In this study we examined the association between maternal depressive symptoms and IFPs using a computed index suggested by Ruel and Menon [29]. The key contribution of this study is to show the effect of maternal depressive symptoms on IFPs in rural Ethiopia. The findings have important implications for policy makers, researchers, donors and program implementers working on child nutrition in Ethiopia, where the burden of child malnutrition is the highest [14].
The IFPs score is relatively higher during the first 6 months than the second 6 months of age. During the first six months, IFP components need no significant additional costs for rural Ethiopian women but mothers’ commitment and knowledge. However, during the second six months of the infancy period, the IFP components need resources particularly to fulfill the required quality of meal and the frequency. As revealed in this study, less than three percent of infants received a quality diet as measured by dietary diversity. Several previous studies in Ethiopia came up with similar findings of unacceptably low percentage of infant dietary diversity [36–39]. Moreover, we found that the IFP score was the poorest particularly at six months of age. This might be explained by the small proportion of mothers who practiced timely initiation of complementary feeding in this study. Besides, 6–8 months of infancy is the transition period where mothers/caretakers struggle to teach babies to take solid and semi-solid foods.
A statistically significant negative association was found between early postnatal depressive symptoms (within three days of birth) and overall IFP score in this study. So far only few studies have used IFP index in feeding practice studies and to the researchers’ best knowledge there is no study which explores the longitudinal relationship between IFPs and maternal depressive symptoms using an IFP index. However, several previous observational studies reported that maternal postnatal depression is associated with specific components of IFPs; though, the direction of association between breastfeeding and postpartum depression remains unclear [40]. Systematic reviews in 2019 and 2015concluded that depressed women breastfed their child for shorter duration than non-depressed women[23, 41]. Other previous studies also reported a negative association between maternal depression and early initiation of breastfeeding [42], complementary feeding initiation [43] and infants’ dietary diversity [44, 45].
Infants born to women who experienced intimate partner violence were at greater risk of poor IFPs. This finding is consistent with previous studies [46–48] and has important implications, particularly in Ethiopia, where 34 percent of ever-married women experienced such violence [14]. There are many pathways that intimate partner violence can affect maternal health and behavior [49]. Through its biological pathway, intimate partner violence is a stressor to which the autonomic nervous system, the hypothalamic–pituitary–adrenal (HPA) axis, and the cardiovascular, metabolic, and immune systems respond and hence leads to depression [50–52]. As stated above, maternal depression leads to poor IFPs. Furthermore, intimate partner violence has negative outcome on poverty and household food security by affecting couples capacity to organize and manage resources available in order to assure food and nutrition security of the family.
Contrary to many of previous studies, we found that infants in moderately and severely food insecure households rather have better IFP scores. Several previous studies reported that household food insecurity was negatively associated with IFPs [53–55]. However, the direction of the association does not mean that all infants in food secure households received appropriate and adequate feeding. In Uganda, Pascal et al. found that 8 out of 10 infants in food secure households were not receiving the minimum dietary diversity required and reported that household food insecurity explains only 10 percent of the variance of dietary quality determinants [56]. Conversely, our finding agrees with the studies in Kenya and Tanzania [57, 58]; both studies concluded that infants from food insecure households were less likely to receive cow milk before they reached 6 months. Particularly in Kenya, dairy producing households had a 12-fold increased risk for exclusive breastfeeding interruption by early animal milk introduction compared to those in households without cattle.
Another probable reason for the positive association between food insecurity and IFPs in this study could be ENGINE program vulnerable households focused IYCF interventions. ENGINE end-line impact assessment reported that the program achieved over 10 percentage point increase in infant and child feeding index (ICFI) in 50% of intervention Districts [59]. Studies showed that IYCF focused nutrition education for caregivers improved child dietary diversity and nutrition knowledge of caretakers even in food insecure areas [60, 61]. Moreover, as we indicated earlier, the IFP scores were relatively higher during the first 6 months than the second half of infants’ age; during this period the IFP elements are more amenable to improve by IYCF focused social and behavior change communications costing no or minimal resources for a rural mother.
In this study, only half of women reported that they feel they have good social support during pregnancy (43.8%) and immediately postpartum (56.2%). We found that maternal social support was positively associated with IFPs. In agreement with our findings, previous studies reported that maternal social support helps mothers to practice appropriate infant and young child feeding [62, 63]. Similarly, our study revealed that infants whose mothers actively participated in social groups have a better IFP scores than those with poor participation. Previous studies consistently reported that social participation is associated with mental and physical health benefits. Seeman and colleagues found that having three or more regular social contacts, as opposed to zero to two such contacts, is associated with lower allostatic load scores [64]. Lower allostatic load mean lower depression [65, 66] and then better IFP scores. In Ethiopia social groups are main platforms to reach mothers with IYCF messages [67].
Gestational age at birth was positively associated with IFP scores. This implies that preterm infants were not receiving good IFPs as their full term counterparts. Consistent with our findings, previous studies reported that mothers of preterm infants initiated breastfeeding late and that pre-term infants are breastfed for a shorter duration [54–56]. Similarly, observational studies in Italy and the United Kingdom reported early introduction of solid foods with a majority of preterm infants receiving a solid food prior to 4 months of age [71, 72].
A systematic review by Kajali and Vector revealed that restriction or interruption of complementary foods during illness is frequent because of children's anorexia, poor awareness by caregivers' about the feeding needs of sick children, traditional beliefs and behaviors, and/or suboptimal counseling and support by health workers [73]. However, we found that infants with higher morbidity episodes have higher IFP scores too. We presumed that frequent episodes of illness increase mothers’ frequency of contact with health care providers and hence repetitive IYCF counseling which improves mothers’ IYCF awareness and practices. Abegaze and colleagues reported, that in Ethiopia, mothers with prior experience of infant illness were more likely to seek health care for their sick children than their counterparts [74]. Moreover, as a sick infant loses appetite, mothers could frequently serve different type of foods to the infant that potentially increases diet diversity and/or frequency and increase the IFP scores.
Mothers with primary and above school qualification seemed to perform better with respect to IFPs than illiterate mothers. This finding is in agreement with previous studies in Ethiopia and elsewhere [13, 42, 44, 45, 75]. This may be explained by educated mothers having better understanding of IYCF itself and/or had exposure to IYCF awareness raising campaigns (through their ability to read leaflets, posters and banners) that have been conducted for several years by the Ministry of Health and development partners in Ethiopia.
One of the main strengths of this study is that it is based on community based longitudinal data (prospective birth cohort) with appropriate analytical techniques applied. The study had a large sample size, high response rate and low attrition. Data were collected on regular intervals on several important socio-demographic, nutritional and clinical risk factors that could be harvested for this analysis. In addition, we used 14 WHO recommended IYCF core and optional indicators to compute the IFP score[31]. One limitation of this study is that IFP data were based on mothers/caretakers reports and, thus, are subject to possible recall biases. Moreover, presence of depressive symptoms may cause mothers to have more negative views about things around them, including household food security, child health and feeding practices.