Determinants of Exclusive Breastfeeding Practice among Mothers of Children Under Two Years Old In Dilla Zuria District , Gedeo Zone , Snnpr , Ethiopia , 2014

Background: Exclusive breast feeding (EBF) has been defined by world health organization (WHO) as the situation where ‘the infant has received only breast milk from his/her mother or a wet nurse until six months old’. The low prevalence of exclusive breast feeding (EBF) in most developing countries is attributed to various maternal and child factors. Identifying factors associated with low exclusive breastfeeding practices in different contexts is important to take appropriate measures to avoid or reduce determinant factors and assumed to facilitate better advocacy and wider coverage in the Country. Objective: To assess the determinants of exclusive breastfeeding practices among mothers of children under two years old in Dilla zuria district, Gedeo Zone, SNNPR, Ethiopia, 2014. Methods: Cross-sectional community based study was conducted from June to August 2014 at two randomly selected wards in Dilla zuria district, Gedeo Zone, SNNPR, Ethiopia. Quantitative data was gathered from 347 mothers and supplemented by qualitative data from 8 key informants. Binary logistic regression analysis was made to obtain odds ratio and the confidence interval of statistical associations. Result: 57.6 % of respondents practiced exclusive breasted feeding for 6 months. Predictors of exclusive breastfeeding were antenatal care utilization, maternal age, parity and family size. Antenatal care utilization was positively associated with exclusive breast feeding whereas maternal age, parity and family size were inversely associated with exclusive breast feeding. Conclusion: Exclusive breast feeding practice was not satisfactory. Antenatal counseling for breastfeeding was associated with better exclusive breastfeeding practice. Therefore, we suggest strengthening the nutrition counseling during antenatal visit. Birth order and family size were inversely associated with EBF practices. Large family size and high parity are factors that reduce duration of exclusive breast feeding practice. There should be strong work to enable family to maintain appropriate space between consecutive births and limit family size. The low prevalence of EBF in most developing countries is attributed to various maternal and child factors such as place of residence, sex and age of the child, mother working outside home, maternal age and educational level, mothers’ domestic work burden, maternal health care use, number of births and space between children, access to mass media, economical status, maternal health care access and maternal knowledge on infant and young child feeding [4-8]. Despite few local studies conducted in different parts of the Ethiopia, no sufficient study tried to identify the determinants of exclusive breast feeding practice in the study area. Hence, there is a need to carry out a research to come up with the determinants of exclusive breast feeding practice. Different stakeholders working on breast feeding at study

The knowledge of mothers on IYCF was computed based on seven questions which included awareness of the mothers about the timing of breastfeeding initiation after delivery, exclusive breastfeeding, colostrums feeding and its importance, age at complementary feeding, how long breastfeeding should continue, and whether HIV seropositive mother should breastfeed or not.Likewise, last pregnancy is defined as a state of pregnancy for which a mother is pregnant for her index child.
Four bachelor science degree holders collected quantitative data.Before actual data collection process two days training was given for data collectors.
For qualitative: Eight in depth interviews were conducted by principal investigators.The in depth interview addressed EBF practices and factors affected exclusive breast feeding.

Data quality assurance
For quantitative: Questionnaire was prepared in English version and translated in to Amharic and back to English.Before the actual data collection period, the questionnaire was pre-tested on 10% of the calculated sample size in a ward other than study area.Additional adjustments in the sequence and wording of the questionnaire were made based on the results of the pre-test.The collected data was checked daily for completeness by principal investigators.
For qualitative: The principal investigator conducted the in-depth interviews.In order to maintain data quality, tape recorder was used to record in depth interview.

Data processing analysis procedure
For quantitative: The data was checked for completeness, inconsistencies, then coded, entered, cleaned and analysed in SPSS for windows version 16.0.Descriptive statistics were computed to determine the breastfeeding practice.Binary logistic regression analysis was made to obtain odds ratio and the confidence interval of statistical associations.The strength of statistical association was measured by adjusted odds ratios and 95% confidence intervals.Statistical significance was declared at P < 0.05.
For qualitative: Thematic analysis of the transcript of the in-depth interview was performed.The data was transcribed verbatim.Finally, overall interpretation was performed by relating thematic areas to one another and explaining how the various concepts related to the study objective.

Ethical consideration
Ethical clearance was obtained from Dilla University, College of Health and medical Science and referral hospital.Support letter was obtained from Dilla University to Zonal Health office and from zonal health office to district health office.Informed consent was obtained from study participants to confirm willingness for participation after explaining the objective of the study.The respondents were notified that they have the right to refuse or terminate at any point of the interview.The information provided by the respondents was kept confidential.

Socio demographic characteristics of respondents
Total of 347 (98.8%) mothers in quantitative and 8 mothers in qualitative study who have less than two years child were involved in data collection.
In quantitative study, the maternal age range was 20-38 and the mean age was 27.8 ± (6.22 SD).Two hundred fifty two (72.9%)children were age below one year (mean 1.1( ± 0.4)).Majority 145 (41.8) of respondents had Gedeo ethnicity followed by Sidama 100 (28.8).One hundred fifty two respondents were illiterate and 174 attended primary cycle or high school level.Majority (64%) of respondents were follower of protestant Christianity followed by orthodox 34%.Most of (89.6%) the respondents were house wives.More than half (59.9%) of the husbands had primary or high school educational status (Table 1).57.6% of mothers practiced exclusive breast feeding for six months.Mothers who practiced EBF for only one, two-three and four-five were, 2.9%, 12.7% and 26.8% respectively.Comparison of EBF practices was made among different characteristics of respondents.Among mothers visited ANC follow up, 59.8% practiced exclusive breasted feeding for six months.EBF practices for complete six months among 1st, 2 to 3 and 4 and above birth order were 78.2%, 60%, and 46.3% respectively.Among mothers who gave birth at home, 74% practiced EBF for six complete months.From ever breast feeding mothers, 52% practiced EBF.Among not ever breast feeding mothers, 78% practiced EBF for complete six months.EBF practice for complete six months among mothers who started breasted feeding within one hour after birth was 68% and after one hour was 16%.Among mothers of EBF practice for six months who fed colostrums, aware of their HIV +ve status and fed breast, without pre-lacteal food, and also knew the starting time of complementary feeding was 68.9%, 66.9%, 51.7% and 65.7% respectively (Table 2).The EBF practice among civil servant, merchant and daily labourer were 20%, 20% and 0% respectively In depth interviews, all mothers believe that breast feeding is natural gift.They consider all infants should receive breast feeding.A mother of 23 years old said that "breast milk is natural gift, cheap and easily available." Majority of respondents started breast feeding within one hour after birth.Reasons for delay in initiation of breast feeding were maternal and child condition, miss understanding about colostrums.Some mothers do not feed infants colostrums because they believe that it cause stomach pain to infant.Majority believe that colostrums is important for children.A 25 years old mother said that "colostrums is important for infant and it is not only rich in nutrients also it protects infants from diseases." Most of respondents knew that giving pre-lacteal feeding unnecessary and cause disease to infant but yet some mothers are practicing it.A mother age 31 said that "In Previous time water was given to clean infant stomach; currently such practice is reducing." Their knowledge regarding infant and young children feeding is optimal.They obtain basic information and education from health professionals during ANC and from health extension workers.A mother of 34 said that "health extension workers teach us about EBF, complimentary, time of breast feeding initiation, risk of pre-lacteal feeding etc. " Majority of the mothers practiced EBF.Reasons for not practicing EBF are believe that breast milk is not enough food for infant, have large family size, narrow birth intervals, maternal outdoor work etc.A mother of 29 years old said that "I am civil servant and having only three month maternity leave, so that I can't feed my child EBF till 6 6.5 times (p = 0.00) higher EBF practices as compared to aged 30-39.Mothers who have birth order 1st and 2nd to 3rd were 9.8 times (p = 0.00) and 11 times (p = 0.00) higher EBF respectively as compared to 4th and above birth order.Mother belongs to family of 4 and less family size were 2.25 times (p = 0.01) higher to practices EBF as compared to family size above 4 members.Those mothers followed ANC were 5.9 times (0.004) higher to practices EBF as compared to mother didn't visit ANC.

Discussion
The main objective of this study was to assess determinates of exclusive breast feeding among mothers of less than two years old children.
Timely initiation of BF in this study is 77%.It is similar to study done in Mekelle (78%), Ethiopia [12] and Eritrea, (77.9%).This finding is higher when compared to the study conducted in Turkey, [18] (35.2%); in Burkina Faso, (33.3%), in Chad, (43.3%), and in Colombia, (48.9%)).The higher rate of timely initiation of breastfeeding in this study could possibly be explained higher proportion of mothers get education and information about BF during ANC visit and from health extension workers.
In this study, the prevalence of colostrum feeding is 84.1%.This finding is comparable to Arbaminch, Ethiopia [13] study.Common reasons for not feeding colostrums were assumption that it causes stomach pain and it is dirty.However, in-depth interview with mothers indicated majority of mothers considered colostrums as preventive medicine.The improved practice on giving colostrum for the newly born child is probably due to the improved awareness of lactating mothers which is resulted from expansion of health information on importance of EBF and giving colostrum for the infant, by the health personnel at any level of health institutions.
The practice of pre-lacteal feeding in this study is 31.1%.This was much higher than 10.4% of Mekelle, Ethiopia.But lower than studies: Nigeria in 2006 [20][21][22][23] (75%); rural communities of Tigray in [14] (80%) and Gursum, Somali region in 2006 (79%).This higher pre-lacteal feeding might be justified in terms of the residence of respondents where the whole respondents were from rural area in which the tradition of introducing pre-lacteal feeding and discarding colostrums would be higher than in urban area.
Scholars argue that low prevalence of EBF in most of the developing countries is attributed to various factors [4][5][6][7].Using multivariable logistic regressions analysis, after controlling confounders, age of mother, birth order, family size and ANC follow up were significantly associated with EBF practice.Those mothers aged 20-29 were 6.5 times (p = 0.00) higher EBF practices as compared to aged 30-39.Similar result was revealed in Brazil,

Characteristics
No % months".One mother age 21 said that "because I gave birth before my elder baby reached his second birth date, so that I didn't practice EBF for six months to my young child." Mothers started BF within one hour after births were 79%.Colostrum feed, know time of complimentary food started and practices pre-lacteal feed were 84.1%, 77.2% and 31.1% respectively (Table 3).Water (85.5%) was widely practiced as pre-lacteal feed.

Determinates of exclusive breast feeding
Logistic regression model was used to identify determinants of EBF.Using binary logistic regression, association between individual independent variable and outcome variable was assessed.Maternal educational status, birth order, birth interval, place of birth, maternal occupation, time of breast feeding started, colostrums feed and father educational status were significantly associated with EBF (p<0.05).For instance, likelihood of EBF practice in mothers who were illiterate and primary to secondary were 13 times (p = 0.00, CI = (3.6,46.2) and 6.8 times (p = 0.00, CI = (1.9,24)respectively higher as compared to certificates and above educational status.Likelihood of EBF between mothers have 1st and 2nd to 3rd parity were 4.1 times (p = 0.00 CI = (2.3,7.4)) and 1.7 times (p = 0.03, CI = (1.0,2.9))respectively higher as compared to 4 and above parity.EBF practices of mothers who gave birth at health center were 4.1 (p = 0.03 CI = (2.3,7.4)) higher as compared to mothers gave birth at home.Civil servants and merchants were 15 times (p = 0.04 CI (0.4, 0.5) and 10 times ( p = 0.04) less likely to practices EBF respectively as compared to house wife (Table 4).
Adjusted odds ratio was computed to declare predictors of EBF.Multivariable logistic regressions model was used.Variables, their P-value are less than 0.05 in binary logistic regression, were considered for Multivariable logistic regression model.In Multivariable logistic regression analysis age of mother, birth order, family size and ANC follow up were predicators of EBF.Those mothers aged 20-29 were showed a greater chance of exclusive breastfeeding in women between 25 and 29 years of age.As study is conducted in the rural area where most of the household activities are carried out by mothers.When age of mothers increased burden to care household activities increased.This might limit their utilization health care and information that enable them to practice EBF.
In this study mothers who have birth order 1st and 2nd to 3rd were 9.8 times (p = 0.00) and 11 times (p = 0.00) higher EBF practice respectively as compared to 4th and above birth order.This finding is in line with study conducted in Arbamich, Ethiopia.It revealed that mothers who gave birth less than or equal to two children were more appropriately fed their children compared to who gave many births [13].It might be explained by the short birth interval/spacing and other economic factors.Mother belongs to family of 4 and less family size were 2.25 times (p = 0.01) higher to practices EBF as compared to family size above 4 members.
Those mothers followed ANC were 5.9 times (0.004) higher to practices EBF as compared to mother didn't visit ANC.This finding supports study conducted in east Ethiopia which revealed Nonexclusive breastfeeding was more likely to be practiced by mothers who had no access to health facility AOR (95% CI) = 2.9 (1.9,4.3)[10] and Nigeria which revealed that mothers who visited health professionals, or made 4 or more antenatal clinic visits were significantly more likely to exclusively breastfeed their babies, and these findings suggests that appropriate message about breastfeeding are being delivered by antenatal care staff [11].In the qualitative study, those mothers had contact with health professionals have adequate knowledge regarding EBF.In addition, these findings were similar to those reported in earlier studies [20,21].

Conclusion
In multiple logistic regressions, EBF practice was significantly associated with ANC follow up, birth order, family size and maternal age.Having antenatal counseling about breastfeeding was found to be associated with better exclusive breastfeeding practice.Birth order and family size were inversely associated with EBF practices.

Recommendation
Based on the results of the study, it is suggested that • Educate mothers about EBF practices at different occasions

• Facilitate enabling factors to promote EBF
• Enable family to maintain appropriate space between consecutive births and limit family size

Table 1 :
Socio demographic characteristics of the respondents at Dilla Zuria district, 2014.

Table 2 :
Obstetric, health service related and other characteristics of the respondents at Dilla zuria district in 2014G.C.

Table 3 :
Distribution of timely initiation and other characteristics of mothers of less than two years old children Dilla zuria districts, SNNPR, Ethiopia, 2014.Year old children Dilla zuria districts, SNNPR, Ethiopia, 2014.

Table 4 :
Distribution of factors associated with EBF practices using binary logistic regression.