Socio-demographic characteristics
A total of 722 study participants were included, yielding a response rate of 96.8%. The respondents' ages ranged from 18 to 42 years (mean = 27.1 years, SD = ± 6.5 years). Less than half (42.7%) of the study participants were rural residents and quarter (25.1%) were housewives and had post-secondary education level( 24.1%)(Table 1).
Table 1
Socio-demographic characteristics of study participants and their infants, Dire Dawa Administration, eastern Ethiopia, 2023 (n = 722)
Variables
|
Category
|
Frequencies
|
Percentage
|
Age (in completed years)
|
35 and above
|
240
|
33.2
|
25–34
|
258
|
35.7
|
24 and less
|
224
|
31.0
|
Residence
|
Rural
|
308
|
42.7
|
Urban
|
414
|
57.3
|
Level of education(women)
|
No formal education
|
145
|
20.1
|
Primary level
|
264
|
36.6
|
Secondary level
|
139
|
19.3
|
Post-secondary level
|
174
|
24.1
|
Marital status
|
Married
|
665
|
92.1
|
Single
|
36
|
5
|
Divorced
|
13
|
1.8
|
Widow
|
8
|
1.1
|
Level of education (husbands, n = 665)
|
No formal education
|
95
|
14.3
|
Primary level
|
157
|
23.6
|
Secondary level
|
174
|
26.2
|
Post-secondary level
|
239
|
35.9
|
Occupation
|
House wife
|
181
|
25.1
|
Merchant
|
256
|
35.5
|
Private employee
|
79
|
10.9
|
Public employee
|
97
|
13.4
|
Daily laborer
|
109
|
15.1
|
Monthly income
|
< 100USD
|
206
|
28.5
|
100-150USD
|
442
|
61.2
|
> 150 USD
|
74
|
10.2
|
Religion
|
Muslim
|
315
|
43.6
|
Orthodox
|
136
|
18.8
|
Protestant
|
230
|
31.9
|
Catholic
|
41
|
5.7
|
Age of infants
|
< 6 months
|
254
|
35.2
|
6–12 months
|
468
|
64.8
|
Sex of infants
|
Male
|
306
|
42.4
|
Female
|
416
|
57.6
|
Obstetric characteristics
Half (50.4%) of study participants were multiparous, and majority( 90.3%) had antenatal care visits and were gave birth at a health facility (86%) (Table 2).
Table 2
Obstetric characteristics of study participants, Dire Dawa Administration, eastern Ethiopia, 2023 (n = 722)
Variables
|
Category
|
Frequencies
|
Percentage
|
Parity
|
Grand multiparous
|
251
|
34.8
|
Multiparous
|
364
|
50.4
|
Primiparous
|
107
|
14.8
|
ANC
|
Yes
|
652
|
90.3
|
ANC counseled(n = 652)
|
Not counseled
|
481
|
73.8
|
Counseled
|
171
|
26.2
|
Place of delivery(last baby)
|
Home
|
101
|
14.0
|
Health facility
|
621
|
86.0
|
PNC counseled(n = 621)
|
Not counseled
|
332
|
53.5
|
Counseled
|
289
|
46.5
|
Sing/twins delivery
|
twins
|
39
|
5.4
|
single
|
683
|
94.6
|
Use Of Traditional Food And Herbs To Enhance Breast Milk
Out of the total of 722 respondents, two hundred thirty seven, 32.8% (95% CI: 29.4–36.6%) used traditional food and local herbs to increase perceived insufficient breast milk for their child. More than half (67.2% and 51.5%) of them perceive having insufficient and source from families and relatives respectively. They use this in three forms as using herbs only, traditional food only and food mixing with herbs, this being the most (Table 3).
Table 3
Use of traditional food and herb to enhance perceived insufficient breast milk, Dire Dawa Administration, eastern Ethiopia(n = 722), 2022
Variables
|
Category
|
Frequencies
|
percentage
|
Do you feel your breastmilk is adequate for your child?
|
1.Yes
|
485
|
67.2
|
2. No
|
237
|
32.8
|
If no, what do you do to enhance your breast milk?(n = 237)
|
1. herbs use only
|
13
|
5.5
|
2. Traditional food use only
|
26
|
11
|
3. food with herbs
|
198
|
83.5
|
Frequency of traditional foods and herbs taken in a day
|
1. Only once
|
51
|
21.5
|
2. twice
|
109
|
46
|
3. 3 times
|
56
|
23.6
|
4. >3 times
|
21
|
8.9
|
How was special food/herb used?
|
Added to food
|
198
|
83.5
|
Prepared separately
|
39
|
16.5
|
Source of information(n = 237)
|
1. Family and relatives
|
122
|
51.5
|
2. Friends
|
93
|
39.2
|
3. Internet
|
22
|
9.3
|
Prior experience
|
Yes
|
245
|
33.9
|
No
|
477
|
66.1
|
Perceived efficacy of lactogogue use
|
“good”
|
371
|
51.4
|
“poor”
|
351
|
48.6
|
Awareness of harm in lactogogue use
|
Lack
|
310
|
42.9
|
Not
|
412
|
57.1
|
Is there breast problems?
|
Yes
|
101
|
14.0
|
No
|
621
|
86.0
|
Presence of co-medical illness
|
Yes
|
130
|
18.0
|
No
|
592
|
82.0
|
Types of co-medical illness(n = 130)
|
Intestinal parasites
|
32
|
24.6
|
DM
|
9
|
6.9
|
Bacterial infection
|
28
|
21.5
|
chronic hypertension
|
11
|
8.5
|
Gastritis
|
29
|
22.31
|
Types Of The Common Traditional Foods
The common traditional foods were from this study were 1. “green lentil dish” a traditional food which is mad of green lentils, olive oil, tomatoes, green chills, red onion, salt, pepper, mustard, lemon and its juice. It is popular during lent when meat is prohibited.
2. “Genfo” is a traditional porridge which is mainly made with barley or wheat flour and mound with a hole in the center, filled with a mixture of “niter kibbeh”, prepared butter and pepper. Thought to have a benefit of postpartum physical, physiological recovery of the women and to enhance breast milk production and amount.
3. “Bulla” is another traditional porridge which is a processed starch made from “Enset” (Enset ventricosum), commonly known as the “false banana.” However, it is the root of enset that is consumed, after cooked and mixed with “niter kibbeh”, prepared butter or honey.
4. “Borde” with “Bekolt” or “Nifro”: “Borde” is another traditionally produced through traditional fermentation taken along with traditionally prepared local foods “Nifro”. “Nifro” is ether the cooked bean or cooked maize” while “Bekolt” is similar to “Nifro” except that which is stayed inside water more time until the bean or maize brings up a growing root.
5. “Hulbat Merek” : It refers to a broth with meat along with berbere (optional), fenugreek, tomato, onions, potato and other spices. But the meat and fenugreek, being the main ingredient can be smelt more than the other spices.
6. “Abish wet”: It is slightly sour and habitually made with meat (optional), potatoes, fenugreek (Trigonella foenum-graecum),lentils and “shiro”, powder of pea.
7. “Hanid “ is made out of goat meat that has been cooked very slowly in an oven made from the soil around termite mounds. The unctuous meat is then dipped into tamarind sauce and a little berbere.
8. “Ful plus yogurt”: Cooked beans are blended into a smooth paste and the tomatoes, peppers, onions, and chili are served separately. Then homemade yogurt is added and usually eaten with bread or sometimes injera
9. “Camel hump”: a traditional food made of raw camel meat + herbs( either Rue or flax seed and spices, peppers, and salt.
10. “ Yebeg Alcha wet”: a traditional food made of sheep’s lean meat, mustard, spices, and salt.
Types Of The Common Local Herbs
Papaya( Carica papaya), flax seed (Linum Usitatissimum),mustard ( Brassica nigra), garlic (Allium sativium), green lentil (Lens culinaris)were the most commonly used herbs to enhance the perceived insufficient breast milk(Table 3).
Table 2
Commonly used herbs to enhance the perceived insufficient breast milk by study participants, Dire Dawa Administration, eastern Ethiopia (n = 237), 2022
Local name/English name
|
Scientific name
|
Frequency
|
Reason of use with frequency
|
Part use
|
Other additive used with
|
“Papaye”/papaya
|
Carica papaya
|
41
|
to enhance the perceived insufficient breast milk
|
Leaves
|
Honey, water & sugar
|
“Talbaa”/flax seed
|
Linum Usitatissimum
|
37
|
to enhance the perceived insufficient breast milk, increase appetite and decrease constipation
|
seeds
|
Yogurt or honey
|
“Sinafch”/mustard
|
Brassica nigra
|
35
|
to enhance the perceived insufficient breast milk and appetite
|
leaf
|
banana/Musca paradisiac
|
“Nech shinkurt”/garlic
|
Allium sativium
|
33
|
to enhance the perceived insufficient breast milk
|
bulb
|
honey or sugar ginger
|
“Misir”/green lentil
|
Lens culinaris
|
29
|
to enhance the perceived insufficient breast milk
|
seeds
|
Yogurt
|
“Shifera”/moringa
|
Moringa oleifera
|
22
|
to enhance the perceived insufficient breast milk and constipation
|
Leaf
|
Yogurt or honey
|
“Tenaadam”/Rue
|
Ruta chalepensis
|
17
|
to enhance the perceived insufficient breast milk and constipation
|
leaves
|
zinger garlic
|
“Zingibil”/Ginger
|
zingiberofficinale
|
12
|
to enhance the perceived insufficient breast milk
|
root
|
with honey
|
“Abish”/fenugreek
|
Trigonella foenum-graecum
|
11
|
to enhance the perceived insufficient breast milk
|
Seeds
|
Yogurt or moringa
|
Regarding the influential reasons for the use of traditional foods and herbs, the majority (41.35%) stated tradition or norm, followed by parents and relatives (12.6%) (Fig. 1).
Factors Associated With The Use Of Traditional Foods And Local Herbs To Enhance Breast Milk
In the multivariable logistic regression analysis, the use of traditional foods and herbs to increase breast milk was associated with women's age group of 35 or older (AOR = 2.31, 95%CI: 1.37–3.90), rural residence (AOR = 1.98, 95%CI: 1.21–3.23), no formal education (AOR = 2.25, 95%CI: 1.16–4.36), primary level education (AOR = 2.02, 95%CI: 1.18–3.46), presence of medical illness (AOR = 4.73, 95%CI: 1.96–11.43), prior use experience (AOR = 2.81, 95% CI: 1.78–4.46) and a lack of postnatal counseling (AOR = 1.80, 95% CI: 1.20–2.70) (Table 3).
Table 3
Bivariate and multivariable analysis of factors associated with the use of traditional foods and herbs to increase breast milk, Dire Dawa Administration, Ethiopia ( n = 722), 2022
Variables
|
Category
|
Food and herb use
|
COR(95% CI)
|
AOR(95% CI)
|
P-value
|
Yes
|
No
|
Age(in completed years)
|
35 and above
|
50(20.8%)
|
190(79.2%)
|
3.12(2.10–4.70)***
|
2.31(1.37–3.90)
|
.002
|
25–34
|
86(33.3%)
|
172(66.7%)
|
1.64(1.13–2.40)**
|
1.39(0.83–2.31)
|
.207
|
24 and less
|
101(45.1%)
|
123(54.9%)
|
1
|
1
|
|
Residence
|
Urban
|
174(42.0%)
|
240(58.0%)
|
1
|
1
|
|
Rural
|
63(20.5%)
|
245(79.5%)
|
2.80(2.01–3.96)***
|
1.98(1.21–3.23)
|
.006
|
Education level
|
No formal education
|
36(24.8%)
|
109(75.2%)
|
1.63(1.03–2.70)*
|
2.25(1.16–4.36)
|
.016
|
Primary(1-8th grade)
|
83(31.4%)
|
181(68.6%)
|
1.20(0.78–1.77)
|
2.02(1.18–3.46)
|
.010
|
Secondary
|
57(41.0%)
|
82(59.0%)
|
0.78(0.49–1.23)
|
1.02(0.58–1.78)
|
.955
|
Post-secondary
|
61(35.1%)
|
113(64.9%)
|
1
|
1
|
|
Occupation
|
housewife
|
41(22.7%)
|
140(77.3%)
|
3.11(1.90–5.20)***
|
1.67(0.77–3.64)
|
.194
|
Merchant
|
72(28.1%)
|
184(71.9%)
|
2.33(1.50–3.71)***
|
1.46(0.70–3.06)
|
.309
|
Private employee
|
38(48.1%)
|
41(51.9%)
|
0.98(0.55–1.76)
|
1.84(0.74–4.60)
|
.192
|
Public employee
|
34(35.1%)
|
63(64.9%)
|
1.70(0.96–2.96)*
|
1.40(0.62–3.16)
|
.414
|
Daily laborer
|
52(47.7%)
|
57(52.3%)
|
1
|
1
|
|
Education level(husbands’, n = 665)
|
No formal education
|
33(34.7%)
|
62(65.3%)
|
1.42(0.87–2.33)
|
.54(0.17–1.64)
|
.274
|
Primary(1-8th grade)
|
41(26.1%)
|
116(73.9%)
|
2.14(1.40–3.32)**
|
.61(0.25–1.50)
|
.281
|
Secondary
|
48(27.6%)
|
126(72.4%)
|
1.99(1.31–3.02)**
|
.45(0.19–1.05)
|
.067
|
Post-secondary
|
103(43.1%)
|
136(56.9%)
|
1
|
1
|
|
Husbands’ occupation
|
Daily laborer
|
36(36.0%)
|
64(64.0%)
|
1.50(0.93–2.42)
|
1.64(0.55–4.84)
|
.373
|
Merchant
|
43(25.9%)
|
123(74.1%)
|
2.41(1.60–3.70)***
|
2.11(0.91–4.88)
|
.082
|
Farmer
|
33(21.7%)
|
119(78.3%)
|
3.04(1.92–4.82)***
|
4.73(1.96–11.43)
|
.001
|
Civil servant
|
113(45.7%)
|
134(54.3%)
|
1
|
1
|
|
Prior use experience
|
No
|
202(42.3%)
|
275(57.7%)
|
1
|
1
|
|
Yes
|
35(14.3%)
|
210(85.7%)
|
4.41(2.95–6.58)***
|
2.81(1.78–4.46)
|
.000
|
Medical illness
|
No
|
207(35.0%)
|
385(65.0%)
|
1
|
1
|
|
Yes
|
30(23.1%)
|
100(76.9%)
|
1.79(1.15–2.80)*
|
1.67(0.84–3.31)
|
.145
|
Awareness of harm
|
“good”
|
158(38.3%)
|
254(61.7%)
|
1
|
1
|
|
“Lack”
|
79(25.5%)
|
231(74.5%)
|
1.82(1.32–2.51)***
|
1.24(0.82–1.89)
|
.308
|
Perceived efficacy
|
“low”
|
152(43.3%)
|
199(56.7%)
|
1
|
1
|
|
“High”
|
85(22.9%)
|
286(77.1%)
|
2.60(1.86–3.54)***
|
1.49(0.93–2.39)
|
.093
|
Place of delivery
|
Health facility
|
220(35.4%)
|
401(64.6%)
|
1
|
1
|
|
Home
|
17(16.8%)
|
84(83.2%)
|
2.71(1.60–4.70)***
|
1.19(0.61–2.34)
|
.610
|
PNC counseled
|
Yes
|
108(37.4%)
|
181(62.6%)
|
1
|
1
|
|
No
|
81(24.4%)
|
251(75.6%)
|
1.85(1.31–2.61)***
|
1.80(1.20–2.70)
|
.004
|
Significant at:*p = < 0.05, **p = < 0.01, ***p = 0.000, 1 = reference, Hosmer-Lemeshow test = 0.541 |
Qualitative Results
A total of nine focus group discussants were involved. Their average age was 35.6 years; 66.7% were urban residents, 77.8% were married, 22.2% were widowed, 33.3 were merchants, and 66.7% were housewives. 77.8% and 22.2% had primary and secondary education levels, respectively, and 44.4% were Muslims, 44.4% were Orthodox, and 11.1% were protestant religion followers. 55.6% were grandpara, 44.4% were multiparous, and all (100%) had ANC visits, institutional delivery, and traditional food and herb usage experiences for enhancing breast milk.
Traditional food and herb use related
Many women, especially multiparous mothers, choose traditional foods and herbs to enhance their breast milk for the reason that "they perceive inadequacy for the child and some norms enforce them to do so."
A 40-year-old female discussant shared her experience as follows: "During my last pregnancy, I was forced to take a traditional food called "Bulla," a traditional porridge that is made from "Enset" (Enset ventricosum), cooked and mixed with "niter kibbeh," prepared butter or honey. Personally, I had no interest in it, but my parents advised me to do it for the purpose of increasing my breast milk for my child and to be strong enough. (FGD-3)
Similarly, focus group discussants (FGD) 1, 2, 5, 6, and 7 stated that "women in our living area are using traditional foods like "Borde" with "Bekolt" or "Nifro," "Hulbat Merek," "Abish Wet," and "Camel Hump" to enhance breast milk commonly." "This is known as traditional support for her body and milk amount enhancement," as they stated it.
Furthermore, focus group discussants (FGD) 3 and 4 also stated that "Full Plus Yogurt," "Yebeg Alcha Wet," "Abish Wet," "Green Lentil Dish," "Genfo," and "Hanid" are used to enhance breast milk by women when they feel that their supply is insufficient or if they are told that it is insufficient by others, like family or friends," as they reported.
Regarding the common local herbs used to enhance the perceived insufficiency of breast milk, focus group discussants (FGD 9, 1, 2) reported "Talbaa" (flax seed; Linum usitatissimum); "Papaye" (carica papaya); "Nech shinkurt" (garlic; Allium sativium); and "Sinafch" (mustard; Brassica nigra) are used by most women.
Other types mentioned by focus group discussants (FGD 7, 8, and 6) included "Zingibil" (ginger, Zingiber officinale), "Tenaadam" (Ruta chalepensis), and "Shifera" (Moringa oleifera).
Moreover, focus group discussants (FGD3, 4, and 5) added "Misir" (green lentil, Lens culinaris) and "Abish" (fenugreek, Trigonella foenum-graecum) as major local herbs used by most women in their area to enhance insufficient breast milk.