DOI: https://doi.org/10.21203/rs.3.rs-72239/v1
Background
Ethiopian government implemented baby-friendly hospital initiative and community integrated management of childhood illnesses program. Despite early initiation of breastfeeding taken as a key tool for tackling neonatal mortality, EIBF is still low and most of the neonatal mortalities were existed due to delayed initiation of breastfeeding in Ethiopia in general and the practice is not well documented in South West Ethiopia in particular. Therefore, this study aimed to assess early initiation of breastfeeding practice and associated factors among mothers of children aged less than six months of old in Mizan-Aman town, southwest Ethiopia.
Methods
A community-based cross-sectional study was employed from April 15 to May 15, 2018. A total of 487 recently delivered mothers were included. The data was collected through face to face interview by using a pre-tested and structured questionnaire. Binary and multivariable logistic regression analysis were employed and p-value < 0.05 was identified as statistically significant factors, and the quality of the data were assured, checked, coded, cleaned and entered in Epi-Info version 3.5.3 and
exported to SPSS version 25 for the analysis.
Result
The prevalence of timely initiation of breast feeding was 296(64.50%) in Mizan- Aman Town. Mothers who had < 24 months birth spacing history 1.85(AOR: 95% CI: 1.22, 2.81), mothers’ income level between 1001-1500 Ethiopian Birr 2.21 (AOR: 95% CI: 1.12, 4.37), Primipara mothers 2.00 (AOR: 95% CI: 1.24, 3.23) and home delivery 2.76(AOR: 95% CI: 1.24, 6.14) were important positive predictors for timely initiation of breast feeding. Furthermore, Government employee and merchant mother by occupation was found to be protective factors.
Conclusion and recommendation
The practice of early initiation of breast feeding was suboptimal and still below the national average. Intervention at the community and facility level should paid special attention.
Early initiation of breastfeeding is putting newborns to the breast within the first hour of life and saves lives and provides benefits that last a lifelong [1].
Globally, an estimated 2.5 million newborns died in the first month of life in 2018, approximately 7,000 every day.99% of all neonatal deaths occur in in low and lower-middle income countries. If the problem is left untreated, more than 60 countries will miss the target for neonatal mortality (12 deaths or fewer per 1,000 live births) by 2030[2]. In Ethiopia, 2019 EMDHS reveals that the neonatal mortality rates were 30 deaths per 1,000 live births [3].
Worldwide in 2017, it is estimated that 78 million newborns delayed more than one hour to be put to the breast. which means that 42% or only two out of five newborns, the majority born in low- and middle-income countries, were initiated breast feeding within the first hour of life. The practice varies worldwide from (35%) in the Middle East and North Africa to (65%) in Eastern and Southern Africa. Ethiopia found in eastern Africa region, the practice of early initiation of breast feeding in 2016 was 73.3%, slight improvement has been made from 2005 practice 66.2% [4].
Early initiation of breast feeding has beneficial effect on baby’s as well as maternal health like: save more than 800,000 children each year, increase cognitive development, prevent overweight and obesity, boosts immunity system and protect against all half of diarrheal and one third of respiratory infectious diseases [5]. Indeed, mothers benefited from breast feeding involving: a lower risk of 20,000 breast cancer death, ovarian cancer, improve birth spacing, post-partum hemorrhage, depression, type 2 diabetes and saved $300 billion to the global economy each year [5–7].
The longer newborns delayed for breast feeding, the greater their risk of death. New studies revealed that when compared with newborns who initiated breastfeeding within an hour of birth, the risk of dying during neonatal period is 33% higher for those who initiated 2–23 hours after birth, and was two times higher for those who initiated one day or longer after birth [8].
There are many factors which determine the practice of early initiation of breast feeding like: outdated practices in health facilities, lack of knowledge about breastfeeding after a caesarean section, cultural practices like prelacteal feeding, Massive missed opportunity, skilled birth attendants, place of deliveries, Programme and policy-related factors and Access to antenatal care [4, 9–11].
Despite Ethiopia have been implemented different programs on optimal breast feeding as key tool to tackle neonatal and infant mortality, yet not meet the desired outcome [12–14]. Although the importance of early breast-feeding practice, limited information is documented in southwest Ethiopia. Therefore, this study was attempted to fill this information gap and come up with recommendation on possible intervention for timely initiation of breast-feeding improvement and associated factors in Mizan -Aman town, southwest Ethiopia.
Study setting and study period
The study conducted in Mizan-Aman town, the capital town of Bench Maji Zone, is situated 561 Km south west of Addis Ababa capital town of Ethiopia, from April 15 to May 15/2018.The town is administratively structured by 7 kebeles and has a total population of 49,590 of which 26,392 are males and 23,197 are females. Out of all female population 11, 554 of them are women in the reproductive age group (15-49 years). About (1,582) or 3.9% of the total population is accounted by children less than one years of age. It has one public hospital, one health center, three health post, 10 private health institution and 17 drug stores.
Study design
A community based cross-sectional study was employed in Mizan-Aman town
Sampling size determination
The sample size was determined using single population proportion formula. The following assumption were considered: 95% level of confidence, 5% margin of error and 50% of women estimated to be initiated breast feeding within one hour. Since population size was 1582, which is less than 10,000, sample size was adjusted using correction formula, 2 design effects were considered and by adding 5 % non-response rate, the final sample size became 487.
Sampling procedure
Since it is multistage among the two sub-cities (Mizan and Aman sub-city), Mizan sub-city was selected by lottery method. Among five kebeles in the selected sub city, three of them were selected by lottery method. proportional allocation to size was done in each 3 selected kebeles. Then after a systematic random sampling technique was employed at the kebele level by using health extension family record book as a sample frame. Following random selection of the first household with a woman who fulfilled the selection criteria, subsequent households with women meeting the criteria were selected from every three house until the desired sample size was reached in each kebele. For households with more than one eligible woman, one of the women was chosen using a lottery method.
Data collection tools and procedures
The data collection tool was adapted from Ethiopian Demographic and Health Survey (EDHS) 2016 document [15] and translated into local Amharic languages. Training was given for data collectors and supervisors how to make face to face interview and assuring the quality of data. pre-test was done in 5% of the sample size in Tapi town.
Operational definition
Early initiation of breastfeeding: Is putting newborns to the breast within the first hour of life [1].
Level of information about breastfeeding: Those mothers who mentioned ≥2 components of breast-feeding information (1. Benefits of breast feeding 2. positioning of the baby 3. exclusive breast feeding 4. managements of breast problem 5. Expression of breast milk) were considered as having good level of information and mentioned ≤1 components of information were considered as the counterpart [15].
Data quality control
Prior to data collection period, data collectors trained about the objective of the research. The PI was given the training about the objective of the study and data collection system by using semi-structured questionnaires in a one-day period. The questionnaires would prepare in English, translated into Amharic and back translated into English to check consistency. Pre-test carried out on Tapi town to familiarize the interviewer with the tools and to check the coherence. To keep the quality of data, principal investigator was checking the questionnaires for its completeness in each day.
Data processing and analysis
The data was cleaned, coded and entered in to Epi Info version 3.5.3 and exported to SPSS version 25 statistical package for analysis. Descriptive statistics was computed to determine the magnitude of early initiation of breast feeding. Furthermore, bivariate logistic regression and multivariate analysis with 95% confident interval were done in order to determine predictors of early initiation of breast feeding. Variable with a P value of < 0.05 was taken as the criterion for statistical significance.
A total of 487 mother-child pairs were included in the study, resulting in a response rate of 459(94.3%).
Of the total respondents, the majority: 279(60.8%) had ≥ 4 number of family, 173(37.7%) were 20–24 years of age mothers, 435(94.8%) married, 157(34.7%) had primary level of education(1–8 grade), 186(40.5%) orthodox in religion, 134(29.2%) were Amhara in ethnicity, 268(58.4%) were house wife in occupation, 302(65.8%) had gotten < 500 Eth Birr/month, 247(50.9%) infants were male, 215(46.8%) were first order/first child for their family and were no previous birth (Table 1).
| Demographic variable | Frequency(N = 485) | Percentage (%) |
|---|---|---|
| Age of mothers in years | ||
| 15–19 | 47 | 10.2 |
| 20–24 | 173 | 37.7 |
| 25–29 | 155 | 33.8 |
| 30–34 | 48 | 10.5 |
| 35–49 | 36 | 7.8 |
| Maternal marital status | ||
| Single | 19 | 4.1 |
| Married | 435 | 94.8 |
| Divorced | 5 | 1.1 |
| Maternal educational level | ||
| unable to read and write | 100 | 21.8 |
| able to read and write | 35 | 7.6 |
| Primary (1–8) | 157 | 34.2 |
| Secondary (9–12) | 99 | 21.6 |
| college and above | 68 | 14.8 |
| Religion | ||
| Orthodox | 186 | 40.5 |
| Protestant | 170 | 37.1 |
| Muslim | 103 | 22.4 |
| Maternal ethnicity | ||
| Bench | 106 | 23.1 |
| Kaffa | 101 | 22 |
| Amhara | 134 | 29.2 |
| Oromo | 43 | 9.4 |
| Others | 75 | 16.3 |
| Maternal occupation | ||
| house wife | 268 | 58.4 |
| government employee | 55 | 12 |
| Merchant | 55 | 12 |
| Farmers | 45 | 9.8 |
| Private employee | 36 | 7.8 |
| Mothers income level | ||
| < 500 ETH Birr | 302 | 65.8 |
| 500–1000 ETH Birr | 74 | 16.1 |
| 1001–1500 ETH Birr | 18 | 3.9 |
| > 1500 ETH Birr | 65 | 14.2 |
| Age of the infant in month | ||
| < 1 | 27 | 5.9 |
| 1–6 | 432 | 94.1 |
| Sex of the infant | ||
| Male | 247 | 50.9 |
| Female | 238 | 49.1 |
| Birth order of the infant | ||
| First | 215 | 46.8 |
| 2–3 | 185 | 40.3 |
| 4–6 | 51 | 11.1 |
| ≥ 7 | 8 | 1.8 |
| Birth spacing of the infant | ||
| No previous birth | 216 | 47.1 |
| < 24 month | 30 | 6.5 |
| ≥ 24 month | 213 | 46.4 |
| No of children in the family | ||
| ≤ 3 | 398 | 86.7 |
| ≥ 4 | 61 | 13.3 |
| Family size | ||
| ≤ 3 | 180 | 39.2 |
| ≥ 4 | 279 | 60.8 |
The majority of the total respondents, 240(52.3%) were Multipara mothers, while 219 (47.7%) were primipara. Regarding maternal health service utilization; the majority of respondents 446(97.2%) were attending ANC, 304(66.2%) attended ANC four and more times, 263(57.3%) had gotten breast feeding Counseling at ANC Clinic, 415(90.4%) delivered their child at health facility, 413(90%) delivered through normal spontaneous and their delivery was assisted by health professional (Table 2).
| Variables | Frequency(N = 459) | Percentage (%) |
|---|---|---|
| Attending Antenatal care(n = 459) | ||
| Yes | 446 | 97.2 |
| No | 13 | 2.8 |
| Utilization of Antenatal care (n = 446) | ||
| 1 time | 9 | 2 |
| 2–3 times | 133 | 29 |
| ≥ 4 | 304 | 66.2 |
| Get breast feeding Counseling at ANC Clinic(n = 446) | ||
| Yes | 263 | 57.3 |
| No | 183 | 40 |
| Place of Delivery(n = 459) | ||
| Health Facility | 415 | 90.4 |
| At Home | 49 | 9.6 |
| Mode of Delivery(n = 459) | ||
| CS Delivery | 46 | 10 |
| Normal Spontaneous Delivery | 413 | 90 |
| Delivery Attendant(n = 459) | ||
| Health Professionals | 413 | 90 |
| Traditional Birth Attendants | 46 | 10 |
All mothers have breastfed ever their current infant. out of those, 296(64.5%) newborns were put to the breast within one hour and 163(35.5%) were delayed initiation breast feeding more than one hour (Fig. 1). The main reason for delayed initiation of breast feeding were 31(6.75%) breast feeding problem and 8 (1.7%) due to maternal medical illness.
The majority, 274(59.7%) of mothers have good level of information about breast feeding, while 185(40.3%) have poor level of information. The majority, 413(90%) of respondents mentioned beneficial of breast-feeding, while only 31(6.5%) of mothers mention about expressed breast milk.
In multivariate analysis; Mothers who had < 24 months birth spacing history 1.851(AOR: 95% CI: 1.218, 2.813), mothers’ income between 1001–1500 Birr 2.207 (AOR: 95% CI: 1.115, 4.368), Primipara mothers 2.002 (AOR: 95% CI: 1.241, 3.229) and home delivery 2.755(AOR: 95% CI: 1.237, 6.135) were important positive factors for timely initiation of breast feeding. indeed, gov’t employee and merchant mother by occupation and were found to be protective factors for timely initiation of breast feeding, respectively (Table 3).
| Variables | Timely initiation of BF | Crude odds ratio (C.I: 95%) | Adjusting odds ratio (C.I: 95%) | |
|---|---|---|---|---|
| Yes | No | |||
| Occupation | ||||
| Private employee | 19(52.8%) | 17(47.2%) | 1 | 1 |
| Government employee | 41(74.5%) | 14(25.5%) | 0.137(.024, .785) * | 0.074(.006, .867) * |
| Merchant | 35(63.6%) | 20(36.4%) | 0.229(.041, 1.289) | 0.079(.007, .933) * |
| House wife | 176(65.7%) | 92(34.3%) | 0.029(040, 1.099) | .212(.35, 1.275) |
| Farmer | 25 (55.6%) | 20(44.4%) | .320(.056, 1.827) | .364(0.55, 2.416) |
| Income level | ||||
| < 500 ETH Birr | 187(61.9%) | 115(38.1%) | 3.533(1.152, 10.841) | 3.172(1.023, 9.836) |
| 500–1000 ETH Birr | 46(62.2%) | 28(37.8%) | 2.688(1.221, 5.883) * | 2.235(1.003, 4.979) * |
| 1001–1500 ETH Birr | 10(55.6%) | 8(44.4%) | 2.716(1.392, 5.299) * | 2.207(1.115, 4.368) * |
| > 1500 ETH Birr | 53(81.5%) | 12(18.5%) | 1 | 1 |
| Birth space | ||||
| No previous birth | 125(57.9%) | 91(42.1%) | .693(.283,1.696) | 0.709(.28, 1752) |
| < 24 months | 23(76.7%) | 7(23.3%) | 1.658(1.114, 2.467) * | 1.851(1.218, 2.813) * |
| ≥ 24 months | 148(69.5%) | 65(30.5%) | 1 | 1 |
| Gave live birth | ||||
| Primipara | 127(58%) | 92(42%) | 1.724(1.172, 2.536) * | 2.002(1.241, 3.229) * |
| Multipara | 169(70.4%) | 71(29.6%) | 1 | 1 |
| Place of delivery | ||||
| Health facility | 278(66.8%) | 138(33.2%) | 1 | 1 |
| At home | 18(41.9%) | 25(58.1%) | 2.798(1.476, 5.304) * | 2.755(1.237, 6.135) * |
| *Statistically significant at p < 0.05 in the crude analysis and after adjusting for selected confounding variables. | ||||
our study revealed that Breastfeeding practices were sub-optimal in the study setting due to the delayed initiation of breast feeding. The prevalence of timely initiation breast feeding in Mizan-Aman town is found to be 64.5%. This figure is consistent with study findings which were conducted in Debre Berhan town, Kenya, Lesotho and Jamaica (62.6%, 62.2%, 65.3% and 64.7% respectively) [16, 11, 17, 21].
The practice of early initiation of breast feeding in our study area was higher than study from in Zimbabwe (58.3%) ,south Gondar (54.7%),Axum Town (41.6%) and Goba district (52.4%) respectively[17, 18, 19, 20].this difference could be due to study setting, some of them were from rural side, population character, when the study subjects are those mother of children more than 6 months of age they might not recall well when to start to initiate breast feeding, information and health service utilization and socio economic difference between the referenced subject and the study place.
Higher rate of timely initiation of breast feeding was reported from Malawi (76.9%) [21], Bahirdar city (75.4%) [22], Debre Tabor town (76.8%) [23] and Motta town (76.8%) respectively [21, 22, 23, 24]. the difference might be due to methodological difference, socioeconomic, cultural difference and access to health service.
Mothers’ income level between 1001–1500 Eth Birr were two times (AOR: 95% CI: 1.115, 4.368) more likely initiated breast feeding within one hour than mothers’ income > 1500 Eth Birr. While, this study is contradicted with Debre Berhan town [16], those mothers’ income level > 1969 Eth Birr were more likely initiated early breast feeding. This difference might be due to having higher income and being sophisticated city women, empowers the women to make medical decision. they can afford and prefers elective Cesarean section delivery in order to avoid labor pain. This in turns leads to delayed initiation of breast feeding. Indeed, this is supported by evidence in this study, gov’t employee and merchant mother by occupation, the majority of them have gotten > 1500 ETH Birr/month, were 0.074 (AOR: 95% CI: .006, .867) and 0.079 (AOR: 95% CI: .007, .933) less likely to initiate breast feeding within one hour.
Our study revealed that the odds of timely initiation of breast feeding among primipara mothers were two times (AOR = 2.002 ,95% CI: 1.241, 3.229) higher than their counterpart. This is similar with report from Malawi [21], while contradicted with report from south Gondar [16]. Since primipara mothers are less experienced, might fear of complication. Therefore, for the sake of their infant health, they might seek frequent medical advice from the care providers. This implies that having good level of information about newborn care will result putting their newborn to breast early.
Our study showed that the odds of early initiation of breast feeding among home delivered mothers were nearly three times (AOR = 2.755, 95% CI: 1.237, 6.135) higher than as compared as had institutional delivery. This is contradicted with report from Gurage zone Gunchere woreda [25], Arsi Tiyo woreda [26], Malawi [21], Bahirdar city [22] and Motta town [24], respectively. This might be due to more births take place in health institutions with skilled providers doesn’t mean necessarily will result optimal breast-feeding practice. Rather, missed opportunities, having less committed skilled attendant and having not appropriately trained staff with essential newborn care will result negative effect between institutional delivery and early initiation of breast feeding. This implies that quality of care should be improved in order to have positive relation between institutional delivery and putting newborns to breast within one-hour practice.
This study is a community based and tried to represent and made generalization by involving relatively adequate number of study subject. Tried to reduce recall bias by involving only those mother of infant age less than 6 months. But it will share the cross-sectional design limitations.
The practice of early initiation of breast feeding was sub-optimal and below the national average in study place. Mothers who had < 24 months birth spacing history, mothers’ income between 1001–1500 Birr, Primipara mothers and home delivery. Risky groups like; multipara mothers, high income level mothers and having ≥ 24 months birth spacing practice shall be given special attention and provided intensive health education program at the community and facility level. Improving quality of care in health facilities through providing training and support for staff members on maternal and newborn care. Furthermore, improve access to skilled breastfeeding counselling for all mothers are recommended. The Future researcher shall be employed follow up and mixed study.
AOR: Adjusted Odds Ratio; ANC:Ante Natal Care; CS:Cesarean Section; EDHS:Ethiopia Demographic and Health Survey; EIBF:Early Initiation of Breastfeeding; EMDHS:Ethiopia Mini Demographic and Health Survey; SDG:Sustainable Developmental Growth; WHO:World Health Organization
Ethics approval and consent to participate
Ethical clearance was secured from Wollo University, college of medicine and health science (Ref. No:-SL./NO/205/16/2018) research and community service office to Mizan-Aman town health unit. Permission letters was obtained from Mizan-Aman town health unit and respective kebeles. Study participant mothers were asked by explaining the objective of the study and its significance. Since the research topics is less sensitive/ no more principal risk would be potential harm unless breach of confidentiality, and then verbal/unsigned informed consent were obtained after clearing up verbal version of a consent form (information sheet) and subjects give their verbal consent in place of written consent to participate. Mothers who are unwilling were exempted from the study. Confidentiality was maintained anonymously and not communicated for other purposes.
Consent to publish
Not applicable.
Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. All relevant data supporting the current research investigation can be found in the manuscript.
Competing interests
The authors declare that they have no competing interests.
Funding
Wollo University contributed all financial need for the research.
Authors’ contributions
The authors’ responsibilities were as follows: TB and MA design the study, performed
the statistical analysis, interpret the result and wrote the manuscript, and critically revised the manuscript, supervised the data collection process and approve quality of the data. All authors also highly participated in preparing and revising the final manuscript. The author(s) read and approved the final manuscript.
Acknowledgements
we would like to thank Wollo University, health Science College for arranging to conduct the study. We would like to express our deepest gratitude to all Mizan-Aman Sub-city administrative, kebele leaders, data collectors for their support and study participants involved in the study.