Assessment of Knowledge, Attitude and Practice Towards Colostrum Feeding Among Antenatal Care Attendant Pregnant Mothers in Mizan Tepi University Teaching Hospital, Bench Maji Zone, SNNPR, South West Ethiopia, 2016/2017 G.C

Background: United Nation children’s fund and world health organization recommend colostrums as newborns perfect food that should be initiated within the first hour after birth. Breastfeeding is a common practice in Ethiopia, importance of colostrums feeding is still poorly understood. Objective: To assess knowledge, attitude and practice towards colostrums feeding among ANC attendant pregnant mothers in MTUTH, Bench-Maji, SNNPR and South West Ethiopia 2016/2017. Methods: The data was collected by using semi-structured questionnaire which contain variables as well as both open and close-ended questions in face to face interview for a total of 207 women who follow ANC were included in the study. Results: This study showed that 65.2% of mothers had information about colostrums feeding during pregnancy from various source. 138 (66.66%) of mothers have knowledge about advantage of colostrums feeding. Most mothers had positive attitude (69.4%) about colostrums feeding and 72.46% agreed that colostrums is good milk for body growth and mental development for newborn. Conclusion and recommendation: Many women had good knowledge, positive attitude and practice about colostrums feeding but the data still indicates further effort are required to improve knowledge, attitude and practice of colostrums feeding. so, there should be clear policy guideline to promote colostrums feeding as well as EBF. Its practicability should monitor by concerning body. which needs a “warm chain” made by mother-infant contact. It is secreted in very less amount (30-100 ml), so the mothers need to be explained that this small amount of colostrums is adequate for infant and must not be denied [7]. Colostrums is universally acknowledged as the perfect first food for infants. A review of the custom of expressing antenatal by all women is followed by the maternal and infant medical reasons for expressing and storing colostrums. A suggested regime for expressing and storing of colostrums during pregnancy is included with advice about skin-to-skin contact in the first 24 h to maximize breast milk output in the long term [8]. Statement of the Problem Globally, it estimated that every day, as many as 4,000 infants and young children die worldwide because they do not get colostrums within the first hour after birth. Many of the world’s infants are given liquids other than mother’s milk in the first few days after birth [9]. Mother and

which needs a "warm chain" made by mother-infant contact. It is secreted in very less amount (30-100 ml), so the mothers need to be explained that this small amount of colostrums is adequate for infant and must not be denied [7]. Colostrums is universally acknowledged as the perfect first food for infants. A review of the custom of expressing antenatal by all women is followed by the maternal and infant medical reasons for expressing and storing colostrums. A suggested regime for expressing and storing of colostrums during pregnancy is included with advice about skin-to-skin contact in the first 24 h to maximize breast milk output in the long term [8].
children constitute one fourth of the total national population. They are the most vulnerable group to ill health.
One of the main causes of neonatal mortality and morbidity is inadequate breastfeeding, following faulty breastfeeding technique, ignorance of mother regarding feeding practices, lack of health education given by the health care providers [7]. Many cultural belief and practices all prevalent in postpartum period that some mothers may not feed the baby immediately after birth. They neglect "COLOSTRUM" instead of it they will give sugar water, plain water, honey, etc., all these practices lead to suppression of lactation as prolactin gradually ceases and the breast stops secreting milk [9,10].
Women are recognized as the "keepers of the culture" or the main people who transmit costumes to the next generation. Chief among these costumes is the method for feeding newborns. The rate of breastfeeding varies in communities from almost 70% to a low of 13% as this is culturally influenced [11]. If a woman comes from a family where no one has ever breastfed, she may be very interested in being a "pioneer" in her family. On the other hand, she may be more interested in following her family's tradition of formula feeding. How soon woman wants to begin breastfeeding after birth is also culturally determined. Although it is the usual practice in hospitals to begin immediately after birth. So initiation of breast feeding while colostrum is still being produced is thought to decrease infant mortality, especially in non-industrialized populations, by the risk of gastroenteritis, diarrheal diseases, respiratory infections, ear infections and influenza [12,13]. So the nursing professionals should motivate the community peoples towards colostrum feeding practice [10].
Some mothers in developing countries avoid colostrum feeding on the basis of traditional or cultural beliefs that range from viewing it as having no nutritional value, seeing it as harmful to the infant's health (making the baby sick or even causing death) or seeing it as 'bad luck' for the family [14][15][16][17]. Some women may specify no reason for avoiding colostrum other than tradition [18,19].
Ethiopia has one of the highest infant mortality rates in the world and inappropriate neonatal feeding is a primary factor [20][21][22][23][24][25][26]. Although breast-feeding is almost universal across Ethiopian ethnic groups and geographical areas, it does not always meet WHO/ UNICEF recommendations [27][28][29][30][31][32]. Data from the 2005 Ethiopian Demographic and Health Survey show that this is true for groups living in the Amhara region that includes the village that was the subject of the present study [33]. Among all births in Ethiopia's eleven major regions between 2001 and 2005, Amhara mothers had the second lowest percentage of breast-feeding in the first hour after birth (62.6%) and breast-feeding within one day of birth. Less than half of Amhara infants (44.8%) received colostrum, placing it the fourth lowest among eleven regions. A recent study compared breast-feeding practices in the Gondar province (an urban Amhara town) with those in the northern most province of Tigray [34]. New mothers in Tigray were almost twice as likely as mothers in Gondar to initiate breastfeeding within the first hour of birth (Tigray 59% and Gondar 34.2%). A recent UNICEF press release on Ethiopian breastfeeding notes, 'Often, infants are not fed with colostrum as it is considered unclean' [31].
The Ethiopian linkages breast-feeding educational programme reports that mothers 'often discard colostrum's [35]. A report from the Amhara region quotes a traditional birth attendant who describes her former belief that breast milk should not be used until the placenta is passed, which could take as long as 3 day in difficult births [36]. Before the programme, the birth attendant endorsed the belief that the 'first milk' was 'bad' for the baby. Amhara mothers interviewed by Almedom noted a positive correlation between valuing colostrum and early breast-feeding initiation and reported a delay in breast-feeding 'when colostrum was considered ''heavy'' [37]. He also reported prelacteal feeding for all ethnic groups represented (Gurage, Oromo, Amhara, Sidama, Wolaita and Dorze) with one exception (Tigray) [37].
The fact that only a few mothers deliver in Ethiopia hospital means that the majority deliver from their homes often with the help of unskilled birth attendants. These newborns are often subjected to colostrums avoidance and unhygienic delivery practices arising from traditional beliefs that put their survival at risk in mizan-teferi and Ethiopia Country in general [38].
The 2011 EDHS collected data on the types of foods given on the day and night preceding the survey to the youngest child under age 2 living with the mothers. In Ethiopia, among breastfeeding children under age two, very few (2%) consume infant formula. However, a much higher proportion (18%) receives other milk or other liquids [39]. The introduction of other liquids, such as water, juice and formula, takes place earlier than the recommended introduction at age six months. Among the youngest breastfeeding children (0-1 month), 6% consume other milk and 3% consume other liquids. Consumption of other milk increases gradually with age until age 6-8 months, when 24% of breastfeeding children consume milk. Consumption of other liquids also shows increasing trends with age through age 12-17 months, when 26% of breastfeeding children consume other liquids [40].

Significance of Study
The study is significant because, it is anticipated to identify the gaps on colostrums feeding and recommend ways of bridging on the identified gaps to improve neonatal survival. Also this study will help to know the concept of colostrums among general population [41][42][43][44]. It also decrease poor interaction of health personnel with the pregnant women for promoting and supporting colostrums is still unsatisfactory as only few percentages of women received antenatal advice regarding colostrums feeding. Huge gaps may exist in colostrums feeding behaviors, mostly due to lack of awareness. So, it helps the community to create awareness about the importance of colostrums feeding and advice mothers to practice it in every delivery. Appreciate and initiate Counseling methods to reinforce specific, priority messages by health facility staff and community-based workers at all contact points with pregnant women. It also provides base line information for further study [45][46][47][48]. The study about colostrums was not conducted in bench Maji zone southern Ethiopia. So, this study therefore will explore the knowledge, attitude and practice that influence colostrums feeding among mothers in Mizan town.

Objectives General objective
To assess knowledge, attitude and practice towards colostrums feeding among ANC attendant pregnant mothers in MTUTH, Benchi-Maji Zone, SNNPR, South West Ethiopia, 2017.

Specific objective
1. To identify the knowledge towards colostrums feeding among ANC attendant pregnant mothers.

2.
To determine the attitude towards colostrums feeding among ANC attendant pregnant mothers.

Study Area
Mizan Aman town is located in SNNP regional state and 568 Km from Addis Ababa capital city of Ethiopia and 839 Km from its regional state Hawassa. Mizan teferi has a latitude and longitude of 7°0'N 35°35'E/7.000°N 35.583°E with an altitude of 1451 m above sea level [49]. Administratively, the town is structured in to five Keble's (smallest administrative units) and two sub cities. The Town is bordered by Republic of Kenya in the south, the Republic of south Sudan in the southwest, the western Gambella region and Oromiya region in the northeastern Ethiopia. Mizan town is the administrative and trading center of Bench-Maji zone. The average annual rainfall of the town is 1290 mm/year and the temperature of the town ranges between 14°C and 30.5°C. There are one governmental health centers and one hospital in the town. The hospital is under governmental health institution and it provides various services with its departments of Surgery, Gynecology, Pediatrics, Obstetrics, Emergency services, Laboratory, Pharmacy, ART clinic, ANC and EPI. It is also a location of three higher education institutions, Aman Health Science College, Aman Polytechnic College and Mizan Tepi University [50].

Study Design and Period
Institutional based cross-sectional study was used to assess the KAP of colostrum feeding among ANC attendant pregnant mothers, which was conducted between April 10-30 in MTUTH, Mizan Aman town, Ethiopia.

Source population
The source population was all pregnant mothers who have been attending ANC clinic in MTUTH.

Study population
The study population was selected pregnant mothers who was attending ANC clinic during data collection period in MTUTH.

Inclusion criteria
• All pregnant mothers who have ANC follow up in MTUTH antenatal clinic.

Exclusion criteria
• Mothers who are primigravida.
• Those unable to speak or/and hear.
• Pregnant mother who will be appointed for second visit within data collection period after interview of those mothers.

Sample Size Determination
The sample size (n) required for the study was calculated using the formula to estimate a single population proportion by considering the following assumptions.
Zα/2=critical value for normal distribution at 95% confidence level which equals to 1.96 (Z value at alpha=0.05).
P=(58%) According to study conducted in Raya Kobo district of Amahara region, 2014. d=margin of error of 0.05 with 95% confidence level. Since the source population is less than 10.000, an adjustment formula (FPC), nf=n/1+n/N is used, where, N=Source population-all estimated pregnant mothers.
nf=Required Sample Size, n=calculated sample size. Hence, the sample size was calculated at total of source population N=378 and n=374 and nf=188. Non-response rate of 10% is 18.8, so the total sample size was 207 pregnant mothers.

Sampling Technique
Simple random sampling technique was employed to draw ANC mothers who are going to be included in the study and direct interview technique using prepared questionnaire during exit from ANC was used. The average number ANC per day was 21 and the service were given in all working days.

Study Variables
• Knowledge of colostrums feeding.

Data Collection Tools
The data was collected by using semi-structured questionnaire which contain variables as well as both open and close-ended questions in face to face interview [53]. The information was collected from each selected ANC attendant pregnant mothers and the questionnaire was delivered to assess KAP of colostrums feeding among ANC attendant pregnant mothers in MTUTH. Responses for open ended questions were written as statement while for close ended ones; there were choices to be selected from.

Data Processing and Analysis
The data was checked for its completeness and any incomplete information were excluded from entry after data collection. Data was processed using tally system for each item and processing carried out by investigators using related methods. The statistical procedure for analysis consists of simple frequency distribution, percentage and composition. Additionally, tables and figures were used to present the findings.

Pre-test
The questionnaire was pre-tested on 5% of the calculated sample size in Mizan health center which is not selected in the study before the actual data collection period. The questionnaire will be modified based on information obtained from pre-test results.

Data Quality Assurance
To maintain the quality of data, semi-structured and pre tested questionnaire was used to collect information on colostrums feeding. The questionnaires was prepared in English language and then translated to local language, i.e., Amharic. Then the questionnaires will be checked for completeness by principal investigators [54].

Ethical Consideration
A formal letter was obtained from college of health science, department of nursing of Mizan-Tepi University. The purpose of study was explained to the study subject at the time of data collection verbal consent will be taken from participants to conform whether they are willing to participate [54]. Those not willing to participate were given the right to do so. Confidentiality of respondents was also ensured throughout the research process.

Dissemination of Results
The findings of this study was presented to college of health science department of nursing and distributed to MTUTH office managers and to other organizations, such as health center working on related area.

Knowledge of respondents about colostrums feeding
According to the set criteria for colostrums feeding knowledge 153 (73.81%) were found to be knowledgeable, 54 (26.19%) fairly knowledgeable (Table 4).
According to the response of mothers' on knowledge measuring questions the majority 138 (66.66%) believed that colostrums has advantage for baby. And most 105 (76.06%) respondent also believed that starting breast feeding within one hour after delivery is important.

Attitude of respondent towards colostrums feeding
According to set of criteria for colostrums feeding attitude, this study indicated that the majority 144 (69.4%) of mothers have positive attitude towards colostrums feeding. But the remaining 63 (30.6%) have negative attitude. Almost all mothers (72.46%) agree that colostrums is important for growth and mental development (Tables 7 and 8).

Practice of respondents towards colostrums feeding
Among the mothers studied, higher proportion 158 (76.22%) gave colostrums for their baby, while the remaining 49 (23.67% ) did not. From those gave colostrums for their baby 101 (63.9%) start colostrums feeding within 1 h after delivery (Tables 9 and 10).
The reason for not giving colostrums was mothers believed that It is forbidden in culture 55 (26.57%), cause abdominal cramp and diarrhea 29 (14%) and it is dirty part of breast milk 42 (20.28%) ( Table 11).
Concerning pre-lacteal feeding from 161 mothers 46 (28.57%) gave additional food before starting breast milk. Among those most (23.91% n=11) mothers have given plain water and 7 (14.89%) have gave water with sugar. The remaining 111 (71.42%) did not give any additional food before starting breast feeding ( Figure 6).

Level of knowledge Frequency Percentage
Good knowledge 153 73.8 Poor knowledge 54 26.19 Total 207 100

Discussion
This study examined mothers Knowledge, Attitude and Practice towards colostrums feeding at Mizan Aman town, Ethiopia. Among mothers studied the majority 135 (65.2%) have had information on colostrums feeding during pregnancy from different source which means above half mothers have information but it is lower as compare to Nepal (74%). The variation may be because of socio-cultural difference between study areas. And also the variation may be due to sample size and study. Most respondents 95 (70.37%) received information on colostrums feeding from health professionals and it is greater than previous finding of EDHS2016 that was 62.7%. The gap may be due to small sample size in our study. This also shows that other sources of information such as television 14 (10.37%), radio 7 (5.18%) and relatives 19 (14.07%) did not have expected role in advertising colostrums feeding information for mothers, Concerning about mother's knowledge towards colostrums feeding 153 women (73.81%) has had knowledge. It is very higher than previous study in Dhahran (25%) has had knowledge about advantage of colostrums. The difference may be as result of socio cultural difference between Ethiopia and Dhahran or may be good awareness was created on advantage of colostrums feeding through health extension worker in Ethiopia and study period difference.
Regarding initiation of colostrums feeding 105 (76.06% ) of study population start colostrums within one hour but it is lower than colostrums feeding initiation in Nepal (92%). It is due to lack education during antenatal, delivery and postnatal period of pregnant mothers in our study area.
Our study shows that studied population believed that colostrums should discarded 40 (19.3%), it is dirty part of milk 42 (20.28%), forbidden in culture 55 (26.57%) and causing diarrhea and abdominal cramp 29 (14%) but this study gate different ideas, by which majority of mothers indicated that they offered colostrums for their baby immediately after birth 105 (76.08%) and verbalized as it is important for growth of body and mental development (47.10%), protect from illness (31.15%), high tendency to catch cold (3.62%) and have better nutrients concentration (18.11%). This indicates that better understanding about colostrums feeding among mothers, which is higher than pervious study (Raya kobo district, northern -east Ethiopia 2014) shows that studied believed that it colostrums is dirty part of milk (25.9%), have tradition (23.5%) and 58% not awarded. The reason behind variation may be cultural difference between Mizan Aman and Raya kobo.
The finding of this study indicates that 144 (69.4%) had a positive attitude which is higher than previous finding in Dhahran (20.6%). The reason behind variation may be our study concern on institutional based or small sample size and also may be it is due to lack awareness regarding colostrums feeding in Dhahran community.
In this study the prevalence of colostrums feeding practice was 126 (60.88%), which is lower than the prevalence of colostrums feeding practice reported from Bhaktapur, (80%). In consistent prevalence in colostrums feeding practice could be because the culture in Mizan Aman community is different to Bhaktapur. And also colostrums feeding practice is higher in our study area as compare to India (23%). The variation may be sociocultural difference between India and Mizan Aman (Ethiopia).
According to our study, 28.57% had practice pre-lacteal feeding, among those 25.5%were giving butter, which is lower than study report in Raya Kobo district that shows 37.8% of mothers were feed pre-lacteal feeding. The reason for variation is may be due to lack of awareness about colostrums and also it is due to cultural difference between Raya Kobo district and Mizan Aman town Ethiopia.

Conclusion
This study concludes that most of mothers had good knowledge and attitude on importance of colostrums feeding. Colostrums feeding practice was more common among mothers who gave birth at institution. Due to education promoting institutional delivery and creating awareness on advantage of colostrums feeding, increase colostrums-feeding practice.
Many pregnant women have awareness about colostrums feeding but the results study still indicate that further awareness are necessary to improve KAP of colostrums feeding in Mizan Aman town. And also this study shows most mothers have positive attitude towards colostrums feeding but some mother need further advice on colostrums feeding because they think colostrums case diarrhea and abdominal cramp, it is forbidden in culture and it is dirty part of milk.    Figure 6: Mothers distribution in practice of pre-lacteal feeding in Mizan Aman town, Ethiopia, 2017.