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Abstract
Objective This study aims to assess the prevalence of early initiation of breast feeding (EIBF) and associated factors among mothers having children less than 2 years of age in Ethiopia.
Design Community-based cross-sectional study.
Setting In this analysis, data from 2019 Ethiopia Mini Demographic and Health Survey (EMDHS) was used. The survey included all the nine regional states and two city administrations of Ethiopia.
Participants We extracted data of 2054 mothers who had last-born children and those mothers who ever breast fed or still breast feeding their children during the survey from the 2019 EMDHS datasets.
Main outcome measures We performed a two-stage multilevel mixed-effects logistic regression to identify individual and community-level determinants of EIBF. In the final model, variables with a p-value less than 5% and an adjusted OR with a 95% CI were reported as statistically significant variables with EIBF.
Result The prevalence of EIBF among mothers having children aged 0–23 months was 73.56% (95% CI: 71.65% to 75.47%). Women who delivered at a health facility (adjusted OR (AOR)=1.98; 95% CI: 1.39 to 2.79) and have children with birth order second–fourth (AOR=1.76; 95% CI: 1.24 to 2.49) were more likely to initiate early breast feeding than their counterparts. On the other hand, women who gave birth by caesarean section (AOR=0.21; 95% CI: 0.13 to 0.33), had multiple births (AOR=0.35; 95% CI: 0.13 to 0.92) and had postnatal check-up (AOR=0.62; 95% CI: 0.44 to 0.91) were less likely to practise EIBF as compared with their counterparts. Region of residence of women was also significantly associated with EIBF.
Conclusion In this study, the overall prevalence of EIBF was good. Place of delivery, mode of delivery, postnatal check-up, type of birth, birth order and region were factors significantly associated with EIBF. Therefore, government and stakeholders need to show commitment to improve access and utilisation of basic maternal health services to increase the practice of EIBF.
- Public health
- PAEDIATRICS
- Nutritional support
- NUTRITION & DIETETICS
Data availability statement
Data may be obtained from a third party and are not publicly available. The survey dataset used in this analysis are third party data from the demographic and health survey website (https://dhsprogram.com) and permission to access the data can be granted after sending a request for registration. Any interested researcher can obtain the data after completing the registration process (https://dhsprogram.com/data/dataset_admin/login_main.cfm) and submitting a short abstract of their proposed manuscript.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
The current study used most recent nationwide secondary data that show proportion of early initiation of breast feeding (EIBF) practice among women of children aged less than 24 months in Ethiopia.
We extracted data of 2054 mothers of children under 24 months from the 2019 Ethiopia Mini Demographic and Health Survey (EMDHS) dataset for this analysis.
Multilevel mixed-effects model was performed to overcome the hierarchical nature of EMDHS data and to identify both individual and community-level factors of EIBF.
Recall bias is the most relevant limitation of the study.
Introduction
Early breast feeding refers to the percentage of infants who have been breast fed, began breast feeding within 1 hour after birth, began breast feeding within 1 day after birth and received breast milk pre-feeding.1 The WHO recommends that breast feeding be started as early as 1 hour after birth. Although it is one of the core indicators for assessing infant and young child feeding,1 2 it is far from universal practice. Data from 2002 to 2005 show that 46 low/middle-income countries have included early initiation of breast feeding (EIBF) in their population health surveys. Among them, 54% of the records indicate that less than half of newborns are breast fed within 1 hour after birth. In addition, no country has a baby breastfeeding rate of more than 80% within 1 hour after birth. Globally, it is estimated that less than half (42%) of newborns are breast fed within the first hour of life.3
Recent evidence showed that late initiation of breast feeding (2–23 hours) increases the probability of a baby dying in its first month by 40% and the risk doubles if delay exceeds a day or more. Unfortunately, recent global statistics show that three in five newborns are not breast fed within the first hour after birth, which increases the negative impact on the baby.4 5 Other evidence suggests that starting breast feeding as early as 1 hour after birth can reduce neonatal and early infant mortality by about 45%.6 The survival of infants and children, especially children under 5 years of age, is an urgent issue that requires attention and has been on the global agenda since the 1978 Alma-Ata Declaration.
Therefore, breast feeding has been globally accepted as the easiest, cost-effective and successful intervention for the satisfactory physical and mental health of children.7 8 The recent studies in Ethiopia, Ghana, Bolivia and Madagascar found that breast feeding could prevent 20%–22% of neonatal deaths.9 10 Additionally, late initiation of breast feeding increases the risk of morbidity and mortality due to diarrhoea by fivefold.7 9
In some developing countries other than Ethiopia, the prevalence of EIBF has been recorded 41% in Ghana, 54.2% in Sudan, 70% in Zambia and other countries. It was 49.5% in Jordan, 86.6% in North Jordan, 72.2% in Nepal and 74% in Bolivia. In Ethiopia, one-third of babies are not breast fed within the first hour after birth. According to the records, the prevalence of breast feeding is low throughout the country and there are large regional differences.2 7–9 Moreover, the coverage of EIBF in Ethiopia ranges from 47.3% to 81.8%.11–15 According to the Demographic and Health Survey (DHS) report, there was progressive improvement in the country from 52% in 2011to 72% in 2019.16 The Ethiopian government is aware of the importance of starting breast feeding in a timely manner and developed guidelines for infant and young child feeding in 2004, adequately emphasising key information to begin breast feeding in a timely manner.17
Even though previously conducted studies examined different determinants of EIBF in the country, the coverage is still below the national target indicating the need for further investigation. Therefore, this study aims to assess the prevalence and determinants of EIBF among mothers who had children aged 0–23 months old in Ethiopia using secondary data from the 2019 Ethiopia Mini Demographic and Health Survey (EMDHS).
Methods
Study design
This study used a secondary data of the 2019 EMDHS. Originally, the survey sample was stratified and selected in two stages. The country is stratified into nine regions and two city administrations. Then, each region was stratified into urban and rural areas. In the first stage of selection, 305 enumeration areas (EAs) were selected using probability proportional to EA size according to the sampling frame created for the upcoming Ethiopian population and housing census. Consecutively, a list containing household in all selected EAs was developed. In the second stage, a fixed number of households (30) per cluster was selected from the newly created household listing using an equal probability systematic selection. Additional data on survey sampling strategies are provided in the DHS handbook.18
Participants
Generally, all women in childbearing age (15–49 years) who were either permanent residents of the selected households or visitors who slept in the household the night before the survey were eligible for the survey. The source population for the present study were mothers who breast fed and had children less than 2 years of age.
Eligibility criteria
All mothers of last-born children born in the 2 years preceding the survey (both surviving and dead) were included in the analysis, whereas mothers who had never breast fed their children were excluded from the study. Hence, data of 2054 mothers who had last-born children and those mothers who ever breast fed or still breast feeding were extracted from the 2019 EMDHS datasets for this analysis. Figure 1 depicts the method of selection of study participants that we followed to identify eligible mothers for this study (figure 1).
Eligibility assessment for early initiation of breast feeding (EIBF) among women having children aged 0–23 months in Ethiopia, 2019.
Study setting
The data for this study come from a standardised community survey of the 2019 EMDHS data, which was conducted in Ethiopia from March 2019 to June 2019. It included all the nine regional states and two city administrations of Ethiopia.
Measurements of variables of the study
Dependent variable
EIBF is the outcome variable of the study. It is defined as giving breast milk within the first hour of birth to the last child born in the last 2 years preceding the survey.18 During the survey, all women were asked how long after their babies were born to breast feed for the first time. According to the self-report of the child’s mother, it is coded as ‘1’ if the child is breast fed within the first hour after birth and ‘0’ otherwise.
Independent variables
The covariates in this study include variables at the individual and community level. The selection of explanatory variables is based on data from previous similar studies and the availability of variables in the 2019 EMDHS dataset. Maternal age, educational level, marital status, religion, family size, wealth index and possession of radio/television were individual-level sociodemographic and economic characteristics of the mothers included in the analysis.
Obstetric and variables related to the use of health services were parity, number of antenatal care (ANC) visits, place of delivery, mode of delivery, type of delivery assistance, postnatal check-up, type of birth and counsel on breast feeding during the first 2 days of delivery.
Other individual-level factors included in the analysis were child-related characteristics. These were age of child in months, sex of child, number of living children, birth order, preceding birth interval and child lives with whom.
Place of residence, region, community-level women education, community-level health facility delivery, community-level ANC utilisation and community poverty level were community-level variables included in the analysis. Community-level factors, which were not directly obtained from the survey dataset, were derived by aggregating individual-level factors (table 1).
Description of individual and community-level variables of early initiation of breast feeding among mothers of children under 2 years in Ethiopia, 2019
Data management and statistical analysis
STATA V.14 was used to clean, recode and analyse the 2019 EMDHS kids’ data. Sample weight was applied to adjust for sampling error and for non-responses. Descriptive statistics were used to present the distribution of background characteristics among the study participants. We employed a two-level multilevel mixed-effects logistic regression analysis so as to account for the hierarchical nature of the EMDHS data and to identify the true association between the individual and community-level factors and EIBF. Consequently, four models containing variables of interest were fitted: null model (without any explanatory variables), model I (with only individual-level variables), model II (with only community-level variables) and model III (with both level variables). Intraclass correlation coefficient (ICC) and a proportional change in variance (PCV) were tested to determine the clustering effect and the degree to which community-level factors explain the unexplained variance of the null model. Moreover, goodness of fit of the model was assessed by the deviance and the model with the lowest deviance was used as the best-fitted model. Finally, multicollinearity between explanatory variables was checked by variance inflation factor (VIF) and a mean value of VIF <10 indicates absence of multicollinearity. Both individual and community-level factors having a p-value of less than 0.2 in the bivariable analysis were selected as candidate variables for the multivariable multilevel mixed-effects logistic regression analysis. Likewise, variables with a p-value less than 5% and an adjusted OR (AOR) with a 95% CI were reported as statistically significant variables with EIBF in the final model.
Patient and public involvement
Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Result
Sociodemographic characteristics of women and children
A total of 2054 women who had children aged 0–23 months at the time of survey were included in this analysis. Out of the total respondents, nearly half (51.70%) were aged 25–34 years, 992 (48.30%) did not attend formal education, the vast majority (94.69%) were married and slightly greater than half (55.01%) of the respondents had five to eight family members. Nearly two-thirds (63.88%) of households of the respondents did not own radio or television and almost half (48.30%) were from low-income family. In the current study, relatively one-quarter of the respondents (24.88%) were urban residents, 12.41% were from Oromia regional state and 49.22% were Muslim religion followers (table 2).
Sociodemographic characteristics of women with children aged 0–23 months in Ethiopia, 2019
Obstetric and maternal healthcare service utilisation-related characteristics of the respondents
Of the participants, one-quarter has no ANC visits, 44.84% gave birth at home, 92.89% gave birth through vagina and almost all women (98.83%) gave single births. In addition, nearly one-tenth of women (12.37%) received postnatal care at least once and healthcare provider counselled 4 in 10 (40.21%) women on breast feeding within the first 2 days of delivery.
Majority of the respondents (73.03%) had one to four numbers of living children and about half of the children (49.81%) were male. Out of the total children, nearly one-quarter was first born, almost all (99.00%) lived with the respondents and 28.14% children were in the age group of 0–5 months at the time of the survey (table 3).
Obstetric and maternal healthcare service utilisation-related characteristics of women with children aged 0–23 months in Ethiopia, 2019
Prevalence of EIBF
In the current study, the prevalence of EIBF among women having children aged 0–23 months in Ethiopia was 73.56% (95% CI: 71.65% to 75.47%) (figure 2).
Prevalence of early initiation of breast feeding (EIBF) among mothers of children aged less than 24 months in Ethiopia, 2019.
Factors associated with EIBF
From both individual and community-level variables, which were eligible (p<0.20) for multivariable multilevel analysis in the final model (model III), place of delivery, mode of delivery, postnatal check-up, type of birth, birth order and geographical regions were significantly associated variables with EIBF among women having children aged 0–23 months in Ethiopia.
The likelihood of EIBF was nearly two (AOR=1.98; 95% CI: 1.39 to 2.79) times higher among women who delivered at a health facility than their counterparts. Concerning mode of delivery, mothers who delivered through caesarean section had 79% (AOR=0.21; 95% CI: 0.42 to 0.92) lower odds of EIBF as compared with their counterparts. Women who had postnatal check-up at least once had 38% (AOR=0.62; 95% CI: 0.42 to 0.92) lower odds of EIBF as compared with those who had no postnatal check-up. The odds of early initiation were 65% (AOR=0.35; 95% CI: 0.13 to 0.92) lower among mothers who gave multiple births as compared with those who gave a single birth. The odds of EIBF were 1.76 (AOR=1.76; 95% CI: 1.24 to 2.49) times higher among mothers whose children’s birth order was between second and fourth than those with first-born children. Women who lived in Southern Nations, Nationalities, and People’s Region (SNNPR) were two (AOR=2.06; 95% CI: 1.01 to 4.20) times more likely to practise EIBF than women who were from Tigray region. On the other hand, women from Somali region of Ethiopia were 52% (AOR=0.48; 95% CI: 0.24 to 0.96) less likely to practise EIBF (table 4).
Factors associated with EIBF among women having children aged 0–23 months in Ethiopia, 2019
Random-effect analysis result
The results of random-effect estimates obtained after fitting the four models (null model, model I, model II and model III) were presented in table 4. The presence of likelihood of EIBF practice variation within the nine regions and two city administrations of Ethiopia was shown by the ICC of the null model (ICC=17.8%). This indicates that 17.8% of the variation in EIBF practice among mothers of children less than 2 years old was attributed to the difference between the regions. Additionally, the highest PCV (43.05%) in the final model (model III) implies the majority of variations of EIBF practice among mothers observed in the null model were explained by both individual and community-level factors. In addition, the lowest deviance in the last model showed that model III was the best-fitted model (table 5).
Random-effect analysis result and model fitness for assessing factors associated with early initiation of breast feeding in Ethiopia, 2019
Discussion
EIBF significantly reduces the risk of neonatal morbidity and mortality. It also lessens the risk of postpartum haemorrhage of mothers by stimulating contraction of uterus after delivery.19–21 In this study, we examined the effect of individual and community-level factors on EIBF among women who have children 0–23 months in Ethiopia. The current study result showed that 73.56% of women having children aged 0–23 months in Ethiopia put their child to breast within the first hour of birth. The prevalence was higher when compared with studies conducted in Ethiopia,11 22–27 other sub-Saharan African countries28–35 and Papua New Guinea.36 The finding was consistent with other study findings done in different parts of Ethiopia13 37 38 and Malawi.39 Conversely, the prevalence was lower than the studies conducted in South Ethiopia,12 40–42 North Ethiopia43 and Tanzania.44 These discrepancies could be due to the variation of the study period, access and utilisation of health service and sociocultural conditions among the respondents. Moreover, the differences might be due to poor maternal educational status, access to various sources of health information and resistance to change in behaviour due to traditional beliefs.
The study at hand revealed that women who delivered at a health facility were more likely to initiate breast feeding within the first 1 hour of birth than their counterparts. This finding is in line with studies conducted in South Ethiopia,41 Northwest Ethiopia,26 38 Economic Community of West African States,45 sub-Saharan Africa,33 Peru46 and Romania.47 As it is stated in literature, initiation of breast feeding within the first hour of birth is an integral part of the safe delivery procedure. Accordingly, qualified health professionals attending the delivery can motivate, empower and assist to start breast feeding within the first hour of birth. This might be the possible explanation for the discrepancy of EIBF among women who delivered at a health facility and at home.
In the present study, postnatal check-up was inversely associated with EIBF. Women who had postnatal check-up had lower odds of EIBF as compared with those who had no postnatal check-up. The reason behind this might be connected with the reverse sequence of the events. It is known that women usually receive postnatal service after breast feeding was initiated. Thus, it is difficult to directly relate EIBF to the outcome or effect of postnatal check-up.
It has been reported in previous work that one of the preconditions to early initiate breast feeding is keeping the mother with the newborn and putting the infant skin-to-skin contact on the mother’s abdomen immediately after delivery.48 This fact was also supported by our current study. Women who delivered via caesarean section had lower odds of EIBF as compared with those who had spontaneous vaginal delivery. This finding is in concordance with the findings of various studies conducted inside and outside Ethiopia. As it was documented in previous studies, long postoperative care delays skin-to-skin mother-to-baby contact for mothers who gave birth through caesarean section. This separation of mother to baby for a short period due to factors attributed to caesarean section results in delayed initiation of breast feeding. Similarly, production of inadequate milk because of reduced oxytocin release that comes after anaesthesia might also contribute to the delay.26 37 38 46 48 49
Consistent with studies done elsewhere,26 33 46 the odds of EIBF were lower among women with multiple births when compared with women who gave a single birth. The reason behind this might be, in most cases, a woman with multiple pregnancies gave birth via caesarean section. As discussed earlier, delivery via caesarean section necessitates mother to baby separation resulting in delayed initiation of breast feeding. In addition, it could be due to the probability of giving preterm birth was higher among women who gave multiple births than those who gave single births.50 As a result, there might be a delay in initiating breast feeding until the neonate is capable of sucking breast milk.
In this study, birth order of children was significantly associated with EIBF. This finding is in agreement with studies conducted in sub-Saharan Africa.11 13 29 45 51 The possible explanation for this might be that women who had more birth experiences could have a better chance of receiving a health professional’s advice on EIBF. Since women who gave birth more than once would be more exposed to and use maternal health services as compared with their counterparts.
Similar to reports from earlier studies,28 38 the current study found that some variations on EIBF existed among the geographical regions of the country. Women from SNNPR had higher odds of EIBF practice, while women from Somali region of Ethiopia had lower odds of EIBF practice as compared with women from Tigray region. This might be due to the sociocultural and basic health infrastructure variations among the regions. Women who live in the Somali region might not access basic maternal health services as compared with women who live in the Tigray region. Moreover, evidence revealed that prelacteal feeding practice is more common in Somali region than Tigray region.52
Strengths and limitations
The current study was conducted in Ethiopia and individual and community-level factors associated with EIBF were identified by using a multilevel analysis. As a result, policymakers and other stakeholders can use the findings of this study to plan and implement appropriate strategies and interventions. However, this study has some limitations. The study was subjected to recall and social desirability bias since the outcome variable was assessed based on the maternal report. In addition, we are unable to supplement our findings with qualitative data and unable to include some quantitative variables like access to mass media, size of the child at birth, obstetric and neonatal complications, early skin-to-skin contact, prematurity and other related variables since this study used secondary data of a national survey. Furthermore, establishing temporal relationship between EIBF and its determinants was impossible due to the type of the study design, cross-sectional, used for the survey.
Conclusion
According to the WHO infant and young child feeding rating, the overall prevalence of EIBF among women having children aged 0–23 months in Ethiopia was good. Place of delivery, birth order and geographical region (SNNPR) were factors positively associated with EIBF, whereas mode of delivery, postnatal check-up, type of birth and geographical region (Somali) were factors negatively associated with EIBF. Therefore, concerned bodies need to promote institutional delivery, give special care for mothers who gave multiple births and encourage mothers of first-born infants to initiate early breast feeding.
Data availability statement
Data may be obtained from a third party and are not publicly available. The survey dataset used in this analysis are third party data from the demographic and health survey website (https://dhsprogram.com) and permission to access the data can be granted after sending a request for registration. Any interested researcher can obtain the data after completing the registration process (https://dhsprogram.com/data/dataset_admin/login_main.cfm) and submitting a short abstract of their proposed manuscript.
Ethics statements
Patient consent for publication
Ethics approval
This study used secondary data of the EMDHS. The authors obtained permission to access the data from the MEASURE Demographic and Health Survey repositories upon sending an abstract of our study to an online request form (http://www.measuredhsprogram.com). Ethical approval for the study was obtained from National Ethics Committee of the Federal Democratic Republic of Ethiopia, Ministry of Science and Technology and the ICF Institutional Review Board. Hence, consent to participate is not applicable.
Acknowledgments
We would like to forward our heartfelt appreciation to MEASURE DHS Programme and its partners for allowing us to use the 2019 EMDHS data.
References
Footnotes
Contributors SS was the guarantor and involved in conceptualisation, data curation, analysis and writing the manuscript. GG, BT and SA were equally involved in the data analysis and writing the manuscript. All authors have read and approved the final manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests The authors declare that they have no competing interests.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.