Knowledge, and Practice of Mothers and Its Associated Factors on Colostrum Feeding of Neonates at Este (Mekane-eyesus), South Gondar Amhara, North West, Ethiopia: Community Based Cross-sectional Study 2020

Introduction - Feeding of human breast milk, especially colostrum, is the normative standards for infants and regarded as a complete form of nutrition. The positive health benets of breastfeeding/breast milk feeding as part of caring for premature, sick and vulnerable newborns are well documented in the scientic literature. Objective Method – community-based cross sectional study design was conducted among 376 mothers, from March 10/2020 to May 2020. The study participants were selected by multistage sampling technique after selecting 02 urban and 03 rural kebeles by simple random sampling technique. Each participant was also selected from household after determining and proportionately allocating of samples in each selected kebeles. During selection of participants, house to house visit was made. To select the study participants from each household, K th interval was determined for each proportionally allocated 3rural and 02 urban kebeles. Multivariable binary logistic regression model was tted and adjusted odds ratios with 95% condence interval were computed to determine the strength of association between each variable with milk teeth extraction. Variables with P-value < 0.05 was considered as statistically signicant. and 98.4% respectively and which was considered being high when compared the study conducted in Northern Ethiopia and post-natal educations in health institutions.


Introduction
Back ground of the study Colostrum is de ned as the rst breast milk of the mother produced after birth and it is the most important for the promotion of health and prevention of infections of the newborn immediately after birth [1,2].
Breastfeeding/breast milk feeding also reduces mortality rate and provides good nutritional support for such small babies. As society continues to view breastfeeding as problematic to the new born, many mothers truly believe that they cannot breastfeed, or they have been so hurt by the negative reactions of others that they stop doing so. Many women choose not to breastfeed for reasonable and pragmatic reasons, but when their baby is well, parents are often motivated to provide breast milk for their infants [1,3].
World Health Organization(WHO) thrives on improved nutrition including breastfeeding, successful immunization programs and scaling up of integrated management of respiratory illnesses and diarrheal diseases played a signi cant role in improving health and survival of children and breastfeeding is considered the gold standard of infant nutrition and has been strongly recommended for preterm newborns due to the immunological properties of breast milk, its role in gastrointestinal maturation or gut priming and in the establishment of mother-child bond, thus contributing to a better growth and development prognosis [4,5].
It is also the natural rst food for babies. It continues to provide up to half or more of the child's nutritional needs during the second half of the rst year, and up to one third during the second year of life.
Breastfeeding is the safest, least allergic, and best infant feeding method. It has nutritional, immunological, behavioral and economic bene ts and provides desirable mother infant bonding [6,7].
Breastfeeding confers bene ts on both children and mother; including helping protect children against a variety of acute and chronic disorders. Mothers' poor knowledge about the correct breastfeeding attachment and positioning technique and negative attitudes toward breastfeeding, particularly in developing countries, may in uence the practice of effective breastfeeding [8][9][10]. Therefor this study aims to reduce problems related with knowledge and practice of mothers on colostrum feeding of their neonates at Este (Mekane -Eyesus) in 2020 G.C.

Method And Materials
Study area and period Based on gures Central Statistical Agency in 2005, this woreda has an estimated total population of 403,956, of whom 199,325 are men and 204,631 are women; 16,014 or 3.96% of its population are urban dwellers, which is less than the Zone average of 8.3%. With an estimated area of 2,368.13 square kilometers.The largest ethnic group reported in Este was the Amhara (99.98%), and Amharic was spoken as a rst language by 99.98%. The majority of the inhabitants were Ethiopian Orthodox Christianity, with 96.53% of the population reporting they observed this belief, while 3.45% of the population said they were Muslim The study was conducted in Este (Mekane-Eyesus) among neonates, from March10/2020 to May 2020.

Study design
Community based cross sectional study was employed.

Sources population
All infants <=28 days of age found in Este (Mekane-Eyesus) administrative kebeles were the source population for this study.

Study population
Neonates who are found in randomly selected 02 urban and 03 rural kebeles in Este (Mekane-Eyesus) and who ful ll the inclusion criteria were the study population.

Sampling Unit
Households which found in the selected 02 urban and 03 rural kebeles were the sampling unit that the samples had been taken.

Sample size determination
In this study, sample size was determined by using single population proportion formula Speci c objective 1 aimed to identify practice of mothers on colostrum feeding of neonates at Este (Mekane-Eyesus), south Gondar Amhara, North Central, Ethiopia, 2020. n 0 = 341.5 n 0 = 342 By adding 10% none response rate the total sample size is The total sample size will be=376 Where: n= the desired sample size P= knowledge of mothers about colostrum feeding, Bench Maji Zone (66.66%) Zα/2 = standard normal variation value at a con dence interval of 95% (1.96) d= the margin error between the sample and the population (5%) Sampling technique and sampling procedure The study participants were selected by multistage sampling method after determining and proportionately allocated of samples. In Mekane -Eyesus there are 03 urban and 05 rural kebeles. The total samples (n=376) will be proportionally allocated based on total population and the required sample size. From this study area about 7676 neonates found distributed among 08 kebeles in Mekane -Eyesus. Among 08 kebeles, 05 kebeles were selected by lottery method, and then proportionally allocating study participants based on the target population who are living in those 05 kebeles. Each participant also selected from household after determining and proportionately allocated of samples in each selected kebeles. During selection of participants, house to house visit was made and all those neonates in one household would be included in the selection process. To select the study participants from each household Kth interval was used to select households which contain the required samples -value was calculated by using the formula N/n for each selected kebeles i.e. For K1=561/376=1 st interval, K2=949/376=3 rd, Mekane-Eyesus=1369/376=4 th, Dengolt 1170 /376=3 rd and iguara=1208 /376=3 rd .So the sample will be taken to each kebele every 1 st , 3 rd , 4 th , 3 rd and 3 rd interval from K1, K2, Mekane-Eyesus ,Dengolt and iguara respectively according to index neonates residence.

Data collection tools and procedures
Data was collected using structured interview based questionnaire. The questionnaire contains socio demographic characteristics, magnitude related questions, Level of Knowledge, sources of on colostrum feeding and practice part regarding colostrum feeding. Data also collected by using open ended questions and both open ended and closed ended interview based questionnaires primarily being prepared in English then translated to local language questionnaires with local language (Amharic) for its consistency and understandability to the community in which this research conducted. During time of translation all the concern and the local linguistic had been put into consideration and the local language (Amharic) was translated back to English for the appropriateness and conformability of analysis the nding of the research. Pretest was conducted among 5% of the participants in Woreta town and modi cation will be considered according to its ndings. After modi cation and amendment of the data collected by face to face interview by two BSc holder nurses and one health extension workers who are not working in the assigned area after they obtain a one day training on the tools and necessary cares needed. The parents/guardians were interviewed in their residence.

Operational de nitions
Knowledge: In this study refers to awareness about colostrum feedings of pregnant woman during breast feeding period. It will be evaluated by the mothers answer to the questions Good knowledge: Those answers greater than or equal to 60% questions out of total knowledge related questions.
Poor knowledge: Those answers less than 60% questions out of total knowledge related questions.
Practice: The overt behavior habit or custom of women Good practice: Score > 60% on the overall practice questions.
Poor practice: Those who answer <60% of practice related questions Data processing and analysis First the data was checked for its completeness, consistency and validity. After checking the collected data, then the data entered to EPI-data version 4.5 and transferred to SPSS version 23 statistical software for analysis. Data will be cleaned, and coded for completeness, consistency and to minimized errors. Both Bi-variable and multivariable logistic regression was used to identify factors and variables with pvalue of 0.20 and less would t to logistic model for multivariable analysis. SPSS version 23 statistical software was used and frequencies and odds ratio was determined. Factors associated with the outcome variable at Bi-variable analysis had been identi ed and the variables with p-value of 0.20 and less would t to logistic model for multivariable analysis to determine relative prediction level of independent variables to the outcome variable. P-value less than 0.05 at 95% con dence interval had been considered as statistically signi cant. Model goodness-of-t would be checked by Hosmer Lemeshow test. Multicollinearity was checked by durbin-Watson, tolerance and Variance In ation Factors. Chi square also been calculated to test any association between dependent and independent variables .Lastly the result was presented with the form of texts, gures and tables by using frequency and summary statics such as mean, standard deviation, and percentage to relevant variables.

Data quality control
The quality of data was ensured by doing the questioner pre-tested on 5% of the total sample size at Woreta town that is assumed to have relatively similar characteristics of the targeted population. Based on their feedback the necessary amendment was done and the questioner was assessed for its clarity; completeness and evaluate the validity and content of the questionnaire and modi ed accordingly .Close supervision also made during the data collection and appropriate feedback was provided. Training was given to the data collectors for one day by the principal investigator and the training was focused on the objective, how to obtain consent, keeping con dentiality of the information they gathered. The collected data been cheeked for its completeness every day before the following day of data collection by supervisors and the principal investigator and corrective measures had been taken according to the nding during supervision.

Data presentations
After the data analyzed the ndings of the result was presented by descriptive and analytic forms. Descriptive analyzed statistical results was presented by texts, graphs, diagrams and tables but analytic form of ndings was presented by text form of odds ratio.

Ethical consideration
Ethical clearance was obtained from Ethical Review Board of Debre Tabor University college of Medicine and Health Sciences, and department of mc midwifery. Letter of permission was granted to Este (Mekane-Eyesus) and South Gondar Zone. After obtained permission from those organizations, the data collectors were going to house to house and starting data collection. The data also was collected after clearly explained the purpose of the study to the participants and after obtained informed consent was got from each study participant.

Result
Socio-demographic characteristics of the respondents   factors and negatively associated with knowledge of mothers on colostrum feeding but all the above variables with p-value of less than 0.2 are exported to multivariable conditional forward analysis.
Mother's occupation whose occupation employed is reducing the risk of none acquiring knowledge by 77.3% when compared with those mothers who have housewife occupation [AOR: 0.2270(.055, 0.93]. On the other way mothers who transported by vehicle 10-20 minutes were signi cantly associated 4.056 times with knowledge of mothers about colostrum feeding than mothers who transports < 10 minutes by   showed that about (73.8% study participants had knowledge regarding colostrum feeding [11]. The magnitude of the current study was higher from the study which was conducted in Ethiopia. This high magnitude could be due to increase in awareness creation about colostrum feeding, proper health education and appropriate ANC follow up [12][13][14].However the study nding of the current research was similar(inline) with the study conducted in Egypt with knowledge level (82.6%) toward colostrum feeding reported .The similarity of ndings could be due to similarities among health settings ,counseling and proper education of mothers about colostrum feeding [15].This nding also higher when compared similar research conducted in Pakistan .From Pakistan the overall knowledge of mothers about colostrum feeding was (70.1%).The level of knowledge in Pakistan not only lower than the current study but also it is lower than studies in Egypt and Ethiopia. The difference of knowledge among lactating mothers could be different in understanding level, improper understating of mothers about the importance of colostrum feeding for their neonates rather they understand as colostrum bad for their neonates [10,16].
Even though the current study which reveals as knowledge of mothers about colostrum feeding was higher than most studies, study conducted in Nepal showed that 100% mothers knowledgeable about colostrum feeding whereas the study conducted in India reported that 30-40% of Indian women discard colostrum [15,17].
As evidenced above the overall practice of mothers on colostrum feeding was 98.4% which was higher the knowledge level of the current study ,however the study conducted in Colostrum avoidance, prelacteal feeding and late breast-feeding initiation in rural Northern Ethiopia revealed that (21%) of the study participants feed colostrum. This was very lower when compared the ndings of the current study. The higher practice may be due to place of delivery at health institution, post-natal counseling and education about colostrum feeding [5,18,19].
The practice of colostrum feeding differs from country to countries, for instance from the current study about 98.4% practice colostrum feeding .Similarly the study conducted in Daharan showed that colostrum was fed by 95% and the two research ndings showed that there is similarities between them but the study conducted in Pakistan showed that about 72.1% mothers offered colostrum feeding while 27.9% discarded colostrum and the ndings was lower than compared with the two study ndings [16,20] Countries like rural Northern Ethiopia and in India revealed that 21% of mothers in urban areas had discarded colostrum whereas 79 % in urban and 70.5% in rural practices colostrum feeding. The study ndings lower both the current study and the study conducted in Daharan [7,18,21].
Colostrum feeding affected factors like mother's occupation and counseling about colostrum feeding were signi cantly associated with knowledge of mothers about colostrum feeding but delivery at was signi cantly associated with practice of mothers about colostrum feeding.
However from similar research colostrum feeding had been in uenced by maternal age, gravidity, and occupation. Similarly educational status of the mothers, socioeconomic status, place of delivery, mode of delivery were found to be signi cant association with colostrum feeding [7,21].

Limitation
Knowledge of mothers about colostrum feeding was assessed by quantitative way is good but to furthers explore qualitative method is suggestive but due to COVID-trait qualitative mixed method was not used.

Page 21/23
Discarding of colostrum ( rst milk) is still common in Este (Mekane-Eyesus) and the surrounding rural kebeles. The current knowledge and practice level of colostrum feeding among mothers was 96.4% and 98.4% respectively and which was considered being high when compared the study conducted in Northern Ethiopia, Egypt and India. Even though the knowledge and practice level of mothers about colostrum feeding was high and satisfactory still mothers practicing butter, water and gruel feeding to their babies immediately after delivery and which is very bad practice recommended to be corrected. Data will be available upon request from the corresponding author.