Assessment of Knowledge, Attitude and Practice of mothers on early breast feeding initiation after delivery in Debre Tabor Referral Hospital, and South West Ethiopia 2019 : Institution based crosses sectional Study.

The global breastfeeding recommendation states that all infants should be put to the breast within one hour of birth, which is defined as timely initiation or early initiation of breastfeeding. Early initiation of breastfeeding is having the capability to reduced risk in infant illness and death. Understanding the determinants of delay in initiation of breastfeeding might spur health staff and policy makers to foster timely breastfeeding. Therefore, this study was intended to assess Knowledge, Attitude and Practice of mothers on the early initiation of breast feeding in the study area. Objective To assess knowledge, attitude and practice of mothers on the early breast feeding initiation after delivery in Debre Tabor Referral Hospital from December 1/2018-January 30/2019. Methods Institutional based cross sectional study design was done to assess knowledge, attitude and practice of mothers on the early breast feeding initiation after delivery in Debre Tabor Referral Hospital from December 1/2018-January 30/2019 with a total sample of 336. Simple random sampling technique was used and data was collected by using structured questionnaire. Data was entered into Epi info version 7.2.0.1, and exported to SPSS window version 20 for analysis and the result was presented in tables and graphs.


Objective
To assess knowledge, attitude and practice of mothers on the early breast feeding initiation after delivery in Debre Tabor Referral Hospital from December 1/2018-January 30/2019.

Methods
Institutional based cross sectional study design was done to assess knowledge, attitude and practice of mothers on the early breast feeding initiation after delivery in Debre Tabor Referral Hospital from December 1/2018-January 30/2019 with a total sample of 336. Simple random sampling technique was used and data was collected by using structured questionnaire. Data was entered into Epi info version 7.2.0.1, and exported to SPSS window version 20 for analysis and the result was presented in tables and graphs.

Result
The overall knowledge, attitude and practice of breast feeding mothers about early initiation of breast feeding were 79.23%, 59.6% and 62.5% respectively, and 31% of mothers discard first milk or colostrum.

Conclusion and recommendations
The overall knowledge score of the pregnant mothers about early initiation of breast feeding was satisfactory while compared with different researches in Ethiopia and African but attitude of breast feeding mothers toward early initiation of breast was lower when compared with knowledge and practice of mother for this study and to alleviate this problem the organization and the health care providers should integrated and mobilize, educate and counsel about early initiation of breast feeding.

Background
Early initiation of breast feeding prevent constipation by laxating the infants stool since it has high fat content in addition to it contains immunoglobulin which acts as a defense mechanism to fight and prevent against disease causing agents (1). Although the benefits of immediate, continuous, uninterrupted skin-to-skin contact (SSC) and early breastfeeding have been widely researched and confirmed with different literatures, the challenge remains to improve the consistency of this practice. Fewer than half of newborns worldwide are breastfed in the first hour (2).
Early initiation of breastfeeding (EIBF) lowers the risk for all-cause mortality in babies, including those with low birth weight. However, rates of neonatal mortality and delayed initiation of breastfeeding remain high in most low and middle-income countries and the mortality rate was decreased by 82.5% (3,4). The impacts of optimal infant feeding practices on diarrhea have been documented in some developing countries, but not in countries with high diarrhea mortality as reported by the World Health Organization/United Nations Children's Fund. Generally delayed initiation of breast feeding were a problem of both developed and developing countries, but the burden bears more in developing countries especially in sub Saharan Africa. ((5, 6, 7). Mother and newborn skin-to-skin contact (SSC) after birth brings about numerous protective effects; however, it is an intervention that is underutilized where a globally considerable rate of maternal and child death has been reported and SSC facilitates good initiation of breast feeding and vice versa (7).
The global breastfeeding recommendation states that all infants should be put to the breast within one hour of birth, which is defined as timely initiation or early initiation of breastfeeding. Early initiation of breastfeeding is associated with reduced risk in infant illness and death. Understanding the determinants of delay in initiation of breastfeeding might spur health staff and policy makers to foster timely breastfeeding (8).
Different literatures showed that in many sub Saharan African countries revealed that, first milk or colostrum considered as an important and discarded, this practice enhances delayed EIBF and neonates will acquire different infections, since the first milk acts as an antimicrobial (2).
Even though timely initiation of breastfeeding can decrease neonatal mortality, however, the study done in Congo showed about 50% of newborns are not breastfeed within 1 hr. of birth (9).
Early initiation of breastfeeding (EIBF) lowers the risk for all-cause mortality in babies, including those with low birth weight. However, rates of neonatal mortality and delayed initiation of -2 -breastfeeding remain high in most low-and middle-income countries (10). Several reasons influence breastfeeding practice including mothers' socio-demographic and obstetric characteristics, and factors related to time around childbirth, decides this Meta-analysis in china revealed that inappropriate and delayed initiation of breast feeding lead to diabetes mellitus in addition to respiratory and constipations (3) .
Generally EIBF brings much importance at lying beside on mothers and babies regardless of its knowledge, attitude and practice of mothers on the EIBF.But, limited studies have been conducted at Institution level regarding to Assessment of Knowledge, Attitude and Practice of mothers on early breast feeding initiation after delivery in Ethiopia; particularly in the study area. Therefore, this study was assessed the Assessment of Knowledge, Attitude and Practice of mothers on early breast feeding initiation after delivery in Debretabour Referral Hospital, Northwest Ethiopia.

Study Area and study period
Study was conducted at Debre Tabor Referral Hospital. Debre Tabor is far from 103 km from capital city of Amhara National Regional State. It is found 666 kilometers away from Addis

Study design and participants characteristics
Institution based cross sectional study design was conducted. All pregnant mothers who follow ANC at Debre Tabor Referral Hospital and planned to give birth at this hospital considered as a source population, and study population was all mothers who give birth at Debre Tabor Referral Hospital during the study period and who are fulfilled the inclusion criteria. All delivered mothers with in the study period and who voluntary to participate in the study and can communicate well without mental problem would be included. However, Women's who are seriously ill, unable to communicate had been excluded from the study

Simple size determination and sampling procedure
Sample size was determined by using single proportion based on the following assumption in -4 -95% CI and 5% of Margin error with early initiation of practice of breast feeding 62.6% from previous study dune in Debre Berhan (20).Ni = (Z α/2 ) 2 p (1-P) Since the population is less than 10,000, reduction formula was used So, So,

=305
By adding 10% none response rate the final result would be =305+30.5

=336
Simple random sampling technique was employed to select the study participants.

Study variables
 Socio-Demographics (Age of mothers, age of Neonate, residence, Mothers Marital status,

Data collection tools
Data was collected using a pre-tested and structured interviewer-administered questionnaire, which was adapted from WHO and published articles with some modifications to the local context (11, 12, 13, 15, 16, 18, 20, and 21). The questionnaire was prepared in the English version and it translated to the local language (Amharic which was used to collect the data). The questionnaire has thirty six questions and five parts: socio-demographic and economic characteristics assessment status, early breast feeding information related assessment, Knowledge of mothers regarding to EIBF related assessment, Practice of mothers regarding to EIBF related assessment, and Attitude of mothers regarding to EIBF related assessment.

Data collection techniques
A total of Two BSc Nurses as data collector and one BSc Nurses as a supervisor (who have an experience of data collection) were selected. After briefly presenting the study purpose and getting oral consent from each mother with an eligible infant, data collectors interviewed participants.

Data Quality Control
The quality of the data was assured by pre-testing the questionnaire on 5% of the sample (17 participants) in Mekane Eyesus primary hospital prior to the start of the actual study to test the fitness of the questionnaire for the study settings. Training about the data collection tool as well as data collection procedures (ways of approaching the eligible mothers and how to obtain permission for an interview) was given to data collectors and supervisors for a total of two days prior to the data collection process.
The objectives of the study were clearly explained to the data collectors as well as supervisors.
The respondents were given brief orientation before they are interviewed and supervision was done at the spot by the supervisors. Throughout the course of the data collection, interviewers was supervised at each site, regular meetings was held between the data collectors, supervisor, and the principal investigators to discuss the problem arising in each interview, and detailed feedback was provided to the data collectors.
In addition, the collected data was checked daily for its completeness, accuracy, and clarity by supervisors. The principal investigator checked every questionnaire before data entry. Data was kept in the form of a file in a private secured place.

Data processing and analysis
After checking the completeness of the data, it was entered into Epi info version 7.2.0.1, and then; it was exported to SPSS Version 20 for analysis. Descriptive analysis was done by computing proportions and summary statistics. The data was checked for its completeness and any incomplete information was excluded from entry after data collection and then the data was entered to possible statistical software for analysis. Data was cleaned and coded for completeness and consistency and the result was presented with in the form of texts, figures and tables by using frequency and summary statics such as mean, standard deviation, and percentage to relevant variables.

Ethical consideration
Ethical clearance was obtained from Research Ethics Committee of Debre Tabor university department of Nursing. Then, the participants of the study were informed about the purpose of the study, the importance of their participation, and their right to withdraw at any time. Verbal informed consent was obtained prior to data collection, then data collects from volunteer mothers. Mothers who are not practice EIBF during the data collection period were advised regarding to Neonatal feeding.

Socio-demographic characteristics of the respondents
A total of 336 mothers-neonates pairs were included in the study, resulting in a response rate of 336(100%).Among all study participants 60.7% (204) the incorporated mothers from the study were between the age group of 25-34years of age. Regarding age of the neonates ,37.2 %(125) of neonates with the respondent mothers age ranged 0-7 days and this was considered as majority of the new born found in early neonatal age .Almost all of 98.8% (332) the respondent mothers Amhara nations and 88.7% (298) of the mother who were undergone for this study follow

Discussion
From this study the cumulative knowledge of mothers on the EIBF was 79.23% but the study conducted in Asia on cluster randomized controlled trial to determine whether early home-based breastfeeding support by a maternal and child health nurse revealed that 72.5 % the mothers know the advantages of soon imitation of breast feeding and its advantages, in this study higher number of participants were knowledgeable when compared with the study conducted in Asia but lower than the study conducted in California since 84% of the study participants had a good knowledge about early initiation of breast feeding and this difference may be due to different in health education and wariness creation (1) (2). As shown above 79.23 % of the study participant from this study had good knowledge about EIBF but other qualitative study conducted in china signifies that on the EIBF knowledge was higher among mothers (3). The survey conducted in Namibian DHS showed that 61.2% of mothers had knowledge on the EIBF and the outcome of early breast feeding which is very low when compared with this study and diff may be due to different in study period (4). A quasi-experimental study was conducted in England among 108 mothers to assess KP of mothers on the initiation of breast feeding explicated that 87.4% of the mothers knew properly how to initiate breast feeding early but 12.6 % of the respondents were provide different reason to hastate the initiation of early breast milk feeding and this paper result showed better amount of mothers had knowledge on the EIBF which compared with Namibia and this study and the difference may be good awareness creation and counseling about EIBF (5).The survey which conducted on human development in Indian district revealed that only two-fifths (44%) of children receive breastfeeding within 1 hour of birth ,this result were very low which compared with Namibia, and this research (6) .From this study 79.23 % of the study participants know how to initiate breast feeding early but the study used the most recent Demographic and Health Survey datasets collected in nine sub-Saharan African countries with high diarrhea mortality was seen on inappropriate feeding like mixed feeding of the infants and studies on Juba on EIBF is associated with reduced risk in infant illness and death. 48% of the mother start EIBF but majority of the mothers of 52% start breast feeding delayed than 1 hour and the result revealed higher when compared with the study the above study and difference may be due to socio economic status as well as information access (7,8). The study conducted in Congo revealed that only 50% of the mothers had knowledge to intimae breast feeding early and have of the respondents were not having sufficient knowledge to initiate breast feeding early and in the recommended time ,this was the list what I have seen from the above 8 literatures including this study (9). From this study 59.6(200) of the mothers support EIBF but some of the mothers or 40.4(136) of the mothers do not support EIBF ,on the other way the study conducted on the impact of peer counseling on EIBF and exclusive breastfeeding rates for mother-infant pairs living in urban slum by randomized controlled trial enrolled 350 motherinfant pairs from selected slums between September 2014 and July 2016 revealed that 46.3 % of the mothers only had positive attitude towards EIBF, which is lower than this study (10).
Another study conducted on the same topic in Saudi Arabia revealed 67.85 % of the mothers had positive attitude for the EIBF, which higher than this study and the difference may be due to value and belief difference (11). Meta-analysis to assess the prevalence of four key breastfeeding indicators in four sub regions of 29 sub-Saharan African countries revealed that only 37.84% the mothers initiate breast feeding early, this result showed that very low when compared the research conducted in Saudi Arabia and this study (12). From this study 62.5% (167) of mothers practice EIBF and 79.5 %( 267) of the mothers give breast milk to their new born but the study conducted in Bangladesh revealed that. 67% initiated breastfeeding within one hour of birth at health facilities which is higher when compared with this study and the study conducted in Brazil on breast-feeding, complementary feeding and EIBF in Brazilian lowincome urban community of closed observational study showed that 65% of the mothers practice breast feeding soon after delivery which is intern higher than this study(13) (14).A cross-sectional questionnaire survey of mothers in the postnatal wards of Da Nang Hospital for Women and Children in central Viet Nam on the initiation of breast feeding within 1 hour of delivery among breast feeding mothers showed that 78.7% of mothers initiate breast feeding within 1 hour of delivery, this result higher than the study conducted in Brazil and this study and this difference may be due to awareness creation and understanding of the advantages of breast feeding (15).
The study in Bangladesh on skin to skin contact and EIBF by DHS survey method explains the result that 67% of the mothers of full term babies initiate breast feeding within 1 hour. and this result low when it compared with the research conducted in Brail and it higher than this study (16).A cross sectional study in Spain on the assessment of prevalence of EBF at 3-months postpartum, and the early initiation of breast feeding for discontinuation provide a result of 67 % of the mother could initiate breast feeding early and the result was low when compared with the literature result of Brail but higher than this study (17). Similar literatures with my research topic that have been done in Colombia 67% of the respondent mothers feed breast exclusively which is in line with the research conducted in Spain but higher than this study (18) and Demographic and Health Survey Studies evaluating child feeding in Madagascar are scarce despite its importance in child growth during the first two years of life revealed that the rates of initiation of breastfeeding within one hour after birth was (77.2%), and this was better next to the study conducted in Brᴢail and higher than this study (19).A cross sectional studies in Ethiopia on delayed bathing and EIBF reveals 62.6% of the baby was initiate breast feeding early which is in line with this research (20). The cross sectional conducted on the assessment practice of knowledge, attitude of mothers about colostrum feeding revealed that 67.8 within 2 hours of delivery and this result almost similar with the study conducted in Spain and Colombia but higher than this study (21). On the other way the study conducted in Ethiopia on the avoidance of colostrum, results revealed that 54.8% of the mothers feed as early as within 2hrs of delivery despite 46 % of colostrum avoidance, which is lower than this study (22) .Generally the result of this study, was comparatively similar with most studies but lower in results with some studies.

Limitation  Time and budget constraint
 Study participants might also perceive that responding as early initiation of breast feeding might bring benefits; this can result in overestimation of KAP score  Since the research follows cross sectional study ,the cause and effect determined in separately  Most of the incorporated pregnant mothers were urban dwellers ,incorporation of rural mothers was limited

Conclusion
The overall knowledge score of the pregnant mothers about EIBF was satisfactory while compared with different researches in Ethiopia and African but attitude of breast feeding mothers toward EIBF was lower when compared with knowledge and practice of mother for this study .So proper community mobilization and awareness creation about EIBF is very crucial.

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Availability of data and materials: Data will be available upon request from the corresponding author.