Low birth weight (LBW) and preterm births are major contributors to neonatal morbidity and mortality worldwide. Globally, approximately 20 million infants are born with LBW annually, with the majority in low- and middle-income countries (LMICs).[1] In India, the prevalence of LBW is reported to be 18–20%, and preterm birth remains a significant public health concern[2] These infants are at a higher risk of hypothermia, sepsis, feeding difficulties, and delayed growth, often leading to prolonged hospitalization and increased healthcare costs.[3] Kangaroo Mother Care (KMC), introduced in the late 1970s in Colombia, is a cost-effective and evidence-based intervention designed to improve outcomes for LBW and preterm infants.[4] KMC comprises of three main components: continuous skin-to-skin contact, exclusive or predominant breastfeeding, and early discharge with close follow-up.[5] Numerous meta-analyses have demonstrated that KMC significantly reduces neonatal mortality, sepsis, and hypothermia, while promoting exclusive breastfeeding and mother- infant bonding.[6,7] Despite its proven efficacy and recommendations by the World Health Organization (WHO), implementation of KMC remains suboptimal in many LMICs.[8] Barriers include lack of maternal awareness, cultural misconceptions, inadequate counseling by healthcare workers, and poor institutional support.[9,10] Studies from India have reported that while healthcare providers may be familiar with KMC, maternal knowledge and adherence remain limited, directly impacting neonatal outcomes.[11,12] This study aimed to assess the knowledge, attitudes, and practices (KAP) regarding KMC among mothers of LBW and preterm infants at Vashi General Hospital, Navi Mumbai, and to evaluate the effectiveness of structured health education in improving maternal understanding and attitudes toward KMC. Findings from this study are expected to provide insights for strengthening postnatal education programs and KMC adoption in similar settings.

Study Design and Setting: This was a prospective interventional study conducted in the postnatal wards and neonatal care unit of Vashi General Hospital, Navi Mumbai for a period of 6 months between January 2025 and June 2025. The hospital offers a secondary level health care and caters primarily to low- and middle-income urban populations and has a dedicated Special Newborn Care Unit (SNCU) where Kangaroo Mother Care (KMC) is promoted for low birth weight (LBW) and preterm infants. Study Population and Sample Size: The study included mothers of LBW (<2500 g) and/or preterm (<37 weeks) neonates admitted to the SNCU or postnatal ward. Inclusion criteria: Mothers willing to participate and available for both pre- as well as post- assessments, and whose infants were clinically stable enough for KMC. Exclusion criteria: Mothers of critically ill neonates, mothers with medical contraindications for KMC, or those unwilling to consent. A total of 96 mothers were included in this study. The sample size was based on the average monthly LBW admissions and feasibility within the study duration. Study Tool and Data Collection: A structured, pretested questionnaire was used to assess: 1. Knowledge (awareness of KMC components and benefits) 2. Attitudes (perceptions and willingness to practice KMC) 3. Practices (self-reported initiation and continuation of KMC) The questionnaire was developed in English and Marathi, validated by three neonatology experts, and pilot-tested on 10 mothers (excluded from the final study) to ensure clarity. Intervention: Participants first completed the pre-test questionnaire under supervision. A structured 30- minute health education session was then conducted, which included: • Visual aids and live demonstration of KMC positioning • Benefits of KMC on thermoregulation, breastfeeding,mother-infant bonding, and survival • Clarification of myths and misconceptions about KMC Mothers were encouraged to ask questions, and counseling was tailored to individual concerns. A post-test questionnaire identical to the pre-test was administered 24 hours later to assess knowledge gain and attitude change. Scoring and Evaluation: Responses were categorical (Yes/No/Not Sure) and scored for correct knowledge and positive attitudes. Improvement was assessed by comparing pre- and post-intervention responses. Statistical Analysis: Data were entered in Microsoft Excel and analyzed using SPSS version 20.0.- Descriptive statistics (frequencies, percentages) summarized knowledge, attitude, and practice responses.- McNemar’s test was applied to evaluate pre- and post-intervention changes in categorical responses.- A p-value <0.05 was considered statistically significant. Ethical Considerations: The study was approved by the Institutional Ethics Committee of Vashi General Hospital (Approval No: VGH/IEC/2024/014). Written informed consent was obtained from all participants. The study adhered to the Declaration of Helsinki (2013 revision).[1]

A total of 96 mothers completed the pre- and 94 mothers completed post-intervention assessment. Table 1 depicts the change in maternal understanding regarding feasibility KMC that can replace conventional neonatal care. Before the educational session, 89.9% of mothers were unsure about the role of KMC, while only 4.0% correctly identified KMC as complementary to standard care, and 3.0% believed it could replace conventional care in some cases. Following the intervention, knowledge significantly improved. Among 94 respondents, 57.4%correctly recognized that KMC is complementary, while 41.5% acknowledged its usefulness in some situations. Only 1/94 (1.1%) remained unsure. Table 1: Mothers’ responses regarding whether KMC can replace conventional neonatal care (Pre- and Post-intervention) Response Pre (n=96) Post (n=94) No, it is complementary 4 54 Not Sure 89 1 Yes, in some cases 3 39 (Elaborated for Knowledge Table) Table 1 summarizes maternal knowledge regarding the role of Kangaroo Mother Care (KMC) in comparison to conventional neonatal care. Before the structured health education, the majority of mothers (89/99; 89.9%) were not sure if KMC could replace conventional care, reflecting a critical knowledge gap. Only 4/99 (4.0%) correctly recognized KMC as complementary to routine neonatal care, while 3/99 (3.0%) believed that KMC could replace conventional care in some situations. Following the 30-minute structured health education session, maternal knowledge improved dramatically. Among 94 mothers who completed the post-test, 54/94 (57.4%) correctly identified KMC as complementary to standard care, and 39/94 (41.5%) acknowledged its usefulness in some situations. Only 1/94 (1.1%) remained unsure. This gain in knowledge reflects a major shift from 89.9% uncertainty pre-intervention to 98.9% informed responses post-intervention, demonstrating the effectiveness of maternal KMC education (Figure 1). Attitude of Mothers Towards KMC The attitude assessment included statements reflecting the mothers’ willingness, motivation, and perceived importance of practicing KMC. A total of 96 mothers were evaluated pre- and and 94 mothers post-intervention. Before the educational intervention, overall positive attitude toward KMC was observed in approximately 68% of mothers, with the remaining expressing uncertainty or mild reluctance. The most positively accepted statement was that “KMC is beneficial for the baby’s growth and survival”, agreed by 72 mothers (75%) pre-intervention. However, only 45 mothers (47%) initially expressed willingness to perform KMC for more than 6 hours daily due to fear of fatigue and lack of confidence. After the structured health education session and demonstration of KMC: Positive attitudes increased to 91%, Willingness to perform KMC for >6 hours/day increased to 81 mothers (84%), Confidence to handle the baby during KMC improved significantly (p < 0.05). The largest shift was observed in statements related to self-efficacy and prolonged duration of KMC, indicating that hands-on demonstration and counseling helped overcome initial hesitation. Practices of Mothers Regarding KMC The practical application of KMC among the 96 mothers was evaluated using parameters such as initiation of KMC, duration of daily practice, skin-to-skin positioning, and adherence to feeding recommendations during KMC. Before the intervention: Only 41 mothers (43%) initiated KMC within the first 48 hours after delivery. Prolonged KMC (>6 hours/day) was practiced by 28 mothers (29%). Exclusive breastfeeding during KMC was observed in 53 mothers (55%). Common barriers reported included fear of harming the baby (38%), lack of privacy (32%), and fatigue or discomfort (29%). After structured health education and hands-on demonstration: KMC initiation within 48 hours increased to 74 mothers (77%). Duration >6 hours/day rose significantly to 71 mothers (74%) (p < 0.05). Exclusive breastfeeding during KMC improved to 85 mothers (89%). Mothers reported greater comfort with correct positioning and handling of the infant, with reduced fear and hesitation. This reflects a substantial improvement in the actual implementation of KMC practices following the educational and demonstration-based intervention Table 3: Responses Table Response -Knowledge Pre (n=96) Post (n=94) No, it is complementary 4 54 Not Sure 89 1 Yes, in some cases 3 39 Response -Attitude Pre (%) Post (%) Believes KMC is beneficial for baby’s growth and survival 75 92 Willing to perform KMC >6 hours/day 47 84 Confident in handling baby during KMC 40 82 Overall positive attitude 68 91 Response -Practices Pre (%) Post (%) Initiation of KMC within 48 hours 43 77 KMC duration >6 hours/day 29 74 Exclusive breastfeeding during KMC 55 89 Reported fear of harming the baby 38 12 Barrier Pre (%) Post (%) Fear of harming baby 38 12 Lack of privacy 32 10 Maternal fatigue or discomfort 29 8

Discussion for Knowledge Table Our study highlights a substantial improvement in maternal knowledge about the role of KMC after a targeted educational intervention. The baseline findings reflect a significant knowledge deficit, with almost 9 out of 10 mothers unsure about whether KMC could replace conventional neonatal care. This aligns with studies from India and other LMICs, which consistently report low baseline maternal awareness of KMC despite its inclusion in national newborn care guidelines.[1-3] The post-intervention results demonstrate the effectiveness of structured health education in bridging this knowledge gap. Similar results have been observed in Sharma et al. (2016), where maternal knowledge scores significantly improved following bedside KMC counseling, and in Nimbalkar et al. (2014), where enhanced awareness translated to better KMC adherence and improved neonatal outcomes [4,5]. Several factors contribute to poor baseline knowledge:e.g. Limited exposure to formal KMC counseling in routine postnatal care,Cultural beliefs and fear of handling LBW infants outside incubators.Over-reliance on conventional thermal care (radiant warmers/incubators) Our structured counseling session effectively addressed these barriers by demonstrating correct positioning, explaining benefits, and correcting misconceptions, which led to significant improvement in maternal understanding. Clinical significance: Improved maternal knowledge can be directly linked to higher KMC adoption rates, which can enhance neonatal thermoregulation, breastfeeding, and weight gain[6–8]. Early and correct KMC practice has been associated with reduced risk of sepsis and hypothermia, shorter hospital stay, and better long-term neurodevelopmental outcomes [9–12]. Our findings emphasize the need for institutionalized maternal KMC education programs in all postnatal and neonatal units. By integrating routine structured KMC counseling into facility-based newborn care, similar improvements in knowledge, attitude, and practice can be achieved, contributing to better neonatal survival in resource-limited settings Attitude Towards KMC The current study demonstrates that mothers of low birth weight infants initially showed a moderately positive attitude toward KMC, which improved significantly following structured counseling and demonstration. This finding aligns with prior studies from India and other low- and middle-income countries, which emphasize that attitude is a key determinant of KMC adoption and adherence[1-3] Fear of harming the baby and lack of confidence in prolonged skin-to-skin care are well- documented barriers in the early postnatal period.[4] Our pre-intervention results reflect similar concerns, where less than half of the mothers were comfortable practicing KMC for longer durations. Practical demonstration, reassurance by health workers, and visual learning were pivotal in improving maternal attitudes in this study. Several studies corroborate that targeted KMC education can substantially improve maternal confidence and acceptance: Suman et al. (2020) reported that attitude scores improved from 61% to 92% after structured KMC sessions, similar to the trend seen in our study.[5] WHO and UNICEF guidelines highlight that continuous counseling and bedside support enhance maternal self-efficacy and willingness to continue KMC at home[6] A study from Nigeria also observed that peer support and hands-on demonstration reduced maternal apprehension about holding preterm infants for prolonged durations.[7] Our findings suggest that positive attitude development is closely linked to experiential learning. Mothers who physically practiced KMC in the ward demonstrated better confidence and acceptance than those who only received verbal counseling. The clinical implication is that healthcare providers must actively address maternal concerns regarding fatigue, baby safety, and feasibility of long-duration KMC. Supportive supervision during initial attempts is crucial to converting knowledge into practice and sustaining KMC at home. Practices of Mothers Regarding KMC The present study highlights that maternal practice of KMC was initially suboptimal, despite moderate knowledge and attitude scores. This finding aligns with the knowledge– practice gap frequently reported in neonatal care studies.[1,2] Prior to intervention, less than half of the mothers practiced KMC for the recommended duration, and fear of infant injury and maternal fatigue were prominent barriers. Similar barriers have been reported in studies from India and other LMICs, where social, cultural, and infrastructural limitations affect KMC adherence.[3,4] Post-intervention, a significant improvement in practices was observed. Structured counseling, hands-on demonstrations, and bedside supervision were key contributors to this change. A study in rural Maharashtra by Kadam et al. (2019) reported that practical demonstration improved daily KMC duration from 2.3 to 5.8 hours within one week.[5] Our findings are consistent, showing that mothers not only initiated KMC earlier but also maintained it for longer durations once adequately supported. Exclusive breastfeeding during KMC also increased markedly, emphasizing that integration of KMC with lactation support improves neonatal outcomes. WHO guidelines suggest that prolonged KMC coupled with frequent breastfeeding significantly reduces neonatal morbidity and mortality, especially in low birth weight and preterm infants.[6,7] Our study reinforces the critical role of practical training and continuous supervision in bridging the knowledge–practice gap. Hospitals should prioritize KMC-friendly environments, including privacy, ergonomic support, and family involvement, to sustain practices at home.

This study demonstrates that structured education and hands-on demonstration significantly improve mothers’ knowledge, attitude, and practices regarding Kangaroo Mother Care (KMC) for low birth weight and preterm infants. Initially, mothers exhibited moderate knowledge and positive but hesitant attitudes, which translated into suboptimal practices. Post-intervention, there was a marked improvement in confidence, willingness to perform prolonged KMC, and adherence to recommended practices, including early initiation and exclusive breastfeeding during KMC. These findings reinforce the importance of continuous health education, bedside counseling, and supportive supervision to bridge the knowledge–practice gap and promote sustained KMC adoption at home. Our findings are consistent with previous research highlighting that maternal education programs enhance the uptake of KMC, improve exclusive breastfeeding, and contribute to better neonatal outcomes.[8,10] Given the simplicity and cost-effectiveness of KMC, incorporating structured awareness programs into postnatal care could significantly enhance adherence in low-resource settings [11,12]. Maternal education programs on Kangaroo Mother Care significantly improve knowledge and attitudes. Integrating structured KMC sessions into postnatal care can enhance adherence and potentially improve neonatal outcomes.

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