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Health Professional Assisted Kangaroo Mother Care Practice in Ethiopian Health Facilities: Evidence from the 2016 Ethiopian Demographic and Health Survey Data

Background Worldwide, 15 million babies born prematurely every year and over one million babies died because of premature birth complications. However, three-fourths of deaths from preterm birth complications are preventable without intensive care units. One of the prevention methods is Kangaroo Mother Care, which is a method of holding a small neonate in skin-to skin contact, upright prone position on the maternal chest. An evidence stated that KMC can prevent up to half of all deaths in babies weighing <2000 gm at birth. Ethiopian guidelines also mentioned that all LBW babies need to receive KMC. The aim of this study was to assess health professional assisted Kangaroo mother care practice and association among mothers who gave birth in a health facility in Ethiopia. Methods This study produced from the 2016 Ethiopian Demographic and Health Survey data (EDHS). The 2016 EDHS used a stratied two stage sampling method to select a representative sample for the country, Ethiopia. According to the 2016 EDHS data, all the regions were stratied into urban and rural areas. The study sample rened from EDHS and used in this secondary analysis is 2,760 mother-child pairs. A logistic regression model was used to assess the associations with the size of a child at birth. Results mothers who gave birth in a health facility and practiced kangaroo mother care were 1808 (62.1%), 95% CI (60,3, 63.9).The others 1102(37.9%), 95%CI(36.1, 39.7) of mothers did not practiced KMC, although they were gave birth in health facilities under the support of trained health professionals. In the multivariable logistic regression analysis, only wealth index, poorest ((AOR), (95%CI)), ((0.60), (0.43, 0.81)), and poorer ((0.62), (0.46, 0.86)) were associated with health professionals assisted KMC practice.

Ethiopia. According to the 2016 EDHS data, all the regions were strati ed into urban and rural areas. The study samples used in this secondary analysis is 2,760 mother-child pairs. A logistic regression model was used to assess the associations with the size of a child at birth.

Article Summary
Strengths This is the rst study that assessed the impact of health professionals on increasing KMC practice in health facilities

Limitations
It consider only mothers who were under the follow up of a professional and might decrease the prevalence of KMC Through exhaustive screening or selecting case, the sample size become too small Background Worldwide, 15 million babies born prematurely every year and over one million died because of premature birth complications (1). Preterm birth (birth before 37 completed weeks of gestation) is the direct and leading cause to three million neonatal deaths each year and the second leading cause of all deaths in under-ve children globally (2,3). However, three-fourths of deaths from preterm birth complications are preventable without intensive care units (4). Neonatal period by itself presents the greatest risk of death, which is exacerbated for preterm newborns as they have less physiological reserve, have greater challenges in temperature regulation, have immature organs, have poor immune function, and heightened vulnerability to severe infections putting them at risk for problems associated with the transition to extra uterine life (5,6). Because of these and many other reasons, neonatal health begun to emerge as a global and national public health priority, especially through attention to child survival in the Millennium Development Goals (7), which contribute more to emphasize on Kangaroo Mother Care (KMC). Kangaroo Mother Care is a method of holding a small neonate (< 2000 gm) in skin-to skin contact (STS), prone and upright on the maternal chest. The neonate is enclosed in maternal clothing for thermal regulation (8).
KMC is an evidence-based inpatient care technique for premature and low-birth weight (LBW) baby when he/she weigh less than 2000 gm (9,10). It is an easily available and biologically sound method of care for all newborns, but in particular for premature babies (11). The clinical e cacy and health bene ts of KMC to preterm and low-birth weight babies (< 2000 gm) has been widely demonstrated. According to a study, KMC can prevent up to half of all deaths in babies weighing < 2000 gm at birth (10). According to Ethiopian and World Health Organization (WHO) guidelines, all LBW babies need to receive KMC. But, sick and very small neonates should initially be cared in a radiant warmer and KMC would be initiated once the baby is thermodynamically stable (12). However, KMC may use in economically challenged countries like Ethiopia where access to conventional services of incubators is limited or too expensive for the general population (13). KMC is a strategy to decrease neonatal mortality in Ethiopia as stated in the HSTP, but only 46.4% of eligible babies were received KMC (14). This indicated that the coverage of KMC has remained low and its implementation has largely been limited to specialized hospitals (15,16).
However, KMC shorten hospital stay and create opportunities for teaching mothers and assessing the progress, and means for better use of health care (10,(17)(18)(19). Furthermore, a study indicated a difference in between health facilities on practicing KMC in the country, Ethiopia (20). Unlike Ethiopia, KMC has been widely implemented in western and some African countries including Nigeria, Madagascar, Malawi, Ghana, Indonesia (21,22) and South Africa (23). Thus, the aim of this study was to assess health professional assisted Kangaroo mother care practice and association among mothers who gave birth in health facilities in Ethiopia.

Methods
Data collection period, study design, and data collection procedure The data collection period for the 2016 EDHS was from January 18 to June 27, 2016. The 2016 Ethiopian Demographic and Health Survey (EDHS) data was used for this further analysis. The 2016 EDHS data was the fourth survey conducted in Ethiopia. The survey collected information on household's and respondent's characteristics, child health, infant and child mortality, malaria, maternal health, maternal mortality, nutrition, tobacco use, women's empowerment, anemia, domestic violence, environmental health, family planning, female genital cutting, fertility and fertility preferences, and etc. The purpose of the EDHS is to provide up-to-date estimates of the key demographic and health indicators of the population (24). The survey included reproductive age group women, under-ve children, and productive age group men (aged 15-59 years) (24,25) Sampling technique and study population The 2016 EDHS data was collected using a strati ed two stage sampling method to select a representative sample. All the regions of the country were strati ed into urban and rural areas. From all the 11 administrative states, 21 sampling strata were yielded. The samples of enumeration areas (EAs) were selected independently in each stratum at two stages. The implicit strati cation and proportional allocation were achieved at each of the lower administrative levels by sorting the sampling frame within each sampling stratum before sample selection according to the administrative units in the different levels, and by using a probability proportion to size selection at the rst stage of sampling. For the 2016 EDHS data collection, 645 EAs were selected with a probability proportional to the EA size and with independent selection in each sampling stratum. The EA size is the number of residential households in the EA that was determined in the 2007 Ethiopian Population and Housing Census. According to the 2016 EDHS procedures, a household listing operation was implemented in the selected EAs, and the resulting lists of households served as the sampling frame for the selection of households in the second stage.
The data collectors interviewed only the pre-selected households. In the EDHS, there were no replacements or changes of the pre-selected households in the implementing stages to prevent bias. All the under-ve children, who were usual members of the selected households or who spent the night before the survey in the selected households were eligible for the child survey (25). After managing the missing data, 2910 respondents that had under-ve children were included for this further analysis.
However, the 2016 EDHS data collected data from 10641 children.

Data collection tools and procedures
The 2016 EDHS usually use ve groups of questionnaires in collecting the data. Those questionnaires are the Household questionnaire, the woman's questionnaire, the man's questionnaire, the biomarker questionnaire, and the health facility questionnaire. The questionnaires were adapted from the DHS program's standard demographic and health survey questionnaires in a way to re ect the population and health issues relevant to Ethiopia. Questions that stated about children were integrated to woman's questionnaire.
Variables The outcome variable of this further analysis was health professional assisted KMC. The independent variable were socio-demographic variables of both children and mothers, health services

Health professional assisted KMC
The prevalence of health professional assisted KMC practice among mothers who gave birth in a health facilities were 1808 (62.1%), 95% CI (60,3, 63.9).The others 1102(37.9%), 95%CI(36.1, 39.7) of mothers did not practiced KMC, although they were gave birth in a health facilities under the support of trained health professionals.

Discussions
The aim of this study was to assess the practice and association of Kangaroo mother care among mothers who gave birth at health facilities in Ethiopia. The practice of KMC among mothers who gave birth in the health facilities was 1808 (62.1%), 95% CI (60,3, 63.9).The others 1102(37.9%), 95%CI(36.1, 39.7) of mothers did not practiced KMC while they were in health facilities, although they gave birth in a health facilities too. The current study's level of KMC practice is higher than studies that reported 41.9% KMC (26), 46.4% KMC, 54.15% KMC (27), and 28.1% KMC (28). The difference might be as a result of study population difference, sample size difference, eligibility criteria, and socio-demographic difference. Our study considered only mothers who followed by health professionals starting from before birth, during birth, and till post-partum. However, all the referred papers included mothers who visited health facilities in post-partum irrespective of their place of birth. The present study reported a lower KMC practice than a study reported from Ghana that was 84.6% (29). This variation might be because of sociodemographic difference between Ghana and Ethiopia. In addition, the health care service provided in Ghana might be better than in Ethiopia. Furthermore Ethiopia integrated KMC to the National Strategy for Newborn and Child Survival lately in 2015/16 than Ghana that started some years before Ethiopia (30).
The current study have a similar KMC practice with a study that conducted from Ghana, home based KMC practice (29), and other study that reported 61.6% (31). This also re ects the socio-demographic difference between the study areas, Ethiopia and Ghana. Because the KMC practice in the Ethiopian health facilities become equal with Ghanaian Home based KMC practice. In assessing the association of KMC and determinates, religion, residence, wealth index, maternal education, and birth weight were associated with health professional assisted KMC practice at binary logistic regression model. However, in the nal model, logistic regression, only wealth index was associated with health professional assisted KMC practice. Mothers who had poorest ((AOR), (95%CI), ((0.60), (0.43, 0.81) and poorer ((AOR), (95%CI), ((0.62), (0.46, 0.86) wealth index were more prone to practice KMC than mothers from richest households. However, a study from Aksum, Ethiopia reported the lack of association between neonatal care, KMC practice and wealth index (32). The difference in these studies might be as a result of study area variation. Our study derived from EDHS, in which both urban and rural areas represented proportionally. However, the study from Aksum considers only urban residents, who might have similar degree of economic class. This positive as

Conclusions
The prevalence of health professional assisted KMC practice was low, which was far lower than the expectation for mothers who gave birth in health facilities. The lowest wealth index was protective for not practicing KMC. The reason might be that mothers from higher income households might not initiate breast feeding, which might contribute for not practicing KMC. Thus, the minister of health or other researchers should study further why mothers from high income did not practicing KMC in considering the assumption of this author.

Limitations
Some of the variables were excluded while managing the missing values. Due to this, the sample size was small that might compromise the inclusiveness of this research. The raw materials that support the conclusions of this research can be uploaded as a supplementary le together with the manuscript documents.

Competing interests
The authors have no con ict of interests Funding Not applicable Author's contribution For this study MWK, SAM, AMA, AMK, and BBA Conceived the title and designed the study, preparing a complex data for analysis, analyzing the complex data, critically revising the work and writing the nal manuscript. All the authors read and approved the nal version of this manuscript. The authors agreed to be accountable for all aspects of this work.