Barriers and Facilitators of Kangaroo Mother Care Adoption in Five Chinese Hospitals: a Qualitative Study

doi:10.21203/rs.3.rs-20067/v1

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Research article

Barriers and Facilitators of Kangaroo Mother Care Adoption in Five Chinese Hospitals: a Qualitative Study

https://doi.org/10.21203/rs.3.rs-20067/v1

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published 13 Aug, 2020

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Background Kangaroo mother care (KMC) has been proved to be a safe and cost-effective intervention for preterm babies. Despite this evidence and global guidelines promoting KMC, it has not been widely adopted in China. In this study, we aim to assess barriers and facilitators of KMC adoption in neonatal intensive care units (NICUs) and postnatal wards in China.

Methods We conducted clinical observation and semi-structured interviews in seven NICUs and postnatal wards housed in five hospitals from different provinces in China between August and September 2018. We conducted interviews with pediatricians, obstetricians, nurses and parents who performed KMC to understand their perspectives on barriers and facilitators of KMC implementation and sustainability. We further explored health system’s readiness and families’ willingness to adopt KMC following its introduction in pilot hospitals. We coded data for emerging themes related to perceived barriers and facilitators of KMC adoption, specifically those unique in the Chinese context and less commonly reported in previous systematic reviews from other countries.

Results Five hospitals were included for clinical observation and 38 semi-structured interviews were conducted. Common cultural barriers included concerns with postpartum confinement (Zuo-yue-zi) and grandparents’ resistance, while strong family support enabled KMC adoption. Parents may feel anxious and guilty about having a preterm baby, this is a parental-level barrier to KMC. Hospital-level factors such as fear of nosocomial infection and shortage of staff and spaces impeded KMC implementation, and hospital-led supportive community and peer group contributed to KMC uptake. Financial barriers included lodging costs for caregivers and supply costs for hospitals.

Conclusions Barriers and facilitators exist across cultural, hospital, parental and financial levels. While several factors were common in other study settings, there are also barriers and facilitators unique to Chinese context, e.g. concerns with postpartum confinement (Zuo-yue-zi), grandparents’ resistance and staff’s fear of nosocomial infection. We recommend interventions specificially targeting these barriers and facilitators including family and peer support for improved KMC adoption in China. We also recommend that specific barriers and challenges to KMC in particular settings be identified and be taken into account prior to KMC uptake in other settings.

Health Policy

Kangaroo mother care

qualitative

implementation research

China

Kangaroo mother care (KMC) is an evidence-based approach, recommended by the World Health Organization (WHO) for the care of preterm newborns [1]. There are several key features of KMC including early, continuous, and prolonged skin-to-skin contact between infant and caregiver; exclusive breastfeeding; early discharge from hospital; and adequate support for caregiver and infant at home. Continuation of KMC is recommended until the newborn's gestational age reaches term or weight reaches 2500 g [2].

Systematic reviews of KMC studies reported that in low- and middle-income countries, the practice of continuous KMC was associated with a significant reduction in the risk of neonatal mortality as well as sepsis, hypoglycemia, and hypothermia [3]. KMC has multiple benefits for newborns and their families, including improved duration of breastfeeding, weight gain and physiological response [4]. Evidence also shows that KMC supports maternal-infant bonding and child development, including improved longer term neuro-behavioral, psychomotor development and brain maturation [5-7].

KMC was initially proposed as an alternative to the conventional contemporary method of care for low-birth-weight infants, and has been introduced to some low-income countries including Bangladesh, Malawi, Nepal. In these countries, the preterm/low birth weight prevalence is high while the medical resources are limited, KMC was performed as an alternative to incubators or warmers [3]. Currently, KMC is considered one of the most cost-effective interventions to promote the well-being of preterm infants, and has been widely used including in high-income countries. It was estimated that KMC was practiced in some form (mostly intermittent) in 82% of all neonatal intensive care units (NICUs) in the United States [8].

Despite many studies showing that KMC has many benefits for the growth and development of premature infants, especially those with low-birth-weight, KMC has not been widely used and promoted in China, one of the top ten countries with highest numbers of preterm births [9]. One of the main reasons is that in most NICUs in China, parents are denied entry to the NICU or visits are limited to a few minutes per week [10]. The separation of mother and baby is not conducive to the establishment of the mother-infant relationship, and increases parents' anxiety. Late preterm infants with stable status generally room-in on the postnatal ward, staying only one to four days, limiting the opportunity for parents to practice KMC and gain confidence in its use prior to discharge home.

Since 2014, China’s Premature Birth Intervention Programme has carried out to raise awareness and promote the implementation of KMC amongst its network of 50 hospitals across China. Technical support included international expert meetings and KMC stakeholder workshops involving nurses, pediatricians and other health workers at their individual hospitals. Under this programme, a network of self-selected hospitals from different provinces in China participated in a pilot to implement standard guidelines in China’s NICUs and postnatal wards to assess the feasibility and factors influencing adoption of intermittent KMC in the Chinese context. Due to space and human resources constraints, intermittent rather than continuous KMC was practiced in the hospitals. Intermittent KMC was also recommended to be continued post discharge. While KMC was largely accepted in China’s hospitals more rapidly than was initially anticipated, we nevertheless undertook this study to better understand and provide tailored guidance for the intervention to be adapted to the Chinese context to scale up KMC use across all hospitals in the country.

Previous systematic reviews suggested barriers for KMC practice in developing and developed countries included “issues with the facility environment /resources,” “negative impressions of staff attitudes or interactions with staff,” “lack of help with KMC practice or other obligations,” “low awareness of KMC/ infant health.” “pain/fatigue,” “actual increased workload” and “concerns about other medical conditions”. On the other hand, the main facilitators to practice KMC included “mother-infant attachment” and “support from family, friends, and other mentors” [9]. However, there are limited studies in Asia, and we are not aware of any such prior published studies in China where hospital management policy and resources as well as traditional culture are different.

Using clinical observation and semi-structured interviews data from five hospitals, we aimed to 1) understand the knowledge, attitude, behaviors and perceptions of KMC from nurses, doctors, and parents of the preterm infants; 2) establish a conceptual framework to analyze the barriers and facilitators to facilitate KMC scale-up; and 3) provide recommendations for KMC adaptations in Chinese hospitals to ensure sustainability and scale up.

The present study is part of the larger project aimed to investigate the implementation of KMC in the neonatal and postnatal wards of piloting hospitals in China, after the development of standardized guidelines for KMC. In the current study, we collected data from clinical observation and semi-structured interviews in seven NICUs and postnatal wards housed in five hospitals, and analyzed the barriers and facilitators of KMC implementation in these hospitals.

Study setting

The research was conducted in seven NICUs and postnatal wards across five level-III hospitals from different provinces in China between August and September 2018. These hospitals are self-selected for this research and are located in five provinces which vary in geographic locations, economic development and cultural custom. Among the five hospitals, hospital B is a general hospital, and the other four hospitals are specialized maternal and child hospital. All hospitals had not formally adopted KMC prior to the implementation study. During the implementation phase, hospital A and D KMC both in NICUs and postnatal wards, while the other three hospitals implemented KMC only in NICU wards. Prior to KMC implementation, all of the NICUs in pilot hospitals were closed to parent visitation, separating newborns and mothers; whereas the postnatal wards allowed rooming-in, where the newborns and mothers stay together.

Participants

The KMC study coordinators, usually head nurses of the wards, helped identify medical staff and parents that were involved in KMC implementation or had KMC experience. In each study site, we recruited a mix of pediatricians/obstetricians, nurses and parents from the NICUs and postnatal wards. We included full-time nurses and pediatricians/obstetricians on site, and parents who had experience with intermittent KMC so long as they provided written informed consent to be interviewed and recorded.

Data collection

Data collection was conducted by six research assistants. Prior to data collection, all team members received training on data collection processes, including observation and interview techniques. All study team members were involved in data collection, transcription, data cleaning and analysis.

Data collection processes included clinical observations and semi-structured interviews with study participants. Use of observation in implementation research is common as a means to collect detailed information on processes and work roles, as well as insights into organizational values, norms and communication. The qualitative data collection approach was informed by the Consolidated Framework for Implementation Research (CFIR), commonly used in implementation-focused needs assessment, which provides a structured guide of five domains (i.e., intervention characteristics, outer setting, inner setting, characteristics of individuals, and process), each with accompanying constructs associated with the process of effective intervention implementation [11, 12].

The study team conducted observations to understand the general clinical activities at the beginning of the site visit to each hospital, including work patterns, patient flow, medical team roles, and clinical process, and completed a standard observation form (Appendix I). To facilitate the accurate documentation of the processes, the study team members asked questions to clinical staff as necessary and appropriate.

They study team conducted recorded, semi-structured interviews with medical staff and parents. The interviews with medical staff gathered their perspectives on barriers and facilitators of KMC program implementation and sustainability, and helped to assess the readiness and willingness to adopt KMC program post-intervention. The interviews with parents who participated in KMC focused on their infants’ clinical condition, knowledge of KMC, confidence of practicing KMC, and perceived benefits and barriers for KMC practices. Interviews were conducted over one to two days at each site. Each interview lasted about 30-40 minutes, and all interviews were conducted in Mandarin. The study team members conducted interviews in private rooms at the hospital and used the interview guide (Appendix II) that was designed to combine broad, open-ended questions with targeted, prompting questions. All the tools were field tested for validation and modified before the data collection. And all interviews were conducted with the informed consent of the participants.

Data analysis

Semi-structured interviews conducted in Mandarin were audiotaped and transcribed by translational software verbatim for the initial transcripts. These initial transcripts were manually verified against the recording for fidelity in transcription by the interviewers. The verified transcripts were then imported as PDF files into a qualitative data analysis software Dedoose to facilitate data coding, text searching, and analysis (Dedoose Version 8.1.8, 2018). Descriptor data on the interviewee’s age, gender, interview site, position at the hospital (or parent information), tenure at the hospital was added to the Dedoose project and linked to each transcript for further analysis. Data were systematically examined for emerging codes, themes and patterns. A codebook with 17 major and sub-themes was also created by the research team with the CFIR domains identified a priori and others emerging from the data. To ensure inter-coder agreement, two study team members developed open coding schemes independently on a subset of interviews, then made comparisons to derive consensus on the coding strategy. The coders independently coded another subset of interviews to ensure consistency of the implementation of the coding strategy. In this paper, we focused on the barriers and facilitators of KMC adoption, specifically barriers and facilitators unique in the Chinese context and less commonly reported in previous systematic reviews. Barriers to KMC adoption refers to the factors that can potentially hinder KMC implementation roll-out or make sustainability of KMC practice more difficult. Facilitators are the positive factors that either assist initial KMC implementation or enhance the KMC sustainability in China. A preliminary conceptual frame focusing on both the infrastructure and psychological-level barriers and facilitating factors was also presented in the result section.

Themes related to knowledge of KMC, perceptions of KMC benefits, KMC implementation barriers, KMC’s impact on workflow and resources, inner and outer environmental factors that influenced the dynamics of KMC adoption emerged as the most relevant themes to the health professionals. Through axial coding and developing thematic tables and matrices, we extracted direct quotes of the hospital staff and parents into excerpts, organized excerpts into categories and themes, and analyzed relationships found among the themes.

Ethical approval

Ethical approval was obtained by Peking University First Hospital Biomedical Research Ethics Committee. Verbal informed consent was obtained from all participants.

3.1 General characteristics of the study participants

38 semi-structured interviews were conducted during August to September 2018. The distribution of respondents in various hospitals is shown in Table 1. As hospitals A and D had both NICUs and postnatal wards participating in KMC, three nurses from each ward were included in the interviews. All 18 nurses and six of the ten physicians interviewed were women, while only one father was sampled among the ten parents of the pre-term babies although he was not the only father providing KMC. Of the nurses and the physicians interviewed, half were from the NICU wards and half from the postnatal wards. 30% of the parents delivered a baby for the first time. For physicians included in the study, 70% were junior and 30% were senior in clinical ranking; as for nurses, half of them were junior and half of the were senior in ranking (e.g., Head Nurses, Chief Medical Residents, or Department Chiefs).

3.2 Summary of the barriers and enablers

In this study, we categorized the facilitators and barriers of adopting KMC into different levels, including cultural level, hospital level, parental level and financial level. A preliminary conceptual framework focusing on different level barriers and facilitators is presented in Table 2. In the results section, we specifically describe those barriers and facilitators unique in the Chinese context and less commonly reported in previous systematic reviews.

3.2.1 Postpartum confinement

Most families in China still follow the deeply rooted “Zuo-Yue-Zi” (postpartum confinement) culture, in which the new mother has to stay indoors (mostly in bed) without doing any housework, consume only warm water and food, and not take a shower in order to reduce the possibility of long-term complications related to delivery. While this cultural practice could potentially bring health benefits to mothers and newborns, it was mentioned as a major cause of hesitation of mothers to participate in KMC during the first month after delivery, especially as they fear being criticized by their mothers, in-laws, and other caregivers if they wanted to forgo the postpartum confinement practice. These mothers often ended up delaying KMC initiation or asking the father or even their parents to act as a substitute for KMC. The relatives can provide KMC but certainly cannot breastfeed the baby at the same time.

The biggest challenge, as mentioned earlier, is that they may be unwilling to come during postpartum confinement. Some would postpone rather than saying that they will not come. Some say I might come perhaps after my confinement period or the first ten or twenty days after childbirth. (Hospital E, NICU nurse 34)

As many Chinese people are very traditional, they are reluctant to come outdoor worrying that it's bad for their recovery. (Hospital C, NICU nurse 18)

3.2.2 Grandparents’ resistance to KMC

In addition, many grandparents were not used to the idea of allowing new born babies to remain naked with the mother; they were concerned that sweating in summer and cold temperatures in winter might harm the babies during KMC practice. Some mothers new to KMC were also nervous about touching their babies’ delicate skin.

…My concern is that there might be (resistance) during the winter season. Our program started in summer, thus the parents accepted it well. If we promoted KMC in winter, perhaps some grandma and elders would be worried that the babies catch cold. This depends on their acceptability towards this practice. Young parents can accept it easily. (Hospital A, Obstetric nurse 7)

3.2.3 Anxiety of carrying for preterm baby

Parents reported anxiety of preterm babies’ “fragility” and were afraid to touch their newborns, especially if their newborn had unstable vital signs. For example in NICUs, most parents have to hold the baby facing the medical monitors, some babies might have non-invasive ventilators. As the babies’ vital signs change during KMC, parents become more hesitant to perform KMC.

It was difficult for me at first, because the baby was so small, I dared not to touch it… as I felt it’s inappropriate no matter where I touch. (Hospital D, parents 32)

(Some parents) were worried that the oxyhemoglobin saturation of some babies dropped to too low, and dared not to hug it. Later perhaps the condition became stable and we explained it to them again and again, so they hugged it again and contacted it. However, once they hugged it and the oxyhemoglobin saturation dropped again, they were reluctant to do this again. (Hospital B, NICU doctor 13)

3.2.4 Lack of private space

Another side-effect of having people other than the mother performing KMC was that there’s a lack of private spaces for mothers and fathers. As NICUs are crowded with six to ten people including both men and women, mothers reported that they felt embarrassed when exposing their body during KMC, especially in KMC rooms where curtains or dividers between the chairs are unavailable. Hospitals that provided curtains between KMC chairs/beds received much better remarks on this aspect. Some mothers expressed the embarresment to be naked in front of medical staff especially the male physicians. Embarresment was also a factor for fathers as when providing KMC they had to be naked in front of women.

In the postnatal wards wards, even though we have a curtain, it’s difficult to protect the privacy if when the family members come and go. So I think their privacy cannot be protected, this is a limitation for sure. (Hospital D, Obstetric nurse 30)

There are too many people in different wards, and some are male, the baby is naked, and I am almost naked in the upper part, it's inconvenient. (Hospital A, Parents 31)

3.2.5 Maternal guilt associated with preterm birth

Some mothers also considered that delivering a pre-term baby was a “failure” due to belief in perfectionism. These mothers of low-birth-weight preterm babies often felt stigmatized, stressed and depressed, which often impeded their willingness to face and hold the baby everyday.

The mother had anxiety, she always asked her mother to perform KMC and refused to face the fact…She had huge societal pressure and refused to face a 30 gestational week or 1000g, 900g baby, she cannot face it…At first, she was reluctant to enter NICU, as she could not believe that she had given birth to such a tiny baby. (Hospital A, NICU doctor 4)

3.2.6 Fear of nosocomial infection

While physicians are less involved in the daily implementation of KMC, their discussions on the barriers for KMC focused on traditional concerns about nosocomial infection in the NICUs. Some nurses and physicians said they were only convinced of KMC’s benefit after the hospital routine statistics showed the infections in the hospital did not increase after KMC implementation. Some physicians also expressed concerns about the pressure on hospital resources when parents practicing KMC used hospital-provided diapers, water stations, and bathrooms.

When KMC practice started, hospital administration was prioritized over medical practice, thus patients were not allowed to enter the wards as it may increase the risk of cross infection and waste the measures for disinfection and isolation. There were high resistance due to infection control. (Hospital A, NICU doctor 28)

Some nurses also expressed concerns about the increased chance of bacterial infection in the crowded environment, especially when mothers do not shower due to “Zuo-Yue-Zi” (postpartum confinement).

Some mothers do not wash their head or shower during postpartum confinement. We told them to wash and dressed neatly and cleanly. Still, some parents have not cleaned themselves well when they come. (Hospital C, NICU nurse 17)

3.2.7 Parents monitoring work

Due to the limited visitation policies of NICUs in China, nurses and physicians are not used to performing clinical procedures on newborns whilst their parents are observing. Medical staff are concerned that parents may monitor their routine procedures, including injections, and their emergency treatment and are worried that conflict may arise between parents and themselves, if parents consider medical procedures to be too “brutal”. This is a reflection of the tense doctor-patient relationship in China. Nonetheless, medical staff and parents reported that after parents became familiar with the routine work of medical staff, they become less anxious and many reported better relationships with doctors and nurses.

Our wards were “closed-door” operating before and the nurses were afraid when family members came in (for KMC), especially the new nurses – they were very nervous, they did not know how to talk to them or how communicate the disease condition to them, because the condition that the nurses could explain to them is very limited, just some very normal things, so family members may had less trust in the nurses. (Hospital A, NICU nurse 9)

3.2.8 Leadership of the hospital’s administration/Motivation system

Many nurses and doctors attributed their enthusiasm for KMC to the leadership of senior hospital administrators. In these circumstances, administrators supported KMC and ensured provision of training and discussion at whole-hospital and individual-department levels, they provided necessary equipment, including reclining chairs, KMC rooms, and identified an existing nurse to specialize in KMC. Routine supervision on KMC implementation was reported as one of the incentives for the medical staff to continue KMC work.

Parents' understanding, support of from hospital leadership, the cooperation of doctors and parents had assisted us greatly in our work. We have only one or two from the beginning. Three or four beds has been expanded to six beds, and there will be more opportunities to expand in the future. (Hospital C, NICU nurse 18)

3.2.9 Creating supportive community: Social media group

WeChat is the most popular form of social media in China, many hospitals use it for health promotion and education as well as connecting parents of preterm infants through establishing Wechat groups. The former provides a platform where parents can understand the benefits of KMC, and the latter enables parents to communicate with each other and share KMC experiences.

In terms of promotion, I also think of WeChat accounts…you bring together the parents of premature babies…Through these platforms you promote the theory (of KMC), which will facilitate the actual operation later. If parents do not have any knowledge of KMC and are directly taught to perform KMC, it would be hard. They can learn from the pictures or videos and know what’s their role in KMC. When they perform, they could be less anxious. (Hospital A, NICU nurse 9)

3.2.10 Parents with good financial status

Some of the parents lived far away from the hospital, and reported long commute times. Some parents even had to rent a house near the hospital. Therefore, for families with poor economic conditions, the extra cost of transportation and rent for KMC may become a burden. Some families with good financial status considered the benefit of KMC outweighed the cost.

So some parents considered the money, the rent, so they may live at a place farther. Moreover, the accommodation nearby is expensive. Some families have already spent a lot on assisted reproduction, so they would consider saving money. (Hospital B, NICU nurse 11)

The parents are willing to rent a house in the village near the hospital, because compared with the spending for treatment of some infection, the housing rent is nothing. (Hospital A, NICU doctor 4)

The present study is the first study that assessed the barriers and facilitators of KMC in China. Through the analysis of 38 semi-structured interviews, we found that barriers and facilitators exist at cultural, hospital, parental and financial levels. Our results also suggested that there are barriers and facilitators unique to the Chinese setting, that should be highlighted and understood for optimal KMC implementation scale-up in China.

Barriers and facilitators at cultural level

We found that there were specific cultural barriers that impeded KMC implementation in China, including postpartum confinement and grandparents/community members resistance due to their tradition. Postpartum confinement is one traditional custom in China [13, 14] but also seen in other countries including India and Bangladesh [15, 16]. In China and India, most mothers are advised to stay at home after delivery, and in Bangladesh postnatal women need to remain with their newborn alone, in bed, inside the room where the delivery occurred. While this cultural practice could potentially bring health benefits to mother and their newborn, it also led to mother and family’s hesitation to initiate KMC. This specifically applies to preterms in the NICUs where mothers and preterm infants are separated post-delivery and mothers who have been discharged home are prohibited by custom from going to the hospital to perform KMC. Moreover, resistance from grandparents and community members regarding allowing mothers to be naked with their fragile preterms also discouraged parents from performing KMC.

While concerns with postpartum confinement is a cultural barrier to KMC implementation in specific countries, most studies have identified some socio-cultural barriers specific to their context or country. For example, carrying babies on the back instead of the front is commonly reported as a barrier in many countries, and early bathing behaviors are common in Ghana and Bangladesh, both making KMC adoption difficult [17, 18]. Addressing these cultural barriers requires an understanding of health promotion and social mobilization specific to these local settings. A previous study in Malawi educated grandparents about maternal and newborn health they subsequently provided individual and group counselling in their villages using songs, drama and poems, which was successful in promoting behavior change in maternal and neonatal care [19]. Previous studies have also shown that mothers need help from family members during KMC, especially with household chores [16, 18, 20]. Our analysis also suggested that family and peer support is a key facilitator to KMC adoption. If mothers receive enough family support to perform KMC and their families would take responsibilities of chores, they are more willing to perform KMC. While introducing KMC as an intervention that would not increase the risk of infection during postpartum confinement, additional health promotion and social mobilization activities targeting grandparents and other family members on benefits of KMC might be useful in reducing grandparents’ resistance towards KMC and lead to improved uptake.

Barriers and facilitators at hospital level

At the hospital level, lack of KMC space and human resources at the hospital were reported as the primary concerns, similar with previously published studies [18, 21, 22]. Population density and large numbers of deliveries especially at tertiary-level mean that hospitals are constantly struggling to secure sufficient space for NICU. Accommodating rooms for KMC, chairs and maintaining sufficient privacy for the parents in NICUs add an additional burden. The crowding and noise created by inviting parents and family members to NICUs discouraged nurses from introducing KMC. Due to space and human resources constraints, intermittent rather than continuous KMC was practiced in the hospitals in China. Parents often need to wait for the hospital to arrange their KMC activities and also with limited duration of each KMC session.

Besides, the nurse to preterm babies ratio in China is 1:6 to 1:8 [23], whereas the ratio is usually 1:2 in other high-income countries like the United States [24]. This already overwhelming workload can be further taxed by the necessity to train and supervise mothers providing KMC. Moreover due to the lack of relevant systems, most hospitals rely on nurses to record research, evaluation and monitoring data for KMC. The frequent recording of body temperature and other indicators required for a baby receiving KMC in Chinese hospitals further adds to nurses workload.

For parents and other caregivers, lack of privacy and KMC resources at facilities presented obstacles to KMC adoption, also mentioned in previous study published elsewhere [25]. Structurally, there was a lack of private space for mothers to perform KMC and a lack of space for mothers to remain in the hospital with their newborns. Mothers felt uncomfortable and exposed as medical staff continued to come in and out during KMC.

While the above-mentioned barriers are also seen in other low- to middle-income countries [9, 18], what is unique to China is its restrictive parental visiting policies of NICUs where parents are denied entry to NICUs [10]. The concept of close-off management originated from hospitals’ concern for nosocomial infection [18]. As many mothers do not shower due to postpartum confinement, and the NICUs are often overcrowded, hospital administraters, physicians and nurses initially expressed huge concerns over KMC and feared it may lead to the spread of nosocomial infection. After advocacy, visits to other hospitals and individual experience of managing the first few cases of KMC practice, medical staff gradually were convinced that KMC’s benefits outweigh the fear of nosocomial infection, and accepted and promoted KMC.

Our analysis also suggested that hospital-led peer support groups and educational platforms enable KMC adoption. Previous systematic reviews also highlighted that peer support among mothers in maternity wards contributed to KMC acceptance [27]. While mother-initiated groups are less common in China, hospitals that invested in using social media for health promotion and establishing WeChat groups were perceived well among parents. This might be especially helpful in the initial stage of KMC promotion.

Barriers and facilitators at parental level

Parents’ perception of KMC benefit is the most important motivator for KMC adoption, which is consistent with previous studies [21]. Mothers were less likely to accept KMC if healthcare workers could not clearly explain the benefits of KMC [18]. Clearly conveying the benefits of KMC could lead to successful KMC initiation. Besides, this could also increase communication between parents and medical staff, which can alleviate the possible conflict between doctors and patients to some extent.

In our analysis, we identified a number of maternal individual factors that impeded KMC adoption. Some parents are affected by perfectionism and expressed stigma/fear/anxiety over their premature infants [9]. Such negative emotions affect the establishment of bonding with infants, mothers often have difficulty in facing their premature babies. Medical staff should look out for warning signs and offer support to parents by introducing them to peer support groups. Some parents were unable to provide KMC or could not continue with it for a long time due to the pain, fatigue, complications and other physical factors [17, 18, 21, 28]. Therefore providing comfortable chairs and environment for mothers could encourage them to practice KMC for longer duration.

Barriers and facilitators at financial level

In the previous studies in low-income countries, commuting between home and KMC wards was a barrier to the provision of KMC. In cases where the newborn remained in the hospital after the mother was discharged, lack of money for transportation and the distance to the hospital were reported as challenges to KMC implementation [29]. This was also shown in our findings, though very rarely. Our analysis indicated that good economic status is more conducive to the implementation of KMC, which was rarely mentioned in previous literature. Despite being a cost-effective intervention, performing KMC in China especially in the NICUs requires parents come for hospital visits on a regular basis. Transportation costs or lodging costs to stay near the hospital might be burdensome for parents.

In addition, some nurses reported that inviting parents into the NICU wards requires additional hospital expenses as families would propose to change diapers for newborn babies when nurses felt they did not need to. There was no charge for parents to be able to provide KMC in the hospitals interviewed. Securing financial resources from hospital administration and/or medical insurance to facilitate KMC provision will be needed if KMC is to be scaled-up in China.

Recommendations

Based on the results of our analysis, we can draw the following recommendations of relevance to others implementing or rolling out KMC at a national or sub-national level:

An understanding of the specific barriers and challenges to implementing KMC in particular settings is fundamental to the success of implementation. Performing a barrier analysis prior to implementation is recommended.
The support of hospital administration and leadership was crucial for the successful integration of KMC into routine practice. Support from hospital administrators and leaders meant that space and resources were made available for KMC provision and that staff received training in KMC, it also acted as a motivator for staff to promote KMC. Activities that increase the likelihood of hospital administrative support for KMC need to be included in KMC scale up plans, this could include targeting hospital administrators in awareness raising activities about the benefits and feasibility of KMC and the formation of a KMC network comprised of leaders from implementing hospitals.
Staff motivation to offer and support the practice of KMC is vital for implementation. The support of KMC should be recognised as a key part of nursing care and considered by hospital administrators when assessing staffing levels and workload.
Our findings and the findings of others highlight the impact of traditional cultural practices such as postpartum confinement (Zuo-yue-zi) on the uptake of KMC. Grandmothers and communities were perceived by the mothers and health workers interviewed as key influencers of maternal practice. This indicates a need for public promotion of KMC, potentially targeted at grandmothers alongside promotion in health facilities be included in scale-up plans.
Whilst maternal provision of KMC is preferable, primarily due to the establishment of breastfeeding when a newborns mother is unavailable, this study has shown that paternal provision of KMC is both feasible. It is recommended that fathers be engaged in the provision of KMC when mothers are unavailable.

Strengths and limitations

This is the first multi-hospital qualitative study conducted in China on KMC adoption in hospital NICUs and postnatal wards. The five hospitals in the pilot study vary in geographic locations, hospital specialties, local economic development, and have different exposures to KMC knowledge and practice prior to programme initiation. While our study findings maybe specific to hospitals in these provinces, the summarized KMC barriers and facilitators could be similar to those of other provinces of China, and could be useful to countries initiating KMC programs.

Despite being the first study of its kind on KMC barriers and facilitators in China, several limitations should be considered. The perceived barriers and facilitators from parents’ perspectives might be baised as we only included parents who participated in KMC. We did not interview those who refused KMC, those deemed not eligible by the hospitals, or who did not have access due to the limited numbers of beds and rooms available for KMC in the hospitals. Reporting bias by medical staff due to social desirability was possible despite the research team repeatedly assuring the hospital staff that the interviews were not for service quality control. Many medical staff were also concerned about being judged for their knowledge of KMC (as trainings and tests happened often), but they usually relaxed after the first few questions; the private space and the guarantee of confidentiality also helped to ensure the authenticity of their answers.

In this qualitative study, we analyzed the perceptions of KMC barriers and facilitators in China’s NICUs and postnatal wards, using data from observation and semi-structured interviews from five hospitals. We found that barriers and facilitators exist in cultural, hospital, parental and financial levels. While several factors were common with other study settings including shortage of staff, increased workload and lack of space, we also discovered barriers and facilitators unique to the Chinese context, e.g. postpartum confinement, grandparents’ resistance and staff’s fear of nosocomial infection. We recommend interventions targeting these barriers and facilitators including family and peer support for improved KMC adoption in China. We strongly recommend that specific barriers and challenges to KMC in particular settings be identified and be taken into account prior to KMC uptake.

Ethics approval and consent to participate: Ethical approval was obtained by

Consent for publication: Not applicable

Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests: The authors declare that they have no competing interests.

Funding: Save the Children International

Authors' contributions: JY, GZ and JB conceived of the analysis, JY, JL, SW, BZ, QZ, LZ and JB contributed to data collection and analysis. JY and JB wrote the first draft of the manuscript. SW, YZ, SW, GW and GZ provided critical feedback on the first draft. LZ and YZ managed the production process. All authors read and approved the final manuscript.

Acknowledgements: We thank Ying Cao for her assistance for the manuscript production and all the hospitals and participants involved in the research.

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Table 1. Distribution of respondents in various hospitals

Study site	Unit included	Interviewee
Hospital A	NICU + PNW	6 nurses, 2 doctors, 2 parents
Hospital B	NICU	2 nurses, 2 doctors, 2 parents
Hospital C	NICU	2 nurses, 2 doctors, 2 parents
Hospital D	NICU + PNW	6 nurses, 2 doctors, 2 parents
Hospital E	NICU	2 nurses, 2 doctors, 2 parents

Note: NICU, neonatal intensive care unit; PNW, postnatal wards

Table 2. Conceptual framework of barriers and facilitators for kangaroo mother care adoption in China

Cultural bariers

Postpartum confinement
Grandparent resistence
Fear of sweating in summer/ cold in winter

Hospital barriers

Fear of nosocomial infection
Shortage of staff
Lack of space
Parents monitoring work
Increased workload

Parental barriers

Anxiety/ fear of being in hospital
Loss of privacy/ lack of private space
Perfectionist psyche
Maternal guilt associated with preterm birth

Financial barriers

Lodging costs
Loss of work time
Transportation/ traffic
KMC supply costs to

hospitals

Cultural facilitators

Strong family support

Hospital facilitators

Hospital readiness: chairs, training, nurses
Leadership of the hospital’s administration/ motivation system
Creating supportive community: social media group

Parental facilitators

Benefits to mothers
Benefits to newborns

Financial facilitators

Parents with good financial status

KMC Kangaroo mother care

NICU Neonatal intensive care unit

PNW Postnatal wards

WHO World Health Organization

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Barriers and Facilitators of Kangaroo Mother Care Adoption in Five Chinese Hospitals: a Qualitative Study

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