Evaluation of Kangaroo mother care implementation after the DIB project in three health facilities in the central region of Cameroon

Abstract

Background

Neonatal mortality remains high in Cameroon, stagnating at 28 per 1,000 live births since 2014 according to the 2018 Demographic and Health Survey (DHS). As part of the strategy to reduce this mortality, the Development Impact Bond (DIB) project was implemented in ten health facilities in Cameroon from January 2019 to January 2021, over a two-year period. Our objective was to determine the level of implementation of Kangaroo Mother Care (KMC) and its effect on neonatal mortality in three health facilities in the Centre region.

Methods

We conducted a cross-sectional study using a mixed-methods approach (quantitative and qualitative) with simultaneous triangulation and retrospective data collection. To assess the level of KMC implementation, we adopted the progress monitoring model proposed by Bergh et al. in [1]. On the qualitative side, we used an observation grid and a semi-structured interview guide to collect participants’ accounts across the different phases of KMC implementation. We also analyzed mortality trends throughout the implementation process.

Results

Analysis of the post-DIB project evaluation indicated that all assessed health facilities had progressed to the institutionalization stage according to the measurement framework developed by Bergh et al. in [1]. Scores obtained were 24.5, 25, and 27.5 out of 30 points for YGOPH, YUTH, and BDH respectively. However, although positioned at the institutional level, none of these care centers had achieved sustainable KMC practice. During the program implementation phase, a gradual decrease in mortality was documented, with reduction ratios of 1.6, 2, and 4 times for YGOPH, YUTH, and BDH respectively. An upward mortality trend was observed in two first-category urban health facilities, particularly YUTH and YGOPH. Several barriers appeared to explain this deterioration in outcomes once the project ended. Notable gaps were observed in the involvement of administrative leadership, motivational burnout among caregivers, staff turnover, and the discontinuation of free emergency services and financial incentives that had characterized the DIB implementation phase.

Conclusion

Following the DIB project, and with the support of other neonatal care strategies, the level of KMC implementation had reached the institutionalization stage in all health facilities. Two of them were on the “path” toward sustainable KMC practice without having fully achieved it. A mortality rebound was observed six months after the end of the DIB project. Several barriers to KMC implementation could help explain the failure to progress toward sustainable practice, owing to certain instabilities caused by managerial, social, technical, and environmental challenges.

Background

Kangaroo Mother Care (KMC) is a therapeutic approach designed for premature and/or low-birth-weight newborns. It rests on three fundamental pillars: maintaining direct skin-to-skin contact between the newborn and the mother (or another substitute caregiver), nutrition based on exclusive breastfeeding, and early, anticipated hospital discharge [2]. In our context, prematurity is one of the leading causes of neonatal mortality [3]. This neonatal mortality remains high in Cameroon, stagnating at 28 per 1,000 live births since 2014 according to the 2018 Demographic and Health Survey (DHS) [3]. To reduce this mortality, Cameroon adopted WHO recommendations in 2017 aimed at promoting KMC in all developing countries [4]. The Development Impact Bond (DIB) project was implemented in ten health facilities in Cameroon over a two-year period (January 2019 to January 2021), with the objective of establishing quality KMC practice in Cameroon [5]. Six months after the project ended, we conducted this study to determine the level of KMC implementation and its effect on neonatal mortality in three health facilities in the Centre region of Cameroon.

Methods

We conducted a cross-sectional study using a mixed-methods approach (quantitative and qualitative) with simultaneous triangulation and retrospective data collection. The sites included in our study were referenced within Cameroon’s health pyramid, which is organized into three main levels from base to apex.

At the base lies the peripheral level, comprising integrated health centers (IHC) and district medical centers, which constitute the first point of contact with the population. At the intermediate level are district hospitals (such as BDH), classified as second-category facilities. At the apex of the pyramid is the central level, composed of regional hospitals (first category) as well as central and general hospitals (such as YGOPH and YUTH. First-category hospitals, which include regional and central hospitals, have a capacity of at least 200 beds, are staffed with specialist physicians, and offer multiple specialties including cardiology, nephrology, neurology, and neonatology. District hospitals are primarily staffed with general practitioners and provide basic services including general medicine, general surgery, pediatrics, and maternity care. Their technical capacity remains basic, encompassing radiology, a simple laboratory, and ultrasound. They perform minor surgery and caesarean sections, and serve a single health district (Table 1).

Table 1.

Characteristics of the Cameroonian Health Pyramid

Level	Category	Type of Facility	Capacity (beds)	Medical Staff	Services Offered	Technical Platform	Catchment Area
Peripheral (Base)	3rd	Integrated health centers (IHC), District medical centers	< 50	Nurses, midwives	Primary healthcare, prenatal consultations, simple deliveries	Basic (small laboratory, essential medicines)	Local community
Intermediate	2nd	District hospitals (e.g., HDB)	50–150	General practitioners, specialized nurses	General medicine, minor surgery, pediatrics, maternity, cesarean sections	Basic (radiology, simple laboratory, ultrasound)	Health district
Central (Top)	1st	Regional, central and general hospitals (e.g., CHUY, HGOPY)	≥ 200	Specialist physicians (neonatologists, pediatricians, surgeons, etc.)	Multiple specialties: cardiology, nephrology, neurology, neonatology, major surgery	Advanced (CT scan, MRI, resuscitation, intensive care)	Multiple districts or entire region

Legend: HDB Bafia District Hospital, CHUY Yaoundé University Teaching Hospital, HGOPY Yaoundé Gynecology, Obstetrics and Pediatrics Hospital

Our study sites were three health facilities in the Centre region of Cameroon involved in the “Cameroon Neonatal DIB” project: the Yaoundé University Teaching Hospital (YUTH), the Yaoundé Gynecology, Obstetrics and Pediatrics Hospital (YGOPH), and the Bafia District Hospital (BDH). YUTH and YGOPH are first-category health facilities within the Cameroonian health pyramid, while BDH is a fourth-category hospital. In terms of health services, YUTH and YGOPH had highly qualified human resources (neonatologists, pediatricians, specialized nurses, etc.), while the neonatology unit at BDH was managed by a midwife trained in KMC prior to the DIB project.

Regarding infrastructure, all three health facilities were equipped with the basic installations required for KMC practice, namely one or more incubator rooms, a mother-infant room, and outpatient consultation rooms.

From a technical standpoint, the KMC care protocol was standardized across all health facilities included in our study. It was based on the KMC care guide proposed and validated by the Fundación Canguro of Colombia. Under this protocol, Kangaroo Mother Care (KMC) is indicated for premature newborns born before 37 weeks of gestation, regardless of weight, as well as for all newborns weighing less than 2,500 g (low birth weight). This therapeutic approach is founded on the skin-to-skin principle and rests on three essential components: the kangaroo position, kangaroo nutrition based on breastfeeding, and outpatient follow-up. Initiating KMC requires a rigorous assessment of the eligibility of the newborn, the carrier, and the family.

The baby must demonstrate clinical stability characterized by regular breathing without bradycardia or cyanosis, good skin color, and the absence of seizures and fever. No lower limit of weight or gestational age is imposed. The carrier, who is generally the mother, must voluntarily agree to carry the baby following adaptation counseling, be fully available, in good health, and committed to medical follow-up. The family must also accept the method, support the mother, and participate in consultations. The kangaroo adaptation phase is the preliminary step allowing the carrier to understand the principles of KMC, accept them, and practice them under medical supervision, while strengthening the mother-infant bond.

Kangaroo position

This fundamental component consists of continuous skin-to-skin contact between the mother and the infant, placed vertically between the maternal breasts, ideally 24 h a day with a minimum of 2 consecutive hours. The infant, dressed only in a hat, diaper, and booties, is held in place by an elastic support that prevents obstruction of the airway. Bergh and colleagues define prolonged positioning as more than 20 h per day, which is correlated with better weight gain. This position warms the infant, strengthens the maternal bond, and protects against external agents. It is maintained until approximately 40 weeks of corrected age, when the infant no longer tolerates it.

Kangaroo nutrition

Exclusive breastfeeding for six months constitutes the nutritional cornerstone, administered orally according to the premature infant’s sucking capacity. Staff should preferentially encourage this approach; accordingly, any prescription of breast milk substitute must be justified and documented in the medical record. Three stages of sucking maturation are distinguished: immature sucking (3 to 5 bursts, requiring cup or tube feeding), transitional sucking (5 to 10 bursts), and mature sucking (more than 10 continuous bursts). This daily sucking assessment enables day-to-day adaptation of the feeding route. The practice targets a weight gain of 15 g/kg/day, mimicking fetal growth in utero up to 40 weeks of corrected age. Supplementation with vitamins A, D, E, C, and B9 is considered only after ruling out various causes: incorrect breastfeeding position, maternal stress, insufficient milk production, breast pathologies, intercurrent infections, and neonatal anemia.

Discharge and outpatient follow-up

Hospital discharge is based on successful kangaroo adaptation, coordinated sucking-swallowing-breathing, normal weight gain over two consecutive days, and the family’s commitment to follow-up. Weight and age are not determining criteria for patient discharge. Once discharged, the newborn must return for appointments twice a week for the first two weeks, then once a week, then once every two weeks, and finally once a month until the age of one year. In practice, multidisciplinary outpatient follow-up involves a psychologist, physiotherapist, ophthalmologist, ENT specialist, and cardiologist. After 40 weeks of corrected age, high-risk follow-up continues until the age of two to enable early detection of neuropsychomotor and sensory developmental disorders, KMC offering a unique opportunity for close monitoring of these vulnerable children (MINSALUD).

For compliance purposes in our context, the above protocol was adapted to our practice conditions in a low-resource country setting. This concerned specifically the number of hours in the kangaroo position, which was reduced to one hour per day instead of the 24-hours-a-day standard in Colombia, where families benefit from hospital and home amenities that facilitate constant kangaroo carrying and more visible outcomes. It was also necessary to adapt existing infrastructure to meet the standards set by the Fundación Canguro (incubator rooms, mother-infant rooms, and outpatient follow-up rooms). In terms of nutrition, we adopted the exclusive use of breast milk via the enteral route, as lipid and protein concentrated and epicutaneous central venous access lines and their inputs are not available in our context. Regarding follow-up, multidisciplinary management was deferred until after patient discharge, as the required specialists were not located within the same health facilities. Appointment management could not follow Colombian standards given the absence of social insurance coverage, and the distance mothers must travel without adequate facilities to access the health facility multiple times per week.

Certain emergency care components of the protocol were provided free of charge or covered by the DIB project, such as oxygen therapy and umbilical venous catheter insertion. However, the use of Continuous Positive Airway Pressure (CPAP) ventilation and epicutaneous central venous lines was not available in our setting. The equipment and consumables provided by the project, in addition to what facilities already possessed, were the minimum required to manage premature infants alongside KMC.

At the start of the project, each health facility included in our study had a staffing team composed of one physician or pediatrician, two nurses, one midwife, one physiotherapist, and one clinical psychologist. This personnel was previously trained in KMC at the KMC Training Center of Excellence at Laquintinie Hospital in Douala [5].

To assess the level of KMC implementation, we adopted the progress monitoring model proposed by Bergh et al. in [1] in South Africa six months after the project [1] (Fig. 1). The model was conceptualized around three phases — pre-implementation, implementation, and institutionalization — and six dimensions describing the progression of implementation: awareness, concept adoption, resource mobilization, evidence of practice, evidence of routine and integration, and sustainable practice [1]. This progress monitoring model is a validated questionnaire with items assessed for each phase. Each item is assigned points, the sum of which yields a maximum score of 30 points for each evaluated health facility. The scores for each health facility are then interpreted according to the progress monitoring model’s interpretation table, as illustrated in Fig. 1 [1].

Fig. 1.

Model for monitoring progress in implementing the Kangaroo Mother Care according to Bergh et al. [1]

According to the same authors, awareness and concept adoption represent progression levels in KMC implementation where there is a willingness to practice and basic theoretical knowledge of KMC principles, without actual practice. Concept appropriation and evidence of practice are achievement levels where KMC has been partially implemented at the practical level within institutions. Institutional KMC practice corresponds to a more established form of practice involving all actors within the health facility from the bottom up, with visible communication and promotion of KMC. Finally, sustainable KMC practice corresponds to the implementation progression level at which the health facility provides quality care with a highly committed staff, strong KMC promotion, the conduct of audits for practice improvement, and a willingness to expand to other institutions [1].

Regarding sampling for the qualitative component, we selected personnel from the decision-making chain in the three health facilities, both administrative and clinical (medical and paramedical), with or without KMC training. We used an observation grid and a semi-structured interview guide to collect their accounts across the different phases of KMC implementation in their respective health facilities. These tools allowed us to triangulate data obtained from the progress assessment grid, field observations (photographs), interview data, and registry data that we consulted. We reached a sample of 21 participants at the point of saturation. Accounts were transcribed and categorized according to the phases and dimensions of the monitoring model.

Mortality data were collected during the investigation phase at the study sites, from the registries of the various neonatology units, covering the periods before the project, during the project, and six months after the project ended.

Quantitative data statistical analysis was performed using Excel software under macOS version 16.87 (2020) and expressed as frequencies. From an ethical standpoint, all required administrative authorizations were obtained from each health facility prior to data collection. Two ethical approvals were obtained from the Catholic University of Central Africa and the Yaoundé Gynecology, Obstetrics and Pediatrics Hospital (YGOPH), under reference numbers N°2021/020967/CEIRSH/ESS/MSP and N°256/CEIRSH/DM/2022 respectively. Informed consent was also obtained from all participants.

Results

Quantitative component

Level of implementation

Assessment of the KMC implementation level across our three health facilities revealed scores of 24.5, 25, and 27.5 out of 30 points for YGOPH, YUTH, and BDH respectively (Table 2). According to the interpretation table (Table 3; Fig. 2), these scores (from 24 points onward) objectively confirmed that all health facilities had reached the institutionalization stage of KMC practice. Looking more closely, YUTH and BDH had higher scores that classified them as being on the “path” toward sustainable KMC practice. No health facility had reached the sustainable KMC practice stage according to this scale.

Table 2.

Overall distribution of points for all phases by health facility

Table 3.

Interpretation table for the KMC implementation progress monitoring model according to Bergh et al. [1]

Fig. 2.

Flow chart for monitoring the progress of MMK implementation in the Central Cameroon region in three health facilities

Neonatal mortality trends

Neonatal mortality trends across the three health facilities, as shown in Fig. 3; Table 4, indicated a general downward trend in mortality across all facilities one year after the start of implementation in 2020. This decrease, more significant at BDH, was in the order of 1.6, 2, and 4 times for YGOPY, YUTH, and BDH respectively. Conversely, after the end of the DIB project, an upward trend in neonatal mortality was observed across all our health facilities. These were raw neonatal mortality data (all etiologies combined) recorded annually at each health facility (Table 4).

Fig. 3.

Trends in neonatal mortality before, during and after the Cameroon neonatal ‘DIB’ project

Table 4.

Overall distribution of annual mortality rate in each health facility

Qualitative component

Our qualitative investigation used an observation grid that allowed us to document the effectiveness of KMC practice according to established protocols and to corroborate participants’ statements in their verbatim accounts. Analysis of the interview guide data revealed several reasons that could partially explain the difficulties of KMC implementation at all stages of the progression process. We note that our respondents constituted a heterogeneous population, whose perception of certain questions could differ according to their level, function, educational background, and administrative responsibilities. Within the context of our study, we identified several issues that could explain the positive aspects and certain barriers to KMC implementation during and at the conclusion of the DIB project (Table 5).

Table 5.

Explanatory qualitative data from different stakeholders regarding KMC practice in health facilities

Questions	Categories	Subcategories	Respondents	Responses
Can you tell us about the degree of involvement of your hospital administration?	Involvement	Intense	R4 HDB	“From the beginning, the administration has been very committed and has always supported us regarding KMC…"
		Partial	R7 CHU	“…the administration got involved (…) But looking closely, I would say that this involvement is partial. (…) I haven’t yet seen the general management come in relation to this KMC.”
		None	R4 HGOPY	“Hmm, I don’t really feel it, do they make visible efforts…really I don’t see, I don’t really see.”
In your opinion, what has KMC changed in your health facility?	Positive effect	Reduction in mortality	R5 HGOPY	“In premature care we have an improvement in survival, thus a reduction in mortality (…)”
		Community action	R2 HDB	“KMC has improved inter-community collaboration with the support of the district and partners"
		Anticipation	R6 CHU	“KMC has changed our attitude towards the threat of premature delivery, (…)”
What assessment would you give to the quality of KMC implementation?	Quality of implementation	Good	R2 HDB, R3 HDB	“For me the process was very good, it was very well implemented. The DIB project and its partners spared no effort to respond to our complaints.” “I would say that this implementation was very good, excellent even. But when the administration changed there were gaps"
		Difficult	R1 HGOPY	“We started this timidly. (…), even though the pediatricians were convinced of KMC’s effectiveness, it was necessary to convince the administration and the rest of the medical staff to do it.”
Can you tell us about the obstacles you have encountered since the beginning of implementation?	Obstacles related to personnel	Selective involvement in KMC, Lack of motivation	R4 HGOPY	“(…) Unfortunately not everyone got involved in the same way. (…). The willingness is not the same.”
	Obstacles related to socio-cultural conditions	Culture, Xenophobia	R2 HDB	“The major obstacle is culture. The populations here are very xenophobic. Also Islam is very widespread here. (…) For skin-to-skin contact, you have to see the mother’s nudity, what husband will accept that?”
At the end of the pilot project, what provisions have been made for the continuity of material supply?	None	Stopping free care during the project	R2 CHU	“After this project, I see that we are moving towards the old system. Because if we don’t have the minimum required to help parents, it’s the parents who will assume the care.”
What is your opinion on staff rotation?		For rotation	R7 CHU	“Rotation is important provided that all staff are trained, (…)”
		Against rotation	R4 HGOPY	“Doing rotation at any cost will have an impact on the performance of present staff. (…) during this time there will be babies to care for…no no. (…)”
What vision do you now have of KMC practice in your health facility after this pilot phase?	Vision of practice based on	Motivation	R10 CHU	“Staff must be motivated. I think for my part that staff don’t really adhere because they are not motivated, motivation could be financial or…I don’t know how to say….even congratulations.”
		Community action	R1 HDB	“For an even more community action, we will organize with the district during their coordination meeting and even during campaigns.”
How do you proceed to ensure the sustainability of KMC practice?	Sustainability based on	Training	R7 CHU	“To sustain this method I will return to training, recycling. Because we are transient. If we don’t recycle staff, if we don’t train them, how will we sustain KMC?”
		Staff stability	R3 HDB	“It’s about focusing the strategy on training and stabilizing this trained staff. This is the most difficult thing here in Bafia.” Preserving achievements is crucial

Regarding administrative involvement

Administrative involvement was deemed satisfactory and well received by most respondents. On the other hand, some respondents considered administrative involvement to be only partial. Several additional obstacles were mentioned in respondents’ verbatim accounts, such as delays in project launch due to construction works, difficulties in hiring staff, and sudden changes in administrative leadership within the decision-making chain (Table 5).

Regarding KMC implementation

KMC implementation was considered good by more than half of the participants. Similarly, others found implementation to be timid and slow, and felt it needed greater conviction among stakeholders regarding its merits (Table 4).

The principal investigator’s observations, combined with respondents’ statements, revealed non-compliance with infrastructural and protocol standards for KMC practice, as well as communication difficulties with mothers. Mothers’ non-adherence to instructions was linked to language barriers, religious barriers, the patriarchal tendency of the community in which only the father makes decisions, or simply to the use of ineffective communication techniques. Beyond the difficulties mentioned above, respondents shared their perceptions of what KMC could bring to daily practice. These included preventive care, mortality reduction, and the benefits of community outreach as experienced by BDH (Table 4).

Selective staff involvement, loss of motivation, xenophobia, cultural and religious weight, redeployment of KMC-trained staff, the discontinuation of certain free care services, and the lack of continuing education were obstacles encountered both during and after KMC implementation. Staff motivational decline was a bottleneck raised by several respondents, notably the cessation of financial incentives once the project concluded. Finally, not all health facilities encountered the same barriers; these depended on the social and cultural environment and the category of the health facility (Table 4).

Regarding mortality

The downward mortality trend was mentioned by several participants, some empirically noting the reduction in the cries and distress sounds that had previously been frequent in the unit. Others attributed this reduction in their accounts to a decrease in the frequency of nosocomial infections. Several positive statements regarding the benefits of KMC accompanied this observation on mortality. KMC was described as a beneficial and humanitarian practice, particularly in peri-urban areas subject to energy deficits. At the community level in BDH, one participant noted that the practice of KMC in the town had prompted the involvement of the Bafia Health District, which participated in organizing community follow-up visits. This strategy proved necessary given that the area has a large Muslim community in which health decisions are reserved for the head of the household, and that many zones were difficult to reach.

Discussion

Quantitative component

The scores obtained by YUTH and BDH were the highest of any KMC implementation progress monitoring evaluation we encountered in the literature. Rwanda and Mali are the two countries that achieved a maximum of 24.5 points out of 30 at the end of a KMC implementation project in sub-Saharan Africa (Integrated Maternal and Child Health Program) [6].

Unlike Mali and Rwanda, where the best-performing health facilities were either university teaching hospitals or urban hospitals, in our study it was a rural district hospital (BDH) that reached an advanced implementation level despite insufficient trained staff observed after the end of the DIB project. The reasons for this performance are explained by the qualitative analysis data we obtained, which pointed to strong involvement of the administration and remaining staff, the fact that KMC care remained free of charge even after the project, and the community-based practice of KMC (Table 4).

Similarly, in a mixed cross-sectional study in Ethiopia and India involving 3,802 newborns weighing less than 2,000 g, Mony et al. in 2021 found high KMC practice coverage of approximately 86% and 87% respectively, twelve months after KMC implementation [7]. However, these authors did not use a progress monitoring score to assess KMC implementation and did not specify the different strategies that could explain their performance.

The downward trend in overall neonatal mortality observed in our study during KMC implementation corroborated data from the meta-analyses and systematic reviews of Conde-Agudelo et al. and Charpak et al. in 2012 and 2021 respectively [8, 9]. These studies demonstrated a reduction in prematurity-related mortality during KMC practice. This was also the case in the recent work of Esterlita et al. in 2021 in the Philippines, involving sixteen randomized controlled trials with 1,738 infants in the KMC group and 1,674 infants in the control group. This team found a 41% reduction in the risk of death among premature and low-birth-weight infants who received KMC compared to conventional medical care (3.6%) [10].

In our literature review, we found very few studies with a profile similar to ours, combining assessment of KMC implementation with mortality trends during and after the implementation phase. However, in 2022 in Bangladesh, Ehtesham Kabir et al., in evaluating KMC program implementation, found a drastic drop in hospital neonatal mortality related to prematurity of more than 50% by the end of the fourth year of implementation [11]. This reduction appeared more relevant as it targeted only prematurity-related neonatal mortality, whereas in our study, mortality assessment was global (all causes combined). It would be difficult to attribute this decrease solely to KMC practice, even though prematurity is documented to cause approximately 50% of neonatal mortality in our context [3].

However, in the interest of scientific rigor, it is important to note that the downward mortality trend observed in our study was likely influenced by several other confounding factors. According to Rodha et al. in 2018 in Ghana in a cross-sectional study, improved care for pregnant women and newborns, ongoing staff training and parent education, the implementation of emergency obstetric care, prematurity prevention measures, and infection control were interventions that improved neonatal mortality [12]. In our study, all health facilities had benefited from national training in emergency obstetric care as well as essential newborn care and management of threatened preterm delivery. Furthermore, the context of the COVID-19 pandemic, with its associated lockdown measures during the project period, had led to additional public health preventive measures that were beneficial to neonatal health. Hedley et al. in 2022 in Denmark found in a retrospective study a decrease in the prevalence rate of extreme prematurity and low birth weight, although a reduction in neonatal mortality was not observed [13]. Taking into account all the confounding factors mentioned above, which are not exhaustive, it can be said that prior KMC training before the project was an additional resource for improving neonatal mortality.

Qualitative component

Commitment to KMC implementation took shape through the motivation of the various actors involved, political support, and the foundational elements without which the initiative could not have achieved its objectives. As in our study, Kourouma et al. in 2021 in Côte d’Ivoire conducted a qualitative study and found strong involvement of pediatric department heads and hospital directors through staff training, equipment provision, and advocacy to adopt the KMC vision [14]. In contrast to our study, Bangladesh and South Africa in 2021 maintained a high level of KMC practice after the implementation period by using “KMC Champions” and volunteers, who continued to sustain a high level of involvement in both the decision-making and practical aspects of KMC [15, 16].

Several barriers to KMC implementation were identified in our study, including difficulties in engaging mothers, communication challenges, and cultural and religious barriers. These findings are similar to those of Mehjabeen et al. in 2021, where mothers were not involved in decision-making, and communication sessions were organized in the presence of husbands and/or in-laws to ensure adequate adherence [16]. Several studies place communication with mothers at the heart of successful KMC practice. Kampekete et al. in 2018 in Zambia demonstrated this in a mixed study by highlighting a statistically significant difference between effective communication and acceptance of KMC implementation [12]. Regarding community action, the literature identifies it as an innovative strategy that promotes health equity and significantly enhances the long-term effectiveness of KMC [17]. The loss of motivation we found is echoed by several authors [18], though in those cases the reasons were not financial but rather related to increased workload, insufficient staffing, and lack of staff development [19, 20].

During the DIB project implementation period, an independent monitoring institution conducted systematic quarterly follow-up of all neonatal records for infants receiving KMC care. Staff received these audit reports while being informed of both advances and obstacles to practice. A symbolic financial reward was then given to staff as encouragement. This financial incentive, known and referenced in the project agreement protocol, was seen by project promoters as a strategy to motivate staff to practice KMC; however, it proved to be a factor that would undermine the sustainability of KMC practice once funding ceased. We found no study discussing the cessation of financial incentives as a cause of decreased staff motivation. Beyond the discontinuation of financial incentives, this factor was particularly pronounced because staff had become accustomed to receiving them and were making efforts to continue earning them. All health facilities received these financial incentives, but it was at YGOPH that their discontinuation was most acutely felt. Additionally, the transfer and reassignment of KMC-trained professionals constituted a further source of staff demotivation [16] (Table 5).

The rise in mortality observed after the project could be explained by the following factors: the conclusion of the project and the simultaneous cessation of financial incentives, discontinuation of audits, termination of certain free services, absence of continuing education, and the excessive transfer and redeployment of already trained KMC staff [21].

Conversely, the intensification of community outreach, practiced more extensively in rural areas, proved to be an added value in reducing neonatal mortality under resource-limited conditions. Mazumder et al. in 2019 in India emphasized that integrating community action with KMC enabled the evolution of deeply rooted cultural and religious perceptions, and that community actions could significantly and sustainably reduce neonatal mortality in low-resource countries [17].

Strengths and limitations

This study enabled us to assess the level of KMC implementation across our three health facilities. We also identified the main barriers to this implementation in our context. We were able to collect data from administrators and healthcare staff in the selected facilities. We also took into account the use of the KMC protocol and the different phases of KMC practice assessment. Our investigation included an observation phase that allowed us to corroborate participants’ claims regarding KMC practice. This approach gave us a comprehensive view of the improvements that should be made to enhance KMC deployment.

However, this study is not without limitations. On the qualitative side, a more holistic approach could have integrated the perspectives of mothers of premature infants, families, and community leaders to capture their own perceptions of KMC practice. For stronger inferential capacity, selecting a larger number of health facilities across other regions of the country would likely have revealed additional implementation barriers related to the country’s sociodemographic, political, and cultural diversity.

Regarding neonatal mortality analysis, the downward mortality trend could be explained by the existence of known confounding factors associated with improved neonatal survival, as well as the context of the COVID-19 pandemic. Nevertheless, the findings of this regional-level study could serve as lessons learned in the pre- and post-project phases for other health facilities in the country as Cameroon moves toward community-level KMC deployment.

Conclusion

Following the DIB project, the level of KMC implementation had reached the institutionalization stage in all health facilities. Two of them were on the “path” toward sustainable KMC practice without having fully achieved it. However, this progress was undermined by a degree of instability stemming from persistent managerial, social, and technical difficulties, as reflected in the qualitative data. Nonetheless, the performance of this implementation appears to have had an effect on overall neonatal mortality, both in terms of reduction during the project and increase following its conclusion. This observation highlights the existence of other neonatal health improvement strategies that may have contributed to this performance within the context of the COVID-19 pandemic. The various implementation barriers identified, while not exhaustive, could explain the failure to reach the sustainability stage of KMC implementation in our three health facilities in the Centre region. Resolving these barriers — including the partial engagement of certain administrators and caregivers, the cessation of financial incentives, motivational erosion, the interruption of free emergency services, the mobility of KMC-trained staff, and the insufficiency of continuing education — could support the optimization of KMC implementation and facilitate its deployment at the national scale.

Abbreviations

BDH

Bafia district hospital

DHS

Demographic and health survey

DIB

Development impact bond

KMC

Kangaroo mother care

FKC

Cameroon Kangaroo foundation

WHO

World health organization

YGOPH

Yaoundé gynecology, obstetrics and pediatrics hospital

YUTH

Yaoundé university teaching hospital

Authors’ contributions

M.N.E.M, G.C.M.K, L.L.B: conducted the literature review M.N.E.M, M.A.N, E.K.O, S.N.U.S: participated in study design M.N.E.M, G.C.M.K: collected field data M.N.E.M, E.K.O, M.A.N, L.L.B, S.N.U.S: performed statistical analysis M.N.E.M, S.N.U.S.: wrote the main manuscript M.N.E.M, G.C.M.K, L.L.B, M.A.N, E.K.O, S.N.U.S.: performed revision.

Funding

This research received no specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability

The datasets used and/or analyzed during the present study are available from the corresponding author on reasonable request.

Declarations

Ethical approval and consent to participate

Ethical approval for this study was granted by two institutional review committees: the Ethics Committee of the Faculty of Health Sciences of the Catholic University of Central Africa (approval number: 2021/020967/CEIRSH/ESS/MSP) and the Ethics Committee of the Gynecological and Obstetric Hospital (approval number: 256/CEIRSH/DM/2022). Both committees operate under the supervision of Cameroon’s National Ethics Committee for Health Research (CNERS), which ensures that all health research protocols comply with applicable regulatory standards, good clinical practice guidelines, and ethical principles stated in the Declaration of Helsinki and International Conference on Harmonisation guidelines. The research was conducted in accordance with fundamental ethical principles including: respect for persons, beneficence (avoiding harm and promoting well-being), justice, scientific and social value, and confidentiality.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.