KNOWLEDGE, ATTITUDE AND PRACTICE OF KANGAROO MOTHER CARE AMONG POSTNATAL MOTHERS IN A TERTIARY CARE CENTER OF HARARI REGION, HARAR, ETHIOPIA

Background: Kangaroo Mother Care (KMC) is a method was invented by Dr. Rey in 1978 and developed by Dr. Martinez and Dr. Navarrete until 1994. It is holding a small nappy neonate in skin to skin contact, prone and upright on the maternal chest. At first it was developed to alleviate overcrowding, and insufficient resources in neonatal intensive care units. But today it is formally approved by WHO. Objective: The aim of this study was to assess knowledge, attitude and practice of Kangaroo mother care among postnatal mothers in a tertiary care center of Harari region, Harar, Ethiopia, 2020. Method: An institution based cross-sectional study method was conducted in Hiwot-Fana Specialized Referral Hospital in Harar town. Sample size was calculated by using single population proportion sample formula and the final sample size was 166. The study subject was selected by using consecutive sampling method, and adopted data collection tool was used. Data were analyzed using SPSS version 20. Descriptive analyses were performed and bivariate analyses were used to find out the association of independent variables. Results: There was 82.53% of mothers had good knowledge, 82.53% had positive attitude towards KMC, 32.12% practiced KMC correctly. The participants also reported the benefits of KMC, such as protection from infection, warmth to the baby, exclusive breast feeding, weight gain and growth, early discharge from hospital, safety and love. Conclusion: The finding of this study showed that there was a clear gap in knowledge and practice. Therefore, it is very important to have health education sessions during ANC follow-up on KMC. A qualitative research to explore temporal relationship is also recommended.


BACKGROUND
Kangaroo Mother Care (KMC) is a method was invented by Dr. Rey in 1978 and developed by Dr. Martinez and Dr. Navarrete until 1994. It is holding a small nappy neonate in skin to skin contact, prone and upright on the maternal chest. At first it was developed to alleviate overcrowding, and insufficient resources in neonatal intensive care units. But today it is formally approved by World Health Organization (WHO, 2003).
The key components of kangaroo mother care are skin-to-skin contact of the infant on the mother's chest, optimal breast feeding and support to the mother and infant. It has more advantages over usual new born care for mother and infant, such as effective body temperature control, exclusive breastfeeding, preventing infection, motherinfant bonding, early discharge, decreased mortality and morbidity. It is also an answer to the separation of mothers and infants (Conde-Agudelo & Díaz-Rossello, 2016;M Ludington-Hoe, 2011;Nyqvist et al., 2010).
Globally, each year nearly 7.7 million children under five years die; among this, about 3.1 million of the newborns die during the neonatal period and almost all (99%) deaths occur in the developing countries (Rajaratnam et al., 2010). World Health Organization estimation, neonatal deaths account for 45% of the under-five deaths (WHO, 2017). Three-quarter of the neonatal deaths takes place in the first seven days of birth and one-third of deaths take place in the first 24 h of birth (Akter, Dawson, & Sibbritt, 2016;Lawn, Cousens, Zupan, & Team). The three leading causes of neonatal mortality and morbidity worldwide are infections (35%), preterm birth and LBW (28%) and asphyxia (23%) (WHO & UNICEF, 2009).
Globally, babies with low birth weight accounts 25 million and preterm accounts 15 million nearly all of them (96%) are in developing countries. Africa accounts the world's population of 12% and 25% of the world's new-born deaths takes place there (WHO, 2003;WHO & UNICEF, 2004).
The implementation of KMC also focuses on the decision-making process not depends only on the mother's desire and willingness, but also on the support provided by the family members as well as kindhearted health care teams (Chisenga, Chalanda, & Ngwale, 2015).
Study showed that only about 10% to 25% of preterm and/or low birth weight babies receive KMC in Ethiopia between 2015-2017, the estimates was derived from an assessment that was conducted in two hospitals that were providing KMC services in Ethiopia, after training; these hospitals provided KMC services to 36% of preterm babies (Lakew & Worku, 2014). Mothers are the main caregiver to newborns hence the care is habitually dependent on their level of knowledge, attitude, and practice (KAP) about newborn care. Therefore, this study aimed to study the KAP of mothers about KMC.

Study Setting and Participants
Cross-sectional study was conducted from 1 March to 30 March 2020 in HiwotFana Specialized University hospital located in Harar, Ethiopia. Harar is located at eastern direction of 526 km away from the capital Addis Ababa. HiwotFana Specialized University hospital is one of the specialized university hospitals in the country which was established in 2006 and providing service for more than 5 million people in the catchment area.

Sample Size Determinations and Sampling Techniques
Sample size was calculated by using single population proportion formula by taking 19.53 % from a similar study (Jamie & Ahmed, 2020). Using the 95% CI and 5% marginal error (d) (n= (Zα/2)2p(1−p)/ d2), the given sample size is 242. According to Hiwotfana specialized university Hospital's delivery report, a total of 400 women delivered per month. Since the total population is less than 10,000, correction formula was applied (n=n/1+n/N). So, the final sample size after adding 10% non-respondent rates was 166.
HiwotFana Specialized university hospital provides advanced services including Neonatal Intensive Care Unit (NICU) and KMC units, so the hospital was chosen deliberately due to this reason. Preterm and/or low birth weight (LBW) who were born among postnatal mothers were selected successively until the needed sample size was obtained. If there were two or more one baby was selected by lottery method to the study.
Normal postnatal mothers having pre term, LBW, stable infants breathing on their own, and infants without life-threatening disease or malformations that are willing to participate were included in this study.

Ethical Clearance
Ethical clearance was obtained from Ethical Clearance Committee of Harar Health Science College (Reference number: HHSC-093/2020). Consent was obtained from the administrative bodies of the health facility and from the participants.

Data Collection and Data Analysis
Data were collected by face-to-face interview using standardized questionnaire. For practice part, direct observation was done when they position, breast feed and ambulate. After data collection, the questionnaire was checked for completeness and coded. The data were entered into Epi-info version 3.5.3 and exported, cleaned and analyzed by using SPSS version-20. Descriptive analyses were performed and bivariate analyses were used to find out the association of independent variables. Variables with a p<0.05 in the bivariate analysis were entered into multiple logistic regression and variables with p<0.05 in the multivariate analysis were considered to have statistically significant associations.

Socio-Demographic Characteristics
One hundred sixty-six (166) Table 2). The majority of the participants respond that the heard the information about kangaroo mother care through health professionals, mass media, friends, and posters 86%, 65%, 23.3% and 17.4%, respectively.

Attitudes of Care Takers on KMC
One hundred thirty-seven (82.53%) of mothers believed positive regarding implementation of KMC for it corrects the temperature and promotes growth and development of their small babies. On the contrary, only 19 (11.45%) respondents answered that both parents should be involved in kangaroo care, the majority left 147 (88.55%) said that only mother should be involved for the care of the neonates (See Table  3).

Practice of Care Takers on KMC
Participants were asked and observed on the correct practice of Kangaroo mother care on kangaroo position, clothing during KMC, KMC initiation and type of KMC. About 44 (32.12%) of respondents performed kangaroo position in setting or semi-reclined position appropriately, whereas the rest of respondents' position was inappropriate. Most 49 (57%) of respondents dressed the baby with cap, socks and nappy appropriately, whereas the rest of them did not dress their baby properly. Nearly all 123 (89.70%) of KMC was performed by mothers, 14 (10.22%) were performed by others which include grandmothers, aunts and maids, but there was no single one which was performed by fathers (See Table 4). Over all knowledge, attitude and practice score sum of the care givers towards KMC illustrated as follow.

DISCUSSION
Findings of this study revealed the level of good knowledge among mothers (82.53%), which was very high compared to the study done in Rohilkhand Hospital Bareilly that the knowledge was 33.3% (Sharma & Verma, 2019). Whereas it was lower than the study done in North Ethiopia (99.3%) (Tsegay, 2015), Malawi (84%) (Chisenga et al., 2015), and Ghana (90%) (Nguah et al., 2011). This difference might be due to a difference in socio-demographic/cultural /economic characteristics in different regions and methodological difference.
This study showed that 82.53% of mothers had positive attitude towards KMC. The finding was lower than the study done among Indian mothers, which the acceptance of KMC was 96% (Parmar et al., 2009), and the study done in Cape Town with the acceptance of KMC was 96.6%, and 87.1% mothers who had favorable opinion towards the practice of KMC (Rosant, 2009). This could be influenced by sociodemographic/cultural /economic characteristics in different regions and methodological difference.
In this study, the level of correct practice was 32.12%, it is lower than a study done at Hawasa University Hospital which was 61.6% (Getinet K, 2008). This difference may be due to the cultural characteristics of the respondents, study methodology and set up of services. Also, 42.77% of the participants agreed that KMC reduces hospital stay, the result was lower than that of a study done in South India 56.69% strongly agreed that KMC reduces hospital stay (Suhasimi Mekala, 2019). This difference could be related to the difference in study methodology.
Our findings also indicated that the participants reported the benefits of KMC, such as protection from infection, warmth to the baby, exclusive breast feeding, weight gain and growth, early discharge from hospital, safety and love. These have been also reported by other studies (March of Dimes, PMNCH, Save the Children, & WHO, 2012;WHO, 2003).
Since the study incorporates only public facility but not private facilities, so the findings may be difficult generalizable for general population.

CONCLUSION
The finding of this study on knowledge, attitude and practice of caretakers regarding kangaroo mother care showed that 82.53 % had good knowledge, 82.53 % had positive attitude, and 32.2 % practiced correctly. However, there were clear gaps in knowledge and practice in the study. Therefore, it is very important to have health education sessions during ANC follow-up on KMC. Furthermore, it is recommended to conduct qualitative research to explore the temporal relationship.

Declaration of Conflicting Interest
The author declares no conflict of interest.

Funding
The author declares that no financial support for this research.