Knowledge, attitude and practice towards kangaroo mother care among postnatal women in Ethiopia: systematic review and meta-analysis

Abstract

Background: Kangaroo mother care is a key procedure in reducing neonatal mortality and morbidity associated with preterm birth. In Ethiopia, neonatal death remains a serious problem, and this study aims to determine the prevalence of the knowledge, attitudes and practice of kangaroo mother care among Ethiopia women.

Methods: PubMed, Web of Science, Google Scholar, EMBASE and the Ethiopian University online library were searched. Data were extracted using Microsoft Excel and analysed using STATA statistical software (v. 11). Publication bias was checked by forest plot, Begg’s rank test and Egger’s regression test. To look for heterogeneity, I² were computed and an overall estimated analysis carried out. Subgroup analysis was done by region, study setting, publication, gestational age, birth weight and component of kangaroo care. The Joanna Briggs Institute risk of bias assessment tool was used. We carried out a leave one out sensitivity analysis.

 Results: Out of 273 articles retrieved, 16 studies met the eligibility criteria and are thus included in this study. Those 16 studies had a total of 12,345 respondents who reported kangaroo mother practice, with five (comprising 1,232 participants combined) reporting that both knowledge and attitude were used to determine the overall estimation. The pooled estimates of good knowledge, positive attitude and poor practice of kangaroo mother care were found to be 64.62% (95% CI: 47.15%–82.09%; I² = 97.8%), 61.55% (49.73%–73.38%; I² = 94.8%) and 45.7% (95% CI: 37.23%–54.09%; I² = 98.5%), respectively. This study is limited to postnatal women and does not take account their domestic partners or health providers.

Conclusion: The findings revealed significant gaps in the knowledge, attitudes and practice of kangaroo mother care in Ethiopia when compared with other developing countries. Therefore, kangaroo mother care training to women, along with further studies on domestic partners and health providers.  

Introduction

Low birth weight and preterm birth represent the two major public health challenges during the neonatal period (1). During this period, 36% of deaths occur on the day of birth, while 73% occur within the first week of life (2).In addition, More than 80% of neonatal deaths occur in low birth weight neonates two-thirds of whom were are born prematurely(3). Complications related to prematurity are the major cause of neonatal mortality (4). Worldwide, 25 million babies are born a low birth weight annually while 15 million are born prematurely with 96% of these preterm babies occurring in developing countries (5, 6).In Ethiopia, systematic review and meta-analysis studies have reported the pooled prevalence of preterm birth(to be 10.8%), and that of low birth weight(to be 17.3%) (7, 8).

Due to the prevalence of preterm births and low birth weight, as well as associated health care burden, comprehensive interventional procedures for primary prevention are required such as Kangaroo Mother Care (9).According to the world health organization (WHO), kangaroo mother care involves an early, uninterrupted, and prolonged skin–to–skin contact between mother and the baby (10). Although kangaroo mother care is recommended by World Health Organization, Baby Friendly Initiatives, United Nation International Children Emergency Fund, and American Academy of pediatrics, the prompt separation of the baby from the mother after birth remains a significant challenge (11–14).

Several studies have reported that kangaroo mother care to be a cost-effective intervention for reducing mortality and morbidity in preterm infants (15). It has also been found to have a positive impact on maternal health in low, middle, and high-income countries (16–22). In fact, studies have shown that kangaroo mother care reduced neonatal mortality (17, 23), sepsis (17, 23), hypothermia(17, 23), hypoglycemia(23), and length of hospital stay (17) when compared with conventional care approaches.

The findings of a number of systematic review studies have indicated that kangaroo mother care increased the success, initiation, and duration of breast feeding (24–29). Moreover, it has also been found to improve maternal anxiety and stress( 30), enhanced-cognitive and motor development ( 31),reduce the likelihood of hospital readmission (32, 33) and lowered the premature infant profile(34). Another study reported that Kangaroo mother care improves the growth of low birth weight and preterm infants (35–41).

In Ethiopia, kangaroo mother care was first introduced in 1996 at Black Lion Hospital in Addis Ababa. Since then the service has been expanded to other health facilities and hospitals. In addition, the Federal Ministry of Health has integrated kangaroo mother care into National Strategy for Newborn and Child Survival, Health Sector Transformation Plan, and National Health Care Quality Strategy with the later focusing on ensuring that 80% of preterm babies to receive kangaroo mother care, although initiation currently remains low (42–44). Moreover, the neonatal mortality rate in Ethiopia is 30 per 1000 live births, which means that the problem remains significant (45). By the end of 2030, Ethiopia aims to have lowered the neonatal mortality rate to 12 deaths per 1000 live births (46). To help achieve this target, Kangaroo mother care is expected to play a significant role in anticipating neonatal hypothermia (11).

The prevalence of kangaroo mother care has been determined to range from 1% in Tanzania (47) to 96% in Denmark (48). In Ethiopia, knowledge of kangaroo mother care has been found to range from 35.5–82.53% (49–53), attitude from 50–82.53% (49–53) and practice from 23–83% across the nation (49–64). Given these variations, there is no overall estimate of the prevalence of kangaroo mother care based on representative national data in Ethiopia. Therefore, the present study sought to determine the pooled prevalence of knowledge, Attitude, and practice regarding of kangaroo mother care among postnatal women in Ethiopia. The aim was to provide fundamental data for policymakers, clinicians, and other stakeholders in order to help develop an appropriate strategies and interventions for the control and management of low-birth weight and preterm birth using kangaroo mother care.

Methods

Results

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.

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

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 

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).

Discussion

Kangaroo mother care was first introduced in Ethiopia in 1996 at the Black Lion Hospital in Addis Ababa. Since then, kangaroo mother care services have expanded to other hospitals and health facilities at all levels. Nowadays, they have been issued in a series of policy documents by the Federal Ministry of Health, the New born and Child Survival Strategy 2015–2020, the Health Sector Transformation Plan, and the National Healthcare Quality Strategy. Despite a governmental emphasis on reducing neonatal mortality via evidence-based strategies such as kangaroo mother care, Ethiopia is one of the sub-Saharan African countries with the most neonatal mortalities.

Due to the scant availability of literature, we conducted this systematic review and meta-analysis to better understand the knowledge, attitudes and practices among Ethiopian women. We included all available studies using a variety of electronic search engines and were also able to undertake a sub-group analysis assessing the proportion of knowledge, attitudes and practices by study setting, study region, gestational age, component of kangaroo mother care, birth weight and publications.

This study’s findings reveal that the pooled prevalence of good kangaroo mother care knowledge was 64.62%. This is lower than the results of a study conducted in the USA (75%) among nurses working in intensive care units (66). This inconsistency can be attributable to existing socio-economic, healthcare system infrastructure, study population variation, and methodological differences (including study design) across the studies. The sub-group analysis, based on components of kangaroo mother care, showed that participants were more knowledgeable concerning skin-to-skin contact only compared to both skin-to-skin contact and exclusive breastfeeding. This finding is not surprising because exclusive breastfeeding has received much attention lately.

More than half (61.5%) % of women who gave birth in Ethiopia had a positive attitude towards kangaroo mother care. This finding is consistent with a US result, which showed that over 60% of respondents had a positive perception of kangaroo mother care (66). The sub-group analysis also revealed that participants had a positive attitude towards skin-to-skin contact only over both skin-to-skin contact and exclusive breastfeeding, which might be due to the lack of long-term exposure to exclusive breastfeeding.

The pooled level of poor kangaroo mother care practice was 45.7%. This was relatively lower than the findings of studies conducted in New Zealand (69%) and Singapore (92%) (67, 68). One conceivable clarification for the disparity is the methodological differences, such as study design and socio-cultural difference, between the countries, which, in turn, affect the practice of kangaroo mother care. Furthermore, Ethiopia is a third-world country with a poor economic status and poor maternal and paediatric health coverage, along with low levels of skilled deliveries. The sub-group analysis showed that poor practices were observed in the community-based study, skin-to-skin contact and exclusive breastfeeding (at any weight or gestational age); in contrast, a high level of practice was reported in Addis Ababa. This indicates the significance of kangaroo mother care for very-low-birth-weight, low-birth-weight and preterm neonates, as well as the need to enhance the procedure at the community level. Regarding region, Addis Ababa had a greater share of kangaroo mother care practice, which might be due to the adaptation of the procedure by both mothers and healthcare providers for a long time since its introduction at the Black Lion Hospital (one of Ethiopia’s earliest specialised hospitals), located in Addis Ababa, Ethiopia.

In this study, we utilised a random-effect model to manage a significant variation that resulted in between-study heterogeneity. We assessed leave-one-out sensitivity and the results show that every study had a significant impact on the pooled good level of knowledge, positive attitude, and poor level of kangaroo mother care practice. We also assessed the possible variability source via sub-group analysis using the study settings, regions, publications, gestational ages, birth weights and components of kangaroo mother care. The high heterogeneity might be due to differences in the sample populations, paper qualities, or socio-cultural, ethnic and regional differences.

Conclusion

In conclusion, this systematic review and meta-analysis reported that there was a significant gap in knowledge, attitudes, and practices of kangaroo mother care among Ethiopian women. Besides, the pooled prevalence of knowledge, attitudes, and practices differed based on the study settings, regions, publications, gestational ages, birth weights and components of kangaroo mother care. The information generated from these findings should be used for the provision of accurate and up-to-date training and education of kangaroo mother care. Accordingly, it is better to have periodic kangaroo mother care training for postnatal women and, subsequently, expand service dimensions across the community level.

Declarations

Acknowledgments

Not applicable.

Authors’ contributions

 NA conceived and designed the study. NA and KA established the search strategy.NA, GA, and EA did the statistical analysis of this research.   NA, KA, GA, BA, GA, and EA wrote the review. All the authors read the manuscript before they have given the final approval for publication.

Authors’ information

NA: School of Midwifery, College of Medicine and Health Sciences, Wolaita Sodo University, Sodo, Ethiopia.

KA: School of Midwifery, College of Medicine and Health Sciences, Wolaita Sodo University, Sodo, Ethiopia 

GA: School of Midwifery, College of Health Science and Medicine, Wolaita Sodo University, Wolaita Sodo, Ethiopia

BA: Department of Anesthesia, College of Health Science and Medicine, University of Gondar, Gondar, Ethiopia

EA: School of Nursing, College of Health Science and Medicine, Wolaita Sodo University, Wolaita Sodo, Ethiopia

GA:School of Public Health, College of Health Science and Medicine, Wolaita Sodo University, Wolaita Sodo, Ethiopia

Funding

The authors received no specific funding for this work.

Availability of data and materials

  All data generated or analyzed during this study are included in this published article.

Ethics approval and consent to participants

Not applicable because no primary data were collected.

Consent for publication

Not applicable.

Competing interests

The authors declared that they have no competing interests.

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