Table 2.

Matrix of barriers and enablers for HCWs and health facilities

		Buy-in	Support and Empowerment	Time	Medical concerns	Access	Cultural norms
HCWs	Enablers	Experience with KMC Nurses were more likely to perform KMC if they believed it worked	Management: Management mobilization of resources Nurse involvement in care related decision making	Workload Some nurses reported that KMC did not increase the amount of time they spent on each patient	Practicing securing catheters lowered nurses’ concerns Nurses with 5 or more years of experience more likely to implement KMC	Expanding training to other healthcare personnel besides nurses	Some HCWs advised mothers to delay bathing so infant would not get cold
			Other HCWs: Multiple health worker support facilitated SSC—nutrition workers, CHWs and clinical workers
	Barriers	Nurses believe KMC based on perception and not scientific fact Inconsistent application of KMC within facilities and among HCWs Concerns on the stability of the infant	Management: Lack of leadership and support from management Felt newborn care was not a priority in the health system	Workload Training mothers to do SSC would take additional time out of health workers’ schedules, increase their workload, and reduce time with other critical patients	Did not believe KMC was safe for LBW newborns Staff not trained in preterm care	KMC training not part of a broader healthcare training curriculum Poor training lead to conflicting knowledge on time and duration of SSC	Traditional Newborn Care Bathing practices and wrapping infants soon after birth delayed SSC In warm climates staff did not believe hat and socks were necessary
			Other caregivers: Some HCWs considered parents and visitors as a barrier Limited communication between HCWs
Health Facilities	Enablers	Companions for mothers promoted KMC Posters of KMC in the facility	Use of technology Use of KMC guidelines	Greater or unlimited visitation time enhanced support from family and promoted KMC KMC ward	Shorter crying times in response to pain with KMC compared with incubator care	Access to private space/privacy screens Relaxed atmosphere with dim lighting	Include KMC in health facility statistics
	Barriers	Management reluctance to allocate space for SSC High leadership turnover	KMC protocols perceived as inflexible	Shortage of staff nurses limited parental access and shortened visitation time. The shorter the visitation period was, the more of an interference staff thought parents were Visitation policies were difficult due to strained communication between parents and staff. Visitors were an obstacle to breastfeeding and KMC performance	Few NICUs had written KMC protocols No checklist for KMC admission procedures. Follow-up and discharge procedures not well structured	Space: Lack of privacy Space limitations induced discharge within hours Crowding and insufficient space in the NICU. Allocation: Staff need to bargain with managers to increase and maintain resources for newborn care KMC was not budgeted for, and resources were mismanaged	No record of SSC Difficulty adapting/teaching electronic medical records for KMC Implementing continuous KMC was difficult. Many facilities reported performing continuous KMC, but few actually practiced it

KMC, kangaroo mother care; HCW, healthcare worker; SSC, skin-to-skin contact; LBW, low birth weight.