Prevalence of neonatal hypothermia and its associated factors in Ethiopia: A systemic review and meta&shy;-analysis

Asnake Tadesse Abate; Walelign Asime Afework; Temesgen Birlie Asmare; Negesse Zurbachew Gobezie; Habtie Bantider Wubet; Getachew Mekete Diress; Gebresilassie Tadesse; Abere Gebru Abuhay; Gezahagn Demsu Gedefaw; Tsehayu Melak Siyoum; Begizew Yimenu Mekuriaw; Biruk Demissie

doi:10.12688/f1000research.171872.1

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Systematic Review

Prevalence of neonatal hypothermia and its associated factors in Ethiopia: A systemic review and meta-analysis

[version 1; peer review: awaiting peer review]

Asnake Tadesse Abate ¹, Walelign Asime Afework², Temesgen Birlie Asmare³, [...] Negesse Zurbachew Gobezie³, Habtie Bantider Wubet³, Getachew Mekete Diress³, Gebresilassie Tadesse⁴, Abere Gebru Abuhay⁵, Gezahagn Demsu Gedefaw¹, Tsehayu Melak Siyoum¹, Begizew Yimenu Mekuriaw⁶, Biruk Demissie⁷

Asnake Tadesse Abate ¹, Walelign Asime Afework², [...] Temesgen Birlie Asmare³, Negesse Zurbachew Gobezie³, Habtie Bantider Wubet³, Getachew Mekete Diress³, Gebresilassie Tadesse⁴, Abere Gebru Abuhay⁵, Gezahagn Demsu Gedefaw¹, Tsehayu Melak Siyoum¹, Begizew Yimenu Mekuriaw⁶, Biruk Demissie⁷

PUBLISHED 03 Nov 2025

Author details Author details

¹ Department of Neonatal Health Nursing, College of Medicine and Health Sciences, and Comprehensive Specialized Hospital, University of Gondar, Gondar, Ethiopia
² Department of Adult Health Nursing, Debre Tabor University, Debre Tabor, Ethiopia
³ Department of Anesthesia, Debre Tabor University, Debre Tabor, Ethiopia
⁴ Department of Psychiatry, University of Gondar College of Medicine and Health Sciences, Gondar, Ethiopia
⁵ Department of Pediatrics and Child Health Nursing, Debre Tabor University, Debre Tabor, Ethiopia
⁶ Department of Midwifery, Debre Tabor University, Debre Tabor, Ethiopia
⁷ Department of Environmental health, Debre Tabor University, Debre Tabor, Ethiopia

Asnake Tadesse Abate
Roles: Conceptualization, Formal Analysis, Investigation, Methodology, Software, Writing – Original Draft Preparation, Writing – Review & Editing

Walelign Asime Afework
Roles: Conceptualization, Formal Analysis, Methodology, Supervision, Writing – Review & Editing

Temesgen Birlie Asmare
Roles: Investigation, Methodology, Software, Visualization

Negesse Zurbachew Gobezie
Roles: Conceptualization, Investigation, Software, Writing – Review & Editing

Habtie Bantider Wubet
Roles: Conceptualization, Formal Analysis, Software, Validation, Writing – Review & Editing

Getachew Mekete Diress
Roles: Conceptualization, Data Curation, Investigation, Visualization, Writing – Review & Editing

Gebresilassie Tadesse
Roles: Data Curation, Formal Analysis, Investigation, Software, Writing – Review & Editing

Abere Gebru Abuhay
Roles: Conceptualization, Investigation, Methodology, Writing – Review & Editing

Gezahagn Demsu Gedefaw
Roles: Conceptualization, Data Curation, Investigation, Visualization, Writing – Review & Editing

Tsehayu Melak Siyoum
Roles: Conceptualization, Data Curation, Investigation, Visualization, Writing – Review & Editing

Begizew Yimenu Mekuriaw
Roles: Conceptualization, Data Curation, Methodology, Software, Writing – Review & Editing

Biruk Demissie
Roles: Conceptualization, Formal Analysis, Investigation, Methodology, Software, Visualization, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS AWAITING PEER REVIEW

Abstract

Background

Neonatal hypothermia is a major cause of neonatal morbidity and death in the world, especially in low-income countries like Ethiopia. In Ethiopia, despite many studies being conducted on neonatal hypothermia, the reported findings are inconsistent. Therefore, the main aim of this study is to assess the pooled prevalence and factors associated with neonatal hypothermia in Ethiopia.

Objectives

This study aims to assess the pooled prevalence and factors associated with neonatal hypothermia in Ethiopia.

Methods

An extensive systematic review and meta-analysis were performed to extract studies on the pooled prevalence of neonatal hypothermia in Ethiopia. The PubMed, Medline, Google, Google Scholar, CINAL, and EMBASE were systematically searched. Nine articles assessed the pooled prevalence of neonatal hypothermia and associated factors in Ethiopia were included. Articles selected and extracted using a Microsoft Excel spreadsheet and exported to Stata version 14 for analysis. I-squared was used to assess the heterogeneity of the included papers, while Egger’s regression test and the funnel plot were used to check publication bias.

Results

A total of nine primary articles that going well together the inclusion criteria with a total population of 4075 were included in this meta-analysis. The pooled prevalence of neonatal hypothermia in Ethiopia was found to be 61.81% (95% CI: 57.21%, 66.41%). Neonates who had delayed initiation of breast feeding (Odds Ratio: 3.1; 95% CI: 2.37, 4.05), neonates who had no skin to skin contact (Odds Ratio: 4.4; 95% CI: 3.08, 6.27), neonates delivered at night time (Odds Ratio: 2.99; 95% CI: 1.90, 4.69), being low birth weight (Odds Ratio: 3.61; 95% CI: 2.35, 5.54) and neonates who had early bathing (Odds Ratio: 5.27; 95% CI: 2.73, 10.17) were factors significantly associated with hypothermia.

Conclusion

We found that the pooled prevalence of neonatal hypothermia was high. Thus, The concerned stakeholders should work to strengthen the neonatal care practice to include the possible significant factors of neonatal hypothermia.

Keywords

Hypothermia, Neonate, systematic review, meta-analysis, Ethiopia

Corresponding author: Asnake Tadesse Abate

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2025 Abate AT et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Abate AT, Afework WA, Asmare TB et al. Prevalence of neonatal hypothermia and its associated factors in Ethiopia: A systemic review and meta-analysis [version 1; peer review: awaiting peer review]. F1000Research 2025, 14:1202 (https://doi.org/10.12688/f1000research.171872.1) First published: 03 Nov 2025, 14:1202 (https://doi.org/10.12688/f1000research.171872.1) Latest published: 03 Nov 2025, 14:1202 (https://doi.org/10.12688/f1000research.171872.1)

Introduction

Neonatal hypothermia is a condition in which neonate’s body temperature is less than 36.5 degree centigrade within 28 days of life.¹ Hypothermia is a significant concern as it can have both immediate and long-term physiological effects like respiratory distress, cardiovascular instability, metabolic changes, and impair immune function, while long-term physiological effects as such neurodevelopmental impairment, growth and development disruption, and increased morbidity and mortality.^2,3

It is one of the major causes for neonatal death, and the most common health problems encountered in neonates as they have less subcutaneous fat and a reduced amount of brown fat, and a poorly developed response to thermal stress.^4,5 Despite the inconsistency of primary studies conducted in Ethiopia, a systematic review and meta-analysis to estimate the pooled prevalence and associated factors of neonatal hypothermia has yet to be performed. Therefore, this study aims to assess the pooled prevalence of neonatal hypothermia in Ethiopia, providing a baseline for clinicians and policymakers to inform future infrastructure development and strengthen health systems.

Research objectives

To estimated pooled prevalence of neonatal hypothermia in Ethiopia.

To determine the pooled effect of factors associated with neonatal hypothermia in Ethiopia.

Methods

Protocol and registration of this study

The protocol for this systematic review and meta-analysis was registered (ID = CRD42024513932) with the International Prospective Register of Systemic Review (PROSPERO) and it was carried out to determine the pooled prevalence of neonatal hypothermia in Ethiopia using the standard PRISMA checklist guideline.⁶

Searching strategies and appraisal of studies

To find the possible studies, International searching engines (PubMed/Medline, Google Scholar, Google, CINAL, EMBASE, Web of science and HINARI), were extensively searched. Common keywords for the formulation of the search protocol includes “Prevalence” OR “Magnitude” OR “Proportion”) AND (“associated factors” OR “risk factors” OR “determinants” OR “predictors”) AND (“hypothermia”) AND (“neonatal intensive care unit” OR “delivery ward”) AND (“neonates”) AND (“Ethiopia”).

Eligibility of the study

All accessible published full text observational study designs written only in English language that reported on the prevalence of neonatal hypothermia in different regions of Ethiopia were included. Whereas case reports, case studies, and articles lacking full text or qualitative findings were not included.

Data extraction

Once all database results had been collected, the articles were exported to a Microsoft Excel spreadsheet. After carefully looking over all of the screened and included published papers, the authors separately extracted the data using a standardized data extraction format in Microsoft Excel spreadsheet. The name of the first author’s, year of study, study area, study design, sample size, the prevalence of neonatal hypothermia, associated factors with neonatal hypothermia with the 95% confidence interval and odds ratio were extracted.

Outcome measurement

The measurement outcome of this systematic review and meta-analysis had two main outcome variables. Neonatal hypothermia was the primary outcome of this study, and associated factors of neonatal hypothermia in Ethiopia was the other outcome of this study.

Quality assessment

The authors are independently appraised the standard of the studies using the standard critical appraisal tool (Joanna Briggs Institute (JBI) standardized quality appraisal checklist)⁷ (S1 File). The qualities of the articles were assessed by using the following indicators; those with high quality (a score of 8 and above), moderate (a score of 5–7), and low quality (a score of 0–4). This review included articles with quality scores of 5 and above.

Data synthesis and analysis of results

The authors used STATA version 14.0 software to analyze the result after extracting the relevant data from the studies using Microsoft Excel 2016. A texts, table a forest plot and flow chart were used to summarize and present the results of the current study. The authors explored the potential heterogeneity among the reported prevalence of the studies using I² test.⁸ Given that the test statistics indicated a significant degree of heterogeneity within the included articles at a 95% confidence interval (I² = 88.1%, p = 0.000), the pooled effect was estimated using a random effects model. We also undertook subgroup analysis using publication year and regional state to identify the possible sources of heterogeneity, in which values of 25%, 50%, and 75% represented low, medium, and high heterogeneity, respectively. Sensitivity analysis was carried out to check the effects of a one study on the pooled prevalence of hypothermia. Possible publication bias was also subjectively examined usig a funnel plot for symmetrical distribution.⁹ To confirm the publication bias, objectively examined using Egger’s weighted regression test was employed and publication bias considered when the value of p was less than 0.05.¹⁰ The test results showed that there is no a significant publication bias (p = 0.337).

Results

Search results

We had the opportunity to find a total of 136 articles using an electronic search of PubMed/Medline, Google Scholar, Google, CINAL, EMBASE, Web of science, HINARI and reference lists of earlier prevalence studies. Among the reviewed articles, 98 articles were screened after duplicates were removed, and after reading the abstracts and titles, 84 of them were excluded. The eligibility of the remaining 14 full-text articles was evaluated. Lastly, 9 articles met the eligibility criteria and were included in the final analysis, as shown in the chart of study selection process ( Figure 1).

Figure 1. Flow chart on the article selection strategy for systematic review and meta-analysis of prevalence and associated factors of hypothermia among neonates in Ethiopia, 2024.

Characteristics of the included studies

This systematic review and meta-analysis includes nine articles conducted between 2015 and 2023. Of these articles, three were conducted in Amhara, two in SNNPs, two in Addis Ababa, one in Harar and one in Sidama with a total participants of 4075. All articles were conducted through cross sectional study design. The studies that are included in this systematic review and meta-analysis had sample sizes that vary between 216 at minimum to 769 at maximum. Among the included articles, the highest prevalence was reported from the Amhara regional state (69.8%) and the lowest prevalence was reported from SNNPs (50.3%) ( Table 1).

Table 1.

Characteristics of studies included in this systematic review and meta-analysis on neonatal hypothermia in Ethiopia.

Authors	Year of study	Study design	Study area	Sample size	Prevalence of hypothermia (%)
S. Nebiyu et al.⁴³	2020	Cross-sectional	Amhara	341	61.5
Ukke GG et al.⁴⁴	2019	Cross-sectional	SNNPs	395	50.3
Demissie et al.⁴⁵	2018	Cross-sectional	Addis Ababa	571	64
Yitayew YA et al.⁴⁶	2020	Cross-sectional	Amhara	422	66.8
Fenta B et al.⁴⁷	2023	Cross-sectional	SNNPs	769	62.9
Mahlet et al.⁴⁸	2020	Cross-sectional	Addis Ababa	423	63.4
GT Feyisa et al.⁴⁹	2023	Cross-sectional	Sidama	216	51.8
Seyum T et al.⁵⁰	2015	Cross-sectional	Amhara	535	69.8
Alebachew Bayih et al.⁵¹	2018	Cross-sectional	Harar	403	66.3

Pooled prevalence of neonatal hypothermia

Nine articles were analyzed in this systematic review to identify the overall prevalence of neonatal hypothermia in Ethiopia. As a result the pooled prevalence of neonatal hypothermia in the study area was found to be 61.81% (95% CI: 57.21%, 66.41%; I² = 88.1%; p = 0.000). Additionally, the weighted prevalence of hypothermia was also determined ( Figure 2).

Figure 2. The forest plot shows the pooled prevalence of hypothermia among neonates in Ethiopia.

Heterogeneity and bias test

There was significant heterogeneity between the included articles, as shown on the test statistic (I² = 88.1%, p = 0.000) ( Figure 2). A funnel plot and the Egger’s regression test were used to assess the publication bias. A funnel plot indicates that the absence of publication bias in the included articles ( Figure 3). To confirm the absence of publication bias, Egger’s test was employed and the test revealed a P value of 0.337, which indicates there is no evidence for publication bias ( Table 2).

Figure 3. A funnel plot shows the pooled prevalence of hypothermia among neonates in Ethiopia.

Table 2.

Egger’s test of neonatal hypothermia in Ethiopia.

Std-Eff	Coef.	Std. Err.	T	P > t	95% Conf.Interval
Slope	44.25199	16.64798	2.66	0.033	4.885775 83.61821
Bias	7.130301	6.914885	1.03	0.337	-9.220803 23.48141

Sub-group analysis

The subgroup analysis was done through stratified by region of study area, and year of study. Based on this, the pooled prevalence of hypothermia among neonates was found to be 66.1% (95% CI: 60.92%, 71.29%) in Amhara region, 63.69% (95% CI: 60.21%, 67.17%) in Addis Ababa city administration, and 56.66% (95% CI: 44.31%, 69.01%) in the SNNPs region. Based on the year of study, the prevalence of hypothermia among neonates was found to be 63.19% (95% CI: 58.57%, 67.81%) before 2021, while it was 57.26% (95% CI: 46.38%, 68.13%) from studies conducted after 2021 ( Table 3).

Table 3.

Sub-group analysis of pooled prevalence of hypothermia and associated factors among neonates in Ethiopia.

Variables	Sub-groups	Number of studies	Prevalence (95%CI)	I² (%)	P-value
Region	Amhara	3	66.11 (60.92, 71.29)	66.4	0.051
	Addis Ababa	2	63.69 (60.21, 67.17)	0.0	0.886
	SNNPs	2	56.66 (44.31, 69.01)	92.1	0.000
Year of study	<2021	7	63.19 (58.57, 67.81)	83.2	0.000
Year of study	≥2021	2	57.26 (46.38, 68.13)	92.7	0.000

Sensitivity analysis

Sensitivity analysis was computed to evaluate whether the exclusion of the single article altered the pooled prevalence of neonatal hypothermia. None of the articles were not altered the summary pooled prevalence of neonatal hypothermia. The pooled prevalence of neonatal hypothermia was varied between 60.77% (95%CI: 56.20%, 65.34%) and 63.20% (95%CI: 58.81%, 67.50%) after exclusion of a single study ( Table 4).

Table 4.

Sensitivity analysis pooled prevalence of neonatal hypothermia in Ethiopia

Authors	Estimated 95%CI	Heterogeneity
Authors	Estimated 95%CI	I²	P-value
S. Nebiyu et al.⁴³	61.85 (56.68, 67.03)	90.3%	0.000
Ukke GG et al.⁴⁴	63.20 (58.81, 67.50)	85.6%	0.000
Demissie et al.⁴⁵	61.54 (56.41, 66.68)	89.4%	0.000
Yitayew YA et al.⁴⁶	61.24 (56.3, 66.18)	89.1%	0.000
Fenta B et al.⁴⁷	61.68 (56.46, 66.9)	89.5%	0.000
Mahlet et al.⁴⁸	61.62 (56.45, 66.79)	89.5%	0.000
GT Feyisa et al.⁴⁹	63.15 (59.19, 67.11)	80.4%	0.000
Seyum T et al.⁵⁰	60.77 (56.20, 65.34)	86.1%	0.000
Alebachew Bayih et al.⁵¹	61.24 (56.21, 66.27)	88.7%	0.000

Significant factors associated with neonatal hypothermia in Ethiopia

This study confirmed that five factors were significantly associated with neonatal hypothermia in Ethiopia. Based on the findings of this systematic review and meta-analysis, the likelihood of neonatal hypothermia occurrence was 3.1 times higher among neonates who had delayed initiation of breast feeding than neonates with initiation of breast feeding with in one hour of birth [adjusted odd ratio (AOR) = 3.10; 95% CI 2.37, 4.05]. Neonates who had no skin to skin contact with their mother immediately after delivery were 4.4 times more likely to develop hypothermia when compared with those who have skin to skin contact immediately after delivery (AOR = 4.40, 95% CI: 3.08, 6.27) in eight studies that were included in this meta-analysis.

The pooled effect of six articles found that night time delivered neonates increased the odds of hypothermia by 2.99 times as compared with day time delivered neonates (AOR = 2.99, 95% CI: 1.90, 4.69). The findings from the four studies showed that the pooled prevalence of neonatal hypothermia was significantly associated with low birth weight. The probability of hypothermia was 3.6 times higher among neonates who had low birth weight as compared to normal birth weight (AOR = 3.61, 95% CI: 2.35, 5.54). The pooled effect of four studies found that early bathing increased the odds of neonatal hypothermia by 5.27 times as compared to those neonates bathed after 24 hours of birth (AOR: 5.27; 95% CI: 2.73, 10.17) ( Figure 4).

Figure 4. The forest plot shows factors significantly associated with the pooled prevalence of hypothermia among neonates in Ethiopia.

Discussion

The pooled prevalence of neonatal hypothermia in this meta analysis was found to be 61.81% (95% CI: 57.21%, 66.41%). The finding of this meta-analysis was consistent with the meta-analysis done in Ethiopia (62.68%)¹¹ and East Africa (57.22%),¹² a systematic review conducted in sub Saharan Africa (62%)⁴ and a primary study conducted in Nigeria (64.4%).¹³

In this study the pooled prevalence of neonatal hypothermia was relatively lower than a study conducted in Uganda (83%),¹⁴ Nepal (92.3%),¹⁵ and the global systematic review report (85%).¹⁶ However, the pooled prevalence of neonatal hypothermia is higher than studies conducted in South Africa (21%),¹⁷ Bangladesh (34%),¹⁸ Pakistan (49.5%),¹⁹ Iran (13.6%)²⁰ and Brazil (51%).²¹ The possible disparity may be due to the differences in sample size, study population, and study design. Additionally, this variation might be due to the fact that the other studies conducted in other countries had a single result but the current meta-analysis had the pooled prevalence from different studies.

The current study have assessed the relationship between neonatal hypothermia and delayed initiation of breastfeeding, without skin to skin mother contact immediately after delivery, delivered at night time, low birth weight, and bathed within 24 hours of birth.

Neonates who had no early initiation of breastfeeding within one hour of birth were 3.1 times more likely to develop hypothermia compared to those who had started breastfeeding within one hour after birth. This finding was supported by the study conducted in Nigeria,²² Nepal,²³ East Africa²⁴ and Sub-Saharan Africa.⁴ This could be because early initiation of breastfeeding within one hour of birth is beneficial for neonates in several ways, including the prevention of hypothermia. The first milk produced by the mother’s breasts in the initial days after delivery is colostrum, which is the thick, yellowish milk and rich in nutrients and contains antibodies that help protect the newborn from infections. When a baby breastfeeds early, they receive colostrum, which provides warmth and energy, helping to maintain their body temperature.^25,26

The other possible reason is early initiation breastfeeding often involves placing the baby skin-to-skin with the mother and this direct skin contact helps transfer body heat from the mother to the newborn, assisting in regulating the baby’s temperature. The delay in initiating breastfeeding can lead to a delay in skin-to-skin contact, reducing the warmth provided to the baby and increasing the risk of hypothermia.^27–29

Those neonates who had no skin to skin contact with their mother immediately after delivery were 4.4 times higher odds for hypothermia when compared with neonates those who have skin to skin contact immediately after delivery. This is supported with primary studies carried out in in Nigeria,²² Zambia³⁰ and Iran.³¹ Due to the fact that skin-to-skin contact between the mother and the newborn provides direct heat transfer from the mother’s body to the baby. The mother’s body warmth helps to regulate the baby’s body temperature and prevent hypothermia.^32,33 In addition, the baby’s skin is thin and has limited insulation properties, making them more susceptible to heat loss. When they are not placed skin-to-skin with their mother, there is a lack of a natural insulating barrier, which increases the risk of hypothermia.^34,35

The odds of neonatal hypothermia were almost three times higher among neonates who were born at night time compared with those neonates born at day time. This finding is supported with the study conducted in East Africa.¹² The possible rationale could be night time temperatures tend to be cooler compared to daytime temperatures. If the delivery room or the environment where the baby is kept after birth is not adequately heated or insulated, the newborn is more likely to experience heat loss and develop hypothermia.^3,36

This meta analysis showed that the odds of hypothermia among neonates with low birth weight was 3.6 times higher compared with those neonates with normal birth weight, which was in line with a systematic review and meta analysis studies conducted in Ethiopia,¹¹ sub-Saharan Africa,⁴ East Africa²⁴ and USA.¹⁶ The possible reason could be low birth weight neonates are more susceptible to hypothermia due to various physiological and environmental factors,factors. such as limited fat stores, thin skin, immature thermoregulation, a high surface area to body weight ratio, reduced brown adipose tissue, and an increased metabolic rate.^37,38

This meta analysis also identified that the odds of having hypothrmia among neonates who were bathed within 24 hours were 5.3 times higher compared with those neonates who had not been bathed within 24 hours of age, which was supported by the study conducted in Nepal.²³ This could be because neonates who are bathed within the first day of life are at increased risk of hypothermia due to different physiological reasons. Such as newborn’s ability to regulate body temperature is underdeveloped and relies on non-shivering thermogenesis, which involves heat production from brown fat. This mechanism can easily be overwhelmed by heat loss during bathing. Bathing increases evaporative heat loss, which is the primary mechanism of neonatal heat loss, as water evaporates from their skin. If the baby is not dried and wrapped properly after bathing, it can lead to significant cooling.^38,39

Limitations of the study

During the article searching, only the English language was taken into consideration, which may infuence the overall prevalence or this could lead to reporting bias. Lack of sufficient studies on prevalence and factors associated with neonatal hypothermia in Ethiopia and some of the included articles in this meta analysis had a relatively small sample size.

Conclusion and recommendation

The pooled prevalence of neonatal hypothermia was found to relatively higher. In the subgroup analysis, the highest prevalence was observed in Amhara region and in the studies conducted less than 2021. To prevent the risk of hypothermia in neonates, stakeholders should focus on the above associated factors.

Supporting information legends

Supporting file 1: Quality assessment of the included studies.

Data availability statement

Figshare: Hypothermia outcome data Excel.xlsx: https://doi.org/10.6084/m9.figshare.30451280.v2.⁴⁰

Data are available under the terms of the: https://creativecommons.org/licenses/by/4.0/

Figshare: Online resource for PRISMA Checklist of items to be included in reports of observational studies in epidemiology Checklist for cohort, case-control, and cross-sectional studies (combined): Abate, Asnake (2025). PRISMA Checklist.docx. figshare. Journal contribution.

https://doi.org/10.6084/m9.figshare.30453161.v2⁴¹

Data are available under the terms of the: https://creativecommons.org/publicdomain/zero/1.0/

Figshare: Supporting file: https://doi.org/10.6084/m9.figshare.30453413.v2⁴²

Data are available under the terms of the: https://creativecommons.org/licenses/by/4.0/

Acknowledgments

We would like to express our gratitude to all authors of the articles included in this systematic review and meta-analysis.

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