Health system intervention packages on improving coverage of kangaroo mother care for preterm or LBW infants: a mixed-methods systematic review

Introduction. Global coverage of Kangaroo mother care (KMC) remains low and health system intervention strategies that may improve coverage are not known. Methods. We conducted a systematic review of studies evaluating the effect of health system intervention strategies for KMC implementation compared to no or different interventions, on KMC coverage in preterm or LBW infants. KMC coverage achieved by various studies was summarized. All included studies were classified as those that achieved increased KMC coverage (defined as ≥25% increase from baseline, with final coverage ≥50%) or low KMC coverage (defined as <25% increase from baseline or final coverage <50%). Studies that achieved increased KMC coverage were further classified based on the mean duration of skin-to-skin contact (SSC; hours per day) achieved. Health system interventions in different categories were summarized by WHO health system building blocks to understand factors linked to increased KMC coverage. Findings. We identified 16 studies evaluating 15 health system intervention packages for KMC implementation that applied interventions in one or more health system building blocks that reported KMC coverage. All three studies that applied interventions across 5-6 building blocks (100%), two of the four studies that applied interventions across 3-4 building blocks (50%), and three of the nine studies that applied interventions across 1-2 building blocks (33%), achieved increased KMC coverage. Studies that did not achieve increased coverage had interventions primarily targeting health workforce and service delivery and were weak on leadership and governance, financing, and health information systems. All three studies that achieved increased KMC coverage with mean SSC ≥8h/d (100%), three of the five studies that achieved increased KMC coverage with mean SSC <8h/d (60%), and three of the eight studies with low KMC coverage (38%) had high-intensity interventions in at least one health system building blocks. High-level leadership engagement, KMC supportive policies, staff licensing, and facility standards regulations, strengthened numbers and capacity of nursing staff, government funding and expanded health insurance, wards with conducive environment, and recording KMC-specific indicators in clinical registers were key factors among studies that achieved increased KMC coverage. Conclusion. High-intensity interventions across multiple health system building blocks should be used for equitable scale-up of KMC. ### Competing Interest Statement NB reports personal fees from Bill & Melinda Gates Foundation for Immediate KMC Study, other from own enterprise NINO Academy, personal fees from NINO Academy, outside the submitted work. In addition, NB has a patent for Emotion monitor for infants pending to University of Cape Town, and a patent Trademark for Kangaroula in USA issued to NINO Academy. Nils Bergman and Megan Talej received a small grant from WHO to conduct this review. SG is a staff member and SR is a consultant with WHO. ERS declares no conflict of interest. ### Funding Statement This study did not receive any funding ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors. [https://www.crd.york.ac.uk/PROSPEROFILES/271834\_STRATEGY\_20210804.pdf][1] [1]: https://www.crd.york.ac.uk/PROSPEROFILES/271834_STRATEGY_20210804.pdf