Effect of Being Housewife and Counseling During Antenatal Care on Exclusive Breastfeeding Practice Among Mothers with Less than Two Years of Age in Northeast Ethiopia, 2019

Background Exclusive breastfeeding is the practice of a woman feeding an infant for six months, which has an irreplaceable bene�t. However, the practice is still low with salient factors in a different place. Therefore, this study was aimed to assess exclusive breastfeeding practice and associated factors among mothers of having children less than two-years of age in Northeastern Ethiopia, 2019


Background
Breastfeeding is the practice of a woman feeding an infant & young child (1), which has extreme product given to a baby, natural food, and uniquely adapted to baby's needs (2).
Breast milk contains all the essential nutrients that a healthy child needs (3).World Health Organization (WHO) infant-feeding guidelines recommend that all infants should be breastfed within one hour of birth and exclusively breastfed until six months of life.Optimal feeding of infants and children means exclusive breastfeeding from birth to six months.It is followed by the introduction of complementary foods drawn from the local diet at about six months (4).Currently it is only 39% of all infants who are exclusively breastfed worldwide.The prevalence is about 30% in most developing world countries.
The salient factors associated with exclusive breastfeeding are maternal age, maternal level of education, maternal employment status, maternal knowledge, place of delivery, residence, culture, and household wealth status (11,12,15,17,19).

Study area and participants
A community-based cross-sectional study was conducted from March 12 to December 18 2019 in six districts of Northeastern Ethiopia.The study was among mothers who had less than two years of age child.The districts were selected using simple random sampling lottery method among 21 districts.
The sample size was calculated using a single population proportion formula by considering the following assumptions; proportion (50.1%) of excessive breastfeeding from the study in Motta town, Ethiopia (17).The level of con dence 95%, margin of error (d) = 5% and 10% non-response rate.Using a simple random sampling technique 423 mothers participated in the study.To select study participants from each district, rst the sample size was proportionally allocated to size and nally a lottery method was used to select each study participant.The actual age of the infant was determined by asking the mothers and reviewing the birth certi cate.

Data collection procedure
An interviewer-administered structured questionnaire was applied for data collection.The questionnaire was designed originally in English and translated to local (Amharic) language for the purpose of data collection and then the results were entered by the English version.It was constructed by adopting from Ethiopian Demographic and Health Survey (EDHS) 2016 (10) and from the previous research done on similar topics (17,20,21) and modi ed accordingly.The mothers recall method on an infant's diet was used for assessing excessive breastfeeding.

Operational de nition
Exclusive breast-feeding: Exclusive breast-feeding means breast feed a baby duration of 6th months and a frequency of 8-12 times per day (1,22).
Complementary feeding: Means the provision of other foods or liquids along with breast milk after six month of life (23).

Data processing and Analysis
he collected data were checked and cleaned manually for completeness, and then it was coded and entered in Epi Info version 3.5.3and exported to SPSS version 23 for advanced analysis.Descriptive statistics of socio-demographic characteristics and the prevalence of exclusive breastfeeding were used.Binary logistic regression was carried out to identify factors associated with exclusive breastfeeding practice.First bivariable logistic regression was performed to each independent variable with the outcome variable, and those variables with a p-value < 0.2, were tted in the nal (multivariate analysis) model.The strength of association was measured using odds ratio, and 95% con dence intervals.
Statistical signi cance was declared at a p-value < 0.05.

Socio-demographic characteristics
A total of 423 mothers with a child less than two years of age participated with a response rate of 96.4%.More than half (52%) of mothers were between 25-34 years of age.From the study, participants were most (89.2%)married 62.7% housewives and 65% Muslim religious followers.Regarding educational status more than half were either unable to read and write (15.4%) or able to read and write but did not have formal educations (43,8%).Smallest (7.3%) and highest (47.7%) proportion of mothers had less than 1000 and greater than 2500 Ethiopian birr monthly income at household level respectively (Table 1).Breastfeeding practice of mothers with less than two years of age children Two hundred sixty-eight (65.8%) of 408 mothers put their newborns to breastfeed within one hour of birth.But, only 30(7.3%) of mothers initiated breastfeed let after one day.Three hundred and fty-one (86%)of 408 mothers did not give food other than breast milk within the rst three days of birth.The prevalence of exclusive breastfeeding practice in this study was 77.5%(95%CI: 73.5, 81.5%).This was computed from mothers who have six and above years of age child during data collection.
Among mothers who still breastfeeding during the survey, 147(36.2%)were nursing their child less than 8 times per day, but the highest 227(55.8%) of mothers were breastfeeding 8 − 1 2 times per day.One hundred one (24.7%) of 408 mothers were breastfeeding while their child is crying (Table 3).On the other hand, employed mothers were around 78% less likely to practice exclusive breastfeeding than unemployed housewife mothers.Concerning education, unable to read and write mothers were 89% less likely to practice exclusive breastfeeding than mothers with secondary and above educational status (Table 4).
Initiation of EBF during an hour after delivery is recommended to prevent 13% of child death (7), protect infants from otitis media for at least four months (26).In this study, the higher prevalence (65.8%) of mothers was initiated breastfeeding within one hour after delivery.This result was congruent with the studies in Amhara (60%), Oromia (77%), and Southern Ethiopia (50%) (27).Whereas, it was higher compared to a study in Dabat, Gondar (23.2%) (13), and lower from a study in Tigray (99.1%)(16).These variations might be due to incomparable sample size, study designs used and study setting (community based and institutional) difference of the study areas.
Concerning factors associated with breastfeeding practices like mother's level of education, marital status, occupation, ANC, place of delivery, and counseling about breastfeeding practice during ANC visit were the variables that signi cantly associated with exclusive breastfeeding practice.
The study showed that the odds of exclusive breastfeeding among mothers having an educational level unable to read and write 89% less likely than mothers who have secondary and above educational levels.
This is a discordant result when compared to study determinants of exclusive breastfeeding in Ethiopia(28).
After controlling the confounding variables, unemployed(housewife) mothers practiced EBF better than employed mothers.Employed mothers were about 78% less practiced exclusive breastfeeding than housewife mothers.This result is similar to studies in Malaysia (29,30), Cameroon (31), Ghana (32,33), Awi Zone, Ethiopia (34), Northwest Ethiopia (35), and Debre Markos, Ethiopia (21).This might because women spent their time at home are more frequently in contact with their child.
This study revealed that mothers who had antenatal care had four times more likely of practicing exclusive breastfeeding practice.This is supported by a nested case-control study in Northwest, Ethiopia(36), Jima, Ethiopia (37), and breastfeeding guidelines(38, 39).However, it has no association with EBF practice according to a study in Motta town, Ethiopia (17).This might be attributed to the study year (the former is conducted ve years back), and the study population included.
Mothers who gave birth in a health institution were more likely to practice exclusive breastfeeding compared with those who gave birth at home.This nding had in agreement with the studies done at Bahir Dar, Ethiopia (33) and Ghana (32).This could be due to the fact that mothers who give birth in institution have more opportunities to be counseled about the bene t of breastfeeding by health care providers.In contrast to this, study done in Motta, Ethiopia indicated that birth place do not associate with exclusive breast feeding practice.This discrepancy might be due to the study period, study populations and sociocultural difference.
In this study breastfeeding counseling during antenatal care service was found to facilitate exclusive breastfeeding practice.This is parallel with studies done with low income Latinos in United states (40), Nigeria (41), and Debre Markos, Ethiopia (21).This could be health education and counseling increases mothers' knowledge about the need and bene ts of EBF.
Culture was one of the independent predictor of exclusive breastfeeding in this study.The study showed that mothers who had a culture of giving different prelacteal foods (like; water, coffee, fresh butter, etc.) were around 80% less likely practicing of exclusive breastfeeding.This was in line with studies in Afar, Ethiopia (42), avoidance of prelacteal practice in rural Ethiopia (43), and a study exclusive breast feeding measurements and indicators in Israel (44).This might be the fact that, most Ethiopian mothers believe that their child will be affected by the devil if they did not make their child test a portion of food that the mothers tested (visual witness from elders).
Although a cross-sectional study design was used, this study had a strength of inclusion of large study areas.However, the limitations of this study were unable to assess qualitative aspects; like the attitude of both parents towards exclusive breastfeeding, factors related to health institutions, and detailed cultural factors like ingesting fresh butter to the infant at birth.Likewise, since this study included mothers with up to two years of a child, recall bias might under/overestimate the prevalence of exclusive breastfeeding.

Conclusion
This study revealed an appreciable prevalence of breastfeeding.Being married, having antenatal follow up, institutional delivery, and counseling about breastfeeding during antenatal service were the variables that increase exclusive breastfeeding practice.While, unable to read and write educational status and being employed were the negative factors for exclusive breastfeeding.

Table 1
Socio-demographic characteristics of mothers and children (n = 408) in Northeast Ethiopia, 2019

Table 3
Breast feeding practice of mother having child less than 2 years, Northeast Ethiopia, 2019.
birthplace and breastfeeding counseling of mothers were the independent predictors of exclusive breastfeeding practice.Mothers who were in married marital status were 2.57(1.688,5.654)timesmore likely to breastfeed their child exclusively.Likewise, mothers who had antenatal care 4.11(2.662,11.172),institutionaldelivery4.07(2.992,10.722),andmotherswho got breastfeeding counseling during their ANC follow up 1.96(1.124,4.732)more odds of exclusive breastfeeding practice compared to their counterparts.

Table 4
Factors associated with exclusive breastfeeding practice among mothers with children age less than two years in Northeast Ethiopia, 2019