Kangaroo Mother Care prior to clinical stabilisation: Implementation barriers and facilitators reported by caregivers and health care providers in Uganda.

Kangaroo mother care (KMC) is an evidence-based method to improve newborn survival. However, scale-up even for stable newborns has been slow, with reported barriers to implementation.  We examined facilitators and barriers to initiating KMC before stabilisation amongst neonates recruited to the OMWaNA study in Uganda. A qualitative sub-study was conducted during the OMWaNA randomized controlled trial examining the mortality effect of KMC prior to stabilisation amongst newborns (700-2000g). At the four trial site hospitals, focus group discussions (FGDs) were conducted with caregivers, and separately with healthcare providers and in-depth interviews (IDIs) with caregivers (admitted/recently discharged), and key informant interviews (KII) with hospital administrators/neonatal healthcare providers. The WHO Building Blocks was used to guide thematic analysis. Eight FGDs (4 caregivers, 4 healthcare workers), 41 caregiver IDIs (26 mothers, 8 grandmothers and 7 fathers) and 23 KIIs were conducted. Key themes based on the building blocks were family and community support and involvement, health workforce, medical supplies and commodities, infrastructure and design, financing, and health facility leadership. We found availability of an additional family member in the hospital, and support from healthcare workers, were facilitators for KMC before stability. The caregiver’s positive attitude towards KMC facilitated KMC practice but was impeded by the lack of knowledge on the benefits of KMC or how to perform it. Implementation barriers included: Fear of inadvertently causing harm to the newborn, inadequate space to perform KMC in the neonatal care unit and a limited number of trained healthcare workers coupled with insufficient medical supplies. In the Ugandan government hospital setting, the presence of a family member in the hospital, adequate provision of healthcare workers knowledgeable in supporting KMC prior to stability, and adequate space for KMC beds where neonatal care is being delivered, can enable implementation of KMC before stability. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement Funded by Global Health Trials scheme of the Department of Health and Social Care, the Foreign, Commonwealth and Development Office, the Medical Research Council, and the Wellcome Trust (MR/S004971/1). A grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health (K23HD092611) awarded to Melissa Morgan also supported this work. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Uganda Virus research Institute Research Ethics Committee. London School of Hygiene and Tropical Medicine Observational / Interventions Research Ethics Committee Uganda National Council for Science and Technology I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes This was a qualitative study with no datasets, but interview scripts. The scripts are available the the Medical research Council research Unit in Uganda in case they are required