- Introduction
Preterm birth and low birth weight (PBLBW) are among the leading causes of infant mortality in children under five, making them a significant public health challenge that account for a large portion of the global disease burden (Darmstadt et al. 2023). According to definition, a preterm birth occurs when an infant is delivered prior to 37 weeks of gestation, whereas low birth weight (LBW) refers to babies who weigh under 2500 grams at delivery and independently of gestation age (Krasevec et al. 2022; De Costa et al. 2021). The impacts of PBLBW continue to be seen after the neonatal period. The babies born as such have an increased risk of health problems for a lifetime (Risnes et al. (2021). These include respiratory distress syndrome, necrotizing enterocolitis, cognitive impairments, developmental delays, sensory deficits such as vision and hearing impairments, and a higher likelihood of chronic conditions like cardiovascular diseases and chronic kidney disease (McPherson and Wambach, 2018; Crump et al. , 2019).
With more than 15 million infants born preterm every year—accounting for approximately 11% of all live births worldwide—the urgency to address this issue aligns directly with Sustainable Development Goal 3 (SDG 3), which aims to ensure healthy lives and promote well-being for all at all ages. Specifically, SDG 3.2 seeks to end preventable deaths of newborns and children under five, making interventions that improve neonatal survival, such as Kangaroo Mother Care (KMC), essential in achieving this global target (Darmstadt et al. 2023). Similarly, LBW affects around 20 million newborns each year, further exacerbating the global health burden (Krasevec, J. et. al, 2022; Cao et al. 2022).
The burden of preterm births (<37 weeks of gestation) and low birth weight (LBW) infants (<2,500 grams) is disproportionately high in low- and middle-income countries (LMICs), accounting for over 80% of preterm births and nearly 91% of LBW babies, which highlights the seriousness of the problem (Blencowe et al., 2019; Chawanpaiboon et al., 2019). Southern Asia bears nearly half of the global burden, with approximately 10 million LBW babies and 9 million preterm infants born annually (Blencowe et al., 2012; Blencowe et al., 2019). India, in particular, has the highest number of preterm births globally, with around 3.5 million preterm births and 8 million LBW infants recorded annually (Blencowe et al., 2012; WHO, 2004, Jana A, 2023). The prevalence rates of preterm births (13%) and LBW infants (40%) in India remain among the highest in the world, making it the country with the highest neonatal mortality, accounting for 779,000 deaths annually (Chawanpaiboon et al., 2019; Lawn et al., 2014; WHO, 2004).
Although there is a noted improvement in the recent years with India’s neonatal mortality rate (NNMR) decreasing from 29.5 per 1,000 live births in NFHS-4 (2015-16) to 24.9 in NFHS-5 (2019-21); and the infant mortality rate (IMR) declined from 40.7 to 35.2 per 1,000 live births during the same period (NFHS) (MoHFW, 2022, Press Information Bureau PIB, 2022), there are still concerns over certain patterns. Thus, the National Family Health Survey (NFHS-5) 2019-21 highlights a stark rural-urban disparity in neonatal mortality rates (NMR), with rural areas reporting 27.5 deaths per 1,000 live births, significantly higher than 18.0 in urban regions. States like Kerala (3.4), Tamil Nadu (7.6), and Goa (4.4) have the lowest NMR, reflecting strong healthcare systems, while Bihar (34.5), Uttar Pradesh (32.7), and Madhya Pradesh (30.4) report the highest rates, indicating critical gaps in maternal and neonatal care. Strengthening healthcare infrastructure, improving access to skilled birth attendants, and enhancing maternal health services are essential to bridging this gap (NFHS 5, 2019-20).
Kangaroo Mother Care or KMC, as mentioned and acknowledged globally today, has emerged as a major intervention to tackle the issues of child health and wellbeing development. It involves continuous skin-to-skin contact between the mother and the baby, early and exclusive breastfeeding, and close monitoring of the infant’s health. It is a cost-effective and evidence-based intervention that significantly reduces neonatal mortality and morbidity, particularly among preterm and low-birth-weight infants. Despite its proven benefits in improving neonatal survival rates and long-term developmental outcomes, KMC remains underutilized in many LMICs. The available evidence underscores the superiority of Kangaroo Mother Care (KMC) over the Conventional Method of Care (CMC) in improving neonatal outcomes. KMC has been shown to enhance survival rates, promote bonding, and provide essential warmth, especially for low-birth-weight infants.This research aims to highlight the evidence supporting KMC, identify challenges hindering its widespread adoption, and explore policy implications for scaling up its implementation. By synthesizing existing literature and examining successful case studies, this review seeks to advocate for KMC as a cost-effective and sustainable intervention to improve neonatal care, particularly in resource-constrained settings.
In order to do this, this issue briefly synthesizes existing secondary research and policy discussions to evaluate the effectiveness, challenges, and policy implications of KMC for PBLBW infants in low- and middle-income countries, with a specific focus on India. The research is structured around three key themes: evidence on KMC’s impact on neonatal survival and developmental outcomes, barriers to large-scale adoption and implementation, and policy recommendations for improving KMC integration into neonatal care programs.
To achieve these objectives, a systematic review of peer-reviewed journals, government reports, and policy documents was conducted using databases such as PubMed, Google Scholar, and WHO archives. The search focused on studies published between 2000 and 2022, emphasizing clinical trials, meta-analyses, and policy evaluations. Search terms included “Kangaroo Mother Care,” “Low Birth Weight,” “Neonatal Mortality,” “Preterm Births,” and “Public Health Interventions in LMICs.” Additionally, global case studies from countries like Colombia, India, and South Africa were analyzed to extract best practices for successful implementation.
The research adopts a comparative analysis framework, contrasting KMC with conventional neonatal care approaches. Policy analysis methods were used to evaluate national strategies and identify gaps in existing neonatal care programs. Furthermore, a health systems approach was applied to assess socio-cultural, infrastructural, and regulatory barriers affecting KMC adoption. This multi-dimensional analytical lens ensures a comprehensive understanding of the factors influencing KMC implementation and scale-up in LMICs.
Despite its structured approach, this study has some limitations. Since it relies on secondary data, it does not include primary field research or clinical trials. Additionally, language restrictions limited the review to English-language publications, potentially excluding relevant studies published in other languages. While the research synthesizes findings from multiple sources, it does not conduct a quantitative meta-analysis but instead presents a policy-oriented discussion.
- Kangaroo Mother Care – An Overview
Kangaroo Mother Care (KMC) is a low-cost, high-impact intervention that provides standardized care for low-birth-weight infants. Annually, globally speaking, around 15 million premature infants necessitate hospitalization in a neonatal intensive care unit (NICU) (World Health Organization WHO, 2019). This situation is frequently overwhelming and unforeseen for families, as newborns are separated from their mothers and placed in a highly medicalized and strange setting (Al Maghaireh et al., 2016; Phuma-Ngaiyaye & Welcome-Kalembo, 2016; WHO & UNICEF, 2020). Such separation presents considerable challenges for breastfeeding, resulting in critically low rates of exclusive breastfeeding in the NICU. Merely 22.5% of preterm infants achieve the WHO’s guideline for exclusive breastfeeding during the initial six months of life (Wang et al., 2019). This deficiency endangers maternal-infant bonding (Phuma-Ngaiyaye & Welcome-Kalembo, 2016) and raises the likelihood of infant morbidity (Smith et al., 2017c) and mortality (Garcia et al., 2011; Smith et al., 2017b).
Kangaroo Mother Care (KMC) has surfaced as a validated, evidence-based intervention to counter these difficulties. KMC consists of placing a preterm infant (clad only in a diaper) against the caregiver’s bare chest in an upright position to facilitate continuous skin-to-skin contact. The fundamental elements of KMC comprise early and extended skin-to-skin contact, exclusive breastfeeding, prompt discharge, and organized post-discharge care (WHO & UNICEF, 2020). Acknowledged worldwide as a standard practice for preterm infants, KMC fosters maternal-infant bonding, elevates breastfeeding rates, and improves neonatal survival and health outcomes (Charpak et al., 2020; Moore et al., 2016; Seidman et al., 2015).
KMC has demonstrated high cost-effectiveness, decreasing hospital stay durations, reducing the occurrence of complications like necrotizing enterocolitis, and post-discharge healthcare expenses (Campbell-Yeo et al., 2015). These benefits render KMC an appealing option in both high-resource and low-resource environments. Notwithstanding, the implementation of KMC encounters notable obstacles. Instituting KMC in NICUs necessitates comprehensive modifications across three essential domains: healthcare facilities, healthcare providers, and parental involvement.
2.1. Kangaroo Mother Care in India
India has been at the forefront of kangaroo mother care (KMC) promotion and implementation in the past three decades, introduced in 1994 and the KMC network of India established then (Udani, P.N & Bergh, 2024). The Government of India has demonstrated its commitment to enhancing child health by prioritizing newborn care services aimed at improving child survival rates (MoFHW, 2024). In 2014, the Child Health Division of the Ministry of Health and Family Welfare (MOHFW) introduced the “Kangaroo Mother Care and Optimal Feeding of Low-Birth-Weight Infants: Operational Guidelines” to facilitate the implementation of kangaroo mother care (KMC) at healthcare facilities. Additionally, the India Newborn Action Plan (INAP), also released in 2014, emphasized KMC as a key intervention for small and sick newborns weighing less than 2,000 grams. As part of INAP’s priority actions, the establishment of fully functional KMC units or wards in healthcare facilities providing newborn care was highlighted .
To support this initiative, the MOHFW allocated funds to states for creating and adapting KMC spaces within special newborn care units. INAP had stipulated coverage targets of NICU in a phase-wise manner starting from 2017 with 35%, 2020 with 50%, 2025 with 75%, and 2030 with 90% levels of coverage (India MOHFW, 2014a). One of the priority actions under the plan was to establish fully functional Special Newborn Care Units (SNCUs) with dedicated KMC units or wards. The “Operational Guidelines” provided comprehensive guidance such as protocols for the criteria for eligibility to KMC, standards for the provision of infant care, requirements for the construction of KMC facilities, institutional and follow-up strategies, budget plans, and communication approach.
Protocols for implementing KMC at the facility and community levels were incorporated into a series of training packages that aim to improve health staff competencies in newborn care. As of now, according to the minutes of the KMC Acceleration Partnership meeting held in 2016, India had 630 SNCUs at that time. This number increased to 712 and, as of UNICEF’s 2024 report, stands at 1,054. Of the 712 SNCUs, 265 were reported to have KMC units (IIPS and Macro International, 2017). However, only 15% of these units met the recommended standard of eight beds per KMC unit. Unfortunately, no updated data is available regarding the number of SNCUs equipped with KMC units beyond the 2017 IIPS and Macro International findings.
In April 2017, the Government of India (GOI) formed a technical advisory group to strategize and support the nationwide scale-up of KMC (USAID, 2019). Two working groups were established, led by the KMC Foundation in Gujarat and the Postgraduate Institute of Medical Education and Research in Chandigarh, to develop training modules and reporting tools for KMC. At present, there is no formal mechanism to systematically collect data on KMC implementation parameters. However, reports submitted by 18 states to the GOI revealed that in 12 states, only 0–20% of SNCU-admitted babies received KMC, while in six states, more than 20% of SNCU-admitted babies benefited from the intervention.
- Factors Influencing Neonatal Healthcare Services in Low- and Middle-Income Countries (LMICs)
While Kangaroo Mother Care (KMC) has been recognized as an effective intervention for improving neonatal survival in India, its impact must be understood within the broader context of multiple factors influencing neonatal health in low- and middle-income countries (LMICs). These factors, including healthcare infrastructure, socio-economic conditions, and maternal education, plays a crucial role in determining the success and scalability of KMC interventions, necessitating a broad and inclusive approach.
For instance, In China, a family-centered, child-friendly multidisciplinary clinic was more effective in monitoring high-risk preterm neonates, enabling earlier diagnoses of neurodevelopmental impairments and cerebral palsy (Huang et al.). In Ethiopia, fewer than 10% of neonates received postnatal check-ups. Strategies to improve this include increasing antenatal care (ANC) visits, promoting institutional deliveries, raising awareness of neonatal danger signs, enhancing access to healthcare facilities, and implementing home-based neonatal care visits by healthcare providers (Birhane et al.).
Home visitation is a widely accepted and effective model for delivering intensive care during pregnancy, childbirth, and the postnatal period, significantly improving maternal and child health outcomes (Babyar JC, 2017 and Ashwell HE, Barclay,L 2009) Grounded in ecological theory, home visitation programs emphasize the interaction between children, their families, and the health systems within multi-layered environmental conditions (Krasevec, J. et al 2022). These programs are cost- and time-efficient interventions (Yoshikawa H, 1995; Olds DL, Kitzman H.m, 1998) that enhance mothers’ skills, knowledge, and awareness of childcare, early illness detection, and timely care-seeking (Chapman J et al 1990).
Accredited Social Health Activists (ASHAs) serve as key community health workers in India, with over one million ASHAs deployed across 600,000 villages (Peacock S, et al 2013). Under initiatives like Janani Shishu Suraksha Karyakaram (JSSK, launched in June 2011) (Nandan D, 2010) and Home-Based Newborn Care (HBNC, initiated in August 2011) (WHO,2011), ASHAs are responsible for visiting pregnant women, facilitating institutional deliveries, and conducting six to seven home visits during the postnatal period (MoHFW, 2014). Recently, in 2013, the Norwegian India Partnership Initiative (NIPI) introduced the Home-Based Newborn Care Plus (HBNC Plus) program, piloted in four states—Rajasthan, Madhya Pradesh, Bihar, and Odisha. ALthough generally, these visits include counseling on essential newborn care, breastfeeding, and early danger sign recognition, the HBNC Plus Program added four additional home visits during the first year of life, focusing on counseling for age-appropriate feeding, hygiene practices, early child development, immunization, and growth monitoring (Pappu K, 2011).
Even though challenges persist in the quality and impact of home visitation services, it remains one of the most prudent and expedient practices that can be replicated in other low- and middle-income countries and has demonstrated a positive impact on improving child and maternal health outcomes (Garg, S. et al 2022; Rasaily R, et al 2020). In fact, multiple secondary research indicates that an adequate number of high-quality home visits by ASHAs can significantly improve physical and cognitive development in newborns and infants, ensure early illness detection, and reduce mortality and morbidity rates (Bang AT et al, 1999). However, evaluations of the performance of ASHA have highlighted multiple fronts on which it can be strengthened. Firstly, one may consider the matter of non-standardization which may be instrumental in the different performances across different geographies.
For instance, mothers in Karnataka rated ASHAs poorly for advice on obstetric danger signs and neonatal care (Kochukuttan S et al. 2013). Similarly, internal evaluations of the NIPI program found home visitation under HBNC and HBNC Plus to be inadequate, with less than 10% of sick young infants mobilized to health facilities by frontline workers (UNDP, 2014). While programmatic challenges are well-documented, the social, cultural, and personal constraints faced by ASHAs remain under-researched (Glenton C,2013). The HBNC Plus program evaluation highlighted difficulties in translating training and incentives into the desired outcomes, such as the number and quality of home visits (ibid). There are other studies which have highlighted this such as the one conducted by Vaishali Deshmukh in the Raisen district of Madhya Pradesh which undertook a grounded theory and nexus planning approach to find that key constraints included societal issues such as caste and economic discrimination, personal challenges like domestic responsibilities and cultural restrictions, and programmatic gaps in technical knowledge, mentoring systems, communication skills, and remuneration (Deshmukh V, et al. 2022).
While frontline workers like ASHAs play a crucial role in neonatal care through home visits, the challenges they face are only one aspect of the broader complexities of pediatric healthcare in LMICs. As per the guidelines by NHSRC in the Handbook for ASHA on Home-Based Care for Young Child, ASHA workers are crucial in home visitations. They play a vital role in promoting and facilitating Kangaroo Mother Care (KMC) by educating mothers on its benefits, ensuring adherence, and providing community-based support for neonatal care(NHSRC, 2021). As health systems in these regions evolve, they must also grapple with managing long-term and specialized neonatal conditions, such as congenital birth defects. For instance, managing complex birth defects like bladder exstrophy (BE) involves a long-term care course, significantly affecting caregiver distress in India (Spencer et al., 2022). From 2018 to 2020, a multi-method evaluation of caregiver distress was conducted as part of the International Bladder Exstrophy Collaboration in Ahmedabad, Gujarat. Pilot data collected in 2018 through cognitive interviews revealed that village stigma (26.5%) and concerns about future fertility and marital prospects (52.9%) were primary stressors. In 2019, structured interviews confirmed that anticipated (31%) and experienced stigma (65.5%) largely originated from community attitudes. By 2020, findings indicated that emotional well-being declined as the number of subsequent surgeries increased (75%, p = 0.002). Caregivers of children who underwent initial surgery within five years reported higher anxiety levels (63.8%), exacerbated by repeated surgeries (p = 0.043). Despite these challenges, caregivers found the collaboration to be a positive source of support (36.5%) (Spencer, K (2022).
- Effectiveness of KMC in Improving Survival and Developmental Outcomes
The WHO recommends using Kangaroo Mother Care (KMC) for newborns weighing 2.0 kg or less, starting as soon as the baby is clinically stable in a healthcare facility. Clinically stable means the baby can breathe well, has a steady heart rate, and can maintain body temperature without needing intensive medical support. Whenever possible, these newborns should receive continuous KMC. If continuous KMC is not feasible, intermittent KMC is recommended as an alternative to conventional care. However, there is currently no recommendation for KMC in unstable neonates weighing less than 2.0 kg (WHO, 2015).
A recent Cochrane review found that infants with a birth weight of less than 2.0 kg who received KMC had a 40% lower mortality rate compared to those who received standard hospital care at 40 to 41 weeks postmenstrual age. In nearly all studies included in this review, KMC was initiated only after the infant was clinically stable, with the median age at initiation ranging from 3.2 to 24.5 days (Conde-Agudelo A, 2016). Two randomized controlled trials (RCTs) conducted in South Africa and Vietnam compared immediate versus conventional KMC and demonstrated favorable outcomes for immediate initiation (Worku B, Kassie A., 2005; Bergman NJ, Linley LL,2004; Chi Luong K, et al. 2016).
4.1 KMC and Neurodevelopmental Outcomes
Another key factor of KMC is its impact on the neurodevelopmental outcomes of the child. Research has shown that KMC helps reduce episodes of bradycardia and oxygen desaturation in preterm infants, contributing to physiological stability and potentially supporting neurodevelopment(Mitchell AJ, et al 2013). Studies on stable infants have linked KMC to both short-term and long-term neurodevelopmental benefits, with protective social and behavioral effects observed even two decades after intervention (Adejuyigbe, E. A. et al. (2023). This, in turn, may positively influence child behavior. While the direct effects on cognition, language, motor skills, auditory function, and vision vary across studies, most findings suggest an overall positive trend.
Additionally, emerging evidence from smaller studies indicates that KMC may have neuroprotective effects, as reflected in improved sleep cycles, brain maturation patterns observed on EEG, and enhanced stress responses, which have been linked to long-term emotional and cognitive development. A study by Adejuyigbe, E. A. et al. (2023) hypothesizes that initiating KMC immediately after birth can improve physiological stability, potentially leading to structural or functional brain changes in the neonatal period. This could enhance brain maturation and neural pathway development, thereby reducing the risk of neurocognitive impairments and hypoxia-related morbidities.
4.2 Impact of KMC on Morbidity, Mortality, and Breastfeeding
Despite this growing support, certain areas still require further investigation and evidence-building, including the efficacy and safety of early-onset continuous KMC in unstabilized LBW infants, its long-term neurodevelopmental outcomes, and the associated costs of care. Notably, KMC is closely linked to infant feeding practices and has a significant influence on long-term breastfeeding. A study conducted in Sweden highlighted this role, reporting that very preterm infants who were breastfed at 1, 2, 5, and 6 months had spent more time in KMC per day than those who were not breastfeeding during these periods. The study aimed to examine the relationship between KMC duration and breastfeeding success in mothers of very preterm and preterm singleton infants. Interestingly, among preterm infants, there was no statistically significant difference in KMC duration between breastfed and non-breastfed infants. However, the authors concluded that KMC positively impacts breastfeeding, particularly in very preterm infants who are more vulnerable and require longer KMC exposure (Flacking R et al. 2011). In essence, the duration of KMC plays a crucial role in strengthening the mother-infant bond, which, in turn, enhances breastfeeding practices and supports infant development.
Conclusion:
The available evidence highlights the comparative advantage of Kangaroo Mother Care (KMC) over Conventional Method of Care (CMC), particularly in improving neonatal survival, supporting exclusive breastfeeding, and facilitating early discharge from the hospital. Initially proposed for resource-limited settings to address the high neonatal mortality rates associated with preterm and low birth weight (LBW) infants, KMC has since received endorsement from the World Health Organization for neonatal care in both high-income (developed) and low-income (developing) countries.
In developed countries, the implementation of KMC may be limited due to the widespread availability of incubators and other technology-based components of CMC. However, significant progress has been made in many developing countries, where facility-based KMC has been institutionalized. Despite its proven cost-effectiveness, global implementation of KMC faces country-specific, multifaceted challenges.
Many developing countries, however, have launched national policies aimed at scaling up KMC services (WHO, 2023). To overcome the challenges inherent in these resource-constrained settings, it is essential to enhance caregiver confidence and experience by creating dedicated spaces within hospitals and employing specialized staff to ensure adequate ambulatory follow-up and continuous health education. KMC can further reduce mortality rates by enhancing neonatal survival, promoting exclusive breastfeeding, and facilitating early hospital discharge (BoundyEO, et al 2016). To overcome challenges in resource-constrained settings, it is essential to strengthen the skills and credibility of frontline health workers, such as Accredited Social Health Activists (ASHAs), and provide the necessary infrastructure. ASHA workers play a crucial role in promoting and facilitating Kangaroo Mother Care (KMC) by educating mothers on its benefits, ensuring adherence, and providing community-based support for neonatal care (NHSRC, 2021).
International aid agencies can play a pivotal role in supporting these initiatives, ensuring that KMC becomes a cornerstone of neonatal care in India and other low- and middle-income countries.
