The Magnitude of Pre-lacteal Feeding Practice and its Inuencing Factors Among Mothers with Children Under the Age of Two Years in Afar Region of Ethiopia: A Community based Quantitative and Qualitative Study

Background: Pre-lacteal feeding is a barrier to implement optimal breastfeeding 26 practices and caused new-born disease. Pre-lacteal feeding is primarily practiced in 27 developing countries, where cultural and social structures are based on descent and 28 relationships. The aim of study was to determine the magnitude of pre-lacteal 29 feeding practice and its influencing factors among mothers with children under the 30 age of 2-years in Afar region of Ethiopia. 31 Method: A community based cross sectional study supplemented by qualitative 32 study was employed. In the quantitative study, 235 study participants were included, 33 whereas seventeen study subjects participated in the qualitative study. Bivariate and 34 multivariate logistic regression was used to determine factors associated with pre- 35 lacteal feeding practice. The qualitative data was analyzed using thematic approach. 36 Result: The magnitude of pre-lacteal was 36.6%. Being a housewife 37 CI: and having male indexed child (AOR=4.9, 95% CI: 1.8- 38 were more likely to practice pre-lacteal feeding than those of trade and female, 39 respectively. However, pre-lacteal feeding practice decreased in those mothers with 40 three and above ante natal care visits (AOR=0.31, 95% CI: 0.1-0.9), delivered at 41 health institutes (AOR=0.1, 95% CI: 0.02-0.3), starting breastfeeding within one hour 42 (AOR=0.04, at 95% CI: 0.01-0.1) and getting breast feeding counseling (AOR=0.21, 43 at 95%CI: 0.06-0.7). Milk, plain water, sugar solution, honey, butter, dates (‘temir'), a leaf, and condo pepper were the most common pre-lacteal foods reported by study participants. Cultural beliefs and the assumption of cleaning new-born throat and bowel were the most common reason to practice pre-lacteal feeding. Conclusion: The magnitude of pre-lacteal feeding was high due to socio-cultural 48 and maternal health service utilization factors. Water, milk products, sweet foods and 49 some of plant types were the most common pre-lacteal foods. 50


Introduction 66
Breast-feeding delay was frequently a cause of pre-lacteal feeding. Cultural taboos 67 and beliefs influenced the majority of mothers' weaning (1). The practice of giving 68 certain types of food to babies before commencing breast milk is common in both 69 urban and rural areas. Some of the most frequently reported pre-lacteal meals are 70 tamarind juice, honey, jaggery, sugar and glucose water, animal milk, and 71 commercial powdered milk (2). From 2010 to 2018, the pooled prevalence of pre-72 lacteal feeding in eleven East African countries was 12%, with the greatest rate 73 (39%) in the Comoros and the lowest in Malawi (3%). Pre-lacteal feeding was 74 associated with wealth index, antenatal care (ANC) visit, health institutional delivery 75 and mode of delivery (3). In a meta-analysis study, the pooled prevalence of pre-76 lacteal feeding was found to be 25.29% in Ethiopia. Antenatal care, infant feeding 77 counseling, timely breastfeeding initiation and urban residence were associated with 78 a lower risk of pre-lacteal feeding, but home birth was associated with a greater risk 79 (4). In Sodo district of southern Ethiopia, the prevalence of pre-lacteal feeding was 80 20.6%. Plain water (7.7%) was the most common pre-lacteal feeding and the main 81 in pre-lacteal feeding practices (7). The prevalence of pre-lacteal feeding was 10.1% 91 in the Axum town, North Ethiopian. Mothers with no previous children, birth spacing 92 of less than two years, not giving colostrum, less than four anti-natal care visits, 93 cesarean section and perceiving the benefits of pre-lacteal feeding were associated 94 with pre-lacteal feeding (8). In a study conducted in Eastern Tigray region of 95 Ethiopia, 24.7% of women practiced pre-lacteal feeding. Pre-lacteal feeding had 96 associated to parity, late breastfeeding initiation and colostrum avoidance (9). Pre-97 lacteal feeding decreased from 29% in 2005 to 8% in 2016. The practice of pre-98 lacteal feeding was significantly influenced by distance from the health institution, 99 wealth level, occupation, antenatal care visits and desired last child. Lower rates of 100 pre-lacteal feeding were seen in Benishangul, Tigray, most of Amhara, the western 101 part of Gambela and the eastern parts of the southern nation nationality people 102 region. The Somalia and Afar regions had greater rates of pre-lacteal feeding (10). A 103 meta-analysis was conducted in Ethiopia to investigate the relationship between 104 home delivery and pre-lacteal feeding. Pre-lacteal feeding accounted for a total of 105 26.95% (95% CI: 6.1% -75.8%). The highest prevalence was in the Afar area. The 106 pooled odds of pre-lacteal feeding was increased by 5.16 times when comparing 107 women who gave birth at home to those who gave in health institutions (95% CI: 3.7-42.9% of mothers gave their children pre-lacteal feeding. Raw butter (54.2%) and 116 animal milk (28.5%) were the most frequent pre-lacteal feeding. Pre-lacteal feeding 117 was significantly associated with housewife, having a husband with no formal 118 education, starting breastfeeding after one hour of birth, having a higher household 119 income and a lack of information about good breastfeeding practice (13). A cross-120 sectional study was conducted in the town of Samara-Logia in 2017. Ninety percent 121 of mothers responded that breastfeeding is beneficial to their infants. However, 122 45.3% of women thought it was useful to provide feeds other than breast milk. About 123 45% of the women started breastfeeding within an hour after birth. Within three days 124 after delivery, more than half of the newborns (62.5%) had received pre-lacteal 125 feeding (14). A community-based cross-sectional study was conducted in Dubti 126 district, Afar region. About 93% of mothers began breast feeding their babies within 127 an hour after birth. Pre-lacteal feeding and avoided colostrum were practiced by 128 16.8% and 15.6% of mothers, respectively (15).

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A clear understanding the magnitude of pre-lacteal feeding practice and associated 130 factors is essential to create an appropriate intervention in a pastoral community 131 where the social and cultural conditions were conducive to such practice. The 132 current study explores favorite socio-cultural characteristics and maternal health 133 service utilization factors that were associated with pre-lacteal feeding practice since 134 there is limited study in the Afar region of Ethiopia. Exploring the key factors of pre-135 lacteal feeding practice can be achieved by qualitative and quantitative study. The 136 finding could be useful in establishing intervention programs and promoting early 137 breastfeeding initiation as a strategy to enhance mother and new-born health at the 138 community, regional, and national levels, as well as in developing nations.

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This study was conducted in Algante village and Dasa village which were found

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A community-based cross-sectional study with qualitative study was used to 177 investigate pre-lacteal feeding practice and associated factors. The research 178 conducted from July 18 to July 23, 2021. The sample size for the quantitative study 179 was estimated using 16.8% prevalence of pre-lacteal feeding in Dubti district (15) 180 and a 95% confidence level with 5% precision. Thus, the sample size was 215. By 181 adding 10% none response rate, the final sample size was 237.

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Inclusion and exclusion criteria of study population. 183 Biological mothers with children under the age of two years in the specified villages 184 were included in the study. Non-biological mothers, women who had not lived in the 185 study area for six months, and mothers who were unable to talk or hear were also informants for the qualitative study since they were the main agents in the practice of 188 pre-lacteal feeding and had more information about it.

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Variables and operational definitions 190 The independent variables were selected after a thorough review of the literature.

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The dependent variable was pre-lacteal feeding practice, which was recorded as a 192 binary result (yes/no).

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Pre-lacteal feeding: Giving any solid or liquid foods other than breast milk during the 194 first three days after delivery.

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Quantitative data: Systematic sampling technique was used to select the required 197 study subjects. The sampling interval (K) was determined by dividing the total 198 number of households in the two villages by the total sample size, which is 199 approximately two. Equal sample size was allocated for each village. To decide 200 which direction (north, south, east, and west) to begin data collection, we used a 201 lottery method. Following that, the first household was chosen by lottery method from 202 the first two households, and then every second household was selected until the 203 required sample size was attained.

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Qualitative data: The participants were selected from mothers with children under the 205 age of two years and key informants. Key informants were selected from traditional 206 birth attendants using a purposive sample technique. Key informants were recruited 207 with the help of community elders and community health extension workers. The 208 process of selection was continued till the information was redundant. The interview 209 participants for the qualitative study were not the same as those who were sampled 210 for the quantitative data participants.

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First the qualitative data was collected by In-depth interviews using open-ended 213 guiding question which was developed based on the study objective. To collect 214 quantitative data, closed-ended structured interview questionnaires that were 215 constructed from literatures were used. Five data collectors were trained to collect 216 quantitative data, and four data collectors were recruited and trained to collect 217 qualitative data. For both qualitative and quantitative data collection, all of the data 218 collectors were BSc degree in public health officer. During qualitative data collection, 219 the two data collectors (one note taker) were allocated to each village at the same 220 time. The purpose of study was explained for each study participant before data 221 collection started. Those who agreed to take part in the study were then interviewed 222 face-to-face in a quiet location at their home in order to better understand each other 223 and ensure confidentiality. Information was collected on women's demographic, 224 socio-cultural and obstetric characteristics as well as pre-lacteal feeding practices.

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The guideline used to conduct in-depth interviews was shown (Table 1).   The magnitude of pre-lacteal feeding and the reasons for practicing these 298 foods in Dubti woreda, North East Ethiopia.

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The magnitude of pre-lacteal foods practice by those mothers was 36.6%. Milk 300 (33.7%) and plain water (24.4%) were the most commonly pre-lacteal foods, 301 followed by sugar solution and butter. The most common reason to practice these pre-lacteal foods were cultural belief (54.7%) and the desire to clean the new born's 303 throat and bowel (20.9%) (Table 4). To calm the baby 10 (11.6) 95% CI: 1.4-12.2) and having male indexed child (AOR=4.9, 95% CI: 1.8-13.5) were 315 more likely to practice pre-lacteal feeding than those of trade and female, 316 respectively. However, pre-lacteal feeding practice was reduced by 69% in those 317 mothers who had three and more antenatal care visits when compared to those 318 mothers with less than three ante natal care visits (AOR=0.31, 95% CI: 0.1-0.9).

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For qualitative data, a mother was selected purposively until redundant information 327 was reached. A total of 17 participants were chosen based on this, with four of them 328 serving as key informants. foods found among study participants were milk product, some plant types, sweet 341 foods and water (Table 5). The following study participants explained the above pre-lacteal feeding practice. The purpose of the study was to determine the magnitude of pre-lacteal feeding 446 practice and its influencing factors among women with children under the age of 2-447 years in sub-districts of Dubti woreda, Afar region of Ethiopia. This study found that 448 the important of different social-cultural and maternal health service utilization factors 449 that are associated with pre-lacteal feeding practice, as well as types of pre-lacteal 450 foods. In this study, the magnitude of pre-lacteal feeding was 36.6%. This result is 451 higher than that of a study in East Africa (3) and meta-analysis studies in Ethiopia (4, 452 11). Moreover, the present finding is higher than the previous studies in southern (5,453 6) and northern part of Ethiopia (8,9,15), as well as it supports a spatial and 454 multilevel study in Ethiopia reported that the Afar region has the greatest rate of pre-455 lacteal feeding (10). The different between the current study and the previous studies 456 could be attributed to regional and ethnic differences in traditional practices. The 457 other variation may be health coverage disparities and a lack of effective health 458 education between study settings. However, the magnitude of current finding is lower 459 than that of study in south-west Ethiopia (7), Harare district in Eastern Ethiopia (12) 460 and studies in Afar region (13,14). The variation could be study period, and study 461 participants were near Samara, the Afar region's main city, where they might have 462 access to maternal and child clinics, as well as health education or information via 463 television and newspapers. Housewives were more likely to practice pre-lacteal 464 feeding than those of trades. The finding is consistent with a study conducted in Afar 465 region (13) and a meta-analysis study in Ethiopia (10). Mothers of male-indexed 466 children were also more likely to practice pre-lacteal feeding than mothers of female-467 indexed children. The reason could be that male children are given more attention in on pre-lacteal feeding practices. As a result, health education should be provided on 470 the equality of males with girls and the disadvantage of pre-lacteal feeding practice.

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In the current study, pre-lacteal feeding practice was reduced by 69% in those 472 mothers who had three and more antenatal care visits when compared to those 473 mothers with less than three antenatal care visits. This evidence supports the 474 previous studies (3,4,8,10,12). The reduction of pre-lacteal feeding could be that 475 mothers have been given breastfeeding advice during antenatal care visits. Mothers 476 who give birth at health institutes were less practicing pre-lacteal feeding than those 477 of home delivery. This finding is in line with the previous studies (3,4,6,7,(10)(11)(12).

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The possible reason for this reduction of pre-lacteal feeding practice could be that 479 the delivery was attended by health professionals who advised that breastfeeding 480 should be started as soon as after birth. Those who received breast feeding 481 counseling were 79% less likely to practice pre-lacteal feeding than those who did 482 not. This is consistent with previous studies (4-8, 13). The decrease in pre-lacteal 483 feeding may be attributed to better understanding of the benefits and harmfulness of 484 pre-lacteal feeding practice during breastfeeding counseling. About 54% of mothers 485 initiated breastfeeding within one hour. This result is lower than a study conducted in 486 Afar region (15), but higher a previous study in this similar area (14). In this study, 487 those who started breastfeeding within an hour had lower pre-lacteal feeding 488 practice than those who started after one day. This evidence is similar to the 489 previous studies (1,4,7,9,12,13 Availability of data and material: All materials and data were in the manuscript and 537 supplementary materials (Table S1).

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Competing interest: There is no any competing interest.