Prevalence of Neonatal Sepsis in Ethiopia: A Systematic Review and Meta-Analysis

Abstract

Introduction:
Neonatal sepsis is a systemic infection occurring in infants during the first 4 weeks of life and is a major cause of mortality and morbidities of newborns due to their age-related weak and immature immune systems. In Ethiopia, despite many studies being conducted on neonatal sepsis, the reported findings are inconsistent. The aim of this study is to determine the prevalence of neonatal sepsis to enhance the utility and interpretation of the evidence.

Methods:
An extensive systematic review and meta-analysis were performed to extract studies on the prevalence of neonatal sepsis in Ethiopia. The PubMed, Cochrane Library, ScienceDirect, Web of Science, and Google Scholar were systematically searched. Two independent authors selected and extracted the data from each included article. The heterogeneity of included studies was assessed using the Higgins I2 test, and a random-effects model was performed in Stata/se Version 14.

Results:
Eighteen studies with a sample size of 10,495 study subjects were included with a reported range of neonatal sepsis from 17% to 78%. The pooled prevalence of neonatal sepsis was 45% (95% CI: 35, 55; I2 = 99.3%, p < 0.01). Early onset neonatal sepsis was found to have a prevalence of 75.4% (95% CI: 68.3, 82.6). Subgroup analysis in the study area (i.e., by region) was calculated revealing the highest neonatal sepsis in Amhara region at 64.4% (95% CI: 44.9, 84.0) and the lowest in Southern Nations, Nationality, and People at 28% (95% CI: 16, 40).

Conclusion:
In this review, the prevalence of neonatal sepsis in Ethiopia was found to be high, especially in terms of early onset neonatal sepsis. As a result of the findings, it is important to consider the early and optimal points for interventions to better manage the prevalence and outcomes of neonatal sepsis. Further research is needed to investigate the neonatal sepsis status at different regions and associated factors for neonatal sepsis not yet studied.

Full text

Research Article
Prevalence of Neonatal Sepsis in Ethiopia: A Systematic
Review and Meta-Analysis
Moges Agazhe Assemie ,
1
Muluneh Alene,
1
Lieltwork Yismaw,
1
Daniel Bekele Ketema,
1
Yonas Lamore,
2
Pammla Petrucka,
3,4
and Simegn Alemu
1
1
Department of Public Health, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
2
Department of Environmental Health, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
3
College of Nursing, University of Saskatchewan, Saskatoon, Canada
4
School of Life Sciences and Bioengineering, Nelson Mandela African Institute of Science and Technology, Arusha, Tanzania
Correspondence should be addressed to Moges Agazhe Assemie; agazhemoges@gmail.com
Received 31 October 2019; Revised 29 January 2020; Accepted 2 March 2020; Published 15 April 2020
Academic Editor: Alessandro Mussa
Copyright © 2020 Moges Agazhe Assemie et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.
Introduction. Neonatal sepsis is a systemic infection occurring in infants during the first 4 weeks of life and is a major cause of
mortality and morbidities of newborns due to their age-related weak and immature immune systems. In Ethiopia, despite many
studies being conducted on neonatal sepsis, the reported findings are inconsistent. The aim of this study is to determine the
prevalence of neonatal sepsis to enhance the utility and interpretation of the evidence. Methods. An extensive systematic review
and meta-analysis were performed to extract studies on the prevalence of neonatal sepsis in Ethiopia. The PubMed, Cochrane
Library, ScienceDirect, Web of Science, and Google Scholar were systematically searched. Two independent authors selected and
extracted the data from each included article. The heterogeneity of included studies was assessed using the Higgins I2test, and a
random-effects model was performed in Stata/se Version 14. Results. Eighteen studies with a sample size of 10,495 study
subjects were included with a reported range of neonatal sepsis from 17% to 78%. The pooled prevalence of neonatal sepsis was
45% (95% CI: 35, 55; I2=99:3%,p<0:01). Early onset neonatal sepsis was found to have a prevalence of 75.4% (95% CI: 68.3,
82.6). Subgroup analysis in the study area (i.e., by region) was calculated revealing the highest neonatal sepsis in Amhara region
at 64.4% (95% CI: 44.9, 84.0) and the lowest in Southern Nations, Nationality, and People at 28% (95% CI: 16, 40). Conclusion.
In this review, the prevalence of neonatal sepsis in Ethiopia was found to be high, especially in terms of early onset neonatal
sepsis. As a result of the findings, it is important to consider the early and optimal points for interventions to better manage the
prevalence and outcomes of neonatal sepsis. Further research is needed to investigate the neonatal sepsis status at different
regions and associated factors for neonatal sepsis not yet studied.
1. Introduction
The neonatal period is the most vulnerable time for chil-
dren’s survival. Globally every year about 4 million children
die in the first 4 weeks of life, of which 99% of the deaths
occur in low- and middle-income countries and of which
75% are considered avoidable [1]. Even though neonatal
mortality shows a declining trend over the last 20 years from
50.6 per 1000 live births in 1998 to 28.9 per 1000 live births in
2017 [2], Ethiopia continuous to struggle with a prevalence of
about 42% or 81,000 newborn deaths every year [1]. Thus,
neonatal sepsis is a major cause of neonatal mortality due
to a higher risk of infection because of their weak and imma-
ture immune systems related to their age [3, 4].
Neonatal sepsis is a systemic infection occurring in
infants at the first 4 weeks of life which can be classified as
either early or late onset sepsis [1, 5]. Clinical signs and
symptoms of sepsis in newborns vary by gestational age
and severity of infection. It is more common for a septic
infant to be hypothermic upon presentation [6]. Among all
major causes of neonatal deaths, sepsis accounts for 25% of
all neonatal deaths in sub-Saharan Africa and southern Asia
Hindawi
International Journal of Pediatrics
Volume 2020, Article ID 6468492, 9 pages
https://doi.org/10.1155/2020/6468492

[7]. Even though there are some improvements to access
essential preventive, primary child health care services and
sector training [1], neonatal sepsis is still the major cause of
newborn deaths resulting in more than one-third of all neo-
natal deaths [1, 8].
To date, there are inconsistent findings and no systematic
review and meta-analysis have been done to enhance the
quality and consistency of the evidence. Therefore, the aim
of this study was to consider the evidence to determine the
prevalence of neonatal sepsis in Ethiopia while serving as a
baseline for clinicians and policy makers to design future
infrastructure and system strengthening to improve the qual-
ity of health.
2. Methods
2.1. Search Strategy. To locate potential articles, PubMed,
Google Scholar, Cochrane Library, Web of Science, and
ScienceDirect were comprehensively searched between
January 27 and June 3, 2019. We extended our search by
reviewing reference lists of eligible articles, hand searching
for grey literature, and other important literature collections
including the Addis Ababa Digital Library and Saint Mary’s
University repositories. The search protocol was formulated
by using common keywords: prevalence AND associated fac-
tors AND pediatrics OR infant OR newborn OR neonate’s
sepsis AND Ethiopia (MeSH Terms). The data selection of
this systematic review was presented according to the pre-
ferred reporting items for systematic reviews and meta-
analysis (PRISMA) guidelines [9]. However, it was not regis-
tered on the prospective registration of systematic review and
meta-analysis (PROSPERO), which is addressed in Limita-
tions of the Study.
2.2. Eligibility. Included articles were both published and
unpublished full text observational study designs reporting
the prevalence of neonatal sepsis in Ethiopia, whereas case
reports, national reports, clinical studies, and reviews were
excluded.
2.3. Outcome Variables. Neonatal sepsis is the main outcome
of the study and calculated as the total number of sepsis cases
divided by the total number of live birth infants in the study
multiplied by 100. Neonatal sepsis can be classified as early
onset sepsis acquired from birth to 7 days and late onset
sepsis acquired after delivery in the normal newborn nurs-
ery, the neonatal intensive care unit, or the community (8
to 30 days). Thus, meta-analysis was performed for two or
more studies reporting the same outcomes [10].
2.4. Data Selection and Extraction. Two independent
reviewers (SA and YL) screened the downloaded articles
and extracted all necessary data from included articles; dis-
cussions and mutual consensus were used when discrepan-
cies arose. The extraction format included primary author,
study design, classification of sepsis onset, data source, health
Identification
Records aer duplicates removed (n = 236)
Records screened (n = 236)
Screening
Articles excluded by title (n = 82)
and articles excluded aer
reading abstracts (n = 37)
Eligibility
Full-text articles assessed for eligibility (n = 117)
Full-text articles excluded with reasons:
Outcome of interest not reported (32)
Conducted in other countries (41)
Inaccessibility of the full text (26)
Included
Studies included in the final meta-analysis (n =18)
Total of (N = 1167) articles identified through
electronic database searching: PubMed, Google
Scholar, Web of Science, Science Direct, and others
(i)
(ii)
(iii)
Figure 1: PRISMA study selection flow diagram for systematic review and meta-analysis on neonatal sepsis in Ethiopia, 2019 (n=18).
2 International Journal of Pediatrics

Table 1: Descriptive summary of studies included in the systematic review and meta-analysis of neonatal sepsis in Ethiopia.
Authorship
(reference) Study period Publication
(yr) Study design Facility name Study area (region) Source of data Sample Early onset
sepsis
Late onset
sepsis
Prevalence
(95% CI)
Woldehanna and
Idejene [21] 1/9/1994–31/8/1999 2005 Retrospective GTH Gondar (Amhara) Chart review 330 NA NA 75 (70, 80)
Tewabe et al. [22] 30/4/16-30/5/2016 2018 Retrospective FHRH Bahir Dar (Amhara) Chart review 410 NA NA 24 (20, 28)
Farah et al. [19] 8/2014-2017 2018 Retrospective KGH Karamara (Somalia) Char review 792 NA NA 22 (19, 25)
Kokeb and Desta [23] 1/1/2014- 31/3/2014 2016 Cross-sectional GTH Gondar (Amhara) Primary 325 NA NA 78 (73, 82)
Yismaw and
Tarekegn [24] 1/2016–3/2018 2018 Retrospective GTH Gondar (Amhara) Chart review 516 NA NA 78 (74, 81)
Sorsa et al. [25] 4/2016–5/2017 2019 Cross-sectional ATH Asela (Oromia) Primary 902 NA NA 33 (30, 36)
Ketema et al. [26] 9-10,2017 2019 Retrospective JGH Jinka (SNNP) Chart review 335 NA NA 33 (28,39)
Roba and Diro [18] 1/1/2013-10/1/2017 2017 Retrospective DRH Dire Dawa Chart review 3418 NA NA 35 (34, 37)
Woldu et al. [27] 15/4/2014-
15/10/2014 2014 Cross-sectional BGH Bishoftu (Oromia) Primary 306 81 19 72 (67, 77)
Serbesa and Iffa [28] 2–5,2017 2019 Cross-sectional ARH Mekelle (Tigray) Primary 301 65.1 34.9 23 (18, 28)
Mersha et al. [29] 22/4/2018-29/6/2018 2019 Cross-sectional WSTH & SCH Wolaita (SNNP) Primary 275 66.5 34.5 34 (28, 39)
Getabelew et al. [20] 2/2016-2/2017 2018 Cross-sectional SRH and MGH Shashemene
(Oromia) Primary 244 65 35 78 (73, 83)
Demisse et al. [30] 1/12/2015–31/8/2016 2017 Retrospective GTH Gondar (Amhara) Chart review 769 87.7 12.3 68 (65, 71)
Mengistie et al. [31] 1-2/2018 2018 Cross-sectional HTH & AGH Hawassa (SNNP) Primary 402 80.9 19.1 62 (57, 68)
Alemu [32] 9/2016 2/2017 2017 Retrospective TASH Addis Ababa Chart review 304 80 20 17 (13, 21)
Bayana et al. [33] 1/1/2016-31/12/2017 2018 Retrospective JTH Jimma (Oromia) Chart review 341 NA NA 20 (16, 25)
Gudeta [34] 11/8/2014-1/11/2016 2017 Retrospective TASH Addis Ababa Chart review 356 NA NA 19 (15, 23)
Getachew [17] 11/2017-7/2018 2018 Cross-sectional TASH Addis Ababa Primary 169 NA NA 40 (32, 47)
MGH = Melkaoda General Hospital; WSTH = Wolaita Sodo Teaching Hospital; SCH = Sodo Christian Hospital; HTH = Hawassa Teaching Hospital; AGR = Adare General Hospital; ARH = Ayder Referral
Hospital; BGH = Bishoftu General Hospital; FHRH = Felege Hiwot Referral Hospital; ATH= Asela Teaching Hospital; JGH= Jinka General Hospital; JTH =Jimma Teaching Hospital.
3International Journal of Pediatrics

facility, study area/region, study period, publication year,
quality score, sample size, and prevalence with 95% confi-
dence interval.
2.5. Quality Assessment and Appraisal. We had performed
a critical appraisal of the research evidence to assess the
methodological quality of a study to determine the extent
to which a study has addressed the possibility of bias in
its design, conduct, and analysis using a standardized data
appraisal format adapted from the Joanna Briggs Institute
(JBI) checklist [11].
Moreover, to assess the quality of each primary study,
the Newcastle-Ottawa Scale (NOS) for cross-sectional stud-
ies was adopted [12]. The tool has three main components
and uses a star grading system. The first component has
possible five stars and considers the credibility on the selec-
tion of study groups. The second section of the tool deals
with the comparability of the groups with a possibility of
two stars. The third section of the grading system focuses
on the ascertainment for either exposure or outcome of
each original study with a possibility of three stars to be
assessed. In addition, quality appraisal of included studies
was evaluated by two authors (MA and LY) independently
and any discrepancy was resolved by a third author (MAA).
Articles with a NOS score of ≥5 stars out of 10 were con-
sidered as high quality [13] for the purposes of our work
(Supplementary Table).
2.6. Risk of Bias Assessment. The risk of bias assessment of
included articles was evaluated by two authors (LY and SA)
independently using the Hoy et al. (2012) adapted tool for
prevalence studies which consists of 10 items addressing four
domains of bias plus a summary risk of bias assessment [14].
Any discrepancy was resolved by discussion and mutual con-
sensus mediated by a third author (MAA).
2.7. Data Processing and Analysis. Data were extracted in
a Microsoft™Excel spreadsheet, and analysis was carried
out using Stata/se Version 14 statistical software. Hetero-
geneity among reported prevalence was assessed by comput-
ing pvalues of Higgins’sI2statistics; I2was considered as
significant at a pvalue <0.10 [15]. The DerSimonian and
Laird’s random-effects meta-analysis model was used to
determine the pooled effect size, since the true effect is not
the same in all studies [16].
We deal heterogeneity with subgroup analysis, metare-
gression, and sensitivity analysis. Subgroup analysis was done
based on study settings. In addition, an effort to understand
the sources of heterogeneity, univariate metaregression anal-
ysis was conducted for sample size, publication year, study
design, quality score, and midyear study period. Metaregres-
sion was used instead of subgroup analyses since it allowed
for the use of continuous covariates and permitted the inclu-
sion of more than one covariate at a time. Moreover, sensitiv-
ity analysis was computed to assess the influence of a single
study on the pooled estimates.
A forest plot was used to describe pooled prevalence
with 95% confidence intervals. The size of each box indi-
cated the weight of the study, while each crossed line refers
to a 95% confidence interval with the mean effect at the
center. The possibility of publication bias was assessed
visually with funnel plots, and the objectivity test of Egger’s
test with pvalue less than 0.05 was considered evidence of
publication bias.
Overall (I2 = 99.25%, p <0.001)
Mersha et al. (2019)
Yismaw et al. (2018)
Serbesa et al. (2019)
Getabelew et al. (2018)
Study
Ketema et al. (2019)
Sorssa et al. (2019)
Gudeta et al. (2017)
Mehretie et al. (2016)
Woldu et al. (2014)
Bayana et al. (2018)
Tewabe et al. (2018)
Demisse et al. (2017)
Alemu et al. (2017)
Roba et al. (2017)
Farah et al. (2018)
Mengistie et al. (2018)
Woldehanna et al. (2005)
Getachew et al (2018)
0.45 (0.35, 0.55)
0.34 (0.28, 0.40)
0.78 (0.74, 0.81)
0.23 (0.19, 0.28)
0.78 (0.72, 0.83)
ES (95% CI)
0.33 (0.29, 0.39)
0.33 (0.30, 0.36)
0.19 (0.15, 0.23)
0.78 (0.73, 0.82)
0.72 (0.67, 0.77)
0.20 (0.16, 0.25)
0.24 (0.20, 0.28)
0.68 (0.64, 0.71)
0.17 (0.14, 0.21)
0.35 (0.34, 0.37)
0.22 (0.20, 0.25)
0.63 (0.57, 0.68)
0.75 (0.70, 0.80)
0.40 (0.33, 0.47)
0.1 1 2
Figure 2: Forest plot of the pooled prevalence of neonatal sepsis in Ethiopia, 2019 (n=18).
4 International Journal of Pediatrics

3. Results
3.1. Study Selection. We followed the PRISMA guideline to
present the findings of this review. We extracted 1167 articles
regarding neonatal sepsis using PubMed, Google Scholar,
Cochrane Library, Web of Science, and ScienceDirect. After
removing duplicates, 236 articles were screened of which
119 were excluded after reading the title and abstracts. The
remaining 117 full text articles were assessed for eligibility.
Eighteen studies met the eligibility criteria and were included
in the final analysis, as shown in the chart of study selection
process (Figure 1).
3.2. Descriptive Summary of Included Neonatal Sepsis
Articles. As described in Table 1, these 18 studies were
cross-sectional and cohort study designs published between
March 2005 and March 18, 2019, along with selected grey lit-
erature. In the current systematic review and meta-analysis,
10,495 neonates were included. The sample size by study
ranged from 169 in Tikur Anbesa Specialized Hospital
(TASH), Addis Ababa [17], to 3418 in Dilchora Referral Hos-
pital (DRH), Dire Dawa City Administration [18]. The prev-
alence of neonatal sepsis reported was between 22% in
Karamara General Hospital (KGH), Somalia region [19],
and 78% in Shashemene Referral Hospital (SRH), Oromia
region [20].
3.3. Prevalence of Neonatal Sepsis in Ethiopia. Prevalence
of neonatal sepsis was found to be 45% (95% CI: 35, 55;
I2=99:3%,p<0:01) which indicates high heterogeneity
(Figure 2). Hence, subgroup analysis, based on the study
regions, was computed and did not show a significant level
of difference/heterogeneity for neonatal sepsis. The highest
prevalence was found in Amhara region to be 64% (95%
CI: 45, 84), followed by the Oromia region at 51% (95% CI:
24, 77), whereas the lowest prevalence was found in Southern
Note: weights are from random effects analysis
Overall (I-squared = 99.2%, p <0.001)
Subtotal (I-squared = .%, p = .)
Oromia
Subtotal (I-squared = 94.9%, p = 0.000)
Getachew et al
Authors
Yismaw et al.
Amhara
Subtotal (I-squared = .%, p = .)
Alemu et al.
Mehretie et al.
Subtotal (I-squared = 98.8%, p =0.000)
Mersha et al.
Serbesa et al.
Bayana et al.
SNNP
Gudeta et al.
Roba et al.
Addis Ababa
Mengistie et al.
Dire Dawa
Subtotal (I-squared = .%, p = .)
Farah et al.
Subtotal (I-squared = 99.3%, p = 0.000)
Sorssa et al.
Subtotal (I-squared = 99.2%, p = 0.000)
Somalia
Tigray
Getabelew et al.
Ketema et al.
Tewabe et al.
Woldehanna et al.
Demisse et al.
Woldu et al.
2018
2018
2017
2016
2019
2019
2018
Publication
year
2017
2017
2018
2018
2019
2018
2019
2018
2005
2017
2014
45.03 (34.83, 55.24)
22.90 (18.15, 27.65)
27.90 (15.88, 39.92)
39.90 (32.52, 47.28)
77.70 (74.11, 81.29)
35.30 (33.70, 36.90)
77.80 (73.28, 82.32)
40.36 (12.06, 68.67)
33.80 (28.21, 39.39)
22.90 (18.15, 27.65)
19.90 (15.66, 24.14)
18.80 (14.74, 22.86)
35.30 (33.70, 36.90)
62.50 (57.06, 67.94)
22.30 (19.40, 25.20)
22.30 (19.40, 25.20)
50.70 (24.43, 76.97)
64.44 (44.92, 83.96)
77.90 (72.69, 83.11)
33.40 (28.35, 38.45)
23.80 (19.68, 27.92)
75.00 (70.33, 79.67)
67.90 (64.60, 71.20)
72.20 (67.18, 77.22)
Prevalence (95% CI)
16.90 (13.24, 20.56)
33.00 (29.93, 36.07)
77.90 (72.69, 83.11)
0.1 10
Figure 3: Subgroup analysis of neonatal sepsis by study area (region) of Ethiopia, 2019 (n=18).
5International Journal of Pediatrics

Nations, Nationality, and People at 28% (95 CI: 16, 40)
(Figure 3).
Among the included studies, seven of the studies
reported neonatal sepsis as early and late onset neonatal sep-
sis classification. Thus, early onset neonatal sepsis was
reported in the range of 65% SRH, Oromia, and 88% in Gon-
dar Teaching Hospital (GTH), Amhara. Thus, we found
75.4% (95% CI: 68.3, 82.6) pooled early onset neonatal sepsis
(Figure 4).
In addition, univariate metaregression analysis was con-
ducted to identify possible sources of heterogeneity for mid-
year study period, publication year, quality score, and sample
size. Again, all of these covariates were found to be statisti-
cally nonsignificant (Table 2).
Moreover, sensitivity analysis was computed to evalu-
ate whether the exclusion of any single study altered the
magnitude or statistical results of the summary estimate.
None of the studies influenced the summary pooled esti-
mates (Figure 5).
Publication bias was assessed by a funnel plot and
absence of bias was represented by substantial symmetry
(Figure 6). To confirm the absence of publication bias,
Egger’s test was employed and did not show the presence of
bias (p=0:627).
4. Discussion
Neonates are at a higher risk of infection because of their
developmentally weak and immature immune systems. In
this study, the pooled prevalence of neonatal sepsis for Ethi-
opia was found to be 45%, while early onset neonatal sepsis
acquired before or during delivery accounted for 75.4%.
This study revealed that pooled prevalence of neonatal
sepsis in Ethiopia is consistent with the findings from Cam-
eroon (37.9%) [35], Tanzania (38.9%) [36], and Egypt
(45%) [37]. However, our finding is higher than previous
studies reported in Iran (18.4%) [38], Mexico (4.3%) [39],
and Egypt (8.6%) [40]. This variation could be due to unique
cultural features of the population, local obstetrics and neo-
natal practices, socioeconomic and sexual practice, hygiene,
and nutritional differences over settings [41] as well as due
to clinical features for sepsis identification, study methodol-
ogy, and sample size difference which we observed during
our study.
The subgroup analysis of neonatal sepsis studies based on
region of the country found 64% (95% CI: 45, 84) in Amhara
region where studies were from specialized hospital chart
review followed by the Oromia region at 51% (95% CI: 24,
77), whereas the lowest was observed in Southern Nations,
Nationality, and People at 28%(95% CI: 16, 40) primary
study at district hospital. The possible explanation for this
variation could be due to the differences in health facility,
study design, and sample size variation across studies.
4.1. Limitations of the Study. A number of the studies
included in this review had a relatively small sample size
which may decrease the power of the study. Secondly, there
are studies only from five regions and two city administra-
tions of Ethiopia, which restrict the representativeness of
Note: weights are from random effects analysis
Overall (I-squared = 95.1%, p <0.001)
Mengistie et al.
Getabelew et al.
Alemu et al.
Woldu et al.
Mersha et al.
Demisse et al.
Serbesa et al.
Authors
2018
2018
2017
2014
2019
2017
2019
Publication year
75.44 (68.27, 82.61)
81.00 (77.17, 84.83)
65.00 (59.02, 70.98)
80.00 (75.50, 84.50)
81.00 (76.60, 85.40)
88.00 (85.70, 90.30)
65.00 (59.61, 70.39)
66.50 (60.92, 72.08)
Prevalence (95%CI)
0.110
Figure 4: Prevalence of early onset of neonatal sepsis in Ethiopia, 2019 (n=7).
Table 2: Univariate metaregression for related factors to
heterogeneity of neonatal sepsis.
Variables Coefficient pvalue
Sample size -0.0000 0.62
Publication year -0.0342 0.053
Quality score -0.0055 0.97
Midyear study period -0.0177 0.15
6 International Journal of Pediatrics

the study. This study also emphasized only the prevalence of
neonatal sepsis. In addition, this study is not registered in
PROSPERO which could compromise transparency and
credibility of the study.
5. Conclusion
In this review, the prevalence of neonatal sepsis in Ethiopia
was found to be high, especially in terms of early onset neo-
natal sepsis. As a result of the findings, it is important to con-
sider the timing and optimal points for interventions to
better manage the occurrence of neonatal sepsis. Further
research is needed to investigate the neonatal sepsis status
at different regions not yet studied and associated factors
for neonatal sepsis.
Data Availability
Minimal data can be accessed upon request from first author.
Conflicts of Interest
The authors declare that they have no competing interests.
Estimate (95%CI) I2pvalue
0.43 (0. 31, 0.55) 99.24 <0.001
0.46 (0. 34, 0.58) 99.28 <0.001
0.46 (0. 34, 0.58) 99.24 <0.001
0.43 (0. 31, 0.51) 99.23 <0.001
0.43 (0. 31, 0.54) 99.21 <0.001
0.45 (0. 33, 0.58) 99.26 <0.001
0.45 (0. 33, 0.58) 99.31 <0.001
0.45 (0. 33, 0.58) 99.09 <0.001
0.43 (0. 32, 0.55) 99.26 <0.001
0.46 (0. 34, 0.58) 99.28 <0.001
0.45 (0. 33, 0.58) 99.31 <0.001
0.43 (0. 31, 0.54) 99.24 <0.001
0.43 (0. 32, 0.56) 99.24 <0.001
0.44 (0. 31, 0.56) 99.3 <0.001
0.47 (0. 35, 0.58) 99.24 <0.001
0.46 (0. 35, 0.58) 99.27 <
0.46 (0. 35, 0.58) 99.26 <0.001
0.45 (0. 33, 0.57) 99.33 <0.001
0.43 [0.32,0.55]
0.46 [0.34, 0.58]
0.46 [0.34,0.58]
0.43 [0.31, 0.54
0.43[0.31,0.54]
0.45 [0.33,0.58]
0.45 [0.33,0.58]
0.45 [0.33, 0.58]
0.43[0.32,0.55]
0.46 [0.34, 0.58]
0.45 [0.33, 0.58]
0.43 [0.31, 0.54]
0.43 [0.32, 0.55]
0.44 [0.32, 0.56]
0.47 [0.35, 0.58]
0.46 [0.35,0.58]
0.46 [0.35,0.58]
0.45 [0.33, 0.57]
Summary proportions leaving out each study
Tewabe et al.(2018)
Woldehanna et al.(2018)
Farah et al. (2018)
Mehretie et al. (2016)
Yismaw et al. (2018)
Sorssa et al. (2019)
Ketema et al. (2019)
Roba et al. (2017)
Woldu et al. (2014)
Serbesa et al. (2019)
Mersha et al. (2019)
Getabelew et al. (2018)
Demisse et al. (2017)
Mengistie et al. (2018)
Alemu et al. (2017)
Bayana et al. (2018)
Gudeta et al (2017)
Getachew et al (2018)
0.3 0.35 0.4 0.45 0.5 0.55 0.6
Figure 5: Sensitivity analysis for neonatal sepsis eligible studies in Ethiopia, 2019 (n=18).
–0.5
0
.5
1
1.5
1 2 3 4 5 6
logpr
Funnel plot with pseudo 95% confidence limits
s.e. of logpr
Figure 6: Funnel plot with 95% confidence limits of the pooled prevalence of neonatal sepsis in Ethiopia, 2019 (n=18).
7International Journal of Pediatrics

Authors’Contributions
MAA helped in the conception of research protocol, study
design, literature review, data extraction, data analysis, inter-
pretation, and drafting the manuscript. MA contributed on
data extraction, quality assessment, data analysis, and manu-
script review. LY contributed on data extraction, quality
assessment, data analysis, interpretation, and manuscript
review. DBK helped in the study design, data analysis, edit-
ing, and manuscript review. YL contributed on study design,
literature review, data extraction, data analysis, interpreta-
tion, and manuscript review. SA helped in the conception
of research protocol and study design and contributed on
data extraction, quality assessment, data analysis, and manu-
script review. PMP contributed on critically review, editing,
and validating the research and manuscript content. All
authors read and approved of the final manuscript.
Acknowledgments
The authors of the primary study is acknowledged.
Supplementary Materials
Table S2: assessing the risk of bias for the included studies.
(Supplementary Materials)
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