Kangaroo mother care (KMC) is an evidence-based cost-effective approach which has benefits beyond immediate newborn survival including healthy growth and long-term development [1, 2]. KMC with near-universal coverage can avert up to 450,000 preterm deaths every year [3]. Potential barriers to KMC implementation and coverage include issues with facility resources and environment, health care provider’s attitude, and their lack of awareness about KMC benefits.

It is truly remarked that ‘one size fits all’ approach cannot guide KMC implementation. KMC is a complex intervention and each unit has its unique barriers and enablers which decide its uptake. Shifting healthcare provider beliefs, improving parental presence, identifying creative solutions to overcome space constraints, and development of clear guideline for KMC are some avenues which may provide impetus to change practices and overcome barriers [4].

Two recent studies suggested an improvement in KMC duration [5, 6] through a quality improvement (QI) approach in a tertiary-care neonatal unit. A QI team was formed, solutions were prioritised through focus group discussions and implemented through Plan-Do-Study-Act (PDSA) cycles. While the first study suggested that the duration of KMC improved [5], the second study also suggested an improvement in the timing of initiation of KMC. The average day of initiation of KMC improved from 8th to 3rd day of life [6].

In this issue of the Journal, the study by Kapoor et al. included one-to-one intensive counseling of mother and residential elderly woman (REW) on the benefits and procedure of KMC [7]. A brief 10 min video film, pictorial brochures, and focussed group discussion formed a part of this educational package. The intervention resulted in early initiation of KMC and increased duration of KMC. It increased proportion of neonates receiving KMC in the unit and at home after discharge and also improved exclusive breast-feeding rates.

While, intensive counseling and education, increasing support from staff is known to scale up KMC practices, the effect may be transient and fade away after withdrawal of support [8, 9]. It is important to see the sustenance of the gains beyond the study period. Other outcomes like maternal satisfaction, sleep deprivation due to frequent milk expressions (median approximately 8 expressions per mother per day in intervention period in the index study) and staff feeling overworked due to intensive one-to-one counseling are other parameters which would be important to look at. This is important because utilization of existing resources, facility infrastructure and staff satisfaction and involvement without feeling overworked are important determinants for long-term sustenance of any quality improvement work. Audit-and-regular feedback mechanism is yet another step for changing health worker behavior in addition to an ongoing policy formation for sustenance of quality improvement work in the unit. Overall, the study did demonstrate that simple KMC education protocol is feasible and results in improved outcomes in preterm neonates.