Integrating Immediate Kangaroo Mother Care into Level II Small and Sick Newborn Care: Multi-Country Implementation Research

Background: Immediate kangaroo mother care (iKMC), skin-to-skin contact initiated before clinical stabilisation, reduces neonatal mortality, and the World Health Organization (WHO) recommended its practice for all preterm and low-birthweight infants in 2022. However, evidence on how to integrate iKMC into routine small and sick newborn care (SSNC) at scale is limited. We evaluated the development, optimisation, and implementation of an iKMC model across four countries.

Methods: We conducted a multicountry mixed-methods implementation research study in six Level II newborn care sites in Bangladesh, Ethiopia, India, and Nigeria between December 2023 and August 2025. Using formative research, co-design workshops, iterative optimisation cycles, programme learning, and continuous quality improvement, facilities integrated iKMC into routine SSNC through the establishment of mother-special newborn care units (M-SNCUs), workforce strengthening, health system redesign, and mentorship. The primary outcome was iKMC coverage, defined as skin-to-skin contact (SSC) initiated within two hours of birth (or admission for eligible outborn infants) and maintained for an average of ≥8 hours/day during hospitalisation. Quality indicators included SSC during respiratory support, breastfeeding practices, and effective KMC at discharge.

Findings: A total of 2,561 infants were enrolled, including 823 during the 3-month evaluation period. A common implementation model emerged across diverse settings, with context-specific adaptations. Overall, 73·1% (602/823) of eligible infants received iKMC, while four of six sites exceeded 80% coverage. SSC was initiated within two hours in 84·0% of infants, with a mean SSC duration of 12·7 hours/day during hospital stay. Effective KMC at discharge (SSC ≥8 hours and exclusively breast milk fed) exceeded 90% in five sites.

Interpretation: Immediate KMC can be integrated into routine Level II SSNC through health-system redesign, leadership engagement, continuous mentorship, and quality improvement. These findings provide practical implementation evidence to support national and global scale-up of WHO recommendations for iKMC.