Magnitude and associated factors of prelacteal feeding practices among mothers of under one-year-old children in Rural Pastoralist Communities of Afar, North Eastern Ethiopia: A community based cross-sectional study.

In Ethiopia, inappropriate feeding including prelacteal feeding is one of the immediate causes of undernutrition. The objective of this study was to assess the magnitude and associated factors of prelacteal feeding practices among mothers of children aged less than one year in Rural Pastoralist Communities of Afar, Ethiopia. A cross-sectional study was conducted in the Afar Region, Ethiopia from May to June 2016. A total of 424 mothers were included in the study. A two-stage cluster sampling technique was used to select sample clusters and households. A pre-tested and structured questionnaire was used as a data collection instrument. SPSS version 25 was used to analyze the data. Model goodness of fitness was assessed using Hosmer and Lemeshow test. Multi-collinearity between independent variables was checked. Binary logistic regression analysis was used to identify the association between the explanatory variables and prelacteal feeding practices. Multivariable logistic regression was also used to determine the independent predictors of prelacteal feeding practices.


Background
In Ethiopia, inappropriate feeding including prelacteal feeding is one of the immediate causes of undernutrition. The objective of this study was to assess the magnitude and associated factors of prelacteal feeding practices among mothers of children aged less than one year in Rural Pastoralist Communities of Afar, Ethiopia.
Methods A cross-sectional study was conducted in the Afar Region, Ethiopia from May to June 2016.
A total of 424 mothers were included in the study. A two-stage cluster sampling technique was used to select sample clusters and households. A pre-tested and structured questionnaire was used as a data collection instrument. SPSS version 25 was used to analyze the data. Model goodness of fitness was assessed using Hosmer and Lemeshow test. Multi-collinearity between independent variables was checked. Binary logistic regression analysis was used to identify the association between the explanatory variables and prelacteal feeding practices. Multivariable logistic regression was also used to determine the independent predictors of prelacteal feeding practices.

Result
In this study, 75.7% (95% CI 71.1%, 79.7%) of mothers gave prelacteal feeds to their newborns. The odd of prelacteal feeding was 2.32 times higher in mothers whose husbands didn't attend formal education as compared to their counterpart (AOR = 2.32, 95% CI: 1. 18-4.5). The odds of prelacteal feeding was 7 times higher for infants delivered at home compared to infants delivered at a health facility (AOR = 7.52, 95% CI:3.44, 16.45). Fail to have skin to skin contact between the mother and the newborn increases the odds of prelacteal feeding by 5 times than their counterparts (AOR=5.12, 95%CI: 2.14, 12.21).

Conclusion
Three-fourth of the children in Rural Pastoralist Communities of Afar received prelacteal feeding. Home delivery, husband education and skin to skin contact immediately after birth were found to be independent predictors of prelacteal feeding in the pastoralist communities. Strengthening the behavior change communication on optimal infant and young child feeding, promotion of husband education and institutional delivery and skin to skin contact immediately after birth are the recommendations.

Background
According to the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF), children have to initiate breastfeeding within the first hour of birth, feed colostrum, exclusively breastfeed for the first six months of life, introduce appropriate complementary feeding at 6 months of age and should continue breastfeeding up to 2 years and beyond. From birth to 6 months of age, children should take only breast milk no other foods or liquids even water except medicines prescribed by health professionals [1,2]. The early initiation of breastfeeding is critical to newborn survival and to establishing breastfeeding over the long term. If the initiation of breastfeeding is delayed or if prelacteal is given, the consequences can be life-threatening. Improving breastfeeding practices could save the lives of more than 800,000 children under 5 every year. Breastfeeding boosts children's brain development and mother will be less risk for breast cancer, ovarian cancer and type 2 diabetes [2]. Optimal infant and young child feeding practices rank among the most effective interventions to improve child health [3].
Adequate diets and related feeding practices are essential to ensure the health, growth, and development of children to their full potential. The first breast milk contains colostrum, which is highly nutritious and has antibodies that protect the newborn from diseases.
Prelacteal feeding is feeding of newborn anything other than breast milk before breast milk is initiated. It deprives the child of the valuable nutrients and protection of colostrum and exposes the newborn to the risk of infections[4]. Prelacteal feeding practice is a worldwide problem which ranges from 10.8% in Malawi to 75.2% in Burkina Faso in Sub-Saharan Africa, from 40.9% in Nepal to 93.9% in Cambodia in South Asia and from 26.7% in Nicaragua to 46.2% in Dominican in Latin America and the Caribbean [5]. Over twothirds of deaths among under-five children are associated with inappropriate feeding practices that occur during the first year of life[6[. In Ethiopia, 8% of children received prelacteal feeding [7]. Systematic review and meta-analysis on prelacteal feeding practice was conducted in Ethiopia and found a pooled magnitude of prelacteal feeding practice 26.95% but the magnitude in the primary studies were ranging from 6.1%( SNNPs) to 75.8% (Oromo Region) [8]. Inappropriate feeding including prelacteal feeding is one of the immediate causes for under nutrition.
According to the global nutrition report of 2017, globally about 22.2% (150.8 million) of under-five children were stunted, 7.5% (50.5 million) were wasted [5]. By the same token, about 37%, 21%, and 7% of under-five children in Ethiopia are stunted, underweight and wasted respectively. This high burden of undernutrition contributes to the high child mortality rate. According to mini EDHS, 2019 neonatal mortality, infant mortality and under-five mortality are 30, 43 and 55 per 1,000 live births respectively [9].
By considering the burden and consequences of the problem, the government of Ethiopia established the National Nutrition Programme II (NNP II) and the National Guideline on Adolescent, Maternal, Infant, and Young Child Nutrition (AMIYCN) in 2016 and nutrition and food policy in 2019 to promote optimal feeding and care practices in all Regional States of Ethiopia [7]. Of course the practice of prelacteal feeding decreased from 29% in 2005 to 27% in 2011 and dropped further to 8% in 2016 but despite this effort and reduction, still prelacteal feeding is highly practiced in Ethiopia. Prelacteal feeding predisposes newborns for acute respiratory tract infections and diarrhea. Furthermore, prelacteal feeding was linked with poor breastfeeding outcomes such as higher odds of delayed initiation, nonexclusive breastfeeding and early cessation of breastfeeding, and delayed secretion of breast milk. Despite the negative health and nutritional consequences of prelacteal feeding, little is known about it in the Afar region. It is crucial to study prelacteal feeding practices as a barrier to optimal breastfeeding practices, especially for exclusive breastfeeding. Thus, this study was aimed to assess the magnitude and associated factors of prelacteal feeding practices among mothers of children aged less than one year in Rural Pastoralist Communities of Afar, Ethiopia. The finding of this study could help health professionals, program managers and implementers to design and implement interventions to reduce prelacteal feeding and promote optimal breastfeeding practices.

Study area
The study was conducted in the Afar Regional State, Ethiopia. Afar Regional State is one of the nine regional states of Ethiopia and has a total surface area of 97, 256 km 2 . Afar is bordered by Eritrea and Tigray in the North, Oromia regional state in the South, Republic of Djibouti in the East and Amhara regional state in the West. Afar is classified under the desert and semi-desert agro-ecological zone. The majority of the area in the region is low

Study design and period
The study design was community-based cross-sectional and it was conducted from May to June 2016.

Study population
The study populations were women of 15-49 years of age who had given birth (excluding stillbirths) in the previous one year preceding the study. Data collection instrument and procedure A structured questionnaire was used as data collection instruments. The questionnaire was translated to Amharic and field-tested before the actual data collection. Prior to the actual study, the data collectors, supervisors, and coordinators were made to receive five days of training on the objective of the study and data collection tools. Moreover, the designed questionnaire was tested in the field level at a location that has not been selected for the actual study. Based on the result of the pre-test, the data collection tools were reviewed and revised for data collection. Twelve data collectors and six supervisors were deployed.

Data quality assurance procedures
The core team implemented its standard data quality control procedures at each critical stage of the survey design and implementation. Quality assurance started at the very beginning, with the training of data collectors, supervisors and pre-testing of data collection instruments, and covers each stage of the implementation, the physical handling of survey instruments and data, to the final data entry and analysis.

Data entry and cleaning process
The quality of data was further ascertained during the data entry and cleaning process.
There was strict supervision throughout the entire period of the data entry process.
Ranges and necessary rules for variables were set during data entry, so that unlikely values are rejected. Template and codebook before data entry were checked. Finally, all entered data were visually checked for outliers.
Data management and analysis SPSS version 25 was used to analyze the data. Descriptive statistical analysis was made to compute the mean, frequencies and percentages on selected variables. The outcome variable which is prelacteal feeding practice was dichotomized into yes = 1 and no = 0.
Binary logistic regression analysis was applied to identify the associated factors.
Accordingly, bivariate logistic regression was performed and variables with a p-value < 0.25 were transferred to multivariate logistic regression to identify the risk factors. In the multivariate logistic regression analysis, variables with p-value < 0.05 were taken as statistically significant factors. Adjusted odds ratio with its 95% confidence intervals was also considered to assess the association of the factors and prelacteal feeding. Model goodness of fitness was assessed using Hosmer and Lemeshow test and the p-value for the Hosmer and Lemeshow test was > 0.05 which suggests a good model. Multicollinearity between independent variables was checked using variance inflation factor (VIF) and there was no multicollinearity (VIF < 8). The findings are presented using a textual description, and tables.

Socio-demographic and Economic characteristics
A total of 424 mothers participated in this study. The mean age of the respondents was 26.2 years (standard deviation (SD) ± 5.2 years). Almost all (99.1%) of the participants were Muslims, 97.4% had ethnicity of afar and 98.7% of them were married. The majority (82.8%) of the husbands and 90.6% of mothers did not attend any formal education. Three hundred thirty-two (78.3%) of them had a monthly income of less than 500 Birr (local currency) (Table 1).  Factors associated with prelacteal feeding practice Binary logistic regression analysis was done to identify possible associated factors for prelacteal feeding practice. Initially bivariate logistic regression analysis was applied to identify variables for multivariate logistic regression analysis at a p-value of < 0.25. In the bivariate analysis, place of delivery, age at first marriage, presence of health facility in the kebele, maternal education status, availability of radio, paternal education status, ANC visit, skin to skin contact between mother and the newborn immediately after birth had p-value < 0.25. Then, these variables were transferred to the multivariable logistic regression model. In the multivariable logistic regression analysis women of husbands without formal education, home delivery, and failure to make the skin to skin contact between the mother and the newborn immediately after birth were found to be independent predictors of prelacteal feeding practice at a p-value of < 0.05. The odd of prelacteal feeding was 2.32 times higher among mothers whose husbands didn't attend formal education as compared to their counterpart (AOR = 2.32, 95% CI: 1.18-4.5). The odds of prelacteal feeding was 7 times higher for infants delivered at home compared to infants delivered at a health facility (AOR = 7.52, 95% CI:3.44-16.45). No skin to skin contact between the mother and the newborn increases the odds of prelacteal feeding practice by 5 times than their counterparts (AOR = 5.12, 95%CI: 2.14-12.21) ( Table 3).

Discussion
This study revealed that the magnitude of pre-lacteal feeding practice in Afar Regional State was 75.7%. This practice interferes with colostrum feeding and exclusive breastfeeding in the first few days after birth. This affects optimal breastfeeding of the child and it has a serious negative implication on child nutrition and health. The magnitude in this study was in line with the finding of study conduct in Vietnam [11] which was 73.3%. However, this magnitude was higher as compared to magnitude reported from studies conducted in Aksum town [12], Raya Kobo district [13], rural Sidama [14], Wolaita zone [15], Mettu district [16], Harari Region [17], Motta Town [18], Bahir Dar City [19], Debre Berhan district [20], Debre Markos town [21], Ethiopia [22]  service availability and utilization. Similarly, this finding is higher than findings from studies conducted in the same regional state (Afar) but the urban area which includes Dubati town 16.8% [23] and Semera city 62.5% [24]. However, the current study includes both urban and rural areas. Again this magnitude was higher than magnitude reported from studies conducted in South Sudan [25], India [26], Nepal [27] which was 53%, 22.4%, 32.7%, respectively. This might stem from differences in cultural beliefs and practices, study setting, health and nutrition policy, and strategies. But, it is lower as compared to the magnitude reported from studies conducted in rural Nigeria 85.2% [28]. In this study, the most frequently used type of prelacteal feed was non-human milk 44.8% and butter 23.1% which is similar to the findings of other studies [11,12,29,30].
The odds of practicing prelacteal feeding among mothers who gave birth at home were 7 times higher than mothers who gave birth at a health facility (AOR = 7.52; 95% CI: 3.44, 16.45). This finding is similar to a study conducted in Raya Kobo district [13], Mettu district [16], Harari Region [17], Debre Berhan district [20], Debre Markos town [21], Bahir Dar City [19], Ethiopia [8]. Those mothers who gave birth at health institutions could get information on the advantage of optimal breastfeeding and disadvantage of prelacteal feeding from health professionals which can result in avoidance of prelacteal feeding.
Those mothers who gave birth at home could be influenced by family/relatives and friends to practice prelacteal feeding. This study showed that nearly two-thirds (63.7%) of mothers practiced prelacteal feeding by the influence of tradition. Again, this could be due to the low literacy rate of the mothers in the region which was in this study 9.4% and a little less than three fourth (72.4%) of the mothers didn't have ANC follow up.
Women whose husbands did not attend formal education were about 2 times more likely to practice prelacteal feeding as compared to those whose husbands attended formal education (AOR = 2.32;95%; CI:1.18, 4.55). This might be due to the fact that women of husbands who attended formal education might have good knowledge of optimal breastfeeding and increased utilization of health services. A similar finding was found from a study conducted in the Afar regional state [31]. Failure to make the skin to skin contact between the mother and newborn immediately after delivery was found to increase prelacteal feeding by five times as compared to their counterparts. This study had some limitations. First, this study used a cross-sectional study design, making it difficult to establish causal relationships. Secondly, since the information gained was based on the recall, there could be a possibility to have recall bias and lastly but not least there was no assessment of knowledge and attitude of mothers towards prelacteal feeding.

Conclusion
Three-fourth of the children in Rural Pastoralist Communities of Afar received prelacteal feeding. Home delivery, husband education and skin to skin contact immediately after birth were found to be independent predictors of prelacteal feeding in the pastoralist communities. Strengthening the behavior change communication on optimal infant and young child feeding, promotion of husband education and institutional delivery and skin to skin contact immediately after birth are recommended. University before the beginning of the actual data collection. The probability and magnitude of harm or discomfort anticipated in this study were none existent. Data collectors were trained and required to strictly adhere to ethical principles. Verbal consent was obtained from study participants before the start of interviewing and in this study, there was no parent or guardian under 16 years old and this was approved by the ethics committee mentioned above. Respondents were assured that the data wouldn't have any positive or negative consequences on their current or future aspects of their life and study