Knowledge, Attitude, Practices and Associated Factors Towards Colostrum Feeding among Mothers of Infants in Ambo District of West Shewa Zone, Oromiya Region, Ethiopia


 Background: Colostrum is the first breast milk produced after birth and is important for promotion of health and prevention of infections of the newborn. Though breastfeeding practices are well known but the necessity of colostrum feeding is still poorly understood by mothers.Objective: To assess Knowledge, Attitude, Practices and associated factors towards colostrum feeding among mothers of infants in ambo district of west Shoa zone, Oromia, Ethiopia.Methods: A community-based cross-sectional study was conducted from March to April 2019 among 429 mothers of infants selected by simple random sampling technique. The data were collected using structured questionnaire, focus group discussion & key informant interview by semi structured guiding questionnaire. Descriptive analysis like frequency, percentage, & mean were performed. Binary and multiple logistic regression analysis were employed to identify associated factors. Variables with p-value <0.05 with 95% confidence interval identified statistically significant.Results: Among the respondents, 278 (64.8%) mothers had good knowledge & 250 (58%) had favorable attitude. But colostrum feeding was practiced only by 227(56.5%). Mothers of neonates without any illness/finding at birth (AOR =14.87 [ 95% CI: 5.00-44.27]) & postnatal care within the first 2-3 days (AOR = 3.48 [95% CI: 1.23-9.85]) were positively associated factors; but unwanted pregnancy/birth (AOR = 0.243 [95% CI: .113-.527]), mothers suffering from any health problems during pregnancy/birth (AOR = 0.380 [95% CI: .161-.903]), lack of counseling (AOR = 0.264 [95% CI: .103-.675]), home delivery (AOR = 0.239 [95% CI: .111-.516]), & lack of information on colostrum (AOR = 0.040 [95% CI: .013-.125]) were negatively associated with colostrum feeding practices. Conclusions: Majority of respondents had good knowledge & favorable attitude but with poor practices of colostrum feeding. Good neonatal health at/soon after birth & postnatal care attendance within two to three days were positively associated with colostrum feeding practices. But, unwanted pregnancy/birth, any sickness of mother at birth/during pregnancy, lack of counseling on colostrum feeding, home delivery, & lack of information on colostrum feeding were less likely to feed colostrum.Strengthening family planning service, antenatal care, institutional delivery, postnatal care, information provision for counseling & the revision of DHIS2 for inclusion of colostrum feeding indicators were recommended interventions.

Conclusions: Majority of respondents had good knowledge & favorable attitude but with poor practices of colostrum feeding. Good neonatal health at/soon after birth & postnatal care attendance within two to three days were positively associated with colostrum feeding practices. But, unwanted pregnancy/birth, any sickness of mother at birth/during pregnancy, lack of counseling on colostrum feeding, home delivery, & lack of information on colostrum feeding were less likely to feed colostrum.
Strengthening family planning service, antenatal care, institutional delivery, postnatal care, information provision for counseling & the revision of DHIS 2 for inclusion of colostrum feeding indicators were recommended interventions.

Background
Colostrum is the rst milk lasting for 2-4 days after the lactation is started, secreted at the time of parturition. It differs from the milk secreted later by containing more lactalbumin, lacto protein, & rich in antibodies that confer passive immunity to the newborn. Colostrum, which, is very important component of the breast milk and it has role to play in immune system of every mammal. Human colostrum is particularly rich in immunoglobulin, antimicrobial peptides (lactoferrin and lacto-peroxidase) and other bioactive molecule, including growth factors which are important for nutrition, growth and development of infants. It is highly concentrated in very less volume of 30-100 ml. It is gold/bright yellow in color, thick, and sticky consistency (1).
Colostrum acts as a primer for breast milk, leading pediatric nutrition specialists refer to it as "liquid gold". It can be also considered as the rst vaccine which needs a "warm chain" made by mother-infant contact (2). It establishes important bacteria in the baby's gut and also acts as 'paint', coating the infant's gastrointestinal tract. Therefore, colostrum provides natural immunity against many bacteria and viruses (3). Passing immunity to a wide variety of disease-causing pathogens for protection from bacteria, viruses, fungi, and even protozoan parasites like giardia. Not even antibiotics can deliver such broadspectrum protection. Moreover, pathogens do not develop resistance to colostrum as they do to manmade antibiotics. It also provides good growth, strength and longevity for the infant (4).
The World Health Organization recommends breastfeeding within the rst hour to three days after birth.
In addition to colostrum feeding, early initiation of breastfeeding can enhance exclusive subsequent breastfeeding and mother-infant bonding. Many perinatal deaths are potentially preventable if newborns are breastfed within one hour to three days of birth. Breast milk should be made a baby's rst taste within an hour, hence any pre-lacteal feeds should be avoided (2).
How soon woman begin breastfeeding after birth is also culturally determined. Many cultural beliefs and practices may make mothers not to feed the baby immediately after birth (5). Some mothers in developing countries avoid colostrum feeding on the basis of traditional or cultural beliefs that range from having no nutritional value and viewing as harmful to the infant's health making the baby sick or even causing death (6). Even, some women may specify no reason for avoiding colostrum other than tradition (7). Especially in non-industrialized populations, initiation of colostrum feeding within an hour is thought to decrease infant mortality from the risks of gastroenteritis, diarrheal diseases, respiratory infections, ear infections, and in uenza (8). In societies where colostrum is considered heavy, thick, dirty, toxic, harmful to children's health, & believe to cause diseases, it is believed that discarding a portion of it can alleviate the problems(9).
The National Newborn and Child Survival Strategy (2015/16-2019/20), which is part of the HSTP covering same period, aims to reduce under ve mortality from 64/1,000 live births (2013 level) to 29/1,000 live births, infant mortality rate from 44/1000 live births to 20/1000 live births and NMR from 28/1,000 live births to 11/1,000 live births. The strategy plans to ensure universal coverage of quality high impact newborn and child health interventions like early initiation of breast/colostrum feeding within an hour along with meaningful community empowerment to create demand for the services(10).
Colostrum feeding was recommended in the Ethiopian Infant and Young Child Feeding Guideline.
However, colostrum avoidance is still practiced in many parts of Ethiopia including Oromiya regional state. Moreover, there is a scantiness of evidence regarding knowledge, attitude, practices, and associated factors towards colostrum feeding practices among mothers in Oromiya region, chie y in Ambo district. This study will help to know the concept of colostrum among the general population. It also helps the community to create awareness about the importance of colostrum feeding and advise mothers to practice it in every delivery. Appreciate and initiate counselling methods to reinforce speci c, priority messages by health facility staff and community-based workers at all contact points with women. Hence, this study aimed to investigate KAP & associated factors towards colostrum feeding practices among mothers of infants in Ambo district, central-west Ethiopia(11).

Study area & period
The study was conducted in Ambo district from March 1 to April 7/2019. Ambo is one of the districts of west Shoa zone in Oromia Region of Ethiopia. It is located at 114 km west to Fin nee/Addis Ababa on the main road to Wollega. Bordered by T/kutaye to west, by Cobi and Ilfeta to north, by Dendi to east, by Wonchi district of Southwest Shewa Zone to south. Based on the information from Ambo district administration health o ce, the district has 32 rural and 1 urban totally of 33 "Gandas" (small administration units). The district has six health centers, 31 health posts, 66 health extension workers and 82 all category health workers. According to the projected population by the health o ce for 2018/19, the total population was estimated to be 138,011 among which 50.9% (70248) were women and 3.22% (4,444) were mothers of children aged less than 12 months/surviving infants (o ce 2018/19).

Study design
A quantitative community based cross-sectional study design supplemented by qualitative study was used.

Source population
Quantitative: All mothers of infants in Ambo district.
Qualitative: All husbands, mother-in-laws, & traditional birth attendants for focus group discussions; and Abbaa-Gadaas/elders in Ambo district, health extension worker and maternal & child health coordinator of Ambo district for key informant interview.

Study population
Quantitative: Selected mothers of infants living in the selected Gandas who ful ll the inclusion criteria.
Qualitative: Selected husbands of mothers of infants in the selected Gandas, mother-in-laws, and traditional birth attendants in Ambo district for focus group discussions; and Abba Gadaas/elders, health extension worker and maternal & child health coordinator of the district for key informant interview.

Inclusion and exclusion criteria
Inclusion criteria: a) All biological mothers who live in the ganda/kebele at least for the last six months & had under oneyear old Child.

Exclusion criteria
Mothers who were acutely sick and unable to communicate during data collection.

Sample size calculation
The sample size (n) required for the study was calculated using the formula to estimate a single population proportion by considering the following assumptions. Zα/2 = critical value for normal distribution at 95% con dence level which equals to 1.96 (Z value at alpha = 0.05).
According to the study conducted in Debremarkos town of Amhara region in 2015, about 76.72%, 78.84% and 77.71% of mothers had good knowledge, favorable attitude and good practice of colostrum feeding respectively (27). Here, from the study conducted in Debremarkos town of Amhara region, the result for knowledge of the respondents bequeathed representative sample size for this study. Since the sampling procedure during this study was affected by design effect, the sample size becomes, (299*1.5 = 449).
Concerning focus group discussion, till saturation of ideas, two FGDs were conducted. The rst was conducted in A/Qora ganda at Awaro HP and the second was conducted at Meti HC including mother in laws, mothers of infants, husbands of a mothers of infants, & traditional birth attendants. Three participants for key informant interview were purposively selected and interviewed. The participants were the district MNCH-coordinator, HEW, and one religious leader in Ambo district.

Sampling procedure
Ambo district administration has 33 Gandas (the smallest administrative unit in Oromiya). Thirty percent (11) Gandas were selected as study Gandas by lottery method. These were: Y/Cebo, Bilo, G/Qora, G/wadessa, Golja, U/Qorke, Mexi, N/Warqa, Amaro, Tule, and Wadessa. Study population were assigned proportionally to the selected gandas/sub districts. From family folder/there is a list of mothers of infants. The list/sampling frame was already there, because these were targeted for immunization. Then, to select the study population, all source population of respective gandas were coded. Mothers of infants were selected by simple random sampling, lottery method. Since the households' zone/Gare were clearly indicated on the cover of the family folder, the selected mothers were easily traced and interviewed.
Where it was di cult, local guiders were hired in two kebeles for some days to reach those selected households with mothers of infants.

Study variables
Dependent variables: Knowledge towards colostrum.
Practice of colostrum feeding within an hour to 2-3 days. Operational De nition Knowledge: In this study refers to awareness of mother of infant (s) about colostrum breast milk. It was evaluated by the mother's answer to the questions (11).
Good knowledge: Those mothers who answer ≥ 60% questions of knowledge related questions (11).
Poor knowledge: Those mothers who answer < 60% questions of knowledge related questions (11).
Attitude: The way that mothers of infants think towards colostrum feeding to their infants.
Positive attitude: Those mothers who answer ≥ 60% of attitude related questions.
Negative attitude: Those mothers who answer < 60% of attitude related questions.
Practice: The behavior of mothers of infants on colostrum feeding to their current infants within one hour to two-three days(9, 21, 31-33).

Data collection instrument and methods
Structured questionnaire for face to face administration and semi structured guiding questionnaire for quantitative & qualitative data collection were adapted and modi ed from previous similar studies respectively (9,21,(31)(32)(33). For qualitative, in addition to semi-structured questionnaire, smartphone was used. One teacher from each selected Gandas as data collector and 11 supervisors who have BSc from respective PHCU were provided one day training/orientation. Qualitative data were also collected through FGD, and key informant interview. After the data collection for qualitative, the data were transcribed in to English to answer the semi-structured questions. The investigator and two supervisors facilitated the sessions of FGD but the investigator alone conducted the three in-depth interviews.

Data quality control
The tools for quantitative data collection were prepared in English language and translated in to Afaan Oromo and then re-translated back to English by language expert/professional for its consistency. Data collectors and supervisors were trained for one day on how to interview and record. Pre-test was done in A/Qora at 5% (5%*449 = 20) of actual respondents. After the pre-test, no unclear questions were founded to amend. But the data from the pre-test was not included in the analysis of actual study. Regularly, monitoring and supervision of the overall activity was conducted by the supervisors & investigator. To maintain the quality of data while entering data, Epidata version 3.1 was used.

Data processing and analysis
After checking the completeness and consistency of the quantitative data on the printed form of the questionnaire; it was cleaned, coded and entered into Epidata version 3.1. The data analysis was performed by using SPSS version 21.0 statistical package for analysis. Descriptive statistics was used to show the knowledge, attitude and practices of the mothers on colostrum feeding in the district. Binary and multivariable logistic regression analyses were carried out to identify the factors associated with colostrum feeding. The variables with p-value < 0.2 in binary logistic regression were included in multivariable regression analysis model. Variables at p-value < 0.05 in the nal multivariable model were concluded as factors associated with the practice of colostrum feeding.
Qualitative data were transcribed into English text by the investigator. Thematic framework analysis approach was used to analyze the qualitative data. Finally, the result was presented in triangulation with the quantitative ndings.

Socio demographic characteristics
A total of 429 mothers of children aged less than 12 months were included in the study with response rate of 95.54%. The mean (± SD) age of mothers was 26.61 (± 5.7) years ranging from 16 to 41. The majority of the mothers 125 (29.1%) were between 26-30 years of age. Almost all, 393 (91.61%) of the respondents were rural dwellers. About two-third of the study population, 255 (59.4%) were Orthodox but 135 (33.5%) were protestant religion followers. Almost all of the respondents 424 (98.8%) were from Oromo ethnic group. About one fth of mothers 78 (18.2%) cannot read and write. Most of the mothers 397 (92.5%) were in marital union. Regarding average monthly income of the house-hold of study participants, 306(71.3%) were earning less than 1000 birr, 108 (25.2%) were earning 1000-3000 birr, 10 (2.3%) were earning 3001-5000 birr, and 5 (1.2%) earned more than 5000 birrs per month (Table 1).

Knowledge of respondents about colostrum feeding
To assess the knowledge of the mothers on colostrum feeding, according to the predetermined criteria, 278 (64.8%) mothers had good knowledge (Fig. 4). Of the participants of the study, 335 (78.1%) responded that colostrum is yellowish, thick and sticky in consistency. While about two third 257 (59.9%) knew that colostrum is the rst vaccine that prevents diseases and best to be given to baby within an hour, slightly more than half of the respondents 242 (56.4%) responded that colostrum is rich in protein which helps the baby grow well (Table 3). The mother knows early initiation of BF with colostrum feeding strengthen baby-mother bondage.
394(91.8%) 35(8.2%) The mother is aware of the initiation of colostrum feeding within an hour and continue to three days after birth.  Practice of respondents towards colostrum feeding Among breast feeding (402 (93.7%) mothers, 227 (56.5%) gave colostrum to their baby within one hour to three days. Seventy three percent (73.1%) of colostrum fed mothers were feeding within an hour but the rest 61 (26.9%) fed after one hour to one day. According to the response of the mothers for not feeding colostrum within an hour, 54 (88.5%) delayed till they took bath, 2(3.3%) forbidden culturally and 5 (8.2%) due to illness either to the babies or mothers/both.
Among those mothers who didn't ever feed colostrum to their neonate (43.5%), 75 (42.9%) reasoned out that mother-in-law forbidden, 77 (44%) explained that colostrum causes illness even death, and the rest 23 (13.1%) couldn't justify why they avoided colostrum. Fourteen (14) of the mothers fed the rst 2-3 days with other foods (pre-lacteal) till colostrum goes, but the majority 161 (92%) expressed and discarded the colostrum before each feed till it goes (Table 5). Regarding the qualitative data collected, two sessions of focus group discussions were conducted.
Supporting the practices of colostrum feeding to baby within one hour to three days, about two thirds of both focus group discussants, stated that "colostrum is the rst vaccine that prevents diseases, rst food to build the baby and helps to grow, prevents hunger, and so that, any pre-lacteals should be avoided and colostrum should be the rst teste of the neonate". In contrast to this, 47 & 53-year-old mothers said that "in their community, colostrum is believed to cause abdominal cramp, hence to prevent such problem as grandmother of children both said that 'we recommend to express the colostrum rst then feed breast milk for the rst two to three days'. Another woman who was 39 years old said that, 'since colostrum causes abdominal cramp and raw butter cleans the stomach of infants, I recommend mothers to discard colostrum and to feed with raw butter before breastfeeding initiation". One of untrained traditional birth attendant also supported the idea of expressing & discarding colostrum in the rst 2-3 days before each feed.
The district MNCH coordinator and one HEW on separate interview said that 'lack of indicators for breast/colostrum feeding in DHIS 2 /in supervisory checklist was the problem affected colostrum feeding.
This causes health providers not to give counselling service on the advantage of colostrum feeding at every contact point; And even they fail to help the mothers who gave birth at health facilities during the stay at health institutions for immediate post-natal care on colostrum feeding'. Additionally, both respondents responded that 'there is also low commitment of service providers on transmission of health information on the importance of colostrum feeding & even some materials like ip charts were not clear for easy use and outdated. As a result, lack of awareness of the community as a whole, especially the most in uential segment, is also the underline cause of colostrum feeding malpractice. Hence, as actions to be taken they proposed that'DHIS 2 & supervisory checklist has to be revised, IEC/BCC need to be updated & made easy to use at all levels especially at community level by central and regional governments'.
Factors associated with colostrum feeding among the study participants In binary logistic regression analysis; maternal age 21-25, completing preparatory & above schools, being house wife in occupation, being owner of the house, wanted/planned birth to the young infant, stable maternal health during pregnancy/birth, attending ANC, counselling on importance of colostrum feeding, ANC attendance for two & above sessions, participating on pregnant mother forum, giving birth at HFs, good neonatal health at/soon after birth, visit for PNC within the rst two to three days, & mothers who got information on advantages of colostrum were found positively associated with colostrum feeding practice (Table 6).
In multivariable logistic regression analysis, good health status of the neonate at or soon after birth, and maternal PNC visit within the rst two to three days were positively associated with colostrum feeding practice. But unplanned/unwanted pregnancy/birth to the infant, mothers who were suffering from any health problem during pregnancy/at birth, lack of counseling on the importance colostrum feeding, giving birth at home, lack of information on the importance of colostrum feeding were negatively associated factors with colostrum feeding practices. Mothers who gave birth to healthier babies were 15 times (AOR 14.87, 95% CI: 5.00-44.27) more likely to feed colostrum than mothers who had babies with any health problem. The mothers who were attending PNC within the rst two to three postpartum days were 3 times (AOR 3.48, 95% CI: 1.23-9.85) more likely to feed colostrum than mothers who didn't attend PNC services.
Among the study participants, mothers whose pregnancy/birth was unwanted were 75.7% (AOR 0.243, 95% CI: 0.113-0.527) less likely to feed colostrum compared to mothers whose pregnancy/birth is wanted. Mothers who were having any complain/health problem during birth/pregnancy were 62% (AOR 0.380, 95% CI: 0.161-0.903) less likely to practice colostrum feeding for their neonate compared to mothers who were healthy during pregnancy/giving birth. Mothers who were attending ANC service but not counselled on the importance of colostrum feeding were 73.6% (AOR 0.264, 95% CI: 0.103-0.675) less likely to feed colostrum than mothers who were counselled. The mothers who gave birth at home were 76.1% (AOR 0.239, 95% CI: 0.111-0.516) less likely to practice colostrum feeding than those mothers who gave birth at health institutions. Mothers who didn't get information on the advantage of colostrum feeding were 96% (AOR 0.040, 95% CI: .013-.125) less likely to feed colostrum for their neonates with colostrum than mothers who had information on the importance of colostrum feeding ( Table 6). participate for the study conducted in Mekelle. But it looks slightly higher than the study conducted in Raya Kobo district of Amhara region (9) (58%) due to the difference of the study participants. In Raya Kobo, less than 24 months old children mothers were study participants where the response of mothers mostly might affected with recall biases. Cultural differences might also be the other reason for the differences.
Regarding attitude of the mothers towards colostrum, 58% of current study participants have favorable attitude towards colostrum breast milk. In contrary to the current study, the study conducted in Mizan Tepi teaching hospital in 2017 of SNNPR, 69.4% mother had favorable attitude towards colostrum (33).
This difference might be due to, the study conducted in SNNPR was hospital based, studied among small sample size participants (207) while the current study was rural community based. Cultural & sociodemographic difference of the communities might also be another reason for the variation.
Though breast feeding practice is optimum (93.7%) in Ambo district, only 56.5% study participants fed their babies with colostrum. Compared to global, this was by far lower than the studies conducted in India 76.0% (8) and Kuwait 81.8% (35). Here, the huge difference might be due to the study area, cultural and sociodemographic differences. In addition, study conducted in Kuwait employed prospective cohort study design.
The studies conducted in Mekelle town (11), Kombolcha town (36) and in Raya Kobo district (9) revealed that (80.5%), (88.6%), and (86.5%) of the mothers were feeding colostrum to their neonate respectively. In general the difference might be due to cultural and sociodemographic differences. Speci cally, for the studies conducted in Mekelle & Kombolcha, the studies were conducted in town and health facility based. Additionally, small number of participants (195) were used for the study conducted in Mekelle town.
In current study, the mothers reported that grandmothers/other relatives/neighbors and/or untrained traditional birth attendants (38.7%) were the most in uential to let to avoid colostrum. Moreover, FGDs and KII revealed that grandmothers and untrained traditional birth attendants thought colostrum causes abdominal cramp in infants. Therefore, they in uence mothers to avoid colostrum. Similarly, grandmothers tend to have strong in uence not to feed colostrum to their infants in Somalia (37) and Bangladesh (38).
Similar to the practices in current study, the national nutrition program colostrum feeding practice in Ethiopia (39) and study conducted in Mizan Tepi (25) showed colostrum feeding practices as 60.2% & 60.88 & respectively. This is consistent with the current study might be due to the similarity of study design.
The other study conducted to assess suboptimal breast feeding and associated factors in rural communities of Jimma Arjo district in western Oromiya showed that among mothers who ever breastfed, more than half of mothers (62.6%) initiated breastfeeding within rst hour of delivery (40). Almost the nding of this study was similar with current study nding. This might be due to similarity of study design, cultural and sociodemographic characteristics of study populations.
According to the current study mothers who gave birth to babies without any health problem & mothers who were attending PNC within the rst two to three postpartum days were positively associated with colostrum feeding practices. Similarly, this was consistent with the study conducted in northern Ethiopia (30) and Aksum town of Tigray region in (31). The similarity might be due to similar study design with the current study.
But, colostrum feeding practice was negatively associated with mothers whose birth/pregnancy was unwanted, the presence of any type of maternal sickness during pregnancy/birth, lack of maternal counselling on importance of colostrum feeding, home delivery, and lack of information on importance of colostrum breast milk were negatively associated with the practices of colostrum feeding to the neonate within one hour to three days (Table 6). similarly the study conducted in Kombolcha town of Amhara region (41): mothers with sick neonate, mothers who didn't counselled on colostrum feeding were more likely to avoid colostrum. In contrary to the nding of current study: area of residence, employment status of the husband, participation on pregnant mothers' forum, believes that pre-lacteal food is good were associated factors with avoidance of colostrum breast milk.
In this study, mothers who didn't give birth at health institutions were 76.1% less likely to practice colostrum feeding compared to mothers who gave birth at health institutions. Similarly, in India, mothers who gave birth at home were more likely to discard colostrum compared with mothers who gave birth at health institutions (34). Grandmothers and traditional birth attendants usually attend the birth in homes.
Moreover, the ndings from FGDs and KII of this study showed that grandmothers and traditional birth attendants thought colostrum causes abdominal cramps in infants. Lack of indicators for breast/colostrum feeding in DHIS 2 data entry/in supervisory checklist was the other problem obtained from KII. According to the respondents of the interview, this hindered health providers from provision of counselling on the advantage of colostrum feeding at every possible contact. Giving birth at home may create a favorable environment for different socio-cultural malpractices/colostrum avoidance. Alternatively, mothers who gave birth in health institutions might be counselled by health professionals about the advantages of colostrum.

Strengths and limitations
The strength of this study was that it included both quantitative and qualitative methods. But, as limitation, the information obtained from mothers might be subjected to recall bias and also shares the limitation of the cross-sectional study design.

Conclusion
This study showed that only about half of the mothers fed colostrum to the neonate within an hour to three days. While mothers who gave birth to baby without any health problem and PNC attendants within the rst two to three days were positively associated with practice of colostrum feeding, but unplanned/unwanted pregnancy/birth to the infant, presence of maternal health problem during pregnancy/soon after birth, lack of counseling on the importance colostrum feeding to the neonate, home birth to the youngest infant, and lack of information on the importance of colostrum feeding were the factors negatively affecting the practices colostrum feeding.

Recommendation
Depending up on the nding of the study, even if it is di cult to recommend national/regional institution with the ndings of one district, I would like to recommend FMOH/Oromiya regional health bureau, ZHD, district health o ce, health facilities as well as providers with the following recommendations.

FMOH & ORHB:
The policy makers can/need to initiate new strategies and programs that addresses community needs.
Taking the associated factors towards colostrum feeding into account, community-oriented, targeted, and speci c, interventions has be designed. So that, counseling on colostrum feeding is made routine health service by service providers, indicators of colostrum feeding has to be integrated in to DHIS 2 and supervisory checklists of family health activities.
Zonal health department, Ambo district administration health o ce and PHCU: Strengthen capacity building for experts & service providers. The intervention has to be implemented at household, community, and health facility level targeting important segments of the communities.
Strengthen facilitative supervision to every level by using integrated supervision checklist, and provision of feedback for improvement. Regular meeting on performance review and planning has to be strengthened at all levels.
Service providers: Provision of health information on bene t of colostrum feeding to communities such as mothers, adolescents, and other in uential.
So that pregnancy/delivery is wanted & provide counseling on the importance of colostrum breast milk: strengthen family planning, antenatal care, skilled delivery, postnatal care within the rst two to three days For wanted pregnancy/child birth and get counselling on the importance of colostrum breast milk. explaining the aim of the study, indicating that anything identi er of the participants never included in the questionnaire, they were informed about con dentiality of the information they provided. For both literate and illiterate mothers, informed verbal consent was obtained before conducting the interview.

Consent for publication
It is not applicable.

Availability of data and materials
The datasets that used in this study for analysis and other information are available currently in the hands of the corresponding author and principal investigator. Therefore, they can provide it if requested.

Competing interests
None of the authors have any competing interests.

Funding
This study done at Ambo University material support that received by hands of Dereje Minase. However, the funder had no role in overall activities in the study such as; in study design, data collection, and analysis. Finally, the funder had no role in the decision to publish, or preparation of the manuscript for publication.
Authors' contributions DM is the principal investigator. DM, JD and ET conceived and designed the study. DM analyzed the data and interpreted the results. JD, ET and TT assisted the analysis and interpretation of data. JD and TT prepared and critically reviewed the manuscript. All authors have read and approved the manuscript.

Figure 1
Schematic presentation of sampling procedure to assess KAP and associated factors towards colostrum feeding among mothers of infants in Ambo district, Ethiopia