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  • Research article
  • Open Access
  • Open Peer Review

Breastfeeding performance in Afar regional state, northeastern Ethiopia: a cross sectional study

BMC Pediatrics201818:375

https://doi.org/10.1186/s12887-018-1353-y

  • Received: 29 November 2017
  • Accepted: 21 November 2018
  • Published:
Open Peer Review reports

Abstract

Background

In Ethiopia fewer than 20% of infants aged less than six months are appropriately fed. This study aimed to identify predictors of poor breastfeeding performance among mother-infant pairs in Samara-Logia city administration, Afar Regional State, Ethiopia.

Methods

Five hundred and seventy six mothers of infants aged less than six months were recruited to participate in face-to-face structured interviews at their home. Infant feeding practices were measured by breastfeeding performance index (BPI). Infants who scored 0–3 BPI were classified as achieving ‘Low BPI’, 4–5 as ‘Medium BPI’, and 6–7 scores as ‘High BPI’. A pre-tested instrument was used to assess demographic characteristics of mothers and their experiences of infant feeding. EpiData version 3.02 was used to enter, clean and code the data. Then, data were analyzed using SPSS version 20.

Results

Five hundred thirty six (93.1%) of the study mothers had ever breastfed their infants. About 83% [95% CI: 80.0, 86.0%] of infants had achieved low or medium BPI scores. Being older than 34 years [AOR: 4.55; 95% CI (1.33, 15.73)], having an infant aged 4–5 months [AOR: 2.49; 95% CI (1.08, 5.76)], giving birth at home [AOR: 4.25; 95% CI (1.37, 13.23)] or by caesarean section [AOR: 8.00; 95% CI (2.78, 23.09)] and receiving advice on proper infant feeding practices at postnatal checkup [AOR:0.28; 95% CI (0.13,0.59)] were independent predictors of low/medium BPI scores.

Conclusion

This study revealed that nearly eight in ten infants aged less than six months achieved low/medium BPI scores. Being older than 34 years, having an infant aged 4–5 months, giving birth at home or by caesarean section and lack of advice on proper infant feeding practices were associated with higher odds of low/medium BPI scores.

Keywords

  • Breastfeeding performance index
  • Exclusive breastfeeding
  • Semera-logia city
  • Afar
  • Ethiopia

Background

Human milk provides the necessary nutrients for optimal growth and development in the first six months; hence breastfeeding is the ultimate infant feeding approach and has important infant and maternal health advantages [1, 2]. For instance, breastfeeding has well-established short-term benefits, particularly in the reduction of morbidity and mortality due to infectious diseases in childhood. Breastfeeding protects against diarrhea incidence and respiratory infection [3].

Globally, about 35% deaths among under-five children are attributed to under nutrition. More than two third of neonatal deaths are attributed to inappropriate infant feeding practices [4]. Low and medium BPI scores are responsible for 45% of infectious, 30% of diarrheal and 18% of acute respiratory deaths among preschool children [4, 5]. A meta-analysis showed association between breastfeeding and minimum prevalence of overweight later in life. In addition, breastfeeding have a protective effect against diabetes among adolescents [6].

Exclusive breastfeeding is an infant’s consumption of only breast milk but not any type of foods or drinks, except for medical indications in the first 6 months [7]. Compared to infants who were exclusively breastfed, infants who were not exclusively breastfed have 88% higher risk of mortality. Breastfeeding protects infant from hospital admission [8]. Moreover, above 13% of mortality among preschool children can be prevented by providing exclusive breastfeeding [7].

Breastfeeding performance index (BPI) is measured by seven measurements; early breastfeeding initiation, prelacteal feeding, current breastfeeding, bottle feeding, and any liquid (except medicine), any solid food and formula given in the last 24 h [9].

Ethiopia has adapted infant and young child feeding guideline since 2004 [10], and the national nutrition program in 2013 [11] to unlock the lifesaving potential of optimal breastfeeding practices through multi-sectoral approaches. However, fewer than 20% of infants in Ethiopia are appropriately fed during the first six months of life, and lower BPI was associated with increased risks of diarrhea and fever [12]. This study aimed to identify predictors of poor breastfeeding performance among mother-infant pairs in Samara-Logia city administration, Afar Regional State, Ethiopia.

Methods

Study setting and period

A community based cross sectional study was conducted from February 11–25/2017 in Semera-Logia city administration of Afar Regional State. Semera-Logia city administration is located at 574 k meters from Addis Ababa (the capital of Ethiopia). The city administration has thirteen ketenas (the smallest administrative units next to kebele in Ethiopia).

According to the national statistics population projection for 2016/2017, the city administration has a total population of 45,980 in which 21,610 were females. Based on Afar Regional Health Bureau estimate, in the city administration the number of the target mother-infant pairs was estimated to be 1380. There are 2 health centers and 13 private clinics in the city administration.

Sample size determination and sampling procedure

A sample size of 610 was determined using the following formula;
$$ \mathrm{n}=\mathrm{D}\left[\frac{{\left(\mathrm{z}\frac{\upalpha}{2}\right)}^2\mathrm{p}\left(1-\mathrm{p}\right)}{{\mathrm{d}}^2}\right] $$

Assumptions: n = required sample size, \( \mathrm{z}\frac{\upalpha}{2} \) = critical value for normal distribution at 95% confidence level (1.96), P = prevalence of low/medium BPI score in Ethiopia (76.4%) [12], d = 0.05 (margin of error), D = 2 (cluster effect) and 10% for nonresponse.

In this study a ketena was defined as a cluster. Then, the city administration was divided in to thirteen clusters. Then, six clusters were randomly selected by lottery method. All mothers of infants aged less than six months in the selected clusters were included. Women who were unable to communicate and non-biological were not included in the study.

Study variables

Breastfeeding performance was the outcome variable measured by breastfeeding performance index (BPI). BPI scores were constructed by allocating one point for each of the following: early breastfeeding initiation; complete avoidance of prelacteal feeds; complete avoidance of feeding bottles; current breastfeeding; not receiving liquids; not receiving formula or other milk; and not receiving solids in the last 24 h [9]. Scores for each item on the BPI were summed to give a total score that could range between 0 and 7). Infants who scored 0–3 BPI were classified as achieving ‘Low BPI’, 4–5 as ‘Medium BPI’, and 6–7 scores as ‘High BPI’ [12].

Independent variables: maternal age, child age, parity and gravidity were continuous variables. Categorical variables were: maternal related variables (religion, ethnicity, occupation, educational and marital status), antenatal care (ANC) attendance, postnatal care (PNC) attendance, infant feeding counseling services at PNC or ANC checkups, paternal educational status, child’s sex, household head, site and mode of delivery.

Data collection tools and procedures

Data were collected using structured and interviewer administered questionnaire adapted from the EDHS [13] and other related literatures [12, 1423]. It was prepared first in English then translated in to Afar’af. The data collectors (10 diploma nurses) were trained for two days on the questionnaire, consent procedures and interview techniques. The questionnaire was pretested on one ketena, which was not included in the study. Then, the questionnaire was improved and contextualized to fit the local condition and the study objective. Finally, Afar’af version of the questionnaire was used to collect the data.

Data management and processing

Data were checked for completeness and inconsistencies. EpiData version 3.02 was used to enter, clean and code the data. Then, SPSS version 20 was used to analyse the data.

The crude odds ratio (COR) was estimated in the simple logistic regression analysis. Variables with p-value < 0.3 in the simple logistic regression analysis were included in the multivariable logistic regression analysis. The Hosmer-Lemeshow goodness-of-fit with backward LR was used to assess the necessary assumptions for the application of multivariable logistic regression analysis, and a good fit test will yield a p-value> 0.05.

Adjusted Odds Ratio (AOR) with 95% confidence interval was estimated to assess the strength of the association. A p-value < 0.05 in the multivariable logistic regression analysis was used declare independent predictors of low/medium BPI score.

Ethical considerations

This study was approved by the Research Ethics Review Committee (RERC) of Samara University dated 23 Dec 2016, and numbered ERC/0025/2016. An official letter was written from Samara University to the Semera-Logia city administration office. Then, support letters were sent to each selected ketena. A signed consent was taken from the study participants after informing the study subjects on study objectives, expected outcomes, benefits and the risks associated with it. In the case of participants under the age of 18 years, parental/legal guardian consent was taken on the participants’ behalf. Confidentiality of responses was maintained throughout the study.

Results

Socio-demographic characteristics of the study subjects

Totally 576 mother-infant pairs participated in the study (estimated response rate 94.4%). The majority of the mothers were Muslims (80.2%) followed by Ethiopian Orthodox Christians (15.3%). More than half of the mothers were aged 20–34 years with mean (+SD) age of 31.79 (±7.18) years. In addition, the mean (±SD) age of the study infants was 3.6 (±1.4) months. About 72% of the households were led by males (Table 1).
Table 1

Socio-demographic characteristics of mothers of infants aged less than six months (N = 576) in Samara-Logia town Administration, Northeast Ethiopia, 2017

Characteristics

Frequency

Percent

Maternal age (years)

 17–20

35

6.1

 20–34

322

55.9

  > 34

219

38.0

Maternal religion

 Muslim

462

80.2

 Ethiopian Orthodox

88

15.3

 Protestant

26

4.5

Ethnicity of the mother

 Afar

133

23.1

 Amhara

302

52.4

 Oromo

62

10.8

 Tigray

79

13.7`

Marital status

 Married

456

79.2

 Divorced

76

13.2

 Widowed

31

5.4

 Single

13

2.2

Maternal Education

 None

128

22.2

 Primary

175

30.4

 Secondary and above

273

47.4

Maternal Occupation

 Housewife

242

42

 Government employee

220

38.2

 Merchant

64

11.1

 Daily laborer

36

6.3

 Othersa

14

2.4

Age of the infant (months)

 0–1

53

9.2

 2–3

227

39.4

 4–5

296

51.4

Birth order

 1

132

22.9

 2

247

42.9

  > 3

197

34.2

Paternal education

 None

54

11.8

 Primary

52

11.4

 Secondary and above

350

76.8

Household head

 Mother of index infant

159

27.6

 Father of index infant

417

72.4

Having Radio

 Yes

199

34.5

 No

377

65.5

aStudent, agro-pastoralist. ETB Ethiopian Birr

Maternal health service utilization

Three hundred and seventy five (65.1%) of mothers had attended at least one ANC check-up, with only 7.5% attending four or more visits. About 40% of the study infants were delivered at home (Table 2).
Table 2

Maternal health service utilization and obstetric history among mothers of infants aged less than six month, in Samara-Logia town, Northeast Ethiopia, 2017

Variables

Frequency

Percent

ANC checkupa

 Yes

375

65.1

 No

201

34.9

Number of ANC checkups

 1

202

53.8

 2

102

27.2

 3

43

11.5

  > 4

28

7.5

Mothers counseled on infant feeding at ANC checkup

 Yes

319

85.1

 No

56

14.9

Place of delivery

 Home

229

39.8

 Health institution

347

60.2

Mode of delivery

 Vaginal

521

90.5

 Cesarean section

55

9.5

Parity

 Primipara

178

30.9

 Multipara

398

69.1

PNC checkupa

 Yes

264

45.8

 No

312

54.2

Mothers counseled on infant feeding at PNC checkup

 Yes

245

92.8

 No

19

7.2

aat least one checkup. ANC Antenatal care. PNC postnatal care

Knowledge and awareness on infant feeding practices

Five hundred sixty one (97.4%) of the study participants had heard about recommended infant feeding practices. Nearly 90% of the mothers reported that breastfeeding has benefits for their infants. However, 45.3% of mothers reported that it is good to provide feeds other than breast milk immediately at birth (Table 3).
Table 3

Knowledge and awareness of mothers of infants aged less six months on infant feeding practices (N = 576) in Samara-Logia town, North East Ethiopia, 2017

Variables

Frequency

Percent

Heard About infant feeding recommendations

 Yes

561

97.4

 No

15

2.6

Breastfeeding benefits for the health of infants

 Yes

515

89.4

 No

61

10.6

Breastfeeding benefits for the health of the mother

 Yes

333

57.8

 No

243

42.2

Newborn should start breastfeeding within 1 h after birth

 Yes

356

61.8

 No

220

38.2

Colostrum should be given to the newborn

 Yes

377

65.5

 No

199

34.5

Providing feeds other than breast milk at birth is good to the newborn

 Yes

261

45.3

 No

315

54.7

Mothers breast milk is enough without addition of water and/or other fluids in the first six months

 Yes

335

58.2

 No

241

41.8

The infant should start complementary food at six completed months

 Yes

346

60.1

 No

230

39.9

Infant feeding practices and breastfeeding performance index (BPI) score

Five hundred thirty six (93.1%) of the study mothers had ever breastfed their index infants. About 45% of the study mothers had initiated breastfeeding within an hour after birth. More than half (62.5%) of the infants had received prelacteal feeds within three days after birth, while 66.8% of infants fed on a bottle with a nipple. In addition, 45.7 and 37.2% of infants were introduced to fluids and solid foods before six months of age, respectively.

The mean (+SD) of BPI score was 3.41(+ 0.69). More than half (56.8%) of mothers achieved low BPI scores, around a quarter (25.8%) achieved medium scores, and fewer than one in five achieved high BPI scores (Table 4).
Table 4

Feeding practices of mothers of infants aged less than six months and BPI score (N = 576) in Samara-Logia town, Northeast Ethiopia, 2017

Variables

Frequency

Percent

Score

Ever breastfeeding

 Yes

536

93.1

 

 No

40

6.9

 

Early breastfeeding initiation

 No

316

54.9

0

 Yes

260

45.1

1

Current breastfeeding

 No

256

44.4

0

 Yes

320

55.6

1

Prelacteal feeding

 Yes

360

62.5

0

 No

216

37.5

1

Bottle feeding

 Yes

385

66.8

0

 No

191

33.2

1

Liquids given

 Yes

263

45.7

0

 No

313

54.3

1

Formula milk given

 Yes

271

47.0

0

 No

305

53.0

1

Solid foods given

 Yes

214

37.2

0

 No

362

62.8

1

Over all BPI score

 Low

327

56.8

 

 Medium

149

25.8

 

 High

100

17.4

 

BPI Breastfeeding Performance Index

Factors associated with low/medium BPI score

Mothers aged older than 34 years were about four times more likely to achieve low/medium BPI score as compared to mothers younger than 20 years. Mothers of infants aged 4–5 months were 2.5 times more likely to achieve low/medium BPI score as compared to those mothers having infants under 2 months. Women who gave birth at home or by cesarean section had more odds of low/medium BPI score achievement as compared to their counter parts. Mothers who received infant feeding advice at postnatal checkup were 77% less likely to achieve low/medium BPI score (Table 5).
Table 5

Factors associated with low/medium BPI scores among mothers of infants aged less than six months in Samara-Logia town administration, Afar Regional state, Northeast Ethiopia, 2017

Variables

Low/medium BPI score

COR (95% CI)

AOR (95% CI)

Yes

No

Maternal age (years)

 17–20

29

6

1

1

 20–34

248

74

0.69(0.28,1.73)

1.06(0.34,3.28)

  > 34

199

20

2.06(0.76, 5.55)

4.55(1.33, 15.73)*

Maternal occupation

 Housewife

193

49

0.71(0.46,1.09)

 

 Othera

283

51

1

 

Maternal educational status

 Non formal education

118

10

2.97(1.49,5.89)*

 

 Formal education

358

90

1

 

Religion

 Muslim

378

84

0.74(0.41,1.31)

 

 Christianb

98

16

1

 

Household head

 Mother of index infant

142

17

2.08(1.19,3.63)*

 

 Father of index infant

334

83

1

 

Ethnicity

 Amhara

240

62

1

 

 Afar

112

21

1.38(0.80, 2.37)

 

 Oromo

53

9

1.52(0.71, 3.25)

 

 Tigre

71

8

2.29(1.05, 5.01)*

 

Parity

 Primipara

167

11

1

 

 Multipara

309

89

0.23(0.12,0.44)*

 

Marital status

 Currently married

373

83

1

 

 Currently unmarried

103

17

1.35(0.77,2.37)

 

Age of infant (month)

 0–1

35

18

1

1

 2–3

188

39

2.48(1.28,4.82)*

2.18(0.95,5.00)

 4–5

253

43

3.03(1.57,5.82)*

2.49(1.08,5.76)*

Birth order

 1

117

15

1

 

 2

194

53

0.47(0.25,0.87)*

 

  > 3

165

32

0.66(0.34,1.28)

 

Advice on infant feeding at ANC checkup

 Yes

232

87

0.14(0.08, 0.26)*

 

 No

244

13

1

 

Place of delivery

 Home

223

6

13.81(5.93,32.14)*

4.25(1.37,13.23)*

 Health institution

253

94

1

1

Mode of delivery

 Vaginal

426

95

1

1

 Cesarean section

50

5

2.23(0.87,5.74)

8.00(2.78,23.09)*

Advice on infant feeding at PNC checkup

 Yes

167

78

0.15(0.09, 0.25)*

0.28(0.13,0.59)*

 No

309

22

1

1

Hosmer and Lemeshow Test = 0.455. COR = Crude odds ratio. AOR Adjusted odds ratio. CI confidence interval. *Significant at p < 0.05. astudent, agro-pastoralist, merchant, government employee, daily laborer. bEthiopian Orthodox, Protestant. ANC Antenatal care. PNC postnatal care

Discussion

More than half (56.8%) of mothers achieved low BPI scores, around a quarter (25.8%) achieved medium scores, and fewer than one in five achieved high BPI scores. This is relatively similar with a finding in Ethiopia, where 80% of infants achieved low/medium BPI score [12]. This can be justified by high prevalence of infant feeding malpractices in the country. For instance, prelacteal feeding and colostrum discarding are common in different cultures of Ethiopia. In Afar Regional State, nearly 43% of children aged 6–23 months received prelacteal feeding [22]. In northeastern Ethiopia, colostrum is assumed to cause abdominal cramp; therefore, grandmothers and traditional birth attendants influence mothers to discard colostrum, and to nourish infants with prelacteal feeds [24].

This study showed that as infants got older the overall breastfeeding performance index (BPI) score decreases. Mothers of infants aged 4–5 months were 2.5 times more likely to achieve low/medium BPI score as compared to those mothers having infants aged less than 2 months. Similar findings were also reported at Cameroon [16], Dubti town [17] and Hawassa of Ethiopia [18]. It is not surprising that children aged 4–5 months were more likely to achieve low/medium BPI score. They are on the cusp of transition to complementary foods and many are likely to have received formula and solid foods as mothers may perceive them to be ready for complementary foods. In addition, traditional postpartum care is given in the first few months of delivery where women stay at home with their infants; providing the chance of proper breastfeeding that will increase the BPI score.

Mothers aged older than 34 years were about five times more likely to achieve low/medium BPI score as compared to mothers younger than 20 years. In North Wollo zone of Ethiopia, eldest mothers were more likely to practice infant feeding malpractices as compared to youngest mothers [25, 26]. This can be justified in such a way that first time mothers learn about child care from older female family members [27]. However, grandmothers and traditional birth attendants recommend colostrum avoidance and prelacteal feeding [24, 27]. This supports the finding that older females are more likely to achieve low/medium BPI score.

Compared to women who gave birth at health institution, women who delivered at home were about four times more likely to achieve low/medium BPI score. Likewise, in Amhara region of Ethiopia, higher odds of early initiation of breastfeeding were noted among mothers who gave birth at a health institution compared to those who did it at home [19, 20]. This might be due to the fact that home delivery provides favorable environment for family and community influence on mothers to practice infant feeding malpractices. Therefore, it is important to educate traditional birth attendants and/or households members who exert influence on mothers’ behaviors [24].

Women who delivered the study infants by cesarean section had more odds of achieving low/medium BPI score as compared to their counter parts. Similar findings were reported at Egypt where caesarean section delivery was an independent predictor of low BPI [4]. In the Amibara district of Ethiopia, caesarean section delivery was positively associated with late initiation of breastfeeding. This can be associated with long recovery time taken by mothers due to anesthesia effects, and infants born by cesarean section might be taken to intensive care unit [21].

Mothers who received advice about infant and young child feeding at postnatal checkup were less likely to achieve low/medium BPI score. In Dubti town, mothers who received counseling during postnatal checkup was associated with increased odds of exclusive breastfeeding [17]. In Afar regional state, lack of awareness on proper breastfeeding practices were associated with increased odds of prelacteal feeding [22]. Likewise, mothers who received postnatal care were more likely to practice exclusive breastfeeding [23]. Furthermore, mothers having high knowledge on infant and young child feeding (IYCF) had more odds of timely breastfeeding initiation compared to mothers having poor IYCF knowledge [20]. These findings highlight the importance and value of providing mothers with infant feeding advice particularly at postnatal care visits.

Limitations

This study could be subjected to social desirability bias where study participants might tend to report the desired infant feeding recommendations which were not their actual practices. Second, since the data were collected based on self-report of the mothers of infants aged less than six months, it may be subjected to recall bias.

Conclusions

This study revealed that roughly 8 in every 10 infants achieved low/medium BPI score. Being older than 34 years, having an infant aged 4–5 months, giving birth at home or by caesarean section and lack of advice on proper infant feeding practices were associated with low/medium BPI score. This indicates promoting institutional delivery, supporting breastfeeding education and counseling programs are vital. Hence, health care professionals at antenatal, postnatal and delivery care units should provide counseling on proper infant feeding practices. In addition, appropriate supervision and assistance to health care staffs during cesarean section are important interventions to improve BPI score. Further research is also required to identify and address barriers to institutional delivery and postnatal care service uptake.

Abbreviations

AOR: 

Adjusted odds ratio

BPI: 

Breastfeeding performance index

CI: 

Confidence interval

COR: 

Crude odds ratio

ERC: 

Ethical Review Committee

IYCF: 

Infant and young child feeding

RERC: 

Research Ethics Review Committee

Declarations

Acknowledgments

Authors thank Samara University for the ethical review process, and the study subjects for their participation.

Funding

No external funding was received; we authors cover the financial expense of this study.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Authors’ contributions

JH, SA and MLL participated in designing the study, and JH managed the data collection process. MLL analyzed and interpreted the data, drafted and finalized the manuscript. All authors read and approved the final manuscript.

Ethics approval and consent to participate

The study was approved by Research Ethics Review Committee (RERC) of Samara University dated 23 Dec 2016, and numbered ERC/0025/2016. A signed consent was taken from the study subjects before interview. Consent from a legal guardian was also acquired on behalf of underage participants.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

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Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Health and Nutrition specialist department, Save the children, Afar, Ethiopia
(2)
School of Public Health, College of Health Sciences, Mekelle University, Tigray, Ethiopia
(3)
Department of Public Health, Faculty of Health Sciences, Woldia University, Amhara, Ethiopia

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