Sexual & Reproductive Healthcare 16 (2018) 181–185

Contents lists available at ScienceDirect

Sexual & Reproductive Healthcare

journal homepage: www.elsevier.com/locate/srhc

Becoming a mother – Mothers’ experience of Kangaroo Mother Care T

a b b,c
Josefine Norén , Kerstin Hedberg Nyqvist , Christine Rubertsson ,
⁎
Ylva Thernström Blomqvista,b,
a
University Hospital, Neonatal Intensive Care Unit, Uppsala, Sweden
b
Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
c
University of Lund, Department of Health Science, Lund, Sweden

A B S T R A C T

Objective: To describe mothers’ experiences of providing their preterm infants with Kangaroo Mother Care
(KMC).
Study design: A qualitative descriptive design.
Setting: Two level III neonatal intensive care units (NICUs) in Sweden.
Participants: Thirteen mothers of preterm infants.
Methods: The mothers were interviewed when their infant had reached a corrected age of 4 months ± 2 weeks.
The interviews were recorded and transcribed and data were analyzed using qualitative content analysis.
Results: The mothers described the skin-to-skin contact with, and closeness to, the preterm infant as something
they valued, and involuntary physical separation as something they had to accept and adapt to. Providing the
infant with breast milk by expressing and tube feeding was experienced as time-consuming and as impinging on
the skin-to-skin contact.
Conclusion: Mothers want to stay close to their preterm infant. The NICU environment and staff can facilitate
KMC by providing a private space for parents and infants, and enable mothers to breastfeed and express breast
milk by giving them support based on science and proven experience.

Introduction
Separation between mothers and their preterm infants occurs daily
in Neonatal Intensive Care Units (NICUs) as the infant is commonly
placed in an incubator, leading to an interruption in the attachment and
bonding processes [1]. The staff members often act as the infant’s pri-
mary caregivers during the NICU stay, which contributes to the se-
paration. Many mothers perceive the separation from their infant as a
stressful event [2]. By contrast, Kangaroo mother care (KMC) can pre-
vent separation and reinforces the parents’ role as the infant’s primary
caregivers [3].
Kangaroo mother care is defined as early, prolonged, and con-
tinuous (or as allowed by circumstances) skin-to-skin contact between a
mother (and/or her substitute) and her newborn preterm or low
birthweight infant. The infant is placed on the parents’ chest with flexed
arms and legs and adequately covered to remain warm. The definition
of Kangaroo mother care also includes exclusive breastfeeding when-
ever possible and early discharge combined with adequate follow-up
and support [4].
In high income countries, skin-to-skin contact is mainly practiced
intermittently (for a few hours a day) but, depending on the infant’s
medical condition, can also be used as an alternative to the conven-
tional incubator care 24 h a day [5]. However, mothers in high income
countries have also expressed willingness to perform skin-to-skin con-
tact continuously or almost continuously, provided they are given the
amount of support and help they request [6]. The body of evidence
regarding the benefits of KMC and skin-to-skin contact between parents
and their infants is growing and includes positive effects on infant brain
development [7], the parent–infant relationship, and parental psycho-
logical wellbeing [8]. Length of hospital stay [7], breastfeeding dura-
tion [9], pain response during painful procedures [10] and physical
growth [11] are all improved when KMC is implemented. Furthermore,
mother–infant bonding and infants’ cognitive, perceptual, and emo-
tional development benefit from KMC [12].
It has been demonstrated in numerous different settings that
Kangaroo Mother Care boosts the parenting process (including feelings
of being the infants parent and primary caregiver) by improving par-
ents’ ability to perceive and respond appropriately to their infant’s cues;
KMC also facilitates the interaction and thereby supports the infant’s
attachment to the parents, and the parents’ bonding with their infant

⁎
Corresponding author at: Department of Women’s and Children’s Health, Uppsala University, 751 85 Uppsala, Sweden.
E-mail address: ylva.thernstrom_blomqvist@kbh.uu.se (Y.T. Blomqvist).

https://doi.org/10.1016/j.srhc.2018.04.005
Received 14 September 2017; Received in revised form 6 April 2018; Accepted 8 April 2018
1877-5756/ © 2018 Elsevier B.V. All rights reserved.
J. Norén et al.
[3]. Reported barriers to KMC practice are restrictions for parents’
presence in the care facility, and limitations regarding the facilities
physical environment and resources. Together with negative im-
pressions of staff’s attitudes and interaction with parents, these factors
are the most common obstacles mentioned by mothers [13].
The second component of KMC is infant nutrition, which, whenever
possible, should consist of breast milk [4]. Before the preterm newborn
is breastfeeding, this is mainly achieved by mothers’ expression of
breast milk. However, there is evidence that preterm infants have the
capability to cope with direct feeding at the mother’s breast as early as
28 weeks of postmenstrual age [14]. Skin-to-skin contact between the
mother and the preterm infant increases the mother’s volume of breast
milk [15] and has a positive effect on breastfeeding duration [9,16].
The third component of KMC is environment: the skin-to-skin con-
tact can take place both in hospital and at home after early (depending
on circumstances) discharge, until at least the 40th week of postnatal
gestational age with adequate follow-up [4]. The discharge from the
NICU to home can involve feelings of parental stress and anxiety [17].
To facilitate discharge, it is important to include the parents in the
infant’s care as soon as possible, preferably around the clock [18].
To better understand what enables and obstructs the implementa-
tion of KMC, it is essential to further investigate how mothers of pre-
term infants experience all components of KMC; the skin-to-skin con-
tact, the infant’s nutrition and the preparation for discharge from
hospital. Thus, the aim of this study was to describe Swedish mothers’
experiences of KMC.
Methods
The design of this study was qualitative and descriptive. This study
is part of a larger project aimed to investigate different aspects of KMC.
Setting
The mothers included in this study spent time together with their
preterm infants in two level III NICUs in Sweden. The NICU at hospital
A had three intensive care nurseries, with four intensive care spaces
each. Close to every care space was an adult bed and the parents had
opportunities to perform skin-to-skin contact 24 h a day. There were
also screens that could be folded out to increase privacy. In the same
ward, there were nine family rooms where both parents and siblings
could stay together with the preterm infant. There were no restrictions
regarding visiting except in case the visitor had an ongoing infection;
furthermore, parents and visitors were obliged to adhere to the ward’s
hygiene routines. In the NICU at hospital B, there was one intensive
care nursery with five care spaces. Next to each care space, there were
one or two armchairs with a footrest, where the parents could sit
holding their infant. The ward had two family rooms where the parents
could cohabit with the infant a few nights before the infant’s discharge
from the hospital. There were no visiting restrictions regarding the
parents, who could spend as much time during daytime as they liked in
the unit. There were some restrictions regarding visits by siblings and
other relatives, such as a maximum number of persons visiting si-
multaneously.
Participants
Mothers of singleton infants who were born at the postmenstrual
age of 28 weeks to 33 weeks and 6 days, and whose condition was not
life-threatening, were consecutively recruited to the study. Only mo-
thers who mastered the Swedish language were included. During their
stay at the NICU, they were asked if they were willing to participate in
an interview by the time their infant had reached the corrected age of
4 months. The first 13 mothers who agreed to participate received an
information letter and a phone call and were asked to confirm their
agreement once again. The time and place for the interview was
182
Sexual & Reproductive Healthcare 16 (2018) 181–185
determined according to the mother’s wishes.
The mothers’ age ranged between 25 and 42 years, and all were
married or cohabiting with the infant’s father. Eight of the interviewed
mothers were first-time mothers, four had older children at home; for
one mother this information was not obtained. Two of the mothers did
not speak Swedish as their native language. Eleven of the mothers had
had their first skin-to-skin contact with the infant on the day the infant
was born, and two on the day after the birth.
The infants, four girls and nine boys, were born at a gestational age
of between 29 + 3 and 33 + 2 weeks + days, with birth weights ran-
ging between 1175 g and 2500 g. During their NICU stay, these infants
received skin-to-skin contact for a median of 507 (range 242–1.237)
minutes per day. The infants’ median length of hospital stay was 35
(range 15–57) days. At the time of discharge, they had reached a
median postmenstrual age of 36 (range 34–38) weeks. Seven infants
were breastfed exclusively at discharge, and four partly; two were not
breastfed.
Data collection
Interviews were conducted and digitally recorded by an experienced
interviewer who had not had any previous contact with the mothers.
The interviews were performed in the mothers’ homes during 2009,
when the infants had reached a corrected age of 4 months ± 2 weeks.
The interviews were based on an interview guide designed by the au-
thors and based on clinical experience and the available literature [5].
The opening question was “What was your experience of your infant’s
stay at the NICU?” The interview focused on the mothers’ experiences
of, and opinions about, the KMC model. The interviews lasted between
30 and 74 min.
Ethical considerations
This study was approved by the Research Ethics Committee of the
Medical Faculty at Uppsala University, Uppsala, Sweden (Dnr 2006/
313/1). All mothers who participated in the study signed a consent
form and were informed both orally and in writing that their partici-
pation was voluntary and would not have any influence on the care
their infant received.
Data analysis
The data were analyzed according to the research question using
qualitative content analysis [19]. The first step of the analysis was
performed by the first and last author, but the research group met
several times to discuss the preliminary results until consensus was
reached. In this study, we followed the method of qualitative content
analysis as described by Graneheim and Lundman [20]. The data ana-
lysis process began by reading the transcribed interviews several times
to gain a sense of the entire body of the text and the overall content.
Three content areas were identified based on the definition of KMC.
Table 1
An overview of the content areas and categories.
Content areas Skin-to-skin contact Breast milk as Early discharge
nutrition if possible from the NICU
Categories – Separation or – Expression of – Early
closeness breast milk discharge
– Becoming a – Breastfeeding – Closeness at
mother home
– Taking turns
– Practical aspects
around KMC
– Experiences of
KMC
KMC = Kangaroo Mother Care; NICU = Neonatal Intensive Care Unit.
J. Norén et al.
Content areas are described either as parts of the text based on theo-
retical assumptions or as addressing a specific topic. Meaning units,
which are words and sentences that relate to the same central meaning,
were identified in the text. These were condensed and coded with one
word or a few words that label the content of the meaning unit. This
enables the data to be seen and interpreted in a new way. The codes
were then grouped into categories, which are groups of content that
share similarities, in order to summarize the data (Table 1).
Results
Skin-to-skin contact
Separation or closeness
The main issue mentioned by the mothers was related to closeness
to, or separation from, their infant. Those mothers who were able to
stay at the NICU around the clock (hospital A) valued this highly, and
access to a family room was highlighted as important by most of the
mothers. Besides the advantage of not splitting the family, staying at
the NICU allowed them to socialize with other parents who were in the
same situation. The mothers reported this to be a crucial supportive
factor. However, mothers described the high level of noise and the large
number of people (staff and other parents) in the intensive care nur-
series, combined with a lack of privacy, as barriers to KMC. The mo-
thers who were unable to stay overnight at the hospital found this
difficult to cope with, particularly at the beginning. One mother be-
longing to the NICU at hospital B described the separation at nights as
follows:
They had to drag me out of there, I remember. It was so hard at first,
leaving him and just walking away.
The mothers at this NICU adapted to the situation and learned to
cope with it. The separation became normal and they tried to see ad-
vantages instead, for example to rest from the hospital during the night
helped them gain energy. Despite this, they said they would have stayed
at the hospital if this had been an option. Several mothers said, “It
should be mandatory to provide parents with access to family rooms at
NICUs.”
Becoming a mother
In the parenting process, the skin-to-skin contact seemed to play an
important role for the mothers. They described a special closeness to
their infant.
The moment she placed him on my chest, I felt this warm sense over my
heart, and then I couldn’t leave him, I just wanted to sit there all the
time...
This experience also seemed to play a role in mothers’ gaining
control and adapting to the unforeseen, new situation.
if he would just be lying there in the incubator, it would take much longer
to understand, and you wouldn’t completely understand that it [the in-
fant] is yours. Look but don’t touch! The closeness [of KMC] you got
immediately, it’s really important, both for him and for us...
All mothers reported that participating in their infant’s daily care,
such as changing diapers, performing cup or tube feeding, recording the
infant’s temperature, and so on, was highly appreciated. They felt re-
inforced in their parental role when the staff supported them to perform
caregiving activities.
Taking turns
Mothers described that they built a team together with their
partner. By taking turns both of them could get some rest and provide
their infant with continuously skin-to-skin contact. One mother ex-
plained that the father took care of the cup feeding while she was ex-
pressing breast milk.
183
Sexual & Reproductive Healthcare 16 (2018) 181–185
We took turns all the time; it was such a relief when N.N. [the father]
could stay with us.
Practical aspects around Kangaroo Mother Care
Mothers who performed KMC during most of the day experienced
the skin-to-skin contact as exhausting, mainly because it reduced their
mobility. Some mothers who performed KMC overnight found it espe-
cially exhausting because of lack of comfort (a hard bed, the position
they had to maintain while providing KMC in bed, not being able to
move around), and said that they had to take breaks to get some rest.
Kangaroo Mother Care carriers; a kind of baby-wearing slings or
pouches in textile were used sometimes. These infant-carrying articles
support the infant’s correct position during skin-to-skin contact and
enable parents to perform KMC without using their hands for support.
Some mothers found them helpful because they increased their mobi-
lity, while others said they had felt that their infant did not seem
comfortable, or that using a carrier was too complicated.
Factors mentioned by the mothers as facilitators of KMC were access
to a private room, a television set or computer, a cellphone, and a
kitchen where they could prepare their own food and socialize with
other parents. Other circumstances mentioned by the mothers as fa-
cilitators were that they were provided with breakfast at the ward and
were able to have visitors.
Experiences of Kangaroo Mother Care
All mothers described positive attitudes towards KMC. The skin-to-
skin contact was perceived as cosy and natural; it made them feel safe.
During the skin-to-skin contact, they felt less worried and more in
control.
I mean, what did they do before this? Have you always had this skin-to-
skin method, or what did you do before? Did you just sit there watching
your child or what?
They explained that even though the skin-to-skin contact could be
exhausting they found it worth the trouble.
I would probably have thought that having her in an incubator and just
touching her with my hand would have been awful, because this com-
pensates I know I’m going to have impaired sleep for a month or two, but
I know that it is really good for me and the baby, so it compensates for a
lot...
The mothers believed that the skin-to-skin contact had a positive
impact on their infant, both in the short and in the long term. They
described that the infant slept better and was calmer during skin-to-skin
contact. Some mothers associated their child’s present positive beha-
viors and characteristics with his or her experience of KMC during the
hospital stay.
I believe that it has been very good for her… she feels very secure, she’s
very calm … So I believe that it has had an impact on her …
Breast milk as nutrition if possible
Expression of breast milk
Some mothers found the expression of breast milk challenging be-
cause it was time consuming and tiresome. They felt that it interfered
with the skin-to-skin contact because it was difficult or impossible to
express milk while being skin-to-skin with their infant. They felt
stressed and pressured regarding this, especially if they had difficulties
in establishing a satisfactory breast milk supply.
Sometimes I would say that I had been expressing milk, even though I
hadn’t. I was too exhausted at the end, so I started to skip it sometimes
because it felt hopeless.
According to the mothers, the main source of stress with regard to
J. Norén et al.
milk expression was the staff. Questions from staff regarding frequency
of expression and quantity were perceived as stressful. According to one
mother, another circumstance adding to this stress was that they could
easily see and compare the quantity of breast milk expressed by other
mothers, because they had a common refrigerator for storage of breast
milk. Mothers who did not have access to a family room sometimes felt
that they lacked privacy while expressing breast milk, and found this
stressful.
Breastfeeding
Mothers who had problems breastfeeding were not satisfied with the
support they received from the staff. They had experienced pressure
rather than support, for example, a lot of advice was not perceived as
helpful; instead, it just contributed to more stress. The mothers who
never established successful breastfeeding blamed themselves and ex-
perienced this as a personal failure. They said they wished they could
have more individual support.
Early discharge from the Neonatal Intensive Care Unit
Early discharge
To be offered the opportunity of early infant discharge from the
hospital was appreciated. By gradually taking over their infant’s care
during the hospital stay the mothers felt well prepared for going home
with their baby. They appreciated the opportunity to take their infant
home, despite the infant’s continued need for nasogastric tube feeding.
Closeness at home
Most of the mothers continued provision of skin-to-skin contact at
home. It was gradually decreased and replaced by other forms of clo-
seness. This decrease was mainly attributed to the larger number of
duties awaiting the mother at home, which forced them to interrupt
KMC, in contrast with their situation in hospital. Some mothers ex-
pressed concern that the infant might get cold, because the room
temperature was lower at home than at the hospital.
Discussion
This study investigated how mothers experience KMC, focusing on
all three KMC components (skin-to-skin contact, breastfeeding, and
early discharge) in two high-tech NICU environments. The mothers
described that the skin-to-skin contact and the closeness to their pre-
term infant had had several positive effects, on both themselves and
their preterm infant. Mothers at hospital B described involuntary phy-
sical separation from their infant as something they just had to accept
and adapt to. Providing the infant with breast milk by expressing and
tube feeding was experienced as time-consuming; furthermore, it im-
pinged on the skin-to-skin contact. The mothers said they wished they
had been given better individual support from the nursing staff re-
garding breastfeeding.
Being separated from, and not being able to provide their preterm
infant with skin-to-skin contact was perceived negatively by the mo-
thers interviewed in this study, which is similar to findings by others
[2]. However, they adapted to the situation and accepted the separation
and even saw certain advantages, like being able to rest and gain energy
when away from the infant. This could be interpreted as normalization
of the separation. However, it is possible that environmental limita-
tions, such as lack of opportunities to stay at the NICU around the clock,
influenced some mothers’ perceptions of separation.
The emotional relationship between the mother and the preterm
infant seemed to benefit from their close physical contact. All mothers
appreciated the skin-to-skin contact and described it as valuable. In
addition to being perceived as cosy and natural, it helped the mothers
to realize that they had become mothers and thus to adapt to the un-
foreseen, new situation. They also experienced the skin-to-skin contact
as something they were able to do that had a positive impact on their
184
Sexual & Reproductive Healthcare 16 (2018) 181–185
infant. These experiences, described by the mothers, indicate that skin-
to-skin contact plays an important role in the attachment/bonding
process between the preterm infant and the mother and is important for
the mother’s psychological wellbeing.
All mothers participated in their infants’ care, including provision of
tube feeding and changing diapers; this involvement made them gain
confidence, and it also helped them positively in the parenting process.
This is supported by a previous Swedish study by Heinemann et al.
[21]. Similar to findings by Blomqvist et al. [22], the mothers in our
study stated that taking turns with the father in the infant’s daily care
and provision of KMC was necessary in order to cope with the situation.
Further, it is important to keep in mind that, if the parents feel tired or
stressed, the staff can help them with many of the practical things re-
garding the infant’s care, such as warming up the infant’s food so that
the parents can prioritize and focus on caring for the infant skin-to-skin.
The coping process was also facilitated by access to a family room,
enabling the whole family to stay together close to the infant at the
NICU around the clock. Even though some mothers described how the
skin-to-skin contact impaired the quality of sleep, which has also been
shown by previous studies [23], they were sufficiently motivated to
perform skin-to-skin contact because they were convinced they were
doing something good for their infant. On the other hand, some mothers
reported that taking breaks from the skin-to-skin contact was necessary
to gain new energy.
Kangaroo Mother Care carriers were perceived as helpful by some
mothers and as too complicated by others. We noted that some mothers
complained about their reduced mobility while performing KMC. This
confirms how important it is that nursing staff give parents adequate
instruction in the use of KMC carriers for making the parents feel safe
while using them.
The importance of a NICU environment that makes mothers feel
included has been emphasized previously [8]. Likewise the mothers in
this study mentioned both positive aspects of, and limitations in, the
NICU environment. On one hand, they described the environment as
noisy and crowded, leaving no room for privacy; on the other hand,
access to a family room was something all mothers appreciated. In
addition to the great advantage of having the opportunity to be close to
the infant around the clock, the mothers also described the opportunity
to meet other parents who were in the same situation as an important
supporting factor. Visits by friends and relatives were important to the
mothers who stayed at the ward, and gave them energy. Tessier et al.
[24] found that mothers who performed KMC around the clock were
prone to feel isolated and lonely, as the nurses did not approach them so
often; on the other hand, they also had a higher sense of competence
and felt less stressed. Generous guidelines regarding visitors and access
to KMC carriers may facilitate the provision of KMC, enabling parents’
mobility in the NICU, and thus prevent feelings of isolation.
Providing their infant with their own breast milk by expression and
tube feeding was described by the mothers as time-consuming. The
expression of breast milk was perceived as something particularly en-
ergy-draining and stressful, and sometimes it interrupted the skin-to-
skin contact.
Also in accordance with these authors’ findings, the mothers in our
study were dissatisfied with the support given by the nursing staff
concerning breast milk expression. Rather, the staff contributed to the
mothers’ stress as they frequently asked them about the amount of
breast milk. Some mothers were also stressed when they saw and
compared the amounts of other mothers’ breast milk with their own
milk production. Further studies should address whether the origin of
mothers’ stress originates from questions from staff, and whether staff
perceive breast milk expression as a measure of mothers’ capability as
mothers, an opinion that may be noticed by mothers. The mothers who
never achieved successful breastfeeding said they wished they had been
given less conflicting advice and better support from the nursing staff.
This demonstrates how important it is that staff show a supportive at-
titude towards breast milk expression and breastfeeding and do not
J. Norén et al.
focus on the frequency of expression and the quantity of breast milk
alone.
Most the mothers continued performing skin-to-skin contact to some
extent after they had returned home with the infant, which confirms
that they found the skin-to-skin contact truly valuable. Early discharge
from the hospital felt natural since the mothers had gradually taken
over most of the infant’s care and become the infant’s primary caregiver
during the hospital stay. When nursing staff hold on to the role of the
infant’s primary caregiver up to the infant’s discharge the transition
from hospital to home is probably harder and feels less safe for the
mother.
This is a relatively small study performed in a small Nordic country.
Nevertheless, the results could contribute to increased knowledge and
understanding of mother’s experience when providing KMC.
Furthermore, this knowledge and awareness can help NICU staff to
continue improve routines and working methods, to enhance their fa-
cilitation of mothers’ presence with their infants as much as possible
days and nights.
One limitation of this study was that the study sample consisted of
mothers from two high tech NICUs in a Western country with national
guidelines for parental benefits that allow both parents to be together
with their infant during the entire NICU stay, instead of continuing to
working. Therefore, the results can only be generalized to similar set-
tings. Furthermore, in a qualitative study, the evaluation of trust-
worthiness involves consideration of the richness of each interview
rather than of the sample size [25]. The present study was conducted
about ten years ago, despite this, the study uniquely reports mothers’
own narratives about their experience of KMC and about being close to
or separated from their infants during the NICU stay. Still, NICU’s all
over the world needs to improve their design to meet healthcare
workers and family’s needs in their goals to care for their infant’s skin-
to-skin.
The interviews in this study were rich in information; therefore, the
amount and quality of the data can be considered as constituting an
adequate sample size. Although this study was performed some time
ago, guidelines and practices regarding KMC still vary between settings,
and therefore we consider it valuable to describe mothers’ response
regarding the extent of KMC they had the opportunity to practice.
Clinical implications
The physical environment at the NICU has an impact on the extent
to which mothers perform KMC. Neonatal Intensive Care Units can offer
an environment that supports KMC performance, mainly by no re-
strictions regarding parents’ presence at the NICU day and night, by
offering family rooms, and by a unit culture, shared values by all staff
members, that supports parents’ presence and participation in their
infant’s care.
Conclusions
This study shows that mothers found KMC valuable, both for
themselves and for their preterm infant. Expression of breast milk and
breastfeeding are delicate issues that are facilitated by staff who have
the necessary knowledge, and are encouraging and responsive to mo-
thers’ individual need of support.
Acknowledgments
The authors would like to express their deep gratitude to the all the
mothers who generously shared their experiences with us.
Author contributions
KHN, CR and YTB were all responsible for the study design; YTB
185
Sexual & Reproductive Healthcare 16 (2018) 181–185
recruited mothers, JN and YTB made the initial data analysis and the
first drafting of the manuscript; JN, KHN, CR and YTB all made critical
revisions to the paper.
Funding
This study was funded by the Uppsala county council (YTB).
Conflict of interest statement
We have no conflict of interest to declare.
References
[1] Bialoskorski M, Cox CL, Hayes JA. The nature of attachment in a Neonatal Intensive
Care Unit. J Perinat Neonatal Nurs 1999;13(1):66–77.
[2] Treherne SC, Feeley N, Charbonneau L, Axelin A. Parents' perspectives of closeness
and separation with their preterm infants in the NICU. J Obstet Gynecol Neonatal
Nurs 2017 Aug 9 [Epub ahead of print].
[3] Nyqvist K, Anderson G, Bergman N, Cattaneo A, Charpak N, Davanzo R, et al.
Towards universal Kangaroo Mother Care: recommendations and report from the
first European conference and Seventh International Workshop on Kangaroo Mother
Care. Acta Paediatr 2010;99(6):820–6.
[4] Cattaneo A, Davanzo R, Uxa F, Tamburlini G. Recommendations for the im-
plementation of Kangaroo Mother Care for low birthweight infants. International
Network on Kangaroo Mother Care. Acta Paediatr 1998;87(4):440–5.
[5] Nyqvist K, Anderson G, Bergman N, Cattaneo A, Charpak N, Davanzo R, et al. State
of the art and recommendations. Kangaroo mother care: application in a high-tech
environment. Acta Paediatr 2010;99(6):812–9.
[6] Blomqvist YT, Nyqvist K. Swedish mothers’ experience of continuous Kangaroo
Mother Care. J Clin Nurs 2011;20:1472–80.
[7] Charpak N, Ruiz-Pelaez JG, De Figueroa CZ, Charpak Y. A randomized, controlled
trial of kangaroo mother care: results of follow-up at 1 year of corrected age.
Pediatrics 2001;108(5):1072–9.
[8] Flacking R, Lehtonen L, Thomson G, Axelin A, Ahlqvist S, Moran V, et al. Closeness
and separation in neonatal intensive care. Acta Paediatr 2012;101(10):1032–7.
[9] Flacking R, Ewald U, Wallin L. Positive effect of kangaroo mother care on long-term
breastfeeding in very preterm infants. J Obstet Gynecol Neonatal Nurs
2011;40(2):190–7.
[10] Johnston C, Campbell-Yeo M, Fernandes A, Inglis D, Streiner D, Zee R. Skin-to-skin
care for procedural pain in neonates. Cochrane Database Syst Rev 2014;21(1).
[11] Suman R, Udani R, Nanavati R. Kangaroo mother care for low birth weight infants:
a randomized controlled trial. Indian Pediatr 2008;45(1):17–23.
[12] Feldman R, Eidelman AI, Sirota L, Weller A. Comparison of skin-to-skin (kangaroo)
and traditional care: parenting outcomes and preterm infant development.
Pediatrics 2002;110:16–26.
[13] Seidman G, Unnikrishnan S, Kenny E, Myslinski S, Cairns-Smith S, Mulligan B, et al.
Barriers and enablers of kangaroo mother care practice: a systematic review. PLoS
ONE 2015;10(5).
[14] Nyqvist KH, Sjödén PO, Ewald U. The development of preterm infants' breast-
feeding behavior. Early Hum Dev 1999;55(3):247–64.
[15] Acuña-Muga JL, Ureta-Velasco N, de la Cruz-Bértolo J, Ballesteros-López R,
Sánchez-Martínez R, Miranda-Casabona E, et al. Volume of milk obtained in rela-
tion to location and circumstances of expression in mothers of very low birth weight
infants. J Hum Lact 2014;30(1):41–6.
[16] Renfrew MJ, Craig D, Dyson L, McCormick F, Rice S, King SE, et al. Breastfeeding
promotion for infants in neonatal units: a systematic review and economic analysis.
Health Technol Assess 2009;13(40):1–146.
[17] Raines DA, Brustad J. Parent's confidence as a caregiver. Adv Neonatal Care
2012;12(3):183–8.
[18] Larsson C, Wågström U, Normann E, Thernström Blomqvist Y. Parents experiences
of discharge readiness from a Swedish Neonatal Intensive Care Unit. Nurs Open
2016;4(2):90–5.
[19] Sandelowski M. Using qualitative research. Qual Health Res 2004;14(10):1366–86.
[20] Graneheim UH, Lundman B. Qualitative content analysis in nursing research:
concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today
2004;24(2):105–12.
[21] Heinemann AB, Hellström-Westas L, Hedberg Nyqvist K. Factors affecting parents’
presence with their extremely preterm infants in a neonatal intensive care room.
Acta Paediatr 2013;102(7):695–702.
[22] Blomqvist YT, Rubertsson C, Kylberg E, Jöreskog K, Nyqvist KH. Kangaroo mother
care helps fathers of preterm infants gain confidence in the paternal role. J Adv
Nurs 2012;68(9):1988–96.
[23] Leonard A, Mayers P. Parents' lived experience of providing kangaroo care to
nearness or separation-mothers’ experience of kangaroo mother care their preterm
infants. Health SA Gesondheid 2008;13(4):16–28.
[24] Tessier R, Cristo M, Velez S, Giron M, De Calume ZF, Ruiz-Palaez JG, et al.
Kangaroo mother care and the bonding hypothesis. Pediatrics 1998;102(2):e17.
[25] Sandelowski M. Sample size in qualitative research. Res Nurs Health
1995;18(2):179–83.