Assessment of timely initiation of breastfeeding and associated factors among mothers who have infants less than six months of age in Gunchire Town, Snnpr, Ethiopia 2019 CURRENT

Background: Timely initiation of breastfeeding is defined as the initiation of breastfeeding within one hour after childbirth. Despite breastfeeding has benefit for both mothers and infants, globally breastfeeding within one hour of life in the world was less than half. In least developed countries (53%), Eastern and southern Africa (60%), Ethiopia (73%) of infant breastfed within one hour. The aim of this study was to assess timely initiation of breastfeeding and associated factors among mothers who have infant less than six months of age in Gunchire town, Ethiopia. Methods : The study was conducted from May 6 to 20, 2019 by using face to face interview of structured questionnaire. Community based cross-sectional study was employed on 333 women. The study participants were selected by Simple random sampling techniques. The data were coded, entered, cleaned and analyzed by SPSS with windows version 21.0. Binary and multivariate logistic regression statistical model were used. Adjusted odds ratio with 95% CI will be computed to see the strength of association. Results: In this study the magnitude of timely initiation of breastfeeding was 80.5%. Governmental employed mothers (AOR=2.914, 95%CI: 1.139, 7.46), Antenatal care visit (AOR=5.99, 95% CI:1.29, 27.81), Baby skin to skin contact (AOR=2.4, 95%CI:1.092, 5.34), Vaginal delivery (AOR=5.82 95%CI:1.68, 20.14) Institutional delivery (AOR=5.5, 95CI%:1.66, 18.3), Good knowledge of breastfeeding (AOR=4.02, 95%CI:1.04, 15.59) and Breast disease (AOR=0.24, CI95%: 0.08, 0.73) were significantly associated with timely initiation of breastfeeding. Conclusion: More than third quarter of the respondent mothers timely initiated breastfeeding. Being governmental employed, Antenatal care visit on current baby, skin to skin contact, vaginal delivery, institutional delivery, breast disease and knowledge of mothers about breastfeeding were significantly associated with timely initiation of breastfeeding. Recommendation:


Abstract
Background: Timely initiation of breastfeeding is defined as the initiation of breastfeeding within one hour after childbirth. Despite breastfeeding has benefit for both mothers and infants, globally breastfeeding within one hour of life in the world was less than half. In least developed countries (53%), Eastern and southern Africa (60%), Ethiopia (73%) of infant breastfed within one hour. The aim of this study was to assess timely initiation of breastfeeding and associated factors among mothers who have infant less than six months of age in Gunchire town, Ethiopia.
Methods : The study was conducted from May 6 to 20, 2019 by using face to face interview of structured questionnaire. Community based cross-sectional study was employed on 333 women. The study participants were selected by Simple random sampling techniques. The data were coded, entered, cleaned and analyzed by SPSS with windows version 21.0. Binary and multivariate logistic regression statistical model were used. Adjusted odds ratio with 95% CI will be computed to see the strength of association.
Results: In this study the magnitude of timely initiation of breastfeeding was 80.5%. Governmental Conclusion: More than third quarter of the respondent mothers timely initiated breastfeeding. Being governmental employed, Antenatal care visit on current baby, skin to skin contact, vaginal delivery, institutional delivery, breast disease and knowledge of mothers about breastfeeding were significantly associated with timely initiation of breastfeeding. Recommendation: We would like to recommend Enamore woreda health office to provide information to give further education about breastfeeding.
To Gunchire primary Hospital staffs work at maternal and child health clinic recommend them to provide appropriate services and stimulate the mothers to initiate breastfeeding, skin to skin contact enhancing within first hour of birth. Further study on timely initiation of breastfeeding at institution level is suggested.
Key word: Timely, Breastfeeding Background Timely starting of breast sucking is the starting of breast sucking within the first hour of childbirth. It is started by skin-to-skin contact with their mothers after birth and the mothers helped to initiate breast sucking with in the first hour of birth. Timely starting of breast feeding is one in which the child friendly hospital initiative was founded and launched in 1992 (1,2). The WHO and UNICEF were recommended an early starting of breast sucking within the first hour of birth (3). Whether the breast milk arrival or not it does not matter, but it is important to consider about the length of time after birth when the mother attempt to initiate breast sucking. An attempt to initiate suckling started when a mother putting her infant directly to her breast and trying to get the infant's mouth to handle the nipple. Not only this but also, skin-to-skin contact could also be regarded as attempting to initiate breast sucking; since the infants would naturally make a movement towards the breast (4). The WHO and UNICEF also recommended that an exclusive breast sucking for the first six months then up to two years or beyond with an appropriate complementary feeding (5).
Early breastfeeding and skin-to-skin contact help to control the body temperature of the newborn baby and increases the chances of establishing early exclusive suckling (7). But also, early starting of breast sucking stimulates breast milk production, increases uterine activity and reduces the risk of heavy bleeding and infection (6), fosters mother-child bonding and increases the duration of the breast sucking (2). During the first days of life, breast sucking helps to prevent low blood sugar and low temperature. Colostrum provides the baby with a high level of antibodies, immune cells, vitamin A and other protective factors (6). Early starting of exclusive breastfeeding serves as the starting point for a continuum of care for mother and newborn that can have long-lasting effects on health and development. It is fact that promoting early starting of breast sucking and EBF for six months after birth helps to reduce maternal and neonatal morbidity and death (5). Delay of starting of breast sucking is greater risk of neonatal mortality (9). This is particularly relevant and happened in Africa where neonatal and infant mortality rate were very high (10).
Even though breast sucking has extraordinary benefits, only 43% of the newborns start breast feeding with in the first hour after birth globally. The result is even lower in developing countries. Early starting of breast sucking across the regions were in the least developed countries(53%), Eastern and Southern Africa(60%), Latin America and Caribbean(49%), South Asia(42%), East Asia and Pacific(41%) and West and Central Africa(35%) (11).
In Ethiopian, Ministry of Health targeted an increase in the proportion of newborn to start breast sucking within the first hour of life to 92% by 2015 as one strategy to improve child health (12). But only 52% of newborn started breast sucking within one hour of life. Starting of breast sucking within one hour was lowest in the Amhara and Somali regions (38% and 40%, respectively) and highest in the South Nation Nationality of People (SNNP) and Dire Dawa regions (67% and 66 %, respectively) (13). According to EDHS 2016, Seventy-three percent of children began breast sucking within 1 hour of birth, and 92% within 1 day of birth. The practice of pre-lacteal feeding was decreased dramatically from 29% in 2005 to 27% in 2011 and 8% in 2016 (14). The national study indicated that there is the existence of problems in the inappropriate practice of the timely starting of breast sucking (TIBF).
Despite timely starting of suckling is very important for the continuation of exclusive breastfeeding, much of the focus is given for breast sucking advocacy. This again shows the problem of early starting of breast sucking in Ethiopia needs further focus and intervention both in urban and rural sides of the country. To reduce child morbidity and mortality, infant suckling has been identified as one of the major intervention areas both globally and nationally.

Study Area and Study Period
Gunchire town is one of the urban address found in the Enamore district. It is around 199 km from the capital city of Ethiopia Addis Ababa toward south-western and 301 km from Hawassa capital of the SNNP region and 42 km from Wolkite, the town of Guraghe zone. Gunchire town has 1 Primary hospital which was established in 2016 and 2 health posts with 8 health workers (4 in each Health Extension). According to Gunchire town municipality data, Gunchire town has total populations of 6502 peoples of these 49% are males and 51% females. Study was conducted from May 1 to 28, 2019 (32).

Study Design and Study Participants
Community based cross-sectional study design was conducted among mothers who have an infant less than six months of age from both 01 & 02 addresses.

Inclusion and Exclusion criteria
Mothers who have an infant less than six months of age and living in the study area for more than six months. While, those who have not biological care giver or mothers who are unable to communicate due to serious illness at the time of data collection were excluded.

Sample Size Determination and Sampling Procedure
Sample size was determined by using single population proportion formula. Based on the following assumption: The level of confidence of the study 95%, margin of error is 5%, the proportion (P) was 0.73 which estimates the proportion of timely starting of breast feeding in Ethiopia according to EDHS 2016(14). Accordingly, by considering 10% for non-response rate 333 respondents were selected by Simple random sampling technique from Gunchire town 01 & 02 kebeles.

Operational Definitions
Timely starting of breast feeding: an infant's first intake of breast milk (or colostrum) within one hour of birth.
Good knowledge about timely starting of breastfeeding: If the mother can answer above the mean value asked to measure timely starting of breastfeeding awareness.
Poor knowledge about timely starting of breastfeeding: If the mother answers less than or equal to the mean value asked to measure timely starting of breastfeeding.

Data Collection Methods and Procedures
The data were collected by using a structured hospital-based face to face interview pre-tested questionnaires administered by trained data collectors in the class arranged for data collection after the mothers were assured to be stable. The questionnaire was adapted from other similar studies and prepared in English. It was translated in to Amharic. Finally, it was translated back to English to check for consistency. The questionnaire contained questions that address socio-demographic characteristics of respondents, health services and history of pregnancies, labor and birth related factors and awareness of mothers measuring questions related to timely starting of breastfeeding.

Data Quality Assurance and Control
One-day training was provided for data collectors and supervisors by the principal investigator to create awareness on timely collection and data management on the basic technique of data collection, approaches and on the issue of confidentiality and privacy. To get informed consent and reliable data, a clear explanation of the purpose and procedure of the study was given to the study participants. Moreover, the data collectors were supervised daily by supervisors.

Method of Data Analysis
After checking the completeness and appropriateness of the data, the collected data were entered into SPSS version 21 for analysis. Statistical analyses including descriptive statistics, binary and multivariate logistic regression analysis were conducted. First binary logistic regression was used to identify variables and after these variables having p-value less than 0.25 was fitted to multivariate logistic regression model to determine the relationship between the dependent and independent variables. Adjusted odds ratio with 95% CI was computed to see the strength of association. The findings of this study were interpreted in the form of figure, table, percentage, proportion and frequency.

Socio-Demographic Characteristics
A total of 333 mothers of children less than 6 months in Enamore woreda, Gunchire town, Gurage Zone were interviewed with 100% respondent rate. The most common ethnic group in the study area Factors associated with timely starting of breastfeeding Multivariate analysis indicated that government employed mothers were 3 times more initiate breast feeding than mothers who were housewife (AOR = 2.914, 95%CI: 1.139, 7.46). Presence of ANC follow up on current baby were 6 times more likely to initiate breastfeeding (AOR = 5.99, 95% CI:1.29, 27.81) than mothers who had no ANC follow up on current baby. Baby placed on abdomen of mothers immediately after birth (AOR = 2.4, 95%CI:1.092, 5.34) were 2.4 times more likely to initiate breastfeeding than that of baby don't placed immediately after birth. The baby who delivered vaginally (AOR = 5.82 95%CI:1.68, 20.14) were 5.8 times more likely to initiate breastfeeding within first hour of birth than who delivered by cesarean section. Mothers who delivered their last baby at health institution (AOR = 5.5, 95CI%:1.66, 18.3) were 5.5 times more likely to initiate breastfeeding than that of delivered at home. Mothers who had good knowledge about breastfeeding (AOR = 4.02, 95%CI:1.04, 15.59) were 4 times more likely to initiate breastfeeding than mothers had poor knowledge within first one hour of child birth. Those mothers who had breast disease were 0.24 less likely to initiate breast feeding than mothers who had no breast disease (AOR = 0.24, CI95%: 0.08, 0.73) ( Table 5).
Multivariate analysis revealed that governmental employed mothers were three times higher than initiating breast sucking than those who were housewife. But the study conducted at Alhassa Saudi Arabia shows that educated and employed women were less likely to initiate and maintain breast sucking despite their relatively higher level of awareness (18). Its fact that more the governmental hired were educated and this can influence mothers to get adequate knowledge about the benefits of initiating breast feeding early.
Mothers who had antenatal care visits during their last pregnancy were about 6.76 times higher to initiate breast sucking within one hour after childbirth than who had no antenatal care visit during their last pregnancy. This could be happened because of mothers who had antenatal care visits during their pregnancy could access counseling sessions on the importance of timely starting of breastfeeding, and thereby be more likely to practice it. This result is supported by a study conducted in western Ethiopia, study done in Nigeria, study done in south Gondar Ethiopia and Dembecha district which showed that counseling on breastfeeding during antenatal visit increases the rate of timely starting of breast sucking (20,27,30,31).
Babies those placed on mothers' abdomen immediately after birth were 3.93 times more likely to start breast sucking after birth than baby don't placed on the mother's abdomen. This might be most newborns are ready to find the nipple and latch on to the breast within the first hour of childbirth, if provided with immediate skin-to-skin contact and naturally the newborns tend toward the breast. This finding is supported by study done at urban dwellers of western Ethiopia showed that placing the baby on mothers abdomen immediately after birth increase practicing of timely starting of breastfeeding (20).
Mothers who gave last birth vaginally were 4.46 times more likely to initiate breast sucking within the first hour of childbirth than those deliver by cesarean section. This could be due to delay recovery from anesthesia and discomfort to initiate breast sucking. This finding is supported by study done in Alhassa Saudi Arabia and study done at south Gondar Ethiopia showed that vaginal delivery were more likely to initiate breast sucking than those delivered by cesarean delivery (18,30).
The mothers who gave birth at health institution were 6.75 more likely to initiate breast sucking within the first hour of childbirth than those delivered at home. This is because of the midwives/ Obstetrician stimulated to initiate breast sucking and tell the mothers about the importance of timely starting of suckling. This finding is supported by study done in Goba woreda, study done in Nigeria and study done in south Gondar Ethiopia showed that delivery at health institution increases the rate of timely starting of breastfeeding (19,27,30).
This study revealed that those mothers who had breast disease were less likely to initiate breast sucking than mothers who had no breast disease. The same to this finding according to study done in India, breast abnormality like inverted/retracted nipples was identified major barriers to starting of suckling identified included (29). In fact, if the breast of the mothers was infected there might be high probability not initiating sucking due to the pain and also the risk to infect the baby was dramatically high.
The mothers who had good awareness about breast sucking were 4.23 times more likely to start breastfeeding than those who had poor awareness about timely starting of breastfeeding. This is because the mother becomes and prepares herself for timely breastfeeding. This finding is supported by study in urban dwellers Western Ethiopia showed that good awareness increases the rate of timely starting of breast sucking (20). However, the limited nature of the cross-sectional study design in determining cause-effect relationship, and recall bias may be introduced since this study also included mothers who experienced childbirth up to 6 months of the data collection period.

Conclusion
More than third quarter of the respondent mothers timely initiated breastfeeding. Presence of ANC follow up on current baby, baby placed on abdomen of mothers immediately after birth, vaginal delivery, institutional delivery and knowledge of breastfeeding were significantly associated with timely starting of breastfeeding. Therefore, we would like to recommend Enamore woreda health office to provide information to give further education about breastfeeding. To Gunchire primary Hospital staffs work at MCH clinic recommend them to provide appropriate services and stimulate the mothers to initiate breastfeeding, skin to skin contact enhancing within first hour of birth. Further study on timely starting of breastfeeding at institution level is suggested. University, college of medicine and health sciences. After an appropriate permission obtained, official letter was given to concerned stakeholders. Verbal and written informed consent were obtained from each participant, and for under 16 years old from their parents, before starting to administer the questionnaire. Purpose and procedure of the study was explained and informed consent was obtained from the study participants. Any information obtained from participants during the study kept confidential. Finally, data was collected by respecting the right of others, culture, norms, and other ethical issues.

Consent to publication
Not applicable Availability of data and materials Datasets will not be shared to protect the participants' confidentiality

Competing interests
The authors declare that they have no competing interests Funding Not applicable Authors' contributions EY wrote the paper, participated in data analysis and prepare manuscript, TT participated in data collection, drafted the paper, TG approved the proposal with some revisions, and revised subsequent drafts of the paper. All authors read and approved the final manuscript. study.

32.
Gunchire Town Enamore woreda population data and town municipality 2011.    Starting of breast milk makes the infant to get liquid only Yes 91

Tables
No 242 Skin to skin contact is important for timely starting of breastfeeding.

Yes 246
No 87 Only breastfeeding is enough for the baby immediately to birth. Yes 321

No 12
Breast milk contains all nutrients necessary for the infant.

Yes 325
No 8 Colostrum provide the infant with the immunity to disease Yes 322

No 11
Squeeze out and throw away colostrum has disadvantage for the infant.

No 15
Knowledge of mothers about BF Good knowledge 318 Poor knowledge 15