Review question / objective

The objective of this review is to synthesize experiences of kangaroo care among the parents of preterm infants in neonatal intensive care units.

Background

Kangaroo care (KC), which is also called kangaroo mother care (KMC), is defined as early, prolonged and continuous care involving mothers or fathers holding their infants upright with skin-to-skin contact (SSC) between the low birth weight (LBW) infant and the baby's mother, or a substitute for her, such as the father or another relative.1,2 In 1978, rising morbidity and mortality rates, along with a shortage of caregivers and resources in Bogota, Colombia, led Dr Edgar Rey to institute protocols that would come to be known as KC. He defined KC as mothers maintaining continuous skin-to-skin contact with their babies in order to keep them warm and provide exclusive breastfeeding on demand. Kangaroo care now consists of three core components: SSC (baby wearing), breastfeeding and a critical perception shift. With KC, the biological and emotional needs of the baby and the mother are met, while at the same time the desire of care providers and institutions to provide the best care possible for a premature infant is achieved.3 It is suggested that KC should start in the hospital and, if necessary, be continued at home for as long as the infant needs it for temperature control, which can be up to term age. Ideally, the infant should have breast milk as nutrition, be cared for by the mother or one or more relatives at home after early discharge, and be followed up in an appropriate manner.

In the past 50 years, the survival rates of LBW and very low birth weight infants (VLBW) have improved significantly. This improved survival has been at the price of separating the infant from the mother who should be carrying out KC.4 For parents or families with a premature baby, this is a crisis and they experience a range of emotions including fear, disappointment and anxiety.5

Some studies have shown that KC can strengthen the ties between infants and parents and enhance their intimacy, as well as bring about active parenting.6 When a premature baby is hospitalized for medical assessment and treatment in a neonatal intensive care unit (NICU) following birth, it represents a crisis for both parents.7,8 A preterm infant cared for in a NICU is associated with highly technical equipment and parents can experience difficulties with respect to the fact that the infant is their baby and that the infant needs them. Studies have shown that parents want to have encounters with their infant and participate in the care of their infant in the NICU. Parents might be fearful of approaching their fragile and small baby; furthermore they are likely to also need more information on the premature condition of their baby and how to communicate/care for their fragile child. Kangaroo care is a nursing practice that, to some extent, is accepted worldwide and meets the newborn infant's important needs for warmth, stimulation, parental contact and love.9 During the time that a premature infant faces a health crisis, the child also needs parental love in order to face this difficult time of growth. In this context, KC is an important nursing practice that promotes inter-subjectivity between parents and their infants within the NICU. Thus, it is vital to understand the parental experience when carrying out KC in a NICU.

Parental experiences with premature neonates when carrying out kangaroo care in a NICU

A range of studies have investigated KC and these have included both qualitative and quantitative studies. In a quantitative structured review of the effectiveness of enhanced parent-infant bonding using KC, seven electronic databases were searched for research papers published between 2000 and 2011. Six papers were identified that reported experimental studies that involved KC with premature infants. The findings showed that KC is able to increase the maternal-infant bond, enhance the father-infant bond, enhance relationships within the entire family, decrease maternal stress, decrease depressive emotions, decrease infant distress and reduce infant pain.10 Furthermore, another quantitative systematic review critically appraised articles from national and international literature published from 2000 to 2011. These findings revealed that infants who participated in a KC program showed improvements in their development and that factors such as LBW, prematurity and learning disorders have a close association with the onset of motor impairments and changes in psychomotor development.11

In addition to the above quantitative studies, Anderzen-Carlsson, Lamy and Eriksson used a qualitative systematic review method to study parental experiences of KC with newborn babies. Four databases were searched and 29 original qualitative papers were selected; these reported the experiences of 401 mothers and 94 fathers from nine countries. The authors identified two major themes related to parental experiences a restoring experience and an energy-draining experience.12,13 A few studies have focused on the parental experience of preterm newborns who underwent KC. Roller used transcendental phenomenology to analyze the experiences of mothers providing KC for their preterm newborns at a NICU. Tape recorded, semi-structured interviews were conducted at one to four weeks postpartum. The findings of this study revealed two essential elements of the mothers' experiences when providing KC for their preterm newborns; these were being "kept from knowing" the newborn and "getting to know" the newborn.2(p210) There were four dominant themes within the essential elements. These were interruption of the maternal-newborn acquaintance, unpleasantness, reassurance and KC.5 Reddy and Mclnerney also investigated the experiences of premature mothers who carried out KC in a NICU. They used a phenomenological design to interview mothers who had babies below 2000 grams and who undergone delivery at a regional hospital in KwaZulu-Natal, South Africa. A total of ten mothers participated in this study. They found three maternal themes: feelings, management of mothers and support.4 Recently, Salimi et al. used the focus group method to try to understand the experiences of mothers of premature babies who carried out KC in a NICU. They found two major categories: the mothers' experiences concerning the advantages of KC in terms of interactions with the neonate, and the mothers' feelings related to the physical-mental health of the neonate.14 Furthermore, a few studies have investigated the experiences of premature fathers in such circumstances at a NICU; one such study was by Blomqvist et al. who used individual interviews and qualitative content analysis. The results of this study indicated two themes: firstly, that the fathers' opportunity to be close to their infants facilitated the attainment of their parental role in the NICU, and, secondly, that KC allowed them to feel in control and to feel that they were doing something good for their infant, even though caring for the infant was demanding and stressful.6

The aim of this qualitative systematic review is to synthesize the experiences of mothers, fathers or parents when they carry out KC with their preterm infants in a NICU. In the Anderzen-Carlsson qualitative systematic review, parental experiences related to SSC with their newborn infant were investigated.12 Specifically, 29 original qualitative papers were included for this review with a focus on the parents of newborn infants.10 In contrast, our qualitative systematic review will focus on premature infants and their mothers, fathers or parents.

Inclusion criteria

Types of participants

This review will consider studies that include mothers, fathers or parents who have preterm infants with a gestation age ranging from 24 to 37 weeks.

Phenomena of interest

The phenomenon of interest to this review is the experiences of mothers, fathers or parents of preterm infants who have carried out KC.

Context

This review will consider studies where the preterm infant has resided in a NICU. Studies that investigate the parental experience of KC in a home setting or other contexts will be excluded.

Types of studies

This review will consider studies that focus on qualitative research, including but not limited to, designs such as phenomenology, grounded theory and ethnography research.

Search strategy

The search strategy aims to find published studies. A three-step search strategy will be utilized for this review protocol. An initial limited search of PubMed and CINAHL will be undertaken, followed by an analysis of the text words contained in the title/abstract of the identified articles as well as the index terms used to describe these articles. A second search will then be undertaken using all the identified keywords and index terms across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies and a citation search will also be done on relevant studies. All studies published in English and Chinese will be considered for inclusion in this review. The search will be carried out in cooperation with a librarian. Filters will be used to limit the search to humans, to studies published in the English and Chinese.

The following databases will be searched:

PubMed (1966-2015)

CINAHL

Psychoanalytic Electronic Publishing Archive, PEP Archive

Chinese Electronic Periodical Services, CEPS (1991-2015).

Initial key words search terms

English search terms:

Type of participants: mother, father, parent*, preterm*, prema*

Phenomenon of interest: kangaroo care, experience, attachment, bonding

Types of study: qualitative inquiry, phenomenology, ethnography, focus group, hermeneutic phenomenology.

Context: neonatal intensive care unit

Chinese search terms:

Assessment of methodological quality

Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardized critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or by a third reviewer. Authors of primary studies may be contacted for missing information or to clarify unclear data.

Data extraction

The data to be extracted from the papers for inclusion in the review will be obtained using the standardized data extraction tool from JBI-QARI (Appendix II). The data extracted will include specific details about the phenomena of interest, populations involved, study methods used and outcomes of significance to the review question and the specific objectives of this study.

Data synthesis

Qualitative research findings will, where possible, be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent the aggregation; this will be done by assembling the findings rated according to their quality, and categorizing these findings on the basis of similarity in meaning. These categories will then be subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form.

Conflicts of interest

There are no conflicts of interest to declare.

Acknowledgements

The reviewers acknowledge the Institute of Taichung veterans general hospital, Taiwan for its support in this review.

References