Experiences of Xhosa women providing Kangaroo mother care in a tertiary hospital in the Western Cape, South Africa

Kangaroo mother care has been recognized as a credible intervention to improve preterm birth outcomes by the World Health Organization. Kangaroo mother care requires high user engagement and consists of continuous skin-to-skin contact between the mother and infant and exclusive breastfeeding. We conducted a qualitative study of Xhosa women (n = 10) practicing Kangaroo mother care in a tertiary hospital in the Western Cape, South Africa. All interviews were conducted in isiXhosa, audio-recorded, and transcribed. The transcribed data were analysed using thematic analysis. Four themes emerged: (1) Kangaroo mother care, a beneficial but foreign concept; (2) distress in the Kangaroo mother care ward; (3) the missing umbilical cord: cultural experiences of mothers in the Kangaroo mother care ward; and (4) the Kangaroo mother care village: interpersonal relations in the ward. Our study showed that cultural practices still pose a challenge to fully accepting Kangaroo mother care. We suggest more studies on cultural sensitivity to encourage acceptance of interventions that affect culturally diverse groups.


Introduction
Approximately 15 million babies are born prematurely worldwide every year, with 60% being born in Africa and South Asia (World Health Organization [WHO], 2018).Kangaroo mother care (KMC) is recommended by the WHO as an intervention to improve preterm birth outcomes, specifically for the routine care of newborns weighing 2.000 g or less at birth and as soon as they are clinically stable (WHO, 2015).KMC consists of continuous skin-to-skin contact between the mother and the infant, exclusive breastfeeding, and early home discharge in the kangaroo position (Charpak et al., 2017).Skin-to-skin contact during KMC triggers the release of oxytocin, which is known to minimize both the risk for depressive symptoms and decrease maternal stress (Badr & Zauszniewski, 2017).A recent study suggested that the perinatal period, particularly the postnatal period, may be critical for the prevention of maternal depressive symptoms -given that the presence of mental illness in the mother during this period may influence and affect her engagement and interaction with the new infant, potentially affecting later developmental milestones (Zou, 2021).KMC has also been found to promote emotional bonding and support between mothers and their babies (Cho et al., 2016).In a randomized controlled trial exploring KMC versus traditional care over 20 years, Charpak et al. (2017) found that parents who provided KMC were more protective and nurturing than those who did not.
A systematic review by Mathias et al. (2021) examining KMC utilization in low-and middleincome countries showed that cultural and traditional beliefs need to be included in KMC training, as they affect acceptability and utilization of the intervention.A qualitative review paper on traditional postpartum practices and rituals found that cultural/traditional practices may have beneficial health effects and facilitate the transition to motherhood (Dennis et al., 2007).In general, within African cultures, there are several traditions that signal the importance of birth.Often the older women teach younger women how to breastfeed.There is a pattern of 'mothering the mother', which is seen in most cultures including those in South Africa (Dennis et al., 2007).This pattern demonstrates the biological mother as playing a non-dominant role in child rearing during the first few weeks after birth (Dennis et al., 2007).There are also several cultural postbirth practices within the Xhosa culture, including a period of confinement and a ritual which concludes with a community celebration, introducing the child to the community, and ceremonial handling of the umbilical cord (Molefe, 2010).
Cultural postbirth rituals and practices have not been adequately explored as a source of barriers or facilitators to KMC practice.As preterm births are more prevalent in Africa than in high-income countries (Beck et al., 2010), it would be of interest to understand the experiences of African Xhosa women in terms of their experiences of delivering premature babies and to understand the impact of providing KMC in a setting that in many cases is different to their cultural context and background.Given that most tertiary hospitals in South Africa are situated in urban areas, there is a lack of understanding of the impact this may have on mothers from rural areas.There are no documented local studies on the cultural implications for Xhosa mothers in an urban setting of having to reconcile their cultural expectations of early parenting with the constraints and limits of a Western hospital setting.Considering the increasing rates of migration between the Eastern Cape and Western Cape provinces (Mlambo, 2018), resulting in cultural diversity among childbearing women in many health care settings in the Western Cape, it is essential to understand cultural postpartum practices and the ways in which they may influence the provision of perinatal health care.This awareness can assist in potentially offering culturally competent perinatal services.The aim of this study was to explore the experiences of Xhosa mothers providing KMC to their preterm babies at a tertiary hospital in the Western Cape.

Participants
Study participants included 10 isiXhosa-speaking mothers attending the KMC ward at a public tertiary hospital in the Western Cape.Mothers were either admitted to the KMC ward for 5 or more days or travelled between the ward and home while providing KMC to their infants.All mothers were physically well.
Participants' ages ranged from 19 to 36 years, with an average age of 27.2 years.Of the 10 participating mothers, 8 were single and 4 mothers were employed.Three mothers were attending university, three had attended Grade 12, two Grade 11 and one Grade 9. Three mothers were firsttime mothers, the rest had an average of two children at home.

Instruments
Semi-structured interviews were used to obtain qualitative data.Interview questions explored how the Xhosa mothers experienced KMC (e.g., How does being on the KMC ward affect how you think about yourself, being a mother and your relationship with your baby?), their understanding of KMC (e.g., What is your understanding of KMC?What do you like or dislike about KMC?), their thoughts and feelings while providing KMC to their infants (e.g., How did you feel when you were told that you had to be admitted to KMC? How do you feel on the ward?), their interpersonal relationships and the support they received while in the KMC ward (e.g., Explain to me your interactions with staff [nurses, medical staff, cleaners and social workers, fellow patients, and their babies] What is your relationship with the mothers in the ward?), and how their cultural backgrounds influenced their experiences of KMC (e.g., What usually happens to women around birth and postpartum in your culture?How does being in the KMC unit affect your cultural practices?).

Procedure
Purposeful sampling was used to recruit participants.The hospital ward manager assisted in recruiting participants by identifying patients in the KMC ward who met the inclusion criteria for the study.The primary investigator described the study to the prospective participant and obtained written informed consent from those interested in participating.
The interviews were conducted in a private room in the KMC ward of a tertiary hospital in the Western Cape.The average length of interviews was 40 minutes.Interviews were audio-recorded, and notes were taken during the interviews to record nuances that would not be reflected in the audio recordings.
All semi-structured interviews were conducted in isiXhosa and translated to English and transcribed.The interview data had to be translated for the other investigators to partake in data analysis.

Ethical considerations
Permission to conduct this study was obtained from the Health Research Ethics Committee, Stellenbosch University (S19/09/175) and the National Department of Health.All participants provided written informed consent and were assured that their anonymity and confidentiality would be maintained.Participants were also informed that they had the right to withdraw from the study at any time and that their participation would have no influence on the medical care that they received in the ward.In the transcription of the data, pseudonyms were used, and all identifiable information was removed.

Data analysis
Thematic analysis was chosen to analyse the data because of its flexibility and potential to generate new insights, thereby enriching our understanding of participants' experiences relating to KMC.We used the thematic analysis guidelines set out by Braun and Clarke (2006) which consisted of familiarizing ourselves with the data through transcribing, reading, and rereading the transcripts; noting down initial ideas and generating initial codes; coding interesting features of the data in a systematic fashion across the entire data set; collating data relevant to each code and searching for themes by collating codes into potential themes; and gathering all data relevant to each potential theme.Atlas.tiversion 9 was used to manage the data.Finally, data analysis and writing of the results was an iterative process with the authors discussing and reflecting on the analysis of the data.

Results
The findings are organized according to four main themes, namely (1) KMC, a beneficial but foreign concept; (2) distress in the KMC ward; (3) the missing umbilical cord: cultural experiences of mothers in the KMC ward; and (4) the KMC village: interpersonal relations in the ward.

KMC, a beneficial but foreign concept
Most participants felt that providing KMC was beneficial to their infants, but some found it to be a foreign concept.None of the mothers expected to give birth to a premature baby or knew about KMC prior to admission to the ward.The mothers expected to take their babies home after birth but were instead taken to the KMC unit.Many mothers compared their experience in the KMC unit with what they expected to happen at home.Mothers stated that at home, their family, especially the older women, would gather around them after childbirth.The purpose of the gathering was usually to teach the new mother how to care for the baby, including breastfeeding and changing nappies.
Most of the mothers were in the hospital for some time prior to giving birth and moved between different hospital wards.Many reported feeling elated at being admitted to the KMC ward because they considered it a predischarge ward.
As we sit here the other mothers will tell you that if you are going to the KMC ward it means you are close to going home.(Thembi, 30-year-old mother of one) Participants stated that it was customary in Xhosa culture for mothers and babies to go to the mother's parents or older aunts to assist and teach them about newborn care.Admission to the KMC unit meant that they did not have that opportunity.Instead, they reported that the KMC ward and nurses around them mimicked that home environment.Many believed that the KMC ward became a training ground for motherhood and the nurses took on the role of older women in the family training the new mothers.This was especially true for the first-time mothers.
Yes, it helps because I never knew how to take care of a baby, I never knew how to change nappies, I was never able to take care of babies.It helps a lot to learn how to take care of a baby.The nurses are very helpful and show us what to do when I am discharged.I think I will know how to look after him.(Ziya, 22-year-old first-time mother) Most of the participants were originally from the Eastern Cape but resided in the Western Cape at the time of giving birth.They had either planned for their relatives to travel to the Western Cape or that they would travel to the Eastern Cape after giving birth to receive support from relatives.These mothers reported that the way they were cared for in the KMC ward was similar to what they expected to get at home.
The KMC ward provided a safe space for mothers and babies.Some mothers reported that in Xhosa culture, new mothers stay indoors for a certain period.One mother stated that taking a baby outside exposes the baby to illnesses and evil spirits.As mothers and babies could not leave the ward, the ward offered protection to the baby according to Xhosa tradition.
The KMC environment also provided the mothers with an opportunity to bond with their babies.In some cases, this bonding was facilitated by nurses.Participants stated that the nurses gave them books and encouraged them to read isiXhosa books to facilitate bonding, which they would not have thought of doing themselves.
Mothers also reported that the KMC environment facilitated their responsiveness towards their babies.The mothers said that being in the ward helped them to recognize the different cries of their babies.Some mothers felt that being in close proximity to their babies facilitated bonding more than when babies were in incubators because babies were more accessible.
I stay with him all the time, they used to wake me up on the other side and call me for him because he was crying but here, I know that I am here next to him.I can easily meet all his needs.(Thembi, 30-year-old mother of one) Even though the mothers reported positive experiences within the KMC ward, they considered KMC a foreign, Western phenomenon.According to these participants, an important principle of KMC is keeping the baby on your chest.This principle seemed to conflict with their Xhosa culture.Xhosa mothers do not hold babies in their hands for long periods, as it is believed that holding the baby would cause the baby to constantly cry out for the mothers' arms.
As umXhosa, you deliver child, feed, and put him down on the bed, clean the house don't put them in your chest because they are going get used to being held by the mom.That is why I say it's for white people because we don't teach babies to stay in our arms.(Zuki, 27-year-old first-time mother of twins) Zuki went on to state that she saw other mothers struggling to put their babies down because the babies cried when they were not skin-to-skin.Thus, while the benefits of KMC were acknowledged, there were some hesitations relating to the culture that the mothers experienced.

Distress in the KMC ward
All the participants reported that their experiences of motherhood in the ward were distressing.The mothers were fearful, worried, stressed, and anxious.In this theme, we describe some of the sources of distress reported by the mothers.
Physical demands related to KMC.Some of the participants reported that they found KMC to be physically demanding.
Although practicing KMC assisted mothers in feeling close to the babies, having to practice continuous KMC meant that the baby was on their chests all day and night, impairing their sleep.The majority of the mothers found this to be strenuous and reported that they were continuously sleep deprived.Participants reported that their sleep deprivation resulted in them feeling overwhelmed and stressed.
It is difficult because I have to be awake at night.I am not used to being awake at night, the child cries sometimes and you do not know why.You are awake . . .when the baby cries . . .you just lose hope and ideas and start crying too . . .I start crying too.(Pat, first-time single mother) The women stated that they felt that they had no relief in the ward from continuously providing KMC.The opportunity to have a break from KMC would have been possible at home, and so added to the distress experienced in the ward.In the ward, mothers alone were responsible for the baby's well-being and did not have any respite as they would have had at home.Another aspect of KMC that proved to be overwhelming for participants was the regular feeding of their babies, leaving them tired all the time.
It's too much because they need to be fed every two hours, there's no sleep at night, no sleep . . .(Nonku, 28-year-old mother of one) Some participants also reported that their babies' feeding tubes were a source of stress for them.The mothers reported that they were concerned that the tubes were not working and that the nurses did not help alleviate their concerns by regularly checking the tubes for them.
Mental health of KMC mothers.The mothers reported feelings of fear and anxiety in the ward.They reported that they were anxious that they would drop their babies because the beds were uncomfortable and small.The mothers also reported feeling overwhelmed and distressed at the thought of caring for their small babies, which they did not know how to handle.Many expressed worry and anxiety about the health of their babies, especially given that they were premature babies and some of them were sick and the mothers were not sure of the actual cause of the illness.Other concerns included worries about milk production, with some mothers indicating that they did not have enough milk to give to their babies.
What stressed me is not having milk . . . it stressed me, and I would cry all the time . . .I would eat at breakfast but my kids would not eat . . .I was crying all the time . . .I still cry when my milk does not come.(Zuki, 27-year-old first-time mother of twins) Finally, mothers reported that they were preoccupied with their babies' weight.Babies were weighed daily and only allowed to leave the KMC ward when they reached a certain weight.The mothers were desperate to leave the ward with their babies and obsessed about the babies' weight and ruminated about the causes of weight loss or insufficient weight gain.The mothers blamed factors such as stress in both themselves and the baby and poor milk supply.For many, this resulted in self-blame, which contributed to their distress, which they found difficult to cope with.
It's stressful, you must always watch her unlike the baby who is term.When you are holding the baby, you are also concerned because he is so small you don't want to drop him.(Thembi, 30-year-old mother of one) The KMC environment was considered a stressful environment by participants, filled with uncertainty.The participants reported that they saw the value of being in the ward but also missed the support from their families that they would usually have.

The missing umbilical cord: cultural experiences of mothers in the KMC ward
The participants were ambivalent about cultural practices immediately after birth.They wanted to hold on to the rituals that they knew about but at the same time, many stated that they did not have enough information on the significance of these rituals.Instead, they practised them to please their elders.The women reported that they did not know much about postbirth rituals.
The mothers alluded to the significance of the umbilical cord in their culture or family of origin but could not precisely articulate the importance of this ritual.There seemed to be a deferral of responsibility and knowledge to the older people in the family which included the elderly mother or uncle, usually based in the Eastern Cape.Most of the mothers spoke about burying the cord in the garden at their homesteads or in the kraal.One mother could not find her baby's umbilical cord and spent the day searching the bins in the ward to find it because she thought that there would be repercussions if she did not.The mother blamed the nurses for the missing cord, indicating a lack of cultural sensitivity within the ward.
So, the nurses lost my baby's umbilical cord.I had left it the night before and saw that it was about to fall off.I put on gloves and searched through three bins until I finally found it.(Thembi, 30-year-old mother of one) There was also ambivalence about the type of care that the babies received.The mothers mentioned that they had a sick baby that was receiving Western medication, at the expense of much needed traditional medication.The KMC ward stood in the way of the child receiving traditional medication.For example, Zuki told us about uxakaka, referring to increased respiratory secretions that she would ordinarily have had treated by a traditional healer, but she could not have access to this treatment while in the ward.In the following quotation, her frustration is evident when she stated that her hands were tied.
My child has 'xakaxa'(increased respiratory secretions) . . .and you get this medicine from abathandazeli (praying healers) . . . the hospital cannot help with xakaxa, they say it's an infection. . .if she was not in hospital she would go get that medication . . .I feel like my hands are tied . . .when we get discharged we will one day get help.(Zuki, 27-year-old first-time mother of twins) As indicated, the mothers experienced some ambivalence when it came to cultural practices in the KMC ward.However, they did not speak to medical staff in the ward about the cultural practices but stated that they would engage with these practices when they left the ward.

The KMC village: interpersonal relations in the ward
The KMC environment consisted primarily of mothers, nurses, and doctors.The mothers described a spectrum of ways of relating to the health care workers.The participants reported feelings of gratitude, but also concern regarding poor communication.In this theme, we describe the relationships participants had with nurses, doctors, and other mothers in the ward.

Relationships with nurses
The nurses were mostly viewed as supportive and as the personification of the 'elderly women' of their communities who could teach and be available as a form of physical support.This support is reflected in the following extract from Noni (19-year-old mother of one): They [nurses] come in and listen to you.Even if you have something that is bothering you, you can share with them.They will reassure you when you feel like things are not going right.
While the nurses were viewed in a positive light, some participants noted that the ward was understaffed and perceived the nurses to have a poor work ethic or regarded nurses as unapproachable and impolite.Some mothers stated that they did not trust the nurses with their babies.One mother reported that a nurse was drunk on duty.
Two participants reported feeling excluded and unwelcome by a nurse and thought that this was related to the colour of their skin or because of their tribal background.Similarly, another participant reported that she felt nurses were prejudiced against the isiXhosa-speaking patients.Furthermore, the participants reported that the nurses did not explain to them what KMC was and did not offer enough information.They needed to ask the other mothers for information.In the following interview extract, Nonku (28-year-old mother of one) refers to the nurses as 'lazy': The nurses are lazy . . .The nurses are chatting no stop in the other rooms and not giving us the food.The baby is not eating.We wish they could leave the food in the rooms.

Relationships with doctors
Doctors were described as sweet and caring.However, participants reported that they struggled when doctors used medical jargon and did not explain to them what was happening with their infants.
And I think they will come back and explain . . .no they will not come back and explain.I look in the file at their handwriting which is not clear . . .but doctors do not speak or explain, they always just write down, they do not update me.(Nonku, 28-year-old mother of one) Participants stated that doctors briefly asked mothers about their emotional well-being.The mothers stated that they did not express their emotional state to doctors because they wanted the doctors to prioritize caring for the babies.

Relationships between mothers
Participants reported that mothers in the ward were a source of support, providing informational and emotional support, making the environment lighter, and instilling hope.
I spoke with other mothers who were not having premature babies for the first time, they would encourage me that their other kids where 5 or 7 years old and they were fine now, that gave me hope.(KK, 36-yearold mother of three) Ordinarily, women in the ward helped other mothers when needed.However, because of COVID-19, mothers were not allowed to touch babies that were not their own.As a result, some mothers were sad because they could not pick up someone else's baby when they cried to comfort and help the mother.
There is a lady with triplets here and her other two were in the other room, so we asked if we can't help the other baby and feed him.They said we could not because of COVID-19.So, the baby will just cry because of the different feeding times.(Thembi, 30-year-old mother of one) The mothers seemed to live as a community, even supporting each other by sharing food and toiletries, when needed.Mothers also listened to the doctor when they were talking to the nurses and patients, so that they could discuss what the doctors had said and confirm that they heard correctly.
When it came to interpersonal support in the ward, it seemed like the mothers were irresolute about their feelings towards the professional staff, reporting a spectrum of interactions, ranging from supportive to inaccessible.The mothers found solace and support from one another, which helped them navigate and endure the KMC environment.

Discussion
We obtained insights into the Xhosa women's experiences of KMC.Despite KMC being viewed as a foreign concept culturally, the participants were relatively accepting of it.The mothers in the ward found KMC useful because it allowed them to be closer to their babies and to be more attuned to their babies.This was similar to findings from another South African study in Johannesburg where the mothers also reported KMC to be satisfactory, as they felt closer to their babies and could monitor their growth closely (Kipchumba Tarus, 2015).KMC was accepted by the mothers and seen to be a beneficial concept that had some parallels to the Xhosa women's own culture.The ward and period of confinement mimicked a similar period in their own culture where a new mother was required to be confined to one space after birth.Mathias et al. (2021) found a similar concept in their study, where KMC seemed to emulate the cultural norm of mother-infant confinement after delivery to maintain focus on the baby.This served as a good demonstration of how cultural parallels can improve acceptance and better attitudes when introducing health care practices that are new.
The benefits of KMC were generally recognized by participants, but many viewed KMC as a foreign Western practice.A scoping review by Mathias et al. (2021) found that in Africa, KMC was viewed as a luxury and was mostly considered to be a practice for the more privileged.Our findings corroborated this, and mothers indicated that constantly holding their babies went against their cultural practices, which were important to them.Research from Ghana showed that education by local women about KMC demonstrations with dolls and pictures improved acceptability (Bazzano et al., 2012).Perhaps one could speculate about the extent to which the 'foreignness' of KMC is due to the cultural adjustment required and the extent to which it is due to being a new mother with a premature baby.In this case, both truths may be applicable, and the reported unease is acknowledged as a familiar feeling in all new mothers grappling with a change in their role and identity as a mother.However, in this sample, it seems that there is an additional layer to this unease for the Xhosa woman, for whom some consideration should be given for their need to reconcile culturally sanctioned postnatal practices (including childhood modelling, fantasy, and expectation of the role of mothering) with the current environment, which is experientially 'foreign' to their own culture.It may be important to know the acceptability of KMC interventions among people with different beliefs to improve adherence.Traditionally, the 'cultural practice' of carrying babies on the back is challenging in the context of the premature baby, where chest carrying of the baby is critical to fostering physical growth and encouraging the appropriate physiological responses.In this case, nurses can encourage a more nuanced understanding of KMC.
The participants found that being alone in the KMC ward was exhausting, whereas if they were home, they would have extended family support.Most cultures have a similar period of inactivity postnatally that can last from 21 days to 5 weeks (Dennis et al., 2007).A study in Malawi showed that mothers reported that KMC was exhausting and difficult (Nyondo-Mipando et al., 2021).The exhaustion was brought about by compromised sleep, long periods in one position, restricted movement, and boredom.In our study, we found that poor sleep and uncomfortable beds brought on distress and tiredness.It seems as even though the nurse was present and played the role of the 'elder mother', the mothers still felt a need for relief when they felt tired, as would have happened if they were at home.This feeling highlights the need for more support (externally) for the mothers to assist with the exhaustion experienced in the KMC ward.
While the women in this study had respect for traditional postnatal practices, they appeared to have limited knowledge of the significance of these practices.Most of the women knew broadly about traditional postpartum practices, but when probed further, they could not express its significance or meaning, relying rather on the elders to know.The women all mentioned the importance of needing to keep the umbilical cord safe with them until discharge.This cultural meaning of the umbilical cord is similar to that described by Molefe (2010), who considers birth as a rite of passage in Xhosa culture and for whom keeping the umbilical cord in a kraal at home signifies a spiritual connection between the child and their ancestors.Establishing the means for open communication to provide for the cultural needs of the mothers would assist the mothers in receiving input on the culturally sanctioned practices needed at the time.There are creative ways that could be encouraged to facilitate this, including considering telephonic or virtual contact with family members who are far away.
Our study showed that some mothers felt ostracized because of the perception that the colour of their skin made them less included, and the feeling that nurses who spoke other languages were insensitive.This again reinforces the need for specific reflections on inherent or perceived biases among health care workers which may or may not be only related to cultural sensitivity.Cultural humility is a process that consists of openness, self-awareness, ego-lessness, and self-criticism after voluntary interactions with people from different cultures (Greene-Moton & Minkler, 2020).An oscillation was noted in the relationship with the nurses with it being viewed as supportive at times and other times seen as daunting.Having good mother-nursing relationships have been shown to cause good adherence to KMC (Seidman et al., 2015).Our study further highlighted the need for further exploration of this relationship in the context of cultural sensitivity and humility.Providing training like this in health care organizations has the potential to improve the quality of health service delivery.Cultural sensitivity training for staff could use a model where the mothers are viewed as teachers of cultural dynamics and embedding cultural sensitivity in the training curriculums of nursing practitioners.This new era of compassion and sensitivity towards people of different cultural backgrounds will allow mothers to express themselves fully, with their requests to keep the umbilical cords respected, limiting feelings of distress as a result of its loss.
The community of women and peers ensured that the mothers in this study learned more about KMC and could relieve stress when they felt overwhelmed, which facilitated the acceptance of KMC.This finding was consistent with another study in Cape Town, South Africa, that mothers in the ward provided encouragement and were good listeners when they had bad days (Leonard, 2008).In KwaZulu-Natal, a qualitative study also echoed the theme of encouragement from other mothers with the use of positive affirmations towards each other (Reddy & Mclnerney, 2007).In our study, we found that in the ward, there was a feeling of being in a village, there was a palpable spirit of camaraderie between the mothers that ameliorated distress levels.This may stem from shared experiences and spending long periods of time together in the same space.Future studies could look at ways of enhancing this experience to ameliorate distress or boredom.
While the mothers reported feeling distressed in the KMC ward, we did not evaluate distress quantitatively.KMC has been found to be protective against maternal depression with a reduction in anxiety and depression scores in mothers practising KMC versus those who did not (Rosalie Mallonga-Matilac et al., 2021).Even so, in our study, the mothers had a sense of distress with feelings of hopelessness and helplessness.These stemmed from poor breast milk supply, sleep deprivation, uncomfortable sleeping positions, and challenging relationships with the nurses at times.While we did not specifically screen for mental health symptoms, our findings highlight the need for the consideration of the impact of KMC and the sense of distress experienced by mothers in KMC wards.
Although we were able to garner rich data from the participants in this study, our study had several limitations.For example, the findings are not generalizable, and the data were only collected by means of interviews.An ethnographic approach may yield further insights.

Conclusion
The findings of this study provide insight into how a group of Xhosa women experienced a KMC ward.We found that, like similar studies conducted with women in other African countries, KMC was viewed as a foreign concept even though it had benefits.Further studies should be conducted that explore how KMC could be accepted in various cultures.