Table 3. Summary of enablers and barriers to implementation of kangaroo mother care.

Level of implementation	Adoption systems				Health systems access	Context, cultural norms
	Buy-in and bonding	Social support	Access	Medical concerns
Parents
Enablers	Calming, natural, instinctive, healing for parents and infant	Father, health-care worker, family and community support for mothers and fathers was crucial to success of kangaroo mother care	Kangaroo mother care at home allowed parents to perform other duties	Helped mothers recover emotionally	Belief that kangaroo mother care was cheaper than incubator care	Mother preferred kangaroo mother care to incubator, inspired confidence Gender equality
Barriers	Stigma, shame, kangaroo mother care felt forced	Fear, guilt, discomfort of family members to participate or condone kangaroo mother care in public Privacy	Caregivers were unable to devote time Mothers lonely in kangaroo mother care ward	Maternal fatigue and pain	Associated costs Transport	Traditional, bathing, carrying and breastfeeding practices did not always align with kangaroo mother care guidelines
Health-care workers
Enablers	Nurses more likely to use kangaroo mother care after seeing positive effects. Support from more experienced nurses improved buy-in	Management promotion of kangaroo mother care Role of parents and other health-care workers	Kangaroo mother care did not increase workload	Temperature stability. Experienced nurses more comfortable with kangaroo mother care	Virtual communication and training. Integration of kangaroo mother care into health-care curriculum	None
Barriers	Nurses fail to have strong belief in importance of kangaroo mother care Inconsistent knowledge and application of kangaroo mother care	Management did not prioritize kangaroo mother care Parents could serve as a hindrance to health-care worker	Extra workload Takes away time from other patients	Nurses did not feel kangaroo mother care appropriate for infants who they felt were too small/young/ill	Difficulty finding time for training Inadequate/inconsistent training	Traditional protocols interfered (bathing, carrying) Nurse excluding father from infant care was a cultural norm
Facilities
Enablers	Leadership Management support	Staffing support Good communication Use of committees to advocate for kangaroo mother care	Unlimited visitation preferred	Access to private space including family rooms or privacy screen. Higher breast milk feeding rates at discharge when breast feeding was allowed and encouraged throughout the hospital	Access to structural resources Quiet atmosphere within facilities allows mothers to rest Breast milk banks provide milk and can be an educational tool among mothers	Reporting and data Collection of data Use of performance standards and quality improvement measures Site assessment tools
Barriers	Leadership lack of buy-in led to lack of adequate resources	Staffing shortages, high staff and leadership turnover Staff resisted changing protocols	There was limited visitation time due to staff shortages	Disagreement over clinical stability Facilities did not provide food for mothers Only low birthweight infants received kangaroo mother care in some locations	Lack of money at the facility for mother’s transportation Distance to the hospital for mothers without hospital-provided transportation Lack of space and privacy for mothers to do kangaroo mother care Lack of money for transportation, beds and kangaroo mother care wrappers Poor management of resources donated to the hospital	Lack of use of data to document skin-to-skin contact practised on electronic medical record Nurses not given feedback on kangaroo mother care data collected Visitation policies sometimes prevented mothers from performing skin-to-skin contact continuously. Staff found visitors get in the way.