DOI: https://doi.org/10.21203/rs.3.rs-118108/v1
Background: Exclusive Breastfeeding (EBF) can prevent up to 13% of under-five mortality in developing countries. In Sub-Saharan Africa the rate of EBF at six months remains very low at 36%. Different types of factors such as maternal, family-related and work-related factors are responsible for the low rate of EBF among employed women. This study aimed to assess the prevalence of EBF continuation and associated factors among employed women in North Ethiopia.
Methods: A community-based, cross-sectional study was conducted in two towns of Tigray region, North Ethiopia. Employed women who had children between 6 months and 2 years were surveyed using multistage, convenient sampling. Women filled a paper-based validated questionnaire adopted from Breastfeeding and Employment Study toolkit. The questions were grouped into four parts of sociodemographic characteristics, maternal characteristics, family support and work-related factors. Factors associated with EBF continuation as a binary outcome (yes/no) were determined using multivariate logistic regression.
Results: Four-hundred and forty-nine women participated in this study with a mean (SD) age 30.4 (4.2) years. Two hundred and fifty-four (56.4%) participants exclusively breastfed their children for six months or more. The main reason for discontinuation of EBF was the requirement of women to return to paid employment (31.5%). Four-hundred and forty (98.2%) participants believed that breastfeeding has benefits either to the infant or to the mother. Three hundred and seventy-one (82.8%) of the participants received support from their family at home to assist with EBF most commonly from their husbands and mothers. Having family support (adjusted odds ratio [AOR]= 2.1, 95%, CI 1.2-3.6; P = 0.005), having frequent breaks at work (AOR= 2.6, 95% CI, 1.4-4.8; P = 0.002) and the possibility of buying or borrowing required equipment for expressing breast milk (AOR= 1.7, 95% CI, 1.0-3.0; P = 0.033) were statistically associated with increasing chance of EBF.
Conclusion: Although returning to work was reported by the study participants as the main reason for discontinuation of EBF, families and managers’ support have significant roles in EBF continuation which in the absence of six-month maternal leave for employed women in Ethiopia would be of benefit to mothers and their child.
The rate of EBF for six months is suboptimal in many parts of the world. Different factors are responsible for the low rate of EBF among employed women because they need to return to work before six months because paid employment is a necessity. In this study full-time employed women who had children aged between 6 months and 2 years were participated.
The women were asked for how long they exclusively breastfed their last child as an outcome variable. The independent variables were grouped into four 1) demographic characteristics age of infants and mothers, marital status, type of work, educational status of mothers 2) EBF practice and knowledge about the benefits of EBF and breast milk expression; 3) family from their husband and extended family members; and 4) work-related factors.
Of the 449 participants, 254 (56.4%) of them EBF their children for six months or more. The family members most commonly involved in supporting women to EBF were their husbands, their mothers and mothers-in-laws. More than half of the participants agreed/strongly agreed that their co-workers helped them to change their work schedule. Around three fourth of the participants disagreed/strongly disagreed that they had support from their managers. All the participants reported that there is no designated place for breastfeeding or express milk in their workplace.
In conclusion, our findings show a reassuring increased percentage of EBF among employed women compared to previous studies in Ethiopia. Returning to work was reported by the study participants as the main reason for discontinuation.
In 1990 the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) adopted a declaration on protection, promotion and support of breastfeeding focused on the importance of EBF for at least six months (1). Appropriate EBF practice can prevent up to 13% of under-five mortality in developing countries (2). In light of this, UNICEF and WHO have set a target to increase the rate of EBF to 50% by 2025 (3, 4). However, the rate of EBF for six months is suboptimal in many parts of the world (5). In Sub-Saharan Africa only 36% mothers exclusively breastfeed their infants until six months (6). In Ethiopia, the rate of EBF among employed women remains suboptimal. In studies conducted in Gondar town (7) and Fafan zone(2), Ethiopia with the focus on employed and non-employed women, the rate of EBF among employed women was 21% and 24.8%, respectively. Another cross-sectional study conducted in Dukem, central Ethiopia in 2015 showed that only 24.3% employed mothers exclusively breastfed their infants until six months (8).
Different factors are responsible for the low rate of EBF among employed and non-employed women. Good knowledge and positive attitude of mothers about the benefits of EBF plays important role for the continuation EBF until six months (9, 10). A study in Jordan showed support and encouragement from husband and extended family members were associated with increased rate of EBF for six months (11), whereas mother’s return to paid employment negatively impacted the duration of EBF (7, 12, 13). Employed women need to return to work before six months because paid employment is a necessity, not an option for many of them (14). Studies conducted among employed women shows different work-related factors that affect the continuation EBF either positively or negatively (3, 12, 13). Availability of physical facilities and supportive work environment such as flexibility of work and having supportive mangers encourage women to continue EBF (3, 15).
Kebede T. et al reported several factors that triggered EBF discontinuation including having a short duration of maternity leave, full time employment, working in private organizations, lack of flexible working hours unable to express breast milk, lack of break to express breast milk and workplace being far away from the child (8). This study provides some useful insights into some of the barriers to EBF for employed women in Ethiopia; however, the findings may not be generalisable to other areas of Ethiopia, as a very diverse country with different ethnicities and cultural expectations. Hence, the results of a study conducted in central Ethiopia, for example, may not be generalizable to people who live in the Northern part of the country. Moreover, the maternal leave in Ethiopia has been increased from three months to four months in 2019. The current study aimed to assess EBF continuation and associated factors among employed women in North Ethiopia, since the introduction of increased maternal leave. Knowledge of mothers about the benefits of EBF and practice of EBF were also assessed.
This study was part of a larger mixed-methods study looking at determinants of EBF among employed women after they returned to work. This paper reports on the survey results of the study. Findings of this study are reported based on the Strengthening the Reporting of Observational Studies in Epidemiology Guidelines (16).
This community-based, cross-sectional study was conducted in two towns in Tigray region, North Ethiopia between December 2018 and January 2019.
The study participants were full-time employed women who had children aged between 6 months and 2 years. Women working in contract, casual, part time and own business were excluded as they might have more flexible schedules.
Multistage sampling was used to reach the study participants. First, two zones from the seven zones in Tigray region were selected using convenient sampling method. The biggest town was then selected from each zone because these towns are administrative and business centres of the zone in which many employed women live. All kebeles (lowest administrative division) in each town were included in the study. The total number of participants was allocated to each town equally. Finally, purposive sampling was used to recruit women from each kebele (Fig. 1).
Twenty health extension workers from both towns visited women in their home. Potential participants were invited to the study and given the explanatory statement. Those who agreed to take part in the study were provided with a hard copy, self-administered questionnaire. They were told that the questionnaire would be collected two weeks later. The first author supervised the overall data collection process.
We used a survey tool adapted from Breastfeeding and Employment Study (BESt) toolkit, developed by the University of Wisconsin (17). The tool was modified to capture local factors deemed to be important. In total, 11 maternal characteristics and six family support related questions were added. The questionnaire comprises a total of 66 questions, 36 of them were four-point (strongly agree, agree, disagree and strongly disagree) Likert scale questions. The questionnaire was prepared in English, then translated to local language (Tigrigna). Once participants had completed the questionnaire it was back translated to English for data processing and analysis. Prior to distribution, the questionnaire was piloted in five employed mothers to ensure its wording and understandability by local Tigran mothers; no amendment was necessary.
The women were asked for how long they exclusively breastfed their last child. There were five alternatives to respond this outcome variable (Not at all, 3 months or less, 4 to 6 months, 6 months and more than 6 months). The independent variables grouped were into four 1) demographic characteristics age of infants and mothers, marital status, type of work, educational status, monthly salary of mothers, number of children, place and type of birth; 2) EBF practice and knowledge about the benefits of EBF and breast milk expression; 3) family support that focused on the support mothers obtained at home from their husband and extended family members; and 4) work-related factors. Organisational, managers support, co-workers support as well as time and physical environment related questions were addressed under the work-related factors.
The sample size was calculated using G*power using the following parameters: a power of 0.80, true proportion of the population of employed women (21%) based on a previous study conducted in Gondar, Ethiopia (7), a level of significance of 0.05 and a medium effect size of 0.5 and sample size was 507.
We summarized continuous and categorical variables using means (± standard deviations, SDs) and frequencies (percentages), respectively. The outcome variable (duration of EBF) was recoded as either yes (breastfed for 6 months or more) or no (Not at all, 3 months or less, 4 to 6 months breastfed) for the question “did you EBF your infant for six months”. The four-category response (strongly agree, agree, disagree and strongly disagree) were collapsed into two categories (strongly agree/agree and strongly disagree/disagree).
Logistic regression analysis was used to assess the relationship between the dependant and independent variables at 95% confidence interval. Variables with P-value < 0.1 on the univariate logistic regression was included in the multivariate logistic regression. Variables with p-value 0.05 or less were considered statistically significant. SPSS software version 26 was used for the analyses.
Of the 510 questionnaires distributed, 449 (88.0%) were completed with equal number of completed questionnaires returned from each town. Nine out of 449 questionnaires were incomplete for the work-related section, and one out of nine questionnaires was incomplete for all sections except for demographic characteristics. Incomplete questionnaires were included in the descriptive statistics, but not in the logistic regression analysis.
The mean (SD) age of the study participants was 30.4 (4.2) years. Three-hundred and seventy-nine (84.4%) participants were married and 337 (75.1%) had completed education at diploma level or above. Three hundred and twenty-four (72.2%) respondents had either two or more live children, and 140 (31.2%) had monthly income of 107 USD or more. Four-hundred and forty-one (98.2%) mothers gave birth to their last child in a health facility and 303 (67.5%) had a spontaneous vaginal birth (Table 1).
| Question/variable | n (%) |
|---|---|
| Age (years), mean (SD) | 30.4 (4.2) |
| Age of youngest child (months), mean (SD) | 12.1 (4.6) |
| Marital status Partnered Unpartnered (single, divorced, widowed) | 379 (84.4) 70 (15.6) |
| Educational Status Secondary school or less Diploma and above | 112 (24.9) 337 (75.1) |
| Type of work Professional/skill Administrative Others | 207 (46.1) 186 (41.4) 56 (12.5) |
| Monthly salary (USD) Less than 46 46– 76 77–107 More than 107 | 112 (25.2) 97 (21.6) 100 (22.3) 140 (31.2) |
| Number of live children per participant One Two or more | 125 (27.8) 324 (72.2) |
| Place of last birth Home Health center* Hospital | 8 (1.8) 124 (27.6) 317 (70.6) |
| Mode of birth Spontaneous vaginal birth Instrumental assisted vaginal birth Caesarean section | 303 (67.5) 48 (10.7) 98 (21.8) |
| *Health centres are primary health care units that provide preventive and curative services with inpatient capacity of five beds. | |
| Values are n (%) unless otherwise specified. | |
Four-hundred and forty-eight participants responded to the section of questionnaire investigating breast feeding practices and knowledge. Of these women, 393 (87.7%) commenced breastfeeding within one hour of birth and 254 (56.6%) mothers EBF their children for six months or more. For 141 (31.5%) mothers who did not EBF, their primary reason for the introduction additional food/fluids was the requirement to return to paid employment within six months of birth.
Four-hundred and forty (98.2%) participants believed that EBF has benefits. The common reasons participants identified as a motivation for continuing EBF included nutritional benefits (58.0%), disease prevention (66.3%) and growth and development of infants (63.8). Contraceptive effect was another benefit of EBF mentioned by 350 (78.1%) of the study participants. A total of 293 (65.4%) of respondents reported that they had information about expressed breast milk feeding. Health extension workers and professionals were the main sources of information about expressing breast milk for 156 (34.8%) and 158 (35.3%) of mothers, respectively (Table 2).
| Question/variable | n (%) |
|---|---|
| Starting breastfeeding within one hour after birth Yes No | 393 (87.7) 55 (12.3) |
| Duration of EBF 6 months or more less than 6 months | 254 (56.6) 194 (43.4) |
| Reasons given for not adhering to EBF Belief that breast milk alone was not enough Didn’t have enough milk Started paid employment Influence from family Other | 38 (8.5) 26 (5.8) 141 (31.5) 3 (0.7) 2 (0.5) |
| Belief that EBF is beneficial Yes No | 440 (98.2) 8 (1.8) |
| Mothers’ perceptions of benefits EBF for the infant** Nutritional benefits It reduces some diseases Growth and development Bonding between mother & infant | 260 (58.0) 297 (66.3) 286 (63.8) 183 (40.8) |
| Mothers’ perceptions of benefits EBF for herself/women** Contraceptive use Control bleeding after birth Decrease risk of breast/cervical cancer Economic benefits | 350 (78.1) 115 (25.7) 112 (25.0) 162 (36.2) |
| Awareness on how to express breast milk Yes No | 293 (65.4) 155 (34.6) |
| Source of information about expressed breast milk feeding** Health extension workers Health professionals Mass media (Radio, TV etc.) Social Media Other sources* | 156 (34.8) 158 (35.3) 77 (17.2) 30 (6.7) 5 (1.1) |
| Mother has feed her baby using expressed breastmilk Yes No | 109 (24.3) 339 (75.7) |
| Reason for expressed breastmilk feeding Returned to paid employment before 6 months Unable to breastfeed after birth Other | 74 (16.5) 23 (5.1) 12 (2.7) |
| * other sources = individual woman’s knowledge as a health professional, family | |
| **possible to give more than one answer | |
From the total study participants who responded this part (448), 371 (82.8%) reported that they received support from their family at home to continue EBF. The family members most commonly involved in supporting women to EBF were their husbands, their mothers and mothers-in-law as stated by 254 (56.7%), 172 (38.4%) and 61 (13.6%) participants, respectively. The participants also reported that 266 (59.4%) of husbands actively encouraged EBF. The common types of support women obtained at home were baby care 224 (50.0%) and staying with baby at home while they were at work 248 (55.4%). When mothers did not have support from their husband or members of their family, some would leave their infants with domestic workers at home 149 (33.3%) or take them to work 122 (27.2%) (Table 3).
| Question/variable | n (%) |
|---|---|
| Family support to continue EBF following return to paid employment Yes No | 371 (82.8) 77 (17.2) |
| Members of family who provided support at home Husband Mother Mother-in-law Domestic worker Other* | 254 (56.7) 172 (38.4) 61 (13.6) 26 (5.8) 33 (7.4) |
| How do you rate the support you obtained from your husband? Unsupportive Actively supportive Supportive on request Not applicable (no husband) | 59 (13.2) 266 (59.4) 93 (20.8) 30 (6.7) |
| Type of support at home** No support Baby care Staying with baby at home Household activities Other | 58 (12.9) 224 (50.0) 248 (55.4) 150 (33.5) 5 (1.1) |
| If no support at home, how you manage your child with work? Child minded at home by domestic worker Day care (outside home) Child taken to mother’s work Other | 149 (33.3) 24 (5.4) 122 (27.2) 4 (0.9) |
| *others: neighbours, extended family members ** possible to give more than one answer | |
Four-hundred and forty participants identified a number of workplace factors that affected the continuation of EBF including receiving supports from organizations, managers and co-workers, as well as availability of time and physical environment.
In responding to the organizational support related questions, 277 (63.0%) participants agreed/strongly agreed that they had enough maternal leave before going back to work. Three-hundred and fourteen (70.7%) participants disagreed/strongly disagreed that they had policies about breastfeeding in their workplace. One hundred and ninety-six (44.5%) participants strongly disagreed and further 191 (43.4%) disagreed that they had access to an area at work specifically designated for breastfeeding. From the participant mothers, 313 (71.1%) of them reported that their employment would not be at risk if they breastfeed in their workplace. A total of 306 (69.6%) of participants disagreed/strongly disagreed that their opportunities for job advancement would be limited if they breastfeed at work (Table 4).
| Variables | n (%) |
|---|---|
| Organizational support | |
| I would have enough (paid or unpaid) maternity leave to get breastfeeding started before going back to work. Strongly disagree/Disagree Strongly agree/Agree | 163 (37.0) 277 (63.0) |
| My company has written policies for employees that BF or expressing breast milk. Strongly disagree/Disagree Strongly agree/Agree | 314 (71.4) 126 (28.6) |
| I would feel comfortable asking for space to breastfeed/express breast milk at work Strongly disagree/Disagree Strongly agree/Agree | 357 (81.1) 83 (18.9) |
| I’m certain there is a place I could go to breastfeed or express breast milk at work. Strongly disagree/Disagree Strongly agree/Agree | 387 (88.0) 53 (12.0) |
| There is someone at work that would help me plan for BF or expressing breast milk Strongly disagree/Disagree Strongly agree/Agree | 351 (79.8) 89 (20.2) |
| My job could be at risk (e.g. lose my job) if I breastfed or express breast milk at work Strongly agree/Agree Strongly disagree/Disagree | 316 (71.8) 124 (28.2) |
| My opportunities for job advancement would be limited if I breastfed/express breast milk at work Strongly agree/Agree Strongly disagree/Disagree | 306 (69.5) 134 (30.5) |
| Managers support | |
| My manager would support me breastfeeding or expressing breast milk at work Strongly disagree/Disagree Strongly agree/Agree | 320 (72.7) 120 (27.3) |
| My manager would think I couldn’t finish all my work if I ask break for breastfeeding Strongly disagree/Disagree Strongly agree/Agree | 293 (66.6) 147 (33.4) |
| I would feel comfortable speaking with my manager about breastfeeding Strongly disagree/Disagree Strongly agree/Agree | 282 (64.1) 158 (35.9) |
| My manager would make sure my job is replaced if I need break for breastfeeding or expressing breast milk Strongly disagree/Disagree Strongly agree/Agree | 199 (45.2) 241 (54.8) |
| My manager would change my work schedule to let me time for breastfeeding or expressing breast milk Strongly disagree/Disagree Strongly agree/Agree | 319 (72.5) 121 (27.5) |
| My manager would help me deal with my workload to breastfeed/express breast milk Strongly disagree/Disagree Strongly agree/Agree | 316 (71.8) 124 (28.2) |
| Co-workers support | |
| I would feel comfortable speaking with my co-workers about breastfeeding Strongly disagree/Disagree Strongly agree/Agree | 243 (55.2) 197 (44.8) |
| My co-workers would change their break times so that I could breastfeed/express breast milk Strongly disagree/Disagree Strongly agree/Agree | 188 (42.7) 252 (57.3) |
| My co-workers would replace my job duties if I needed time for breastfeeding or expressing breast milk. Strongly disagree/Disagree Strongly agree/Agree | 196 (44.5) 244 (55.5) |
| Time related variables and Physical environment | |
| My breaks are frequent enough for BF or expressing breast milk. Strongly disagree/Disagree Strongly agree/Agree | 358 (81.4) 82 (18.6) |
| I could adjust my break schedule in order to breastfeed or express breast milk. Strongly disagree/Disagree Strongly agree/Agree | 314 (71.4) 126 (28.6) |
| I could buy or borrow the equipment I would need for expressing breast milk. No Yes | 356 (80.9) 84 (19.1) |
| My company would supply the equipment I need for expressing breast milk at work No Yes | 417 (94.8) 23 (5.1) |
| There is a company-designated place for women to breastfeed or express milk No Yes | |
| 440 (100) 0 (0) |
Three hundred and twenty-three (73.4%) women disagreed/strongly disagreed that they had support from their managers to breastfeed at work. From the study participants, 293 (66.6%) mothers disagreed/strongly disagreed with the statement ‘my manager would think I couldn’t finish my work if I needed break for breastfeeding’. Two hundred and eighty-two (64.1%) mothers reported that they did not feel comfortable speaking about breastfeeding with managers. When talking about flexibility of the managers in supporting breastfeeding mothers, 241 (54.8%) participants reported that their managers want to make sure another person is available to undertake the work when the mothers needed time for breastfeeding. Ninety-one (20.7%) agreed and a further 30 (6.7%) strongly agreed, that their managers allowed them to change their work schedule for breastfeeding. However, 316 (71.8%) participants disclosed that their managers did not help them to manage their workload (Table 4).
From the participant mothers, 243 (55.3%) of them did not feel comfortable when speaking with co-workers about breastfeeding. However, 243 (55.3%) agreed/strongly agreed that their co-workers helped them by changing their break time to allow time for breastfeeding or expressing breast milk. Similarly, 244 (55.4%) participants Agreed/strongly agreed that their co-workers undertook their job to allow them time to breastfeed or express breast milk (Table 4).
From the study participants, 80 (18.1%) agreed/strongly agreed that they had frequent enough breaks for breastfeeding or expressing breast milk. A total of 126 (28.6%) of participants agreed/strongly agreed that they could adjust their schedule to get time for breastfeeding. Whereas, when talking about accessibility of equipment for breast milk expression, only 84 (19.1%) reported that they could buy or borrow the equipment for expressing breast milk. All (100%) of the participants reported that none of the companies they work had designated place for women to breastfeed or express milk during the work day (Table 4).
Two-hundred and fifty-four (56.6%) participants reported that they exclusively breastfed their infants until six months. The main reason for 46.4% of the study participants who did not adhere to EBF was returning to work before 6 months.
Of the variables used in the univariate logistic regression, only six variables had a p value of < 0.1 and were used in the multivariate logistic regression (Table 5). Mothers who had family support were two times more likely to continue EBF, compared to those who did not have family support (AOR = 2.1, 95%, CI 1.2–3.6; P = 0.005). Similarly, mothers who agreed/strongly agreed of having frequent enough breaks were 2.6 times more likely to EBF than those disagreed/strongly disagreed (AOR = 2.6, 95% CI, 1.4–4.8; P = 0.002). When the mothers could buy or borrow equipment they need for expressing breast milk, they were 1.6 times more likely to continue EBE compared to those who could not (AOR = 1.7, 95% CI, 1.0–3.0; P = 0.033) (Table 5).
| Variables | n | Crude OR (95% CI); p values | Adjusted OR (95% CI); p values |
|---|---|---|---|
| Age of mother (years) 18–29 30 or more | 265 175 | Ref. 1.2 (0.8–1.9); 0.263 | NI |
| Marital status Partnered Unpartnered (single, divorced, widowed) | 373 67 | Ref. 1.2 (0.7–2.1); 0.439 | NI |
| Educational Status Secondary or less Diploma or more | 103 337 | Ref. 1.3 (0.7–2.2); 0.304 | NI |
| Monthly salary, (USD) 76 or less Greater than 76 | 200 240 | Ref. 0.8 (0.5–1.3); 0.518 | NI |
| Number of children One Two or more | 125 315 | Ref. 0.7 (0.4–1.1); 0.166 | NI |
| Awareness about breast milk expression No Yes | 151 289 | Ref. 0.6 (0.4–0.9); 0.047 | Ref 1.1 (0.7–1.7); 0.469 |
| Family support to continue EBF following return to paid employment No Yes | 77 363 | Ref. 0.4 (0.2–0.7); 0.00 | Ref 2.1 (1.2–3.6); 0.005 |
| I’m certain there is a place I could go to breastfeed or express breast milk at work Strongly disagree/Disagree Strongly agree/Agree | 387 53 | Ref. 2.0 (0.9–4.8); 0.081 | Ref 0.7 (0.4–1.5); 0.455 |
| I would feel comfortable asking for accommodations for breastfeeding or express breast milk at work. Strongly disagree/Disagree Strongly agree/Agree | 357 83 | Ref. 1.7 (0.8–3.5); 0.099 | Ref. 0.6 (0.3–1.2); 0.182 |
| My manager would change my work schedule to allow me time for BF Strongly disagree/Disagree Strongly agree/Agree | 320 120 | Ref. 2.0 (0.9–4.4); 0.062 | Ref. 0.7 (0.4–1.2); 0.282 |
| My breaks are frequent enough for breastfeeding or expressing breast milk. Strongly disagree/Disagree Strongly agree/Agree | 358 82 | Ref. 0.3 (0.1–0.8); 0.018 | Ref. 2.6 (1.4–4.8); 0.002 |
| I could buy or borrow the equipment I would need for expressing breast milk. No Yes | 356 84 | Ref. 0.4 (0.2–0.9); 0.022 | Ref 1.7 (1.0–3.0); 0.033 |
| NI, Not included | |||
In this study more than half of employed women reported EBF and a majority of them were aware of the benefits of EBF to infants and the mothers and reported family support. While more than half of the participants agreed/strongly agreed that their co-workers helped them to change their work schedule, around three fourth of the participants disagreed/strongly disagreed that they had support from their managers. All the participants reported that there is no designated place for women to breastfeed or express milk in their workplace. Over half of the study participants reported EBF at six months. Factors associated with EBF were having family support, having frequent breaks at work and the possibility of buying or borrowing equipment for expressing breast milk.
The prevalence of EBF in our study (56.4%) was higher as compared to other studies conducted in other areas of Ethiopia including Gondar in 2015 (20.9%), Dukem in 2015 (24.3%) and Fafan in 2016 (24.8%) (2, 7, 8). The reason for the increase in EBF might be a consequence of recent improvements in maternal leave in Ethiopia. Besides, women can use their annual leave after they finish their four months maternal leave which assists employed women to extend the duration of EBF at least by one month. Our prevalence of EBF was also higher compared to other reported prevalence in other areas of Africa such as Ghana (10.3%) and Egypt (14.1%) (18, 19). The difference might be due to the difference in leave entitlements, or local cultural practices and social expectations.
Awareness of mothers about the benefits of EBF is crucial for the continuation of EBF. In this study 98.2% participants believe that EBF has benefits. Similar finding was obtained in a study conducted in Fafan, Somali region of Ethiopia in which all the participants were aware of the benefits of EBF (2). Studies conducted in Ghana and South Jordan also found that 99% and 99.3% mothers were aware of the benefits of EBF, respectively (18, 20). However, in studies conducted in Gondar, Ethiopia and Nigeria, 80% and 77.5% participants acknowledged the benefits of EBF, respectively (7, 21). These figures suggested that employed women has good awareness about the benefits of EBF which could motivate them to continue EBF until six months even after they returned to work (7).
In this study, having family support was positively associated with continuation of EBF. The common supports mothers obtained at home include baby care, staying with baby at home while she was at work, helping with cooking and other household activities. Similar finding was found in a study conducted among working women in Indonesia (22). The authors of an Indonesian study found that mothers who had family support were two times more likely than those who did not have the support to EBF (22). However, a study conducted in Gondar, Ethiopia showed that mothers who had no family support were more likely to EBF as compared to those who had family support (7). This was an unexpected finding not supported by the literature. Women who have support at home could spend more time with their infants which helped the children get adequate breastmilk. Therefore, having family support encouraged women to continue EBF after they returned to paid employment.
Participants who had break time in between work were more likely to continue EBF. In this study mothers who agreed/strongly agreed they had frequent enough break were more likely to continue EBF as compared to those disagreed/strongly disagreed. Similarly, in the study conducted in Dukem, central Ethiopia (8), mothers who had no break time in between work were more likely to discontinue EBF as compared to those who had break. This would be because having breaks in between work might encourage women to continue EBF after they returned to work (23). When employed women have break time in between work, either they could go home to breastfeed their infants when their home is nearby or ask someone to bring their infants to work.
Participants who could buy or borrow equipment they need for expressing breast milk, were more likely to continue EBE as compared to those who could not afford. This means, if mothers have access to equipment to express their breast milk, they can EBF longer. However, there is no existing literature to compare with this finding. Therefore, this could be the new finding of this study.
This study has limitations. Firstly, self-administered questionnaire was used to collect the data which make it difficult for the women to ask for clarification for any question. Secondly, employed women with children up to 2 years were included in the study which could lead to recall bias of the exact duration of EBF. Thirdly, the study participants were government employees. Therefore, the findings would not represent to women employed in private organizations. Further research with the focus on private employed women is recommended. Lastly, we used a convenient sampling in Northern Ethiopia and the findings might not be generalizable to all employed women in Ethiopia.
Compared to previous studies in Ethiopia, our findings show a reassuring increased percentage of EBF among employed women which might be due to a recent increase in maternity leave in Ethiopia. Almost all participants were aware of the benefits of breastfeeding. Returning to work before six months was mentioned as a common reason for many employed women to discontinue EBF. Mothers who could afford to buy equipment for breast milk expression were more likely to continue EBF. Maternal leave for six months is the best solution for women to adhere to EBF. In the absence of six-month maternal leave, families and managers’ role is of importance in continuing EBF.
Adjusted Odds Ratio; BESt:Breastfeeding and Employment Study; EBF:Exclusive Breastfeeding; UNICEF:United Nations Children’s Fund; WHO:World Health Organization
Ethics approval and consent to participate
Ethical approval was obtained from Monash University Human Research Ethics Committee (ethics approval number: 13794) and Mekelle University Research Ethics Approval Committee (ethics approval number: ERC 1490/2018). Participation was voluntary and informed consent was obtained from each study participant prior to distribution of the questionnaire. To ensure their privacy, no personal identifiers of participants was used.
Consent for publication: not applicable
Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Competing interests: The authors declare that they have no conflicts of interest.
Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Authors' contributions: KG, HH, VP and EF have made substantial contributions to the conception, design, analysis, and interpretation of the study. All authors read and approved the final manuscript.
Acknowledgements:
The authors would like to acknowledge the participant mothers for sharing their experiences by responding the questionnaire.