Preterm birth, defined as delivery before 37 completed weeks of gestation, remains the leading cause of neonatal mortality worldwide, accounting for approximately one million deaths annually.¹ Globally, an estimated 15 million preterm infants are born each year, with South Asia, particularly India, contributing over 23% of this burden.^2,3 India records over 3.5 million preterm births annually, with significant risks of hypothermia, sepsis, and feeding difficulties.^4,5 To address these challenges, Kangaroo Mother Care (KMC) has been widely endorsed by the World Health Organization as a cost-effective and evidence-based neonatal care strategy, especially in low-resource settings.² KMC comprises early, continuous skin-to-skin contact, exclusive breastfeeding, and early discharge with structured follow-up, and has been shown to improve thermoregulation, promote weight gain, and reduce hospital-acquired infections and neonatal mortality by up to 40%.^6-8 Despite national implementation efforts under the India Newborn Action Plan, the uptake of KMC in many healthcare facilities remains inadequate due to lack of maternal knowledge, cultural barriers, overcrowded wards, and limited counselling by healthcare staff.^9,10 Studies report that the knowledge, attitude, and practice (KAP) of mothers are central to the success of KMC, as mothers are often primary caregivers in neonatal wards.^11,12 Maternal factors such as education level, parity, antenatal counselling, and emotional readiness significantly affect the adoption and quality of KMC practices.^13,14 Institutional influences like trained healthcare providers, privacy for KMC, and ongoing support also determine maternal compliance.^15,16 This study assessed the knowledge, attitude, and practice of mothers with neonates admitted to the neonatal wards of Dr. Sushila Tiwari Hospital, aiming to identify gaps and challenges in Kangaroo Mother Care to inform strategies for improved maternal education and neonatal outcomes.

MATERIALS AND METHODS

This institutional-based descriptive observational study was conducted over a period of 18 months in the maternity wards and Special Newborn Care Unit (SNCU) of Dr. Sushila Tiwari Hospital, Haldwani, following ethical clearance from the Institutional Ethics Committee. The study targeted normal postnatal mothers whose neonates were either preterm or term but had low birth weight (less than 2000 grams) and were clinically stable, breathing spontaneously without life-threatening conditions or congenital malformations. Mothers who were themselves unwell or unwilling to provide Kangaroo Mother Care (KMC), or whose families were unable or refused to participate in KMC, were excluded from the study. Sample size was calculated using Epi Info™ software (CDC, Atlanta, USA), considering a 95% confidence level and a 5% margin of error. In the absence of prior regional data on maternal knowledge, attitude, and practice regarding KMC, an expected prevalence of 50% was assumed to obtain the maximum sample size. Applying the standard formula for population proportion studies, the minimum sample size calculated was 213. To accommodate a projected 10% non-response or loss to follow-up, the sample size was adjusted to a final total of 234 participants. After obtaining informed written consent, mothers who met the inclusion criteria were enrolled. Before any KMC sessions, participants were assessed using a pretested, structured questionnaire to evaluate their baseline knowledge, attitudes, and practices related to KMC. Sociodemographic information including age, education, parity, and socioeconomic status was also recorded. Mothers were also subjected IAP PARENT STRESS QUESTIONNAIRE(IAP-PSQ-4) before starting of KMC and were reassessed   for PSQ after the study. Following this initial assessment, mothers were educated about KMC using verbal explanations and physical demonstrations by trained healthcare staff. Once mothers had completed several sessions of skin-to-skin contact with their babies, the same questionnaire was re-administered to evaluate any changes or improvements in their knowledge and practice levels. Data entry was performed using Microsoft Excel 2016. Statistical analysis was conducted using SPSS version 25 (SPSS Inc., Chicago, IL, USA). Chi-square or Fisher’s exact test was used for comparing categorical variables, and Student’s t-test was applied for continuous variables, with guidance from a qualified statistician.

RESULTS

We studied 234 post- natal mothers for Knowledge, Attitude and Practice of KMC. Demographic details of  mothers are given as below:

Table 1: Demographic Details of Mother

In our study, the average maternal age was 25.92 ± 3.96 years, with most participants being Hindu (78.21%) and from the upper middle class (53.85%). A large proportion had only primary education (41.94%), and nearly all were housewives (99.57%). Vaginal delivery was more common (68.38%) and most mothers were primiparous (27.78%) (See Table 1)

A significant reduction in maternal stress was observed after KMC, with low stress levels rising from 35.5% to 97.9%. High stress (red zone) was completely eliminated post-KMC. The Chi-Square test showed a highly significant association (p < 0.001), demonstrating KMC’s effectiveness in stress reduction (See Table 2).

Table 2: Mother Stress Level Before and After KMC

**Chi-square test used 202.29, p-value <0.001**

Post-KMC counselling significantly enhanced maternal knowledge across all components of KMC, such as its definition, eligibility, timing, location, and posture. Correct response rates rose from <15% to over 85–95% in most areas, indicating the success of the educational intervention (p < 0.006 for all items) (See Figure 1).

Figure 1: Distribution of Knowledge of KMC Among Mothers

Knowledge regarding duration, benefits, clothing, weight gain, and follow-up improved markedly after KMC, with most parameters showing an increase from less than 25% to above 85–95%. The observed improvements were statistically significant, indicating enhanced maternal understanding and preparedness (p < 0.05) (See Figure 2).

Figure 2: Distribution of Knowledge of KMC Among Mothers

Mothers' attitudes toward KMC improved substantially post-intervention, with significant increases in perceived comfort, confidence, bonding, and family support. Negative emotions such as anxiety or stress showed marked reductions, all with statistically significant p-values (p < 0.05), reflecting better emotional adaptation (See Figure 3).

Figure 3: Distribution of attitude of KMC among mothers

KMC practice improved significantly after intervention, especially regarding daily duration, breastfeeding in KMC position, milk expression, and support from family. Mothers also showed increased ability to maintain KMC during sleep and chores, confirming effective practical application (p < 0.05 in most domains) (See Figure 4).

Figure 4: Distribution of  Practice of KMC among mothers

Most neonates were AGA (58.1%) and >32 weeks gestational age, with respiratory distress being the most common comorbidity (21.4%). Feeding practices varied, with direct breastfeeding (38.9%) and OG feeding (31.6%) being common. These characteristics reflect a diverse neonatal population suitable for KMC (See Table 3).

Table 3: Characteristics of Neonates Subjected to KMC

The average neonatal weight was 1.58 kg, with corresponding mean length and head circumference of 41.57 cm and 29.17 cm, respectively. These baseline anthropometric values are indicative of low birth weight/preterm neonates and provide a reference for growth monitoring during KMC (See Table 4).

Table 4: Anthropometric Measures of Neonates Admitted for KMC

DISCUSSION

This study demonstrated that structured counselling significantly improved maternal knowledge, attitude, and practice (KAP) regarding Kangaroo Mother Care (KMC). The mean maternal age in our cohort was 25.92 ± 3.96 years, aligning with Indian studies by Pradhan et al.¹⁷, Jain and Goswami¹⁸, and Urmila et al.¹⁹, confirming that KMC predominantly involves young adult mothers. Socioeconomic status and education levels mirrored regional trends, while vaginal delivery remained the dominant mode, consistent with prior findings. A major highlight was the reduction in maternal stress: moderate-to-high stress dropped from 64.6% to 2.5% post-intervention (p < 0.001), consistent with Worku and Kassie²⁰ and Bergh et al.²¹. Maternal knowledge showed statistically significant gains across all domains—definition of KMC, skin-to-skin care, breastfeeding, and eligibility—with p-values ≤ 0.006, matching studies by Pradhan et al.¹⁷, Urmila et al.¹⁹, and Prasad et al.²². Knowledge of practical components, including timing, clothing, and positioning, also increased substantially. Attitudinal improvements were equally profound. Mothers reporting comfort with KMC rose from 17.0% to 87.5% (p = 0.006), while feelings of safety and bonding increased significantly, in line with Jain and Goswami¹⁸ and Prasad et al.²². Anxiety levels decreased from 29.9% to 4.3%, and confidence in baby handling increased from 33.3% to 87.5%. Family support perception also rose from 29.9% to 98.1% (p = 0.001), underscoring the psychosocial impact of counselling. Practice-wise, hospital-based KMC duration improved remarkably, with mothers providing 12–18 hours daily increasing from 4.3% to 32.5% (p = 0.006). Home continuation, feeding in the KMC position, and ability to practice KMC during sleep and small tasks also improved significantly. These findings are consistent with the Cochrane review by Conde-Agudelo and Díaz-Rossello⁷, Worku and Kassie²⁰, and Cattaneo et al.²³. Neonatal characteristics, including gestational age, weight, and anthropometric parameters, closely matched other global KMC cohorts, validating the representativeness of our population. Importantly, this study also included extremely preterm neonates, demonstrating the feasibility of extending KMC beyond traditional eligibility criteria. In conclusion, structured maternal education significantly enhances KAP and reduces stress, promoting better implementation of KMC. These findings underscore the need to integrate formal KMC counselling into routine neonatal care to optimize maternal competence and neonatal outcomes.

Barriers identified were-

Because of non- availability of KMC binders , mothers were not able to keep baby in KMC position while doing small chores Because of lack of awareness, relatives were not helping mothers in KMC Significant gains were observed across knowledge and attitude but not in practice domain.

CONCLUSION

We concluded that structured, targeted counselling serves as a transformative tool in enhancing maternal knowledge, attitude, and practice toward Kangaroo Mother Care (KMC). The intervention not only improved awareness and behavioral adoption but also significantly reduced maternal stress and boosted confidence in neonatal handling. Our study shows the vital role of mother-centric education is in strengthening KMC implementation.

Antenatally, mothers did not have knowledge regarding KMC, acceptance was low. Introduce antenatal KMC education modules within routine prenatal classes—leveraging multimedia presentations/KMC videos—to establish early familiarity, enhance understanding and willingness among expectant mother. Raising awareness among relatives for KMC support so that they can help in KMC. Use of KMC binders so that KMC can be followed even at home/ while doing small chores. Integrating such evidence-based strategies into routine neonatal care protocols can drive meaningful improvements in both maternal engagement and infant survival outcomes.

Conflict of Interest: None.

Funding: None.

Ethical Approval: Obtained.

Consent: Written consent secured.

REFERENCES

1. Chawanpaiboon S, Vogel JP, Moller AB, Lumbiganon P, Petzold M, Hogan D, Landoulsi S, Jampathong N, Kongwattanakul K, Laopaiboon M, Lewis C. Global, regional, and national estimates of levels of preterm birth in 2014: a systematic review and modelling analysis. The Lancet global health. 2019 Jan 1;7(1):e37-46.
2. Hug L, Sharrow D, Zhong K. United Nations inter-agency group for child mortality estimation. Levels & trends in child mortality [Internet]. 2018
3. World Health Organization. Preterm birth. Preterm Birth. World Health Organization: WHO; 2023. Available from: https://www.who.int/news-room/fact-sheets/detail/preterm-birth
4. Bhutta ZA, Das JK, Bahl R, Lawn JE, Salam RA, Paul VK, Sankar MJ, Blencowe H, Rizvi A, Chou VB, Walker N. Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost?. The Lancet. 2014 Jul 26;384(9940):347-70.
5. Diggikar S, Nagesh NK, Kumar NA, Aladangady N. A study comparing short-term outcome in preterm infants of≤ 30 weeks gestation between a tertiary neonatal care unit in Bangalore, India and one in London, UK. Paediatrics and International Child Health. 2022 Jan 2;42(1):5-11.
6. Global position paper Kangaroo mother care A transformative innovation in health care HEALTH FOR ALL. Available from: https://iris.who.int/bitstream/handle/10665/367626/9789240072657-eng.pdf
7. Conde‐Agudelo A, Belizán JM, Diaz‐Rossello J. Cochrane Review: Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Evidence‐Based Child Health: A Cochrane Review Journal. 2012 Mar;7(2):760-876.
8. Boundy EO, Dastjerdi R, Spiegelman D, Fawzi WW, Missmer SA, Lieberman E, Kajeepeta S, Wall S, Chan GJ. Kangaroo mother care and neonatal outcomes: a meta-analysis. Pediatrics. 2016 Jan 1;137(1):e20152238.
9. Datta V, Ghosh S, Aquino LD. Progressing towards SDG 2030 goals with system changes: the India Newborn Action Plan. BMJ Open Quality. 2022 Oct 1;11(Suppl 1):e001971.
10. Hadush MY, Gebremariam DS, Beyene SA, Abay TH, Berhe AH, Zelelew YB, Asmelash T, Ashebir F, Amare SY, Hadush Z, Medhanyie AA. Barriers and enablers of KMC implementation in health facility and community of Tigray region, Northern Ethiopia: formative research. Pediatric Health, Medicine and Therapeutics. 2022 Jan 1:297-307.
11. Olawuyi O, Ezenwa BN, Fajolu IB, Onwuama M, Ezeaka CV. Knowledge, attitude and practice of kangaroo mother care among mothers in the neonatal wards of a tertiary care center. Pan African Medical Journal. 2021 Apr 14;38(1).
12. Shah RK, Sainju NK, Joshi SK. Knowledge, attitude and practice towards kangaroo mother care.
13. Lawal TV, Lawal DI, Adeleye OJ. Determinants of Kangaroo Mother Care among low-birth-weight infants in low resource settings. PLOS global public health. 2023 Sep 12;3(9):e0002015.
14. Bilal SM, Tadele H, Abebo TA, Tadesse BT, Muleta M, W/Gebriel F, Alemayehu A, Haji Y, Kassa DH, Astatkie A, Asefa A. Barriers for kangaroo mother care (KMC) acceptance, and practices in southern Ethiopia: a model for scaling up uptake and adherence using qualitative study. BMC pregnancy and childbirth. 2021 Jan 7;21(1):25.
15. Dalal A, Bala DV, Chauhan S. A cross-sectional study on knowledge and attitude regarding kangaroo mother care practice among health care providers in Ahmedabad District. Int J Med Sci Public Health. 2014 Mar 1;3(3):253-6.
16. Jayanna K, Rao S, Kar A, Gowda PD, Thomas T, Swaroop N, Washington M, Shashidhar AR, Rai P, Chitrapu S, Mohan HL. Accelerated scale‐up of kangaroo mother care: evidence and experience from an implementation‐research initiative in south India. Acta Paediatrica. 2023 Aug;112:15-26.
17. Pradhan M, Kar S, Sahoo T, Som T, Mohanty PK, Devi U. Knowledge, Attitude, and Practices Toward Kangaroo Mother Care Among Mothers in a Tertiary Neonatal Care Unit. Journal of Neonatology. 2024;38(2):235-240. 
18. Jain S, Goswami VP. Knowledge, Attitude and Behaviour Practices of Kangaroo Mother Care among Beneficiaries in Indore District. IJPHRD. 2024 Jul. 4;15(3):378-82.
19. Urmila KV, Ravikumar, Karunakaran U. Study to assess the knowledge, attitude and practice of Kangaroo mother care among post-natal mothers in a tertiary care centre of North Kerala, India. Int J Contemp Pediatr [Internet]. 2018 Apr. 20 [cited 2025 Apr. 10];5(3):992-6
20. Worku B, Kassie A. Kangaroo mother care: a randomized controlled trial on effectiveness of early kangaroo mother care for the low birthweight infants in Addis Ababa, Ethiopia. J Trop Pediatr. 2005;51(2):93–7
21. Bergh AM, Manu R, Davy K, van Rooyen E, Asare GQ, Williams JK, et al. Translating research findings into practice—the implementation of kangaroo mother care in Ghana. Implement Sci. 2012;7:75.​
22. Prasad NR, Doshetty JY, Sarvi M, Sindhura BM, Joshi CR. Effect of educational intervention on knowledge, attitude and practice of nursing mothers of babies receiving kangaroo mother care and its impact on weight gain: A randomised controlled trial. Indian J Neonatal Med Res. 2024 Apr;12(2):PO39-PO46.
23. Cattaneo A, Davanzo R, Worku B, Surjono A, Echeverria M, Bedri A, et al. Kangaroo mother care for low birthweight infants: a randomized controlled trial in different settings. Acta Paediatr. 1998;87:976-85. Medline:9764894