Given the benefits of Kangaroo mother care, why has its routine uptake been so slow?

In a randomised controlled trial carried out in Vietnam, Luong et al. (1) observed lower levels of physiological instability in low-birthweight infants who received skin-toskin Kangaroo mother care (KMC) from their mothers immediately after birth, compared with infants who received conventional postnatal care, where infants are routinely separated from their mothers. They also noted less need for respiratory support, intravenous fluids and antibiotics in the KMC group. This study replicated the 1994 Bergman & J€ urisoo study, whichwas carried out in a low resource facility in Zimbabwe (2) and found significant differences in survival between infants receiving conventional postnatal care and KMC. Luong et al. (1) emphasised the importance of preventing the separation of mothers and infants, as immediate mother to infant skin-to-skin contact provides stabilising support that enhances the infant’s adaptation to extrauterine life. The authors also recommended replicating their study in smaller infants and in countries with significant neonatal mortality, in order to further explore the potential that KMC has to prevent neonatal mortality. The KMC programme was developed in a neonatal intensive care unit (NICU) in Bogot a, Colombia, in the 1970s. The driving forces behind the programme were the lack of technical equipment and staff, high rates of crossinfection and that fact that infants were frequently abandoned. The core components of the method were defined as warmth, love and breast milk. The first report about KMC in an international scientific journal did not appear until 1985, when Whitelaw and Sleath (3) described it as continuous care of infants with skin-to-skin contact in an upright position on their mothers. They reported sending infants home from a postmenstrual age of 32 weeks and a weight from 700 g for continued skin-to-skin contact and structured follow-up at the KMC unit. They concluded that KMC would not improve survival in NICUs in developed countries, but that these units could benefit from programmes that provided similar education and motivation of mothers and lead to better infant development. The practice of positioning preterm and low-birthweight infants skin-to-skin on their mothers was also gradually introduced into high-tech NICUs in Western countries. The duration of skin-to-skin care has typically been limited to around one hour in these units and not practised on a routine, regular basis. Breastfeeding support was often disregarded, and the early discharge of infants for continued skin-to-skin care at home was not used. Therefore, the International Network for KMC clarified the definition of KMC as the early, prolonged and continuous skin-to-skin contact between a mother, or substitute, and her newborn low-birthweight infant, both in hospital and after early discharge, ideally with exclusive breastfeeding and proper follow-up (4). By early they meant as soon as possible after birth and depending on the circumstances and prolonged and continuous meant not just for a limited time in the NICU, but round-the-clock or as circumstances permitted. Research on the effects of KMC on infant survival has naturally been the main focus in settings that lack adequate healthcare resources. The first comparison between survival rates in the Bogot a KMC unit and a traditional NICU found no difference. The authors proposed that instead of survival, the infant’s quality of life, weight and development should be used as the outcome variables. A community-based study in Bangladesh, which focused on the immediate postnatal application of KMC, found no differences between the intervention and control groups with regard to the overall neonatal mortality rate or the infant mortality rate (5), which could be interpreted as indicating that the KMC method does not affect survival. However, a further data analysis showed that the daily duration of skin-to-skin care in the KMC group was less than seven hours and often merely a token application. This mode of application has been identified as particularly common in settings where mothers must work outside the home and other family members do not provide KMC. Another important prerequisite for infant health and survival, especially in deprived settings, is timely and appropriate follow-up after an infant receiving KMC is discharged early. In high-tech NICUs in affluent settings, the initial focus on evaluating KMC was infant safety. The first study of physiological stability found no differences between the infants’ status before, during and after KMC and the method was declared safe, even for small nonstabilised infants (6). Since then, numerous studies have reported the benefits of KMC for infants, parents and families, such as reducing procedural pain, earlier infant sleep regulation, enhanced