https://orcid.org/0000-0002-1989-2622
Abstract
Several studies have been conducted to examine the complicated relationships between various factors that influence Kangaroo mother care (KMC) for preterm infants. However, the extended socio-economic model has not been seen in any of the previous studies that looked into the factors related to KMC and how it affects the health outcomes of babies born before in our study population. This study examines the various dimensions of KMC implementation and its influence on the health outcomes of premature infants. The current cross-sectional study was carried out in South Punjab, Pakistan, covering both private and public KMC units in obstetrics and gynecology departments. The study included a sample size of 719 patients and was conducted during a period covering 21 September 2022 to 14 October 2023. Multinomial logistic regression analysis is employed to ascertain the factors by using SPSS-26 (SPSS Inc., Chicago, IL). The use of folic acid (OR: 1.44; 95% CI: 0.87–3.11) and factor anemia (OR: 8.82; 95% CI: 1.69–14.59) no significantly correlated with better health outcomes, while environmental toxin exposure had a negative impact (OR: 0.90). The findings underscore the need for comprehensive interventions and policies to bridge socioeconomic gaps, ensuring all preterm infants benefit from KMC.
Introduction
Kangaroo mother care (KMC), also known as kangaroo care (KC) or skin-to-skin care, originated as a significant healthcare advancement during the 1970s at San Juan de Dios Hospital in Bogotá, Colombia [Citation1,Citation2]. Every day, the global community observes the remarkable journey undertaken by premature infants as they navigate the difficulties associated with being born prematurely [Citation3]. Children’s who were born prematurely, courageously engage in a valiant struggle against unfavorable circumstances [Citation3,Citation4]. The World Health Organisation (WHO) reported that 2.4 million newborns died in the first month in 2020, accounting for nearly 47% of all child deaths under 5, compared to 1990. Preterm births, childbirth complications, infections, and birth defects caused the most neonatal deaths in sub-Saharan Africa and central and southern Asia. About 75% of neonatal deaths occurred in the first week, and 1 million died in the first 24 h in 2019. In this global scenario, India lost 490,000 newborns, Nigeria 271,000, and Pakistan 244,000. Ethiopia and the DRC lost 97,000 and 96,000 newborns, respectively. China had 56,000 neonatal deaths, Indonesia 56,000, Bangladesh 51,000, Afghanistan 43,000, and Tanzania 43,000. Children and adolescents had a lower risk of COVID-19 than adults, with less than 0.1% of global deaths in the under-5. It is important to remember that each number represents a life lost and a family changed. These numbers highlight the urgent need for quality antenatal care, skilled birth assistance, postnatal care for mothers and newborns, and specialized care for small and sick newborns in low- and middle-income countries [Citation5–8].
However, it is important to note that this conflict does not occur in a vacuum. The phenomenon occurs within an intricate network of socio-economic inequalities, disparities in healthcare availability, and a notable caregiving methodology referred to as KMC [Citation5,Citation9–11]. In a world where nation’s horizons converge, the global community joins together in an effort to comprehend and confront the challenges faced by preterm infants and their families. Researchers and healthcare professionals (HCPs) from various regions have extensively examined and analyzed the complicated relationship between socio-economic factors and healthcare accessibility in both urban and rural areas [Citation9,Citation12]. These dedicated health advocates have demonstrated that KMC, an extremely simple and effective technique, can improve the health of premature infants [Citation13].
The continuous development of urban areas and the enduring presence of rural communities raise important concerns regarding the disparities in health outcomes among premature infants, leading to fundamental inquiries. What is the influence of birth environments on the health and developmental outcomes of preterm infants? What is the significance of KMC in the context of this complicated equation? [Citation14–18]. To gain a comprehensive understanding of the multifaceted enigmas at hand, we commence on an intellectual exploration into the fundamental aspects of urban and rural settings. Our investigation explores into multiple socio-economic variables that exert influence on the trajectories of development for infants born prematurely.
In the context of Punjab, Pakistan, KMC has embraced a distinctive path to integration within the healthcare system. The KMC was first implemented in specific healthcare facilities, where committed HCPs endured specialized training to deliver KMC services [Citation6,Citation19]. In Punjab, devotion to neonatal health eventually culminated in the formal incorporation of KMC into official healthcare policies and guidelines, setting a pioneering example for other regions. Today, KMC stands as a symbol of Punjab’s innovative approach to neonatal care, leading to significant improvements in health outcomes for premature infants. Within the broader Pakistani context, this unique history exemplifies the nation’s resolute commitment to evidence-based healthcare practices, resulting in a remarkable reduction in infant mortality rates and an overall enhancement of neonatal health [Citation9,Citation20–23].
The present study investigates the intricate interactions of urban and rural settings, wherein socio-economic factors play a dual role as both obstacles and enablers in the context of healthcare accessibility. It investigates the effects of KMC, a simple yet highly influential practice, on the health outcomes of preterm infants. Through the collection of experiences and perspectives from mothers and carers, our aim is to provide a deeper understanding of the various approaches that can contribute to improved outcomes for preterm infants, regardless of their geographic location. Through an analysis of firsthand testimonies provided by individuals who have closely observed these resilient individuals, our objective is to maximize our comprehension of disparities and the efficacious approaches that hold promise for generating transformative results.
Materials and methods
This study was conducted within the premises of a healthcare facility (public and private) to comprehensively evaluate the key parameters related to the KMC process in premature infants. It encompassed both private and public obstetrics and gynecology departments in the South-Punjab region of Pakistan. The research endeavor spanned the period from 21 September 2022 to 14 October 2023. Sample size determination followed the Yamane formula with an error margin of 0.05. Employing a multi-stage probability sampling technique (as mention in ), a representative sample was thoughtfully selected. In the final phase of this meticulously planned data collection process, we focused on women who met specific criteria. Convenience and purposive sampling technique was utilized within the context of the multi-stage sampling framework. The study’s scope encompassed all women aged between 14 and 49 who had given birth between 26 and 38 weeks of pregnancy through a cesarean section. Subsequent to data collection, comprehensive statistical analysis was carried out, utilizing SPSS version 26 (SPSS Inc., Chicago, IL).
Table 1. Structure chart.
Continuous variables underwent statistical analysis to calculate the "mean standard deviation (SD)," while categorical variables were assessed in terms of "number (percent)." To scrutinize the correlation between the mode of premature birth and socioeconomic factors, a Chi-square analysis was conducted. The multinomial logistic regression (MLR) analysis only used the predictors that the multivariate Chi-square test analysis showed to be significant. Statistical significance was declared when the associated p value met the threshold of .05. Odds ratios, along with a 95% confidence interval, were employed to identify the most influential predictors.
The presented socio-ecological model, as depicted in , is structured into six primary categories: demographics, KMC and awareness, urban–rural and socioeconomic factors, health outcomes, maternal health during pregnancy, and urban–rural disparities and access to healthcare. The aforementioned model serves as the framework for our comprehensive examination of health outcomes in preterm infants.
Table 2. SEM of socio-ecological factors influencing preterm infant health outcomes.
Results
In the domain of infant data, we explore a hidden phases of statistical information as shown in . The female infants represent 67.73% of the fields of study, whereas the male infants account for 32.26% of the collection. This investigation explores the aspects, providing the framework for an innovative examination of potential disparities in KMC that might become apparent between different genders. A unique condition emerges as we commence the journey of gestational age at birth. The majority of neonates, comprising 50.20% of the sample, were born in the late preterm period, whereas an additional 29.34% were delivered during the moderately preterm phase. A cohort comprising 14.74% of patients had undergone extremely preterm births, also significant proportion of infants 68.42% were classified within the 1600–2300 g weight range.
Table 3. Interrelated aspects of neonatal and maternal health: an in-depth examination.
Importantly, 37.55% of people who came to KMC were identified by HCPs, and 57.85% were acknowledged by family and friends. About 4.58% of people who found out about KMC through online resources did so in a less well-known area. Surprisingly, 69.68% of those answered that they did not hear enough discussions about KMC in their communities. Of those who answered, 97.49% wanted to learn and educate about KMC, which shows how many people wanted to know.
The location expands up into both urban and rural areas. The vast majority (76.07%) live in urban areas, while only 23.92% call rural areas home. As we explore socioeconomic details, 33.51% of respondents are primary breadwinners. Meanwhile, 70.93% find refuge in government subsidies through Sehat Sahulat Program (SSP) [Citation24]. These numbers show the hidden socioeconomic threads that may influence KMC practices and health outcomes. Education impacts across the landscape, with 36.43% of respondents graduating from high school and 38.38% attending college and technical school. Health insurance covered (28.65%) of the respondents. The covering of protection suggests invisible connections with healthcare resources.
The data revealed that the occurrence of pregnancies was distributed as follows: (87.76%) of individuals had experienced three or more babies, whereas a small proportion (1.80%) had only one child. Prenatal care, a crucial component of maternal health, was utilized by (95.13%) of the respondents, indicating its significant presence and importance. Concurrently, a confusing rate of 4.86% reverberates in the absence of prenatal healthcare. The disclosure of complications during pregnancy is a subject of investigation, with a significant proportion (74.82%) experiencing such challenges, whereas (18.77%) represent a group of individuals who have undergone uncomplicated pregnancies without expressing their experiences. Within the less emphasized aspects of this discourse, one can discern the subtle indications of the utilization of supplements, the reverberations of anemia, and the concealed aspects of health-related practices throughout the course of pregnancy.
Model fitting information demonstrates that all of the regression coefficients in the model are equal to zero under the null hypothesis. The p value is determined to be lower than the alpha level of 0.05. The model is considered significant as a result. The Cox and Snell, Nagelkerke, and McFadden have values of 0.535, 0.723, and 0.401, which means that the proportion of variance in infant health outcomes is explained by independent variables like complications during pregnancy (e.g. gestational diabetes, preeclampsia), number of pregnancies, parental care, environmental toxins or hazards; use of folic acid; experience anemia, consume alcohol, and stressors or emotional challenges. We use the Nagelkerke for the best measurement by the model, with a large value of 72.3%, as shown in .
Table 4. Model fitting information.
In our study on maternal health during pregnancy and its impact on preterm infant health, we have uncovered some key findings. For preterm infants with “Very Good” health outcomes, complications during pregnancy had a strong association (OR: 36.35; 95% CI: 0.09–133.02), although it was not statistically significant. However, our analysis found that the use of folic acid (OR: 1.44; 95% CI: 0.87–3.12) did not demonstrate a statistically significant with improved health outcomes. In our analysis, the presence of anemia (OR: 8.82; 95% CI: 1.69–14.59) also did not demonstrate statistical significance. Exposure to any environmental toxins or hazards during your pregnancy (e.g. pollution, chemicals in industrial areas) that had a negative impact (OR: 0.90; 95% CI: 0.32–2.29) is not significant. “Poor” health outcomes were associated with complications during pregnancy (OR: 3.67; 95% CI: 1.14–11.72), a higher number of pregnancies (OR: 3.36; 95% CI: 0.76–14.76) and the use of folic acid (OR: 2.95; 95% CI: 1.13–7.70). The confidence interval for a higher number of pregnancies includes the value "1," making it non-significant (OR: 3.36; 95% CI: 0.76–14.76). In the “Good” health outcome group, a higher number of pregnancies (OR: 29.80; 95% CI: 11.47–56.28) and receiving parental care (OR: 2.64; 95% CI: 1.22–10.23) were noteworthy factors. “Fair” health outcomes were significantly associated with the number of pregnancies (OR: 12.89; 95% CI: 6.59–46.72) and experiencing anemia (OR: 6.74; 95% CI: 2.96–11.53). “Poor” health outcomes were linked with complications during pregnancy (OR: 3.67; 95% CI: 1.14–11.72), a higher number of pregnancies (OR: 3.36; 95% CI: 0.76–14.76) and the use of folic acid (OR: 2.95; 95% CI: 1.13–7.70) as shown in .
Table 5. Multinomial logistic regression of maternal health during pregnancy and preterm infant health outcome.
Discussion
The findings of our research suggest significant contributions to understanding the multidimensional determinants that impact the health outcomes of premature newborns, with a particular focus on the practice of KMC and its association with socioeconomic inequalities. This highlights the importance of specific interventions to improve infant health and reduce disparities in society. Multiple interconnected factors that affected both KMC adoption and the health of premature infants were observed. The socio-ecological model helped us understand the differences in demographics, KMC awareness, health outcomes, maternal health during pregnancy, socioeconomic factors, and healthcare access between urban and rural areas.
The gender distribution of preterm newborns was notable, with girls comprising 67.73% of the sample and boys constitute 32.26%. Gender differences in KMC adoption and efficacy raise attention that requires further study. The gestational age at birth proved to be a significant factor, 29.3% babies were born moderately preterm, and 50.20% were born late preterm. Interestingly, 14.74% were the first to have a very preterm baby. These variations provide a compelling prospect for analyzing the complex interactions that underlie KMC’s action throughout the range of gestational conditions. Weight at birth emerged as an important factor, as 37.55% of infants fell within the 1600–2300 gram categories. The observation highlights a surprising correlation between birth weight, implementation of KMC, and its subsequent influence on infant health. In our investigation of KMC awareness and education, the important roles of healthcare providers (37.55%) and information collected through personal networks (57.85%). However, the current perception of insufficient community awareness highlights the urgent need for comprehensive outreach and educational programs to enhance the adoption of KMC. Only a small proportion (4.58%) engaged in the digital domain to explore the complexities of KMC by utilizing online resources. This finding highlights the wide range of media available for the sharing of knowledge. The distribution of population between urban and rural areas, with 76.07% living in cities and 23.92% resident in rural areas, highlights the significance of examining the frequently neglected dimensions of urban–rural disparities. This analysis underscores the substantial influence of these disparities on the health outcomes of premature infants.
Socioeconomic factors play a significant role in the context of KMC practices and health outcomes, as demonstrated by the fact that 33.51% of individuals serve as primary breadwinners, and 70.93% receive government subsidies. These factors establish subtle connections between socioeconomic status and the aforementioned practices and outcomes. The educational attainment of both the mother and her partner appeared to influence KMC adoption and the resulting health outcomes. Additionally, the presence of health insurance coverage (28.65%) indicated a possible pathway to accessing healthcare resources. Our in-depth analysis of maternal health during pregnancy and its resonating effects on preterm infant health illuminated a tapestry of findings. For preterm infants with “Very Good” health outcomes, complications during pregnancy held an association (OR: 36.35; 95% CI: 0.09–133.02), though it remained statistically inconclusive. Conversely, using folic acid (OR: 1.44; 95% CI: 0.87–3.11) and experiencing anemia (OR: 8.82; 95% CI: 1.69–14.59) were assessed to improved health outcomes. Exposure to environmental toxins or hazards casts a less favorable outlook (OR: 0.90; 95% CI: 0.32–2.29).
A cross-sectional study was conducted in a hospital in southern Ethiopia in 2021 and examined whether or not mothers were following WHO guidelines for KMC for their premature and low-birth-weight infants. Researchers found that mothers, on average, scored 5.12 out of 10 on KMC practices, with only 9.4% actually using all of the strategies that have been shown to be effective. It became clear that there were a number of important factors influencing compliance. Delivery in a healthcare facility (adjusted odds ratio, AOR = 0.67; 95% CI = 0.48–0.94), maternal knowledge about KMC (AOR = 1.40; 95% CI = 1.05–1.87), and residence in an urban area (AOR = 1.55; 95% CI = 1.33–2.29) were all associated with a lower risk of KMC. The study highlights the importance of addressing the difficulties associated with cesarean deliveries and raising awareness of KMC, particularly in rural areas [Citation25]. In another study in the United Kingdom, the consensus among HCPs and parents regarding the benefits of KC for preterm infants is unwavering. Irrespective of their years in practice, the majority of HCPs express a high likelihood of recommending KC with adequate support (OR 0.4, 95% CI 0.10–1.78, p = .225). Parents, with 81% having had a preterm baby in the last 3 years, hold a deep appreciation for KC. However, they frequently face obstacles including loud environments and inadequate staff support. Active promotion and enhanced resources are crucial for complete KC integration, especially in neonatal units [Citation26].
It is important to note that our study has some limitations. We designed our study using a one-time snapshot instead of following participants over time. In addition, because we relied on people telling us about their experiences, there might be some mistakes or things people wanted to say in a certain way, which could affect our results. Another point is that our study focused on specific places and people; therefore, it may not represent everyone. Although our findings provide a good starting point, it is crucial to consider these limitations in future studies to ensure that we obtain more accurate and widely applicable results.
In summation, our research reveals the complex aspects of KMC implementation and its wide-ranging impact on the well-being of premature infants. Gestational age, birth weight, awareness levels, urban–rural divides and maternal health during pregnancy collectively shape the landscape. With the objective of improving the general health of preterm infants through the implementation of effective KMC, these findings provide a direction for focused interventions and policy recommendations. In the future, further investigation by researchers should be carried out to explore these complicated relationships, while separately considering the diverse array of cultural, social, and economic variables.
Conclusions
In conclusion, this research highlights a broad spectrum of factors that affect the adoption of KMC and its significant effects on the health of premature infants. Collectively, these factors include gestational age, birth weight, awareness discrepancies between urban and rural areas, and maternal health form the condition on which KMC is practiced. In this perspective, the socioeconomic factors including household income, access to medical care, and the educational background of both mothers and fathers are of paramount importance. These economic challenges highlight the importance of specific interventions and policies to close the disparities.
Author contributions
Muhammad Muneeb Hassan: The research project involved the conceptualization of an idea, the formulation and refinement of a theoretical framework, the implementation of coding techniques, the generation of graphical representations, the execution of computational analyses, and the final evaluation and endorsement of the version intended for publication. Muhammad Ameeq: Participates in coming up with ideas, gathering information, writing code, creating charts, and approving the final drafting for publication. M. H. Tahir: Participates in coming up with ideas, writing original article, analysis, gathering information, proof reading and approving the final drafting for publication. Sidra Naz: Participates in coming up with ideas, gathering information, writing code, creating charts, and approving the final drafting for publication. Laraib Fatima: Participates in coming up with ideas, gathering information, writing code, and approving the final drafting for publication. Alpha Kargbo: Participates in coming up with ideas, gathering information, writing code, creating charts, and approving the final drafting for publication. All authors contributed to interpreting data, drafting the manuscript and critically revising the manuscript for intellectual content; all authors approved of the published version.
Ethics statement
The Ethical Review Committee of Hospitals District Muzaffargarh, South-Punjab, Pakistan, approved 294710-14. The committee declared no objections and found no ethical issues with this research project on 16 October 2023.
Consent form
All participants involved in this study have provided their informed consent, confirming their willingness to have their information and outcomes published for research purposes without any reservations or concerns.
Acknowledgements
In our pursuit of knowledge, we express our sincere gratitude to the perpetrated personnel of both public and private Kangaroo Mother Care (KMC) units in the Muzaffargarh, DG Khan, and Bahawalpur District regions of South-Punjab, Pakistan. Their invaluable assist and constant encouragement were essential in facilitating this research. Additionally, we are grateful for the support and resources provided by our colleagues and institutions. The completion of this research has been facilitated by the collaborative endeavors of various both individuals and institutions, which improves our comprehension of the importance of Kangaroo Mother Care in the domain of preterm neonatal healthcare.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Data availability statement
The corresponding author can provide access to the data, models and code that support the findings of this study.
Additional information
Funding
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