What is kangaroo mother care? Systematic review of the literature.

Globally, 44% of under–five deaths occur during the neonatal period, and the proportion of under–five deaths due to neonatal causes continues to rise [1,2]. Preterm birth (before 37 weeks gestation) accounts for 35% of neonatal deaths. Low birth weight (defined as <2500 g) is commonly used as a surrogate measure of preterm birth [3]. Preterm and low birth weight infants who survive the neonatal period are more likely to experience neonatal morbidities including acute respiratory, gastrointestinal, immunologic, central nervous system, hearing and vision problems than both term and normal weight infants [4]. A significant proportion of deaths among preterm and low birth weight infants is preventable. There is evidence that kangaroo mother care (KMC), when compared to conventional neonatal care in resource–limited settings, significantly reduces the risk of mortality in infants born in facilities who are clinically stable and weighing less than 2000 g [5]. KMC also reduces the risk of hypothermia, severe illness, nosocomial infection, and length of hospital stay, and improves growth, breastfeeding, and maternal–infant attachment [5,6]. Despite strong evidence for mortality and morbidity reduction in low– and middle–income settings and endorsement from the World Health Organization (WHO), country–level adoption and implementation of KMC has been limited. In a systematic assessment of health system bottlenecks among countries with a high burden of neonatal deaths, KMC was identified as an intervention with significant health systems barriers to scale–up including leadership and governance, health financing, health workforce, health service delivery, health information systems, and community ownership and partnership [7]. Health intervention priority–setting tools, such as the Lives Saved Tool and Child Health and Nutrition Research Initiative methodology, have identified KMC as a high priority intervention based on criteria such as mortality benefit and equity [8,9]. In response to limited global uptake of KMC, in 2013, a group of newborn health stakeholders led by the Bill and Melinda Gates Foundation and Save the Children’s Saving Newborn Lives Program launched a global KMC Acceleration Convening. The goal was to address barriers to implementation, increase uptake of KMC as part of an integrated Reproductive Maternal Newborn and Child Health package, and identify research priorities [10]. In addition to implementation barriers, a lack of a clear definition of KMC has made effective coverage at scale of KMC challenging. A multi–country study in Africa found variation in KMC implementation across facilities in countries with national commitment to KMC [11]. Regional, country, and facility differences in health worker capacity, financial resources, leadership, health information systems, and cultural and community structures create challenges to developing and adopting a global definition of KMC. The WHO has defined KMC as early, continuous, and prolonged skin–to–skin contact (SSC) between the mother and preterm babies; exclusive breastfeeding or breast milk feeding; early discharge after hospital–initiated KMC with continuation at home; and adequate support and follow–up for mothers at home [12]. While the WHO provides guidance on the components of KMC, guidance on the operationalization and clinical implementation of KMC are needed. There are significant variations in the timing of initiation, duration of SSC, positioning, necessary equipment and supplies, discharge criteria, follow–up frequency, indicators and measurement, and health workforce needs. The variations in these components have differential effects on preterm and low birth weight outcomes. As the global newborn health community begins to accelerate implementation of KMC, a standardized operational definition is needed. We conducted a systematic review of the KMC literature to 1) describe the current definitions of KMC in various settings, 2) analyze the presence or absence of WHO KMC components in each definition, and 3) present a core definition of KMC–common components that are present in at least 70% of all studies and programs–and describe how KMC definitions vary by context. This review provides a basis for development of an operational definition and clinical standards to accelerate the uptake of KMC globally.