In total, 54 interviews were conducted, including 32 with mothers of preterm infants and/or family members practicing KC, and 22 with healthcare professionals (3 doctors, 16 midwives, 3 nurses) involved in KC. We conducted two focus groups (FG) with other parents of preterm infants, focusing on the themes that emerged from the semi-structured interviews, to examine the consistency of the responses given. Those practicing KC were interviewed at home, whereas care staff were interviewed at the BHCs. The interviews were conducted in Malagasy.

Characteristics of the targeted population and description of the BHCs

The results cover the social and demographic characteristics of the 32 individuals involved in the KC of premature infants interviewed (Table 1). One of these individuals was the father of the infant, but all the others were mothers, with, on average, two children each. The mean age of the mothers was 26 years. Most of the interviewed (29/32) worked in the informal sector (housekeepers, laundry workers, saleswomen). Only 3/31 mothers had finished secondary school (obtaining a baccalaureate).

Table 1 Social and demographic characteristics of the 32 individuals involved in the KC of premature infants interviewed

Most of the mothers family model is cohabitation outside marriage (fisehoana or vodi-ondry). The family structures were single-parent families, which was the case for 20/31 mothers (mostly single mothers), nuclear families (couples living under the same roof) for 8/31 mothers, or extended families (4/32). The family context of the women interviewed was largely affected by violence and/or breakdowns of relationships due to violence. Following break-ups, the preterm children become the responsibility of the mother (and her family if there is an extended family).

The healthcare professionals interviewed were mostly midwives (3 doctors, 16 midwives, 3 nurses) and their mean age was 35 years.

The two BHCs in Antananarivo have a special KC room decorated with paintings illustrating mothers carrying their infants in lambaoany (traditional fabrics) and posters providing information about the positioning of the baby and the advantages of KC. However, the two rooms are used by all users of the service and the hygiene infrastructure is unusable. In Mahajanga, none of the five BHCs has a KC space. The rooms allocated for the postpartum period are overcrowded because they lack sufficient modern equipment (beds, etc.).

Identification and management of preterm infants nationwide

Difficulties identifying cases of preterm birth and determining its impact on therapeutic orientation

One of the major challenges faced by healthcare professionals in the management of preterm infants is the identification of the infants concerned. In the health centers investigated, preterm infants were essentially identified based on the appearance of the baby at birth, and particularly low birth weight. It should be possible for professionals to identify preterm infants by observing intrauterine growth retardation with an ultrasound device, but no such devices are available at any of the BHCs studied. The other element that can help to identify preterm infants is the precise determination of the gestational age, also by ultrasound methods. The healthcare professionals interviewed deplored the women’s lack of knowledge about the date of their last menstrual period.

“When the child is born before 37 weeks of gestation, it is preterm, but if we look at the length of the pregnancy, the date of the last menstrual period is not precise because the mothers do not remember it. So, we don’t rely too heavily on the length of pregnancy, but more on the weight. It’s more reliable.” – Antananarivo.

In light of this difficulty and to ensure appropriate care despite the lack of information about the term at which the infant is born, healthcare professionals use the criterion of “low birth weight” to guide management. None of the registers observed during the investigation mentioned a “preterm” child. We understand that preterm birth is not accurately reported at the national level by the Ministry of Health, which may explain the lack of precise statistics. Therefore, as the child is not officially recognized as “preterm”, there is no communication between the healthcare professional and the parents concerning the diagnosis of “prematurity” for their child. As we will see below, parents know little about the term “preterm” and very few use it to characterize their child. Health professionals deem newborns eligible for KC meeting the following criteria: low birth weight, i.e., a weight of less than 2500 g, with a sucking reflex and not suffering from respiratory distress syndrome or other serious illnesses.

Implementation of KC for “low birth weight” children

Our interviews with mothers indicated that they did not know about KC before the birth of their child. Only one of the 32 people involved in KC interviewed reported prior knowledge obtained through a radio spot. The BHC is the leading source of information on low birth weight and KC.

If there are no contraindications (respiratory problems, absent sucking reflex, etc.), healthcare professionals teach the mothers and other caregivers present how to practice KC. In Antananarivo, slings (single-color elastic fabrics) that facilitate the carrying of the child are loaned to mothers by Compassion Madagascar. In the Mahajanga region, mothers carry their babies in traditional fabrics. In both regions, healthcare professionals suggest that families buy diapers for infants from grocery stores or businesses close to the site at which the baby was delivered, rather than using the washable cloth nappies generally used by mothers. They justify this request both by the fact that it limits the hygiene problems that can be caused by unclean nappies and by the desire to optimize the time for which the infant is carried. They also claim that commercial diapers have a greater absorption capacity, making it possible to limit the interruption of the practice of KC and to keep the child warm for longer. As indicated by the following interview excerpt, the health professionals interviewed are aware of the financial obstacle that this represents:

“There are people who cannot buy diapers and we try to convince them by telling them that the baby must be kept warm, because it would be difficult to return this heat to the baby if the baby is cold. Cloth diapers have to be changed frequently if the baby “pees” too often, which is why the baby should be put in a diaper.” Midwife, 29 years of age, married, one child.

In addition to these initial difficulties, the length of the postpartum stay at the health center is also a constraint on the management of low birth weight infants mentioned by healthcare professionals. Indeed, none of the mothers interviewed stayed for more than 24 hours at the BHC after delivery, despite the encouragement of healthcare professionals to stay for 3 days in the room allocated to postpartum care. There were multiple reasons for this rapid departure from the BHC: lack of privacy, hygiene, and accommodation for those accompanying the mother, and too long an absence from home.

Nevertheless, the mother and her newborn can go home once the infant is feeding well, the infant’s body temperature remains stable in the “kangaroo” position, and the infant is gaining weight. As most infants are still preterm when discharged from the facility, mothers are made aware of the importance of maintaining KC at home. The information transmitted mostly concerns the importance of maintaining continuous skin-to-skin contact. Little information is provided about the time for which the infant should be carried or physical aspects of the child that might indicate a change in growth. The healthcare professionals justified this in terms of the need to simplify the information given to mothers, as indicated by the following interview excerpt:

“As the gestational age is not very well-defined, it is difficult to give a number of weeks for which KC should be performed, so we say to do it until the child gains weight.” BHC Midwife – Antananarivo.

The mothers deplored the lack of clarity and content of the information received on this subject. The information received mostly concerned the possible cessation of KC when “we see that the child is gaining weight”, as indicated by a young mother in Antananarivo. The mothers considered this information to be too imprecise, and sometimes stopped KC after only a few days.

KC, as promoted by the WHO, requires regular follow-up by a qualified professional living near the mother’s house. These regular home visits (HVs) ensure that the techniques taught by the healthcare professionals at the BHC are implemented. None of the healthcare professionals interviewed said that they carried out HVs, justifying this by the lack of human resources at their health facility, and a lack of means to reach the mothers, who sometimes live very far from their center. HVs are not part of the designated tasks of healthcare professionals in public BHCs.

Healthcare professionals try to circumvent this difficulty by inviting mothers to visit the BHC 1 week after childbirth, with the purpose of following the change in the infant’s weight, performing the first vaccinations, and monitoring care (sutures for cesarean section or episiotomy, breastfeeding follow-up, etc.). Concerning this subject, a midwife from Mahajanga stated that:

“Each time she does the vaccination, we can see if the infant is growing well…” 38 years of age, married, two children – Majunga.

Healthcare professionals also recommend working with community agents, both for follow-up and to convince mothers that they should go to the health center in the event of a problem.

Nevertheless, this leads to many women being lost to follow-up, raising questions among healthcare professionals concerning the practice of KC at home:

“We don’t know if they really do it or they really don’t! So that’s the difficulty.” Midwife, 35 years of age, married, five children.

Healthcare professionals assume that mothers stop the practice once at home:

“When they leave here, they don’t practice it at their homes.” BHC Midwife, 31 years of age, no children– Antananarivo.

Some mothers lost to follow-up are then contacted by telephone on the personal initiative of certain health professionals.

The economic burden of referring underweight children

Infants not considered fit for KC with a birthweight below 1 kg are referred to the nearest hospital, which should normally be equipped with incubators. According to healthcare professionals, families fear referral to a hospital, notably due to the high cost of hospitalization and the direct and indirect costs associated with hospitalization.

Healthcare professionals affirm that families that do not want to go to the hospital ask for KC:

“We should send them to Androva [hospital] to take care of the child, but often when the family sees that the child is robust then they say: no, we are not going there, and when they don’t go, we show them the kangaroo technique. We teach it to them while they’re still here”. BHC Midwife, 34 years old, married, two children – Majunga.

Healthcare professionals therefore offer this solution as a last resort while stating that KC cannot replace special care.Footnote 4

Three conditions for the success of KC emerged from the interviews and focus groups with the participants. These conditions favor the success of this approach and relate to both the health facilities in which mothers give birth and their homes.

Brakes and levers relating to training and infrastructure

These conditions for success concern the training in KC provided to healthcare professionals and then to the characteristics of the infrastructures and equipment available to mothers and healthcare professionals for the practice of KC, both within healthcare facilities and at home.

Quality of KC training provided to healthcare professionals

In terms of the training of healthcare personnel in KC in the BHCs, there is not yet a national policy for the management of preterm infants. KC is taught in hospitals, but not systematically at all levels of the healthcare pyramid. Nine of the 22 healthcare professionals interviewed reported having received/read a module on KC during their medical training, seven indicated that they had received training during the exercise of their profession (from Compassion Madagascar, for example), and five complained that they had not received any training. Preterm infants should normally be managed at referral hospitals. Training for healthcare professionals in BHCs is essentially based on the Ministry of Health’s curriculum and focuses on the management of low birth weight newborns, preterm labor, and the KC technique. More specialized content is currently being developed for the KC module.

This study highlights heterogeneity in the level of training and in the providers of training, mostly civil society actors in Madagascar or international institutions. For example, we observed a much higher level of training among the healthcare professionals interviewed in Antananarivo, due to the presence of Compassion Madagascar, with six healthcare professionals trained in KC in Antananarivo but only one in Mahajanga. In Mahajanga, training is provided at hospital level. Cooperation agencies, such as the Japanese International Cooperation Agency (JICA), helped to introduce KC into the hospital environment in 2010. However, there are no initiatives specifically targeting health facilities in the community, such as BHCs. Mahajanga health professionals are therefore much less equipped to teach the method due to their own lack of training, as attested by this midwife:

“I have not yet had any training. I gained some knowledge during my internship at the university hospital.” 34 years old, married, one child – Majunga.

In some cases, the only information available about KC is the information transmitted informally during exchanges between healthcare professionals or during initial training.

“I never had training specifically on KC, but we talked about it from time to time during training for maternal and newborn care.” Midwife, 42 years old, married, two children – Majunga.

As these excerpts suggest, KC is delivered without standardized guidelines, with content and formats that vary depending on who is responsible for training.

Many healthcare professionals try to overcome the lack of information and specific training on KC by reading documents available at the BHC. Healthcare professionals described having used manuals and/or informal exchanges between peers when a preterm child was delivered. This was the case, for example, for a midwife in Mahajanga, who was officially trained in KC through the provision of a module in Emergency Obstetric and Neonatal Care (SONU) set up by the Ministry of Health. After receiving this training, she in turn trained her team of midwives and volunteers.

The advice given on the duration of KC, skin-to-skin contact, and the application of KC during the night lacks clarity and precision, as shown by the information received by this mother in Antananarivo: “the midwife did not say much other than take off his clothes and place him on your body”. The knowledge of healthcare professionals about KC is, therefore, heterogeneous and this, in turn, affects the quality of the information delivered to families, as discussed below. In addition to training, our interviews revealed that the characteristics of the infrastructures in which the management of LBW infants by KC takes place can also promote or hinder the correct application of the method.


Two key characteristics relating to infrastructure are considered here: the lack of space dedicated to KC training and the lack of accommodation for visitors.

First, learning KC at the BHC is favored by having a dedicated space, guaranteeing the privacy that parents and families expect. Compassion Madagascar has set up spaces specifically dedicated to KC in Analamanga, but we found that these spaces were occupied indiscriminately by all BHC patients, not specifically the mothers of preterm infants. However, the practice of KC requires skin-to-skin contact with the child and the person carrying the child. According to our research these are mostly women. Who must at least partially expose their body. According to healthcare professionals and mothers, without the appropriate environment that allow for intimacy and calmness, KC cannot be adopted and practiced effectively.

“It would be nice to put a screen here, but we can’t afford it! We need to separate out those who are not doing kangaroo care! But that is not possible, and in the end, we put everyone who gives birth together in this room, even those who do kangaroo care!” BHC Midwife, 48 years old, four children – Antananarivo.

In addition to the elements described above, this lack of a dedicated space contributes to the early departure of mothers from BHCs.

Second, the provision of accommodation for accompanying individuals at the BHCs is a central element that would promote the implementation of KC. The presence of other people willing to carry the baby makes it possible to alternate carrying duties, allowing the mother to rest. Those accompanying the mothers are treated like care assistants, given the lack of water, hygiene facilities, and recurrent drug shortages in the BHCs. They help to feed the mother and take care of her during her stay, functions that are essential to promote longer stays at the BHCs at a time considered important for the practice of KC.

When material becomes indispensable

In theory, it is not necessary to have a particular type of sling for KC. Based on official WHO recommendations, any scarf or fabric can be used to carry the infant. However, the national association lends mothers slings for a limited period at the BHCs in Antananarivo. Families therefore consider these slings to be essential, as they provide a feeling of security, but this can limit the continuation of KC if this material is no longer provided or no longer available. Without the sling provided by the BHC, some mothers feel that they are not practicing the method properly at home. This may lead them to stop applying the method once the sling loaned by the BHC is returned, or to use other techniques (see below):

“We must keep the child warm. It was important to use the bottle for the child, because we had to return the sling.” Mother, 21 years old, one child – Antananarivo.

This situation was also noted by healthcare professionals, as illustrated by this verbatim statement:

“We put the baby in a sling, but then, if there isn’t one, it becomes a reason for them not to do it.” Midwife, 35 years old, married, five children – Majunga.

In addition to these “levers” that health professionals and the individuals practicing KC described as facilitating the practice of KC, our results also indicate elements more closely related to local notions concerning pregnancy and the birth of a child.

Local context: an aid or obstacle to KC?

Among the many elements linked to local contexts in Madagascar, we selected three themes relating to local ideas about pregnancy, family support, and gender.

Local practices concerning pregnancy and the postnatal period

Beliefs about pregnancy and the postnatal period may aid the practice of KC, particularly as techniques for managing preterm or LBW infants may be consistent with KC. Beliefs may also hinder the application of KC (the bottle technique) because they replace KC or jeopardize its implementation.

The bottle technique

In extended families (related group of several people living in the same household), practices in the care of newborns are influenced by older women in several regions of Madagascar. In this study, we observed that practices were strongly influenced by elders, which can hinder the acceptance of KC, as deplored by this midwife: “It is especially the grandmothers or the elderly who are stubborn. They are the ones who are still difficult to convince [to perform KC]. They pretend to accept it when they are at the BHC.” 40 years old, two children – Antananarivo.

As this excerpt indicates, caregivers perceive the role of elders and their support as being determinant in the practice of KC.

Many elders advocate for the bottle technique to care for a child considered “too small” or “too light” at home This technique involves surrounding infants with hot water bottles and wrapping them in a blanket to keep them warm. The bottle technique, which is now strongly discouraged by the WHO, is still widely used. The technique was observed at our two study sites and was unanimously adopted in Antananarivo, where temperatures are lower. Some healthcare professionals themselves advised the use of these “grandmother’s” techniques because they are consistent with the need to keep the child warm.

“I met a midwife who was a bit old here. At that time, there was not much training, but they [healthcare professionals] practiced the bottle technique with hot water … they wrap the bottle with something and put it right next to the baby, I remember at the time they said to me that: ha! It is really very effective for children who are underweight! It was the midwives who did it!” Chief doctor, 55 years old -Mahajanga.

This technique is used by families in alternation with KC to compensate for the impossibility of maintaining KC continuously. It is used when the mother is doing household chores, goes to work, or if the mother or family thinks that it is not possible to practice KC at night.

Mifana/confinement and thermal protection

In the local culture, it is considered important to keep newborns warm, as indicated by the custom of placing hot water bottles near infants and wrapping them in blankets, placing them in direct sunlight in the winter months to warm up, and administering massages with zebu fat or honey, which is supposed to be warming. Mifana, a custom of postpartum confinement specific to Madagascar and practiced in both Mahajanga and Antananarivo, allows the mother to nurse her infant for a month without doing household chores. This practice is favorable for the adoption of KC by the mother, unless she is alone. This custom is advantageous in that it prohibits anything that is “cold” and encourages the mother and infant to stay warm. Nursing mothers limit their exposure to cold water for fear of transmitting the coldness to the baby through their breast milk. The interviewees were aware that cold is a risk for newborns, and this may be beneficial for the implementation of KC. However, in some cases, this injunction to keep the child warm was seen as contradictory to the need for the child to be naked, in skin-to-skin contact with the parent. During our observations, we noted that many families practiced the recommended posture, but with the child in a bodysuit, as described by this caregiver: “they put on his clothes and it’s after that they practice this [KC]”, which is contrary to one of the first conditions of KC: skin-to-skin contact. The nudity of the child is considered to be a risk, so mothers dress their infants before placing them against themselves in the usual position for KC.

Carrying and breastfeeding

Mothers who are used to carrying their child on their back sometimes find it strange to carry their baby on the front:

“Here, people are used to carrying children on their backs but here we do the opposite. We do not carry the child on the back but put it against our chest and we must attach the child.” Midwife, 32 years old, married, two children – Majunga.

Nevertheless, this element is not considered an obstacle in the adoption of KC according to healthcare professionals and parents, who adopt the new position without difficulty when the benefits for the child are well understood.

None of the mothers exclusively breastfed in accordance with the official recommendations, throughout the period of KC. All the mothers mentioned the importance of exclusive breastfeeding, but the extent to which this is put into practice depends on the sociocultural context of the individual. For example, the practice of mifana, a period during which breastfeeding is facilitated, allows compliance with this recommendation. However, even during this period of rest, breastfeeding is combined with the use of rice broth and/or Nursie (a brand of formula milk): “I give him a lot of rice broth so that he is robust!” Mother, 35 years old, three children – Antananarivo. In addition, the introduction of complementary foods is used as a strategy to compensate for the absence of the mother, who has household responsibilities to fulfill. We observed this practice during our discussions with the mothers and a midwife also noted: “They give something other [than milk] to the child.” 36 years old, married, two children – Mahajanga. One caregiver said that she prescribed Nursie for preterm infants without a sucking reflex, which highlights the level of ignorance of providers about the practice:

“When the baby is unable to suckle, the mother is asked to buy a pre-Nursie if she can afford it.” Midwife, 36 years old, married, two children – Mahajanga.

Family support and type of family structure

“Family support” refers to the help provided by other people (other members of the family or the community) to achieve KC. We observed that KC practices were performed more diligently by extended families (or with help from the community), due to the additional support available. This social mechanism makes it possible to reunite favorable conditions for KC. For example, by performing household chores or essentially everyday tasks, allowing the mother to allocate time to carrying the baby. Replacing the mother for KC also ensures the continuity of skin-to-skin contact.

Continual skin-to-skin contact is more difficult if the mother lives in a nuclear family (without an extended family to allow a better distribution of domestic tasks), particularly, if the husband is absent. Most mothers interviewed were single, which made it difficult for them to practice mifana and continual skin-to-skin contact due to the need to perform household chores, such as cooking, cleaning the house, and washing clothes. For example, mothers said that they were unable to cook during skin-to-skin contact with the child. Carrying a child around also gets in the way of household chores. If a woman does the housework in the morning, she can only carry the child in the afternoon, once she has finished her work or household chores. Mothers complained about this inability to continue KC:

“It has become like a great burden for me alone” Woman, 27 years old, three children – Antananarivo.

The healthcare professionals are very aware of this situation, as illustrated by this statement:

“If we don’t help her [the mother], it is possible that the KC will be interrupted, because it is tiring if it is only the mother who does it”. Midwife, 42 years old, married, two children – Majunga.

Gender roles

Fathers play a small role in the care of children and are sometimes not very engaged in society itself: chores and childcare are mostly assigned to women. These gender roles influence the sensitization of healthcare professionals to families, leading them to pay more attention to the grandmothers and aunts of the infants who accompany the mothers. Healthcare professionals say that they cannot involve fathers because they are rarely present during deliveries: “With us at the BHC, there are always people accompanying the mother during childbirth, but they are rarely fathers, rather the mother, the mother-in-law…” BHC Midwife – Antananarivo.

Only one mother said that her husband helped to carry the child during KC. This was confirmed during the interview by the father, who said that he helped by carrying his child while his wife was working to support them. These exceptions show that it is possible for male figures to participate in KC, despite the cultural assignment of female and male roles making it difficult for fathers to participate in this practice.

Perception of the vulnerability of the child

Other conditions may or may not favor skin-to-skin contact with the infant, such as the mother’s view of her child’s vulnerability. Skin-to-skin contact can be perceived as uncomfortable for the infant, with the infant considered too fragile to be held in this position, significantly decreasing the chances of this practice being implemented: “Because the child is still very small and they are afraid to do it” BHC midwife, 31 years old, no children– Antananarivo. Mothers also said that they were afraid to implement KC at night, for fear of crushing the child. None of the women interviewed performed KC at night. The infant was instead generally placed on a bed next to the mother and wrapped in blankets. The bottle technique was also used overnight for preterm infants.