Barriers and Facilitators to Effective Kangaroo Mother Care in Ethiopia: A Qualitative Study

Barriers and Facilitators to Effective Kangaroo Mother Care in Ethiopia: A Qualitative Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Barriers and Facilitators to Effective Kangaroo Mother Care in Ethiopia: A Qualitative Study Beyene Roba Ireso, Abiy Seifu Estifanos This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7685786/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Globally, neonatal deaths account for nearly half of under-five mortality, with over 1 million deaths occurring within the first 24 hours of life—largely due to preterm birth. In Ethiopia, low birth weight newborns contribute to 60–80% of neonatal deaths, with a neonatal mortality rate of 33 per 1,000 live births. Kangaroo Mother Care (KMC) is a proven, cost-effective intervention for preterm and low birth weight babies, now recommended by World Health Organization (WHO) for immediate initiation after birth. Despite national policy support, KMC coverage in Ethiopia remains low, with fewer than 10% of eligible newborns receiving it. Understanding the barriers and enablers to effective KMC implementation is critical to improving coverage and outcomes. Methods The study conducted in August 2023 at Asella Referral and Teaching Hospital and Batu General Hospital in Oromia, utilized thematic analysis to explore barriers and facilitators of effective KMC. Data were collected through observations and in-depth interviews with 14 participants—six mothers and eight neonatal care providers. Semi-structured interviews were conducted in Amharic and Afan Oromo, recorded, and transcribed. Data were manually coded and analyzed thematically. A pre-tested, standardized questionnaire ensured data quality, and collection continued until saturation was achieved, with findings presented in detailed descriptions. Result Our analysis identified health system related barriers to effective KMC including inadequate healthcare infrastructure, skill gaps, low healthcare provider motivation, maternal emotional status, post-operative pain, lack of knowledge about KMC, and cultural norms that hasten mothers to go home after birth. Facilitators comprise quality improvement initiatives, visual aids, effective counseling, maternal willingness and regular pregnancy follow-up. Conclusion Addressing both systemic and individual-level barriers while reinforcing identified facilitators is essential to improve effective KMC uptake. Targeted, system-wide and mother-centered interventions are needed to improve uptake of effective KMC in Ethiopia. Clinical trial number: Not applicable barriers facilitators effective KMC Ethiopia Figures Figure 1 Background Globally, 5 million children die before the age of five, with nearly half of these deaths (2.3 million) occurring during the neonatal period. Over 1 million of these neonatal deaths take place within the first 24 hours after birth, with preterm birth contributing to more than 50% of cases ( 1 ). In Ethiopia, low birth weight (LBW) newborns account for 60–80% of all neonatal deaths each year. According to the 2019 Ethiopian Mini Demographic and Health Survey, the neonatal mortality rate was 33 deaths per 1,000 live births ( 2 ). The WHO recommends a range of interventions for the prevention and care of preterm births, with KMC recognized as a key strategy ( 3 ). KMC is a high-impact, low-tech, and cost-effective intervention for the care of preterm and LBW newborns, who are at elevated risk of neonatal mortality and morbidity ( 4 , 5 ). The WHO now recommends initiating KMC immediately after birth, as early initiation has been shown to be more effective than starting after the newborn is stabilized. Ethiopia has adopted these updated recommendations ( 3 , 6 ). Despite this, both global and national coverage of KMC remains low. In 2021, global KMC coverage was reported to be less than 5% ( 7 ). In Ethiopia, prior to 2021, studies indicated that only 5%–10% of eligible newborns received any form of KMC, irrespective of quality ( 8 , 9 ). Efforts to scale up implementation have largely fallen short, underscoring the importance of understanding the barriers and facilitators to effective KMC adoption. In Ethiopia, although national policies emphasize the expansion of KMC, the proportion of preterm or LBW neonates receiving KMC remains low. The national target, as outlined in the Newborn and Child Survival and Development Strategy, is to achieve 70% KMC coverage among preterm babies by 2025 ( 10 ). The persistently low rate of early and effective KMC initiation highlights the need for a comprehensive understanding of the factors contributing to this gap and for identifying the barriers and enablers affecting the adoption of KMC within the Ethiopian healthcare system. While numerous studies have explored the general barriers and facilitators to KMC implementation, few have specifically focused on the factors influencing effective early KMC. Therefore, we conducted a qualitative study to explore the barriers and facilitators to the effective implementation of KMC in the Ethiopian context. METHODS Study Setting and Period This study was conducted in August 2023 in the KMC unit of two hospitals in the Oromia region: Asella Referral and Teaching Hospital and Batu General Hospital. The KMC unit included pediatricians, medical doctors assigned to the NICU, NICU nurses, and NICU heads. Study Design We employed a qualitative descriptive methodology with thematic analysis to explore the facilitators and barriers to effective KMC. Data collection methods included observation and in-depth interviews. Operational Definition Effective KMC Early, continuous, and prolonged skin-to-skin contact (SSC) between low birth weight (< 2500 grams) and preterm (< 37 weeks gestational age) infants and their mother (or a surrogate caregiver), along with exclusive breastfeeding. Participants and Sampling The study population consisted of two main participant groups: mothers and neonatal care providers. For mothers, convenience sampling was used to include all mothers receiving KMC during the study period and present in the KMC unit at the time of the visit. For neonatal care providers, purposive sampling was used to select participants who could offer relevant, detailed information on the research question. A total of 14 participants were included in the in-depth interviews (IDIs), comprising six mothers and eight neonatal care providers. Interviews continued until data saturation was achieved, with no new information or themes emerging. Eligible participants provided informed consent, and the interviews were conducted in Amharic and Afan Oromo, with audio recordings made for later transcription. Data Collection A semi-structured in-depth interview guide was used for mothers of preterm and/or low-birth-weight infants, as well as healthcare staff in the NICU. Open-ended questionnaires were developed for this study ( Supplementary File 1 ). Data collection involved one-to-one in-depth interview and observation. With participant consent, interviews were audio-recorded in addition to note-taking. Data Analysis Field notes and interview transcripts were reviewed, coded manually using color coding, and analyzed thematically. Audio recordings were transcribed verbatim into Microsoft Word and translated into English. Themes were identified from the data, which were continuously examined during the interview sessions. Transcripts were repeatedly read to familiarize the with the content, and preliminary codes were developed. These codes were then categorized into major themes and sub-themes for presentation. Data Quality Assurance A standardized questionnaire guide, aligned with the study objectives, was developed prior to data collection. Pre-testing was conducted with two mothers and healthcare professionals (HCPs). The questionnaire, initially in English, was translated into Afaan Oromo and back-translated to ensure consistency. Data collection continued until saturation was reached, and detailed descriptions of the data were provided to ensure its transferability. RESULTS In-depth interviews and observations were conducted at each hospital setting. A total of 14 IDIs were carried out: 6 with mothers of preterm and/or low birth weight babies, and 8 with neonatal care providers. This included the NICU head, NICU provider, neonatal care doctors, and pediatricians. Of the 6 mothers, 3 were aged between 20 and 30, and 1 was from a rural area. Among the 8 neonatal care providers, 2 were female, and 3 had more than 5 years of experience. Demographic characteristics of the participants are presented in Table 1 . Table 1 Characteristic of participants Characteristics, (IDI = 14) Mother’s characteristics (IDI = 6) n HCPs characteristics (IDI = 8) n Age group Sex 15–20 2 Female 2 20–30 3 Male 6 \(\:\ge\:\) 30 1 Age group Residency 20–30 5 Rural 5 \(\:\ge\:\) 30 3 Urban 1 Years of experiences Educational status 1–4 5 None 2 \(\:\ge\:\) 4 3 Primary 3 Secondary and above 1 Barriers and Facilitators to Effective KMC Participants acknowledged the importance of early KMC initiation but reported delays in starting it after birth. Primary themes frequently cited as influencing timely KMC initiation and ongoing practice include maternal and infant factors, healthcare system and professional considerations, religious and cultural beliefs, and socioeconomic influences. Illustrative quotes are also provided to further elucidate these themes (Fig. 1 ) Figure 1 : One healthcare provider explained, “There are conditions where they start early, and there are conditions where they do not. For example, most women come here with referrals from health centers due to different complications. Regarding medical factors, first, we treat the case for both the baby and the mother. Even premature babies are referred here if they are in unstable conditions. They are not referred to us solely because they are preterm or to start KMC. However, if they are born here, they can start within 24 hours.” (IDI07, General Practitioner) Healthcare System Factors: Healthcare System Factors pertain to various aspects of healthcare infrastructure affecting KMC. Commonly cited issues by both mothers and healthcare providers include challenges related to KMC facilities, room conditions, and beds. Healthcare providers noted KMC under-utilization due to limited room availability. They also noted issues like a lack of separate rooms for unstable infants. Mothers emphasized bed shortages, describing existing KMC beds as uncomfortable and unsuitable for holding newborns and breastfeeding. One mother mentioned the bed shortage, stating, “I want to mention the shortage of beds; they kept me here due to a lack of beds. Even now, all beds are occupied, and if another mother comes, there's no bed.” (IDI03, mother). During our observation, we observed that the KMC beds were insufficient relative to the number of mothers, and the KMC room was inadequately lit and uncomfortable for mothers. A mother described the KMC room as inadequate, saying, “Most of the time, the KMC room window is left open, there is airflow in the room, and the room quality is poor. People, like family and relatives, enter and exit as they please.” (IDI02, mother). Additional healthcare system factors impeding effective KMC initiation include a lack of educational materials, manuals, and KMC guidelines. In addition, healthcare providers pointed out that KMC is not part of the newborn referral process. As one provider stated, “Even premature babies in unstable conditions are referred here, not specifically for being preterm or for KMC initiation.” (IDI07, General Practitioner) A Neonatal Care Unit (NCU) head noted that the inefficient transfer of babies from the delivery room to the NICU hinders the prompt initiation of KMC. The NICU head explained, “Even within the hospital, challenges arise when transporting babies to our NICU. They often arrive hypothermic, inadequately dressed in just a few clothes provided by their families. Sometimes, babies are sent wrapped in just cotton.” (IDI06, NICU Head) The mentioned healthcare system factors facilitate effective KMC, including the use of visual aids such as television programs and posters. These visual aids were employed to educate mothers, leading to increased awareness and understanding of KMC. Additionally, early KMC was promoted through quality improvement initiatives. Healthcare Professional Factors: Healthcare Professional Factors encompassed healthcare professionals' knowledge of KMC guidelines, their willingness to promote and support KMC, their communication skills in educating and encouraging mothers, and their practical skills in assisting with KMC initiation. Healthcare professional factors revealed that the lack of training and skill gaps among healthcare professionals had emerged as a significant obstacle. This had hindered their ability to confidently initiate KMC, resulting in delays and sub-optimal practices. "It has been a long time; there have been updates since that training. I believe training should be provided more frequently with shorter intervals. This way, we can stay up-to-date and feel more confident in our guidance" (IDI01, NICU provider). Additionally, low motivation and incentives, particularly in the form of low salaries, had contributed to these challenges. The financial constraints faced by healthcare professionals not only demotivated them but also had an adverse effect on their commitment to KMC. Another critical issue was the shortage of healthcare professionals, which had led to overburdened staff and reduced attention to KMC. This scarcity had further exacerbated the situation by limiting the availability of dedicated personnel for KMC initiation. Moreover, the low attention given by healthcare professionals to KMC had been influenced by negative attitudes. These negative perceptions had often arisen from misconceptions and a lack of awareness, thereby hindering the promotion and timely initiation of KMC. Healthcare professional facilitating factors for the early initiation of KMC included the prominent encouragement of family involvement, signifying its critical role. Healthcare professionals who actively promoted and facilitated family engagement in the care process played a pivotal role in improving the acceptance and effectiveness of KMC. Moreover, effective counseling and clear communication with parents emerged as another key factor. Healthcare professionals who could articulate the benefits and procedures of KMC in a supportive and comprehensible manner greatly assisted parents in understanding and adhering to KMC practices. Maternal Factors: Maternal Factors encompass various aspects related to the mother's knowledge, emotions, and physical condition that may influence the timely initiation of KMC. Several maternal factors were found to influence the effective initiation of KMC. One notably significant factor was the maternal fear of holding and seeing their preterm baby, often driven by feelings of despondency and concerns about the baby's survival. This emotional barrier hindered some mothers from promptly initiating KMC. "Immediately after delivery, I felt scared to hold the baby because she was too small. I didn’t know how to handle her without hurting her" (IDI02 Mother)​ Additionally, maternal exhaustion and fatigue after delivery, due to the physical demands of childbirth, made mothers less inclined to initiate KMC immediately. Furthermore, post-operative (C-section) wound pain and discomfort contributed to delays in KMC initiation, as the pain associated with the C-section wound made it challenging for some mothers to hold their babies as recommended for KMC, as expressed by one mother: “The wound, there is a wound on my abdomen [C-section wound], that causes me pain if I hold the baby like they said...” (IDI03, Mother). Many mothers expressed a lack of knowledge about what KMC entails and its benefits, creating a barrier to its prompt initiation. This deficiency in awareness wasn't limited to the mothers alone; it extended to their families as well. Mothers mentioned that they had to be introduced to what KMC is and how it helps their child. As a result, the initial stages of KMC required additional efforts to educate and create understanding about its importance. This lack of awareness among both mothers and their families placed an extra burden on healthcare staff. As one participant noted, "Specifically, there are not many things that facilitate it because there is a lack of awareness among families. For example, when we start KMC with one mother, we begin by introducing what KMC is and how it helps her child. This lack of awareness on KMC also affects us, and it increases the burden on the staff because they don't know about KMC at all." (IDI07, General practitioner) Within the context of maternal factors that influence the early initiation of KMC, two key factors stood out as significant barriers. One prominent factor was the worry about being away from home. Mothers often expressed concerns about being separated from their home environment, which contributed to emotional distress and hesitation in practicing KMC. Another factor, postpartum stress and trauma, played a substantial role. Mothers and their families sometimes experienced immense psychological stress and trauma, fearing that their preterm babies would not survive. In some cases, this resulted in families initially resisting the idea of KMC. The belief that their infants were too small and fragile to survive led some families to run away, leaving their babies at the hospital. However, with effective counseling and as they witnessed improvements in their baby's condition, such as weight gain, families became calmer and more accepting of KMC advice. As one participant described, "Psychologically, parents become stressed and traumatized. They think the baby won't survive. Sometimes families run away, leaving their baby at the hospital, thinking the baby cannot survive and live. They ask for attention to be focused solely on the mother, as they think the baby cannot survive due to its small size. Most families think this way and challenge us. However, as we counsel them and see improvements in the baby's condition, such as weight gain, they become calmer and try to accept our advice." (IDI05, pediatrician) The rare but unfortunate circumstance of a deceased mother emerged as a significant barrier to the initiation of KMC, as it impeded the mother's active involvement in this essential care practice. Maternal non-compliance, characterized by resistance or reluctance to adopt KMC, presented a notable challenge. Moreover, certain mothers expressed a preference for returning home after childbirth instead of participating in the hospital-based KMC protocol, resulting in further delays in the initiation process. Additionally, some mothers harbored doubts and hesitations about the efficacy and benefits of KMC, indicating a lack of belief in the practice. The initiation of effective KMC was facilitated by several maternal factors, each of which played a unique and vital role. Firstly, the willingness of mothers to engage in KMC was a significant facilitator, with those who expressed a strong desire and readiness being more likely to initiate KMC promptly. Additionally, previous experience with preterm births was found to be a facilitative factor, as mothers with prior experience in caring for preterm babies exhibited greater confidence in KMC, positively affecting their readiness to adopt and effectively practice it. As expressed by one participant, "Those who have previous experience with preterm births are generally more confident in caring for their babies" (IDI01, NICU provider). Furthermore, pregnancy follow-up was identified as another contributing facilitator, with mothers who received regular and attentive follow-up during pregnancy showing a higher inclination to initiate KMC early. Maternal stability after delivery, encompassing emotional and physical well-being, played a pivotal role in facilitating early KMC initiation. Maternal satisfaction with the KMC process and witnessing positive progress in their preterm new-borns’ health further motivated effective KMC initiation. Lastly, the educational background of mothers was a facilitative factor, with educated mothers often demonstrating a greater inclination to practice KMC and a better understanding of its principles. Infant factors: Within the context of infant factors affecting the effective initiation of KMC, one prominent element was the occurrence of twin births. Mothers of twins faced unique challenges in initiating KMC promptly. The necessity of holding and breastfeeding two infants simultaneously posed a practical challenge. As one mother of twins described, "As they are twins, I can't hold both of them simultaneously and breastfeed them. It's my mother who holds one for me until I finish breastfeeding one baby. Also, it's tiring to give such care continuously one by one in order. It's tiring for me." (IDI03, Mother). Support: The essential role played by family support, particularly from fathers, in the initiation of effective KMC was evident. However, a recurring challenge within this support structure was the refusal and reluctance of fathers to provide KMC assistance. In many instances, fathers did not actively engage and displayed resistance to accepting their role in KMC. This reluctance was exemplified in a case involving twins, where a mother grappled with holding both infants successively. Efforts by healthcare providers to involve her husband in providing assistance were met with his refusal, as reported by one participant, "Regarding family support, on the father's side, most of the time, they don't get involved in such kind of care. They don't accept that. For example, once there were twins, and the mother was struggling to carry both of them successively, and we asked her husband to assist her, but he refused to help" (IDI07, NICU Head). Socioeconomic Factors and Religious and Cultural Beliefs: In the analysis of the factors influencing the effective practices of KMC, a landscape emerged where socio-economic conditions and religious and cultural beliefs played a defining role. Economic disparities were identified as a significant influence, affecting the ability of families facing financial constraints to promptly engage in KMC. The requirement for suitable clothing and adequate support, emerged as a crucial aspect. The absence of these essential resources often contributed to delays in the initiation of KMC. Participants noted the geographical challenges associated with residing in remote areas or being situated at a substantial distance from healthcare facilities equipped to provide KMC. This underscored the obstacles encountered by individuals living in such remote locales in accessing timely KMC services. Cultural norms that rush mothers to go home after birth (Traditional Postpartum Care) revealed how cultural norms often pressured mothers to leave healthcare facilities swiftly to adhere to traditional postpartum care practices. This rush significantly hindered the timely initiation of KMC, as illustrated by a participant who explained, "But most of the time, they rush to go home after birth because culturally there is 'አራስ' (traditional care for postpartum mothers at home). They become reproached after a while, as they don't expect to wait after delivery" (IDI05, paediatrician). Additionally, the influence of cultural norms that discouraged fathers from actively participating in newborn care was evident. These norms primarily stemmed from restrictions that forbade males from entering rooms where recent postpartum mothers were located. As one participant elaborated, "Additionally, culturally, husbands don't enter rooms where recent mothers who have given birth are located. In fact, there's a saying, 'Gola deessu dhiirri hin seentu,' [which means it's not allowed for any males to enter a room where recent postpartum mothers are]" (IDI06, NICU Head). Barriers to Exclusive Breastfeeding The barriers to exclusive breastfeeding involve a complex interplay of cultural, medical, and maternal factors. The risk of Necrotizing Enterocolitis (NEC) was a prevalent concern that led to delays in breastfeeding initiation. A participant expressed this concern, stating, "Starting breastfeeding too early can expose the baby to risks such as NEC" (IDI01, NICU Provider). Maternal concerns about insufficient milk secretion and occasional requests for formula milk added complexity to the practice of exclusive breastfeeding. The challenge of breastfeeding twins highlighted the importance of specialized support for mothers in such situations. One participant conveyed this challenge, explaining, "As they are twins, I can't hold both of them simultaneously and breastfeed them. It's my mother who holds one for me until I finish breastfeeding one baby. Also, it's tiring to give such care continuously one by one in order. It's tiring for me" (IDI03, Mother). Post-operative pain and discomfort arising from a C-section wound presented an additional barrier to early breastfeeding initiation. Similarly, the gestational age of infants below 34 weeks influenced the readiness for breastfeeding. The challenges associated with expressing breast milk encompassed discomfort, fear, and maternal refusal, impacting the initiation of exclusive breastfeeding. One participant shared, "This also challenges us because even if she is able to express breast milk, sometimes it is difficult due to pain and their refusal. Some mothers say it is not natural; the baby should be breastfed. Some mothers refuse due to pain" (IDI05, pediatrician). Non-compliance emerged as a recurring issue, stemming from a variety of factors. The absence of convenient nasogastric (NG) tubes for premature infants served as a practical challenge to exclusive breastfeeding. Additionally, the lack of materials for expressing breast milk, including breast pumps, underscored the importance of having necessary equipment to promote breastfeeding. The introduction of substances other than breast milk, such as water or cow's milk was a significant concern that necessitated interventions to promote exclusive breastfeeding. Participants also mentioned to baby stability and family resistance as factors influencing exclusive breastfeeding practices. A participant remarked, "We recommend exclusive breastfeeding, but yes, families often give other substances. For example, they give cow's milk, especially when the baby shows signs of abdominal irritation and distension. We ask families if they've given other substances, and they often admit to it. Some families even try to hide it" (IDI07, General Practitioner). Facilitators to Exclusive Breastfeeding Facilitators to Early Initiation and Sustained Exclusive Breastfeeding were influenced by a range of factors that played a crucial role in promoting and supporting this practice. Healthcare professionals provided essential assistance, guidance, and support to mothers on proper holding and attachment positions during feeding. Participants emphasized the significance of promoting adequate rest, fluid intake, and a comfortable environment, including a clean bed and mattress, as well as visual aids and teaching materials to facilitate successful breastfeeding. As one participant noted, "A clean bed and mattress contributed to a sense of calmness, making it easier to express breast milk or breastfeed successfully" (IDI01, NICU Provider). Maternal willingness to initiate breastfeeding as instructed by healthcare workers played a crucial role in the early initiation and sustained practice of exclusive breastfeeding. Additionally, the enforcement of exclusive breastfeeding policies and the presence of educated mothers further contributed to the facilitation of this practice. DISCUSSION This study explores the facilitators and barriers to effective KMC, identifying key factors across domains such as healthcare systems, healthcare professionals, maternal and infant characteristics, support mechanisms, socioeconomic conditions, and cultural and religious beliefs. These categories provide a comprehensive understanding of the complex influences on the implementation of effective KMC. The predominant barriers identified in the healthcare system encompass limited resources (such as KMC beds, teaching aids, and KMC manuals), unfavorable KMC room conditions (including unhygienic settings, issues with temperature control, lack of privacy, and uncomfortable and unsupportive KMC beds), restricted access to KMC facilities, and the absence of KMC inclusion in the referral process. These factors stand out as major challenges hindering the effective implementation of KMC. A comprehensive review study investigating the barriers and facilitators of facility-based KMC in Sub-Saharan Africa revealed that health system and facility-related factors played a central role. Specifically, among the studies analyzed, 70% highlighted barriers within the health system and facility context, while 67% outlined facilitators for initiating KMC within healthcare facilities( 11 ). These findings emphasize the critical importance of addressing healthcare system factors to enhance the timely initiation and utilization of KMC. Consequently, interventions aimed at improving healthcare system and facility-related aspects show promise for advancing KMC practices in the sub-Saharan African context. Additionally, various studies have identified healthcare system factors, including limited resources such as a shortage of KMC beds and insufficient KMC room capacity, as barriers to the early and effective implementation of KMC ( 12 – 17 ). According to the 2023 guidelines set forth by the Ethiopian Minister of Health on KMC technical implementation, specific recommendations were outlined. These guidelines suggest that the number of KMC beds or reclining chairs adjacent to each neonatal bed in the NICU should be 10, 8, and 4 for referral hospitals, general hospitals, and primary hospitals, respectively ( 6 ). Our study findings, within the context of these guidelines, highlight the current disparity or inadequacy in the number of KMC beds and spaces available, as identified by our study. Concerning the effective utilization of KMC, many mothers indicated that an unsuitable KMC environment hindered their continuous practice of KMC. They specifically mentioned challenges related to unhygienic KMC rooms, temperature control issues, lack of privacy, and uncomfortable and unsupportive KMC beds. Consistent with our findings, a study conducted in Uganda reported that intermittent skin-to-skin care was more prevalent than continuous care in 75% of cases due to inadequate environments ( 13 ). Similarly, healthcare providers have identified the absence of temperature control as a barrier to effective KMC practices. Supporting this, existing studies emphasize that an additional obstacle to KMC is the hot and humid atmosphere, which could be addressed by establishing dedicated KMC rooms. These rooms would not only regulate temperature but also ensure mothers' privacy ( 18 , 19 ). Our study identified the absence of KMC guidelines, manuals, and service documentation as barriers to the effective implementation of KMC practices. A parallel study conducted in Malawi mentioned similar findings, indicating that the readiness to provide KMC services was significantly constrained by the lack of guidelines, newborn caps/hats, and service documentation ( 20 ). It is noteworthy that, as of 2023, Ethiopia did not possess a standardized KMC implementation guideline in place ( 6 ). The primary healthcare system factors impeding the timely initiation of KMC by mothers after birth include delivering at health facilities where KMC is not practiced. In Ethiopia, a majority of lower-level health facilities, such as health centers, lack KMC services. Consequently, if a mother gives birth at these facilities and is subsequently referred, it results in a delay in the early initiation of KMC. Additionally, another study in Ethiopia highlighted the absence of KMC rooms and NICUs in numerous health facilities, acting as barriers to facility-based KMC ( 12 ). In a recent KMC implementation guideline in Ethiopia, the recommendation is to commence KMC at the Health Center level. According to this guideline, after the initial stabilization and weight measurement, if the newborn weighs between 2,000–2,500g, is clinically stable, and able to breastfeed, the birth attendant should initiate KMC in the postnatal room and continue care for at least 24 hours before discharge ( 6 ). A prevalent facilitator within the healthcare system, as identified in our study, is the existence of visual aids such as television and posters for educational purposes. Additionally, a supportive policy framework, exemplified by hospital promotion and support, emerged as another key facilitator. In alignment with our findings, a study conducted in Cote d’Ivoire identified strong hospital leadership and active promotion of KMC as facilitators in the successful implementation of KMC practices ( 14 ). A significant obstacle to the optimal application of KMC among healthcare professionals is the lack of comprehensive training and the presence of substantial skill gaps, which impede the proficient implementation of KMC protocols and procedures. A study underscored the critical role of training in enhancing the knowledge and competencies of healthcare professionals in delivering KMC ( 14 ). According to the current KMC guidelines in Ethiopia, neonatal healthcare providers in postnatal wards and NICU KMC rooms for both unstable and stable infants should undergo training and capacity-building ( 6 ). Recognizing training and skill gaps as major barriers, stakeholders of the guideline are committed to addressing and resolving these impediments. Negative attitudes, stereotypes, or biases among healthcare professionals toward KMC can compromise its acceptance and implementation, potentially stemming from inadequate compensation. These factors contribute to limited attention given to KMC, a consequence of the multitude of competing demands and clinical priorities, thereby delaying its initiation and leading to underutilization. A study conducted in Uganda and Malawi revealed that a positive attitude and acceptance of KMC among healthcare providers can foster optimism and full engagement in KMC practices, albeit with associated challenges ( 21 , 22 ). Maternal barriers to optimal KMC can be categorized into emotional challenges (fear, stress, trauma), physical obstacles (exhaustion, post-operative pain), and informational/attitudinal barriers (lack of awareness, non-compliance, preference to go home, lack of belief). Parents expressed anxiety about the perceived fragility of preterm babies, leading to hesitancy in touching their newborns. Maternal stress and fear regarding preterm or low birth weight infants can significantly influence beliefs about their survival and the practice of KMC. Previous research has identified fear, stigma, shame, guilt, and anxiety as substantial hindrances to KMC adoption ( 16 , 23 ). Healthcare providers emphasized the importance of maternal awareness of KMC, revealing that mothers often lacked knowledge about KMC services upon hospital admission. A study in Ghana reported that only 11.4% of mothers knew about KMC at admission, making it challenging to convince them to practice KMC in the initial days after birth ( 24 ). Adequate prenatal care and awareness were identified as proactive measures to prepare mothers for the possibility of preterm birth and the need for KMC. Instances were reported where mothers felt KMC was imposed without proper explanation ( 16 , 22 , 25 ). Post-operative pain and discomfort, especially after C-sections, along with fatigue, were identified as critical barriers to early and effective KMC and exclusive breastfeeding. Another cross-sectional study found that 44% of perceived barriers to implementing and continuing early KMC were attributed to pain and fatigue from operations, such as stitches and C-sections ( 19 ). Additionally, a formative study highlighted barriers including maternal fatigue, post-delivery backache, poor health, and lack of family support ( 26 ). The willingness of the mother to engage in KMC is identified as a pivotal factor in the successful initiation of this care practice. A positive attitude and active participation from the mother significantly contribute to the early implementation of KMC, with several studies highlighting maternal willingness and empowerment as key facilitators ( 11 , 16 , 17 , 27 ). While paternal resistance presents a critical barrier to the early and effective implementation of KMC, our study highlights family support as a robust facilitator for the prompt initiation and sustained utilization of KMC. This finding aligns with several studies emphasizing the positive impact of family support on KMC practices ( 19 , 28 ). Our research indicates that caregivers predominantly acknowledged the significance of both staff and family support, coupled with a strong desire for their babies' well-being, as major contributors to the provision of KMC. The involvement and willingness of other family members to assist the mother in childcare significantly enhance the adoption of KMC, as evidenced by studies conducted in Uganda and Scandinavian countries ( 21 , 29 , 30 ). Our research identified cultural fears and despondency concerning the baby's survival as barriers to the practice of effective KMC after birth. This aligns with other studies that have found prevailing fears and a sense of despondency within certain cultural contexts, discouraging timely initiation of KMC ( 16 , 23 ). Cultural perceptions about preterm birth and associated survival rates may undermine maternal confidence in adopting KMC practices. Addressing these barriers within culturally sensitive frameworks is imperative for fostering broader acceptance and integration of KMC practices across diverse cultural and religious contexts. Our findings revealed that initiating breastfeeding too early was perceived as a potential risk factor for NEC. In contrast, delaying feedings due to concerns about NEC was associated with increased central catheter days, a higher risk of acquired bloodstream infections, and delayed gut development ( 31 ) and is not recommended as a strategy to reduce NEC ( 31 , 32 ). Maternal worries about insufficient milk secretion and occasional requests for formula milk emerged as barriers to sustained exclusive breastfeeding. A study in Ghana highlighted reasons for delaying breastfeeding initiation, including perceived lack of breast milk, post-birth activities, the belief that both the mother and baby needed rest, and the absence of the baby crying for milk ( 33 ). Similarly, in northern Ethiopia, the early initiation of formula feeding acted as a barrier to both early and sustained exclusive breastfeeding ( 12 ). Twin births introduced distinct challenges, with mothers facing the simultaneous tasks of holding both infants and facilitating breastfeeding, contributing to heightened fatigue. This underscores the need for tailored support and interventions addressing the specific demands associated with twin deliveries, emphasizing maternal well-being and infant care. In our study, the majority of mothers expressed an inherent desire to breastfeed, describing it as a delightful experience that enhances the emotional connection and level of attachment between the mother and the infant. This finding is consistent with a study conducted in China ( 34 ). Women's awareness and positive perceptions of breastfeeding emerged as significant motivators for the early initiation of exclusive breastfeeding. A study in Northern Ethiopia highlighted that mothers were aware of the importance of exclusive breastfeeding, understanding that it should be initiated as soon as possible and given frequently ( 12 ). The recent Ethiopia KMC guidelines emphasize that initially, breastfeeding is provided at fixed intervals of 2–3 hours, rather than on demand, to ensure an adequate and assured minimal intake. Mothers are educated on how to breastfeed while the infant is in the KMC position ( 6 ). Our study has both strengths and limitations. One strength is that the study revealed practical challenges and operational realities of optimal KMC implementation, such as adherence to protocols and the integration of recommended KMC practices into routine care. A limitation is that constraints related to time and resources may have impacted the breadth and depth of the study. Conclusion Barriers to effective KMC and exclusive breastfeeding include factors such as limited healthcare resources, skill gaps, healthcare staff attitudes, maternal emotional barriers, post-operative pain, lack of KMC awareness, and cultural pressures for quick post-birth discharge. Conversely, supportive factors include healthcare policies, family involvement, effective counseling, maternal willingness, prior experience with preterm births, regular pregnancy check-ups, and well-informed mothers. Prioritizing training, resource allocation, and culturally sensitive education are critical to bridging the gap in KMC implementation across Ethiopia Abbreviations C/S Caesarean section EBF Exclusive breast feeding IDI In-depth interview LBW Low birth weight NEC Necrotizing Enterocolitis NICU Neonatal intensive care unit Declarations Ethics approval and consent to participate We obtained ethical approval from the Research Ethics Committee of the School of Public Health, College of Health Sciences, Addis Ababa University. The study was conducted in accordance with the Declaration of Helsinki. A written informed consent was obtained from all participants in the study. Participation was voluntary and participants were informed of their right to withdraw from the study when they wished to do so. Data were collected, managed and analyzed in a way to ensure the confidentiality of study participants. Consent for publication Not applicable Availability of data and materials The datasets used and analysed during the current study are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding The author received no specific funding for this work. Authors' contributions BRI conceived the study. ASE and BRI designed the study. BRI analyzed the data. ASE supervised the data analysis. BRI wrote the original draft. Both authors have reviewed and substantively edited the draft. Both authors have read and approved the final manuscript. Acknowledgment We would like to express our gratitude to the School of Public Health, College of Health Sciences, Addis Ababa University, for their financial support. Special thanks are also extended to Asella and Batu hospital, as well as the healthcare providers and mothers who participated in the study. References Liu L, Johnson HL, Cousens S, Perin J, Scott S, Lawn JE, et al. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. The Lancet. 2012 Jun 9;379(9832):2151–61. Ethiopian Public Health Institute (EPHI) [Ethiopia] and, ICF. Ethiopia Mini Demographic and Health Survey 2019: Final Report. EPHI and ICF; 2021. World Health Organizations. WHO recommendations for care of the preterm or low-birth-weight infant. Geneva, WHO; 2022. Eshete A, Alemu A, Zerfu TA. Magnitude and Risk of Dying among Low Birth Weight Neonates in Rural Ethiopia: A Community-Based Cross-Sectional Study. Int J Pediatr. 2019;2019:9034952. World Health Organizations. Kangaroo Mother care: A Practical Guide [Internet]. 2003. Available from: https://www.who.int/publications/i/item/9241590351 Ministry of Health of Ethiopia. Kangaroo Mother Care Technical and Implementation Guideline. Addis Ababa, Ethiopia; 2023. Launch of Kangaroo Mother Care Global Position Paper and Implementation Strategy [Internet]. [cited 2023 Nov 18]. Available from: https://www.who.int/news-room/events/detail/2023/05/16/default-calendar/launch-of-kangaroo-mother-care-global-position-paper-and-implementation-strategy Save the Children; Rapid Health Facility Assessment on Service Availability and Delivery of Care to Premature and/or Low Birth Weight Babies. 2015. Mony PK, Tadele H, Gobezayehu AG, Chan GJ, Kumar A, Mazumder S, et al. Scaling up Kangaroo Mother Care in Ethiopia and India: a multi-site implementation research study. BMJ Glob Health. 2021 Sep;6(9):e005905. Ethiopia Minister of Health. Health Sector Transformation Plan II HSTP II 2020/21-2024/25 (2013 EFY - 2017 EFY). 2021. Kinshella MLW, Hiwa T, Pickerill K, Vidler M, Dube Q, Goldfarb D, et al. Barriers and facilitators of facility-based kangaroo mother care in sub-Saharan Africa: a systematic review. BMC Pregnancy and Childbirth. 2021 Mar 4;21(1):176. Hadush MY, Gebremariam DS, Beyene SA, Abay TH, Berhe AH, Zelelew YB, et al. Barriers and Enablers of KMC Implementation in Health Facility and Community of Tigray Region, Northern Ethiopia: Formative Research. PHMT. 2022 Sep 8;13:297–307. Watkins HC, Morgan MC, Nambuya H, Waiswa P, Lawn JE. Observation study showed that the continuity of skin‐to‐skin contact with low‐birthweight infants in Uganda was suboptimal. Acta Paediatr. 2018 Sep;107(9):1541–7. Kourouma KR, Agbré-Yacé ML, Doukouré D, Cissé L, Some-Méazieu C, Ouattara J, et al. Barriers and facilitators to kangaroo mother care implementation in Cote d’Ivoire: a qualitative study. BMC Health Services Research. 2021 Nov 9;21(1):1211. Chan G, Bergelson I, Smith ER, Skotnes T, Wall S. Barriers and enablers of kangaroo mother care implementation from a health systems perspective: a systematic review. Health Policy Plan. 2017 Dec;32(10):1466–75. 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 Pediatr. 2017 Jan 25;17:35. 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 May 20;10(5):e0125643. Johnson AN. Factors influencing implementation of kangaroo holding in a Special Care Nursery. MCN Am J Matern Child Nurs. 2007;32(1):25–9. Mekle DD, Patil DR, Jha P. Implementation of Kangaroo Mother care for low birth weight babies: supportive factors and barriers perceived by mothers. Pediatric Review: International Journal of Pediatric Research. 2018 Feb 28;5(2):87–92. Chavula K, Likomwa D, Valsangkar B, Luhanga R, Chimtembo L, Dube Q, Gobezie WA, Guenther T. Readiness of hospitals to provide Kangaroo Mother Care (KMC) and documentation of KMC service delivery: Analysis of Malawi 2014 Emergency Obstetric and Newborn Care (EmONC) survey data. J Glob Health. 2017 Dec;7(2):020802. doi: 10.7189/jogh.07.020802. PMID: 29085623; PMCID: PMC5644360. Naloli M, Ssenyonga LVN, Kagoya EK, Nteziyaremye J, Nekaka R. KANGAROO MOTHER CARE: A QUALITATIVE STUDY ON THE PRACTICE AND EXPERIENCES OF MOTHERS OF PRETERM NEONATES IN A TERTIARY TEACHING HOSPITAL IN EASTERN UGANDA. Int J Res Health Sci Nurs. 2021 Nov;7(11):1890. PMID: 36817802; PMCID: PMC9938524. Chisenga JZ, Chalanda M, Ngwale M. Kangaroo Mother Care: A review of mothers׳’experiences at Bwaila hospital and Zomba Central hospital (Malawi). Midwifery. 2015 Feb;31(2):305–15. Yue J, Liu J, Williams S, Zhang B, Zhao Y, Zhang Q, et al. Barriers and facilitators of kangaroo mother care adoption in five Chinese hospitals: a qualitative study. BMC Public Health. 2020 Aug 13;20(1):1234. Nguah SB, Wobil PN, Obeng R, Yakubu A, Kerber KJ, Lawn JE, et al. Perception and practice of Kangaroo Mother Care after discharge from hospital in Kumasi, Ghana: A longitudinal study. BMC Pregnancy and Childbirth. 2011 Dec 1;11(1):99. Kampekete GSM, Ngoma C, Masumo M. Acceptance of kangaroo mother care by mothers of premature babies. African Journal of Midwifery and Women’s Health. 2018 Oct 2;12(4):178–88. Mazumder S, Upadhyay RP, Hill Z, Taneja S, Dube B, Kaur J, et al. Kangaroo mother care: using formative research to design an acceptable community intervention. BMC Public Health. 2018 Mar 2;18:307. Mathias CT, Mianda S, Ohdihambo JN, Hlongwa M, Singo-Chipofya A, Ginindza TG. Facilitating factors and barriers to kangaroo mother care utilisation in low- and middle-income countries: A scoping review. Afr J Prim Health Care Fam Med. 2021 Aug 23;13(1):2856. Cai Q, Zhou Y, Chen D, Wang F, Xu X. Parental perceptions and experiences of kangaroo care for preterm infants in neonatal intensive care units in China: a qualitative study. BMC Pregnancy Childbirth. 2024 Jul 25;24(1):499. doi: 10.1186/s12884-024-06622-9. PMID: 39054436; PMCID: PMC11271036. Calais E, Dalbye R, Nyqvist K, Berg M. Skin-to-skin contact of fullterm infants: an explorative study of promoting and hindering factors in two Nordic childbirth settings. Acta Paediatr. 2010 Jul;99(7):1080–90. 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 Jun;27(2):345–53. Schurr P, Perkins EM. The relationship between feeding and necrotizing enterocolitis in very low birth weight infants. Neonatal Netw. 2008;27(6):397–407. Philadelphia TCH of. Necrotizing Enterocolitis | Children’s Hospital of Philadelphia [Internet]. [cited 2025 Jul 19]. Available from: https://www.chop.edu/conditions-diseases/necrotizing-enterocolitis Tawiah-Agyemang C, Kirkwood BR, Edmond K, Bazzano A, Hill Z. Early initiation of breast-feeding in Ghana: barriers and facilitators. J Perinatol. 2008 Dec;28 Suppl 2:S46-52. Xiao X, Loke AY, Zhu S ning, Gong L, Shi H mei, Ngai F wan. “The sweet and the bitter”: mothers’ experiences of breastfeeding in the early postpartum period: a qualitative exploratory study in China. International Breastfeeding Journal. 2020 Feb 24;15(1):12. Additional Declarations No competing interests reported. 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the age of five, with nearly half of these deaths (2.3\u0026nbsp;million) occurring during the neonatal period. Over 1\u0026nbsp;million of these neonatal deaths take place within the first 24 hours after birth, with preterm birth contributing to more than 50% of cases (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In Ethiopia, low birth weight (LBW) newborns account for 60\u0026ndash;80% of all neonatal deaths each year. According to the 2019 Ethiopian Mini Demographic and Health Survey, the neonatal mortality rate was 33 deaths per 1,000 live births (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe WHO recommends a range of interventions for the prevention and care of preterm births, with KMC recognized as a key strategy (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). KMC is a high-impact, low-tech, and cost-effective intervention for the care of preterm and LBW newborns, who are at elevated risk of neonatal mortality and morbidity (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The WHO now recommends initiating KMC immediately after birth, as early initiation has been shown to be more effective than starting after the newborn is stabilized. Ethiopia has adopted these updated recommendations (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDespite this, both global and national coverage of KMC remains low. In 2021, global KMC coverage was reported to be less than 5% (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). In Ethiopia, prior to 2021, studies indicated that only 5%\u0026ndash;10% of eligible newborns received any form of KMC, irrespective of quality (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Efforts to scale up implementation have largely fallen short, underscoring the importance of understanding the barriers and facilitators to effective KMC adoption.\u003c/p\u003e\u003cp\u003eIn Ethiopia, although national policies emphasize the expansion of KMC, the proportion of preterm or LBW neonates receiving KMC remains low. The national target, as outlined in the Newborn and Child Survival and Development Strategy, is to achieve 70% KMC coverage among preterm babies by 2025 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The persistently low rate of early and effective KMC initiation highlights the need for a comprehensive understanding of the factors contributing to this gap and for identifying the barriers and enablers affecting the adoption of KMC within the Ethiopian healthcare system.\u003c/p\u003e\u003cp\u003eWhile numerous studies have explored the general barriers and facilitators to KMC implementation, few have specifically focused on the factors influencing effective early KMC. Therefore, we conducted a qualitative study to explore the barriers and facilitators to the effective implementation of KMC in the Ethiopian context.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Setting and Period\u003c/h2\u003e\u003cp\u003eThis study was conducted in August 2023 in the KMC unit of two hospitals in the Oromia region: Asella Referral and Teaching Hospital and Batu General Hospital. The KMC unit included pediatricians, medical doctors assigned to the NICU, NICU nurses, and NICU heads.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy Design\u003c/h3\u003e\n\u003cp\u003eWe employed a qualitative descriptive methodology with thematic analysis to explore the facilitators and barriers to effective KMC. Data collection methods included observation and in-depth interviews.\u003c/p\u003e\n\u003ch3\u003eOperational Definition\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eEffective KMC\u003c/strong\u003e\u003cp\u003eEarly, continuous, and prolonged skin-to-skin contact (SSC) between low birth weight (\u0026lt;\u0026thinsp;2500 grams) and preterm (\u0026lt;\u0026thinsp;37 weeks gestational age) infants and their mother (or a surrogate caregiver), along with exclusive breastfeeding.\u003c/p\u003e\u003c/p\u003e\n\u003ch3\u003eParticipants and Sampling\u003c/h3\u003e\n\u003cp\u003eThe study population consisted of two main participant groups: mothers and neonatal care providers. For mothers, convenience sampling was used to include all mothers receiving KMC during the study period and present in the KMC unit at the time of the visit. For neonatal care providers, purposive sampling was used to select participants who could offer relevant, detailed information on the research question.\u003c/p\u003e\u003cp\u003eA total of 14 participants were included in the in-depth interviews (IDIs), comprising six mothers and eight neonatal care providers. Interviews continued until data saturation was achieved, with no new information or themes emerging. Eligible participants provided informed consent, and the interviews were conducted in Amharic and Afan Oromo, with audio recordings made for later transcription.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eA semi-structured in-depth interview guide was used for mothers of preterm and/or low-birth-weight infants, as well as healthcare staff in the NICU. Open-ended questionnaires were developed for this study (\u003cem\u003eSupplementary File 1\u003c/em\u003e). Data collection involved one-to-one in-depth interview and observation. With participant consent, interviews were audio-recorded in addition to note-taking.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eField notes and interview transcripts were reviewed, coded manually using color coding, and analyzed thematically. Audio recordings were transcribed verbatim into Microsoft Word and translated into English. Themes were identified from the data, which were continuously examined during the interview sessions. Transcripts were repeatedly read to familiarize the with the content, and preliminary codes were developed. These codes were then categorized into major themes and sub-themes for presentation.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData Quality Assurance\u003c/h3\u003e\n\u003cp\u003eA standardized questionnaire guide, aligned with the study objectives, was developed prior to data collection. Pre-testing was conducted with two mothers and healthcare professionals (HCPs). The questionnaire, initially in English, was translated into Afaan Oromo and back-translated to ensure consistency. Data collection continued until saturation was reached, and detailed descriptions of the data were provided to ensure its transferability.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eIn-depth interviews and observations were conducted at each hospital setting. A total of 14 IDIs were carried out: 6 with mothers of preterm and/or low birth weight babies, and 8 with neonatal care providers. This included the NICU head, NICU provider, neonatal care doctors, and pediatricians. Of the 6 mothers, 3 were aged between 20 and 30, and 1 was from a rural area. Among the 8 neonatal care providers, 2 were female, and 3 had more than 5 years of experience. Demographic characteristics of the participants are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristic of participants\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eCharacteristics, (IDI\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMother\u0026rsquo;s characteristics (IDI\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHCPs characteristics (IDI\u0026thinsp;=\u0026thinsp;8)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e15\u0026ndash;20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e20\u0026ndash;30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\ge\\:\\)\u003c/span\u003e\u003c/span\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003eAge group\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eResidency\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20\u0026ndash;30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\ge\\:\\)\u003c/span\u003e\u003c/span\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003eYears of experiences\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEducational status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u0026ndash;4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\ge\\:\\)\u003c/span\u003e\u003c/span\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSecondary and above\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eBarriers and Facilitators to Effective KMC\u003c/h2\u003e\u003cp\u003eParticipants acknowledged the importance of early KMC initiation but reported delays in starting it after birth. Primary themes frequently cited as influencing timely KMC initiation and ongoing practice include maternal and infant factors, healthcare system and professional considerations, religious and cultural beliefs, and socioeconomic influences. Illustrative quotes are also provided to further elucidate these themes (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e:\u003c/p\u003e\u003cp\u003eOne healthcare provider explained, \u003cem\u003e\u0026ldquo;There are conditions where they start early, and there are conditions where they do not. For example, most women come here with referrals from health centers due to different complications. Regarding medical factors, first, we treat the case for both the baby and the mother. Even premature babies are referred here if they are in unstable conditions. They are not referred to us solely because they are preterm or to start KMC. However, if they are born here, they can start within 24 hours.\u0026rdquo; (IDI07, General Practitioner)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eHealthcare System Factors:\u003c/h2\u003e\u003cp\u003eHealthcare System Factors pertain to various aspects of healthcare infrastructure affecting KMC. Commonly cited issues by both mothers and healthcare providers include challenges related to KMC facilities, room conditions, and beds. Healthcare providers noted KMC under-utilization due to limited room availability. They also noted issues like a lack of separate rooms for unstable infants. Mothers emphasized bed shortages, describing existing KMC beds as uncomfortable and unsuitable for holding newborns and breastfeeding.\u003c/p\u003e\u003cp\u003eOne mother mentioned the bed shortage, stating, \u003cem\u003e\u0026ldquo;I want to mention the shortage of beds; they kept me here due to a lack of beds. Even now, all beds are occupied, and if another mother comes, there's no bed.\u0026rdquo; (IDI03, mother).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eDuring our observation, we observed that the KMC beds were insufficient relative to the number of mothers, and the KMC room was inadequately lit and uncomfortable for mothers.\u003c/p\u003e\u003cp\u003eA mother described the KMC room as inadequate, saying, \u003cem\u003e\u0026ldquo;Most of the time, the KMC room window is left open, there is airflow in the room, and the room quality is poor. People, like family and relatives, enter and exit as they please.\u0026rdquo; (IDI02, mother).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e Additional healthcare system factors impeding effective KMC initiation include a lack of educational materials, manuals, and KMC guidelines. In addition, healthcare providers pointed out that KMC is not part of the newborn referral process.\u003c/p\u003e\u003cp\u003eAs one provider stated, \u003cem\u003e\u0026ldquo;Even premature babies in unstable conditions are referred here, not specifically for being preterm or for KMC initiation.\u0026rdquo; (IDI07, General Practitioner)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eA Neonatal Care Unit (NCU) head noted that the inefficient transfer of babies from the delivery room to the NICU hinders the prompt initiation of KMC.\u003c/p\u003e\u003cp\u003eThe NICU head explained, \u003cem\u003e\u0026ldquo;Even within the hospital, challenges arise when transporting babies to our NICU. They often arrive hypothermic, inadequately dressed in just a few clothes provided by their families. Sometimes, babies are sent wrapped in just cotton.\u0026rdquo; (IDI06, NICU Head)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe mentioned healthcare system factors facilitate effective KMC, including the use of visual aids such as television programs and posters. These visual aids were employed to educate mothers, leading to increased awareness and understanding of KMC. Additionally, early KMC was promoted through quality improvement initiatives.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eHealthcare Professional Factors:\u003c/h2\u003e\u003cp\u003e Healthcare Professional Factors encompassed healthcare professionals' knowledge of KMC guidelines, their willingness to promote and support KMC, their communication skills in educating and encouraging mothers, and their practical skills in assisting with KMC initiation.\u003c/p\u003e\u003cp\u003eHealthcare professional factors revealed that the lack of training and skill gaps among healthcare professionals had emerged as a significant obstacle. This had hindered their ability to confidently initiate KMC, resulting in delays and sub-optimal practices.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"It has been a long time; there have been updates since that training. I believe training should be provided more frequently with shorter intervals. This way, we can stay up-to-date and feel more confident in our guidance\" (IDI01, NICU provider).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAdditionally, low motivation and incentives, particularly in the form of low salaries, had contributed to these challenges. The financial constraints faced by healthcare professionals not only demotivated them but also had an adverse effect on their commitment to KMC. Another critical issue was the shortage of healthcare professionals, which had led to overburdened staff and reduced attention to KMC. This scarcity had further exacerbated the situation by limiting the availability of dedicated personnel for KMC initiation. Moreover, the low attention given by healthcare professionals to KMC had been influenced by negative attitudes. These negative perceptions had often arisen from misconceptions and a lack of awareness, thereby hindering the promotion and timely initiation of KMC.\u003c/p\u003e\u003cp\u003eHealthcare professional facilitating factors for the early initiation of KMC included the prominent encouragement of family involvement, signifying its critical role. Healthcare professionals who actively promoted and facilitated family engagement in the care process played a pivotal role in improving the acceptance and effectiveness of KMC. Moreover, effective counseling and clear communication with parents emerged as another key factor. Healthcare professionals who could articulate the benefits and procedures of KMC in a supportive and comprehensible manner greatly assisted parents in understanding and adhering to KMC practices.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eMaternal Factors:\u003c/h2\u003e\u003cp\u003eMaternal Factors encompass various aspects related to the mother's knowledge, emotions, and physical condition that may influence the timely initiation of KMC.\u003c/p\u003e\u003cp\u003eSeveral maternal factors were found to influence the effective initiation of KMC. One notably significant factor was the maternal fear of holding and seeing their preterm baby, often driven by feelings of despondency and concerns about the baby's survival. This emotional barrier hindered some mothers from promptly initiating KMC. \u003cem\u003e\"Immediately after delivery, I felt scared to hold the baby because she was too small. I didn\u0026rsquo;t know how to handle her without hurting her\" (IDI02 Mother)​\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAdditionally, maternal exhaustion and fatigue after delivery, due to the physical demands of childbirth, made mothers less inclined to initiate KMC immediately. Furthermore, post-operative (C-section) wound pain and discomfort contributed to delays in KMC initiation, as the pain associated with the C-section wound made it challenging for some mothers to hold their babies as recommended for KMC, as expressed by one mother: \u003cem\u003e\u0026ldquo;The wound, there is a wound on my abdomen [C-section wound], that causes me pain if I hold the baby like they said...\u0026rdquo; (IDI03, Mother).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eMany mothers expressed a lack of knowledge about what KMC entails and its benefits, creating a barrier to its prompt initiation. This deficiency in awareness wasn't limited to the mothers alone; it extended to their families as well. Mothers mentioned that they had to be introduced to what KMC is and how it helps their child. As a result, the initial stages of KMC required additional efforts to educate and create understanding about its importance. This lack of awareness among both mothers and their families placed an extra burden on healthcare staff. As one participant noted, \u003cem\u003e\"Specifically, there are not many things that facilitate it because there is a lack of awareness among families. For example, when we start KMC with one mother, we begin by introducing what KMC is and how it helps her child. This lack of awareness on KMC also affects us, and it increases the burden on the staff because they don't know about KMC at all.\" (IDI07, General practitioner)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eWithin the context of maternal factors that influence the early initiation of KMC, two key factors stood out as significant barriers.\u003c/p\u003e\u003cp\u003eOne prominent factor was the worry about being away from home. Mothers often expressed concerns about being separated from their home environment, which contributed to emotional distress and hesitation in practicing KMC.\u003c/p\u003e\u003cp\u003eAnother factor, postpartum stress and trauma, played a substantial role. Mothers and their families sometimes experienced immense psychological stress and trauma, fearing that their preterm babies would not survive. In some cases, this resulted in families initially resisting the idea of KMC. The belief that their infants were too small and fragile to survive led some families to run away, leaving their babies at the hospital. However, with effective counseling and as they witnessed improvements in their baby's condition, such as weight gain, families became calmer and more accepting of KMC advice.\u003c/p\u003e\u003cp\u003eAs one participant described, \u003cem\u003e\"Psychologically, parents become stressed and traumatized. They think the baby won't survive. Sometimes families run away, leaving their baby at the hospital, thinking the baby cannot survive and live. They ask for attention to be focused solely on the mother, as they think the baby cannot survive due to its small size. Most families think this way and challenge us. However, as we counsel them and see improvements in the baby's condition, such as weight gain, they become calmer and try to accept our advice.\" (IDI05, pediatrician)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe rare but unfortunate circumstance of a deceased mother emerged as a significant barrier to the initiation of KMC, as it impeded the mother's active involvement in this essential care practice. Maternal non-compliance, characterized by resistance or reluctance to adopt KMC, presented a notable challenge. Moreover, certain mothers expressed a preference for returning home after childbirth instead of participating in the hospital-based KMC protocol, resulting in further delays in the initiation process. Additionally, some mothers harbored doubts and hesitations about the efficacy and benefits of KMC, indicating a lack of belief in the practice.\u003c/p\u003e\u003cp\u003eThe initiation of effective KMC was facilitated by several maternal factors, each of which played a unique and vital role. Firstly, the willingness of mothers to engage in KMC was a significant facilitator, with those who expressed a strong desire and readiness being more likely to initiate KMC promptly. Additionally, previous experience with preterm births was found to be a facilitative factor, as mothers with prior experience in caring for preterm babies exhibited greater confidence in KMC, positively affecting their readiness to adopt and effectively practice it. As expressed by one participant, \u003cem\u003e\"Those who have previous experience with preterm births are generally more confident in caring for their babies\" (IDI01, NICU provider).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eFurthermore, pregnancy follow-up was identified as another contributing facilitator, with mothers who received regular and attentive follow-up during pregnancy showing a higher inclination to initiate KMC early. Maternal stability after delivery, encompassing emotional and physical well-being, played a pivotal role in facilitating early KMC initiation. Maternal satisfaction with the KMC process and witnessing positive progress in their preterm new-borns\u0026rsquo; health further motivated effective KMC initiation. Lastly, the educational background of mothers was a facilitative factor, with educated mothers often demonstrating a greater inclination to practice KMC and a better understanding of its principles.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eInfant factors:\u003c/h2\u003e\u003cp\u003eWithin the context of infant factors affecting the effective initiation of KMC, one prominent element was the occurrence of twin births. Mothers of twins faced unique challenges in initiating KMC promptly. The necessity of holding and breastfeeding two infants simultaneously posed a practical challenge. As one mother of twins described, \u003cem\u003e\"As they are twins, I can't hold both of them simultaneously and breastfeed them. It's my mother who holds one for me until I finish breastfeeding one baby. Also, it's tiring to give such care continuously one by one in order. It's tiring for me.\" (IDI03, Mother).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eSupport:\u003c/h2\u003e\u003cp\u003eThe essential role played by family support, particularly from fathers, in the initiation of effective KMC was evident. However, a recurring challenge within this support structure was the refusal and reluctance of fathers to provide KMC assistance. In many instances, fathers did not actively engage and displayed resistance to accepting their role in KMC. This reluctance was exemplified in a case involving twins, where a mother grappled with holding both infants successively. Efforts by healthcare providers to involve her husband in providing assistance were met with his refusal, as reported by one participant, \u003cem\u003e\"Regarding family support, on the father's side, most of the time, they don't get involved in such kind of care. They don't accept that. For example, once there were twins, and the mother was struggling to carry both of them successively, and we asked her husband to assist her, but he refused to help\" (IDI07, NICU Head).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eSocioeconomic Factors and Religious and Cultural Beliefs:\u003c/h2\u003e\u003cp\u003eIn the analysis of the factors influencing the effective practices of KMC, a landscape emerged where socio-economic conditions and religious and cultural beliefs played a defining role. Economic disparities were identified as a significant influence, affecting the ability of families facing financial constraints to promptly engage in KMC. The requirement for suitable clothing and adequate support, emerged as a crucial aspect. The absence of these essential resources often contributed to delays in the initiation of KMC.\u003c/p\u003e\u003cp\u003eParticipants noted the geographical challenges associated with residing in remote areas or being situated at a substantial distance from healthcare facilities equipped to provide KMC. This underscored the obstacles encountered by individuals living in such remote locales in accessing timely KMC services.\u003c/p\u003e\u003cp\u003eCultural norms that rush mothers to go home after birth (Traditional Postpartum Care) revealed how cultural norms often pressured mothers to leave healthcare facilities swiftly to adhere to traditional postpartum care practices. This rush significantly hindered the timely initiation of KMC, as illustrated by a participant who explained, \u003cem\u003e\"But most of the time, they rush to go home after birth because culturally there is 'አራስ' (traditional care for postpartum mothers at home). They become reproached after a while, as they don't expect to wait after delivery\" (IDI05, paediatrician).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAdditionally, the influence of cultural norms that discouraged fathers from actively participating in newborn care was evident. These norms primarily stemmed from restrictions that forbade males from entering rooms where recent postpartum mothers were located. As one participant elaborated, \u003cem\u003e\"Additionally, culturally, husbands don't enter rooms where recent mothers who have given birth are located. In fact, there's a saying, 'Gola deessu dhiirri hin seentu,' [which means it's not allowed for any males to enter a room where recent postpartum mothers are]\" (IDI06, NICU Head).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eBarriers to Exclusive Breastfeeding\u003c/h2\u003e\u003cp\u003eThe barriers to exclusive breastfeeding involve a complex interplay of cultural, medical, and maternal factors.\u003c/p\u003e\u003cp\u003eThe risk of Necrotizing Enterocolitis (NEC) was a prevalent concern that led to delays in breastfeeding initiation. A participant expressed this concern, stating, \u003cem\u003e\"Starting breastfeeding too early can expose the baby to risks such as NEC\" (IDI01, NICU Provider).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eMaternal concerns about insufficient milk secretion and occasional requests for formula milk added complexity to the practice of exclusive breastfeeding. The challenge of breastfeeding twins highlighted the importance of specialized support for mothers in such situations. One participant conveyed this challenge, explaining, \u003cem\u003e\"As they are twins, I can't hold both of them simultaneously and breastfeed them. It's my mother who holds one for me until I finish breastfeeding one baby. Also, it's tiring to give such care continuously one by one in order. It's tiring for me\" (IDI03, Mother).\u003c/em\u003e\u003c/p\u003e\u003cp\u003ePost-operative pain and discomfort arising from a C-section wound presented an additional barrier to early breastfeeding initiation. Similarly, the gestational age of infants below 34 weeks influenced the readiness for breastfeeding. The challenges associated with expressing breast milk encompassed discomfort, fear, and maternal refusal, impacting the initiation of exclusive breastfeeding. One participant shared, \u003cem\u003e\"This also challenges us because even if she is able to express breast milk, sometimes it is difficult due to pain and their refusal. Some mothers say it is not natural; the baby should be breastfed. Some mothers refuse due to pain\" (IDI05, pediatrician).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eNon-compliance emerged as a recurring issue, stemming from a variety of factors. The absence of convenient nasogastric (NG) tubes for premature infants served as a practical challenge to exclusive breastfeeding. Additionally, the lack of materials for expressing breast milk, including breast pumps, underscored the importance of having necessary equipment to promote breastfeeding.\u003c/p\u003e\u003cp\u003eThe introduction of substances other than breast milk, such as water or cow's milk was a significant concern that necessitated interventions to promote exclusive breastfeeding. Participants also mentioned to baby stability and family resistance as factors influencing exclusive breastfeeding practices. A participant remarked, \u003cem\u003e\"We recommend exclusive breastfeeding, but yes, families often give other substances. For example, they give cow's milk, especially when the baby shows signs of abdominal irritation and distension. We ask families if they've given other substances, and they often admit to it. Some families even try to hide it\" (IDI07, General Practitioner).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eFacilitators to Exclusive Breastfeeding\u003c/h2\u003e\u003cp\u003eFacilitators to Early Initiation and Sustained Exclusive Breastfeeding were influenced by a range of factors that played a crucial role in promoting and supporting this practice. Healthcare professionals provided essential assistance, guidance, and support to mothers on proper holding and attachment positions during feeding.\u003c/p\u003e\u003cp\u003eParticipants emphasized the significance of promoting adequate rest, fluid intake, and a comfortable environment, including a clean bed and mattress, as well as visual aids and teaching materials to facilitate successful breastfeeding. As one participant noted, \u003cem\u003e\"A clean bed and mattress contributed to a sense of calmness, making it easier to express breast milk or breastfeed successfully\" (IDI01, NICU Provider).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eMaternal willingness to initiate breastfeeding as instructed by healthcare workers played a crucial role in the early initiation and sustained practice of exclusive breastfeeding. Additionally, the enforcement of exclusive breastfeeding policies and the presence of educated mothers further contributed to the facilitation of this practice.\u003c/p\u003e\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study explores the facilitators and barriers to effective KMC, identifying key factors across domains such as healthcare systems, healthcare professionals, maternal and infant characteristics, support mechanisms, socioeconomic conditions, and cultural and religious beliefs. These categories provide a comprehensive understanding of the complex influences on the implementation of effective KMC.\u003c/p\u003e\u003cp\u003eThe predominant barriers identified in the healthcare system encompass limited resources (such as KMC beds, teaching aids, and KMC manuals), unfavorable KMC room conditions (including unhygienic settings, issues with temperature control, lack of privacy, and uncomfortable and unsupportive KMC beds), restricted access to KMC facilities, and the absence of KMC inclusion in the referral process. These factors stand out as major challenges hindering the effective implementation of KMC. A comprehensive review study investigating the barriers and facilitators of facility-based KMC in Sub-Saharan Africa revealed that health system and facility-related factors played a central role. Specifically, among the studies analyzed, 70% highlighted barriers within the health system and facility context, while 67% outlined facilitators for initiating KMC within healthcare facilities(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). These findings emphasize the critical importance of addressing healthcare system factors to enhance the timely initiation and utilization of KMC. Consequently, interventions aimed at improving healthcare system and facility-related aspects show promise for advancing KMC practices in the sub-Saharan African context. Additionally, various studies have identified healthcare system factors, including limited resources such as a shortage of KMC beds and insufficient KMC room capacity, as barriers to the early and effective implementation of KMC (\u003cspan additionalcitationids=\"CR13 CR14 CR15 CR16\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e According to the 2023 guidelines set forth by the Ethiopian Minister of Health on KMC technical implementation, specific recommendations were outlined. These guidelines suggest that the number of KMC beds or reclining chairs adjacent to each neonatal bed in the NICU should be 10, 8, and 4 for referral hospitals, general hospitals, and primary hospitals, respectively (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Our study findings, within the context of these guidelines, highlight the current disparity or inadequacy in the number of KMC beds and spaces available, as identified by our study.\u003c/p\u003e\u003cp\u003eConcerning the effective utilization of KMC, many mothers indicated that an unsuitable KMC environment hindered their continuous practice of KMC. They specifically mentioned challenges related to unhygienic KMC rooms, temperature control issues, lack of privacy, and uncomfortable and unsupportive KMC beds. Consistent with our findings, a study conducted in Uganda reported that intermittent skin-to-skin care was more prevalent than continuous care in 75% of cases due to inadequate environments (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Similarly, healthcare providers have identified the absence of temperature control as a barrier to effective KMC practices. Supporting this, existing studies emphasize that an additional obstacle to KMC is the hot and humid atmosphere, which could be addressed by establishing dedicated KMC rooms. These rooms would not only regulate temperature but also ensure mothers' privacy (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e Our study identified the absence of KMC guidelines, manuals, and service documentation as barriers to the effective implementation of KMC practices. A parallel study conducted in Malawi mentioned similar findings, indicating that the readiness to provide KMC services was significantly constrained by the lack of guidelines, newborn caps/hats, and service documentation (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). It is noteworthy that, as of 2023, Ethiopia did not possess a standardized KMC implementation guideline in place (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe primary healthcare system factors impeding the timely initiation of KMC by mothers after birth include delivering at health facilities where KMC is not practiced. In Ethiopia, a majority of lower-level health facilities, such as health centers, lack KMC services. Consequently, if a mother gives birth at these facilities and is subsequently referred, it results in a delay in the early initiation of KMC. Additionally, another study in Ethiopia highlighted the absence of KMC rooms and NICUs in numerous health facilities, acting as barriers to facility-based KMC (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). In a recent KMC implementation guideline in Ethiopia, the recommendation is to commence KMC at the Health Center level. According to this guideline, after the initial stabilization and weight measurement, if the newborn weighs between 2,000\u0026ndash;2,500g, is clinically stable, and able to breastfeed, the birth attendant should initiate KMC in the postnatal room and continue care for at least 24 hours before discharge (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eA prevalent facilitator within the healthcare system, as identified in our study, is the existence of visual aids such as television and posters for educational purposes. Additionally, a supportive policy framework, exemplified by hospital promotion and support, emerged as another key facilitator. In alignment with our findings, a study conducted in Cote d\u0026rsquo;Ivoire identified strong hospital leadership and active promotion of KMC as facilitators in the successful implementation of KMC practices (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eA significant obstacle to the optimal application of KMC among healthcare professionals is the lack of comprehensive training and the presence of substantial skill gaps, which impede the proficient implementation of KMC protocols and procedures. A study underscored the critical role of training in enhancing the knowledge and competencies of healthcare professionals in delivering KMC (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). According to the current KMC guidelines in Ethiopia, neonatal healthcare providers in postnatal wards and NICU KMC rooms for both unstable and stable infants should undergo training and capacity-building (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Recognizing training and skill gaps as major barriers, stakeholders of the guideline are committed to addressing and resolving these impediments.\u003c/p\u003e\u003cp\u003eNegative attitudes, stereotypes, or biases among healthcare professionals toward KMC can compromise its acceptance and implementation, potentially stemming from inadequate compensation. These factors contribute to limited attention given to KMC, a consequence of the multitude of competing demands and clinical priorities, thereby delaying its initiation and leading to underutilization. A study conducted in Uganda and Malawi revealed that a positive attitude and acceptance of KMC among healthcare providers can foster optimism and full engagement in KMC practices, albeit with associated challenges (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMaternal barriers to optimal KMC can be categorized into emotional challenges (fear, stress, trauma), physical obstacles (exhaustion, post-operative pain), and informational/attitudinal barriers (lack of awareness, non-compliance, preference to go home, lack of belief). Parents expressed anxiety about the perceived fragility of preterm babies, leading to hesitancy in touching their newborns. Maternal stress and fear regarding preterm or low birth weight infants can significantly influence beliefs about their survival and the practice of KMC. Previous research has identified fear, stigma, shame, guilt, and anxiety as substantial hindrances to KMC adoption (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Healthcare providers emphasized the importance of maternal awareness of KMC, revealing that mothers often lacked knowledge about KMC services upon hospital admission. A study in Ghana reported that only 11.4% of mothers knew about KMC at admission, making it challenging to convince them to practice KMC in the initial days after birth (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Adequate prenatal care and awareness were identified as proactive measures to prepare mothers for the possibility of preterm birth and the need for KMC. Instances were reported where mothers felt KMC was imposed without proper explanation (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePost-operative pain and discomfort, especially after C-sections, along with fatigue, were identified as critical barriers to early and effective KMC and exclusive breastfeeding. Another cross-sectional study found that 44% of perceived barriers to implementing and continuing early KMC were attributed to pain and fatigue from operations, such as stitches and C-sections (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Additionally, a formative study highlighted barriers including maternal fatigue, post-delivery backache, poor health, and lack of family support (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe willingness of the mother to engage in KMC is identified as a pivotal factor in the successful initiation of this care practice. A positive attitude and active participation from the mother significantly contribute to the early implementation of KMC, with several studies highlighting maternal willingness and empowerment as key facilitators (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWhile paternal resistance presents a critical barrier to the early and effective implementation of KMC, our study highlights family support as a robust facilitator for the prompt initiation and sustained utilization of KMC. This finding aligns with several studies emphasizing the positive impact of family support on KMC practices (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Our research indicates that caregivers predominantly acknowledged the significance of both staff and family support, coupled with a strong desire for their babies' well-being, as major contributors to the provision of KMC. The involvement and willingness of other family members to assist the mother in childcare significantly enhance the adoption of KMC, as evidenced by studies conducted in Uganda and Scandinavian countries (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOur research identified cultural fears and despondency concerning the baby's survival as barriers to the practice of effective KMC after birth. This aligns with other studies that have found prevailing fears and a sense of despondency within certain cultural contexts, discouraging timely initiation of KMC (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Cultural perceptions about preterm birth and associated survival rates may undermine maternal confidence in adopting KMC practices. Addressing these barriers within culturally sensitive frameworks is imperative for fostering broader acceptance and integration of KMC practices across diverse cultural and religious contexts.\u003c/p\u003e\u003cp\u003eOur findings revealed that initiating breastfeeding too early was perceived as a potential risk factor for NEC. In contrast, delaying feedings due to concerns about NEC was associated with increased central catheter days, a higher risk of acquired bloodstream infections, and delayed gut development (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) and is not recommended as a strategy to reduce NEC (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Maternal worries about insufficient milk secretion and occasional requests for formula milk emerged as barriers to sustained exclusive breastfeeding. A study in Ghana highlighted reasons for delaying breastfeeding initiation, including perceived lack of breast milk, post-birth activities, the belief that both the mother and baby needed rest, and the absence of the baby crying for milk (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Similarly, in northern Ethiopia, the early initiation of formula feeding acted as a barrier to both early and sustained exclusive breastfeeding (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Twin births introduced distinct challenges, with mothers facing the simultaneous tasks of holding both infants and facilitating breastfeeding, contributing to heightened fatigue. This underscores the need for tailored support and interventions addressing the specific demands associated with twin deliveries, emphasizing maternal well-being and infant care.\u003c/p\u003e\u003cp\u003eIn our study, the majority of mothers expressed an inherent desire to breastfeed, describing it as a delightful experience that enhances the emotional connection and level of attachment between the mother and the infant. This finding is consistent with a study conducted in China (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Women's awareness and positive perceptions of breastfeeding emerged as significant motivators for the early initiation of exclusive breastfeeding. A study in Northern Ethiopia highlighted that mothers were aware of the importance of exclusive breastfeeding, understanding that it should be initiated as soon as possible and given frequently (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The recent Ethiopia KMC guidelines emphasize that initially, breastfeeding is provided at fixed intervals of 2\u0026ndash;3 hours, rather than on demand, to ensure an adequate and assured minimal intake. Mothers are educated on how to breastfeed while the infant is in the KMC position (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOur study has both strengths and limitations. One strength is that the study revealed practical challenges and operational realities of optimal KMC implementation, such as adherence to protocols and the integration of recommended KMC practices into routine care. A limitation is that constraints related to time and resources may have impacted the breadth and depth of the study.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eBarriers to effective KMC and exclusive breastfeeding include factors such as limited healthcare resources, skill gaps, healthcare staff attitudes, maternal emotional barriers, post-operative pain, lack of KMC awareness, and cultural pressures for quick post-birth discharge. Conversely, supportive factors include healthcare policies, family involvement, effective counseling, maternal willingness, prior experience with preterm births, regular pregnancy check-ups, and well-informed mothers. Prioritizing training, resource allocation, and culturally sensitive education are critical to bridging the gap in KMC implementation across Ethiopia\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.4286%;\"\u003e\n \u003cp\u003eC/S\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68.5714%;\"\u003e\n \u003cp\u003eCaesarean section\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.4286%;\"\u003e\n \u003cp\u003eEBF \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68.5714%;\"\u003e\n \u003cp\u003eExclusive breast feeding\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.4286%;\"\u003e\n \u003cp\u003eIDI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68.5714%;\"\u003e\n \u003cp\u003eIn-depth interview\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.4286%;\"\u003e\n \u003cp\u003eLBW \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68.5714%;\"\u003e\n \u003cp\u003eLow birth weight\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.4286%;\"\u003e\n \u003cp\u003eNEC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68.5714%;\"\u003e\n \u003cp\u003eNecrotizing Enterocolitis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.4286%;\"\u003e\n \u003cp\u003eNICU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68.5714%;\"\u003e\n \u003cp\u003eNeonatal intensive care unit\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe obtained ethical approval from the Research Ethics Committee of the School of Public Health, College of Health Sciences, Addis Ababa University. The study was conducted in accordance with the Declaration of Helsinki. A written informed consent was obtained from all participants in the study. Participation was voluntary and participants were informed of their right to withdraw from the study when they wished to do so. Data were collected, managed and analyzed in a way to ensure the confidentiality of study participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analysed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author received no specific funding for this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBRI conceived the study. ASE and BRI designed the study. BRI analyzed the data. ASE supervised the data analysis. BRI wrote the original draft. Both authors have reviewed and substantively edited the draft. Both authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to express our gratitude to the School of Public Health, College of Health Sciences, Addis Ababa University, for their financial support. Special thanks are also extended to Asella and Batu hospital, as well as the healthcare providers and mothers who participated in the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLiu L, Johnson HL, Cousens S, Perin J, Scott S, Lawn JE, et al. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. 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Addis Ababa, Ethiopia; 2023. \u003c/li\u003e\n\u003cli\u003eLaunch of Kangaroo Mother Care Global Position Paper and Implementation Strategy [Internet]. [cited 2023 Nov 18]. Available from: https://www.who.int/news-room/events/detail/2023/05/16/default-calendar/launch-of-kangaroo-mother-care-global-position-paper-and-implementation-strategy\u003c/li\u003e\n\u003cli\u003eSave the Children; Rapid Health Facility Assessment on Service Availability and Delivery of Care to Premature and/or Low Birth Weight Babies. 2015. \u003c/li\u003e\n\u003cli\u003eMony PK, Tadele H, Gobezayehu AG, Chan GJ, Kumar A, Mazumder S, et al. Scaling up Kangaroo Mother Care in Ethiopia and India: a multi-site implementation research study. BMJ Glob Health. 2021 Sep;6(9):e005905. \u003c/li\u003e\n\u003cli\u003eEthiopia Minister of Health. Health Sector Transformation Plan II HSTP II 2020/21-2024/25 (2013 EFY - 2017 EFY). 2021. \u003c/li\u003e\n\u003cli\u003eKinshella MLW, Hiwa T, Pickerill K, Vidler M, Dube Q, Goldfarb D, et al. Barriers and facilitators of facility-based kangaroo mother care in sub-Saharan Africa: a systematic review. BMC Pregnancy and Childbirth. 2021 Mar 4;21(1):176. \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 Facility and Community of Tigray Region, Northern Ethiopia: Formative Research. PHMT. 2022 Sep 8;13:297\u0026ndash;307. \u003c/li\u003e\n\u003cli\u003eWatkins HC, Morgan MC, Nambuya H, Waiswa P, Lawn JE. Observation study showed that the continuity of skin‐to‐skin contact with low‐birthweight infants in Uganda was suboptimal. Acta Paediatr. 2018 Sep;107(9):1541\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eKourouma KR, Agbr\u0026eacute;-Yac\u0026eacute; ML, Doukour\u0026eacute; D, Ciss\u0026eacute; L, Some-M\u0026eacute;azieu C, Ouattara J, et al. Barriers and facilitators to kangaroo mother care implementation in Cote d\u0026rsquo;Ivoire: a qualitative study. BMC Health Services Research. 2021 Nov 9;21(1):1211. \u003c/li\u003e\n\u003cli\u003eChan G, Bergelson I, Smith ER, Skotnes T, Wall S. Barriers and enablers of kangaroo mother care implementation from a health systems perspective: a systematic review. Health Policy Plan. 2017 Dec;32(10):1466\u0026ndash;75. \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. 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Barriers and facilitators of kangaroo mother care adoption in five Chinese hospitals: a qualitative study. BMC Public Health. 2020 Aug 13;20(1):1234. \u003c/li\u003e\n\u003cli\u003eNguah SB, Wobil PN, Obeng R, Yakubu A, Kerber KJ, Lawn JE, et al. Perception and practice of Kangaroo Mother Care after discharge from hospital in Kumasi, Ghana: A longitudinal study. BMC Pregnancy and Childbirth. 2011 Dec 1;11(1):99. \u003c/li\u003e\n\u003cli\u003eKampekete GSM, Ngoma C, Masumo M. Acceptance of kangaroo mother care by mothers of premature babies. African Journal of Midwifery and Women\u0026rsquo;s Health. 2018 Oct 2;12(4):178\u0026ndash;88. \u003c/li\u003e\n\u003cli\u003eMazumder S, Upadhyay RP, Hill Z, Taneja S, Dube B, Kaur J, et al. Kangaroo mother care: using formative research to design an acceptable community intervention. BMC Public Health. 2018 Mar 2;18:307. \u003c/li\u003e\n\u003cli\u003eMathias CT, Mianda S, Ohdihambo JN, Hlongwa M, Singo-Chipofya A, Ginindza TG. Facilitating factors and barriers to kangaroo mother care utilisation in low- and middle-income countries: A scoping review. Afr J Prim Health Care Fam Med. 2021 Aug 23;13(1):2856. \u003c/li\u003e\n\u003cli\u003eCai Q, Zhou Y, Chen D, Wang F, Xu X. Parental perceptions and experiences of kangaroo care for preterm infants in neonatal intensive care units in China: a qualitative study. BMC Pregnancy Childbirth. 2024 Jul 25;24(1):499. doi: 10.1186/s12884-024-06622-9. PMID: 39054436; PMCID: PMC11271036. \u003c/li\u003e\n\u003cli\u003eCalais E, Dalbye R, Nyqvist K, Berg M. Skin-to-skin contact of fullterm infants: an explorative study of promoting and hindering factors in two Nordic childbirth settings. Acta Paediatr. 2010 Jul;99(7):1080\u0026ndash;90. \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 Jun;27(2):345\u0026ndash;53. \u003c/li\u003e\n\u003cli\u003eSchurr P, Perkins EM. The relationship between feeding and necrotizing enterocolitis in very low birth weight infants. Neonatal Netw. 2008;27(6):397\u0026ndash;407. \u003c/li\u003e\n\u003cli\u003ePhiladelphia TCH of. Necrotizing Enterocolitis | Children\u0026rsquo;s Hospital of Philadelphia [Internet]. [cited 2025 Jul 19]. Available from: https://www.chop.edu/conditions-diseases/necrotizing-enterocolitis\u003c/li\u003e\n\u003cli\u003eTawiah-Agyemang C, Kirkwood BR, Edmond K, Bazzano A, Hill Z. Early initiation of breast-feeding in Ghana: barriers and facilitators. J Perinatol. 2008 Dec;28 Suppl 2:S46-52. \u003c/li\u003e\n\u003cli\u003eXiao X, Loke AY, Zhu S ning, Gong L, Shi H mei, Ngai F wan. \u0026ldquo;The sweet and the bitter\u0026rdquo;: mothers\u0026rsquo; experiences of breastfeeding in the early postpartum period: a qualitative exploratory study in China. International Breastfeeding Journal. 2020 Feb 24;15(1):12. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"barriers, facilitators, effective KMC, Ethiopia","lastPublishedDoi":"10.21203/rs.3.rs-7685786/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7685786/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGlobally, neonatal deaths account for nearly half of under-five mortality, with over 1\u0026nbsp;million deaths occurring within the first 24 hours of life—largely due to preterm birth. In Ethiopia, low birth weight newborns contribute to 60–80% of neonatal deaths, with a neonatal mortality rate of 33 per 1,000 live births. Kangaroo Mother Care (KMC) is a proven, cost-effective intervention for preterm and low birth weight babies, now recommended by World Health Organization (WHO) for immediate initiation after birth. Despite national policy support, KMC coverage in Ethiopia remains low, with fewer than 10% of eligible newborns receiving it. Understanding the barriers and enablers to effective KMC implementation is critical to improving coverage and outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study conducted in August 2023 at Asella Referral and Teaching Hospital and Batu General Hospital in Oromia, utilized thematic analysis to explore barriers and facilitators of effective KMC. Data were collected through observations and in-depth interviews with 14 participants—six mothers and eight neonatal care providers. Semi-structured interviews were conducted in Amharic and Afan Oromo, recorded, and transcribed. Data were manually coded and analyzed thematically. A pre-tested, standardized questionnaire ensured data quality, and collection continued until saturation was achieved, with findings presented in detailed descriptions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResult\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur analysis identified health system related \u003cstrong\u003ebarriers\u003c/strong\u003e to effective KMC including inadequate healthcare infrastructure, skill gaps, low healthcare provider motivation, maternal emotional status, post-operative pain, lack of knowledge about KMC, and cultural norms that hasten mothers to go home after birth. \u003cstrong\u003eFacilitators\u003c/strong\u003e comprise quality improvement initiatives, visual aids, effective counseling, maternal willingness and regular pregnancy follow-up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAddressing both systemic and individual-level barriers while reinforcing identified facilitators is essential to improve effective KMC uptake. Targeted, system-wide and mother-centered interventions are needed to improve uptake of effective KMC in Ethiopia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number: Not applicable\u003c/strong\u003e\u003c/p\u003e","manuscriptTitle":"Barriers and Facilitators to Effective Kangaroo Mother Care in Ethiopia: A Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-01 11:53:29","doi":"10.21203/rs.3.rs-7685786/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-03-20T08:23:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"103256675056466654903643134416599806008","date":"2026-03-04T16:43:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-24T16:29:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"89362630575996497636270896382176962306","date":"2025-11-21T16:54:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"284417762336190528023968771569338529325","date":"2025-11-13T12:55:16+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-21T19:45:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-21T05:47:05+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-29T05:44:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-26T13:11:58+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2025-09-26T13:08:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5e760aca-d3ef-444c-b1f6-9bef299bc3b4","owner":[],"postedDate":"November 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-01T11:53:29+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-01 11:53:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7685786","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7685786","identity":"rs-7685786","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}