https://doi.org/10.15218/ejnm.2020.20 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article The Effect of Kangaroo Mother Care Intervention on the Newborns Health Outcome Delivers at Sulaymaniyah Maternity Teaching Hospital ABSTRACT INTRODUCTION Kangaroo mother care (KMC) was first ini- tiated in Colombia in 1978 [1]. The meth- od involves babies being carried on the chest, usually by the mother, with skin-to- skin contact (SSC). SCS is a specially designed form of KMC which influences the physical and psychological develop- ment and the health of an infant over the first years of life and provides neurologi- cal, autonomic, somatic, behavioural, Background and Objectives: Kangaroo mother care is an intervention for all newborns but especially for premature and low birth weight infants. The method involves babies being carried, usually by the mother, with skin-to-skin contact. It is the most achievable way for decreasing neonatal morbidity and mortality and is practical, inexpensive especially for developing countries. This study intended to assess the effect of kangaroo mother care on the newborns’ health outcome at Sulaymaniyah Maternity Teaching Hospital in Sulaymani- yah, Kurdistan Region, Iraq. Methods: A quasi-experimental, pre-post intervention study was conducted in the Neona- tal Intensive Care Unit and Baby Friend Unit of the hospital. One hundred newborn- mother pairs participated in the Kangaroo mother care procedure. The newborns were physiologically monitored before, in the middle and after the procedure. Result: The highest mean of newborn temperature was 37 ̊C after Kangaroo mother care in the visit three and the lowest mean temperature was 36.1 ̊C before Kangaroo mother care. There were statistically significant differences between the before, middle and after- procedure measurements in temperature, heart rate and respiratory rate (p-value <0.05) on all three visits, while there was no significant difference between the means of the oxy- gen saturation at all three visits (p-value was more than the standard alpha 0.05 F- test=0.961). There was a highly significant association between oxygen saturation and newborn birth weight and gestational age. Individual vital signs abnormalities were often corrected during the Kangaroo mother care sessions. Newborns involved in the procedure showed steady and statistically significant improvement in vital physiological parameters during three sessions on all three days. Conclusion: Majority of babies who received Kangaroo mother care showed significant im- provement in vital physiological parameters on all three days without using special equip- ment showing that this strategy can offer improved care to newborn infants. These find- ings support wider implementation of this strategy. Keywords: Kangaroo, mother, care, newborn, health, outcome, effects Awat Hassan Azeez; Department of Nursing, College of Nursing, University of Sulaimani, Sulaimani, Iraq. (Correspondence: awathassan91@yahoo.com) Pary Muhammad Azize; Department of Nursing, Sulaimani Technical Institute Sulaimani Polytechnic University Sulaimani, Iraq. 178 Received: 06/03/2020 Accepted:27/07/2020 Published: 30/11/2020 https://doi.org/10.15218/ejnm.2020.20 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article and motor development benefits. KMC can be applied after birth for maximal effect and can continue to be implemented through the first years of life. Many factors are connected with an infant's growth and development, as well as the initiation and practising of KMC. [2]. The procedure of KMC between the mother and the baby is a secure and economical procedure that has proven advantages for mothers and chil- dren in comparison to an incubator caring method. It plays a symbolic role in infant survival, neurodevelopment, and the quali- ty of mother-infant bonding. KMC balances good essence care and helps providers to ration the use of expensive basics such as warmers and incubators for all newborn babies especially pre-term and those with a low-birth-weight (LBW). Skin-to-skin bond- ing between the mother and her infant re- duces maternal postpartum, depressive symptoms and improves autonomy [3].The KMC is done in three stages, the first and second one are performed in the hospital and the third in the family setting. The first stage is practised at the Intensive Care Unit (ICU) facilitating the bonding of the parents with the baby and positioning of the new- born. The second stage occurs in the Kan- garoo nursery/unit, where the mother ac- tively co-operates in the care of her child under the supervision of the health team. The third stage occurs after discharge at home where the baby should remain in the kangaroo position most of the day [4].The birth of a premature baby is an extremely stressful situation for parents, producing feelings of fear and insecurity. Therefore, the newborn-mother relationship is essen- tial. KMC for pre-term babies is always re- lated to better cognitive and motor devel- opment at six months of age. In addition to neonatal and maternal health outcomes, KMC is an essential tool in reducing the postpartum hospital stay and overall healthcare expense. It provides economic profit to the parents, as pre- term and LBW babies who were given KMC require less time for hospitalization [5]. The World Health Organization (WHO) sup- ported study in Nepal, which showed that hypothermia was common in newborn in- fants early after birth; increased mortality was noted across all ranges of hypother- mia, and the risk was 12 times greater among pre-term babies. [6]. KMC is a prac- tical, inexpensive intervention, for devel- oping countries. It implies putting the new- born baby in intimate skin-to-skin contact with the mother's chest and abdomen with repeated and preferably unique breastfeeding. This is similar to caring for a surrogate, where the premature baby is kept warm in the mother's bag and near to the breasts for unlimited feeding. KMC has emerged as a non-conventional low-cost method that provides warmth, touch, and security to the newborn and is believed to have a significant survival benefit. A recent Cochrane study reported that KMC im- proves breastfeeding outcomes and cardio -respiratory stability in infants without ad- verse effects [7]. A quasi-experimental study at Hawler Maternity Teaching Hospi- tal in Erbil, Iraq from February to May 2017 showed that 48% of mothers who received SSC and 46% with routine care had successful breastfeeding. Newborns who received SSC initiated breastfeeding within 2.41 ± 1.38 (M ± SD) minutes after birth, however, newborns who received routine care started breastfeeding in 5.48  ± 5.7 (M ± SD) minutes. [8]Moreover, the prevalence of hypothermia in the new- borns who received SSC and routine care was 2 and 42% respectively. This study was conducted to assess the effect of KMC on the newborns’ physiological parameters as there has been no research on this subject in the Sulaymaniyah province 179 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2020.20 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article classification of both gestational age and birth weight was used: Gestational age (9) < 28 weeks Extremely pre-term 28 to less than32 Weeks Very pre-term 32 to less than 37 Weeks Moderate to late pre-term 37 to less than 40 Weeks Full-term weeks Post-term Newborn Birth weight/gram (10) <1500 Extremely low birth weight(ELBW) 1500 to less than 2000 Very low birth weight(VLBW) 2000 to less than 2500 Low birth weight(LBW) 2500 to less than 3500 Normal weight (NW) 3500 Overweight(OW) Regarding age and birth weight as follow re, Heart rate, respiratory rate and Oxygen saturation) Part two contained maternal demographic information such as age, edu- cation level, occupation, residency, em- ployment and parity. Part three included the monitoring of physiological parameters, such as body temperature, heart rate, respiratory rate, and oxygen saturation of newborns before and after the demonstration of KMC. The purpose of the study was clearly explained to all the postnatal mothers and relatives, and their verbal consent was obtained be- fore filling the questionnaire. The KMC cus- tom-made was applied on the mother's bare chest, with newborns wearing only a diaper for at least 30 minutes with cover- ing the baby head, back and feet to avoid hypothermia. For implementing KMC, mothers were asked to use any front- opening light dress. Babies were dressed in a cap, socks, and nappy and no other A quasi-experimental, pre-post interven- tion design was used in this study at Sulay- maniyah Maternity Teaching Hospital in Sulaymaniyah in the Kurdistan Region of Iraq. All mothers of newborn babies in the Neonatal Intensive Care Unit (NICU) and Baby Friend Unit (BFU) were asked to par- ticipate in this study. A purposive non- probability sample of one hundred new- born-mother pairs was recruited to partici- pate in the study. The study data were col- lected from all NICU newborn babies. The mothers were interviewed before KMC and monitored with newborns during KMC pro- cedures in the period between the 8th of January 2019 and the 28th of May 2019. The researchers were trained for a month about KMC as preparation for data collec- tion.The research tool included a field- tested questionnaire about the mother and their newborn demographic information. Direct monitoring and documentation were done in the NICU and BFU. The data collec- tion tool was prepared in English and trans- lated to the Kurdish language to be used for the mothers’ interview. The council of the College of Medicine number 4 accept- ed protocol of the study on the 7th of Feb- ruary 2019, which was also approved by the ethical committee of the College of Nursing at University of Sulaymaniyah. An official letter from the College of Nursing at the University of Sulaymaniyah was sent to the Maternity Teaching Hospitals in Sulay- maniya to obtain facilitation and coopera- tion during data collection of this study from the 13th of November 2018.Data were collected through direct structured interview of postnatal mothers using a questionnaire. The study questionnaire consisted of three parts, as follows: Part one included four questions about neona- tal demography and medical history: gesta- tional age (weeks), birth weight (grams), gender and feeding type. The standard 180 Erbil Journal of Nursing & Midwifery METHODS https://doi.org/10.15218/ejnm.2020.20 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article C-Parried samples t-test D-One way ANOVA (F-test) Reliability of Questionnaire It can be seen in Table 1 that the Alpha Cronbach measure was used to get the re- sult of the reliability of the questionnaire. As a result, the value of Alpha Cronbach equalled to 0.896, and the validity was 0.803 showing the high reliability of the questionnaire. Table 2 demonstrates that 36% of the newborns were full-term and post-term in gestation age (the highest rate among all levels of gestational age) followed by 19% of moderate and late pre-term (9%). Re- garding the birth weight, more than half of newborns (51%) had normal weight (2500 - 3500gms) followed by 18% of low birth weight infants (2000 - 2500gms). The ma- jority of the newborns were male reaching 60% of the total. Regarding the feeding type, 46% of newborns were bottle-fed, which was the highest percentage among all the feeding types, 24% were breastfed, and only 3% were on the nasogastric tube (NGT) feeding. Table 3 indicates that out of 100 mothers, 51% were between 20 – 30 years of age. The second-largest group of mothers were 30 to 40 years old (40%). Most of the participants (63%) lived in ur- ban areas. Regarding educational level, the data showed that 26% of mothers had a secondary level of education and 24% were educated at higher education institu- tions. The most frequent occupation was being a housewife (83%). Among the study 181 Erbil Journal of Nursing & Midwifery garments. After placing into KMC bag, the baby was placed upright inside mother's clothing against the bare skin of the chest and abdomen. Head was turned to one side and placed in a slightly extended posi- tion, and eye-to-eye contact between mother and baby was encouraged. The hips were kept flexed and abducted in a ′ frog′ position; the arms were also flexed. The baby was allowed to suck on the breast as often as it wanted. The new- borns were physiologically monitored be- fore the KMC, in the middle, and after the procedure for consecutive three days in three sessions. Four vital physiological pa- rameters of the newborns, such as axillary temperature, respiration rate (RR/ min), heart rate (HR/ min), and oxygen satura- tion (SpO2) were assessed, monitored and recorded. An axillary temperature was tak- en in °C by a digital thermometer. Respira- tion rate was assessed by observing chest movements for a full one minute. The heart rate and oxygen saturation were monitored by the pulse-oximeter. All mothers of newborns including full-term, pre-term babies, low birth weight babies, and postmature babies were trained about KMC. Newborns on Continuous Positive Airway Pressure (CPAP) and unwilling mothers were excluded from participation in the study. All statistical computation was enhanced using the statistical method software SPSS 21. The data were coded, tabulated, and presented in a descriptive form. The statistical procedures that were applied to determine the results of the present study included: 1. Alpha-Cronbach has been used for testing the reliability of the questionnaire. 2. Descriptive statistical data analysis (newborn demographic characteristics and mother demographic characteristics) 3. Inferential data analysis: A. One sample t-test B. Independent samples t-test RESULTS Table 1: Reliability and Validity Methods Result Alpha Cronbach 0.896 Validity 0.803 https://doi.org/10.15218/ejnm.2020.20 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article 182 Erbil Journal of Nursing & Midwifery participants, 57% of the mothers’ parity was low multipara , which represented the highest frequency among all levels of Table 2: Distribution of the newborns’ demographic characteristics Characteristics Frequency Percent Gestational age/week < 28 weeks Extremely pre-term 0 (0) 28 to less than32 W Very pre-term 9 (9) 32 to less than 37 W Moderate to late pre-term 19 (19) 37 to less than 40 W Full-term 36 (36) > 40 weeks Post-term 36 (36) Total 100 (100) Birth weight (grams) < 1500 Extremely low birth weight (ELBW) 7 (7) 1500 to less than 2000 Very low birth weight (VLBW) 8 (8) 2000 to less than 2500 Low birth weight( LBW) 18 (18) 2500 to less than 3500 Normal weight (NW) 51 (51) ≥ 3500 Overweight (OW) 16 (16) Total 100 (100) Gender Male 60 (60) Female 40 (40) Total 100 (100) Feeding type Breastfeeding 24 (24) Bottle feeding 46 (46) Mixed feeding 9 (9) NGT ( nasogastric tube) 3 (3) NPO ( nothing per oral) 18 (18) Total 100 (100) Table 3: Distribution of the mothers’ demographic characteristics Characteristic Frequency Percent Mother age/ years Less than 20 6 (6) 20 – 30 51 (51) 30 – 40 40 (40) More than 40 3 (3) Total 100 (100) Residency Rural 11 (11) Urban 63 (63) Suburban 26 (26) Total 100 (100) Level of education Illiterate 17 (17) Read & write 16 (16) Secondary educated 26 (26) Preparatory educated 17 (17) Higher education 24 (24) Total 100 (100) Employment Employed 17 (17) Housewife 83 (83) Total 100 (100) Parity Primipara 29 (29) Low multipara (1-3) 57 (57) Grand multipara (4-8) 14 (14) Total 100 (100) https://doi.org/10.15218/ejnm.2020.20 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article 183 Erbil Journal of Nursing & Midwifery Table 4 shows the means of the physiologi- cal parameters of the whole sample. There were highly statistically significant differ- ences in means between the before, mid- dle and after KMC measurements in tem- perature, heart rate and respiratory rate at all three visits (P< 0.05). The highest mean of temperature (37 ̊C after KMC) was at Visit 3 and the lowest mean (36.1 ̊C before KMC) was recorded at Visit 1. There were no statistically significant differences be- tween the means of the oxygen saturation at Visit 1 (p=0.088), Visit 2 (p=0.721) and Visit 3 (p=0.384) because the result of the p-value was more than the standard alpha 0.05.Table 5 shows the association be- tween gestational age and temperature at all three visits(before KMC, in the middle of KMC, after KMC). There were statistical- ly significant differences between gesta- tional age and temperature because the p- values were less than the standard alpha 0.05 by using ANOVA table (F-test). The Mean ± SD of temperature (Visit 3 after KMC) in full-term and post-term newborns was 36.9 ± 0.18, which was the highest value of the mean. Furthermore, the mean ± S.D in at Visit 1 in very pre-term infants was 35.6 °C ± 0.72, which was the lowest value of the mean.Table 6 shows the asso- ciation between gestational age and heart rate. Data show that there was a statisti- cally significant difference between gesta- tional age and heart rate (during and after KMC (p=0.01). In contrast, the data from Visit 1 (p= 0.22), Visit 2 (p=0.165), and Visit 3 (p=0.645),(all visits, p=0.18) before KMC (p=0.222), in the middle of KMC (p=0.43) show that there was no statistically signifi- cant difference between gestational age and heart rate because the p-value was greater than the common alpha 0.05. The mean ± SD of heart rate before KMC in moderate to late pre-term was 144 ± 14.99, which was the highest value of the mean. Furthermore, the mean and standard deviation of heart rate after KMC in post-term newborns was 116 ± 7.37, which was the lowest value of the mean. Table 7 demonstrates the associa- tion between gestational age and respir- atory rate during all three visits, before KMC, in the middle of KMC and after KMC). There was a statistically significant difference between gestational age and respiratory rate at Visit 3 (p-value = 0.001) and after KMC (p-value = .048) because the p-value was less than the standard alpha 0.05. The means ± SDs of the respiratory rate before KMC in very pre-term and moderate to late pre-term infants were 43 ± 6.5 and 43 ± 6.16 re- spectively, which were the highest val- ues of the mean. Otherwise, the mean ± SD of respiratory rate after KMC in post- term newborns was 35 ± 3.42, which was the lowest value of the mean. Table 8 indicates the association between ges- tational age and oxygen saturation., There was statistically significant differ- ence between gestational age and oxy- gen saturation at Visit 1 (p=0.046), Visit 2 (p=0.005), Visit 3 (p=0.047), (all visits, p=0.003), before KMC (p=0.008), in the middle of KMC (p=0.045), and after KMC (p=< 0.001) because the p-values were less than the common alpha 0.05. Table 9 shows the association between birth weight and temperature. There was a statistically significant difference be- tween birth weight and temperature at Visit1 (p=0.028), Visit 2 (p=0.001), Visit 3 (p=< 0.001), (al visits, p=0.001), before KMC (p=0.007), in the middle of KMC (p=0.001) and after KMC (p=< 0.001) be- cause of the p-value < 0.05 . The mean ± S.D of the temperature after KMC in ba- bies weighing less than1500 grams was 36 ± 0.69 which was the lowest value of the mean. https://doi.org/10.15218/ejnm.2020.20 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article 184 Erbil Journal of Nursing & Midwifery Table 4: The mean values of physiological parameters of newborns at three visits Table 5: The association between gestational age and temperature Physiological Parameter Visits 1 Visits 2 Visits 3 Before Middle After Before Mid- dle After Before Middle After Tempera- ture °C Mean 36.1 36.4 36.6 36.5 36.6 36.8 36.6 36.8 37 S.D 0.73 0.54 0.49 0.5 0.41 0.35 0.42 0.33 0.27 Minimum 33.8 34.6 34.6 34.6 35.2 35 38.1 37.9 37.8 Maximum 38.3 38.1 38.1 35.1 35.6 35.9 37.8 37.9 37.8 F- test 17.23 15.808 23.458 Sig. < 0.001 < 0.001 < 0.001 Heart Rare Beats/ minute Mean 145 130 123 138 130 119 132 123 115 S.D 19.39 14.69 12.2 17.04 14.86 12.8 6 12.89 13.7 10.92 Minimum 79 91 96 99 100 93 100 98 95 Maximum 184 178 158 190 168 154 160 168 152 F- test 52.745 40.142 44.141 Sig. < 0.001 < 0.001 < 0.001 Respirato- ry Rate Breath/ minute Mean 43 40 37 42 39 37 41 39 36 SD. 6.73 4.93 5.3 6.19 5.65 5.55 7.08 7.1 6.96 Minimum 20 22 24 28 26 24 28 24 24 Maximum 72 58 58 56 54 52 62 60 60 F- test 27.984 23.640 10.775 Sig. < 0.001 < 0.001 < 0.001 Oxygen Satura- tion% Mean 98 98 99 98 98 98 98 99 99 SD. 2.33 2.1 1.77 1.79 1.97 1.67 1.55 1.57 1.41 Minimum 88 91 92 92 92 91 94 94 95 Maximum 100 100 100 100 100 100 100 100 100 F- test 2.452 0.24 0.961 Sig. 0.088 0.787 0.384 Temperature Gestational Age / Weeks 28 to < 32 W 32 to < 37 W 37 to < 40 W ≥ 40 W Very Pre-term Moderate to late Pre-term Full-term Post-term Visit 1 Mean± S.D 35.6 ± 0.72 36.5 ± 0.72 36.4 ± 0.41 36.5 ± 0.57 F-Test 8.039 Sig. < 0.001 Visit 2 Mean± S.D 36.1 ± 0.55 36.6 ± 0.57 36.7 ± 0.24 36.7 ± 0.27 F-Test 7.307 Sig. < 0.001 Visit 3 Mean± S.D 36.3 ± 0.44 36.8 ± 0.37 36.9 ± 0.18 36.9 ± 0.23 F-Test 13.813 Sig. < 0.001 General Mean± S.D 36 ± 0.53 36.6 ± 0.52 36.7 ± 0.24 36.7 ± 0.27 F-Test 10.687 Sig. < 0.001 Before Mean± S.D 35.7 ± 0.63 36.5 ± 0.68 36.5 ± 0.34 36.5 ± 0.37 F-Test +68.159 Sig. < 0.001 Middle Mean± S.D 36 ± 0.49 36.6 ± 0.51 36.7 ± 0.24 36.7 ± 0.27 F-Test 10.251 Sig. < 0.001 After Mean± S.D 36.3 ± 0.52 36.8 ± 0.4 36.9 ± 0.17 36.9 ± 0.18 F-Test 13.595 Sig. < 0.001 https://doi.org/10.15218/ejnm.2020.20 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article 185 Erbil Journal of Nursing & Midwifery Table 6: The association between gestational age and heart rate Heart Rate Gestational Age / Weeks 28 to < 32 W 32 to < 37 W 37 to < 40 W ≥ 40 W Very Pre-term Moderate to late Pre-term Full-term Post-term Visit 1 Mean± S.D 130 ± 10.64 138 ± 14.17 133 ± 12.74 131 ± 13.43 F-Test 1.497 Sig. 0.22 Visit 2 Mean± S.D 131 ± 15.17 134 ± 15.64 128 ± 10.29 127 ± 13.11 F-Test 1.737 Sig. 0.165 Visit 3 Mean± S.D 125 ± 8.61 125 ± 10.19 123 ± 11.42 122 ± 11.02 F-Test 0.557 Sig. 0.645 General Mean± SD. 129 ± 9.04 133 ± 11.09 128 ± 9.41 126 ± 10.15 F-Test 1.662 Sig. 0.18 Before Mean± SD. 134 ± 11.22 144 ± 14.99 137 ± 12.16 137 ± 14.29 F-Test 1.492 Sig. 0.222 Middle Mean± SD. 127 ± 8.49 131 ± 11.73 127 ± 10.49 126 ± 11.86 F-Test 0.929 Sig. 0.43 After Mean± SD. 125 ± 9.00 123 ± 10.09 118 ± 9.63 116 ± 7.37 F-Test 3.57 Sig. 0.017 Table 7: The association between gestational age and respiratory rate Respiratory Rate Gestational Age / Weeks 28 to < 32 W 32 to < 37 W 37 to < 40 W ≥ 40 W Very Pre-term Moderate to late Pre- term Full-term Post-term Visit 1 Mean± S.D 37 ± 5.1 39 ± 4.59 41 ± 5.25 41 ± 3.83 F-Test 1.842 Sig. 0.145 Visit 2 Mean± S.D 41 ± 6.67 41 ± 6.54 39 ± 4.87 38 ± 4.39 F-Test 1.581 Sig. 0.199 Visit 3 Mean± S.D 45 ± 9.23 40 ± 6.12 38 ± 5.98 36 ± 5.49 F-Test 5.732 Sig. 0.001 General Mean± SD. 41 ± 5.2 40 ± 4.89 39 ± 3.93 38 ± 3.66 F-Test 1.534 Sig. 0.211 Before Mean± SD. 43 ± 6.5 43 ± 6.16 42 ± 4.72 41 ± 4.57 F-Test 0.658 Sig. 0.58 Middle Mean± SD. 42 ± 5.22 40 ± 5.12 39 ± 3.81 38 ± 3.81 F-Test 1.528 Sig. 0.212 After Mean± SD. 39 ± 5.18 38 ± 4.65 36.7 ± 4.18 35 ± 3.42 F-Test 2.586 Sig. 0.048 https://doi.org/10.15218/ejnm.2020.20 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article 186 Erbil Journal of Nursing & Midwifery Table 8: The association between gestational age and oxygen saturation Table 9: The association between birth weight and temperature Oxygen Saturation Gestational Age / Weeks 28 to < 32 W 32 to < 37 W 37 to < 40 W ≥ 40 W Very Pre-term Moderate to late Pre-term Full-term Post-term Visit 1 Mean± S.D 97 ± 2.39 98 ± 1.85 98 ± 1.84 99 ± 1.37 F-Test 2.769 Sig. 0.046 Visit 2 Mean± S.D 97 ± 2.25 98 ± 1.79 98 ± 1.3 99 ± 1.12 F-Test 4.482 Sig. 0.005 Visit 3 Mean± S.D 98 ± 1.57 98 ± 1.27 99 ± 0.95 99 ± 1.32 F-Test 2.752 Sig. 0.047 General Mean± SD. 97 ± 1.88 98 ± 1.48 99 ± 0.94 99 ± 0.91 F-Test 5.012 Sig. 0.003 Before Mean± SD. 97 ± 2.24 98 ± 1.6 98 ± 1.25 99 ± 1.02 F-Test 4.199 Sig. 0.008 Middle Mean± SD. 97 ± 1.89 98 ± 1.69 98 ± 1.05 99 ± 1.08 F-Test 2.77 Sig. 0.045 After Mean± SD. 97 ± 2.05 98 ± 1.4 99 ± 0.83 99 ± 0.89 F-Test 6.931 Sig. < 0.001 Temperature Birth weight (grams) <1500 1500 – 2000 2000 – 2500 2500 – 3500 > 3500 ELBW VLBW LBW NW OW Visit 1 Mean± S.D 36 ± 1.1 36 ± 0.99 37 ± 0.5 36 ± 0.4 37 ± 0.34 F-Test 2.85 Sig. 0.028 Visit 2 Mean± S.D 36 ± 0.76 36 ± 0.79 37 ± 0.29 37 ± 0.24 37 ± 0.19 F-Test 5.411 Sig. 0.001 Visit 3 Mean± S.D 36 ± 0.6 37 ± 0.51 37 ± 0.2 37 ± 0.2 37 ± 0.22 F-Test 8.186 Sig. < 0.001 General Mean± S.D 36 ± 0.79 36 ± 0.71 37 ± 0.32 37 ± 0.25 37 ± 0.19 F-Test 5.434 Sig. 0.001 Before Mean± S.D 36 ± 0.99 36 ± 0.91 37 ± 0.45 36 ± 0.33 37 ± 0.3 F-Test 3.756 Sig. 0.007 Middle Mean± S.D 36 ± 0.73 36 ± 0.71 37 ± 0.31 37 ± 0.26 37 ± 0.18 F-Test 5.473 Sig. 0.001 After Mean± S.D 36 ± 0.69 37 ± 0.58 37 ± 0.2 37 ± 0.18 37 ± 0.13 F-Test 8.12 Sig. < 0.001 https://doi.org/10.15218/ejnm.2020.20 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article 187 Erbil Journal of Nursing & Midwifery Table 10 demonstrates the association be- tween birth weight and heart rate. There was a statistically significant difference between birth weight and heart rate after KMC (p=0.042) because the result of the p -value was less than the standard alpha 0.05 using ANOVA table (F-test). The tem- perature at all visits before KMC and in the middle KMC showed no statistically signifi- cant differences between the birth weight and heart rate because of the p-value >0.05. The mean ± SD of the heart rate in the middle of KMC in newborns with a weight of 2000 – 2500 grams was 125 ± 6.45, which was the lowest value of the mean, and the majority of the means of the heart rate in the middle of KMC in in- fants weighing less than 1500 grams were 133.Table 11 shows the association be- tween birth weight and respiratory rate. There was a statistically significant differ- ence between birth weight and respiratory rate at Visit 3 (p=< 0.001), (all visits, p=0.049) in the middle of KMC, (p=0.015) and after KMC (p=0.024) as indicated by the p-value < 0.05. In contrast, at Visit 1 (p=0.438) , Visit 2 (p=0.093) and before significant difference between birth weight and respiratory rate as the p- value was more than the common alpha 0.05 by using ANOVA table (F-test). The mean± SD of the respiratory rate before KMC in newborns with a weight of less than 1500grams was 41 ± 4.18), which was the highest value of the mean. Ta- ble 12 shows the association between birth weight and oxygen saturation. There was a statistically significant difference between birth weight and ox- ygen saturation at Visit 1 (p=0.007) ,Visit 2 (p=< 0.001), Visit 3 (p=0.048), (all vis- its ,p=0.001), before KMC (p=< 0.001), in the middle of KMC (p=0.018) and after KMC (p=0.001) because of the p- value < 0.05 by using ANOVA table (F- test). The mean ± SD of oxygen satura- tion in the middle of KMC in newborns weighing 2500 – 3500 grams was 99 ± 1.07 had the highest value of the mean. At the same time, the mean ± SD of oxy- gen saturation in the middle of KMC in infants with weight less than 1500 grams was 97 ± 1.66, which was the lowest val- ue of the mean. Table 10: The association between birth weight and heart rate Heart Rate Birth weight (grams) <1500 1500 – 2000 2000 – 2500 2500 – 3500 > 3500 ELBW VLBW LBW NW OW Visit 1 Mean± S.D 133 ± 11.75 135 ± 15.98 132 ± 11.0 132 ± 13.58 134 ± 12.42 F-Test 0.212 Sig. 0.931 Visit 2 Mean± S.D 140 ± 12.05 123 ± 12.35 130 ± 12.61 127 ± 12.61 132 ± 13.76 F-Test 2.153 Sig. 0.08 Visit 3 Mean± S.D 129 ± 10.94 125 ± 8.31 119 ± 5.62 123 ± 11.81 125 ± 11.99 F-Test 1.329 Sig. 0.265 General Mean± SD. 134 ± 8.94 128 ± 11.29 127 ± 7.68 127 ± 10.42 130 ± 11.16 F-Test 0.972 Sig. 0.427 Before Mean± SD. 141 ± 9.08 137 ± 15.37 138 ± 14.11 138 ± 13.0 140 ± 16.49 F-Test 0.158 Sig. 0.959 Middle Mean± SD. 133 ± 10.36 127 ± 9.61 125 ± 6.45 126 ± 11.84 132 ± 12.55 F-Test 1.674 Sig. 0.162 After Mean± SD. 129 ± 9.57 121 ± 11.05 119 ± 7.12 117 ± 9.35 119 ± 8.35 F-Test 2.582 Sig. 0.042 https://doi.org/10.15218/ejnm.2020.20 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article 188 Erbil Journal of Nursing & Midwifery Table 11: The association between birth weight and respiratory rate Respiratory Rate Birth weight (grams) <1500 1500 – 2000 2000 – 2500 2500 – 3500 > 3500 ELBW VLBW LBW NW OW Visit 1 Mean± S.D 37 ± 5.97 39 ± 3.05 40 ± 4.83 40 ± 4.78 41 ± 4.32 F-Test 0.952 Sig. 0.438 Visit 2 Mean± S.D 44 ± 5.19 41 ± 7.55 39 ± 5.73 38 ± 4.88 39 ± 3.93 F-Test 2.055 Sig. 0.093 Visit 3 Mean± S.D 48 ± 7.91 43 ± 7.39 39 ± 5.43 37 ± 5.94 37 ± 5.27 F-Test 6.015 Sig. < 0.001 General Mean± SD. 43 ± 4.31 41 ± 5.04 39 ± 4.21 38 ± 3.97 39 ± 3.54 F-Test 2.476 Sig. 0.049 Before Mean± SD. 44 ± 5.47 44 ± 7.23 42 ± 5.88 41 ± 4.63 43 ± 4.29 F-Test 1.025 Sig. 0.398 Middle Mean± SD. 44 ± 4.29 41 ± 4.88 39 ± 3.87 38 ± 4.15 39 ± 3.48 F-Test 3.25 Sig. 0.015 After Mean± SD. 41 ± 4.18 38 ± 4.09 37 ± 4.14 36 ± 4.03 36 ± 3.66 F-Test 2.958 Sig. 0.024 Table 12: The association between birth weight and oxygen saturation Oxygen Saturation Birth weight (grams) < 0011 0011 – 0111 0111 – 0011 0011 – 0011 < 0011 ELBW VLBW LBW NW OW Visit 1 Mean± S.D 69 ±5961 69 ±59.1 69 ±599 69 ±5911 69 ±.9.9 F-Test .9..1 Sig. .9... Visit 2 Mean± S.D 69 ±.9.9 69 ±5916 69 ±591. 66 ±59.. 66 ±.99. F-Test 191.. Sig. <.9..5 Visit 3 Mean± S.D 6. ±5919 69 ±5956 66 ±59.. 66 ±595. 66 ±595. F-Test .916. Sig. .9.19 General Mean± SD. 6. ±5995 69 ±595. 69 ±591 66 ±.96. 69 ±595. F-Test 191.. Sig. .9..5 Before Mean± SD. 69 ±599 66 ±.9.6 69 ±5995 69 ±5955 69 ±59.6 F-Test 99.61 Sig. <.9..5 Middle Mean± SD. 6. ±5999 69 ±5919 69 ±591 66 ±59.. 69 ±59.9 F-Test .95.9 Sig. .9.59 After Mean± SD. 6. ±5999 69 ±5911 66 ±59.. 66 ±.99. 66 ±59.9 F-Test 1991. Sig. .9..5 https://doi.org/10.15218/ejnm.2020.20 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article 189 Erbil Journal of Nursing & Midwifery A study was performed at NICU/BFU at the maternity teaching hospital in Sulai- maniyah over six months between the 8th of January 2019 and the 28th of May 2019. The period of one month before the study was used for training about KMC. The procedure of KMC is an easy and inex- pensive procedure for the care of new- borns. KMC enhances both newborn and maternal well-being and can be practised in any situation without the requirement of special equipment such as special cots, heaters and incubators. Even though ini- tially perceived for use only in developing countries with limited resources, its use has gradually expanded globally as medi- cal caregivers, parents, and administrators have become highly familiar with its physi- ological, psychological, and cost benefits. (11,12,13) This study is generally in agree- ment with earlier studies, as the regular upward trend in temperature during KMC sessions and throughout our study had a p -value of 0 (p=< 0.001), which was a very highly significant finding. Another study about the KMC on pre-term babies found that the mean axillary temperature and the mean heart rate was higher during KMC than during routine care. (14) KMC raises the newborn’s temperature, and as the goal is to ‘retain the warm of the new- born’, the intervention is one of the most inexpensive ways to protect babies during the critical neonatal period (15). Similarly, in this study, very highly significant differ- ences were found in heart rate and respir- atory rate before and after KMC at p=< 0.001. Similarly, Hoe et al. who studied the KMC effect on the mother and newborn physiology, stated that kangaroo care pro- motes stability of physiological function. (16) In his study, the heart rate remained stable, but the respiratory rate ranged be- tween 20 to 72 (mean 41.2), and breath- ing difficulties did not x occur during KMC (17). In agreement to the finding of this study, studies about the effects of KMC on the vital signs of low-birth-weight and pre-term newborn found no significant changes in the phys- iological parameter of oxygen saturation among newborns (18,19). In contrast to that, another study showed increased SpO2 (93.8% vs 97.3%) after performing KMC (20). Earlier studies about KMC and oxygen saturation and paternal bonding found a decrease in apnea and improve- ment in oxygen saturation in mechani- cally ventilated newborns who were able to tolerate KMC transfer and posi- tion changes. (21 ) In the cohort study by Nurian et al. who compared the effect of KMC and conventional care methods on physiological criteria in low birth weight infants in Shahid Beheshti University of Medical Sciences at Tehran in 2009, significant changes were seen between two groups in terms of heart rate, oxygen saturation and respiratory rate 5 minutes after the intervention (p < 0.05). The result shows that KMC affects the sustainability of physiological parameters during care. Thus, caregivers should use KMC for mothers and infants [22].In this study, the infants born be- fore 32-week gestation gained more benefits from KMC application than moderate to late pre-term. In these ba- bies the temperature and gestational age had the p-value = < 0.001 at all three visits and (before, middle, after KMC). Heart rates difference between the gen- eral means of three visits and the three checking periods had p-value between 0.18 and 0.017 that indicates there was a significant difference in the mean and standard deviation of heart rate before KMC in moderate to late pre-term (144 ±14.99). Otherwise, the mean and SD of heart rate after KMC in post-term new- borns was 116± 7.37, which was DISCUSSION https://doi.org/10.15218/ejnm.2020.20 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article 190 Erbil Journal of Nursing & Midwifery the lowest value of the mean, Respiration rate had minimal changes, and oxygen sat- uration had the p-value = < 0.001 at three visits. Contrary to this study findings, a meta-analysis study to determine the physiological effects of skin-to-skin con- tact on newborns and mothers concluded that, although there was an increase in body temperature of 0.22°C, there was no change in heart rate. Likewise, change in oxygen saturation in another study was statistically not clinically significant; show- ing the decline in oxygen saturation of 0.60% during periods of KMC. Prematurity did not affect the regularity of these pa- rameters. [23]Regarding the association between KMC and birth weight, it can be stated that all newborns especially low birth weight newborns receiving KMC showed a modest but statistically signifi- cant rise in temperature, respiration rate, heart rate, and oxygen saturation without the requirement for any special equip- ment. This can aid to avoid complications and the need for more detailed measure- ments. There is a room for making KMC the standard of care for the LBW new- borns in most settings. Nonetheless, ade- quate planning and labour would be re- quired to motivate and train mothers to carried out KMC and to monitor that they do so satisfactorily [24].Furthermore, KMC does have comparative benefits over con- ventional care, especially with aspects of improving neonatal survival, supporting exclusive breastfeeding, and promoting early discharge from the hospital. Even though it was initially proposed for re- source-constrained settings to decrease the high neonatal mortality rates related with pre-term and LBW infants, KMC is now been recommended by the WHO for neonatal care in both developed ( highin come) and developing (low-income) coun- tries. In developed countries, there ap- pears to be a huge gap in its implementation due to the high accessi- bility of incubators and other technology components of conventional care. In- puts have been made regarding KMC implementation in many developing countries where facility-based KMC has been individualized. Continuous training for health professionals and provision of facilities is needed, which could be fi- nanced by international aid organiza- tions to scale up the program in these settings (25,26). Kangaroo Mother Care is protective against a variety of adverse effects on newborn outcomes and has not shown evidence of harm. From the available evidence, KMC significantly improves physiological variables and thus it may positively influence the newborns' physi- cal health. The KMC is one of the essen- tial, inexpensive methods that signifi- cantly improves the newborns' physio- logical outcomes. In Sulaymaniyah, it has the potential to improve neonatal survival, support exclusive breastfeed- ing, and promote early discharge from the hospital. The authors wish to thank the staff of Maternity Teaching Hospital in Sulay- maniyah and the hospital administration for their cooperation. A great thank you to all mothers who accepted to partici- pate in this study. The authors report no conflict of inter- ests. CONCLUSION ACKNOWLEDGEMENT CONFLICT OF INTEREST https://doi.org/10.15218/ejnm.2020.20 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article 191 Erbil Journal of Nursing & Midwifery [1] Heidarzadeh M, Hosseini M B, Ershad- manesh M, Tabari M G, Khazaee S. 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