EMPIRICAL STUDIES doi: 10.1111/j.1471-6712.2012.01040.

Provision of Kangaroo Mother Care: supportive factors and

barriers perceived by parents

Ylva Thernström Blomqvist RN, MA (PhD student), Lovisa Frölund RN, MA (Midwife), Christine
Rubertsson RN, MA, PhD (Midwife, Associate Professor) and Kerstin Hedberg Nyqvist RN, PhD (Associate
Professor)
Department of Women¢s and Children’s Health, Uppsala University, Uppsala, Sweden

Scand J Caring Sci; 2012 Results: Four categories were identified in parents’
responses regarding support and barriers for their perfor-
Provision of Kangaroo Mother Care: supportive factors
mance of KMC: Parent related factors, Time, Infants
and barriers perceived by parents
related factors and The NICU and home environment. The
Background: Kangaroo Mother Care (KMC) supports par- hospital staff and environment were described by the
ents’ role at the neonatal intensive care unit (NICU). To parents as both supportive and barriers for their application
enhance parents’ provision of KMC, it is essential to obtain of KMC. Some mothers described the infants’ feeding
knowledge of what parents perceive as supportive factors process as an obstacle to KMC. Sleeping with the infant
and barriers regarding their opportunities to perform KMC. skin-to-skin in the same position throughout the night
Aim: To identify factors that parents of preterm infants could be difficult, as an uncomfortable sleeping position
perceived as supportive factors or barriers for their per- caused insufficient sleep. A majority of both mothers and
formance of KMC and to explore the timing of and reasons fathers continued providing their infant with KMC to some
for parents’ discontinuation of KMC. extent after discharge.
Methods: A descriptive study performed at two NICUs in Conclusion: Interventions for enhancing parents’ opportu-
Sweden with 76 mothers and 74 fathers of preterm infants nities for performing KMC should address both
born at gestational ages ranging from 28 to 33 weeks. Data hospital staff attitudes and practices and the NICU envi-
on infant characteristics were obtained from the infants’ ronment.
medical records. A questionnaire, based on scientific litera-
ture and the researchers’ clinical experience, was completed Keywords: Kangaroo Mother Care, infant preterm,
by the mothers and the fathers separately, shortly after the neonatal intensive care unit, parent, staff.
infant’s discharge from the hospital. The data were analyzed
with qualitative content analysis and descriptive statistic. Submitted 20 January 2012, Accepted 29 May 2012

ents’ opportunities for being involved in their infants’ care

Introduction
at an NICU depend both on the physical environment at
Neonatal intensive care has improved considerably the last the NICU (3) and on the attitude of the healthcare pro-
decades, both in terms of medical, technical and psycho- fessionals towards supporting parents in the process of
logical care of the infants, which has led to a higher infant becoming their infants’ primary caregivers (4).
survival rate (1). The admission of an infant to a neonatal Kangaroo Mother Care (KMC) is a model of care which
intensive care unit (NICU) has traditionally implied sepa- facilitates low-birthweight infants’ transition from intra- to
ration between the new parents and their infant. However, extrauterine life and supports parents’ role at the NICU (5).
in line with advancements in neonatal care, parents’ par- It consists of early, prolonged, and continuous, or for as
ticipation in their infants’ care at the NICU has upgraded long and as often as circumstances permit, skin-to-skin
the parents from being outsiders to partners (2). The par- contact between the low-birthweight infant and her/his
mother or a substitute for her, such as the father (6). KMC
is mainly applied in two ways: continuous KMC where
parents provide the infant with skin-to-skin contact
Correspondence to:
Ylva Thernström Blomqvist, Department of Women’s and Children’s
24 hours a day as an alternative to incubator care (7) and
Health, Pediatrics, University Hospital, 751 85 Uppsala, Sweden. intermittent KMC, when skin-to-skin contact occurs for
E-mail: [email protected] limited periods, such as one or 2 hours at a time. This

 2012 The Authors

Scandinavian Journal of Caring Sciences  2012 Nordic College of Caring Science 1
2 Y.T. Blomqvist et al.

mode is usually practised when KMC around the clock is parents have the legal right to be together with their infant
not possible (5). One of the positive effects of KMC, no instead of working and thus can save their regular days of
matter whether it is practised continuously or intermit- parental leave for use after discharge. In Sweden, hospital
tently, is that parents feel they contribute to their infants’ care for all children is free of charge.
well-being and that the practice decreases their worries
about the infant (8). For simplification, the term ‘KMC’
Method
will be used here to include both continuous and inter-
mittent KMC. Mothers have described KMC as a safe This descriptive study is part of a larger Swedish project
model of care and preferred KMC to conventional care as it aimed to investigate different aspects of KMC, including
does not separate them from their infants (9). patterns of application, effects on infants and parents, and
There are several advantages of KMC, such as reduced parents’ experiences (22). All parts of this project have not
risk of hypothermia (10), as even extremely preterm yet been published.
infants are able to maintain their body temperature during
skin-to-skin contact (11), shorter duration of hospital stay
Sample
(6, 12), and positive effects on infants’ perceptual,
cognitive, emotional and physical development (13, 14). A consecutive sample of parents of infants born between
Furthermore, KMC may contribute to improved head cir- October 2008 and September 2010 at gestational ages
cumference growth (15) and better weight gain (6, 15) and ranging from 28 + 0 to 33 + 6 weeks + days was recruited
has empowering effects on the breastfeeding process (16). to the above mentioned project. Of 244 eligible infants, 121
A recent study found that Swedish mothers who practised infants did not meet the inclusion criteria which were that
KMC enjoyed having the close contact with their infant, the infant should be cared for at the same NICU from birth to
but they regarded the support and practical information discharge, the parents should master the Swedish language,
about KMC from the NICU staff as inadequate (17). Par- both parents should be willing to participate in the study,
ents who discontinued the performance of KMC before and the infant should be a singleton without any life-
their infants’ discharge from the hospital described the threatening illness. Of the 123 infants fulfilling the inclusion
NICU environment as noisy or overcrowded and com- criteria, 19 were excluded because the parents declined
plained about inadequate privacy and lack of support from participation or were recruited too late for obtaining the
the staff which precluded a gratifying experience when initial data required. The final sample of the main project
performing KMC (18). One study found that mothers who was 104 infants and their parents. Seventy-six mothers and
practised continuous KMC felt more isolated and lonely 74 fathers completed the questionnaire used to meet the aim
than those whose infants received conventional neonatal of this study. The 76 infants of the respondents were born
care (19). This feeling of isolation was more common between gestational weeks 28 and 33 and had birthweight
among mothers whose infants spent a longer time in ranging from 740 to 2920 g (Table 1).
hospital. Another reason for disliking KMC reported by
mothers was that they could not see their infant’s face and
Procedures
eyes when they performed KMC (20).
To further develop neonatal care through enabling A member of the research team asked the parents about
parents to provide KMC to the extent that they desire, also participation before the infant’s birth or within 3 days after
continuously, it is essential to investigate what parents in birth. The purpose of the project was explained to the
high tech NICUs perceive as support or obstacles for their
performance of KMC.
Table 1 Infant characteristics (n = 76)
Therefore, the aim of this study was to identify factors
parents perceived as supportive factors or barriers for their
performance of KMC (intermittent or continuous) and to N m Md SD Min–Max

explore the timing of and reasons why parents discontin- Gestational age, 76 31.8 32.1 1.5 28.42–33.86
ued caring for their preterm infants with KMC. Parents’ birth (weeks)
unrestricted presence in the NICUs was facilitated by the Birthweight (g) 76 1781 1833 459 740–2920
Swedish national insurance system, which allows both Gender: boys/girls 47/29
parents of all Swedish children to share parental benefit for Length of hospital 76 32.4 26 16.1 13–76
480 days per child to take care of their children, and ren- stay (days)
ders their unlimited presence with their infant at the NICU Discharge (PMA) 76 36.5 36.0 1.5 34.4–41
Weight at 75a 2304 2315 305 1525–3080
possible (21). In addition, both parents of an infant
discharge (g)
requiring neonatal care are entitled to ‘temporary parental
benefit’ until the infant is discharged from hospital. This PMA, postmenstrual age: corresponding to gestational age after birth.
a
means that during the infant’s whole NICU stay, both Data missing for the weight at discharge for one infant.

 2012 The Authors

Scandinavian Journal of Caring Sciences  2012 Nordic College of Caring Science
 Provision of Kangaroo Mother Care 3

parents, both orally and in writing, and the parents who for parents’ visits, but visits from siblings and relatives were
chose to participate signed a consent form. restricted to some extent.
Data on infant characteristics were obtained from the
infants’ medical records. After the infants’ discharge from
Data analysis
the neonatal unit, the mothers and the fathers completed a
questionnaire separately. The questionnaire included four All responses from the parents were analysed and reported
survey questions designed by the authors to fulfil the aim as one data set. The specific responses from the mother or
of the present study. The questions which were based on father are only described separately for topics relating to
scientific literature and the researchers’ clinical experience their specific roles, such as fathers’ responses about
were returning to work after discharge, and mothers’ statements
1. Which factors (in your family and social network and at about breast milk expression and breastfeeding.
the NICU) facilitated your provision of KMC to the ex- The parents’ responses to the open-ended questions, and
tent you desired? the free text answers to questions 3 and 4 were analysed by
2. Which factors (in your family and social network and at qualitative content analysis (23) as described by Graneheim
the NICU) rendered it difficult for you to provide your and Lundman (24). This method included the following
infant with KMC to the extent you desired? steps: first, the responses were read to obtain an under-
3. When did you discontinue KMC to the extent you used standing of their contents, and then meaning units were
it during the infants’ NICU stay? identified. The meaning units were coded according to their
4. Why did you discontinue performance of KMC? content, and these codes were grouped into categories
Questions 1 and 2 were open-ended, and questions 3 summarizing the data. Coding and development of catego-
and 4 had fixed response alternatives together with the ries were performed by the first and second authors. The
opportunity for the parents to provide answers and com- whole research group met several times during the analyt-
ments in free text. ical process to discuss and reflect on the preliminary results
The questionnaire, along with a prepaid return enve- until consensus was reached. An overview of the questions
lope, was sent home to the 104 infants’ mothers and with response rates is presented in Table 2. Data from the
fathers within 1 week after the infant’s discharge from the infants’ medical records and the fixed response alternatives
NICU. If no reply was returned within 1 week, text mes- in questions 3 and 4 were analysed by descriptive statistics
sages and E-mail reminders were sent to both the mother using the Statistical Package for Social Sciences (SPSS) ver-
and father. If no response was received after 2 weeks, a sion 18.0 for Windows (SPSS Inc., Chicago, IL, USA). The
letter of reminder, a new questionnaire and a prepaid results are presented in four sections based on the four
return envelope were sent home to the parents. questions in the questionnaire.

Settings Ethical considerations

This study was conducted at the level III NICUs in two The parents were informed both orally and in writing that
Swedish university hospitals. In both NICUs, mothers and their participation was voluntary and that they could
fathers were encouraged to be together with their infant, choose not to participate or withdraw from the study
participate in the infant’s care, and provide the infant with without having to give any explanation, and that non-
KMC as much as they wanted to and found possible. One participation would not influence their infants’ care. A
NICU had three intensive care nurseries, each with four care signed consent form was obtained from the parents during
spaces. Every care-space included an adult bed and privacy
screens to allow the parents to be close to their infant
Table 2 Overview of the parents’ responses to the questions in the
24 hours/day. The unit also had nine family rooms, where questionnaire and number of parents who responded each question
both parents and siblings could stay together with the infant
during the whole hospital stay and provide the infant’s care
Questions N
with support by the nurses. There were no visiting restric-
tions for parents, siblings or relatives. The other NICU had Factors perceived by parents as facilitating 61 mothers
one intensive care nursery with care spaces for five infants. their performance of KMC 54 fathers
Every care-space included one or two arm chairs/recliners Barriers perceived by parents regarding their 68 mothers
with footstools, where parents could sit holding their infant. performance of KMC 58 fathers
There were two parent rooms, where one or both parents Discontinuation of KMC 76 mothers
74 fathers
could room-in with their infant a few nights before dis-
Reasons why parents discontinued perfor- 54 mothers
charge, depending on the current census at the NICU. The
mance of KMC 53 fathers
parents could be together with their infants as much as they
wished during daytime. There were no visiting restrictions KMC, Kangaroo Mother Care.

 2012 The Authors

Scandinavian Journal of Caring Sciences  2012 Nordic College of Caring Science
4 Y.T. Blomqvist et al.

their infants’ hospital stay. Confidentiality was protected infant’s signals he/she liked being skin-to-skin rendered
by deidentification of data and the list of participants was KMC easier. The parents also found it easier to perform
kept in a looked office. The Research Ethics Committee of KMC if the infant required KMC for maintaining normal
the Medical Faculty at Uppsala University, Sweden, body temperature. The fact that infants in the NICU are not
approved the study (Dnr 2006/313/1). dressed was also identified as a facilitating factor for KMC,
otherwise it would have been inconvenient to dress and
undress the infants all the time.
Results
The NICU environment. The parents felt it was safe to care
Factors perceived by parents as supportive for their performance
for the infant with KMC at the NICU. The extent of their
of KMC
use of KMC was facilitated by access to a private space, a
Parent-related factors. The parents supported each other, by quiet atmosphere and being able to shut out staff and
encouraging one another and by taking turns, as they other parents with privacy screens in the nursery and in a
‘shared the job’ of performing KMC. family room, and the opportunity to stay overnight at the
"We took turns in providing our baby’s care using Kangaroo NICU. The parents appreciated that the hospital furniture
Mother Care after each feeding, so we had opportunities to was appropriate for their special needs, such as comfort-
rest in between". able armchairs and height-adjustable beds. Wireless and
Support by the parents’ significant others was an impor- portable monitoring equipment was also helpful.
tant facilitating factor regarding their opportunities to
perform KMC at the NICU. They assisted by preparing and
Factors perceived by parents as barriers for their performance of
bringing meals and helping with laundry, which enabled
KMC
the parents to spend more time with the infant in hospital.
Obliging and competent NICU staff facilitated the par- Parent-related factors. There were NICU routines that
ents’ use of KMC. Information and practical advice about restricted parents’ opportunities to perform KMC to the
KMC, and assistance and encouragement to take the infant extent they desired. For example, one NICU had a routine
out of the incubator, and bringing parents something to that did not permit parents to be present with the infant
drink, was considered valuable. Parents also appreciated during medical rounds because of secrecy. A lack of
when staff confirmed the infant had a satisfactory position information about KMC, and how to use it in practice, also
during KMC and the KMC-carrier had a good fit. presented an obstacle to KMC.
"The staff were obliging and encouraging about our use of Staff attitudes could be a barrier to KMC. Some staff
Kangaroo Mother Care". members were noisy and disturbed parents when they
The parents also mentioned the government as a sup- performed KMC without asking for permission or without
portive factor as it provided both parents with temporary a justified reason. Sometimes staff did not have enough
parental benefit during the infants’ entire NICU stay. This time to help to position the infant on a parent’s chest,
enabled the parents to stay home from work and care for which resulted in delayed and shorter KMC sessions.
their infants with KMC instead. Maternity ward staff did not always encourage mothers to
be at the NICU together with their infants.
Time. The parents reported there were fewer ‘musts’ at Parents’ own physical limitations, such as mothers’ pain
the NICU than at home, which supported their use of after a caesarean section and backache rendered KMC
KMC. At the NICU, it was possible to disregard everyday difficult. Everyday needs, both at home and at the NICU,
chores and focus only on the infant. Some parents appre- such as eating, going to the toilet, taking a shower and
ciated that they could perform KMC without any limita- resting limited the time spent with KMC. Some parents felt
tions at the NICU, others stated that there was nothing else frustrated at not being able to move about as much as they
to do. wanted when they performed KMC. Being a sole caregiver
"In the hospital, all we had to care about was our baby. So at the NICU limited the extent of KMC, as it was difficult to
we could perform Kangaroo Mother Care without any perform KMC 24 hours a day alone. Furthermore, the
interruptions 24 hours per day". parents’ desire to spend time on their own was recognized
as an obstacle. At home, after the infant’s discharge from
Infant-related factors. Kangaroo Mother Care was one way hospital, parents wanted to have more mobility than was
of getting to know and being close to the infant. possible with the infant skin-to-skin. A notable part of the
"It (KMC) was also a way of getting closer to my baby or else parents stated there were no problems at all with providing
he would just lie connected to lots of equipment". their infants with KMC, neither in hospital nor at home.
Parents’ conviction that KMC was good for the infant in-
creased their willingness and motivation and promoted Time. Several parents felt divided between the infant at
their use of KMC. Such perceived benefits included the the NICU and the family, they wanted to be at the NICU

 2012 The Authors

Scandinavian Journal of Caring Sciences  2012 Nordic College of Caring Science
 Provision of Kangaroo Mother Care 5

with the infant and at home with the rest of the family at In the intensive care nurseries with several infants in the
the same time. The parents who were unable to stay same room, it could be difficult to rest, as the sound level
overnight at the NICU felt that commuting between the could be high, especially when several infants cried at the
home and the NICU deprived them of the time they would same time. In addition to infants and parents, the presence
rather have spent together with the infant. of NICU staff contributed to increasing the sound level.
Siblings took a lot of time at home. They also needed Lack of privacy was perceived as an obstacle to KMC, as
their parents’ attention and company in connection with there was limited available space and an inadequate
activities, and baby-sitting had to be arranged. At the NICU, number of screens to provide sufficient privacy when the
it was difficult if siblings could not stay overnight with the parents had the infant skin-to-skin. Feeling uneasy with
parents and the infant, and it was time-consuming to have being undressed in front of strangers was common. Gen-
an infant at the NICU and siblings at home. erally, it could be difficult to maintain a private atmo-
Lack of time was perceived as a barrier for KMC, but sphere in the NICU.
there was more time for KMC at the NICU than at home. Inappropriate furniture at the NICU made it difficult to
At home, there were necessary everyday household tasks perform KMC. Several parents missed comfortable arm-
to manage besides KMC, such as buying food, cooking, chairs and beds for KMC. Uncomfortable beds caused
washing, cleaning and taking care of laundry. Visitors at physical problems such as backache. Some parents
home could be a further hindrance to KMC. After the reported the furniture they had home was not suitable for
infants’ discharge from the NICU, the fathers faced short- KMC.
age of time when they went back to work.

Discontinuation of KMC
Infant-related factors. The mothers described the feeding
process as an obstacle to KMC, as feeding, breastfeeding Only a few parents stopped using KMC before discharge.
and breast milk expression caused interruptions in the A majority reported they continued caring for their infant
skin-to-skin contact. with KMC to some extent after discharge, but some dis-
Sleeping with the infant skin-to-skin in the same posi- continued KMC as soon as they came home (Fig. 1). Among
tion throughout the night could be difficult, as an parents who responded they still performed KMC after dis-
uncomfortable sleeping position caused insufficient sleep. charge, a majority provided KMC at times that suited them
At the NICU, the medical equipment to which the infant and when they enjoyed it (Fig. 2). For example, some per-
was attached made KMC complicated and limited parents’ formed KMC only during night-time, whereas others only
mobility. Tangled wires, noise and beeps from machines did so during day-time. Few parents reported performance
were disturbing, and alarms stressed the parents. A lack of of KMC around the clock at home.
KMC-carriers, both generally and in their own size, made
it difficult to perform KMC, although some parents con-
Reasons for discontinued performance of KMC
sidered use of the KMC-carriers complicated. In addition, it
could be difficult to attach the pulse oxymeter, and ECG Parents’ responses to the fixed response alternatives in the
probes to the infant when a KMC-carrier was used. questionnaire are presented in Fig. 3. Few parents stated
Fear that the infant would stop breathing during KMC that the infant did not want the kangaroo position any-
also contributed to decreasing the application of KMC. more and that the infant became too hot. The majority
Infant medical status such as hyperthermia also compli-
cated KMC. One infant became cyanotic and stopped
breathing during KMC, and another infant had a swollen
abdomen, which rendered KMC impracticable. Some par-
ents expressed the opinion their infant did not appear to
like KMC and that the introduction of baby clothes
decreased the use of KMC.

Neonatal intensive care unit and home environment. Limited

facilities for the parents at the NICU hampered the extent of
KMC. Some parents complained that there were too
few single rooms where parents could stay overnight with the
infant. Some parents were never offered the opportunity to
stay overnight with the infant at the NICU. Figure 1 Parents responses to the fixed response alternatives to the
‘During the first period of his hospital stay we were not question: When did you discontinue Kangaroo Mother Care (KMC) to
allowed to stay overnight and sleep in the hospital, so many the extent you used it during the infants’ neonatal intensive care unit
hours when we could have been close disappeared.’ stay? ‘Other’ indicates parents’ free responses.

 2012 The Authors

Scandinavian Journal of Caring Sciences  2012 Nordic College of Caring Science
6 Y.T. Blomqvist et al.

Lack of KMC-carriers. At home, the mothers missed the

KMC-carrier they had borrowed during the NICU stay, as it
was more difficult to perform KMC without it.

Did not quit completely. It was easier for parents to perform

KMC during the evenings and nights, because of every-
thing that needed to be performed at home in daytime.

Figure 2 Parents, who still performed Kangaroo Mother Care (KMC) to

Closeness with clothes. Many parents felt that they could be
some extent at home: time of the day when they performed KMC.
close to the infant without KMC at home. Instead they had
Some parents gave several answers.
their infant lying on their chest, wearing baby clothes.
‘I often have her on my chest or in a sling, but then she is
dressed, and I can unbutton my clothes so her head is
positioned directly on me.’

Discussion
This study is probably the first investigation of what par-
ents in a high tech NICU setting in an affluent society
perceived as supportive factors and barriers for their
application of KMC, ranging between various degrees of
intermittent use of KMC to continuous (24/7) KMC.
Factors of particular importance for these parents’ per-
Figure 3 Parents responses to the fixed response alternatives to the formance of KMC to the extent they wanted included
question: Why did you discontinue performance of Kangaroo Mother support from the infant’s other parent and the NICU staff,
Care (KMC)? ‘Other’ indicates parents’ free responses. the opportunity to stay with the infant around the clock
during the whole hospital stay, and sufficient privacy at
the NICU. The NICU staff’s attitude strongly affected the
described reasons for discontinuation of KMC in free text parents’ choice of and opportunities to perform KMC,
as reported below. however, both in a positive and negative way. KMC-
carriers were considered both as helpful and as too
The infant did not need KMC any more. When the infant complicated. The mothers particularly perceived the in-
grew well, kept warm with clothes, and the parents per- fants’ feeding process as a barrier, whereas the fathers
ceived her/him as stable and no longer premature, it felt highlighted return to work after the infants’ discharge as
awkward to have the infant without clothes and perform an obstacle. After discharge, most parents continued per-
KMC. Some parents reported they stopped with KMC be- formance of KMC to some extent, often timing KMC when
cause the infant did not want it any more, others because it suited them. Reasons for discontinuation of KMC faced
he/she was too warm. by both parents were the father’s return to work, lack of
time because of household tasks and siblings’ needs. After
Back to work. When the fathers returned to work after the discharge, several parents preferred to achieve closeness to
infant’s discharge from the NICU, they did not have time the infant in other ways than using KMC, such as lying
for KMC. with the dressed infant on their chest.

Uncomfortable and unpractical. Several mothers described

Supportive factors and barriers for KMC
KMC as uncomfortable and unpractical to continue at
home. Once the father started working again, the mothers Regarding supportive factors and barriers, the same four
were alone at home, which rendered KMC inconvenient categories could act both as support and barriers for parents’
and made them feel restricted. performance of KMC. Parents defined NICU staff support as
positive encouragement, information and practical assis-
Time constraints related to siblings and everyday tasks. At tance to the parents. The importance of continuous infor-
home, both mothers and fathers felt it was difficult to find mation to parents of infants at an NICU is important, and the
enough time to perform KMC. Life at home was different type of information parents need has been explored (25). It
from life at the NICU. Siblings could be jealous and is essential that staff understand and confirm the mother’s
demand attention, and household chores took time. The individual needs (26), as mothers find it is easier to voice
mothers perceived breastfeeding took a lot of time. what they desire when they perceive they are understood

 2012 The Authors

Scandinavian Journal of Caring Sciences  2012 Nordic College of Caring Science
 Provision of Kangaroo Mother Care 7

and ‘seen’ by staff, (27). However, the NICU staffs’ attitude KMC. This is unfortunate, as Sweden is a country where
and behaviour at the infant’s care-space could also hamper breastfeeding is the norm, and many mothers connect
KMC, for example, by staff being loud and disturbing the breastfeeding with good motherhood (32).
parents when they had the infant skin-to-skin. This finding Furthermore, in the present study, the design of the NICU
is in line with finding from another study where mothers of environment was crucial for the parents’ opportunities for
preterm infants perceived that there was lack of privacy in performing KMC to that extent they wanted. Similar to what
the NICU (28). Moreover, the mothers were disturbed by was found by Neu (18), the parents stated that the extent of
noise and personal conversations among the staff at the their use of KMC was facilitated by access to a private space,
NICU. As long as the infant is stable, it is important for the family rooms and the opportunity to stay overnight at the
family to be together without disturbance (29). Further- NICU. The importance of the physical environment at the
more, parents noticed differences in opinions on the NICU for parents’ experiences of and opportunities for KMC
encouragement of closeness between the infant and the has been highlighted previously (22). Single-family rooms
parents between NICU staff members as well as between allow infants to be cared for in an environment where they
NICU staff and maternity ward staff. They perceived this as a are protected from stimuli emanating from caregiving and
factor that hindered them from applying KMC. Negative social activities occurring at adjacent care spaces (33).
staff attitudes to parent–infant closeness are contrary to Therefore, single rooms are preferable, as they allow privacy
parents’ preference, as parents have a strong desire to be for the whole family, including siblings and provide parents
close to their infants and perceive separation from the infant with optimal opportunities for becoming their infant’s pri-
as stressful (27, 29). Engler et al. (30) found that nurses mary caregivers, without unfounded delay.
from NICUs that practice KMC seem to have positive per-
ceptions of KMC, about its appropriates and its advantages,
Discontinuation of KMC
but concluded that KMC is an example of nursing practice
that is based on perceptions rather than scientific evidence. An interesting finding is that several parents continued the
Despite research that supports the application of KMC in practice of KMC at home to some extent. This indicates
preterm infants, nurses have voiced concerns whether KMC that parents do not perceive KMC as an obligation to
is appropriate and safe for some preterm infants (31). perform in hospital but as a pleasurable way of being close
In contrast with a study by Tessier et al. (19), no parents in to their baby.
the present study described feelings of isolation or loneliness The reason for combining parents’ responses into one
while they performed KMC. Possible reasons for this are that data set was that the aim was not to compare the parents’
these parents had the opportunity to share the KMC with statements, but to describe what they perceived as sup-
the other parent, and that both study NICUs had generous portive factors or barriers regarding their performance of
visiting guidelines, which allowed the parents to receive KMC. One limitation of this study was that the study
visitors while they were at the NICU with the infant and sample consisted of parents from two high tech NICUs in a
performed KMC. The importance of parents’ turn-taking in Western country with a breastfeeding culture. Therefore,
sharing the task of performing KMC has been noted previ- the results can only be generalized to similar settings.
ously (22). Other researchers have reported mothers dis- Conversely, the sample was large, and data collection oc-
liked KMC because they could not see their infant’s face and curred during 2 years, which supported generalization of
eyes when performing KMC (20). In the present study, no the results. Nevertheless, differences between Sweden and
parent mentioned this, probably because, in both NICUs, other countries in terms of provision for parental leave and
parents were routinely offered hand mirrors to use during maternal/parental benefit after an infant’s birth must be
KMC so they could see their infant’s face. considered in research on parents’ role in the care of their
Family life was affected by the infant’s care and the infants at the NICU and after discharge.
parents’ presence at the NICU. Some parents perceived a
lack of time as they felt torn between the family at home
Recommendations for practice
and the infant at the NICU, and it was stressful for both
parents to have older siblings at home. Other researchers The NICU staff attitudes and environment had crucial
have also found that mothers wanted to be both at home influence on these parents’ opportunities for performing
with older siblings and at the NICU with the infant (29). KMC and could be both supportive and act as barriers. Thus,
An infant factor that negatively affected mothers’ use of it is important that all NICU staff members understand their
KMC was the procedures surrounding the infant’s feeding, importance for parents’ use of KMC and have sufficient
as they intervened with KMC. For example, mothers knowledge about the advantages of KMC and practical skills
discontinued KMC in connection with breast milk to assist and support parents to enable them to perform KMC
expression. If mothers perceive that breast milk expression to the extent that they desire. Furthermore, the NICU
or breastfeeding does not work, is stressful or complicated; environment should be improved to become as family-
this may aggravate other existing barriers to performing centred as possible and give both verbal and nonverbal

 2012 The Authors

Scandinavian Journal of Caring Sciences  2012 Nordic College of Caring Science
8 Y.T. Blomqvist et al.

messages that invite parents to stay with their infant around Christine Rubertsson and Kerstin Hedberg Nyqvist partic-
the clock and perform KMC as much as they wish. Some ipated in the data analysis; Ylva Thernström Blomqvist was
tiring aspects of parents’ role as the infant’s caregiver, such responsible for the drafting of the manuscript; Ylva Ther-
as sleeping with the infant in the kangaroo position and nström Blomqvist, Lovisa Frölund, Christine Rubertsson
breast milk expression, may act as barriers for KMC. To and Kerstin Hedberg Nyqvist made critical revisions to the
reduce these barriers, it is essential to offer parents comfortable paper for important intellectual content; Ylva Thernström
beds in family rooms and nurseries, counsel on different breast Blomqvist obtained funding; Kerstin Hedberg Nyqvist
milk expression techniques and foster a sensitive helping and supervised the study.
supportive attitude among all NICU staff.

Funding
Acknowledgements
This study was funded by the Regional research council in
The authors would like to express their deep gratitude to the Uppsala-Örebro regions, Uppsala county council and
the all the parents who generously shared their experi- the Gillbergska foundation.
ences with us.

Conflict of interest statement

Author contributions
We have no conflict of interest to declare.
Ylva Thernström Blomqvist, Christine Rubertsson and
Kerstin Hedberg Nyqvist were responsible for the study
Ethical approval
conception and design; Ylva Thernström Blomqvist
performed the data collection; Ylva Thernström Blomqvist The Research Ethics Committee of the Medical Faculty at
and Lovisa Frölund performed the first steps of the data Uppsala University, Sweden, approved the study (Dnr
analysis; Ylva Thernström Blomqvist, Lovisa Frölund, 2006/313/1).

Setyowireni D, Quintero S, Tamburlini 11 Maastrup R, Greisen G. Extremely

References
G. Kangaroo mother care for low preterm infants tolerate skin-to-skin
1 EXPRESS Group One-year survival of birthweight infants: a randomized contact during the first weeks of life.
extremely preterm infants after active controlled trial in different settings. Acta Paediatr 2010; 99: 1145–9.
perinatal care in Sweden. JAMA 2009; Acta Paediatr 1998; 87: 976–85. 12 Charpak N, Ruiz-Pelaez JG, Figueroa
301: 2225–33. 7 Charpak N, Ruiz JG, Zupan J, Catta- de CZ, Charpak Y. A randomized,
2 Thomas LM. The changing role of parents neo A, Figueroa Z, Tessier R, Cristo controlled trial of kangaroo mother
in neonatal care: a historical review. M, Anderson G, Ludington S, Men- care: results of follow-up at 1 year of
Neonatal Netw 2008; 27: 91–100. doza S, Mokhachane M, Worku B. corrected age. Pediatrics 2001; 108:
3 Wigert H, Hellstrom AL, Berg M. Kangaroo Mother Care: 25 years 1072–9.
Conditions for parents’ participation in after. Acta Paediatr 2005; 94: 514–22. 13 Feldman R, Weller A, Sirota L,
the care of their child in neonatal 8 Tallandini M, Scalembra C. Kangaroo Eidelman AI. Skin-to-Skin contact
intensive care – a field study. BMC mother care and mother-premature (Kangaroo care) promotes self-regu-
Pediatr 2008; 8: 3. infant dyadic interaction. Infant Ment lation in premature infants: sleep-
4 Nyqvist KH, Engvall G. Parents as their Health J 2006; 27: 251–75. wake cyclicity, arousal modulation,
infant’s primary caregivers in a neo- 9 Ibe OE, Austin T, Sullivan K, and sustained exploration. Dev Psychol
natal intensive care unit. J Pediatr Nurs Fabanwo O, Disu E, Costello AM. A 2002; 38: 194–207.
2009; 24: 153–63. comparison of kangaroo mother care 14 Feldman R, Eidelman AI, Sirota L,
5 Nyqvist KH, Anderson GC, Bergman N, and conventional incubator care for Weller A. Comparison of skin-to-skin
Cattaneo A, Charpak N, Davanzo R, thermal regulation of infants < 2000 (kangaroo) and traditional care: par-
Ewald U, Ludington-Hoe S, Mendoza S, g in Nigeria using continuous enting outcomes and preterm infant
Pallás-Allonso C, Peláez JG, Sizun J, ambulatory temperature monitor- development. Pediatrics 2002; 110: 16–
Wiström AM; Expert Group of the In- ing. Ann Trop Paediatr 2004; 24: 26.
ternational Network on Kangaroo Mo- 245–51. 15 Suman RP, Udani R, Nanavati R.
ther Care. State of the art and 10 Bergman NJ, Linley LL, Fawcus SR. Kangaroo mother care for low birth
recommendations. Kangaroo mother Randomized controlled trial of skin- weight infants: a randomized con-
care: application in a high-tech envi- to-skin contact from birth versus trolled trial. Indian Pediatr 2008; 45:
ronment. Acta Paediatr 2010; 99: 812–9. conventional incubator for physio- 17–23.
6 Cattaneo A, Davanzo R, Worku B, logical stabilization in 1200- to 2199- 16 Flacking R, Ewald U, Wallin L. Posi-
Surjono A, Echeverria M, Bedri A, gram newborns. Acta Paediatr 2004; tive effect of kangaroo mother care on
Haksari E, Osorno L, Gudetta B, 93: 779–85. long-term breastfeeding in very

 2012 The Authors

Scandinavian Journal of Caring Sciences  2012 Nordic College of Caring Science
 Provision of Kangaroo Mother Care 9

preterm infants. J Obstet Gynecol Neo- infants gain confidence in the pater- 29 Lindberg B, Ohrling K. Experiences of
natal Nurs 2011; 40: 190–7. nal role. J Adv Nurs 2011. [Epub having a prematurely born infant
17 Blomqvist YT, Nyqvist KH. Swedish ahead of print]. from the perspective of mothers in
mothers’ experience of continuous 23 Krippendorff K. Content Analysis. An northern Sweden. Int J Circumpolar
Kangaroo Mother Care. J Clin Nurs Introduction to Its Methodology. 2004, SAGE Health 2008; 67: 461–71.
2011; 20: 1472–80. Publications, Thousands Oaks, CA. 30 Engler AJ, Ludington-Hoe SM, Cusson
18 Neu M. Parents’ perception of skin-to- 24 Graneheim UH, Lundman B. Quali- RM, Adams R, Bahnsen M, Brambaugh
skin care with their preterm infants tative content analysis in nursing re- E, Coates P, Grieb J, McHargue L, Ryan
requiring assisted ventilation. J Obstet search: concepts, procedures and DL, Settle M, Williams D. Kangaroo
Gynecol Neonatal Nurs 1999; 28: measures to achieve trustworthiness. care: national survey of practice,
157–64. Nurse Educ Today 2004; 24: 105–12. knowledge, barriers, and perceptions.
19 Tessier R, Cristo M, Velez S, Giron M, de 25 De Rouck S, Leys M. Information MCN Am J Matern Child Nurs 2002; 27:
Calume ZF, Ruiz-Palaez JG, Charpak Y, needs of parents of children admitted 146–53.
Charpak N. Kangaroo mother care and to a neonatal intensive care unit A 31 Flynn A, Leahy-Warren P. Neonatal
the bonding hypothesis. Pediatrics 1998; review of the literature (1990–2008). nurses’ knowledge and beliefs
102: e17. Patient Educ Couns 2009; 76: 159–73. regarding kangaroo care with preterm
20 Anderson GC, Chiu SH, Dombrowski 26 Wigert H, Johansson R, Berg M, infants in an Irish neonatal unit. J
MA, Swinth JY, Albert JM, Wada N. Hellstrom AL. Mothers’ experiences Neonatal Nurs 2010; 16: 221–8.
Mother-newborn contact in a ran- of having their newborn child in a 32 Flacking R, Ewald U, Starrin B. ‘‘I
domized trial of kangaroo (skin-to- neonatal intensive care unit. Scand J wanted to do a good job’’: experi-
skin) care. J Obstet Gynecol Neonatal Caring Sci 2006; 20: 35–41. ences of ‘becoming a mother’ and
Nurs 2003; 32: 604–11. 27 Erlandsson K, Fagerberg I. Mothers’ breastfeeding in mothers of very
21 Forsakringskassan. The Swedish Social lived experiences of co-care and part- preterm infants after discharge from a
Insurance Agency. 2010, Information care after birth, and their strong de- neonatal unit. Soc Sci Med 2007; 64:
retrived from www.forsakringskas- sire to be close to their baby. Mid- 2405–16.
san.se on (last accessed 27 May 2010). wifery 2005; 21: 131–8. 33 White RD. The newborn intensive
22 Blomqvist YT, Rubertsson C, Kylberg 28 Neu M. Kangaroo care: is it for care unit environment of care: how
E, Joreskog K, Nyqvist KH. Kangaroo everyone? Neonatal Netw 2004; 23: we got here, where we’re headed, and
Mother Care helps fathers of preterm 47–54. why. Semin Perinatol 2011; 35: 2–7.

 2012 The Authors

Scandinavian Journal of Caring Sciences  2012 Nordic College of Caring Science