Selection of included studies
There were 273 research articles retrieved using electronic search. Of these articles, 117 were expelled since 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 studies 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 name, 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 had listed out 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 Gumize (63). All were cross-sectional studies. Of the total of sixteen studies, twelve were institutional-based studies, but four were community-based studies. The earliest study was conducted in 2014 and the latest was conducted in 2021. The sample size 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 percent to 100 percent. Eight studies were done with any gestational age (preterm, term, and post-term) infants whereas the remaining was done only on preterm infants.
All selected studies were evaluated for methodological quality based on The Joanna Briggs Institute (JBI) cross-sectional quality assessment method. All sixteen studies were included based on the quality assessment criteria. All of these studies had reported a low risk (Table 1).
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
|
Health center
|
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/unpublished
|
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 /unpublished
|
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 /unpublished
|
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 reported
|
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 knowledge, practice, and attitude towards kangaroo mother care in Ethiopia is presented by the forest plot (Figs. 2–4). By using the random-effect model, the pooled level of good knowledge was found in 64.62% (95% CI: 47.15%-82.09%; I2 = 97.8%). The overall estimated positive attitude towards kangaroo mother care was found in 61.55 % (49.73–73.38%; I2 = 94.8%). The pooled estimate of poor practice towards kangaroo mother care among postnatal women was found in 45.7% (95%CI: 37.297–54.092%; I2 = 98.5%) (Fig. 2).
Leave out-one sensitivity analysis
A leave-out-one sensitivity analysis was done to detect the effect of each study on the overall all prevalence of good level of knowledge, positive level of attitude, and poor level of practice of kangaroo mother care of postnatal women by excluding each study step by step. The result showed that the excluded study brings significant change to the overall prevalence of a good level of knowledge, positive attitude, and poor practice. In the sensitivity analysis, both Jamie, A H. and Mose et.al had shown an impact on the pooled level of good knowledge and positive attitude whereas Lakew B. and B.Worku and Gebre et.al had an impact on the level of poor practice towards 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 type showed that the level of good knowledge was found 74% in only skin-to-skin contact and 51.2% in skin-to-skin contact with exclusive breastfeeding practice. The level of positive attitude towards kangaroo mother care type was found to be 67.98% in skin-to-skin contact only and 51.85% in both skin-to-skin contacts with exclusive breastfeeding practice. In this subgroup analysis, the level of poor practice was done by study region, study setting, publication, type 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 single study was done in single region/multiple regions). In the case of kangaroo mother care type, the prevalence of poor practice was found in 46.57% in only skin-to-skin contact practice and 43.84% in the skin-to-skin contact with exclusive breastfeeding. Regarding gestational age, the level of poor practice of kangaroo mother care was found to be 52.77% in the preterm neonate and 38.68% in any gestational age. The level of poor practice towards birth weight was 57.37% in birth weight less than 1.5Kg, 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 by using funnel plot visualization and Egger test and Begg’s regression test at p-value < 0.05. Egger test and Begg test showed that there was no statistical evidence of publication bias for a good level of knowledge (p = 0.577 and 0.240) respectively (Fig. 5). There was also no statistical evidence of publication bias for a positive attitude with the Egger test (p = 0.928) and Begg test (p = 0.624)(Fig. 6). The results of Begg’s test (P = 0.000) and Egger's test (p = 0.000) showed the presence of publication bias for the level of poor practice of kangaroo mother care. In addition, asymmetric distribution was visualized in the funnel plot (Fig. 7). Subsequently, trim and fill analysis was done and indicated the presence of seven unpublished studies (Fig. 8). The counter-enhanced funnel plot was also done and the missing studies were in the areas of higher statically significance suggested that the cause of asymmetry was due to factors other than publication bias such as variables in the study (Fig. 9).