Kangaroo Mother Care (KMC)
Kangaroo Mother Care, short KMC, is a neonatal care practice which benefits all newborns but particularly those born preterm, with low birth-weight, or in need of immediate medical attention.
The WHO defines the practice as including the following key features :
- continuous and prolonged (8–24 hours per day, for as many hours as possible) skin-to-skin contact, initiated immediately after birth
- exclusive breastfeeding or breastmilk feeding
- when KMC is initiated in healthcare facilities, timely discharge either from the NICU to a lower level of care within the facility or discharge to home (with skin-to-skin contact and close monitoring)
Skin-to-skin contact usually occurs before breastfeeding is initiated and is an effective way to encourage mother and infant to attempt breastfeeding and, once started successfully, to continue doing it. Formula milk should only be provided in exceptional circumstances.
In this view, Kangaroo Mother Care empowers the mother to take control of her own and her infant’s care – a significant reversal of the power dynamics at play in many healthcare systems around the globe. Care is organised around mothers/families and their newborns and prioritises their needs. It marks a paradigm shift by calling for systemic changes in the way maternal and newborn care is organised .
Immediate Kangaroo Mother Care (iKMC)
The most recent WHO guidelines recommend to start with KMC immediately after birth (or initial resuscitation, should that have been necessary) [1, 4]. In fact, immediate Kangaroo Mother Care (iKMC) can already be initiated before the newborn is considered clinically stable, thus avoiding an unnecessary separation of newborn and mother [7, 10]. Only in cases where the newborn is unable to breathe spontaneously after resuscitation, is in shock, or needs mechanical ventilation, does treatment take precedence over iKMC. If the mother cannot engage in iKMC right after birth (e.g. because she needs medical treatment herself), then her partner or other family members should be asked to take over.
The Immediate KMC (iKMC) Study coordinated by the WHO found that infants who received iKMC had
- lower mortality rates,
- lower rates of hypothermia at discharge, and
- less instances of sepsis
compared to infants who received KMC 24 hours after birth . Immediate Kangaroo Mother Care is therefore a powerful intervention to prevent many cases of newborn deaths, indicating that both iKMC and KMC should become routine care practices for all infants born preterm, with low birth-weight, or in need of immediate medical attention.
The special role of the family in Kangaroo Mother Care
When lying on the mother’s chest, the baby recognises the familiar sound of her heartbeat and calms down, feeling safe and secure. It is also the mother who provides nourishing breastmilk which her body automatically adjusts to the baby’s gestational age and other health requirements. KMC has also been shown to help promote (exclusive) breastfeeding, making it a practice which benefits both mother and baby at the same time [e.g. 2, 3].
Nevertheless, recent studies have found that extensive skin-to-skin contact between the newborn and another family member, e.g. the father, is very beneficial as well [13, 14]. When it is the non-birthing partner who provides extensive skin-to-skin contact, even immediately after birth, newborns achieve and maintain thermal stability at similar rates like those newborns who experience skin-to-skin contact with their mother. This is also the case for healthy term-born infants. These findings stress the importance of family involvement in the care for preterm and hospitalised infants as other family members can take turns in caring for the infant, supporting the mother and enabling her to get some rest.
Kangaroo Mother Care in the hospital
KMC can be done in the hospital and at home for as many hours a day as possible. The WHO recommends in its most recent guidelines to practice it for at least 8 hours a day and notes that it can be done as much as 24 hours a day, encouraging a “Zero Separation” policy.
This also means that hospitals need to rethink how they understand the role of parents in the NICU. Adhering to the concept of (immediate) KMC also means that parents should be seen as critical part of the care team and supported to become the main caregivers for their baby. Healthcare professionals and hospital administration should realise that parents are not visitors and allow them into the unit to be with their child 24 hours a day, 7 days a week. These parameters facilitate (immediate) KMC which, in turn, improves health outcomes for infants and their families.
Hospitals with perinatal and neonatal units should therefore be equipped with comfortable chairs and/or beds to aid families in practicing KMC for as long as possible. Breastfeeding support should be available as well, encouraging the feeding of breastmilk and assisting mothers in starting a positive breastfeeding journey with their baby. Moreover, bathrooms should be easily accessible so as to allow the mother to shower and maintain basic hygiene. Healthy and nourishing food should be equally at hand, ideally within a separate area to eat properly. Family members and close friends should be allowed (and encouraged) to take care of the mother. Whenever the mother needs to take a break, one of them should be invited take over for her.
Kangaroo Mother Care at home
Families should be empowered to engage in the practice not only during their hospital stay but also after discharge. This requires close collaboration between families and the healthcare staff. Families should have access to counselling and support as well as regular follow-up visits, either directly at home or at a healthcare facility nearby.
Benefits of (immediate) Kangaroo Mother Care
Studies have shown that KMC has measurable and significant health benefits for infants and parents.
Health outcomes of hospitalised newborns are significantly improved as KMC leads to
- reduced mortality rates [2, 3, 4, 7, 9, 10],
- decreased rates of infections and sepsis [2, 3, 4, 7, 9, 10],
- fewer cases of hypothermia as well as improved temperature management capabilities [2, 3, 6, 9],
- improved weight-gain [4, 6, 9, 10],
- improved growth [4, 8, 9],
- improved motor development ,
- improved sensory development ,
- more stable breathing ,
- improved sleep ,
- more stable heart rates ,
- improvements in brain activity and cognitive development [1, 2, 4, 6, 8], and
- enhanced longer-term social and behavioural outcomes like improved academic performance .
It is also a valuable intervention in pain management as both direct skin-to-skin contact and breastfeeding have been shown to lower pain levels in infants, thus actively protecting brain development [e.g. 11, 12].
Parents/Families also benefit from engaging in the practice. Data show that when KMC is practiced,
- breastfeeding rates increase [3, 4, 6, 7, 8, 9, 10],
- skin-to-skin contact after birth reduces the duration of third stage of labour and postpartum haemorrhage ,
- time spend in the NICU decreases ,
- overall hospital stays are shorter ,
- family bonding is strengthened and attachment between infant and parents deepens [1, 3, 6, 8],
- stress levels are lowered for both parents and infant [3, 5, 6, 10],
- parents become less likely to develop mental health issues like depression [1, 8, 10],
- parents are empowered as primary caregivers of their child and are encouraged to protect and nurture their infant ,
- parents become more confident and competent in their role [1, 3], and
- parents become more involved in all aspects of care for their baby [3, 8].
Parents generally view KMC as an opportunity for parenting and caring for their child. It helps to reduce relationship problems between the parents themselves and positively impacts the home environment in which the child is raised .
Lastly, for hospitals and healthcare systems alike, introducing (immediate) KMC leads to a measurable reduction in costs and lower capital investment as no expensive equipment is needed (which, in turn, needs to be maintained and repaired regularly) and hospital stays tend to be shorter . KMC also facilitates respectful maternal and newborn care . In addition, the infant requires less handling by medical staff which also frees up staff resources [1, 3, 8].
The chemistry behind Kangaroo Mother Care
The benefits of practicing (immediate) Kangaroo Mother Care can also be observed in the bodily responses of mother and infant. These include but are not limited to the following chemical reactions :
- Oxytocin floods the mother’s body in response to continuous and prolonged skin-to-skin contact as well as breastfeeding. It leads to overall feelings of wellbeing, increased breastmilk production, and facilitates exclusive breastfeeding. Interactions between mother and infant are also enhanced.
- The infant’s body also releases oxytocin in response to the skin-to-skin contact and the breastmilk, boosting their immune system to produce T-cells and suppress inflammatory cytokines.
- Skin-to-skin contact immediately after birth decreases cortisol levels and leads to the release of oxytocin, thus reducing and regulating feelings of stress. The heart rate also stabilises.
- During KMC, protective microbiota are transferred from the mother’s skin to the infant, thus enhancing the infant’s immune function.
- Early skin-to-skin contact activates the body’s opioid systems as well as mesocorticolimbic dopamine which, when released, support the development of those neural circuits involved in social cognitive processes.
The St. Joseph Hospital in Berlin Tempelhof practices the simple but very effective method of Kangaroo Mother Care in its daily work and is a pioneer in this field with its certification as a “Baby-friendly Hospital”. In this interview, the experts Prof. Michael Abou-Dakn and Dr. Caroline Schmitt talk about the rooming-in concept for parents and their preterm-born babies, the care of affected families in the course of the “family-friendly” certification, the promotion of breastfeeding through early bonding and future developments in child- and family-centred care. Please note this video is in German.
Expert Dr Carmen Pallás Alonso is Head of the Neonatal Unit at the Hospital Universitario 12 de Octubre in Madrid, Spain; Spanish Maternal & Child Health Network SAMID-RICORS, Health Research Institue Carlos III in Madrid, Spain. In the conversation she explains why Kangaroo Mother Care (KMC) is a care practice which empowers families – particularly mothers – to take control of their own and their baby’s care. Watch the full video on ‘Promoting neonatal health with kangaroo mother care’ and learn and share for better care.
In the LIVE Q&A session from November 10, 2022 together with Dr. Nathalie Charpak, pediatrician, founder and director of the Kangaroo Foundation in Colombia/France and Diane Schultz, NICU nurse at St. Boniface Hospital, Winnipeg, Manitoba, Canada questions oncontact and (KMC) are answered, the benefits of realizing these interventions as early as possible are explained and challenges and lessons learned are discussed as well as impulses to implement KMC within clinical units are provided.
Watch the video ‘Kangaroo Care in the Neonatal Intensive Care Unit’ in which Diane Schultz (NICU nurse at St. Boniface Hospital, Winnipeg, Manitoba, Canada) describes what to do when it’s time to kangaroo, also showing transfer techniques for the NICU patient.
Watch the Kangaroo Mother Care video created by the World Health Organization.
-  Kangaroo mother care: Implementation strategy for scale-up adaptable to different country contexts (World Health Organization 2023) 9789240071636-eng.pdf (who.int).
-  Healthy Newborn Network. “Kangaroo Mother Care.” Healthy Newborn Network, https://www.healthynewbornnetwork.org/issue/kangaroo-mother-care/. Accessed 12 Jan. 2023.
-  World Health Organization. Kangaroo mother care: a practical guide. World Health Organization, 2003, https://www.who.int/publications/i/item/9241590351.
-  World Health Organization. WHO recommendations for care of the preterm or low-birth-weight infant. World Health Organization, 2022, https://apps.who.int/iris/handle/10665/363697.
-  Chan GJ, Labar AS, Wall S, Atun R. “Kangaroo mother care: a systematic review of barriers and enablers.” Bulletin of the World Health Organization, vol. 94, no. 2, 2016, pp. 130-141J. doi: 10.2471/BLT.15.157818.
-  Charpak N, Gabriel Ruiz J, Zpan J, Cattaneo A, Figueroa Z, Tessier R, Cristo M, Anderson G, Ludington S, Mendoza S, Mokhachane M, Worku B. “Kangaroo Mother Care: 25 years after.” Acta Pædiatrica, vol. 94, no. 5, 2005, pp. 514-22. doi: 10.1111/j.1651-2227.2005.tb01930.x.
-  World Health Organization. “Kangaroo mother care started immediately after birth critical for saving lives, new research shows.” World Health Organization, 26 May 2021, https://www.who.int/news/item/26-05-2021-kangaroo-mother-care-started-immediately-after-birth-critical-for-saving-lives-new-research-shows. Accessed 12 Jan. 2023.
-  Lode-Kolz K, Hermansson C, Linnér A, Klemming S, Hetland HB, Bergman N, et al. “Immediate skin-to-skin contact after birth ensures stable thermoregulation in very preterm infants in high-resource settings.” Acta Paediatrica, 2022; https://onlinelibrary.wiley.com/doi/10.1111/apa.16590.
-  Ayala A, Christensson K, Christensson E, Cavada G, Erlandsson K, Velandia M. “Newborn infants who received skin-to-skin contact with fathers after caesarean sections showed stable physiological patterns.” Acta Paediatrica, vol. 110, no. 5, 2021, pp. 1461-67; https://pubmed.ncbi.nlm.nih.gov/33403688/.
-  EFCNI, Bergman NJ, Westrup B, Kuhn P, Daly M, Bertoncelli N, Caballero S, König K. “Very early and continuous skin-to-skin contact.” European Standards of Care for Newborn Health, 2018. https://newborn-health-standards.org/standards/standards-english/infant-family-centred-developmental-care/very-early-and-continuous-skin-to-skin-contact/.
-  Conde-Agudelo A, Díaz-Rossello JL. “Kangaroo mother care to reduce morbidity and mortality in low birthweight infants.” Cochrane Database of Systematic Reviews, no. 8, 2016. doi: 10.1002/14651858.CD002771.pub4.
-  WHO Immediate KMC Study Group. “Immediate ‘Kangaroo Mother Care’ and survival of infants with low birth weight.” The New England Journal of Medicine, vol. 384, 2021, pp. 2028-38. doi: 10.1056/NEJMoa2026486.
-  Choudhary M, Dogiyal H, Sharma D, Datt Gupta B, Madabhavi I, Choudhary JS, Choudhary SK. “To study the effect of Kangaroo Mother Care on pain response in preterm neonates and to determine the behavioral and physiological responses to painful stimuli in preterm neonates: a study from western Rajasthan.” Journal of Maternal and Fetal Neonatal Medicine, vol. 29, no. 5, 2016, pp. 826-31. doi: 10.3109/14767058.2015.1020419.
-  Shukla VV, Bansal S, Nimbalkar A, Chapla A, Phatak A, Patel D, Nimbalkar S. “Pain Control Interventions in Preterm Neonates: A Randomized Controlled Trial.” Indian Pediatrics 55, no. 4, 2018, pp. 292-6. PMID: 29428919.