Study Selection
There were 273 research articles retrieved using an electronic search. Of these articles, 117 were expelled for duplication and 95 studies were excluded after reviewing their titles and abstracts. At the qualification stage, 61 articles were completely gotten to and evaluated for the capability. Finally, 16 studies (49-64) with 12,475 participants were included in this systematic review and meta-analysis. All studies were cross-sectional, and reported the prevalence of knowledge, attitude, and practice of kangaroo mother care (Fig. 1)
Description of included studies
Out of 273 articles retrieved at first, sixteen articles met the eligibility criteria and were included in the final meta-analysis as reported by Fig.1. The author’s names, publication year, study design, sample size, study region, study setting, response rate, birth weight, kangaroo mother care type, gestational age, the prevalence of knowledge, attitude, and practice of kangaroo mother care listed in the below Table1.
Four studies were found in Addis Ababa (50,54-56), three in Southern Nations Nationalities and Peoples Region(49,51,61), two at the national level(57,59), one in Amhara (60), two in Tigray (58,64), one in Somali(62), one in Harar and Dire Dawa (52), one in Harar(53), and one in Addis Ababa, Amhara, Oromia and Benishanguel Gumuize (63). Of the sixteen cross-sectional studies, twelve were institutional-based, and four were community-based. The earliest in 2014 and the latest in 2021. The sample sizes ranged from 86 to 7488. The prevalence of knowledge, attitude, and practice of kangaroo mother care ranged were ranged from 35.5%-82.53%, 50%-82.53%, and 28%-83% respectively. The response rate ranged from 92 to 100 percent. Eight studies reported any gestational age (preterm, term, and post-term) infants, while the remaining only on preterm infants. All sixteen studies were assessed by using Joanna Briggs Institute (JBI) quality appraisal checklist. All of these studies had reported a low risk (Table1).
Table 1
Descriptions of the studies used in the systematic review and meta-analysis for the knowledge, attitude, and practice of kangaroo mother care among postnatal women in Ethiopia.
Author/year
|
Study region
|
Study
Setting
|
Study
design
|
Sample
Size
|
Response rate
|
Good knowledge
|
Good attitude
|
Good practice
|
GA
|
KMC
Type
|
Weight
(KG)
|
Study quality
|
Mose et.al/2021
|
SNNP
|
Hospital
|
Cross-sectional
|
382
|
100
|
35.5
|
50
|
35.3
|
Any age
|
SSC+BF
|
Any weight
|
Low risk
|
Gebre et.al/2018
|
Somali
|
Community
|
Cross-sectional
|
829
|
98.3
|
Not reported
|
Not reported
|
23
|
Any age
|
SSC+BF
|
Any weight
|
Low
Risk
|
Roba AA/2018
|
Harar & DireDawa
|
Hospital
|
Cross-sectional
|
349
|
100
|
69.91
|
63.33
|
54.51
|
Any age
|
SCC only
|
<2.5kg
|
Low
Risk
|
Jamie ,A.H /2020
|
Harar
|
Hospital
|
Cross-sectional
|
166
|
100
|
82.53
|
82.53
|
32.13
|
Any age
|
SSC only
|
<2.5kg
|
Low
Risk
|
Alelign, Zewuditu(un-pub)
|
Addis Ababa
|
Hospital
|
Cross-sectional
|
249
|
100
|
69.1
|
54.22
|
43
|
Preterm
|
SSC+BF
|
<1.5kg
|
Low
Risk
|
Bedaso et.al/2019
|
Amhara,
Addis Ababa,
Oromia
|
Hospital
|
Cross-sectional
|
384
|
100
|
Not reported
|
Not
Reported
|
40.1
|
Any age
|
SSC
|
Any weight
|
Low
Risk
|
Getinet et.al/2019
|
SNNP
|
Hospital
|
Cross-sectional
|
86
|
92
|
68.6
|
57
|
61.6
|
Preterm
|
SSC only
|
<2.5kg
|
Low
Risk
|
Dawit , Aster (un-pub)
|
Addis Ababa
|
Hospital
|
Cross-sectional
|
297
|
100
|
Not reported
|
Not reported
|
71
|
Preterm
|
SSC+BF
|
<1.5
|
Low
Risk
|
Dabere et.al/2020
|
National
|
Community
|
Cross-sectional
|
7488
|
Not reported
|
Not reported
|
Not reported
|
24.3
|
Any age
|
SSC only
|
Any weight
|
Low
Risk
|
Ebrahim yesuf et.al/2018
|
SNNP
|
Community
|
Cross-sectional
|
215
|
100
|
Not reported
|
Not reported
|
41.9
|
Preterm
|
SSC only
|
<2.5kg
|
Low
Risk
|
M.W,Ayele et.al/2021
|
Amhara
|
Community
|
Cross-sectional
|
190
|
97
|
Not reported
|
Not reported
|
46.8
|
Any age
|
SSC only
|
<2.5kg
|
Low
Risk
|
Haftey Gebremedihn et,al (un-pub)
|
Tigray
|
Hospital
|
Cross-sectional
|
397
|
96.6
|
Not reported
|
Not reported
|
54.4
|
Any age
|
SSC only
|
<1.5kg
|
Low
Risk
|
Lakew W. and B.Worku/2014
|
Addis Ababa
|
Hospital
|
Cross-sectional
|
110
|
Not reported
|
Not reported
|
Not reported
|
83
|
Preterm
|
SSC only
|
<1.5kg
|
Low
Risk
|
Weldeargay et.al/2019
|
National
|
Hospital
|
Cross-sectional
|
768
|
Not reported
|
Not reported
|
Not reporter
|
46.4
|
Preterm
|
SSC only
|
<1.5kg
|
Low
Risk
|
Demissie et.al/2018
|
Addis Ababa
|
Hospital
|
Cross-sectional
|
356
|
100
|
Not reported
|
Not reported
|
47.2
|
Preterm
|
SSC+BF
|
<1.5kg
|
Low
Risk
|
Emishaw et.al/
|
Tigray
|
Hospital
|
Cross-sectional
|
109
|
Not reported
|
Not reported
|
Not reporter
|
28.12
|
Preterm
|
SSC only
|
<2.5kg
|
Low
Risk
|
Level of Knowledge, Attitude, and Practice towards kangaroo mother care
The pooled prevalence of the knowledge about, attitudes towards and practice of kangaroo mother care in Ethiopia is presented by the forest plots in Figs. 2–4. A random-effect model showed that the pooled level of good knowledge was 64.62% (95% CI: 47.15%–82.09%; I2 = 97.8%). The overall estimated positive attitude towards kangaroo mother care was 61.55% (49.73%–73.38%; I2 =94.8%), while the pooled estimate of poor practice of kangaroo mother care among postnatal women was 45.7% (95% CI: 37.30%–54.09%; I2 = 98.5%; see Fig. 2)
Leave –one- out sensitivity analysis
A leave-one-out sensitivity analysis was carried out to detect the effect of each study on the overall prevalence of a good level of knowledge about, a positive attitude towards and a poor level of practice of kangaroo mother care among postnatal women by excluding one study at a time. The results showed that the excluded study leads to significant change in the overall prevalence of a good level of knowledge, positive attitude and poor practice. In the sensitivity analysis, both Jamie,AH. and Mose et al. showed an impact on the pooled level of good knowledge and positive attitude, while Lakew B , B. Worku and Gebre et al. showed an impact on the level of poor practice of kangaroo mother care (Table 2).
Table 2
A Leave –out-one sensitivity analysis for knowledge, attitude, and practice of kangaroo mother care among postnatal women in Ethiopia
Knowledge related articles
|
|
|
Study omitted
|
Pooled estimate
|
95%CI
|
Mose et.al
|
72.22
|
64.92-79.53
|
Roba AA et.al.
|
63.31
|
40.30-86.32
|
Jamie ,A.H
|
60.11
|
41.44-78.77
|
Zewuditu Alelign
|
64.02
|
41.59-86.45
|
Getinet et.al
|
63.67
|
43.23-84.12
|
Attitude related articles
|
|
|
Study omitted
|
Pooled estimate
|
95%CI
|
Mose et.al
|
64.48
|
51.46- 77.50
|
Roba AA et.al.
|
61.07
|
44.97-77.17
|
Jamie ,A.H.
|
56.17
|
49.59- 62.76
|
Alelign,zewuditu
|
63.39
|
48.82-77.96
|
Getinet et.al
|
62.58
|
48.82-76.33
|
Practice related articles
|
|
|
Study omitted
|
Pooled estimate
|
95%CI
|
Mose.et.al
|
46.40
|
37.44-55.36
|
Roba AA et.al
|
45.10
|
36.52-53.68
|
M.W. Ayele et.al
|
45.62
|
36.90- 54.35
|
Getinet et.al
|
44.70
|
36.12-53.28
|
Gebere et.al
|
47.26
|
37.83-56.69
|
Dawit, Aster
|
43.96
|
36.11-51.82
|
Bedaso et.al
|
46.08
|
37.17-54.98
|
Dabere et.al
|
47.16
|
38.94-55.38
|
Demissie et.al
|
45.60
|
36.83-54.36
|
Ebrahim Yesuf
|
45.95
|
37.17-54.73
|
Emishaw et.al
|
46.83
|
38.07-55.59
|
Jamie,A.H.
|
46.59
|
37.79-55.40
|
Zewditu Alelign
|
45.88
|
37.09-54.67
|
Tesfaye Geberemedihn
|
45.10
|
36.54-53.67
|
Weldearagay et.al
|
45.65
|
36.75-54.55
|
Lakew. W and B. Worku
|
43.22
|
35.37-51.07
|
Subgroup analysis
The subgroup analysis based on kangaroo mother care component showed that a level of good knowledge was 74% in only skin-to-skin contact and 51.2% in skin-to-skin contact with exclusive breastfeeding. The level of positive attitude towards kangaroo mother care component was 67.98% in skin-to-skin contact only and 51.85% for skin-to-skin contact with exclusive breastfeeding. In this subgroup analysis, the level of poor practice was examined by study region, study setting, publication, component of kangaroo mother care, gestational age and birth weight. The pooled level of poor kangaroo mother care practice by region was 60.99% in Addis Ababa and 39.92% in another region (where a study conducted in single region/multiple regions). In the case of kangaroo mother care components, the prevalence of poor practice was 46.57% in only skin-to-skin contact practice and 43.84% in skin-to-skin contact with exclusive breastfeeding. Regarding gestational age, the level of poor practice was found to be 52.77% in preterm neonates and 38.68% at any gestational age. The level of poor practice relative to birth weight was 57.37% in birth weight below than 1.5 kg and 30.27% at any weight (Table 3).
Table 3
The overall estimated level of Good Knowledge, Positive Attitude, and poor practice towards kangaroo mother care in Ethiopia, 95%CI and heterogeneity estimate with a p-value for sub-group analysis
Knowledge related articles
|
|
|
|
Variable
|
Characteristics
|
Pooled level of good knowledge 95%(CI)
|
I2(p-value)
|
Kangaroo mother care type
|
SSC only
|
74%( 64.744- 83.236)
|
83.1%(0.003)
|
|
SSC+BF
|
51.2%(19.991- 82.318)
|
98.4% (0.000)
|
Attitude related articles
|
|
|
|
Variable
|
Characteristics
|
Pooled level of positive Attitude 95%(CI)
|
I2(p-value)
|
Kangaroo mother care type
|
SSC only
|
67.98%(52.968- 82.997)
|
93.5%(0.000)
|
|
SSC+BF
|
51.85%(47.958-55.749)
|
0.0%(0.335)
|
Practice related articles
|
|
|
|
Variables
|
Characteristics
|
Pooled level of poor practice 95%(CI)
|
I2(p-value)
|
Study setting
|
Community
|
33.067%( 25.397- 40.738)
|
95.4%(0.000)
|
|
Institutional
|
49.697%(41.801-57.594)
|
95.9% ( 0.000)
|
Region
|
Addis Ababa
|
60.992%(43.326-78.658)
|
97.3%(0.000)
|
|
SNNP
|
45.505%(32.660-58.349)
|
90.4%(0.000)
|
|
Tigray
|
45.694%(37.297- 54.092)
|
96.4 %(0.002)
|
|
Other
|
39.228%(26.286-52.170)
|
97%(0.002)
|
|
Nationwide
|
35.282%(13.625-56.939)
|
99.3%( 0.001)
|
Publication
|
Published
|
43.217% (34.943-51.492)
|
98.2%(0.000)
|
|
Unpublished
|
56.200%(40.808-71.591)
|
95.9%(0.000)
|
Kangaroo mother care type
|
SSC only
|
46.572%(35.565-57.579)
|
98.6%(0.000)
|
|
SSC+BF
|
43.844%( 26.763-60.925)
|
98.6%(0.000)
|
Gestational age
|
Preterm
|
52.774%(41.867- 63.681)
|
96.3%(0.000)
|
|
Any age
|
38.675%(29.920 -47.429)
|
97.9%(0.000)
|
Birth weight
|
<1.5kg
|
57.372%(46.223 -68.522)
|
96.5%(0.000)
|
|
1.5-2.5kg
|
44.080%( 34.683-53.478)
|
90.3%(0.000)
|
|
Any weight
|
30.274%(23.871-36.677)
|
94.8%(0.000)
|
Publication bias
The presence of publication bias was checked using funnel plot visualisation and Egger’s and Begg’s regression tests (P<0.05). The Egger and Begg tests both revealed no statistical evidence of publication bias for a good level of knowledge (P=0.577 and P=0.240, respectively; Fig. 5). There was also no statistical evidence of publication bias for a positive attitude in terms of the Egger (P=0.928) and Begg (p=0.624) tests (Fig. 6). The results of the Begg (P=0.000) and Egger (P=0.000) tests show the presence of publication bias for the level of poor practice of kangaroo mother care. Additionally, an asymmetric distribution was visualised on the funnel plot (Fig 7). Subsequently, trim-and-fill analysis was performed and indicated the presence of seven unpublished studies (Fig. 8). A counter-enhanced funnel plot was also calculated, and the missing studies in the areas of higher statically significance suggested that the cause of asymmetry was due to factors other than publication bias, such as the study variables (Fig. 9).