women babysitters was reinforced by fathers in the community. Consequently, the provision of KMC was predominantly considered as the domain of mother and female family members after discharge: Father: (Looking at the mother, he looked angry): “This is her responsibility to take care of the baby and herself. It is she at home always. If she does not take care as per doctor’s advice, what to do?” (Participant 4) The traditional gender roles also left a few mothers conflicted in allowing the fathers to handle the babies: Mother: “I would not allow him to keep the baby on him because he is not gentle with the baby, he does not handle the baby carefully. I am afraid that he cannot do that” (Participant 4). The mothers also mentioned physical and practical barriers to KMC due to the tradition of mothers moving to their parents’ home after the first childbirth. This meant fathers were visitors when seeing the mother and child, and living standards could be lower than what the father was used to, sometimes constituting a barrier to KMC: “He visits here on Saturday and Sunday only, when I ask him to do KMC, he puts the baby for I to 2 hours. I used to force him for doing KMC. (Mother laughs... father also laughs...) He used to live comfortably in A/C room. He is not comfortable under the ceiling fan, in my home. He said how long I keep the baby like this — he walks away. Only my mother will do KMC.” (Participant 7) Burdened by the household chores, many mothers experienced difficulties to practice KMC. Time allocation between household activities and the childcare was found to be barriers to practicing KMC at the community: “I will put KMC in the afternoon sometimes. Morning I am not able to do. I have work in the morning. I have to do all the household jobs.” (Participant 6) Some of the participants thus felt that they did not get the adequate support for KMC from family members at home: "I alone practice it. I don't ask my mother." (Participant 5) But in some families though there was support, the mothers resented the baby being handled by others. They expressed concern for social contact being associated with increased risk for infection in their babies, therefore restricted who could handle the baby. The mothers got the idea of cleanliness during the stay in NICU where there is restricted access to visitors and the mothers felt the relatives as a source of infection and emphasized that they should not touch the baby. This aseptic idea was a barrier for KMC care at home, forcing the mothers to manage the burden of household chore and child care alone. Mother: “Sister, uncle, mother, father, and husband came to the hospital. Many of my relatives live close by, they come but, no one touched the baby. In the hospital they advise me that the baby was very sick. Got discharged, hence at home also only myself and husband should take care. No one should touch the baby.” (Participant 6) However, some fathers and family members took extra efforts to assist the mother in childcare, finding ways to overcome challenges, like space constraints: “There is no space constraint. If the family is willing all can give Kangaroo Mother Care.” (Participant 2) Some families hence managed to balance between the outside work, household chores, and the responsibility of KMC care. The enthusiasm of the father and other family members to support KMC at home was an enabler for long hours of KMC practice. “After discharge I kept the baby in KMC for more than a month; even now I used to follow. My father keeps the baby in KMC, and my husband and my sister do too; whoever it may be, all of us in the family cuddle the baby in bed or use KMC in a chair. On average, in a day, 10-12 hours we did KMC.” (Participant 3) Discussion When the Family support is good, continuity of care in the community is better. The findings from this study provide insight into the family’s experience when they shift care of the new-born from the hospital to the home environment. As shown in the results section, families often acted both as a source of support and as well as conflict to practice KMC at home. Various studies underline the role of families in KMC, and a systematic review by Siedman showed that support from family, friends, and other mothers was a resourcing enabler, with family support being the top-ranked enabler for continuation of KMC practice in LMICs [25]. The results from our study showed that family members were supportive and facilitating KMC in the hospital, but not necessarily in the context of home, where, as per sociocultural norms, many expected caregiving responsibilities to be handled solely by the mother. Support for KMC after discharge therefore varied considerably. Similar findings of mothers not feeling supported in continuing KMC by families or communities have also been reported in previous research. A systematic review of KMC highlighted time constraints as a significant barrier [26], a concern echoed by several participants in this study. However, our findings reveal a more nuanced perspective. While some families allocated more time to household responsibilities at the expense of KMC, others devised innovative strategies through collaborative planning. One family, for instance, exemplified this adaptability and devised a structured plan as per work schedule and commuting time; all family members took turns sharing household work and KMC. Now the question arises: Why do some families brave the odds to continue to practice, while the rest reduce or stop the support? Results from our study reveal that fathers and grandmothers were exposed to KMC in the NICU and played a pivotal role in decision-making, implementing or hindering KMC irrespective of social status. However, in the literature, studies have documented that lack of opportunity to practice is a barrier for fathers to support at home [27]. Fathers in a qualitative study in Australia were unaware that fathers could practice KMC. After they underwent an experiential learning process in the NICU, they supported the process. Similar findings state the importance of Kangaroo Care implementation as a structured education of the fathers [28]. The results from our study showed that some fathers who had experiential learning in the NICU felt emotionally satisfied to be elevated to a maternal role. Similar to our findings, studies from the UK, Sweden, and Denmark have reflected and re-examined the role of father rather than a bystander. When fathers kangaroo care was instigated, fathers felt empowered to take on equal parenting roles [29–35]. On the contrary, Helth and Jarden [34] found that fathers in a Danish study did not perceive themselves as important as mothers in providing KMC. These disparities are often associated with the different cultural backgrounds. In settings like Zimbabwe, fathers voiced unease about performing KMC because of societal norms that childcare should be the role of the mother [26]. The findings from our study both align with and also contradict the results from existing literature but point to a different direction. One ponders about experience: the counselling sessions in a busy governmental hospital—are they adequate to convince the families, or do they need a more structured program? Literature is abundant with various structural educational programs for members of families, including males. A systematic review by Smith [36] states that supervised practice and educating the family by demonstrations can enhance the confidence of family members to do KMC. Many supportive programs in Malawi have utilized the services of respected grandparents to promote KMC. 4000 grandparents were trained in the grandparent’s program, where they provided individual and group counselling in their village to share the messages of positive child rearing [36]. We also saw the resources of grandparents in the current study. One grandmother of one of the participants who stayed for a long time in the hospital took the leadership role and trained recently delivered mothers and became a strong advocate. There is bias in the literature too, where kangaroo care is often reported as Kangaroo Mother Care, emphasizing the mother’s role. However, research by Blomquist and colleagues [31] shows that when fathers were given the opportunity to practice, they were empowered to provide parental support. This raises an important question: Does Kangaroo Care, when practiced by fathers, yield the same benefits as when practiced by mothers? Studies have found no significant differences in infants’ physiological parameters, such as heart rate, temperature, and oxygen saturation, when fathers provide KMC compared to mothers [37, 38]. This evidence suggests that paternal KMC offers comparable psychological and physiological benefits to maternal KMC, reinforcing the idea that the benefits of skin-to-skin contact and emotional bonding are not gender-dependent. One of the fathers in this study lamented that he had to vacate his place in the Father Kangaroo ward to accommodate mothers due to overcrowding. Another father said that if he was given the opportunity to learn the technique of KMC in the hospital, he would have supported KMC at home. Taken together, the evidence suggests re-evaluating the protocols of neonatal care units, creating training programs, and tailoring interventions and adaptations in the infrastructure to support paternal and other family members inclusion in the neonatal care units to ensure continuity of care at home. Further, this evidence highlights the need for longitudinal studies to assess family dynamics, paternal mental health, secondary benefits of reduced burden on mothers in high-stress environments, nuclear families, and dual-career families.Policy Implications from this study are that the policymakers should consider integrating the findings into public health initiatives, advocating for paternal inclusion in neonatal care practices.When families struggle to sustain KMC, they strive to continue breastfeeding but stop skin-to-skin contact. A palpable tension arises when families feel unable to provide optimal care, reflecting the complex interplay between social and structural factors. Mothers facing breastfeeding challenges adopt various strategies. In low-income settings, alternatives like water or formula feeds are common, and exclusive breastfeeding (EBF) is often perceived as a "western practice" [39, 40]. Conversely, in high-income countries, concerns about milk production and infant weight gain frequently shape feeding decisions. Despite extensive public health advocacy, global EBF rates have remained static at approximately 44 to 48% [41, 42]. Existing literature has documented a recurring pattern of high intentions to breastfeed followed by a shift to formula feeds due to difficulties[43]. A study in Australia has introduced the concept of "breastfeeding grief" as a potential mental health issue for women resorting to formula feeding[44]. One mother in our study, used formula as a temporary measure during her illness, and she felt uneasy discussing her inability to breastfeed her infant. Though mothers adapted strategies to overcome the difficulties, novel divergent behaviour emerged from this study. While breastfeeding persists despite difficulties, skin-to-skin contact declines or ceases. Much of the existing literature presents breastfeeding and skin-to-skin contact as a unified KMC intervention. However, this study reveals that families adopt distinct approaches to each component, raising critical questions about the underlying drivers of breastfeeding persistence and skin-to-skin contact (SSC). Breastfeeding persistence often stems from immediate cues such as a crying baby signalling hunger, which makes its necessity more apparent. Conversely, the benefits of SSC are less immediately tangible, as the baby does not actively demand this form of contact. This raises important questions about how families perceive and prioritize SSC compared to breastfeeding, influenced by cultural norms, healthcare education, and support mechanisms. Breastfeeding is an integral part of the culture and grandmother is a culturally accepted key player who transmits the traditional knowledge across generations. Several studies highlight grandmothers as key influencers in initiating and prolonging breastfeeding [45, 46]. A systematic review by Negin identified that grandmothers' positive attitudes toward breastfeeding increased initiation rates by 12%, while negative perceptions reduced breastfeeding likelihood by up to 70%. When grandmothers supported breastfeeding, EBF rates increased by 1.6 to 12.4 times, minimizing formula introduction [45].However, in China, highly educated grandmothers were associated with lower EBF rates, possibly influenced by aggressive formula marketing rather than education itself [47]. Interestingly, in the current study, the integration of traditional knowledge around galactagogues—such as specific foods believed to enhance milk secretion—was prevalent among participants. This phenomenon has been observed in other cultural settings, suggesting a ubiquitous reliance on food and nutrition as essential components of breastfeeding practices among mothers worldwide [48, 49]. Grandmothers in this study actively supported breastfeeding and their role extended to the NICU, where they engaged in KMC practices. While breastfeeding and nutritional supplementation knowledge were culturally embedded, skin-to-skin contact was a novel skill learnt by grandmothers in the NICU. Research highlights the multifaceted benefits of skin-to-skin contact in neonatal care. Baby Friendly initiative of UNICEF emphasizes that SSC, initiated immediately after birth and maintained regularly, stabilizes heart rates, enhances oxygen saturation, regulates temperature, and improves breastfeeding outcomes. It also reduces stress levels, promotes growth, and may decrease hospital stays in neonatal units. For mothers, SSC increases milk supply and fosters a strong emotional bond with their infants, while enabling fathers and other family members to engage in caregiving roles [50]. A study highlighted the physiological benefits of KMC/SSC, showing its efficacy in regulating body temperature, reducing cortisol levels, and improving oxygen saturation in infants. These findings underscore the importance of consistent SSC implementation to maximize benefits while addressing practical barriers [51]. However, practical challenges have been observed. As infants grow, resistance to the kangaroo position may require adjustments, such as increasing breastfeeding frequency and involving family members in providing SSC to support mothers[52]. An important question arises on how far the grandmothers have imbibed the importance and the art of practising skin to skin contact and transmitted the new knowledge to family members at home? As mentioned earlier, in our study it was feasible to train grandmothers. One in particular took the initiative to transfer her knowledge on KMC to new mothers. However, the same engagement was not achieved among other grandmothers. For further implementation of KMC, there is a need to explore strategies for better involvement of the grandmothers and other family members. The lack of attention to grandmothers in global health fits into a larger reality of the neglect of elders in the family by the global health community. There is a gap in global health practice and health promotion involving the older generations[53, 54].Engaging grandmothers can create cascading benefits not only to the child but to the entire families’ health outcome across generations. There are very few public health interventions that can claim such cross-generational impact. "Nurturing Confidence: Need to improve frequency of Postnatal visits " Postnatal interventions at the community level could play a significant role in facilitating the effective implementation of KMC after discharge. Hadush et al. demonstrated that Community Health Workers (CHWs) in Ethiopia effectively utilized antenatal clinics and postnatal follow-up visits to introduce KMC, supported by community acceptance. They also emphasized that CHWs played a crucial role in KMC promotion [55]. Further, a systematic review of 103 publications ranked CHW support as the fourth highest enabler of KMC implementation. In South India, an implementation study on KMC acceleration highlighted the role of CHWs in facilitating family involvement and they used a special link card to support post-discharge communication and continuity of care [56]. Mothers in this study mentioned insufficient postnatal follow-up from CHW on KMC. While they received a nutritional kit, including iron tonic and other supplements, during the antenatal period, these benefits were not extended post-discharge. The findings also pointed towards the gaps in CHW counselling. Participants in this study received counselling and visits during the antenatal period. In these antenatal visits, breastfeeding was a common topic, but many mothers first learned about skin-to-skin care after delivering their preterm infants. A noticeable disparity between antenatal and postnatal follow-up frequencies emerged, with participants emphasizing the need for structured and regular postnatal visits to integrate breastfeeding and skin-to-skin contact effectively. Considering the vulnerable transition from hospital to home, mothers emphasized the urgent need for continued support from CHWs post discharge. A study in Ethiopia highlighted that many caregivers have limited knowledge about KMC, which affects their adoption rates; thus, targeted interventions during antenatal and postnatal periods are critical for overcoming these knowledge gaps. According to that study, mothers who received counselling and follow-up visits from healthcare providers demonstrated higher adherence to KMC practices compared to those who did not receive such support [16]. Taken together, there is a need for systematic policies, structured education, empowering CHW and family members creating a holistic support system that enables mothers to sustain KMC. Strengths and Limitations This study's strength lies in its qualitative approach, which captures the nuanced experiences of families practicing KMC. The inclusion of diverse family dynamics and cultural contexts, covering rural, urban, and tribal populations and participants with different socioeconomic status, enhances the trustworthiness of the findings. By observing the transition from hospital to community and including not only mothers, but also fathers and grandmothers, the study provides a comprehensive view of family and healthcare workers' involvement. While the findings are particularly relevant to LMICs, they might offer transferable insights for diverse sociocultural settings. The specific strategies may differ, but the core principle of inclusive family support remains universally applicable. Limitations of our study include potential response bias and the contextual specificity of the study. Tamil Nadu, as an advanced state in terms of healthcare in India, limits the generalizability of the findings. Additionally, the primary author’s dual role as both a caregiver in the hospital and a researcher in the field may have influenced the interactions and responses of the families. Further research is needed to explore these findings in varied cultural and socioeconomic settings to solidify their applicability. Recommendations for Policy and Practice The challenges and enablers identified can inform policies and programs aimed at promoting family-inclusive KMC practices worldwide. Structured Family Education: Develop programs to actively involve fathers and grandmothers, addressing knowledge gaps and empowering families to sustain KMC. Gender-Inclusive Practice and Terminology: Reframe KMC as “Kangaroo Family Care” to challenge traditional norms and promote inclusivity. Enhancing Community Health Worker (CHW) Roles: Train CHWs to counsel families on skin-to-skin contact during antenatal visits and provide post-discharge support to ensure sustained KMC practices. Promoting Cross-Generational Impact: Engage grandmothers as KMC advocates to leverage their influence for cascading benefits across generations. Health systems worldwide can benefit from incorporating structured educational programs that encourage both maternal and paternal participation in KMC, thus maximizing the potential benefits for infants and families. Conclusion This study contributes to the expanding body of research advocating for inclusive KMC practices that involve all family members, not exclusively mothers. The research highlighted the need to challenge maternal-centric biases prevalent in KMC practices and emphasizes comprehensive family engagement strategies. Promoting gender-inclusive practices, such as rebranding KMC as "Kangaroo Family Care," is essential, particularly in settings where traditional gender roles may limit paternal engagement. By incorporating structured programs that actively involve fathers and other family members, the overall effectiveness and sustainability of KMC practices could be significantly enhanced. The findings emphasize the critical importance of family support and healthcare workers in sustaining KMC post-discharge. While families demonstrate strong commitment to breastfeeding, maintaining consistent skin-to-skin contact tends to decline over time, reflecting systemic, cultural, and resource-related barriers. This inconsistency stresses the urgent need for structured family education and a shift toward collective family responsibility in new-born care interventions. Our study also delves into the variability of family engagement during KMC and raises important questions about the adequacy of counselling sessions in busy governmental hospitals. This prompts a critical examination of whether structured educational programs are necessary to effectively engage families in KMC practices. Strengthening community involvement, addressing infrastructural limitations, and enhancing healthcare provider training are vital steps to bridge the gap between hospital and home-based KMC. This holistic approach will foster sustained KMC practices, leading to improved health outcomes for low-birth-weight infants and a more inclusive model of care. Declarations Ethics approval and consent to participate This study acquired ethical committee approval from the Chengalpattu Medical College Institutional Ethics Committee and the Norwegian Regional Committee for Medical and Health Research Ethics (32413). We confirm that all interviews were performed following the relevant guidelines and regulations. We confirm that informed consent was obtained from all mothers and caregivers and the records were de-identified before analysis. Availability of data and materials The dataset used and analysed during the current study are available from the corresponding author on reasonable request. Materials Consent for Publication Not applicable Funding Ekam Foundation, Chennai, India. Competing interests All the authors declare no competing interests. Authors’ contributions SJ and IK conceptualized the idea. SJ, IK and SR supervised protocol writing and data collection. SJ, IK, SH and SR carried out the analysis, interpreted the result. SJ, IK and SH participated in drafting the manuscript, revised the manuscript, and approved the final manuscript for submission. All authors read and approved the final manuscript. Acknowledgement: We acknowledge the support and contribution of the mothers and families of babies who participated in the study. We thank the Directorate of Medical Education and Directorate of Public Health & Preventive Medicine, government of Tamil Nādu for the permission of the research work. We thank the Dean of CMCH, Professor of Dept. of Neonatology Dr. Muthukumaran, the Nodal officer, SNCU Dr. Manikumar, Professor of Paediatrics Dr. Ravikumar, Professor in-charge of District Early Intervention Centre (DEIC) Dr. Murali, Ms. Reeta Mary Staff Nurse, follow up nurse of SNCU, all the nurses of NICU and staffs of DEIC. We thank Ms. Shenbagam, SNCU data operator, ICDS staffs and village health nurses of Primary Health Centres who helped to track the children. We thank Dr. Vanaja, Director Gandhigram Institute of Rural health for her support. References “Kangaroo Mother Care to Reduce Morbidity and Mortality in Low-Birth-Weight Infants.” Accessed April 16, 2025. https://www.who.int/tools/elena/interventions/kangaroo-care-infants. UNICEF DATA. “Low Birthweight.” Accessed April 16, 2025. https://data.unicef.org/topic/nutrition/low-birthweight/. Ohuma EO, Moller A-B, Bradley E, Chakwera S, Hussain-Alkhateeb L, Lewin A, et al. National, regional, and global estimates of preterm birth in 2020, with trends from 2010: a systematic analysis. The Lancet. 2023; 402:1261–71. McIntyre S, Taitz D, Keogh J, Goldsmith S, Badawi N, Blair E. A systematic review of risk factors for cerebral palsy in children born at term in developed countries. Dev Med Child Neurol. 2013; 55:499–508. Himpens E, Van den Broeck C, Oostra A, Calders P, Vanhaesebrouck P. Prevalence, type, distribution, and severity of cerebral palsy in relation to gestational age: a meta-analytic review. Dev Med Child Neurol. 2008; 50:334–40. Boulet SL, Schieve LA, Boyle CA. Birth weight and health and developmental outcomes in US children, 1997-2005. Matern Child Health J. 2011; 15:836–44. Mervis CA, Decouflé P, Murphy CC, Yeargin-Allsopp M. Low birthweight and the risk for mental retardation later in childhood. Paediatr Perinat Epidemiol. 1995; 9:455–68. Lahat A, Van Lieshout RJ, Saigal S, Boyle MH, Schmidt LA. ADHD among young adults born at extremely low birth weight: the role of fluid intelligence in childhood. Front. Psychol. 2014;5. Kerstjens JM, de Winter AF, Bocca-Tjeertes IF, Bos AF, Reijneveld SA. Risk of developmental delay increases exponentially as gestational age of preterm infants decreases: a cohort study at age 4 years. Dev Med Child Neurol. 2012; 54:1096–101. WHO Immediate KMC Study Group. Immediate Kangaroo Mother Care and Survival of Low-Birth-Weight Infants. N Engl J Med. 2021; 384:2028–38. UNICEF DATA. “Child Survival and the SDGs.” Accessed April 16, 2025. https://data.unicef.org/topic/child-survival/child-survival-sdgs/. Chan GJ, Labar AS, Wall S, Atun R. Kangaroo mother care: a systematic review of barriers and enablers. Bull World Health Organ. 2016; 94:130-141J. Conde-Agudelo A, Belizán JM, Diaz-Rossello J. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database Syst Rev. 2011; CD002771. Lunze K, Bloom DE, Jamison DT, Hamer DH. The global burden of neonatal hypothermia: systematic review of a major challenge for new born survival. BMC Medicine. 2013; 11:24. NHM. India Newborn Action Plan: 2014-2020 Progress Card. National Health Mission. Kwesiga D, Wanduru P, Ssegujja E, Inhensiko J, Waiswa P, Franck L. Improving Post-Discharge Practice of Kangaroo Mother Care: Perspectives from Communities in East-Central Uganda. Front Pediatr. 2022; 10:934944. Mustikawati IS, Pratomo H, Martha E, Murty AI, Adisasmita AC. Barriers and facilitators to the implementation of Kangaroo Mother Care in the community—a qualitative study. Journal of Neonatal Nursing. 2020; 26:109–14. Child Health | National Health Mission Tamil Nadu, Department of Health & Family Welfare, Govt. of Tamil Nadu, India. https://nhm.tn.gov.in/en/r-c-h/child-health. Accessed 31 Mar 2025. Jegannathan S, Natarajan M, Solaiappan M, Shanmugam R, Tilwani SA. Quality improvement initiative to improve the duration of Kangaroo Mother Care in the tertiary care neonatal unit of South India. BMJ Open Qual. 2022;11 Suppl 1: e001775. Manen MV. Phenomenology of Practice: Meaning-Giving Methods in Phenomenological Research and Writing. New York: Routledge; 2016. Lydon M, Longwe M, Likomwa D, Lwesha V, Chimtembo L, Donohue P, et al. Starting the conversation: community perspectives on preterm birth and kangaroo mother care in southern Malawi. J Glob Health. 2018; 8:010703. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006; 3:77–101. Braun V, Clarke V. Reflecting on reflexive thematic analysis. Qualitative Research in Sport, Exercise and Health. 2019; 11:589–97. WMA. WMA Declaration of Helsinki—Ethical Principles for Medical Research Involving Human Subjects. World Medical Association (WMA); 2013. Seidman 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: e0125643. Chan GJ, Labar AS, Wall S, Atun R. Kangaroo mother care: a systematic review of barriers and enablers. Bull World Health Organ. 2016; 94:130-141J. Yogman M, Garfield CF, Committee on Psychosocial Aspects of Child and Family Health, Bauer NS, Gambon TB, Lavin A, et al. Fathers’ Roles in the Care and Development of Their Children: The Role of Paediatricians. Pediatrics. 2016;138: e20161128. Yogman M, Garfield CF, Lavin A, Lemmon KM, Mattson G, Rafferty JR, et al. Fathers’ Roles in the Care and Development of Their Children: The Role of Paediatricians. Pediatrics. 2016;138: e20161128. Jesus NC de, Vieira BDG, Alves VH, Rodrigues DP, Souza R de MP de, Paiva ED. The experience of the kangaroo method: the perception of the father. Revista de Enfermagem UFPE online. 2015; 9:8542–50. Olsson E, Eriksson M, Anderzén-Carlsson A. Skin-to-Skin Contact Facilitates More Equal Parenthood—A Qualitative Study from Fathers’ Perspective. J Pediatr Nurs. 2017;34: e2–9. Blomqvist YT, Frölund L, Rubertsson C, Nyqvist KH. Provision of Kangaroo Mother Care: Supportive Factors and Barriers Perceived by Parents. Scand J Caring Sci. 2013; 27:345–53. Fegran L, Helseth S, Fagermoen MS. A comparison of mothers’ and fathers’ experiences of the attachment process in a neonatal intensive care unit. J Clin Nurs. 2008; 17:810–6. Günay U, Coşkun Şimşek D. Emotions and Experience of Fathers Applying Kangaroo Care in the Eastern Anatolia Region of Turkey: A Qualitative Study. Clin Nurs Res. 2021; 30:840–6. Helth TD, Jarden M. Fathers’ experiences with the skin-to-skin method in NICU: Competent parenthood and redefined gender roles. Journal of Neonatal Nursing. 2013; 19:114–21. Magee J, Nurse S. Supporting the bereaved father in the NICU: A reflective case study. Journal of Neonatal Nursing. 2014; 20:20–3. 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; 17:35. Yurdagül Nİ, Esenay FI. Effect of kangaroo care applied by mothers and fathers in premature infants: A crossover study. Journal of Neonatal Nursing. 2023; 29:501–5. Bauer K, Pyper A, Sperling P, Uhrig C, Versmold H. Effects of gestational and postnatal age on body temperature, oxygen consumption, and activity during early skin-to-skin contact between preterm infants of 25-30-week gestation and their mothers. Pediatr Res. 1998; 44:247–51. Fjeld E, Siziya S, Katepa-Bwalya M, Kankasa C, Moland KM, Tylleskär T, et al. “No, sister, the breast alone is not enough for my baby,” a qualitative assessment of potentials and barriers in the promotion of exclusive breastfeeding in southern Zambia. Int Breastfeed J. 2008; 3:26. Abuidhail J, Al-Modallal H, Yousif R, Almresi N. Exclusive breastfeeding (EBF) in Jordan: prevalence, duration, practices, and barriers. Midwifery. 2014; 30:331–7. Chang Y-S, Li KMC, Li KYC, Beake S, Lok KYW, Bick D. Relatively speaking? Partners’ and family members’ views and experiences of supporting breastfeeding: a systematic review of qualitative evidence. Philosophical Transactions of the Royal Society B: Biological Sciences. 2021;376. “Global Breastfeeding Scorecard 2023 | UNICEF.” Accessed April 16, 2025. https://www.unicef.org/documents/global-breastfeeding-scorecard-2023. Thomson G, Ebisch-Burton K, Flacking R. Shame if you do—shame if you don’t: women’s experiences of infant feeding. Maternal and Child Health Journal. 2015; 11:33–46. Ayton JE, Tesch L, Hansen E. Women’s experiences of ceasing to breastfeed: Australian qualitative study. BMJ Open. 2019;9: e026234. Negin J, Coffman J, Vizintin P, Raynes-Greenow C. The influence of grandmothers on breastfeeding rates: a systematic review. BMC Pregnancy Childbirth. 2016; 16:91. Grassley JS, Spencer BS, Law B. A Grandmothers’ Tea: Evaluation of a Breastfeeding Support Intervention. J Perinat Educ. 2012; 21:80–9. Gong Q, Jackson P. Mediating science and nature: Representing and consuming infant formula advertising in China. European Journal of Cultural Studies. 2013; 16:285–309. Karolina K, Lehman I. The link between knowledge of the maternal diet and breastfeeding practices in mothers and health workers in Poland. International Breastfeeding Journal. 2021; 16:58. Carretero-Krug A, Montero-Bravo A, Morais-Moreno C, Puga AM, Samaniego-Vaesken M de L, Partearroyo T, et al. Nutritional Status of Breastfeeding Mothers and Impact of Diet and Dietary Supplementation: A Narrative Review. Nutrients. 2024; 16:301. Baby Friendly Initiative. “Skin-to-skin contact”. Accessed April 16, 2025. https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/implementing-standards-resources/skin-to-skin-contact/. Durmaz A, Sezici E, Akkaya DD. The effect of kangaroo mother care or skin-to-skin contact on infant vital signs: A systematic review and meta-analysis. Midwifery. 2023; 125:103771. Koreti M, Muntode Gharde P. A Narrative Review of Kangaroo Mother Care (KMC) and Its Effects on and Benefits for Low Birth Weight (LBW) Babies. Cureus. 14: e31948. Hong C, Sun L, Liu G, Guan B, Li C, Luo Y. Response of Global Health Towards the Challenges Presented by Population Aging. China CDC Wkly. 2023; 5:884–7. Papp-Zipernovszky O, Horváth MD, Schulz PJ, Csabai M. Generation Gaps in Digital Health Literacy and Their Impact on Health Information Seeking Behaviour and Health Empowerment in Hungary. Front Public Health. 2021; 9:635943. Hadush MY, Gebremariam DS, Beyene SA, Abay TH, Berhe AH, Zelelew YB, et al. Barriers and Enablers of KMC Implementation in Health Facilities and Community of Tigray Region, Northern Ethiopia: Formative Research. Pediatric Health Med Ther. 2022; 13:297–307. Jayanna K, Rao S, Kar A, Gowda PD, Thomas T, Swaroop N, et al. Accelerated scale-up of Kangaroo Mother Care: Evidence and experience from an implementation-research initiative in South India. Acta Paediatr. 2023;112 Suppl 473:15–26. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 05 Nov, 2025 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Revision requested 18 Aug, 2025 Reviews received at journal 28 Jul, 2025 Reviews received at journal 02 Jul, 2025 Reviewers agreed at journal 26 Jun, 2025 Reviewers agreed at journal 24 Jun, 2025 Reviewers invited by journal 30 May, 2025 Editor invited by journal 25 Apr, 2025 Editor assigned by journal 24 Apr, 2025 Submission checks completed at journal 24 Apr, 2025 First submitted to journal 24 Apr, 2025 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. 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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-6520424","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":464847440,"identity":"4cfef5c0-5b86-4546-9621-0d4d5d9d9a2f","order_by":0,"name":"Sathya Jeganathan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6klEQVRIiWNgGAWjYHACNhCWs29vANIGFsToYAZrMTbgOQDSIkG0FoZEA4kEEE2EFvn288ce89TwJZhLPr+64UeBBAN/e3cCXi0GZ5LZjXmOseVZzs4pu9kDdJjEmbMb8GthSGaT5mFjK2a4nZN2gweoxUAiF78W+f7HQC3/2BIbbp5Ju/mHGC0MN4C28LaxJW64wX7sNlG2GNx4bCY5t4/NWLInh+22jIEED0G/yPcnPpN48+2YHD/78Wc33/yxkeNv7yXgMCBg4mE4BqR4DEAcHoLKQYDxB0MNkGJ/QJTqUTAKRsEoGHkAAIo8REbnH7lRAAAAAElFTkSuQmCC","orcid":"","institution":"Chengalpattu Medical College","correspondingAuthor":true,"prefix":"","firstName":"Sathya","middleName":"","lastName":"Jeganathan","suffix":""},{"id":464847441,"identity":"5fa8d9d0-7ca2-4ff9-b9f2-33b2310a76f1","order_by":1,"name":"Ingrid Kvestad","email":"","orcid":"","institution":"Innlandet Hospital Trust","correspondingAuthor":false,"prefix":"","firstName":"Ingrid","middleName":"","lastName":"Kvestad","suffix":""},{"id":464847442,"identity":"85631903-5d77-492d-915b-b4bc32bc83d8","order_by":2,"name":"Santhini Santhini","email":"","orcid":"","institution":"Gandhigram Institute of Rural Health and Family Welfare","correspondingAuthor":false,"prefix":"","firstName":"Santhini","middleName":"","lastName":"Santhini","suffix":""},{"id":464847443,"identity":"072d71f4-146e-4acc-9873-baa25622d686","order_by":3,"name":"Signe Hjelen stige","email":"","orcid":"","institution":"Department of Clinical Psychology, University of Bergen","correspondingAuthor":false,"prefix":"","firstName":"Signe","middleName":"Hjelen","lastName":"stige","suffix":""}],"badges":[],"createdAt":"2025-04-24 11:38:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6520424/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6520424/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12913-025-13615-7","type":"published","date":"2025-11-05T15:57:30+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":95564017,"identity":"b92f2680-154d-49fb-ad50-801bc96fc90c","added_by":"auto","created_at":"2025-11-10 16:06:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":763142,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6520424/v1/966fcc24-cbdc-419a-99eb-e844ca0d1a61.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eContinuation of Kangaroo Mother Care when transitioning from Facility to Community: Maternal and Familial perspectives from South India\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eKangaroo Mother Care (KMC) is an evidence-based intervention that significantly reduces neonatal morbidity and mortality, particularly among low-birth-weight (LBW) and preterm infants [1]. Globally, LBW remains a pressing concern. In 2020, 14.7% of all babies were born with LBW [2]. Over half of preterm births worldwide occurred in just eight countries, with India accounting for 3.02 million preterm births annually, constituting 20% of the global total [3].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eExtensive research has established a strong association between preterm birth and developmental disorders, including cerebral palsy [4\u0026ndash;6], intellectual disabilities [7], attention deficit hyperactivity disorders (ADHD) [8], and developmental delays [9]. Premature and LBW infants constitute 70% of all neonatal deaths worldwide [10]. These alarming statistics highlight the urgent need to address neonatal care to meet the Sustainable Development Goal (SDG 3.2), which aims to reduce neonatal mortality to 12 per 1,000 live births by 2030 [11].\u003c/p\u003e\n\u003cp\u003eDeveloped in 1978 in South America, Kangaroo Mother Care (KMC) is an essential modality of treatment for low-birth-weight babies. KMC comprises of essential components such as continuous skin-to-skin contact, exclusive breastfeeding, early discharge, and sustained follow-up care [12]. These practices have demonstrated effectiveness in reducing the incidence of neonatal infections, hypothermia, pain responses, and overall mortality [13, 14]. In India, where neonatal care remains a challenge due to the high prevalence of LBW and preterm births, the implementation of KMC was integrated into hospital settings with relative success [15]. However, the transition from hospital-based KMC to community-based care could represent several challenges that impede its effectiveness and sustainability as shown in previous studies [16, 17]. This could be particularly relevant in South India, where social, cultural, and systemic factors play a significant role in determining health outcomes.\u003c/p\u003e\n\u003cp\u003eThe India Newborn Action Plan (INAP) established ambitious targets for KMC coverage, aiming for 35% by 2017, 50% by 2020, 75% by 2025, and 90% by 2030. To achieve these targets, the Indian government has established 894 Sick Newborn Care Units (SNCUs) nationwide, which provide specialized care for small and sick newborns. Tamil Nadu, a southern state with comparatively robust health infrastructure in an Indian context, has ensured the availability of new born care facilities in all districts [15, 18]. Specifically, Chengalpattu Medical College Hospital (CMCH) has implemented quality improvement interventions in its neonatal intensive care unit (NICU) to increase the duration of KMC to over 16 hours per day before discharge [19]. Despite these efforts, little is known about the transition of KMC from hospital to home settings.\u003c/p\u003e\n\u003cp\u003eThis qualitative study explores the factors that enable or hinder the practice of community-based KMC in South India. Specifically, it examines caregivers\u0026rsquo; experiences with KMC at the place of birth, the challenges they face in maintaining KMC practices at home, and their successes or struggles in sustaining the key KMC components, particularly breastfeeding and skin-to-skin contact. By understanding these dynamics, this study seeks to inform interventions that can bridge the gap between the hospital and home care, ensuring that the benefits of KMC reach the most vulnerable populations. Effective community-based KMC has the potential to significantly reduce neonatal mortality and improve health outcomes for LBW and preterm infants, contributing to the broader goal of enhancing new born survival in South India and beyond.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy context and background\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was motivated by the experiences of the primary author, working in the Paediatric department Intensive Care Unit (ICU) and the District Early Intervention Centre (DEIC) at the tertiary care hospital in Chengalpattu district. It was observed that many LBW infants discharged from the Neonatal Intensive Care Unit (NICU) frequently got readmitted in critical conditions. Interestingly, despite having received instructions on KMC during their NICU stay, many families encountered difficulties to practice KMC once they returned home. \u0026nbsp;This study was designed to explore the enabling factors, difficulties and challenges from the caregiver\u0026rsquo;s perspective and gain a deeper understanding of the enablers and barriers to continue KMC post-discharge.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy setting \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in the Kancheepuram and Chengalpattu districts of South India. Chengalpattu Medical College Hospital (CMCH) serves as a tertiary care centre, offering free medical services to residents of both districts, where approximately 60% of deliveries occur. High-risk mothers are routinely referred to CMCH, and both LBW and preterm infants born at CMCH or referred from outside are admitted to the NICU.\u003c/p\u003e\n\u003cp\u003eAt CMCH, the protocol mandates the initiation of KMC in the NICU, with continued KMC practice in the step-down wards. The medical team emphasizes KMC throughout the hospital stay, supported by visual displays and daily counselling sessions, including guidance at the time of discharge. Notably, CMCH features a father KMC ward, equipped with semi-reclining cots to facilitate KMC for fathers, an amenity available only in select centres across the state.\u003c/p\u003e\n\u003cp\u003eInfants are discharged from CMCH upon reaching a weight of 1.6 kg and demonstrating consistent weight gain over three consecutive days. In the community, neonatal health services follow an interdisciplinary model. Primary Health Care (PHC) staff and Integrated Child Development Scheme (ICDS) personnel conduct home follow-ups to monitor the growth and development of discharged infants. These healthcare providers are trained in KMC and are responsible for assisting and monitoring KMC practices at the community level.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study adopted a constructivist paradigm to explore the subjective experiences of participants with KMC, acknowledging that their perceptions are shaped by their social and cultural contexts. A phenomenological approach was chosen because it is well-suited to exploring the lived experiences of mothers and families, aligning with the study\u0026apos;s aim to deeply understand their perceptions and experiences of KMC after hospital discharge [20].\u003c/p\u003e\n\u003cp\u003eIn-depth, semi-structured interviews were conducted within participants\u0026apos; homes to capture authentic family perspectives on practicing KMC at home. The home setting was chosen to promote openness, comfort, and flexibility, enabling participants to share their experiences freely. Mothers could pause or continue the interviews according to their needs and the comfort of the mother-baby dyad. Each participant was assigned a unique code, and interviews were audio-recorded to ensure accurate transcription and facilitate cross-checking.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecruitment and Participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCollaboration was established with the discharge nurse/data entry operator in the NICU and the village health nurse (VHN) at the community level, ensuring that participants informed consent and their voluntary participation were secured before inclusion in the study. \u0026nbsp;A comprehensive list of discharged neonates from the NICU was compiled, and purposive sampling ensured representation from rural, urban, and tribal communities. Mothers of LBW infants were eligible to participate. A total of eight mothers, aged 20 to 30, whose infants had been treated in the NICU and discharged, volunteered to participate after the project was explained to them. In some cases, fathers and grandmothers, who were caretakers or present during the interviews, also participated, providing additional insights into the caregiving dynamics and family support systems.\u003c/p\u003e\n\u003cp\u003eIn this region, it is customary for women to stay at their mother\u0026rsquo;s house for their first delivery, typically spanning 3 to 6 months post-delivery. From the second child onwards, mothers usually reside with their husband\u0026rsquo;s family. The VHN was contacted to determine whether each mother was at her maternal or marital home. Before traveling to the participants\u0026rsquo; homes, the interview team confirmed each mother\u0026rsquo;s willingness to participate in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary author (SJ) did the interview, and she was assisted by a field researcher to create a safe and confidential environment where mothers felt comfortable sharing their childcare experiences. During data collection, special attention was paid to ensure participant comfort and ethical standards. All participants provided informed consent before each interview, and they were assured that their responses would be treated with confidentiality and respect. Audio recordings and transcriptions were securely stored on encrypted devices, and identifying information was removed during transcription to maintain confidentiality.\u003c/p\u003e\n\u003cp\u003eThe in-depth interviews with mothers and family members lasted between 60 and 90 minutes, with an average duration of 70 minutes. Various techniques such as open-ended questions, active listening, probing, and other facilitative methods were used. The semi-structured interview guide adapted from Lydon et al. [21] was reviewed after initial interviews and adjusted slightly to explore emerging themes more deeply.\u003c/p\u003e\n\u003cp\u003eThe interviews were designed to prioritize the mothers\u0026apos; narratives and life experiences. They guided the participants through their journey of care before childbirth, the experience of preterm delivery, the family\u0026rsquo;s experience immediately after birth, the transition to the NICU, and the KMC provided within the healthcare facility.\u003c/p\u003e\n\u003cp\u003eThe second part of the interview focused on the discharge process, the care provided at home, and the support received from family and the community. These interviews aimed to provide researchers insights into the challenges of KMC and to explore the behaviours and strategies families adopted to care for their LBW new-borns.\u003c/p\u003e\n\u003cp\u003eThe interviews were conducted in Tamil, the participants\u0026apos; native language, and were audio-recorded. Additionally, the primary author took visual documentation of the physical surroundings in the homes where children were cared for. This included detailed notes on the space available for KMC and other relevant environmental factors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe in-depth interviews were transcribed verbatim to maintain accuracy. To ensure precision and fidelity, these transcriptions were cross-checked against the audio recordings by two researchers, safeguarding the accuracy and integrity of the collected data. Trustworthiness was enhanced through peer debriefing, maintaining an audit trail, and engaging in reflexive discussions to ensure credibility and confirmability.\u003c/p\u003e\n\u003cp\u003eTo protect anonymity and confidentiality, participants\u0026rsquo; identities were concealed throughout the transcription and analysis phases. Precautionary measures were taken to protect the participants\u0026rsquo; privacy and the sensitive information shared. For effective data management and organization, NVivo 12, a qualitative research software, was employed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe methodological approach grounded in the phenomenological tradition [20] emphasizes a deep alignment with participants\u0026rsquo; experiences. This commitment to understanding participants\u0026apos; lived realities informed the entire analysis process. The analytical process was guided by reflexive thematic analysis (22, 23), and began with a thorough review of the individual interview transcripts by all authors. This initial phase was exploratory and focused on identifying topics within the data that were of significant interest and aligned with the study\u0026rsquo;s aim. The emphasis was on capturing the lived experiences of mothers and families shared during the interviews. The primary author (SJ) conducted the initial data analysis under the supervision of SH and IK.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs the analysis progressed, researchers engaged in extensive reading and discussion of the data, leading to the development of an initial framework. This framework mapped the process of acquiring KMC knowledge within hospital settings and the obstacles faced in practicing community-based KMC (cKMC).\u003c/p\u003e\n\u003cp\u003eIn the subsequent phase, the team further dissected the data into three distinct themes, developing a nuanced understanding of the diverse experiences and challenges encountered. The research team collaborated to achieve a consensus on descriptions of the challenges presented in each interview, reflecting on the varied experiences of participants. Each phase was documented to ensure a high level of transparency, allowing readers to critically evaluate the applicability and credibility of the findings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReflexivity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWith extensive experience in neonatal care, the primary author (SJ) acknowledges that clinical perspectives might influence interpretations. The primary author, who worked in the hospital, visited the homes of families and played the dual role of caregiver in the hospital and researcher in the field. Although the families treated the researcher (SJ) with respect (addressed as \u0026ldquo;Madam\u0026rdquo;), the impression is that they were not hesitant to narrate the real issues. Reflexive journaling was employed to critically evaluate how the author\u0026rsquo;s professional background, assumptions, and positionality influenced data collection and analysis, ensuring participants\u0026apos; voices remained central.\u003c/p\u003e\n\u003cp\u003eThis research also adopted the reflective thematic analysis approach, emphasizing the researcher\u0026rsquo;s role in generating knowledge. The framework proposed by Braun and Clarke [22, 23] was utilized for its flexibility and systematic approach to identifying themes within qualitative data. After the initial reading phase, the authors convened for a reflective discussion on the first day of analysis. These discussions incorporated elements of both analysis and reflection, drawing on the researchers\u0026rsquo; diverse backgrounds in child health, clinical psychology, and sociology. This interdisciplinary approach enriched the analysis and provided multiple perspectives.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study adhered to ethical principles outlined in the Declaration of Helsinki [24]. The research was approved by the Norwegian Regional Committee for Medical and Health Research Ethics (32413) and the Institutional Ethical Committee of Chengalpattu Medical College (ECR/774/INST/TN).\u003c/p\u003e\n\u003cp\u003eAll participants were fully informed about the project and provided their signed informed consent before participating. Ethical handling of participants\u0026apos; interviews and data was prioritized, ensuring confidentiality, respect, and integrity throughout the research process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFindings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe analysis resulted in the construction of the following themes, detailing mothers\u0026apos; experiences with breastfeeding and the practice of skin-to-skin contact in KMC:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u003cem\u003eTheme 1: Breast Feeding \u0026ndash; Persevering Despite Initial Difficulties\u003c/em\u003e-Despite encountering various physical and emotional hurdles, many mothers demonstrated remarkable perseverance, motivated by the health benefits for their new-borns.\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eTheme 2: Kangaroo Mother Care (KMC) \u0026ndash; Seeing benefits but struggling to practice\u003c/em\u003e- The barriers they face in consistent practice, such as physical discomfort, time constraints, cultural influence, lack of family and community support, were examined.\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eTheme 3: Family Boon or Bane (trouble) - Family as a crucial context for Community Kangaroo Mother Care (KMC) practice\u003c/em\u003e- Examined the dual role of family as either facilitators or obstacles in the successful implementation of KMC.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 1: Breast Feeding \u0026ndash; Persevering Despite Initial Difficulties\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnalysis of the participants\u0026rsquo; experience with breastfeeding showed that all of them intended to breastfeed their baby for an extensive period after birth. However, all participants also reported facing several obstacles to breastfeeding during the postpartum period, particularly in the beginning when many were separated from their baby at the hospital.\u003c/p\u003e\n\u003cp\u003eBreastfeeding was seen as health promoting for their babies for most participants, with bottle feeds being associated with health risks. This understanding was often linked to advice given by health professionals:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;At the time of discharge doctor advised me, \u0026lsquo;Babies health is on your hand, you should continue KMC at home with breast feeding and the breast milk is the only nutrition that gives the energy to the baby.\u0026rsquo; So, doctor informed me to continue breast milk for six months.\u0026rdquo; (Participant 1)\u003c/p\u003e\n\u003cp\u003eHowever, most participants faced difficulties initiating breastfeeding during initial stages in NICU. Mothers were upset to see the tiny babies surrounded by lifesaving equipment but tried their best to give breast milk. The options available to the mothers were to strive hard for breast milk or switch to bottle feeds. Many participants were unable to give direct breastfeeding initially, since the baby was taken to intensive care:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Baby was there inside, and I was in the caesarean ward room. I was not giving milk for the first 10 days.\u0026rdquo; (Participant 2)\u003c/p\u003e\n\u003cp\u003eSoon after birth many participants were expressing milk, and family members were delivering the milk at ICU, so that milk could be given through the nasogastric tubes:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGrandmother: \u0026ldquo;We were expressing milk from my daughter, and we were taking into the glass room. It was given to the baby through tube.\u0026quot; (Participant 2)\u003c/p\u003e\n\u003cp\u003eIn addition to the initial separation, many participants experienced inadequacy of milk initially, with the infant\u0026rsquo;s premature status complicating breastfeeding due to weak sucking. When failing to produce sufficient milk initially, five participants resorted to borrowing milk from others:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Sometimes I was not getting adequate milk. I used to have breast engorgement. Then I used to get milk from mothers who were lying on nearby cots and give it to the baby. \u0026nbsp;Later I started to give my own breast milk.\u0026rdquo; (Participant 3)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Though inadequate milk was a challenge, few mothers reported increased milk secretion when they practiced skin-to-skin contact:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Breast milk secreted well, while on KMC, it was good\u0026rdquo; (participant 6).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSome participants were also getting milk from the milk bank when experiencing inadequacy of milk, or when having excess milk. However, few participants were unaware of the milk bank:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;There are sisters who take care of the milk bank. She collects milk and donates to others.\u0026rdquo; (Participant 6)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;We don\u0026rsquo;t know about milk bank and they also not given milk from milk bank.\u0026rdquo; (Participant 5)\u003c/p\u003e\n\u003cp\u003ePhysical discomfort due to the C-section restricted movement, and some mothers expressed the inability to breastfeed, due to the pain:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I had stitches on my body. I was not able to sit. It was very painful.\u0026rdquo; (Participant 1)\u003c/p\u003e\n\u003cp\u003eParticipants also expressed an understanding of how the milk secretion is depending on mother\u0026rsquo;s emotions and food intake. When the milk was perceived as inadequate, the mother and her families tried many methods to increase the secretion especially through supplementing through additional foods. The families took special efforts to prepare foods believed to be galactagogues such as special fish (paal Sura/ Sura putu), garlic, homemade nutritious mix etc:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;In my family, they ask me to eat the special fish and I was adding the fish in the hospital. Special sea food called \u0026lsquo;paalsura\u0026rsquo;. It is available in special fish market.\u0026rdquo; (Participant 8)\u003c/p\u003e\n\u003cp\u003eIn contrast to the common belief that good food assists adequate milk secretion for the baby, two mothers expressed concern about adverse consequence of more food, paving way for more milk which will choke the baby:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Eat more food, then there\u0026rsquo;ll be more milk. And when more milk comes through my breast, it will choke the baby\u0026rsquo;s breath.\u0026rdquo; (Participant 2)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;During the hospital stay as the babies\u0026rsquo; condition improved, they were shifted from ICU to stepdown unit, then to family centred care unit before discharge to home. The families tried their best to adopt the feeding practice, from tube feeds to expressed milk to direct breast-feeding:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;The baby was always tube-feed, finally I came to the room with a screen, the tube was removed and paladai feed (cup feed) was given. The baby got the food through tube, through paladai (cup feed) and also tried breast milk.\u0026rdquo; (Participant 6) \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFrom the hospital the babies were discharged to home. The cultural practice in Tamil Nādu is for the first pregnancy, the mother goes to her parental home soon after discharge, she gets adequate support for rest and childcare. Some mother felt milk secretion increased after arriving home. On the contrary few felt the milk secretion decreased after going home \u0026ndash; overwhelmed by the household responsibilities:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;When I was in the hospital milk secretion was not good and after reaching home, it was good.\u0026rdquo; (Participant 5)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Milk secretion was not good after coming home.\u0026rdquo; (Participant 5)\u003c/p\u003e\n\u003cp\u003eBeing able to breastfeed was felt important to many mothers, exemplified with how they persevered in their efforts despite challenges. Not being able to produce sufficient milk therefore felt uncomfortable, even shameful to some participants. A mother who had delivered twin babies had switched to bottle feeds, lowered her head in guilt while narrating the change to bottle feeds after advice from a private doctor:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I don\u0026rsquo;t take enough food due to fever for the past two days so I don\u0026rsquo;t get good milk. Then I took the babies to private clinic, there the Doctor said, the powder milk is not good for the baby\u0026rsquo;s health but now you are sick, so for time being you can give powder milk.\u0026rdquo; (Participant 1)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 2: Kangaroo Mother Care (KMC) \u0026ndash; Seeing benefits but struggling to practice\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEven though the practice of KMC was new and unfamiliar to the families, they expressed positive attitudes towards KMC. Most families found the environment within the healthcare facility, not only in step down wards but also in intensive care units, to be helpful and a support in learning and initiating KMC as part of their care for their children. This included both support and advice given by the doctors and nurses in why and how to do KMC, as well as information materials about KMC at display around the premises. As a result, most participants practiced KMC while at the healthcare facility:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;The sister will ask me to sit on the chair and she used to keep the baby on the chest. The sister in the ICU helps me to perform KMC, she removes the tubes and places the baby over my chest. There I have been provided with the chair. The doctor has advised to keep the baby in KMC for maximum 18hrs minimum 12hrs; then only the baby will gain weight.\u0026rdquo; (Participant 3)\u003c/p\u003e\n\u003cp\u003eThe mothers also frequently highlighted the importance of having adequate infrastructure facilities to support KMC, like KMC beds, opportunities for privacy and the inclusion of fathers in the care:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;There is a bed for the mother, baby cot, and each bed is covered with a screen to do KMC.\u0026rdquo; (Participant 4)\u003c/p\u003e\n\u003cp\u003eHowever, it was apparent that for some participants verbal guidance alone was not sufficient. They expressed a desire for instructional videos to enhance their understanding to implement these KMC more confidently and effectively:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;They advise only by talking. If more video shown regarding baby care, it will be good for my family members to see and practice.\u0026rdquo; (Participant 8)\u003c/p\u003e\n\u003cp\u003eSome fathers also raised concerns regarding the restrictions on men\u0026rsquo;s access into the NICU. This limitation hindered their ability to practice, which made them feel unable to contribute to this important caregiving practice for the low weight new-born:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;There are lots of deliveries and less discharges. Because of the overcrowding father KMC place was given to mothers. Father ward was given to mother.\u0026rdquo; (Participant 1).\u003c/p\u003e\n\u003cp\u003eThe engagement of fathers in the practice of KMC during their stay at the health facility also influenced the fathers\u0026rsquo; confidence in practicing KMC with their child:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Father: If I had been trained, it will be easier for me to hold now. It needs special skill to handle new-born baby, if we are not holding the neck properly baby will get nerve pain (sprain).\u0026rdquo; (Participant 5)\u003c/p\u003e\n\u003cp\u003eOverall, mothers and caregivers articulated several advantages that babies would gain from adoption of KMC. Many of the participants had given birth prematurely, and they likened KMC to provide womb-like environment for their infants emphasizing the nurturing qualities of the practice:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;This method will help the low birth baby to grow normal like mother\u0026rsquo;s womb.\u0026rdquo; (Participant 5)\u003c/p\u003e\n\u003cp\u003eHowever, although the mothers and their families had received extensive training and counselling on KMC in the health facility and integrated KMC as part of their care in NICU and step-down wards, and also expressed benefits of KMC, many participants did not continue to practice KMC after being discharged:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;(Mother smiled shyly): No, we did not practice such thing at my Home. The doctor said to do KMC, but we never did.\u0026rdquo; (Participant 4)\u003c/p\u003e\n\u003cp\u003eThe seamless flow of healthcare services from the hospital to the community is intricately linked to the knowledge and advice imparted to their families when they are discharged. Family members recounted the valuable guidance, they received from the healthcare team at the time of discharge process. This guidance acts as a pivotal role between the care at the facility and the ongoing care and support the child will receive in the community:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;At the time of discharge, they said I should do KMC, wash hands before taking baby, to give breast milk and to take the baby every week to the hospital.\u0026rdquo; (Participant 6)\u003c/p\u003e\n\u003cp\u003eHowever, there were also families who expressed dissatisfaction with the discharge process. They voiced their concern regarding the lack of guidance or counselling regarding KMC during the discharge. Instead, they felt they were given only a discharge card without advice regarding the crucial practice of KMC:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I did not get any counselling and there was no advice. At the time of discharge there was no advice. I got the discharge card from a lady sitting in computer room and came home.\u0026rdquo; (Participant 4)\u003c/p\u003e\n\u003cp\u003eThough the families received support in the hospital, after discharge they had to manage alone. They expressed the community workers were involved in routine activities and they felt dissatisfied with regards to KMC support in the community:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;The Balwadi (ICDs- Integrated Child Development Scheme) people they give the nutritional mix, the village health nurse from the primary centre, she\u0026apos;s more involved with a vaccination. But we don\u0026apos;t get information about the KMC from anybody.\u0026rdquo; (Participant 2)\u003c/p\u003e\n\u003cp\u003eIn addition, many mothers, especially those who had undergone caesarean sections or who had given birth to twins, encountered difficulties in practicing KMC due to post-delivery pain:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;When I practice KMC I had headache. Pain over the head and I had especially pain over the neck, it was radiating, and it was pulling my neck. So, because of that I was not able to sit.\u0026rdquo; (Participant 1)\u003c/p\u003e\n\u003cp\u003eSome mothers of LBW infants were also worried practicing KMC might cause harm or discomfort to their babies:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I was scared to carry the baby; I was afraid it was a small baby to keep it close to the chest; I was worried that breathing may stop.\u0026rdquo; (Participant 8)\u003c/p\u003e\n\u003cp\u003eBalancing household duties with KMC also proved to be a daunting task. Many families found it hard to simultaneously engage in KMC while managing their household responsibilities:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Morning I am not able to do. I have work in the morning. I have to do all the household jobs.\u0026rdquo; (Participant 6)\u003c/p\u003e\n\u003cp\u003eFinally, the region in Southern India where this study was carried out is characterized by a hot climatic condition, particularly during summer. Families residing in the region expressed various challenges related to the sweltering heat they encountered.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;It is hot. We have only a roof- tile roof. It radiates heat inside and it\u0026apos;s very difficult to keep the baby on the chest when it\u0026apos;s very hot. And my baby also not keeping quiet.\u0026rdquo; \u0026nbsp;(Participant 2)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 3: Family Boon or Bane (Trouble) - Family as a crucial context for Community KMC practice.\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mothers identified themselves as a part of large family network and the collective responsibility of shared household activities and childcare practices were expressed by them. In respect of maternal and new-born health, the families played a pivotal role in care of the child. As we have seen above, the family took active part during the hospital stay and assisted for KMC in the intensive care unit, after being trained by the health team.\u003c/p\u003e\n\u003cp\u003eThe findings from the in-depth interviews suggest that grandmothers played a significant role for the practice of KMC. They were a source of support for both the mother and the infant, serving as important caregivers and decisionmakers. However, the degree of involvement varied among the grandmothers. While some of them actively participated in KMC, care giving activities and emotional support to the mothers, a few of them played a more passive role, deferring decision making to other family members.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe dynamics within the family and the mother\u0026apos;s relationship with her own mother (the grandmother) emerged as a critical factor influencing the acceptance and implementation of KMC. Open communication, shared understanding, and a positive relationship between the mother and grandmother were reported to foster a collaborative approach towards KMC:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;My mother assisted in the hospital to hold; my mother had always cared for the baby! (Grandma approves and smiles).\u0026rdquo;\u0026nbsp;(Participant 2)\u003c/p\u003e\n\u003cp\u003eSome grandmothers also took on a leadership role after staying for more than a fortnight in NICU, teaching KMC to\u0026nbsp;new mothers and grandmothers:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;In the hospital when the baby was there for long time,\u0026nbsp;I used to talk to other mothers and grandmothers and I teach them the position of KMC, whatever I learnt from doctors and sisters, I will tell others\u0026quot;. (Participant 7)\u003c/p\u003e\n\u003cp\u003eNext to the grandmothers, it was the fathers who took the most active role for KMC in NICU. During the hospital stay where the mothers were convalescing in the post operative ward or intensive care unit, the fathers took active part in doing KMC in NICU:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFather: \u0026ldquo;I go in the morning between 11 am to 5 pm, give kangaroo care.\u0026rdquo; (Participant 3) \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe hospital had the practice of allowing the men for particular periods of the day and some fathers expressed a wish for more KMC hours in the hospital. Some fathers were emotional to have the baby on the chest and expressed the feelings for KMC:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;She had the opportunity to carry the baby in womb. But by KMC I too had the chance. (The father felt emotional his eyes were tearing. He brought the hands to the chest as a gesture of gratefulness).\u0026rdquo; (Participant1)\u003c/p\u003e\n\u003cp\u003eThe mothers also narrated the experience of the other family members in NICU supporting KMC in the hospital:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Two of my sisters came to hospital to do KMC, my elder sister and younger one.\u003c/p\u003e\n\u003cp\u003eFive of our family members came to the hospital and they all did KMC.\u0026rdquo; (Participant 1)\u003c/p\u003e\n\u003cp\u003eThough the families were supporting in terms of KMC care and breastfeeding in the hospital, after discharge the dynamics of many families changed. Conflicts or differing opinions for allowing the family members to do KMC posed challenges to the successful practice of KMC. Moreover, during interviews, views were expressed mirroring cultural expectations that the baby care is the mothers\u0026apos; responsibility. Traditional gender roles with men being breadwinners and the women babysitters was reinforced by fathers in the community. Consequently, the provision of KMC was predominantly considered as the domain of mother and female family members after discharge:\u003c/p\u003e\n\u003cp\u003eFather: (Looking at the mother, he looked angry): \u0026ldquo;This is her responsibility to take care of the baby and herself. It is she at home always. If she does not take care as per doctor\u0026rsquo;s advice, what to do?\u0026rdquo; (Participant 4)\u003c/p\u003e\n\u003cp\u003eThe traditional gender roles also left a few mothers conflicted in allowing the fathers to handle the babies:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMother: \u0026ldquo;I would not allow him to keep the baby on him because he is not gentle with the baby, he does not handle the baby carefully. I am afraid that he cannot do that\u0026rdquo; (Participant 4).\u003c/p\u003e\n\u003cp\u003eThe mothers also mentioned physical and practical barriers to KMC due to the tradition of mothers moving to their parents\u0026rsquo; home after the first childbirth. This meant fathers were visitors when seeing the mother and child, and living standards could be lower than what the father was used to, sometimes constituting a barrier to KMC:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;He visits here on Saturday and Sunday only, when I ask him to do KMC, he puts the baby for I to 2 hours. I used to force him for doing KMC. (Mother laughs... father also laughs...) He used to live comfortably in A/C room. He is not comfortable under the ceiling fan, in my home. He said how long I keep the baby like this \u0026mdash; he walks away. Only my mother will do KMC.\u0026rdquo; (Participant 7)\u003c/p\u003e\n\u003cp\u003eBurdened by the household chores, many mothers experienced difficulties to practice KMC. Time allocation between household activities and the childcare was found to be barriers to practicing KMC at the community:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I will put KMC in the afternoon sometimes. Morning I am not able to do. I have work in the morning. I have to do all the household jobs.\u0026rdquo; (Participant 6)\u003c/p\u003e\n\u003cp\u003eSome of the participants thus felt that they did not get the adequate support for KMC from family members at home:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;I alone practice it. I don\u0026apos;t ask my mother.\u0026quot; (Participant 5)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBut in some families though there was support, the mothers resented the baby being handled by others. They expressed concern for social contact being associated with increased risk for infection in their babies, therefore restricted who could handle the baby. The mothers got the idea of cleanliness during the stay in NICU where there is restricted access to visitors and the mothers felt the relatives as a source of infection and emphasized that they should not touch the baby. This aseptic idea was a barrier for KMC care at home, forcing the mothers to manage the burden of household chore and child care alone.\u003c/p\u003e\n\u003cp\u003eMother: \u0026ldquo;Sister, uncle, mother, father, and husband came to the hospital. Many of my\u0026nbsp;relatives live close by, they come but, no one touched the baby. In the hospital they\u0026nbsp;advise me that the baby was very sick. Got discharged, hence at home also only\u0026nbsp;myself and husband should take care. No one should touch the baby.\u0026rdquo; (Participant 6)\u003c/p\u003e\n\u003cp\u003eHowever, some fathers and family members took extra efforts to assist the mother in childcare, finding ways to overcome challenges, like space constraints:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;There is no space constraint. If the family is willing all can give Kangaroo Mother Care.\u0026rdquo; (Participant 2)\u003c/p\u003e\n\u003cp\u003eSome families hence managed to balance between the outside work, household chores, and the responsibility of KMC care. The enthusiasm of the father and other family members to support KMC at home was an enabler for long hours of KMC practice.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;After discharge I kept the baby in KMC for more than a month; even now I used to follow. My father keeps the baby in KMC, and my husband and my sister do too; whoever it may be, all of us in the family cuddle the baby in bed or use KMC in a chair. On average, in a day, 10-12 hours we did KMC.\u0026rdquo; (Participant 3)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eWhen the Family support is good, continuity of care in the community is\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e\u003cstrong\u003e\u0026nbsp;better.\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe findings from this study provide insight into the family’s experience when they shift care of the new-born from the hospital to the home environment. As shown in the results section, families often acted both as a source of support and as well as conflict to practice KMC at home. Various studies underline the role of families in KMC, and a systematic review by Siedman showed that support from family, friends, and other mothers was a resourcing enabler, with family support being the top-ranked enabler for continuation of KMC practice in LMICs [25]. \u0026nbsp;The results from our \u0026nbsp;study showed that family members were supportive and facilitating \u0026nbsp;KMC in the hospital, but not necessarily in the context of home, where, as per sociocultural norms, many expected caregiving responsibilities to be handled solely by the mother. Support for KMC after discharge therefore varied considerably.\u003c/p\u003e\n\u003cp\u003eSimilar findings of mothers not feeling supported in continuing KMC by families or communities have also been reported in previous research. A systematic review of KMC highlighted time constraints as a significant barrier [26], a concern echoed by several participants in this study. However, our findings reveal a more nuanced perspective. While some families allocated more time to household responsibilities at the expense of KMC, others devised innovative strategies through collaborative planning. One family, for instance, exemplified this adaptability and devised a structured plan as per work schedule and commuting time; all family members took turns sharing household work and KMC.\u003c/p\u003e\n\u003cp\u003eNow the question arises: Why do some families brave the odds to continue to practice, while the rest reduce or stop the support? Results from our study reveal that fathers and grandmothers were exposed to KMC in the NICU and played a pivotal role in decision-making, implementing or hindering KMC irrespective of social status. However, in the literature, studies have documented that lack of opportunity to practice is a barrier for fathers to support at home [27]. Fathers in a qualitative study in Australia were unaware that fathers could practice KMC. After they underwent an experiential learning process in the NICU, they supported the process. Similar findings state the importance of Kangaroo Care implementation as a structured education of the fathers [28].\u003c/p\u003e\n\u003cp\u003eThe results from our study showed that some fathers who had experiential learning in the NICU felt emotionally satisfied to be elevated to a maternal role. Similar to our findings, studies from the UK, Sweden, and Denmark have reflected and re-examined the role of father rather than a bystander. When fathers kangaroo care was instigated, fathers felt empowered to take on equal parenting roles [29–35]. On the contrary, Helth and Jarden [34] found that fathers in a Danish study did not perceive themselves as important as mothers in providing KMC. These disparities are often associated with the different cultural backgrounds. In settings like Zimbabwe, fathers voiced unease about performing KMC because of societal norms that childcare should be the role of the mother [26].\u003c/p\u003e\n\u003cp\u003eThe findings from our study both align with and also contradict the results from existing literature but point to a different direction. One ponders about experience: the counselling sessions in a busy governmental hospital—are they adequate to convince the families, or do they need a more structured program? Literature is abundant with various structural educational programs for members of families, including males. A systematic review by Smith [36] states that supervised practice and educating the family by demonstrations can enhance the confidence of family members to do KMC. \u0026nbsp;Many supportive programs in Malawi have utilized the services of respected grandparents to promote KMC. 4000 grandparents were trained in the grandparent’s program, where they provided individual and group counselling in their village to share the messages of positive child rearing [36]. We also saw the resources of grandparents in the current study. One grandmother of one of the participants who stayed for a long time in the hospital took the leadership role and trained recently delivered mothers and became a strong advocate.\u003c/p\u003e\n\u003cp\u003eThere is bias in the literature too, where kangaroo care is often reported as Kangaroo Mother Care, emphasizing the mother’s role. However, research by Blomquist and colleagues [31] shows that when fathers were given the opportunity to practice, they were empowered to provide parental support. This raises an important question: Does Kangaroo Care, when practiced by fathers, yield the same benefits as when practiced by mothers? Studies have found no significant differences in infants’ physiological parameters, such as heart rate, temperature, and oxygen saturation, when fathers provide KMC compared to mothers [37, 38]. This evidence suggests that paternal KMC offers comparable psychological and physiological benefits to maternal KMC, reinforcing the idea that the benefits of skin-to-skin contact and emotional bonding are not gender-dependent. One of the fathers in this study lamented that he had to vacate his place in the Father Kangaroo ward to accommodate mothers due to overcrowding. Another father said that if he was given the opportunity to learn the technique of KMC in the hospital, he would have supported KMC at home. Taken together, the evidence suggests re-evaluating the protocols of neonatal care units, creating training programs, and tailoring interventions and adaptations in the infrastructure to support paternal and other family members inclusion in the neonatal care units to ensure continuity of care at home.\u003c/p\u003e\n\u003cp\u003eFurther, this evidence highlights the need for longitudinal studies to assess family dynamics, paternal mental health, secondary benefits of reduced burden on mothers in high-stress environments, nuclear families, and dual-career families.Policy Implications\u0026nbsp;from this study are that the policymakers should consider integrating the findings into public health initiatives, advocating for paternal inclusion in neonatal care practices.When families struggle to sustain KMC, they strive to continue breastfeeding but stop skin-to-skin contact.\u003c/p\u003e\n\u003cp\u003eA palpable tension arises when families feel unable to provide optimal care, reflecting the complex interplay between social and structural factors. Mothers facing breastfeeding challenges adopt various strategies. In low-income settings, alternatives like water or formula feeds are common, and exclusive breastfeeding (EBF) is often perceived as a \"western practice\" [39, 40]. Conversely, in high-income countries, concerns about milk production and infant weight gain frequently shape feeding decisions. Despite extensive public health advocacy, global EBF rates have remained static at approximately 44 to 48% [41, 42]. Existing literature has documented a recurring pattern of high intentions to breastfeed followed by a shift to formula feeds due to difficulties[43]. A study in Australia has introduced the concept of \"breastfeeding grief\" as a potential mental health issue for women resorting to formula feeding[44]. One mother in our study, used formula as a temporary measure during her illness, and she felt uneasy discussing her inability to breastfeed her infant.\u003c/p\u003e\n\u003cp\u003eThough mothers adapted strategies to overcome the difficulties, novel divergent behaviour emerged from this study. While breastfeeding persists despite difficulties, skin-to-skin contact declines or ceases. Much of the existing literature presents breastfeeding and skin-to-skin contact as a unified KMC intervention. However, this study reveals that families adopt distinct approaches to each component, raising critical questions about the underlying drivers of breastfeeding persistence and skin-to-skin contact (SSC). Breastfeeding persistence often stems from immediate cues such as a crying baby signalling hunger, which makes its necessity more apparent. Conversely, the benefits of SSC are less immediately tangible, as the baby does not actively demand this form of contact. This raises important questions about how families perceive and prioritize SSC compared to breastfeeding, influenced by cultural norms, healthcare education, and support mechanisms.\u003c/p\u003e\n\u003cp\u003eBreastfeeding is an integral part of the culture and grandmother is a culturally accepted key player who transmits the traditional knowledge across generations. Several studies highlight grandmothers as key influencers in initiating and prolonging breastfeeding [45, 46]. A systematic review by Negin identified that grandmothers' positive attitudes toward breastfeeding increased initiation rates by 12%, while negative perceptions reduced breastfeeding likelihood by up to 70%. When grandmothers supported breastfeeding, EBF rates increased by 1.6 to 12.4 times, minimizing formula introduction [45].However, in China, highly educated grandmothers were associated with lower EBF rates, possibly influenced by aggressive formula marketing rather than education itself [47].\u003c/p\u003e\n\u003cp\u003eInterestingly, in the current study, the integration of traditional knowledge around galactagogues—such as specific foods believed to enhance milk secretion—was prevalent among participants. This phenomenon has been observed in other cultural settings, suggesting a ubiquitous reliance on food and nutrition as essential components of breastfeeding practices among mothers worldwide [48, 49].\u003c/p\u003e\n\u003cp\u003eGrandmothers in this study actively supported breastfeeding and their role extended to the NICU, where they engaged in KMC practices. While breastfeeding and nutritional supplementation knowledge were culturally embedded, skin-to-skin contact was a novel skill learnt by grandmothers in the NICU.\u003c/p\u003e\n\u003cp\u003eResearch highlights the multifaceted benefits of skin-to-skin contact in neonatal care. Baby Friendly initiative of \u003cem\u003eUNICEF\u003c/em\u003e emphasizes that SSC, initiated immediately after birth and maintained regularly, stabilizes heart rates, enhances oxygen saturation, regulates temperature, and improves breastfeeding outcomes. It also reduces stress levels, promotes growth, and may decrease hospital stays in neonatal units. For mothers, SSC increases milk supply and fosters a strong emotional bond with their infants, while enabling fathers and other family members to engage in caregiving roles [50]. A study highlighted the physiological benefits of KMC/SSC, showing its efficacy in regulating body temperature, reducing cortisol levels, and improving oxygen saturation in infants. These findings underscore the importance of consistent SSC implementation to maximize benefits while addressing practical barriers [51].\u003c/p\u003e\n\u003cp\u003eHowever, practical challenges have been observed. \u0026nbsp;As infants grow, resistance to the kangaroo position may require adjustments, such as increasing breastfeeding frequency and involving family members in providing SSC to support mothers[52].\u003c/p\u003e\n\u003cp\u003eAn important question arises on how far the grandmothers have imbibed the importance and the art of practising skin to skin contact and transmitted the new knowledge to family members at home? As mentioned earlier, in our study it was feasible to train grandmothers. One in particular took the initiative to transfer her knowledge on KMC to new mothers. However, the same engagement was not achieved among other grandmothers. For further implementation of KMC, there is a need to explore strategies for better involvement of the grandmothers and other family members.\u003c/p\u003e\n\u003cp\u003eThe lack of attention to grandmothers in global health fits into a larger reality of the neglect of elders in the family by the global health community. There is a gap in global health practice and health promotion involving the older generations[53, 54].Engaging grandmothers can create cascading benefits not only to the child but to the entire families’ health outcome across generations. There are very few public health interventions that can claim such cross-generational impact.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\"Nurturing Confidence: Need to improve frequency of Postnatal visits \"\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePostnatal interventions at the community level could play a significant role in facilitating the effective implementation of KMC after discharge. Hadush et al. demonstrated that Community Health Workers (CHWs) in Ethiopia effectively utilized antenatal clinics and postnatal follow-up visits to introduce KMC, supported by community acceptance. They also emphasized that CHWs played a crucial role in KMC promotion [55]. Further, a systematic review of 103 publications ranked CHW support as the fourth highest enabler of KMC implementation. In South India, an implementation study on KMC acceleration highlighted the role of CHWs in facilitating family involvement and they used a special link card \u0026nbsp; to support post-discharge communication and continuity of care [56].\u003c/p\u003e\n\u003cp\u003eMothers in this study mentioned insufficient postnatal follow-up from CHW on KMC. While they received a nutritional kit, including iron tonic and other supplements, during the antenatal period, these benefits were not extended post-discharge. The findings also pointed towards the gaps in CHW counselling. Participants in this study received counselling and visits during the antenatal period. In these antenatal visits, breastfeeding was a common topic, but many mothers first learned about skin-to-skin care after delivering their preterm infants. A noticeable disparity between antenatal and postnatal follow-up frequencies emerged, with participants emphasizing the need for structured and regular postnatal visits to integrate breastfeeding and skin-to-skin contact effectively. Considering the vulnerable transition from hospital to home, mothers emphasized the urgent need for continued support from CHWs post discharge.\u003c/p\u003e\n\u003cp\u003eA study in Ethiopia highlighted that many caregivers have limited knowledge about KMC, which affects their adoption rates; thus, targeted interventions during antenatal and postnatal periods are critical for overcoming these knowledge gaps. According to that study, mothers who received \u0026nbsp;counselling and follow-up visits from healthcare providers demonstrated higher adherence to KMC practices compared to those who did not receive such support [16].\u003c/p\u003e\n\u003cp\u003eTaken together, there is a need for systematic policies, structured education, empowering CHW and family members creating a holistic support system that enables mothers to sustain KMC.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study's strength lies in its qualitative approach, which captures the nuanced experiences of families practicing KMC. The inclusion of diverse family dynamics and cultural contexts, covering rural, urban, and tribal populations and participants with different socioeconomic status, enhances the trustworthiness of the findings. By observing the transition from hospital to community and including not only mothers, but also fathers and grandmothers, the study provides a comprehensive view of family and healthcare workers' involvement. While the findings are particularly relevant to LMICs, they might offer transferable insights for diverse sociocultural settings. The specific strategies may differ, but the core principle of inclusive family support remains universally applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLimitations of our study include potential response bias and the contextual specificity of the study. Tamil Nadu, as an advanced state in terms of healthcare in India, limits the generalizability of the findings. Additionally, the primary author’s dual role as both a caregiver in the hospital and a researcher in the field may have influenced the interactions and responses of the families. Further research is needed to explore these findings in varied cultural and socioeconomic settings to solidify their applicability.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecommendations for Policy and Practice\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe challenges and enablers identified can inform policies and programs aimed at promoting family-inclusive KMC practices worldwide.\u0026nbsp;\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eStructured Family Education: Develop programs to actively involve fathers and grandmothers, addressing knowledge gaps and empowering families to sustain KMC.\u003c/li\u003e\n \u003cli\u003eGender-Inclusive Practice and Terminology: Reframe KMC as “Kangaroo Family Care” to challenge traditional norms and promote inclusivity.\u003c/li\u003e\n \u003cli\u003eEnhancing Community Health Worker (CHW) Roles: Train CHWs to counsel families on skin-to-skin contact during antenatal visits and provide post-discharge support to ensure sustained KMC practices.\u003c/li\u003e\n \u003cli\u003ePromoting Cross-Generational Impact: Engage grandmothers as KMC advocates to leverage their influence for cascading benefits across generations.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eHealth systems worldwide can benefit from incorporating structured educational programs that encourage both maternal and paternal participation in KMC, thus maximizing the potential benefits for infants and families.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study contributes to the expanding body of research advocating for inclusive KMC practices that involve all family members, not exclusively mothers. The research highlighted the need to challenge maternal-centric biases prevalent in KMC practices and emphasizes comprehensive family engagement strategies. Promoting gender-inclusive practices, such as rebranding KMC as \u0026quot;Kangaroo Family Care,\u0026quot; is essential, particularly in settings where traditional gender roles may limit paternal engagement. By incorporating structured programs that actively involve fathers and other family members, the overall effectiveness and sustainability of KMC practices could be significantly enhanced. The findings emphasize the critical importance of family support and healthcare workers in sustaining KMC post-discharge. While families demonstrate strong commitment to breastfeeding, maintaining consistent skin-to-skin contact tends to decline over time, reflecting systemic, cultural, and resource-related barriers. This inconsistency stresses the urgent need for structured family education and a shift toward collective family responsibility in new-born care interventions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur study also delves into the variability of family engagement during KMC and raises important questions about the adequacy of counselling sessions in busy governmental hospitals. This prompts a critical examination of whether structured educational programs are necessary to effectively engage families in KMC practices. Strengthening community involvement, addressing infrastructural limitations, and enhancing healthcare provider training are vital steps to bridge the gap between hospital and home-based KMC. This holistic approach will foster sustained KMC practices, leading to improved health outcomes for low-birth-weight infants and a more inclusive model of care.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study acquired ethical committee approval from the Chengalpattu Medical College Institutional Ethics Committee and the Norwegian Regional Committee for Medical and Health Research Ethics (32413). \u0026nbsp;We confirm that all interviews were performed following the relevant guidelines and regulations. \u0026nbsp;We confirm that informed consent was obtained from all mothers and caregivers and the records were de-identified before analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dataset used and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials Consent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEkam Foundation, Chennai, India.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003einterests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSJ and IK conceptualized the idea. SJ, IK and SR supervised protocol writing and data collection. SJ, IK, SH and SR carried out the analysis, interpreted the result. \u0026nbsp;SJ, IK and SH participated in drafting the manuscript, revised the manuscript, and approved the final manuscript for submission. \u0026nbsp;All authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge the support and contribution of the mothers and families of babies who participated in the study. We thank the Directorate of Medical Education and Directorate of Public Health \u0026amp; Preventive Medicine, government of Tamil Nādu for the permission of the research work. We thank the Dean of CMCH, Professor of Dept. of Neonatology Dr. Muthukumaran, the Nodal officer, SNCU Dr. Manikumar, Professor of Paediatrics Dr. Ravikumar, Professor in-charge of District Early Intervention Centre (DEIC) Dr. Murali, Ms. Reeta Mary Staff Nurse, follow up nurse of SNCU, all the nurses of NICU and staffs of DEIC. \u0026nbsp;We thank Ms. Shenbagam, SNCU data operator, ICDS staffs and village health nurses of Primary Health Centres who helped to track the children. We thank Dr. Vanaja, Director Gandhigram Institute of Rural health for her support.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003e\u0026ldquo;Kangaroo Mother Care to Reduce Morbidity and Mortality in Low-Birth-Weight Infants.\u0026rdquo; Accessed April 16, 2025. https://www.who.int/tools/elena/interventions/kangaroo-care-infants.\u003c/li\u003e\n\u003cli\u003eUNICEF DATA. \u0026ldquo;Low Birthweight.\u0026rdquo; Accessed April 16, 2025. https://data.unicef.org/topic/nutrition/low-birthweight/. \u003c/li\u003e\n\u003cli\u003eOhuma EO, Moller A-B, Bradley E, Chakwera S, Hussain-Alkhateeb L, Lewin A, et al. National, regional, and global estimates of preterm birth in 2020, with trends from 2010: a systematic analysis. The Lancet. 2023; 402:1261\u0026ndash;71.\u003c/li\u003e\n\u003cli\u003eMcIntyre S, Taitz D, Keogh J, Goldsmith S, Badawi N, Blair E. A systematic review of risk factors for cerebral palsy in children born at term in developed countries. Dev Med Child Neurol. 2013; 55:499\u0026ndash;508.\u003c/li\u003e\n\u003cli\u003eHimpens E, Van den Broeck C, Oostra A, Calders P, Vanhaesebrouck P. Prevalence, type, distribution, and severity of cerebral palsy in relation to gestational age: a meta-analytic review. Dev Med Child Neurol. 2008; 50:334\u0026ndash;40.\u003c/li\u003e\n\u003cli\u003eBoulet SL, Schieve LA, Boyle CA. Birth weight and health and developmental outcomes in US children, 1997-2005. Matern Child Health J. 2011; 15:836\u0026ndash;44.\u003c/li\u003e\n\u003cli\u003eMervis CA, Decoufl\u0026eacute; P, Murphy CC, Yeargin-Allsopp M. Low birthweight and the risk for mental retardation later in childhood. Paediatr Perinat Epidemiol. 1995; 9:455\u0026ndash;68.\u003c/li\u003e\n\u003cli\u003eLahat A, Van Lieshout RJ, Saigal S, Boyle MH, Schmidt LA. ADHD among young adults born at extremely low birth weight: the role of fluid intelligence in childhood. Front. Psychol. 2014;5.\u003c/li\u003e\n\u003cli\u003eKerstjens JM, de Winter AF, Bocca-Tjeertes IF, Bos AF, Reijneveld SA. Risk of developmental delay increases exponentially as gestational age of preterm infants decreases: a cohort study at age 4 years. Dev Med Child Neurol. 2012; 54:1096\u0026ndash;101.\u003c/li\u003e\n\u003cli\u003eWHO Immediate KMC Study Group. Immediate Kangaroo Mother Care and Survival of Low-Birth-Weight Infants. N Engl J Med. 2021; 384:2028\u0026ndash;38.\u003c/li\u003e\n\u003cli\u003eUNICEF DATA. \u0026ldquo;Child Survival and the SDGs.\u0026rdquo; Accessed April 16, 2025. https://data.unicef.org/topic/child-survival/child-survival-sdgs/. \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; 94:130-141J.\u003c/li\u003e\n\u003cli\u003eConde-Agudelo A, Beliz\u0026aacute;n JM, Diaz-Rossello J. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database Syst Rev. 2011; CD002771.\u003c/li\u003e\n\u003cli\u003eLunze K, Bloom DE, Jamison DT, Hamer DH. The global burden of neonatal hypothermia: systematic review of a major challenge for new born survival. BMC Medicine. 2013; 11:24.\u003c/li\u003e\n\u003cli\u003eNHM. India Newborn Action Plan: 2014-2020 Progress Card. National Health Mission.\u003c/li\u003e\n\u003cli\u003eKwesiga D, Wanduru P, Ssegujja E, Inhensiko J, Waiswa P, Franck L. Improving Post-Discharge Practice of Kangaroo Mother Care: Perspectives from Communities in East-Central Uganda. Front Pediatr. 2022; 10:934944.\u003c/li\u003e\n\u003cli\u003eMustikawati IS, Pratomo H, Martha E, Murty AI, Adisasmita AC. Barriers and facilitators to the implementation of Kangaroo Mother Care in the community\u0026mdash;a qualitative study. Journal of Neonatal Nursing. 2020; 26:109\u0026ndash;14.\u003c/li\u003e\n\u003cli\u003eChild Health | National Health Mission Tamil Nadu, Department of Health \u0026amp; Family Welfare, Govt. of Tamil Nadu, India. https://nhm.tn.gov.in/en/r-c-h/child-health. Accessed 31 Mar 2025.\u003c/li\u003e\n\u003cli\u003eJegannathan S, Natarajan M, Solaiappan M, Shanmugam R, Tilwani SA. Quality improvement initiative to improve the duration of Kangaroo Mother Care in the tertiary care neonatal unit of South India. BMJ Open Qual. 2022;11 Suppl 1: e001775.\u003c/li\u003e\n\u003cli\u003eManen MV. Phenomenology of Practice: Meaning-Giving Methods in Phenomenological Research and Writing. New York: Routledge; 2016.\u003c/li\u003e\n\u003cli\u003eLydon M, Longwe M, Likomwa D, Lwesha V, Chimtembo L, Donohue P, et al. Starting the conversation: community perspectives on preterm birth and kangaroo mother care in southern Malawi. J Glob Health. 2018; 8:010703.\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006; 3:77\u0026ndash;101.\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Reflecting on reflexive thematic analysis. Qualitative Research in Sport, Exercise and Health. 2019; 11:589\u0026ndash;97.\u003c/li\u003e\n\u003cli\u003eWMA. WMA Declaration of Helsinki\u0026mdash;Ethical Principles for Medical Research Involving Human Subjects. World Medical Association (WMA); 2013.\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: e0125643.\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; 94:130-141J.\u003c/li\u003e\n\u003cli\u003eYogman M, Garfield CF, Committee on Psychosocial Aspects of Child and Family Health, Bauer NS, Gambon TB, Lavin A, et al. Fathers\u0026rsquo; Roles in the Care and Development of Their Children: The Role of Paediatricians. Pediatrics. 2016;138: e20161128.\u003c/li\u003e\n\u003cli\u003eYogman M, Garfield CF, Lavin A, Lemmon KM, Mattson G, Rafferty JR, et al. Fathers\u0026rsquo; Roles in the Care and Development of Their Children: The Role of Paediatricians. Pediatrics. 2016;138: e20161128.\u003c/li\u003e\n\u003cli\u003eJesus NC de, Vieira BDG, Alves VH, Rodrigues DP, Souza R de MP de, Paiva ED. The experience of the kangaroo method: the perception of the father. Revista de Enfermagem UFPE online. 2015; 9:8542\u0026ndash;50.\u003c/li\u003e\n\u003cli\u003eOlsson E, Eriksson M, Anderz\u0026eacute;n-Carlsson A. Skin-to-Skin Contact Facilitates More Equal Parenthood\u0026mdash;A Qualitative Study from Fathers\u0026rsquo; Perspective. J Pediatr Nurs. 2017;34: e2\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eBlomqvist YT, Fr\u0026ouml;lund L, Rubertsson C, Nyqvist KH. Provision of Kangaroo Mother Care: Supportive Factors and Barriers Perceived by Parents. Scand J Caring Sci. 2013; 27:345\u0026ndash;53.\u003c/li\u003e\n\u003cli\u003eFegran L, Helseth S, Fagermoen MS. A comparison of mothers\u0026rsquo; and fathers\u0026rsquo; experiences of the attachment process in a neonatal intensive care unit. J Clin Nurs. 2008; 17:810\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eG\u0026uuml;nay U, Coşkun Şimşek D. Emotions and Experience of Fathers Applying Kangaroo Care in the Eastern Anatolia Region of Turkey: A Qualitative Study. Clin Nurs Res. 2021; 30:840\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eHelth TD, Jarden M. Fathers\u0026rsquo; experiences with the skin-to-skin method in NICU: Competent parenthood and redefined gender roles. Journal of Neonatal Nursing. 2013; 19:114\u0026ndash;21.\u003c/li\u003e\n\u003cli\u003eMagee J, Nurse S. Supporting the bereaved father in the NICU: A reflective case study. Journal of Neonatal Nursing. 2014; 20:20\u0026ndash;3.\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; 17:35.\u003c/li\u003e\n\u003cli\u003eYurdag\u0026uuml;l Nİ, Esenay FI. Effect of kangaroo care applied by mothers and fathers in premature infants: A crossover study. Journal of Neonatal Nursing. 2023; 29:501\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003eBauer K, Pyper A, Sperling P, Uhrig C, Versmold H. Effects of gestational and postnatal age on body temperature, oxygen consumption, and activity during early skin-to-skin contact between preterm infants of 25-30-week gestation and their mothers. Pediatr Res. 1998; 44:247\u0026ndash;51.\u003c/li\u003e\n\u003cli\u003eFjeld E, Siziya S, Katepa-Bwalya M, Kankasa C, Moland KM, Tyllesk\u0026auml;r T, et al. \u0026ldquo;No, sister, the breast alone is not enough for my baby,\u0026rdquo; a qualitative assessment of potentials and barriers in the promotion of exclusive breastfeeding in southern Zambia. Int Breastfeed J. 2008; 3:26.\u003c/li\u003e\n\u003cli\u003eAbuidhail J, Al-Modallal H, Yousif R, Almresi N. Exclusive breastfeeding (EBF) in Jordan: prevalence, duration, practices, and barriers. Midwifery. 2014; 30:331\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eChang Y-S, Li KMC, Li KYC, Beake S, Lok KYW, Bick D. Relatively speaking? Partners\u0026rsquo; and family members\u0026rsquo; views and experiences of supporting breastfeeding: a systematic review of qualitative evidence. Philosophical Transactions of the Royal Society B: Biological Sciences. 2021;376.\u003c/li\u003e\n\u003cli\u003e\u0026ldquo;Global Breastfeeding Scorecard 2023 | UNICEF.\u0026rdquo; Accessed April 16, 2025. https://www.unicef.org/documents/global-breastfeeding-scorecard-2023.\u003c/li\u003e\n\u003cli\u003eThomson G, Ebisch-Burton K, Flacking R. Shame if you do\u0026mdash;shame if you don\u0026rsquo;t: women\u0026rsquo;s experiences of infant feeding. Maternal and Child Health Journal. 2015; 11:33\u0026ndash;46.\u003c/li\u003e\n\u003cli\u003eAyton JE, Tesch L, Hansen E. Women\u0026rsquo;s experiences of ceasing to breastfeed: Australian qualitative study. BMJ Open. 2019;9: e026234.\u003c/li\u003e\n\u003cli\u003eNegin J, Coffman J, Vizintin P, Raynes-Greenow C. The influence of grandmothers on breastfeeding rates: a systematic review. BMC Pregnancy Childbirth. 2016; 16:91.\u003c/li\u003e\n\u003cli\u003eGrassley JS, Spencer BS, Law B. A Grandmothers\u0026rsquo; Tea: Evaluation of a Breastfeeding Support Intervention. J Perinat Educ. 2012; 21:80\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eGong Q, Jackson P. Mediating science and nature: Representing and consuming infant formula advertising in China. European Journal of Cultural Studies. 2013; 16:285\u0026ndash;309.\u003c/li\u003e\n\u003cli\u003eKarolina K, Lehman I. The link between knowledge of the maternal diet and breastfeeding practices in mothers and health workers in Poland. International Breastfeeding Journal. 2021; 16:58.\u003c/li\u003e\n\u003cli\u003eCarretero-Krug A, Montero-Bravo A, Morais-Moreno C, Puga AM, Samaniego-Vaesken M de L, Partearroyo T, et al. Nutritional Status of Breastfeeding Mothers and Impact of Diet and Dietary Supplementation: A Narrative Review. Nutrients. 2024; 16:301.\u003c/li\u003e\n\u003cli\u003eBaby Friendly Initiative. \u0026ldquo;Skin-to-skin contact\u0026rdquo;. Accessed April 16, 2025. https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/implementing-standards-resources/skin-to-skin-contact/. \u003c/li\u003e\n\u003cli\u003eDurmaz A, Sezici E, Akkaya DD. The effect of kangaroo mother care or skin-to-skin contact on infant vital signs: A systematic review and meta-analysis. Midwifery. 2023; 125:103771.\u003c/li\u003e\n\u003cli\u003eKoreti M, Muntode Gharde P. A Narrative Review of Kangaroo Mother Care (KMC) and Its Effects on and Benefits for Low Birth Weight (LBW) Babies. Cureus. 14: e31948.\u003c/li\u003e\n\u003cli\u003eHong C, Sun L, Liu G, Guan B, Li C, Luo Y. Response of Global Health Towards the Challenges Presented by Population Aging. China CDC Wkly. 2023; 5:884\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003ePapp-Zipernovszky O, Horv\u0026aacute;th MD, Schulz PJ, Csabai M. Generation Gaps in Digital Health Literacy and Their Impact on Health Information Seeking Behaviour and Health Empowerment in Hungary. Front Public Health. 2021; 9:635943.\u003c/li\u003e\n\u003cli\u003eHadush MY, Gebremariam DS, Beyene SA, Abay TH, Berhe AH, Zelelew YB, et al. Barriers and Enablers of KMC Implementation in Health Facilities and Community of Tigray Region, Northern Ethiopia: Formative Research. Pediatric Health Med Ther. 2022; 13:297\u0026ndash;307.\u003c/li\u003e\n\u003cli\u003eJayanna K, Rao S, Kar A, Gowda PD, Thomas T, Swaroop N, et al. Accelerated scale-up of Kangaroo Mother Care: Evidence and experience from an implementation-research initiative in South India. Acta Paediatr. 2023;112 Suppl 473:15\u0026ndash;26.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Kangaroo Mother Care, low-birth-weight infants, family support, breastfeeding challenges, community health workers, gender-inclusive practices","lastPublishedDoi":"10.21203/rs.3.rs-6520424/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6520424/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eKangaroo Mother Care (KMC) is an effective intervention shown to significantly lower neonatal morbidity and mortality, especially among low-birth-weight (LBW) infants. Despite its success, many families struggle to implement KMC effectively post-discharge.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod:\u003c/strong\u003e This qualitative study explored the experiences of mothers and families practicing KMC after discharge from the hospital in South India. In-depth, semi-structured interviews were conducted with eight mothers, fathers, and grandmothers, focusing on their experiences with community KMC (cKMC) and their challenges in maintaining cKMC at home.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Analysis resulted in the construction of three main themes: 1) Breast Feeding - Persevering Despite Initial Difficulties; 2) Kangaroo Mother Care - Seeing benefits but struggling to practice; and 3) Family Boon or Bane - Family as a crucial context for cKMC practice. Participants expressed a strong commitment to breastfeeding despite encountering challenges. KMC was adopted positively and benefitted from support by healthcare team and infrastructure during hospital stay, but continuation at home was difficult due to inadequate counselling, lack of community follow-up and challenging home environment. Family emerged both as a support system and a source of a tension to KMC practice. While fathers and grandmothers actively supported KMC in hospital settings, post-discharge traditional gender norms and domestic responsibilities hindered continuity at home.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e To promote sustained family-inclusive cKMC practices, there is a need for structured education to empower all caregivers, including grandmothers and fathers. Adoption of gender inclusive terminology such as “Kangaroo Family Care” can help to dismantle gender-oriented perceptions and encourage participation of all family members. Engaging grandparents as champions of KMC can promote intergenerational support for families and improve the outcome of LBW newborns. Community health teams should strengthen through tailored training on antenatal counselling and post-discharge support.\u003c/p\u003e","manuscriptTitle":"Continuation of Kangaroo Mother Care when transitioning from Facility to Community: Maternal and Familial perspectives from South India","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-02 13:04:56","doi":"10.21203/rs.3.rs-6520424/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-18T07:40:12+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-28T20:16:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-03T01:07:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"122595243033763733187707020406380148217","date":"2025-06-26T12:23:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"132880789933568854594367857524356501169","date":"2025-06-24T10:39:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-30T09:11:17+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-04-25T15:28:36+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-25T01:11:54+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-25T01:10:19+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-04-24T11:29:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8a017e10-f6b4-4abf-923a-f113fc61d28d","owner":[],"postedDate":"June 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-10T16:01:03+00:00","versionOfRecord":{"articleIdentity":"rs-6520424","link":"https://doi.org/10.1186/s12913-025-13615-7","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2025-11-05 15:57:30","publishedOnDateReadable":"November 5th, 2025"},"versionCreatedAt":"2025-06-02 13:04:56","video":"","vorDoi":"10.1186/s12913-025-13615-7","vorDoiUrl":"https://doi.org/10.1186/s12913-025-13615-7","workflowStages":[]},"version":"v1","identity":"rs-6520424","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6520424","identity":"rs-6520424","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}