Breastfeeding is a choice made by all mothers, and this is highly affected by various factors including knowledge about and attitudes towards the benefits of breastfeeding. Despite Ethiopia attempts at increasing the rate of early initiation and duration of exclusive breastfeeding, the success is minimal. To the best of our knowledge, this is the first study assessing predictors of knowledge and attitude towards breastfeeding using validated instruments in Ethiopia. This community-based study revealed that half of the women had adequate knowledge about and the majority of the women had a neutral attitude toward breastfeeding. We also found that knowledge was associated only with maternal occupation while the women’s attitude towards breastfeeding was associated with maternal age, parity, antenatal care visits and BFKQ-AO score.
In the present study, we found that half of the respondents had an adequate level of knowledge about breastfeeding. However, the presence of nearly half of women with a low level of knowledge demonstrates the importance of interventions that aim at improving the knowledge may be important in efforts to encourage women to breastfeed their child, and ultimately achieve the target set in the national health sector plan. Particularly, aspects of knowledge questions that scored lower percentage such as colostrum, breastmilk expression, the problem with breastfeeding and breast engorgement need emphasis during breastfeeding promotion.
Positive attitude toward breastfeeding is a strong predictor of breastfeeding initiation and duration than sociodemographic factors [19–25]. In this study, the mean IIFAS score was in a neutral attitude towards breastfeeding range . The findings from the current study corroborate similar findings in the literature. Similar to the current study, a neutral attitude towards breastfeeding was reported across a diverse group of countries, China and Australia , Spain , Canada , Australia , Japan , and Scotland [20, 36]. Interestingly, most of these studies took place in Europe, and might not be comparable to our setting. However, it is possible that the finding of a neutral attitude could be one of the major reasons for a lower level of EBF in Ethiopia.
In the present study, women who were employed or merchants had higher knowledge about breastfeeding. This finding is similar to a study in China  reporting greater knowledge about breastfeeding among employed women. This is expected since maternal employment has been associated with education and those who are employed may be educated and thus have good knowledge about breastfeeding.
Earlier studies have shown that attitudes have been the focus of research because it is assumed that it always influence behavior; therefore, knowing something about a person’s attitude can help us predict behavior in many contexts . In this study, we found that younger women had higher attitude scores. In contrast, previous studies in China , Taiwan , Singapore , and Romania  showed that older mothers had more positive attitudes toward breastfeeding. The direct relation between higher IIFAS score (positive attitude) with increased age is likely linked to improved experience with breastfeeding. Breastfeeding is also in many aspects a learned behavior.
Maternal education is associated with favorable attitudes toward breastfeeding as highly educated women were more aware of breastfeeding benefits that help them develop a positive attitude. Though statistically not significant in the current study mothers who attended primary school had lower attitude score. Nevertheless, previous studies have shown that higher IIFAS-S scores were positively associated with a higher educational level in Lebanon , Ireland , China , Singapore  and Spain .
Studies report mixed results regarding the association between IIFAS score and occupation. A study from Ireland found that full or part-time employed mothers had more positive attitudes toward breastfeeding compared to housewives , while a study among Chinese women reported no significant difference between infant feeding attitudes and working status . However, in our study, we found that employed or merchant mothers had more negative attitudes toward breastfeeding than housewives, but the difference was statistically not significant. It is conceivable that women who work may suffer from lack of time, fatigue, and experience breastfeeding as exhaustive leading to negative attitudes towards breastfeeding.
Higher maternal IIFAS score has been found by several other studies to be associated with higher family annual income in Lebanon , Taiwan , Singapore , Ireland  Spain . In this study, we estimated household assets to generate a household asset score/wealth index since household income does not measure the value of non-monetary items, particularly in a low-income context. Nevertheless, we did not find that the IIFAS score was associated with the socio-economic status of the household in our setting.
Multiparous women are expected to have a positive attitude towards breastfeeding due to their prior experience, maternal confidence and ability to solve feeding problems. However, unlike findings from the Infant Feeding Survey where multiparous women had more favourable attitudes to breastfeeding , multiparous women in the current study had more negative attitudes towards breastfeeding. One can speculate that Ethiopian women with many children are taxed by household chores and limited time to breastfeed leading to negative attitudes. On the other hand, mothers with fewer children have more time and are more concerned with their newborn.
Pregnant women with ≥ 4 antenatal care visits had higher IIFAS scores. A possible explanation might be that these women had increased exposure to prenatal breastfeeding education/counselling. Moreover, our respondents with high levels of breastfeeding knowledge also had a higher attitude score, in line with a finding from Finland . This suggests that those mothers who have knowledge about breastfeeding also have a positive attitude.
This study has some limitations. Firstly, this is a cross-sectional study in design and thus we cannot establish causal relationships. Our findings are associations that may, or may not reflect cause and effect. Secondly, the majority of our participants had limited schooling, reducing the ability to detect a potentially statistically significant association between knowledge and attitude towards breastfeeding and educational status. The women in this study were homogeneous demographically and the findings may not be applicable across different regions of the country. Additional research is needed to assess the relationship between IIFAS and BFKQ and breastfeeding initiation and duration in urban Ethiopian settings.