Background

Traditional medicine in Africa, including practices like traditional uvulectomy, is deeply rooted in cultural beliefs and passed down through generations [1,2]. Many communities view traditional healers as trusted authorities who provide treatments for various ailments using natural remedies or culturally accepted procedures [3]. In the case of traditional uvulectomy, it is often believed that removing the uvula can prevent or treat conditions like throat infections, breathing difficulties, or even malnutrition in children [4,5]. This practice persists due to limited access to modern healthcare, cultural influences, and a lack of awareness about the potential health risks associated with these procedures [2,6].

However, traditional uvulectomy poses significant health hazards [2,5,7] The procedure is often performed by non-medical individuals using unsterilized tools, leading to complications such as infections, hemorrhaging, oral injuries, and the transmission of communicable diseases like HIV and hepatitis [2,8–10]. It is done on a small soft tissue called uvula that hangs down from the back of the mouth above the throat between the two tonsils [2] It has the natural advantages of preventing aspiration, lubricating oropharyngeal mucosa, serving language communication, boosting immunological function, and preventing breast milk regurgitation through the nose [2,11–13].

Traditional medicine is defined by the World Health Organization (WHO) as a body of knowledge, skills, and practices rooted in the theories, beliefs, and experiences of indigenous cultures [14]. These practices are used in the maintenance of health, the prevention of disease, or for therapeutic purposes [10]. Traditional medicine often incorporates herbal remedies, manual techniques, and spiritual therapies, all of which are deeply connected to the cultural context in which they developed [14,15] Some of these procedures are supported by modern scientific evidence, and some are harmful to the health of the community even if they are practiced, such as childhood traditional uvulectomy. While the uvula’s primary functions, such as aiding in speech and preventing food from entering the nasal cavity, are well-documented, its immunological role is still a subject of debate in the medical community. Some studies suggest that the uvula may have a minor role in immune defense by producing small amounts of saliva rich in antibodies [16] while others argue that its removal does not significantly impair immune function [17]. Nevertheless, currently, in some parts of Sub-saharan Africa, the majority of people depend on traditional medicine for their primary healthcare demands [18,19].

Traditional childhood uuvlectomy is an unsupported and a dangerous cultural malpractice procedure for all childhood sickness, including feeding, breathing, and related diseases [2]. It is often accompanied by life-threatening neonatal morbidities such as infection, septicaemia, anaemia, aspiration, and oral-pharyngeal injuries caused by the use of unsafe instruments such as blades, needles, or thread loops [2]. The instruments used in traditional uvulectomy are often employed on multiple children during the same procedure, significantly heightening the risk of transmitting communicable diseases, particularly HIV and hepatitis viruses. For instance, a study conducted in Nigeria found that the reuse of unsterilized cutting instruments in traditional uvulectomy practices led to a 35% increase in the incidence of hepatitis B among children undergoing the procedure [6]. Additionally, research in Ethiopia indicated that 15% of children who underwent traditional uvulectomy contracted HIV as a result of exposure to contaminated tools [3]. Such statistics highlight the severe public health risks associated with these practices and underscore the urgent need for interventions to prevent these dangerous outcomes [6,13,16].

Moreover, Common complications include anemia, hemorrhage, sepsis, tetanus, aspiration, and prolonged pain following the procedure. For example, a study in Ethiopia reported that 25% of children experienced severe hemorrhage, while 18% were hospitalized due to infections such as sepsis and tetanus after undergoing traditional uvulectomy [20,21]. Additionally, changes in voice, sleep disturbances, and regurgitation of breast milk through the nostrils are reported complications. In Nigeria, research found that approximately 15% of children exhibited significant voice changes post-uvectomy [22]. These complications lead to increased healthcare utilization, requiring interventions such as antibiotics, oxygen therapy, intravenous fluids, blood transfusions, and phototherapy, thereby escalating costs within the healthcare system [2,23,24].

Morbidities resulting from post-uvulectomy complications contributed to the high burden of under-five childhood mortality. Unlike other harmful traditional practices that have diminished over time, traditional childhood uvulectomy continues to be widely performed, particularly in rural communities. For instance, a study in Ethiopia found that nearly 20% of children had undergone uvulectomy, with approximately 15% of those experiencing severe complications that required hospitalization [6]. These figures underscore the urgent need to address the health risks associated with this practice to reduce its impact on childhood mortality.

Despite its significant clinical implications, the pooled prevalence of traditional childhood uvulectomy (TCU) and their associated factors have not been adequately integrated into strategies aimed at reducing neonatal and under-five mortality in Africa. Furthermore, there is a notable absence of current systematic reviews or meta-analyses on this topic, which limits our understanding of the full impact of TCU on child health outcomes. The objective of this review and meta-analysis was estimating pooled prevalence and associated factors of TCU in Africa.

Methods and materials

Outcome measurement

Results

Selection of studies for review

The search strategy retrieved 46 articles, 16 of which were identified as duplicates and removed. Among the screened articles, 30 were from PubMed (n =  12), Google Scholar (n =  10), and the African Health Journal Repository (n =  8) (S4 File). The full texts of twenty-one articles were reviewed, and eleven studies were included in the review and meta-analysis (Fig 1).

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Fig 1. PRISMA flow diagram for pooled prevalence and associated factors of TCU in Africa, 2023.

https://doi.org/10.1371/journal.pone.0316755.g001

Characteristics of the included studies

A total of eleven cross-sectional studies with a pooled sample size of 7,231 children were included in this meta-analysis. Seven studies were found in each part of Ethiopia, particularly two from the Northwest Ethiopia between 2020–2022 [2,11], two from the North Ethiopia in 2013 [5,27], one from the Central Ethiopia in 2016 [8], two from the Southern Ethiopia between 2010–2023 [9,28], two from Nigeria in the Northwest and Plateau states between 2011–2016 [7,29] and one each from the Democratic Republic of the Congo and Niger between 2018–2023 [16,30] (Table 1).

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Table 1. Characteristics of the studies reviewed on the prevalence and associated factors of TCU in Africa, 2023.

https://doi.org/10.1371/journal.pone.0316755.t001

The maximum sample size was 1163, and the minimum sample size was 402 among the reviewed studies, for a total of 7231 children [9,28]. Traditional childhood uvulectomy was not uniformly practiced across Africa; its prevalence varies significantly by region and community. This practice is more common in some places than in others according to this review. Regarding this unequal distribution, the study settings for articles from Ethiopia were as follows: two articles from the Northwest, particularly from Debre Tabor [2,11]; two from southern Hawassa and Gamo [9,28]; two from Northern Axum town by [27]; and one from central region in Debre Birhan town [8].

One study from another part of Africa was from the DRC in South Kivu [16], two studies from Nigeria in the Northwest region and plateau state [7,29], and one study from Niger in Niamey [30].

The studies included in this systematic review and meta-analysis had no considerable risk of bias. Therefore, all the studies were included. We assessed the studies with a JBI risk of bias quality appraisal checklist for systematic review [25]. According to this appraisal checklist, none of the included studies were of poor quality and all included studies had a quality score ≥6 out of 9 criteria. Tables and figures were used to visually display the findings. Ten studies were excluded from the review because they did not fit the outcome measures specified for this review or scored below 6 out of 9 on the quality assessment appraisal. Additionally, qualitative studies were excluded upfront as part of the exclusion criteria. The ten excluded studies were identified after full-text appraisal (Table 2).

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Table 2. List of excluded studies from the review of pooled prevalence and associated factors of TCU in Africa, 2023.

https://doi.org/10.1371/journal.pone.0316755.t002

Meta-analysis

The pooled prevalence of TCU

The pooled prevalence of TCU from eleven studies [2,5,7–9,30,11,16,27–29] was 40.98 (95% CI =  25.04–56.92; I² =  99.61, P =  0.001) (Fig 2).

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Fig 2. Forest plot for pooled prevalence of TCU in some African countries, 2023.

https://doi.org/10.1371/journal.pone.0316755.g002

The absence of publication bias was assessed using Egger’s regression test. A significant result (P <  0.05) suggests potential publication bias, while a non-significant result (P >  0.05) indicates no evidence of bias. In this analysis, Egger’s test yielded p =  0.098, indicating no significant evidence of publication bias (Table 3).

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Table 3. Egger’s test for publication bias for prevalence and associated factors of TCU in Africa, 2023.

https://doi.org/10.1371/journal.pone.0316755.t003

Sensitivity analysis.

A sensitivity analysis was conducted to evaluate the stability and reliability of the findings in this systematic review and meta-analysis. This involved systematically excluding individual studies to assess their impact on the pooled effect size. The results showed that the effect sizes of all included studies ranged from 36.37 to 43.49 (95% CI), which fell within the overall pooled effect size range of 25.04 to 56.92 (95% CI). These findings indicate that no single study had a disproportionate influence on the overall results, confirming the robustness and consistency of the meta-analysis (Fig 3).

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Fig 3. Sensitivity analysis for pooled prevalence and associated factors of TCU in Africa, 2023.

https://doi.org/10.1371/journal.pone.0316755.g003

Subgroup analysis

Subgroup analysis was conducted based on the following factors: country, study setting, and sample size. For the country factor, studies were grouped into those conducted in Ethiopia, which had a higher concentration of primary studies, and other African countries, including Nigeria, the Democratic Republic of Congo (DRC), and Niger.

For the study setting, studies were categorized as community-based or health facility-based. Community-based studies focused on populations living in their residential areas, reflecting traditional practices and behaviors in their natural environments. In contrast, health facility-based studies examined populations accessing modern healthcare services, spanning primary to tertiary care levels.

Regarding sample size, studies were grouped into those with a sample size of less than 500 and those with 500 or more participants to assess the potential influence of study population size on the findings.

However, there was no effect on reducing the heterogeneity of the heterogeneity (I²). According to the seven studies of pooled effects in Ethiopia, the incidence of TCU was 47.19 (26.28–68.10), and according to four studies in other African countries, the incidence of TCU was 30.03 (18.11–41.94). After subgroup analysis by study setting, five studies used a community-based cross-sectional study design, for which the pooled prevalence was 55.56% (32.93–78.20). The remaining six studies used a health facility-based cross-sectional study design and had a pooled prevalence of 28.73% (19.67–37.78). The pooled prevalence of TCU in studies that used health facilities as a source of data was lower than that in studies obtaining data from the community. According to our subgroup analysis by sample size, the pooled incidence in three studies with a sample size less than 500 was 25.30% (13.97–36.63). The pooled incidence was 47.65% (26.04–69.25) for studies with sample sizes greater than 500 in seven studies (Table 4).

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Table 4. Subgroup analysis for pooled prevalence and associated factors of TCU in Africa, 2023.

https://doi.org/10.1371/journal.pone.0316755.t004

Factors associated with TCU

Based on this review, the predictors of traditional childhood uvulectomy according to pooled data from two studies were identified as rural residents and mothers with older children who had a previous history. By pooling studies, rural resident mothers were 2.45 times more likely to have a child who undergo traditional childhood uvulectomy (TCU) compared to mothers living in urban areas [8,9] (AOR =  2.45; 95% CI =  1.59–3.32). Mothers with a history of previous traditional childhood uvulectomy on their children were 8 times more likely to underwent TCU than were those with no history of uvulectomy (AOR =  8.44; 95% CI =  6.27–10.61) [2,11] (Table 5).

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Table 5. Factors associated with TCU by maternal residency and history of having a child with previous TCU in Africa, 2023.

https://doi.org/10.1371/journal.pone.0316755.t005

In a study by Yirdaw et al., mothers who lacked information about uvulectomy and those who perceived the uvula as a cause of infection were significantly more likely to have a child undergo traditional childhood uvulectomy (TCU) compared to mothers who were informed about its complications. Specifically, mothers lacking information were nearly three times more likely to have a child who underwent traditional childhood uvulectomy (TCU) (AOR =  2.98; 95% CI: 2.40–3.56), while those who believed the uvula caused infection were almost five times more likely to do so (AOR =  4.89; 95% CI: 4.64–5.14) [11]. According to maternal attitudes, children with uvulitis (inflammation and swelling of the uvula) that did not respond to medical treatment were nearly four times more likely to undergo traditional uvulectomy compared to their counterparts (AOR =  3.92; 95% CI: 3.28–4.56) [11].

According to other studies by Bayih et al., children who were home-delivered and male neonates were 6 and 4.56 times more likely to receive TCU, respectively, than were their counterparts (AOR =  6.02; 95% CI =  4.36–7.68) and at (AOR =  4.56; 95% CI =  3.08–6.06), respectively [2]. According to studies by Kebede et al. and Kefelew et al., housewife mothers and those with unfavourable attitudes toward modern medical care were nearly three and four times more likely to have a child with TCU, respectively, than were their counterparts and positive attitudes toward health care (AOR =  2.98; 95% CI =  1.72–4.20) and AOR =  4.31; 95% CI =  2.17–6 [8,9] respectively.

Discussion

The pooled prevalence of TCU was notably high at 40.98% (95% CI: 25.04%–56.92%) in certain African countries, with significant variability observed both between countries and across regions within the same country. This finding is comparable, though slightly lower, than the 44% pooled prevalence reported by Getachew et al. (2024), with a 95% CI of 31%–57%[3]. Although this review did not describe the specific traditional medicines used, the most common users of traditional medicine were identified in India, China, and Africa. This prevalence may be attributed to the widespread reliance on traditional medicine by the majority of the population in these regions. In Africa, traditional medicine has historically been the dominant healthcare system, deeply rooted in cultural practices long before the introduction of modern medicine [18,31].

This meta-analysis revealed that rural residents were three times more likely to practice traditional childhood uvulectomy (TCU) compared to their urban counterparts. This disparity can be attributed to several factors. In rural areas, traditional beliefs and practices are often more deeply entrenched, with communities relying on local customs and traditional healers for healthcare [8,9]. This might be because socioeconomic status plays a role in choosing traditional medicine in the community over modern health care [32]. From a modern health-seeking perspective, rural residents might have reduced willingness and poor infrastructure to access health care compared to urban residents, so they prefer to use traditional healers found nearby in their village [4,17,33,34]. Health-seeking behaviors in rural communities might also hinder parents’ choice of care during childhood illness. Traditional medicine is deeply embedded in cultural identity, with parents often favoring herbal treatments or spiritual interventions over conventional medical care. This reliance on traditional practices can delay the timely treatment of childhood illnesses, leading to complications and worsening health outcomes. Additionally, there may be a lack of awareness or mistrust of modern medical practices, further reinforcing the preference for traditional remedies [1,15,32,35].

Having a previous history of traditional childhood uvulectomy (TCU) was associated with an eightfold increase in the likelihood of practicing TCU compared to individuals without such a history [2,11]. This finding may help explain why experienced users of traditional medicine often become advocates within their communities, presenting evidence of the ‘safety’ of traditional childhood uvulectomy (TCU) to new users. In many developing nations, traditional medicine is widely accepted for several reasons: the perceived ineffectiveness of modern medical treatments, beliefs regarding the incurability of certain diseases through contemporary healthcare, and the confidence in the efficacy of traditional remedies. Additionally, traditional medicine is often more affordable and culturally resonant, leading to a preference for these practices. Many individuals also feel embarrassed or stigmatized when seeking care from modern healthcare facilities, further reinforcing their reliance on traditional healing methods [10,15,36].

Conclusion

Traditional childhood uvulectomy (TCU) was prevalent in Africa, with a pooled prevalence of nearly 41% from eleven studies, higher than in other regions. Mothers in rural areas and those who have a child with a history of TCU in a previous pregnancy were more likely to engage in the practice. Therefore, it might be essential to examine its impact on childhood health admissions to fully understand the extent of the problem. Based on these findings, a targeted education outreach program should be developed within maternal and child health (MCH) initiatives to prevent TCU. This program could focus on raising awareness about the health risks associated with TCU and promote alternative practices. By integrating TCU prevention into MCH strategies, the project can help reduce the prevalence of TCU, mitigate its negative health outcomes, and ultimately improve maternal and child health.

Supporting information