DOI: https://doi.org/10.21203/rs.3.rs-779095/v1
Background: Globally, less than 40% of infants under six months of age are exclusively breastfed. Researchers have established the prevalence, nature, and the degree of this problem; however, less is known about the knowledge, attitudes, and practices (KAP) of exclusive breastfeeding (EBF) among mothers of children aged 0-6 months in Ethiopia. This research addresses this knowledge gap by examining (a) the maternal KAP of breastfeeding and (b) the association between sociodemographic variables and KAP.
Methods: This research draws on a sample of women (n = 415) from Finote-Selam town, derived using simple, systematic, and multistage sampling techniques. Data were analyzed using univariate analysis and binary logistic regression.
Results: Results show that the vulnerable groups, such as mothers being illiterate, low-income group, and lived in rural areas have encountered a double burden of death during delivery and having no knowledge of, positive attitudes, and practices of breastfeeding compared with other mothers of children aged 0-6 months because the respondents have differences in socio-economic characteristics and how they are under cultural influence. Furthermore, the results also affirmed that the age limit could also determine approaches and perceptions of mothers for the exclusive breastfeeding of mothers: mothers aged 25-34 and above 35 years old had good knowledge of and attitude towards breastfeeding, respectively. Furthermore, the poor practice of breastfeeding did not save any baseline variable, such as educational level, level of employment, and level of income.
Conclusion: This study would allow policymakers, medical sociologists, and health extension practitioners to develop more effective all-rounded interventions to minimize the poor practice of EBF.
Exclusive breastfeeding (EBF) is defined as an infant’s consumption of human milk with no supplementation of any type of food and drinks except for vitamins, minerals, and medications until six months [26]. Globally, less than 40% of infants under six months of age are exclusively breastfed, despite the documented benefits of breastfeeding [27]. However, this reduces to 38% in the developing world including Africa [27]. Suboptimum breastfeeding, particularly nonexclusive breastfeeding, results in 1.4 million child deaths and 10% of disease burden in children under five years (24). Global risk assessment of suboptimal breastfeeding indicates that 96% of all infant deaths in developing countries are attributable to inappropriate feeding occurring during the first six months of life [16].
Similarly, exclusive breastfeeding prevalence in Ethiopia is very low [3]. A study shows that this country found the prevalence of exclusive breastfeeding less than six months was 29.3% [21]. However, only 43.6% of mothers practiced exclusive breastfeeding for the first six months after delivery [8]. This problem could result in 1 in every 17 children die before the first birthday and 1 in every 11 children dies before the fifth birthday [8]. Over 2/3 of these deaths are often associated with inappropriate feeding practices and occurs the first year of life in this country [28]. Today in Ethiopia, poor exclusive breastfeeding practice among mothers with an infant aged 0–6 months and a paucity of research devoted to investigate KAP of mothers towards exclusive breastfeeding is the public health and sociology of health concern [23]. Therefore, the current study aims to fill the above gaps by examining the KAP of mothers of children aged 0–6 months towards exclusive breastfeeding and associating the respondents’ sociodemographic variables with maternal KAP.
The community-based cross-sectional study was carried to select respondents from September to June 2019 in Finote-Selam district, which is found in Northwest Ethiopia, to assess the maternal knowledge, attitude, and practices (KAP) of exclusive breastfeeding among mothers of children aged 0–6 months in Ethiopia. This method was so important to afford numeric descriptions of knowledge, attitudes, and practices of mothers who have children in the age between 0 and 6 [30, 31].
The target population of the current study included the mothers of children aged 0–6 months but lived in Finote-Selma district of Amhara National Regional State, Ethiopia. A multi-stage random sampling technique was used to identify the actual respondents by firstly selecting mothers of children aged 0–6 months in Ethiopia. Then, within these groups, a random sample of smaller sub-groups such as mothers of children who lived in Finote-Selam and four local administrations-kebeles (2 urban kebeles: 03 & 04 and 2 rural kebeles: Shenbekuma & Bakel) were selected. Afterward, a sample of these smallest sub-groups can be randomly selected to form a target population for the current study. After assessing the potential respondents and the study areas of the present study, the researchers undertook a systematic random sampling technique in the condition that nth aged 0–6 months of mothers at Finote-Selam district was selected. The simple random sampling technique was used to obtain the required sample size calculated by
n = (Zα/2)2 p (1-p), whereby, d2
the prevalence of exclusive breastfeeding in Ethiopia at the national level (P) was considered as 58%, at a 95% confidence level, and 5% degree of desired precision (d). From this assumption, the sample was 375. But, the total sample size for the study area was 413 by considering 10% of the non-response rate.
After selecting the actual respondents of the current study, the researchers used a paper and pencil questionnaire. The current study adopted some questions from the Ethiopia Demographic Health Survey (2016) and modified it to meet the basic objectives and considered the contextual understanding of the study area. The modified questions have checked the consistency of the questionnaire by conducting a pre-test in Burie town (a town that has a similar case of the study area), which was not included in the actual data analysis. After testing the sample questionnaire, corrections were made on unclear questions for the interviewers and interviewees. This reliability of the data was validated by Cronbach’s alpha = 0.81 indicated the quality of data was good.
The researcher-administered questionnaire contained a total of 33 questions and was divided into four parts that addressed the participants’ sociodemographic characteristics (12 questions), breastfeeding knowledge (8 questions), attitudes (5 questions), and practices (8 questions). The knowledge questions have the response options using dichotomous variables: 0 = no, 1 = yes whereas the items represented by five points to reflect the frequencies of maternal attitude on breastfeeding which includes (strongly disagree = 0, disagree = 1, neutral = 3, agree = 4, and strongly disagree = 5), and the questions of maternal practices offered the response options using multiple choices that asked in different manners.
The participants’ scoring system was as follows:
Attitude: Good (14–25 points), Fair (5–13 points), Poor (0–4 points); and
Practice: Good (4–6 points), Fair (2–3 points), Poor (0–1 point).
Questions envisioned to assess the breastfeeding knowledge comprised the information the mothers have, the source of information, types of food given for the infant immediately after delivery, duration of EBF, importance of EBF to maternal and child health, and colostrum feeding for the infant. Questions intended to consider the breastfeeding attitude included importance of EBF for the infant’s health promotion, mother’s health improvement, EBF that continued for (0–6) months, cheese swallow, and colostrum feeding that be necessary for the infants. Whereby, questions anticipated to examine breastfeeding practices held up a time that starting breastfeeding, frequency of breastfeeding per day, duration of breastfeeding, colostrum feeding for the infant, the types of food that infant can take in addition to BF under 6 months and the like.
The current study obtained informed consent from respondents after the purpose and procedure of the study were explained. The current study assured participants they would be protected from physical and psychological harm whilst being participants.
Quantitative data were analyzed starting from checking up the accuracy of the transcription of data and the translation of them from Amharic (local language) to English to checking the accuracy of the labels, the values, and level of measurement for all variables. After finishing this process as intended, the researchers conducted univariate analysis using the Statistical Package for Social Sciences (SPSS) version 20 to identify the respondents’ socio-demographic variables such as age, religion, ethnicity, marital status, place of residence, education, employment status, household monthly income, and distance between house and the health center, and to analyze mean, median, standard deviation of the quantitative data.
Binary logistic regression was used to test the association between the dependent variable of exclusive breastfeeding (mothers of children aged 0–6 months carried out breastfeeding was poor Coded as 1 while not is coded as 0) and sociodemographic variables. Again, binary logistic regression was used to analyze breastfeeding KAP of mothers of children in the age between 0 and 6 months (1 was coded as good and 0 as not good). Breastfeeding KAP and the sociodemographic variables were entered into the regression model and then were checked for exp(B) to ascertain 95% of the confidence intervals (CIs) for the odds ratio of predictor’s contribution to the equation. The goodness of fit of the model was checked by Hosmer and Lemeshow test model using backward likelihood ratio method.
As outlined in Table 1, more than half of respondents were in the age group of 25–34 (55.4%), Orthodox Christian (92%), married (91.3%), unemployed (69.2%), illiterate (45.3%) and low family income (48.4%). However, only 61.2% of the participants were visited by health extension workers.
| Variables | Frequency (%) | |
|---|---|---|
| Age of mother( in years) | 15–24 | 108 (26) |
| 25–34 | 230(55.4) | |
| 35 and above | 77(18.6) | |
| Religion | Orthodox | 382(92) |
| Muslim/other | 33(8) | |
| Marital status | Married | 379(91.3) |
| Separated/ Single | 36(8.7) | |
| Place of residence | Urban kebeles | 178(42.9) |
| Rural kebeles | 237(51.7) | |
| Level of education | Illiterate | 188(45.3) |
| Primary (1–8) | 121(29.2) | |
| Secondary and above | 106(25.5) | |
| Level of employment | No employed | 287(69.2) |
| Employed | 128(30.8) | |
| Household monthly income | Low (0-1000) ETB | 201(48.4) |
| Average (1001–3000) ETB | 127(30.6) | |
| High Above 3000 ETB | 87(21) | |
| Distance between house and the health center | No | 161(38.8) |
| Yes | 254(61.2) | |
| Sample Survey, 2019 | ||
As presented in Table 2, the unadjusted and adjusted odds ratios described the association between the outcome variable of maternal knowledge of EBF and all the categories of the explanatory variables. The results show that the mothers who were between 25 and 34 years (AOR = 1.2, 95% CI = [0.6–2.4]), but lived in urban areas with having employment categorized under a high-income group (AOR = 2.2, 95% CI = [1.3, 4.1]; UOR = 3.6, 95% CI = [2.2, 5.8]), have higher levels of education (AOR = 8.1, 95% CI = [2.5, 26.3], p < = 0.025), and delivered their children in hospitals (UOR = 4.3, 95% CI = [2.6, 7.2]) have had a better knowledge of breastfeeding compared to other baseline variables in more probability.
| Variables | Unadjusted Odds Ratio [95% CI] | Adjusted Odds Ratio [95% CI] | |
|---|---|---|---|
| Mothers’ age | |||
| 15–24 | 1 | 1 | |
| 25–34 | 1.0(0.5–1.7) | 1.2(0.6–2.4) | |
| >or = 35 | 0.5(0.2–0.9)** | 1.0(0.4–2.2) | |
| Place of Residence | |||
| Urban | 2.0(1.2–3.2)** | 0.9(0.5–1.7) | |
| Rural | 1 | 1 | |
| Educational level of mothers | |||
| Cannot read and write | 1 | 1 | |
| Primary(1–8) | 2.1(1.2–3.5)** | 1.8(0.9–3.4) | |
| Secondary and above | 14.5(5.1–41.0)* | 8.1(2.5–26.3)** | |
| Employment status of the mother | |||
| No employed | 1 | ||
| Employee | 1.5(0.9–2.5) | ||
| Monthly income | |||
| Low (below US$ 150) | 1 | 1 | |
| High (above US$150) | 3.6(2.2–5.8)*** | 2.2(1.3-4.0)** | |
| Place of delivery | |||
| Hospital | 4.3(2.6–7.2)*** | 1.1(0.5–2.2) | |
| Home | 1 | 1 | |
| history of ANC | |||
| No visit of ANC | 1 | 1 | |
| At least one visit | 6.8(3.7–12.4)*** | 2.4(1.1–5.3)** | |
| History of PNC | |||
| No visit of ANC | 1 | 1 | |
| At least one visit | 5.2(3.2–8.3)*** | 3.4(1.8–6.5)*** | |
| *Significant at < = 0.001, **significant at < = 0.025, ***significant at < 0.05; 95% CI | |||
| Only multivariate logistic regression was used for interpretation | |||
As depicted in Table 3, the association between the outcome variable of the maternal attitude of EBF and all the categories of the explanatory variables were described by the unadjusted and adjusted odds ratios. The result reveals that the above 35 aged mothers (UOR = 0.6, 95% CI = [0.2, 1.3]) but lived in the urban area (AOR = 0.8, 95% CI = [0.4, 1.8]; UOR = 2.1, (95% CI = [1.1, 3.7], p < 0.05), completed secondary education (AOR = 8.7, 95% CI = [2.6, 28.9], p < 0.001), and visited health centers to get antenatal and postnatal care service utilization had a positive attitude towards the importance of breastfeeding compared to other socio-demographic variables.
| Variables | Unadjusted Odds Ratio [95% CI] | Adjusted Odds Ratio [95% CI] | |
|---|---|---|---|
| Mothers age | |||
| 15–24 | 1 | ||
| 25–34 | 0.9(0.4–1.8) | ||
| >or = 35 | 0.6(0.2–1.3) | ||
| Place of Residence | |||
| Urban | 2.1(1.1–3.7)*** | 0.8(0.4–1.8) | |
| Rural | 1 | 1 | |
| Educational level of mothers | |||
| Cannot read and write | 1 | 1 | |
| Primary(1–8) | 1.9(1.1–3.8)** | 1.6(0.7–3.4) | |
| Secondary and above | 8.7(2.6–28.9)* | 4.3(1.2–15.7)*** | |
| Employment status of the mother | |||
| Not employed | 1 | ||
| Employed | 1.7(0.9–3.4) | ||
| Monthly income | |||
| Low (below US$ 150) | 1 | 1 | |
| High (above US$150) | 4.6(2.4-9.0)* | 3.0(1.4–6.4)** | |
| Place of delivery | |||
| Hospital | 5.1(2.8–9.3)* | 2.7(1.4–5.4)** | |
| Home | 1 | 1 | |
| Visit of ANC | |||
| No visit of ANC | 1 | 1 | |
| At least one visit | 6.6(3.5–12.6)* | 2.5(1.1–5.8)*** | |
| Visit of PNC | |||
| No visit of ANC | 1 | 1 | |
| At least one visit | 4.8(2.7–8.7)* | 2.1(1.1–4.6)*** | |
| *Significant at < = 0.001, **significant at < = 0.025, ***significant at < 0.05 | |||
| Variables | Unadjusted Odds Ratio [95% CI] | Adjusted Odds Ratio [95% CI] | |
|---|---|---|---|
| Mothers age | |||
| 15–24 | 1 | ||
| 25–34 | 1.4(0.8–2.2) | ||
| >or = 35 | 0.7(0.4–1.3) | ||
| Place of Residence | |||
| Urban | 2.9(1.9–4.6)* | 2.8(1.6–4.6)* | |
| Rural | 1 | 1 | |
| Educational level of mothers | |||
| Cannot read and write | 1 | 1 | |
| Primary(1–8) | 1.1(0.7–1.7) | 0.8(0.5–1.3) | |
| Secondary and above | 2.5(1.4–4.4)* | 1.1(0.5–2.1) | |
| Employment status of the mother | |||
| No employed | 1 | ||
| Employed | 1.2(0.8–1.9) | ||
| Low (below US$ 150) | 1 | 1 | |
| High (above US$150) | 2.1(1.4–3.2)* | 1.6(1.1–2.5)*** | |
| Place of delivery | |||
| Hospital | 2.6(1.6–4.3) | ||
| Home | 1 | ||
| History of ANC | |||
| No visit of ANC | 1 | 1 | |
| At least one visit | 3.7(2.1–6.6)* | 2.1(1.1–4.1)*** | |
| History of PNC | |||
| No visit of PNC | 1 | 1 | |
| At least one visit | 0.4(0.235-0.6)* | 2.3(1.4–3.9)* | |
| *Significant at < = 0.001, **significant at < = 0.025, ***significant at < 0.05 | |||
Table 7 reveals the comparison of maternal practices of EBF across socio-demographics. Binary logistic regression’s result indicated that the poor practice of breastfeeding in the study area did not save any baseline variable, such as educational level, level of employment, and level of income. However, ages, place of residence, and place of delivery of mothers of children aged between 0 and 6 months have less likely affected to the poor practice of EBF.
Despite the fact that a plethora of literature tried to describe the factors that affecting EBF in different countries [1, 18, 20], a wide range of studies could not pay due attention to maternal knowledge, attitudes, and practices of EBF in Ethiopia. The major contribution of the current study lies in its attempt to show the KAP of mothers of children aged 0–6 ages and their association with sociodemographics.
Binary logistic regression analysis showed that mothers who attended secondary school and above were 8 times more likely to have good knowledge about EBF compared to those who were illiterate. This finding is similar to the studies that were carried out in Ethiopia. The studies found out that maternal education has a significant role in improving knowledge about EBF practice in the first 6 months of child age [5, 9, 11, 13]. Household monthly income was also another possible determinant factor significantly associated with maternal knowledge about EBF. The current study found out that the upper-income group is seen at greater importance to have a good knowledge of EBF. The previous studies have also assured this finding [4, 10]. The present study also found out that mothers who visited antenatal and postnatal care had higher probabilities of acquiring knowledge of breastfeeding compared to mothers who delivered at home. Congruently, other studies also confirmed the present finding is that maternal history of ANC and PNC service utilization was significantly associated with better maternal knowledge on EBF than those who had no attend ANC and PNC services [7, 26].
In the case of the maternal attitude of EBF, the current research affirmed that the mothers who were 35 ages and above attended in the secondary education and frequently visited health centers to utilize antenatal and postnatal care service had a positive attitude towards the importance of breastfeeding compared to other socio-demographic variables. Similarly, a wide range of studies assured the current finding. For example, the studies depicted that the aged mother [23] who lived in an urban area [22] and completed secondary education [7] but visited health centers [2, 7] have had higher tendencies to have appositive attitude towards breastfeeding.
In relation to the maternal practices of EBF, the present study found out that the poor practice of breastfeeding in the study area did not save any baseline variable. This finding has not been supported by the previous studies. For example, a broader range of studies [14, 17, 29] revealed that maternal attitudes towards early breastfeeding has a direct effect on maternal practices and yet negative attitudes of mothers towards breastfeeding may adversely affect practice regardless of age, education, religion, marital status, and so forth.
The current study examined maternal knowledge, attitudes, and practices of exclusive breastfeeding among mothers of children aged 0–6 months in Ethiopia. The results showed that despite the fact that mothers who lived in urban areas have a better knowledge of and attitude towards EBF compared to mothers who lived in a rural area, the practice of EBF have not observed a significant change in mothers who lived in both places of residence. This means having good knowledge of and positive attitudes toward EBF are not guaranteed to mothers of children aged between 0 and 6 months to practice EBF in more probable because the respondents have similarities in socio-economic characteristics and how they are under the cultural influence. This study has remarkably concluded that if the percentage of knowledge of and attitude towards EBF remained growing, the level of the practice of EBF became declining as the poor practice of EBF did not save any baseline variable. Therefore, the findings require further research to examine factors that affect good knowledge and positive attitudes of mothers towards breastfeeding may adversely affect the practice of EBF. Such studies would allow policymakers, medical sociologists, and health extension practitioners to develop more effective all-rounded interventions to minimize the poor practice of EBF.