Searching results
In the initial search, we found a total of 327 records from the electronic search database of Midline/PubMed, Science Direct, Hinari, Google, and Google Scholar. After removing duplications 278 records remained. Then reviewing their titles and abstracts, we excluded 217 records because these articles were unrelated to our objective. After assessing 61 full articles, 26 articles were further excluded due to differences in the study population and outcome. Finally, 35 studies were included in this systematic review and meta-analysis (figure 1).
Characteristics of the included articles
This meta-analysis included 35 primary studies covering a total of 16, 896 study participants. The studies were conducted from 2010 to 2020 and retrieved from seven regions of the country including 13 studies from the Amhara region, 11 studies from the south region, 4 studies from Oromia, 3 studies from Afar, 2 studies from Tigray, 1 study from Somalia and 1 study from the Harar region [14, 17, 24, 28, 29, 35-66] (Table 1). Five studies conducted in Jigjiga Town, Harar, wolaita zone, Debre Markos, and Mezan-tepi were institution based cross-sectional studies, and the remaining 30 articles were community- based cross-sectional studies. The sample size of the primary studies included in this review ranged from 202 to 860 as reported from Mezan-Tepi (South region) and kersa district Oromia region respectively[24, 46]. The highest prevalence of colostrum avoidance was reported from in Afar region 79.9% and the lowest was reported in the Gununo Health Centre in the Wolaita zone South region 3.3% [28, 29].
Meta-analysis
A random-effect model was used to estimate the pooled prevalence of colostrum avoidance in Ethiopia. The pooled estimate of colostrum avoidance in Ethiopia was 20.5% (95% CI; 16.46, 24.45) (figure 2). Substantial heterogeneity was observed between primary studies (I2= 98.4% and p=000). Publication bias was checked using the Egger’s test, and the results showed that there was significant publication bias, as evidenced by p<0.01. Duval and Tweedie’s trim and fill methods were used to estimate the number of studies missed from a meta-analysis as a source of publication bias but the finding was not significant [67]. We also observed the asymmetrical distribution of the funnel plot indicating, publication bias (figure 3). We also performed subgroup analysis by a region having more than two studies conducted. According to the results, the pooled prevalence of colostrum avoidance was highest in the Afar region, 49.6% (95% CI: 21.7, 77.5), I2 = 99.4% and the lowest prevalence was in the Tigray region, 10.6% (95% CI: 2.1, 19.2), I2= 89.2. This meta-analysis also revealed that the pooled prevalence of colostrum avoidance was higher in rural mothers (24.9%, 95% CI; 17.2, 32.6) than in urban mothers 16.7% (95% CI; 13.0, 20.3) (figure 4).
Factors associated with colostrum avoidance
During this review, we identified numerous factors associated with colostrum avoidance among primary studies in Ethiopia. Variables reported as a significant association with colostrum avoidance in at least three primary studies were included in this metal analysis. Accordingly, antenatal care (ANC) visits, place of delivery, breastfeeding counseling during ANC, timely initiation of breastfeeding, and prelacteal feeding were found to have a significant association with colostrum avoidance.
Antenatal care (ANC) visits during pregnancy were reported as a factor associated with colostrum avoidance among the three primary studies included in this review [35, 56, 58]. A total of 1659 mothers were included to analyze the association between ANC visits and colostrum avoidance. The pooled odds ratio showed that mothers having ANC visits during pregnancy were 72.6% less likely to avoid colostrum than their counterparts [OR= 0.274 (95% CI; 0.175, 0.428)] (Figure 5).
Place of delivery was identified as factor associated with colostrum avoidance among the five primary studies included in our meta-analysis [35, 48, 49, 56, 58]. To analyze the association between place of delivery and colostrum avoidance, 2,709 participants were included. Accordingly, mothers who delivered at home were 3.8 times more likely to discard colostrum than mothers who gave birth at health institutions [OR= 3.8 (95% CI; 2.9, 4.9)](figure 6).
Four primary articles included in this review reported that breastfeeding counseling during ANC was associated with colostrum avoidance [28, 44, 49, 58] with a total of 1,700 study participants. Mothers who received breastfed counselling during the ANC visit were 73.9% less likely to avoid colostrum than mothers who did not receive breastfed counseling during ANC [OR= 0.261(95% CI; 0.147 - 0.462) (Figure 7).
Timely initiation of breastfeeding was associated with colostrum avoidance among the three primary studies included in our review [48, 49, 56]. A total of 1832 study participants were included to analyze the association between the timely initiation of breastfeeding and colostrum avoidance. Mothers who initiated breastfeeding beyond 1 hour of delivery were 3.8 times more likely to avoid colostrum than mothers who initiated breastfeeding within 1 hour of delivery [OR = 3.8 (95% CI; 1.9, 7.4)](figure 8).
Three primary studies included in this review were reported as prelacteal feeding practice was associated with colostrum avoidance [44, 49, 56]. A total of 1,616 participants were included to analyze the association between prelacteal feeding practice and colostrum avoidance. Accordingly, the odds of colostrum avoidance among mothers practicing prelacteal feeding was 5.8 times higher than mothers who never practice prelacteal feeding [OR= 5.77 (95 % CI; 4.03- 8.22)] (figure 9).