Holding hope: maternal experiences of kangaroo mother care within sociocultural contexts in Ethiopia

Abstract

Background

Kangaroo mother care (KMC) is a crucial method for improving the health outcomes of preterm and low birth weight (LBW) infants, particularly in resource-limited settings. However, barriers hinder mothers from effectively practicing KMC. This study aims to explore mothers’ perceptions, hopes, and buy-in regarding KMC in a tertiary care center in Ethiopia.

Methods

A semistructured interview guide was developed on the basis of a literature review. In-depth interviews were conducted with a purposive sample of mothers who had practiced KMC within the past two years at Saint Paul’s Hospital Millennium Medical College (SPHMMC), Addis Ababa, Ethiopia. The interviews, which were originally conducted in Amharic, were transcribed and translated into English. Thematic analysis was performed independently by three coders, who met regularly to resolve discrepancies and refine the codebook. Thematic saturation was reached after 20 interviews.

Results

The participants were from diverse educational, occupational, and religious backgrounds. Three major themes emerged: (1) personal awareness and acceptance of KMC, where mothers highlighted its advantages for both infants and themselves; (2) Community awareness and acceptance of KMC, where, while Ethiopian culture and religion value mother‒child bonding, specific awareness of KMC was low. Skepticism from family and community members often discourages mothers, adding to their mental burden; and (3) Hope impacts KMC care, with subthemes such as factors that threaten hope, consequences of hopelessness, and factors that support hope. Mothers described how limited awareness and lack of support from partners, families, or communities negatively affected their hope, sometimes leading them to leave against medical advice.

Conclusions

While mothers recognize the benefits of KMC, their ability to sustain it is influenced by external factors, particularly social support. Addressing these barriers through targeted awareness campaigns and emotional and practical support and fostering a supportive environment are essential for improving maternal commitment and enhancing KMC uptake. Future research should explore interventions to strengthen maternal engagement and improve outcomes for preterm and LBW infants.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12887-026-07312-5.

Background

Kangaroo Mother Care (KMC) is a continuous care of clinically stable preterm or low-birth-weight (LBW) infants by skin-to-skin contact for at least 8 h per day to as many hours as possible. The World Health Organization (WHO) recommends KMC as routine care that should be initiated immediately after birth, with support for exclusive breastfeeding or breast-milk feeding [1]. This practice decreases mortality, the risk of hypothermia, and infection and increases exclusive breastfeeding rates and weight gain [1]. It also reduces apnea [2], stress and pain in the baby [3], promotes mother‒infant bonding and increases maternal confidence [4].

KMC is recommended as standard care for preterm and LBW infants across all resource settings. Its relatively low implementation cost, combined with a strong evidence base, makes it particularly effective in low- and middle-income countries (LMICs), where the burden of LBW births is highest. More than 90% of infants with LBW are born in these settings. In contexts where infrastructure and staffing are limited, KMC addresses these challenges as a simple method of care for LBW infants [5, 6]. This approach offers a solution to the challenges of overcrowding, cross-infection, poor prognosis, and high LBW mortality rates in hospitals, as well as reducing the length and cost of hospital stays.

Despite the proven benefits, implementing KMC in Neonatal Intensive Care Units (NICUs) remains challenging. KMC services are predominantly available in higher-level or referral hospitals, with limited implementation at the district or primary care (health center) level. Inconsistent data tracking across countries further complicates the situation. A rapid assessment conducted by UNICEF in 2017 across 25 low- and middle-income countries, including several in Africa, such as Kenya, Ghana, Lesotho, Malawi, Namibia, Niger, and Zimbabwe, revealed that only 9% of eligible babies born in health facilities with KMC services actually received such care, highlighting significant missed opportunities [7].

A survey conducted by Save the Children in 2017 estimated that only approximately 14% of eligible preterm babies in Ethiopia received KMC [8]. Even in facilities where KMC is practiced, the duration is typically short, averaging 2–7 h per day [9, 10], rather than the recommended 8–24 h per day (with the goal of as many hours as possible), with early initiation as soon as possible after birth for both stable and unstable preterm and/or LBW neonates [11].

In 2017, a KMC indicator was added to the Ethiopian health management and information system to monitor the proportion of preterm and/or low birth weight babies receiving KMC. More recently, KMC has been incorporated into several policy documents issued by the Ethiopian Ministry of Health, including the Newborn and Child Survival Strategy 2021–2025, the Health Sector Transformation Plan-II, and the Ethiopian National Health Care Quality Strategy. The national newborn and child survival and development strategy aims to achieve KMC coverage of 70% for preterm babies by 2025. Despite its inclusion in national strategies since 2005, the implementation and expansion of quality KMC services have progressed slowly [12].

A number of factors contribute to the limited implementation of this approach in LMIC settings, including cultural and psychosocial factors [13, 14]. A scoping review of studies in Sub-Saharan Africa identified caregiver buy-in and bonding, which refers to the perceptions of mothers regarding KMC, their belief in its benefits, and their perceptions of bonding, as impacting their acceptance and engagement. Poor knowledge and understanding of the purpose and outcomes of KMC care, coupled with guilt related to having birthed a premature infant and a lack of motivation due to skepticism that premature newborns can survive, make mothers reluctant to participate in this care. Similarly, poor understanding and acceptance of KMC by fathers, extended families and communities led to a lack of support. Mothers-in-law and grandmothers often do not view KMC as an appropriate method of caring for newborns. Decision-making is heavily influenced by grandmothers and fathers who are not engaged in KMC counseling [15]. Poor communication or negative interactions with medical staff that fail to correct misconceptions and reassure mothers are also barriers to KMC care [15, 16].

Studies in Ethiopia mirror many of these findings. A lack of support from husbands and family members is commonly reported, with cultural influences and a lack of belief in men’s involvement in newborn care being significant barriers. Additionally, low awareness of KMC, cultural practices such as carrying babies on the back, and misconceptions that incubators provide more effective care pose challenges [17]. Home deliveries, late reporting of babies born at home, and doubt about the survival of preterm infants are further obstacles identified in the community [10]. Hadush et al. also revealed that mothers often lack proper training and counseling on KMC practices at home because of the absence of KMC services in many health facilities and a shortage of trained health workers [18].

While past studies have examined barriers, they have not explored in depth the multifaceted impact of community and familial support on mothers’ psychological well-being and their sustained engagement with KMC. Additionally, comprehensive investigations into effective strategies for enhancing paternal and community involvement in KMC practices and how supportive interventions can bolster mothers’ hope and adherence to KMC are lacking.

To better understand the sociocultural factors that impact mothers’ participation in providing KMC care for their infants, we aimed to explore their perceptions. Specifically, we sought to characterize mothers’ perceptions, hopes, and buy-in regarding KMC care for preterm and LBW infants in a tertiary care center in Ethiopia.

Methods

Study setting

The study was conducted between December 2023 and February 2024 at SPHMMC, a large tertiary-level referral and teaching hospital in Addis Ababa, Ethiopia, that provides comprehensive care to sick neonates. All preterm neonates weighing < 1400 g are admitted to the KMC unit, and a proportion of mothers with neonates weighing ≤ 2000 g are trained to practice KMC without admission to the KMC unit. SPHMMC has an average of 732 births per month and an average NICU admission rate of 242 neonates per month, including both inborn deliveries and referred newborns from surrounding health centers. The neonatal unit at the hospital is experienced in KMC and is one of the basic and routine types of care provided to low-birth-weight infants for thermal control. However, the hospital had only two rooms dedicated to KMC care, each room accommodating up to 8 mother-infant dyads. The KMC unit is staffed by 2 nurses and 1 resident physician, with a nurse-to-patient ratio of approximately 8:1, providing direct support to mothers during their infant’s admission. The NICU team, composed of neonatologists or a senior pediatrician residents, and nurses, makes rounds twice daily in the KMC unit.

The study included mothers of premature and low birth weight neonates who were actively participating or had previously participated in KMC at the NICU at the SPHMMC. A purposive sampling strategy was applied. Half of the mothers were approached during their infant’s admission to the KMC unit, and the other half of mothers were approached at subsequent high-risk infant clinic follow-up visits after discharge. The number of participants chosen for this study was determined on the basis of redundancy/saturation. The interviews were conducted until thematic saturation was reached. Saturation occurred when there was no data variation, no new answers or information, to the given questions. This data saturation was reached after 20 eligible mothers of babies receiving/who received KMC during the study period at the KMC unit and the high-risk infant clinic were interviewed.

Data collection and procedures

Semi-structured in-depth interviews with kangaroo mothers of preterm and LBW infants were conducted via an open-ended interview guide. These open-ended interview guides were developed with potential probes to achieve the study objectives and elicit both positive and negative experiences, to reduce bias and mitigate potential assumptions of the research team of the benefits and acceptability of KMC. The guide was piloted and refined based on feedback from clinicians and parents. The semistructured interview guide used in this study is available in Supplementary Material 1.

In-depth interviews were conducted by a male pediatric resident investigator and an experienced male NICU nurse. Prior to the first interview, both had received training in data collection and how to perform in-depth interviews. Neither the pediatric resident investigator nor the nurse investigator was involved in direct clinical care of the participating infants. The interviewer acquired verbal consent from the participating mothers before each interview. The one-to-one in-depth interviews were conducted in a private room in the hospital, and the mothers were assured of data confidentiality. Because the interviews explored experiences surrounding preterm birth, neonatal hospitalization, and KMC, investigators recognized that probing these topics could evoke feelings of distress, sadness, or guilt in a potentially vulnerable population of new mothers. Participants were informed that they could decline to answer any questions or stop the interview at any time. Likewise, the interviewer was prepared to discontinue the interview if participants became distressed and alert the clinical team for appropriate support.

We recorded all the responses via digital recorders and took notes. Weekly debriefing and discussions between the principal researchers were held during the data collection period. On the basis of the discussion, the interviews were iteratively refined on the basis of identified gaps and emerging ideas in the data.

The interview questionnaires were prepared in English and then translated into Amharic for the interviews. The interview recordings were then retranslated back to English to check consistency. The interviews were conducted in Amharic, audio-recorded, and lasted between 11 and 36 min. The interviews were continued until information saturation was reached, which occurred when there was no data variation or new answers or information to the given question.

Data analysis

All the interviews were transcribed verbatim in Microsoft Word from audio recordings and translated to English. Detailed interview memos and field notes were reviewed continuously throughout the data collection.

This study employed a qualitative descriptive design using inductive thematic analysis. The coding process used ATLAS. Ti coding software version 9.1.3.0 and Microsoft Word were used to organize and support the coding. To enhance reflexivity, coding was performed by investigators with differing cultural and professional perspectives, including an Ethiopian pediatrician practicing in Ethiopia, an American neonatologist, and an Ethiopian pediatric critical care physician practicing in the United States. These diverse perspectives, shaped by different healthcare contexts and cultural environments, were intentionally incorporated to challenge assumptions and promote multiple interpretations of the data. Because all investigators were clinicians familiar with the benefits of KMC, there was a risk of privileging favorable interpretations of participants’ experiences. To mitigate this, transcripts were independently coded with frequent discussion of discrepancies, with particular attention paid to identifying negative cases, barriers, and divergent viewpoints.

The codebook was devised in a collaborative effort after comparing what each coder found and refining it until the codes were all representative of the participants’ words and easily categorizable.

The final codebook and transcribed data were analyzed via an inductive approach, and themes were identified, discussed, and reviewed continuously throughout the analysis period. Following the thematic analysis approach, the themes were then organized into broad categories and subcategories and eventually developed into final themes and subthemes. Qualitative analytical process illustrated in Supplementary Material 2.

This study is reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines; a completed COREQ checklist is provided in Supplementary Material 3.

Results

Twenty mothers were included in this study, with the majority being 26–30 years old and having secondary school education or above. The neonates were nearly equally distributed by sex, with most weighing between 1000 and 1500 g. The characteristics of the interview participants and their infants are shown in Table 1.

Table 1.

Characteristics of interview participants and their infants

Variable	Frequency (N = 20)	Percentage (%)
Age
15-20yr	2	10%
21-25yr	7	35%
26-30yr	9	45%
31-35yr	1	5%
36-40yr	1	5%
Educational status
Read and write	4	20%
Primary school	5	25%
Secondary school	5	25%
College and above	6	30%
Residence
Rural	9	45%
Urban	11	55%
Religion
Muslim	6	30%
Orthodox	11	55%
Protestant	3	15%
Occupation status
Housewife	6	30%
Government employed	1	5%
Self employed	11	55%
Unemployed	2	10%
Sex of the neonate (N = 23)
Female	11	48%
Male	12	52%
Weight of the neonate (N = 23)
Less than 1000gms	2	9%
1000-1500gms	18	78%
1500- 2000gms	3	13%

The majority of mothers were first-time parents, though six reported having prior children. Those who were interviewed during their stay in the KMC unit reported that their infants had been stabilized prior to transfer to the KMC unit and were on unassisted room air or low-flow oxygen nasal cannula for respiratory support at the time of the interviews. All infants were living at the time of the interview. Mothers reported providing KMC for approximately 14 to 18 h per day, most mothers interviewed at the follow-up clinic had experienced KMC admission lasting one to two weeks.

Three major overarching themes arose from the qualitative analysis: 1) the impact of personal awareness on acceptance of KMC, 2) the impact of community awareness on acceptance of KMC, and 3) the importance of hope in acceptance of and adherence to KMC practices.

I. Personal awareness and acceptance of KMC

The mothers in our study described variable knowledge of KMC care prior to giving birth. A few mothers had heard of KMC care and its benefits. One mother said:

“Before I gave birth, I saw posts about KMC on social media. Although I did not know the specifics, I understood its importance when I came to the hospital and was able to hold my baby in the KMC position well” (Participant 14).

Most of the mothers, however, said they had no knowledge of this practice before their baby was born and learned about KMC for the first time following delivery of their preterm infant and admission to the NICU. One mother noted:

“This is my first time hearing about KMC…. it was in the NICU. They told me to take a shower and wear wide clothes. Then, they put the baby in Kangaroo position on my chest for two days at the NICU with their support.” (Participant 10)

Another said:

“I didn’t know about KMC before I got admitted here. When my newborn was in the NICU, they told me to bring expressed breast milk every two hours. Later, they instructed me on how to do KMC, showing me step by step. I began holding my baby in the KMC position for about an hour at a time.” (Participant 2)

Several mothers explained that they would have preferred to have known about KMC earlier, as this would have helped them prepare and optimally engage in this practice. Specifically, mothers described that education around KMC should be ongoing and that the lack of continuous follow-up, guidance, and support of visual aids for guidance were major barriers to mothers continuing this practice.

One mother stated:

“If I had known about KMC earlier and prepared for it during my ANC follow-up, it would have been beneficial. Sometimes they give me a poster about breastfeeding, but it doesn’t mention KMC. A TV in the KMC unit would help if it worked” (Participant 1).

II. Community awareness and acceptance of KMC

Like what they described on a personal, individual level, mothers reported that the community did not have good awareness of the specific benefits and procedures of practicing KMC. They noted that while their culture and religion generally advocate for the bonding of mothers and children, the importance of caring for a baby, and the significance of breastfeeding do not specifically support KMC as a practice. One mother reflected:

“To be honest, I haven’t really heard neither about encouragement nor discouragement, but my religion definitely encourages a mother and her child to be together, to breastfeed her children, and how it is so much better for her child to grow under the care of her mother.” (Participant 6)

A few mothers expressed that their family or community was supportive of their participation in KMC because of past experiences with KMC care that had yielded positive outcomes. One mother explained:

“I knew about KMC because my mother practiced it. She helped me a lot with my baby, and my husband was also very supportive. They helped me believe in KMC and supported me morally and with household tasks.” (Participant 17).

Several mothers, however, noted that they felt that they had to provide education around KMC and its benefits to members of the community before they became supportive of the practice. One mother said:

“The community doesn’t know about kangaroo mother care specifically… I tried to explain what I am doing here. I told them that I’m holding my baby in my chest in the kangaroo position…so, they are usually supportive after telling them what I’m doing here.” (Participant 5)

Others felt that they were met with skepticism and doubt from their community, even when trying to educate them on its benefits. One mother noted:

“One response I got was, I don’t know if it’s because I live in a rural area, but they came to visit me after I went home and said, ‘What is this? We have never seen such a thing. When we gave birth to our children, we just held them and put them to sleep. there was no such thing as kangaroo in our time. What is this new thing that you bring?” (Participant 9)

Some mothers commented that this skepticism from the community and feeling responsible for correcting misconceptions added to their mental burden, which was already elevated by having to parent a preterm neonate.

III. Impact of hope and acceptance on the practice of KMC

Several participants explained that when mothers did not feel that they personally had sufficient knowledge or awareness of KMC and its benefits, this was detrimental to their hope, acceptance of KMC, and willingness to participate in this care. One mother said:

“I noticed that other mothers were not as satisfied with the care. Some mothers who stayed there sometimes lost hope and became depressed. This was often because they did not fully understand the purpose of KMC, its benefits, or its outcomes. The teaching is usually done once, and after that, there is no continuous teaching. It would be better if more support was provided, especially for mothers who came from rural areas.” (Participant 17)

Similarly, when family members and the larger community are not aware of the benefits of KMC, they question the practice and speak to the mother in a way that discourages hope. One mother said:

“No one believed that he would make it out alive… Every person in my family thought I would lose my baby… is because there was no knowledge of KMC in the community and my family members.” (Participant 10)

Another mother remarked:

“I wasn’t able to be visited by community members when I was in the hospital. Even when I went home, they were shocked to see my baby… Some even questioned whether she would grow or become a fully developed human… They said things without considering my situation, which was very disturbing to me. So, the community didn’t help me much.” (Participant 16)

The consequences of skepticism in KMC were impactful for both mothers and infants. For one mother, remaining hopeful despite being discouraged by her spouse led to her being alone and unsupported while caring for her premature newborn. She noted:

“No, I received absolutely no support from my family. My husband and I are not together. When I gave birth to my baby, he told me to leave the baby in the hospital, as he believed there was no hope. But I told him that I would not lose hope and that God is with me. He did not agree with this idea of mine, so he left me and never came back. I stayed without losing hope and believing in God.” (Participant 9)

Additionally, mothers who had successfully participated in KMC reflected on other mothers they had met, who had lost hope due to discouragement from family and community, and lamented that this led these mothers to abandon KMC for their babies, presumably resulting in death or other serious outcomes for their neonates. One mother stated:

“I have seen some other families, close family members, not accepting KMC, which led to them leaving against medical advice. I also noticed some reluctance and acceptance barriers among close family members. This posed a challenge for them to stay at the KMC ward. ” (Participant 16)

All mothers described hope as a key factor that encouraged continuation of KMC. This was supported by family members, the community, religious institutions, other mothers with prior KMC experience, and clinicians. In addition, mothers reported that direct contact with their infants during KMC, including holding and observing them, reinforced their motivation. Exemplary quotations are presented in Table 2.

Table 2.

Sources of hope identified by mothers supporting KMC care

From Family	“My family, who learned about KMC alongside me, has been very supportive. With their support, which contrasts with the community’s initial reaction, I found the strength to stay in the neonatal ICU and hold my babies in the kangaroo position.” (Participant 19)
From the Community	“The community usually gave me moral support and congratulated me…They all accepted this and tried to support me to have KMC, so the community is supportive.” (Participant 12)
From Church/Religion	“I communicated with the local church…They were all supportive and understanding of my situation. They accommodated and morally supported me. My firmness in my religion also gave me hope, and praying was very supportive.” (Participant 16)
From Other Mothers	“One [other mother] in the KMC room and had an experience because she had a child delivered at seven months of pregnancy. She was confident that KMC is very crucial for the development of her child, so she gave me much hope.” (Participant 4)
From Clinicians	“They [the NICU providers] gave me different videos on my phone. One encouraging thing they showed me was a child who had been held in KMC and was now growing and playing with her mother. When I saw that video, I was very eager and it gave me great support. At that time, my feelings and thoughts were that my baby is going to be like her, so that was very supportive.” (Participant 16)
From Doing KMC Care	“When she came to me and I held her on my chest and saw her grow, I had a good feeling that she was going to survive. That gave me hope.” (Participant 5)

Among mothers interviewed at the high-risk clinic, information on the continuation of KMC at home after discharge was collected during the interviews. All mothers reported that they continued practicing KMC at home; however, the duration and frequency were lower than those observed during their infants’ admission in the KMC unit.

Discussion

Prior studies in Ethiopia and Sub-Saharan Africa have documented barriers to KMC uptake, but most have focused on structural and logistical factors at the health facility level. This study adds to that literature by examining the psychological dimension of maternal engagement, particularly the role of hope as a mediating factor between social support and sustained KMC practice. The finding that loss of hope, driven by inadequate community awareness and absent partner support, can lead mothers to leave against medical advice represents a clinically significant and underreported consequence of poor KMC buy-in. This study also captures perspectives from both inpatient and post-discharge mothers at a single tertiary center, providing a more temporally varied account of maternal experience than studies conducted exclusively during hospitalization. Three important findings emerged from the analysis. First, the knowledge levels of mothers about KMC varied significantly before their NICU experience, and possessing this knowledge was crucial for fostering hope and encouraging engagement in the practice. Second, while caring for newborns is deeply valued in Ethiopian culture and religion, the lack of community awareness about KMC has led to skepticism and challenges, including abandonment, loss of support, and a decrease in hope, sometimes resulting in mothers leaving against medical advice. Finally, mothers who successfully practiced KMC received hope and support from various sources, including family, community, church, other mothers, and clinicians, and through the process of performing KMC and witnessing its benefits. These findings have significant implications for promoting the long-term health of both the child and the mother by encouraging participation in KMC care and developing a comprehensive model to expand KMC care throughout the country.

While most of the mothers in our study had heard about KMC at the NICU, there were notable differences in their level of knowledge about KMC, particularly between those from urban areas and those who had received higher education levels. Currently, there is limited availability of KMC in many parts of Ethiopia, especially in rural areas where healthcare services are scarce, so the birth of a premature newborn is often the first exposure to this intervention. Cultural taboos and social norms surrounding preterm births and NICU experiences further hinder the dissemination of KMC knowledge, as the stigma associated with preterm births may lead to reluctance in openly discussing these experiences, limiting awareness and understanding of KMC within communities. Likewise, health literacy levels vary along with mothers’ ability to access healthcare information, leading to disparities around which populations are aware of KMC. Additionally, urban‒rural disparities exacerbate these challenges, as urban mothers have greater access to healthcare facilities and information, whereas those in rural areas may rely more often on traditional health knowledge with limited exposure to modern practices.

Prior awareness of the impact of KMC on a mother’s ability and willingness to engage in the practice has been observed in other low-resource settings. Mothers familiar with KMC before hospitalization are more likely to adopt and adhere to it effectively. By being more confident and capable of participating in KMC, mothers are able to improve outcomes for their infants [4]. Conversely, mothers lacking prior knowledge have been shown to face greater challenges and require more intensive education and support from healthcare providers to build confidence and competence in practicing KMC. This initial lack of understanding can lead to anxiety and resistance, making it more difficult for them to fully embrace KMC [19].

Although the mothers in our study recognized that Ethiopian culture and religion strongly advocate for the mother‒child bond, breastfeeding, and attentive care for newborns, they reported experiencing skepticism and discouragement around KMC from their families and communities. This skepticism, rooted in cultural, social, and gender-related factors, likely arises from the unfamiliarity of KMC, particularly in rural areas where traditional practices dominate. A lack of awareness about the benefits and scientific basis of KMC largely underpins this resistance. We speculate, however, that gender roles and expectations may also contribute. Ethiopian households often require mothers to manage household chores and care for other children, making the intensive nature of KMC requiring extended periods of holding preterm infants burdensome for other family members. Furthermore, decision-making about medical care is often deferred to male relatives, and if they are not informed about or do not understand KMC’s importance, they may discourage its practice. Unfortunately, this has serious implications for the outcomes of mothers and infants, leading to abandonment, loss of hope, and mothers leaving against medical advice, resulting in infant morbidity and mortality.

A few studies have identified similar challenges in gaining acceptance for KMC in Ethiopia and other countries, though these studies often denote these as secondary observations within broader studies of barriers to KMC implementation. An Ethiopian study from the Tigray region revealed that cultural beliefs and gender dynamics play crucial roles in the acceptance of KMC and highlighted that educating both mothers and their families about KMC is essential for its successful implementation [18]. Similarly, research in Uganda and Malawi has shown that cultural beliefs and gender roles affect adoption of KMC [20, 21]. In these studies, mothers often faced opposition from family members who were unfamiliar with the practice and prioritized traditional methods of infant care. Another study in southern Ethiopia noted the importance of community-based interventions to increase awareness and promote KMC, particularly in rural areas [17]. Our study builds on these findings by more deeply characterizing the social and cultural influences impacting KMC care, and examining how social expectations, family acceptance, and community perceptions impact KMC care by shaping maternal hope, participation, and caregiving practices. By exploring these dynamics in greater depth, our findings move beyond documenting the existence of sociocultural influences to elucidating mechanisms by which they operate and affect engagement with KMC.

Because of the potential to benefit newborn survival with relatively modest resource costs, improving awareness and acceptance of KMC among expectant mothers, their families, and communities should receive attention from the Ethiopian Ministry of Health, the Ethiopian Pediatric Society, and other organizations supporting newborn outcomes. Studies from other countries have previously emphasized the importance of knowledge dissemination in improving KMC uptake [4, 22]. Mothers in our study frequently expressed a desire for earlier exposure to information about KMC and prematurity. As most pregnancies do not result in preterm or LBW births, extensive antenatal education for all expectant mothers may not be the most efficient use of limited resources. There are, however, pragmatic entry points that do not require broad population-level campaigns. KMC education can be integrated into existing antenatal and perinatal care encounter platforms for mothers identified as high risk for preterm delivery at relatively low incremental cost. Integrating KMC education into routine healthcare services early in high-risk pregnancies can help mothers receive consistent and accurate information about KMC. Additionally, targeted education directed toward mothers, families, and support networks for those at risk for or experiencing prematurity should continue through the postpartum period, ensuring that all relevant parties understand the benefits and procedures.

Given the relative rarity of preterm birth at population level, broad community education initiatives may not be an efficient or practical initial approach. While perhaps aspirational at this time, community-based interventions, such as workshops, informational sessions, and the distribution of educational materials, could help raise awareness of KMC as the practice is adopted in more centers and settings across the country. Efforts to increase familiarity with KMC in communities served by KMC programs could reduce misconceptions and lessen the burden mothers described in having to explain and defend the practice to others.

Strengths and limitations

This study has several limitations that should be considered when interpreting the findings. First, it was conducted at a single tertiary-level referral hospital with an established KMC program and dedicated staff. The level of institutional support available at SPHMMC, including a structured KMC unit, twice-daily multidisciplinary rounds, and experienced nursing staff, likely exceeds that of lower-level health centers and district hospitals, where KMC is less consistently implemented. The experiences and perceptions of mothers at facilities with less developed KMC programs may differ substantially from those reported here, and the findings may not be generalizable to other regions or healthcare settings across Ethiopia or beyond.

As mothers interviewed at different time points may have had varying levels of exposure to KMC and differing perspectives on the practice, the timing of the interview is acknowledged as a potential source of variability in the findings. Half of the mothers were interviewed during their infant’s admission to the KMC unit, while the remaining half were interviewed at high-risk infant clinic follow-up visits after discharge. This variability may have introduced differences in recall, emotional state, and perceived benefit of KMC that could not be controlled for in the analysis. Additionally, while mothers reported providing KMC for approximately 14 to 18 h per day over a typical stay between one and two weeks, detailed individual-level clinical data on daily KMC duration, exact length of admission, and infant illness severity were not systematically recorded for each participant. Future studies should prospectively collect these variables, as infant illness severity, duration of KMC practice, and interview timing may each influence maternal perceptions.

There is also inherent bias in the sample, as only mothers who were currently practicing or had completed KMC during their infant’s hospital admission were interviewed. Additionally, per maternal report in the interviews, infants had been clinically stabilized prior to transfer to the KMC unit, and all infants of mothers interviewed at follow-up clinic were sufficiently well to survive to discharge and follow-up. While these characteristics reflect mothers’ reported perception of their infants’ clinical status, rather than individually verified clinical records, it suggests that these infants did not have or had recovered from serious or life-threatening illness at the time of the study. Perspectives from mothers who had left against medical advice or whose infants had died were not captured, which may have resulted in an incomplete account of the perspectives around KMC. The fact that even mothers who sustained KMC practice and had good infant outcomes reported substantial personal, family, and community-level barriers suggests that the experiences of mothers who discontinued KMC warrant dedicated investigation in future research. While participating mothers were willing to discuss cultural issues and lack of support, some reluctance to fully disclose sensitive or stigmatized aspects of their experiences cannot be excluded. Likewise, the involvement of healthcare professionals as interviewers may introduce social desirability bias, as participants might modify their responses due to perceived authority or expectations. This potential underreporting may have influenced the depth of findings regarding cultural barriers and community support, and underscores the importance of ongoing efforts to build trust between patients, communities, and researchers. Finally, this study interviewed only mothers, despite evidence that fathers, grandmothers, and other community members play a significant role in shaping maternal decisions around KMC. Their perspectives were not directly captured. Future research should include fathers and key family decision-makers as participants, as their awareness and attitudes toward KMC are likely to be important determinants of maternal engagement and infant outcomes.

Despite these limitations, our study has notable strengths. Thematic saturation was reached after 20 interviews, suggesting that the themes identified are representative of the experiences of mothers practicing KMC at this center, and the findings from our study aligned with the existing literature from Ethiopia and Sub-Saharan Africa. The study captures perspectives from both inpatient and post-discharge mothers, providing a more temporally varied account than studies conducted exclusively during hospitalization. The research team consisted of members with varied professional and cultural backgrounds, including an Ethiopian pediatrician, an American neonatologist, and an Ethiopian pediatric critical care physician, which enriched reflexivity in the analysis. This diversity helped minimize researcher bias and provided a more nuanced understanding of participants’ experiences.

Conclusion

Mothers of preterm and low birth weight infants in our study identified awareness, community acceptance, and hope as critical factors influencing engagement with KMC. This study suggests that acceptance of KMC is shaped by broader social and emotional factors, beyond understanding of the practice itself. Mothers described hope as both a prerequisite for and a product of successful KMC participation, influenced by interactions with family members, communities, clinicians, faith communities, and other mothers. Interventions that address not only informational barriers but also social support and sources of hope may be important for improving uptake and continuation of KMC in resource-limited settings.

Abbreviations

KMC

Kangaroo Mother Care

LBW

Low Birth Weight

LMICs

Low- and Middle-Income Countries

NICU

Neonatal Intensive Care Unit

SPHMMC

Saint Paul’s Hospital Millennium Medical College

WHO

World Health Organization

ANC

Antenatal Care

Authors’ contributions

M.F.A. conceptualized and designed the study, developed the interview guide, collected and analyzed the data, and drafted the initial manuscript and subsequent revisions. B.B.K. participated in the initial coding of the interviews, contributed to the data analysis, interpretation of the results, and critical revision of the manuscript. M.A. provided overall study supervision and reviewed the manuscript. H.N.M. participated in the initial coding of the interviews and assisted with thematic analysis. S.K. provided overall study supervision, guided the qualitative methodology, contributed to data interpretation, and reviewed and edited the manuscript.

Funding

This study received financial support from Saint Paul’s Hospital Millennium Medical College as part of the requirements for completing the specialty training program in Pediatrics. The funders had no role in the study design, data collection, analysis, interpretation, or writing of the manuscript.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Ethical clearance was obtained from the Institutional Review Board (IRB) of Saint Paul's Hospital Millennium Medical College on June 6, 2023 GC, with reference number PM23/912.

Verbal informed consent was obtained from all participants prior to their interview and inclusion in the study.

Consent for publication

Verbal informed consent to publish anonymized responses was obtained from all participants prior to data collection.

Competing interests

The authors declare no competing interests.