Prelacteal Feeding and Associated Factors Among Northwestern Ethiopian Women Having Children Less than Six Months Age: A Community Based Cross- Sectional Study

Background: Prelacteal feeding is administration of any food or uid other than breast milk before initiation of breast feeding. Optimal breastfeeding including discouraging prelacteal feeding could save 823,000 lives per year among children ages ve years old and younger. Despite of this mothers give prelacteal feeding to their child in different part of Ethiopia; However, there is a paucity of information on prevalence of prelacteal feeding and associated factors in the study area. Thus, the current study aimed at determining of the prevalence of prelacteal feeding and associated factors among mothers of children aged less than six months in Gozamen district, East Gojjam zone, North West Ethiopia, 2019-2020 Methods: A community -based cross-sectional study was conducted among 741 mothers of children aged less than six months in Gozamen district from August 2019 to Feb 2020. Stratied cluster sampling technique was used to select study participants. Data were collected by face to face interviewer-administered, pretested and semi-structured questionnaire. Descriptive analysis, bi-variable and multivariable logistic regression model were employed. Adjusted odds ratio with 95% condence interval was used to identify factors associated with prelacteal feeding. Results: In this study the prevalence of prelacteal feeding was found to be 17.1%with 95%CI [14.3, 20]. Mothers who had no ANC follow up [AOR: 7.53, CI; 3.32, 17.05], those mothers who did not discard colostrum [AOR: 0.12, CI; 0.07, 0.12] time of breast feeding initiation [AOR: 3.53, CI; 2.05, 6.11] and mothers who had single ANC visit [AOR: 2.98, CI; 1.52, 5.85] were signicant independent factors associated with prelacteal feeding. Conclusion: This study concluded that prelacteal feeding was high in the study area .Therefore, in order to tackle this health


Background
Breastfeeding (BF) and human milk are the normative standards for infant feeding and nutrition (1). BF is uniquely suited to the human infant, both in its nutritional composition and in the nonnutritive bioactive factors that promote survival and healthy development (1,2). World Health Organization (WHO) and United Nation Child Emergency Fund (UNICEF) discourages this practice and recommends to continue breast feeding up to 2 years and beyond (3,4). Despite of this recommendations, in many parts of the globe including Ethiopian mothers give prelacteal foods to their child (5)(6)(7)(8).
Prelacteal feeding (PLF) is any food or uid except mothers breast milk or medicine given to newborn infants before breast feeding initiation within three days after delivery (9,10). The most common prelacteal foods given to infants in many developing countries could be categorized into three: water only, water-based (rice water, herbal mixture, juice), and milk-based (animal milk, infant formula) (11). Water is hazardous pre-lacteal feed in terms of the detrimental effect on the nutritional aspect and makes the neonate more prone for early risk of severe gastrointestinal infections (12).
Suboptimal breastfeeding, including PLF has been linked with numerous adverse child health outcomes including increased incidence of diarrhea and pneumonia and it interferes with the establishment of any breastfeeding and a healthy gut micro biome (13). PLF may also delay the initiation of breastfeeding (14) and reduce the bene ts of colostrum (15,16). Globally sub optimal BF responsible for 45% neonatal infectious death, 30% diarrheal death, 18% acute respiratory death in children (17). Optimal breastfeeding including discouraging PLF could save 823,000 lives per year among children ages ve years old and younger (18).
Different studies showed that different factors hindered the practice of prelacteal feeding like place of delivery, time of initiation of breast feeding, colostrum's discarding, awareness on risks of prelacteal feeding, ANC follow up and number of ANC visit (6,16,(19)(20)(21). Multiple interventions have been designed to decrease mortality and disability in children and to achieve Sustainability Development Goal (SDG). Among these, breastfeeding is the most cost-effective intervention for protecting children against diarrhea and all causes of mortality (2). Prelacteal feeding is one of the main components to assess optimal breastfeeding practices (22). Ethiopia adopted the Infant and Young Child feeding (IYCF) guide line in 2004 that discourage prelacteal feeding (23); but, after implementation of this guide line still prelacteal feeding is practiced in different parts of Ethiopia. Therefore, this study was aimed to determine prelacteal feeding practices and associated factors among mothers of children aged less than six months in Gozamen District, East Gojjam zone, North West Ethiopia.

Study design and setting
A community-based cross-sectional study was done from August 1 up to September 12/2019 in Gozamen district. Gozamen district is one of the 18 districts in East Gojjam zone. The zonal capital is Debre Markos town which is located 300 Km far northwest from Addis Ababa, capital city of the country and 260 Km from Bahir Dar the capital city of Amhara regional state. The district is divided into 30 kebels administratively (the smallest administration unit next to the district in Ethiopia) of those 5 are urban and 25 are rural kebels. According to the district administrative report, the population size of the district estimated at 164,816 among whom, about 82,573 are women of those, 2536 are mothers who gave birth in the last six months and 82,224 are males. The district has 6 health centers and 26 health posts and they are all providing maternal and child health care (MCH) services.

Study Population
All mothers of children aged less than six months in Gozamen district were the source population and all mothers of children aged less than six months in the selected kebeles/clusters were the study population of the study. All mothers who lived in the area for at least 6 months were included in the study.

Sample Size Determination And Sampling Procedure
The sample size was calculated for the rst objective and second objective. Finally, the largest sample size was taken. Single population proportion was used to determine the sample size for the rst objective by assuming prevalence of prelacteal feeding in Debre markos town 19.1% (10) with a 95% con dence level and 5% marginal error and 10% non-response rate. Based on these assumptions, the total sample size was calculated using the following formula: Where n = required sample size, Z = critical value for normal distribution at 95% con dence level (1.96) P = prevalence of colostrum avoidance in North Wollo zone d = 0.04 (4% margin of error), by considering 10% non-response rate of = 34 and D = 2 (design effect) was used due to cluster sampling method, the sample size was found to be 746. For the second objective the sample size was calculated using Epi info 7.2 (double population proportion) information obtained from the previous study by taking signi cant factors in previous studies and the sample size was greater in the rst objective than the second one, then nal sample size was 746 but since it is cluster sampling method the sample size was 741. Strati ed cluster sampling technique was used to recruit study participants. First the population was strati ed by residence as urban and rural Kebles. The residential strati cation gives 25 rural and 5 urban kebels. Out of those, two urban and 7 rural kebeles were selected randomly by using lottery method.
Finally, all the selected kebeles were used as clusters. Household having two mothers having children less than six months age by lottery method one mother was selected. Households closed during the data collection period were proceed to the next eligible house and returned back for the second time.

Data Collection Tool And Procedures
The data were collected by using a pretested, semi structured and an interviewer-administered questionnaire. The questionnaire was developed by reviewing related literatures and some modi cation was done accordingly. It was rst prepared in English and translated into local language Amharic for data collection and then translated back to English to check consistency by both language experts. The questionnaire had socio-demographic variables, health service utilization variables, obstetrics related variables, and maternal behavior related questions, breast feeding related variables and wealth index related variables. Data were collected by six (Health Extension Workers) HEW under the supervision of the investigators and supervisors.

Data Quality Control
Data collectors and supervisors were given one day training. The data were checked daily manually for completeness and accuracy by principal investigator and supervisors. Pretest was conducted on (5%) of the sample size in the non-selected kebeles of the district to ensure the validity, reliability, and clarity of the data collection instrument. Based on the pretest done some modi cations were done on questionnaire.

Data analysis
Data were cleaned and entered into computer using Epi data 4.4.1 software and exported to Statistical Package for Social Science (SPSS) version 20 for data analysis. Before data analysis, the missing value and outliers were checked and managed appropriately.
Descriptive analysis was employed for categorical variables using frequency, percentage, tables, and charts. For quantitative variables, summary values like median and Intra quartile range was used. PCA was performed to classify the household wealth index into low, middle and high.
Binary logistic regression (bivariable and multivariable logistic regression analysis) was tted to identify factors associated with colostrum avoidance. Variables having p-value of < 0.2 in the bivariable analysis were entered into multivariable analysis. To estimate the strength of the association adjusted Odds ratio (AOR) with their 95% Con dence Interval (CI) was determined. Finally, variables with a p-value of ≤ 0.05 were considered statistically signi cant. Model tness was checked by using Hosmer Lemeshow Goodness-of -t and declared good tted at p-value of > 0.05.

Sociodemographic characteristics of respondents
A total of 741 mothers-child pairs were interviewed and giving a response rate of 100%. Majority (643) of the respondantes were from rural area and the rest were from urban. The median age of the respondents was 30 years ± 10 IQR and the median age of their child was 3 months ± 3 IQR. Majority (93.1%) of respondents were married out of them 566 (82%) of their husband's occupation were farmers and 289 (41.9%) of their husband's educational status were unable to read and write. Three hundred seventy eight (51%) of mothers were unable to read and write. About 643 (86.8%) of study participants residences were rural. From 741 study participants 487 (65.7%) of the Mothers occupation were farmer. Only 57 (7.7%) of respondents were household heads. Almost all respondents (99.5%) were orthodox religious followers and 738 (99.6%) Amhara were by ethnicity (Table 1).

Obstetrics And Maternal Behavioral Related Characteristics Of Respondents
Around three-fourth (75.4%) of the study participants were multiparious and more than half (58%) of them spaced their birth more than 24 months. About 508 (68.4%) of mothers had good knowledge and more than two-third of respondents (72.2%) had favorable attitude (Table 2).  Breast Feeding-related Characteristics Regarding infant breast-feeding practices out of the total 127 (17.1%) of respondents gave prelacteal feeding to their child within three days after delivery before initiation of breast feeding and the main reason was 44 (34.6%) of respondants thoughts to clean the mouth and throat of the baby. The most common prelacteal feeding was butter (81.1%) and 164 participants out of total respondents they discard colostrums within ve days after delivery (Table 4).

Discussion
This study tried to assess the prevalance of prelacteal feeding and associated factors among mothers of children age less than 6 months old in rural area Northern Ethiopia. Accordingly, the prevalence of prelacteal feeding was found to be 17.1% with 95% CI [14.3, 20]. This nding is in line with study done in Indian16.9% (24) (36) and Motta town 20.3% (6). This discripancey might be due to diference in sociodemograhic, socioeconomic difference, cultural variablity and infant feeding style that affcts prelactael feeding.
Turning to the associated factors mothers who had no ANC follow up were 7.5 times more likely to practice prelacteal feeding [AOR: 7.53, CI; 3.32, 17.05] as compared to their counter parts. This is nding is supported by studies done in South west Nigeria and Harari (26,35). The possible reason might be due to mother who have ANC visit may be have more informotion on the risks associated with prelacteal feeding and the may counseled by health proffesstional (9).
Those mothers who did not discard colostrum were 88.5% timeless likely to practice prelacteal feeding [AOR: 0.12, CI; 0.07, 0.12] as compared to those mothers who discarded colostrum. This nding is consistent with study done in Mettu district, South Sudan, Axum town, North Eastern Ethiopia, Mizan aman town and Motta town (5-9, 21, 32). The possible expaniation might be if mother provide colostrum to their child no need of additional foods (7).
The odds of PLF was 3.5 times higher in respondents who initiate BF more than one hour [AOR: 3.53, CI; 2.05, 6.11] than respondents who initiate BF less than one hour. This result is conssistent with study done South west Nigeria, Hareri and Afar regional state (26,35,36). This might be due to the fact that as the time interval increase between delivery and breast feeding initition they have more time to practice PLF and also the revrese is true prelacteal feeding may lead to deley initition of breast feeding (38).
Once more, mothers who had less than four ANC visit were 2.89 times more likely to practice prelacteal feeding [AOR: 2.98CI; 1.52, 5.85] as compared to their counter. This nding is supported with study done in Axum town (9). The possible reason might be due to mothers who attitend more than four ANC visit may be more exposure with health proffesstional and they may adivised by health proffesstional in the fourth visit if the did not advized in the privious visits.

Conclusions
This study revealed that prelacteal feeding was found to be high. ANC follow up, time of BF initiation, colostrum discarding and number of ANC visit were signi cant independent predictors associated with prelacteal feeding. In order to takele this practice strengthening timely initiation of breastfeeding, ANC visit, avoiding colostrum discarding, health education and creating community awarness on risks associated with prelacteal feeding are recommended interventions.

Limitations Of The Study
This study shares limitation cross sectional study does not show cause effect relationship. It was also not triangulated by qualitative study and the information obtained from mothers might be prone to recall and information bias

Declarations
Acknowledgements Authors acknowledges University of Gondar for ethical approval. We would also like to extend our heartfelt gratitude to data collectors, supervisors and the study participants for their cooperation in providing valuable information.

Funding
No speci c funding received by author(s) for this work.
Availability of data and materials The datasets supporting the conclusions of this article are available upon request to the corresponding author.

Authors' contributions
Maezu G/slassie participated in conceived paper, in the conception and design of the study, interpreted the data and drafted the initial manuscript. Ki ay Mulugeta and Abraha Teklay participated in commenting the document, oversaw reviewed data, critically revised manuscript and approved nal version. All authors read and approved the nal manuscript, contributed the critical review of the manuscript.
Ethical approval and consent to participate Ethical clearance and approval was obtained from the Institutional Review Board of University of Gondar.
Then o cial letter was written to Gozamen district health o ce. Verbal informed consent was obtained from participants after explained well the purpose and objective of the study. Con dentiality was maintained at all levels of the study. Participant's engagement in the study was on voluntary basis; participants who were unwilling to participate in the study and those who wish to quit their participation were informed to do so without any restriction.

Consent for publication
Not applicable.