The effects of ANC follow up on essential newborn care practices in east Africa: a systematic review and meta-analysis

In the situation of high maternal morbidity and mortality in Sub-Saharan Africa, less than 80% of pregnant women receive antenatal care services. To date, the overall effect of antenatal care (ANC) follow up on essential newborn practice have not been estimated in East Africa. Therefore, this study aims to identify the effect of ANC follow up on essential newborn care practice in East Africa. We reported this review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). We searched articles using PubMed, Cochrane library, African journal online (AJOL), and HINARI electronic databases as well as Google/Google scholar search engines. Heterogeneity and publication bias between studies were assessed using I2 test statistics and Egger’s significance test. Forest plots were used to present the findings. In this review, 27 studies containing 34,440 study participants were included. The pooled estimate of essential newborn care practice was 38% (95% CI 30.10–45.89) in the study area. Women who had one or more antenatal care follow up were about 3.71 times more likely practiced essential newborn care compared to women who had no ANC follow up [OR 3.71, 95% CI 2.35, 5.88]. Similarly, women who had four or more ANC follow up were 2.11 times more likely practiced essential newborn care compared to women who had less than four ANC follow up (OR 2.11, 95% CI 1.33, 3.35). Our study showed that the practice of ENBC was low in East Africa. Accordingly, those women who had more antenatal follow up were more likely practiced Essential newborn care. Thus, to improve the practice of essential newborn care more emphasis should be given on increasing antenatal care follow up of pregnant women in East Africa.

In developing countries, neonatal mortality has remained resistant to change 3,4 . About three-fourths of deaths among new-born occur in the first week of life, and 25-40% occurs in the first 24 h 5, 6 .
Most causes of neonatal death are preventable and related to cord care to decrease sepsis, temperature control by delaying first bath and initiation of early breastfeeding which has the additional benefit of controlling hypothermia [7][8][9][10] .
Essential Newborn Care (ENBC) utilization is one of the recommended strategies by World Health Organization (WHO) to reduce neonatal mortality and morbidity in both community and facility delivery 11 . ENBC practices include clean cord care, thermal care and initiating breast feeding immediately or within the first hour after birth 3,6,12,13 .
The Ethiopian government has paid special attention to the expansion of quality high impact neonatal interventions by establishing basic newborn care units in health centers and in hospital's neonatal intensive care units 14,15 .
Most newborn deaths occur at home in low-income countries including east African regions due to a lack of access to health care, a limited number of trained health care personnel, and an overall weak health system in the regions 16 .
Hence for safe home based deliveries new strategies should be developed. Thus, essential newborn care practice should be designed for neonates who cannot be managed at home in ensuring proper referral. Further, in domestic settings it would help as an appropriate means of the newborns care 17 .
In developing countries there is low level of adherence to essential new-born care practice despite this recommendation. Accordingly, reports from east African countries demonstrated the low level of essential newborn care practice 16,[18][19][20][21] . For example in Uganda early bathing and spread over materials on cord stump is a custom [21][22][23] . Similarly, studies done in different parts of Ethiopia also demonstrated the low level of utilization of essential new-born care 6,[24][25][26][27][28] .
In east Africa region the period after delivery is frequently noticeable by traditional practices. Bathing the baby immediately following delivery, applying diverse matters on the umbilical cord and giving various pre-lacteal feeds for the neonates were most important cultural performs hamper the health and survival of the newborn. Even if understanding these cultural practices is an essential part of confirming effective and timely newborn care; there is inadequate documented evidence in east Africa where sub-optimal newborn care practices has been widely described 3,29,30 .
Antenatal period (ANC) is one of the instruments to obtain reduction in neonatal mortality by counseling pregnant women to have access for essential newborn care practices preparing them to care for their newborn when they visit health facilities and during home visits made by community health workers 3,31 .
Various studies have assessed factors affecting essential newborn care utilization in East Africa 6,24-28 . But none of them identified the pooled effect of ANC on essential new born care use in East Africa. Therefore, this meta-analysis summarizes the effect of ANC on essential newborn care practice among women in East Africa systematically and quantitatively. Thus, the findings will help to determine how much of an impact have antenatal care follow up on essential newborn care practice in East Africa. In addition, this study provides comprehensive information for policy makers and program managers to design strategies that increase the utilization of essential newborn care.

Methods
Searching strategies. This systematic review has been prepared according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guideline 32 . The systematic review was registered on the PROSPERO prospective register of systematic reviews (registration number: CRD42020207894).
We searched articles using PubMed, Cochrane library, African journal online (AJOL), and HINARI electronic databases as well as Google/Google scholar search engines.
A medical subject head (MeSH) and keyword items was used in separate and combination using Boolean operator: "OR", "AND" or "NOT" in order to identify relevant articles. Thus, searches was conducted using Keywords/search terms like "Prevalence", "proportion", "magnitude", "essential", "essential newborn care" "newborn", "neonatal care", "newborn care", "utilization", "services", "practices", "Antenatal care", "prenatal care", "maternal health care", "delivery care", "East Africa". Inclusion criteria's. Study design and period: all observational studies conducted in East Africa published until September, 2020 were included in this review and meta-analysis.
Participants: women who delivered either in the health facility or at the home. Setting: All community-based and facility-based studies reported ENBC utilization and ANC follow up. Language: Articles published in English language. Exposure: ANC follow up. Outcome: Essential newborn care (ENBC) utilization/practice. We excluded Primary studies inaccessible for full-text article after 2 times author request. In addition, those articles published in non-English languages were also excluded from this review and meta-analysis. Three reviewers (ETA, MY, BK) independently extracted the data and any disagreements between the reviewers were solved through consensus. For incomplete data, we excluded the study after attempts to contact the corresponding author through email.

Data extraction and synthesis.
The quality of the studies was assessed using Joana Briggs Institute (JBI) adapted for observational studies by 2 Authors (MA, WM) before analysis and any discrepancy was resolved by discussion and consensus 33,34 . Heterogeneity and publication bias. We identified the heterogeneity between the studies using I 2 statistics and P values 35 . A forest plot was used to detect the presence of heterogeneity. Furthermore, subgroup analysis and meta-regression was used to identify the possible source of heterogeneity.
To check publication bias, both objective and subjective (funnel plot) methods were used. The presence of publication bias was checked using subjective method (funnel plot) symmetry. In addition, the statistical significance of publication bias was assessed using objective method s Egger's and Beggar's test (P < 0.05) 36,37 . Statistical analysis. After extracting the data, we imported into STATA Version 14.0 statistical software for further analysis. The analysis to identify the effect of ANC follow up on essential newborn care service use was categorized into two parts. The first analysis was to identify the effect of one or more ANC visits on essential newborn care service use and the second was an analysis of the effect of four or more ANC visits on essential newborn care service use. A random effects meta-analysis model was employed to estimate the DerSimonian and Laird's pooled effect because of high levels of heterogeneity 38 . The results were presented in tables and forest plot.

Results
Study selection and screening. As described in Fig. 1 a total of 741 records were retrieved through database searching. Of this 20 articles were removed due to duplication and about 681 articles were removed after reviewing their title and abstracts. About 40 articles were selected for full text review. From these, 5 studies were excluded for not reporting the outcome variable, 5 studies by the study design, and 3 studies by quality of the study. Finally, 27 articles met the eligibility criteria included in the final Meta-analysis ( Fig. 1 (26) were cross-sectional. From a total of 27 articles included in this review, about 17 of them were community-based and the remaining 10 were institutional-based studies ( Table 1). The quality of the studies was assessed using Joana Briggs Institute (JBI) adapted for observational studies by independent evaluators before analysis. We included those studies that fitted to 50% and above the quality assessment checklist. Hence, the results of quality assessment ranged from 60 to 80% and all studies were fit for analysis (Table 1).

Meta-analysis.
In this review and meta-analysis about 27 studies were included to estimate the pooled estimate of essential newborn care practice among women in East Africa. The level of essential newborn care practice was ranged 1.17-92.91% from the included studies (Fig. 2). As illustrated in Fig. 2, the overall pooled estimate of essential newborn care practice was 38% (95% CI 30.10-45.89). In this study, I 2 statistic was detected considerable and significant heterogeneity between studies (I 2 = 99.7, P value < 0.0001). Therefore, a random effect model was used to estimate the overall pooled prevalence of essential newborn care practice in East Africa.
We conducted meta-regression using different factors to identify the possible source of heterogeneity between studies. But, there was no statistical significance variation from the meta-regression result. In addition, subgroup analysis was conducted to explore the source of heterogeneity in Essential newborn care practice using different factors included in the study. But, no significant change was seen as compared with the main meta-analysis. Hence, the heterogeneity might be explained by other covariates which are not included in this study.
Furthermore, a sensitivity analysis was done to identify influential studies. According to the analysis, all of the studies were included in the final analysis since no influential studies were detected.
Publication bias. We have checked publication bias of the included studies using Funnel plot and egger tests. Accordingly, Egger's test showed no statistically significant publication bias (P = 0.64). As depicted in Fig. 3 the funnel plot has also indicated the absence of publication bias since studies represented by dots were asymmetrical (Fig. 3). cross-sectional studies to estimate the effect of ANC follow up on essential newborn care practice in east Africa. The participants of the studies ranged from 417 to 834 ( Table 2). The included studies showed significant heterogeneity and detected using I 2 statistic (I 2 = 74.0%, P value = 0.002) (Fig. 4). Therefore, a random effect model was used to estimate the overall pooled effect of ANC follow up on essential newborn care in the study area.    www.nature.com/scientificreports/ As described in Fig. 4 the random effect model analysis showed, women who had one or more antenatal care follow up were 3.71 times more likely practiced essential newborn care compared to mothers who had no ANC visit [OR 3.71, 95% CI 2.35, 5.88] (Fig. 4).   (Table 3).
Significant heterogeneity was observed between studies and detected using I 2 statistic (I 2 = 68.1, P = 0.024) (Fig. 5). Thus, a random effect model was used to estimate the pooled effect of four and more ANC follow up on essential newborn care practice in the study area ( Table 3).
The pooled effect of 4 studies revealed having four or more ANC follow up was significantly associated with essential newborn care practice in East Africa. Figure 5 illustrated women who had four or more ANC follow up were 2.11 times more likely practiced essential newborn care compared to women who had less than four ANC follow up (OR 2.11, 95% CI 1.33, 3.35).

Discussion
Antenatal care has been used as a strategy to reduce maternal and newborn morbidities and mortalities. In developing countries, different strategies have been implemented to improve the effectiveness of Antenatal care. Nowadays, most developing regions including East African regions used the focused ANC approach which was developed by WHO 39,40 . Thus, this systematic review and meta-analysis aims to estimate the pooled prevalence of newborn care practice and identify the effect of ANC follow up on essential newborn care practice among post-partum women in East Africa.
This review study estimated that the level of Essential newborn care practice among postpartum women in East Africa was 38%. This finding was lower as compared to a meta-analysis done in Ethiopia about 48.77% 7 , Nepal about 70.7% 41 , and India about 66.70% 42 . The possible justification for the discrepancy may be due to differences in socio-economic, differences in socio-cultural aspects, differences in study setting, and differences in sample size. In addition, the discrepancy may be due to the variation in maternal health services coverage across countries based on increased awareness and information about ENBC utilization.
This study revealed that women who attended antenatal care were more likely practiced essential newborn care in the study regions.
Concordant to this result there was a report from low income country 43 and Northern Ghana 44 . This could be related that mothers who visited Antenatal care follow up had an opportunity of obtaining health workers information about the importance of newborn care practice through attending health facilities. Further, Antenatal care has a positive association with essential newborn practices including clean cord care and thermal care 44 . Furthermore, during immediate ANC visits they told from health professional about essential newborn care practice that helps to provide appropriate and timely periodic advice consult which would in turn increases the utilization newborn care 45 .
This review and meta-analysis had using large sample size, which meant that it could detect the effect of ANC on essential new born care practice. However, the study does not address other factors that influence essential newborn care practice.
This research is important for understanding the effect of ANC follow up on essential newborn care practice in East Africa. The finding is also relevant for policymakers to establish criteria for improving the quality of maternal and newborn care in East Africa.

Conclusion
This meta-analysis revealed that Essential newborn care practice among women in East Africa was low. Women who had one or more antenatal care follow up were more likely practiced essential newborn care in East Africa. Thus, women who attend four or more Antenatal care visits were more practiced essential newborn as compared to those who have less than four follow ups in the study area. Therefore, the governments and concerned bodies should give special attention to increase Antenatal care follow up of women to improve essential newborn care use. License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/.