Determinants of early initiation of breast feeding among mothers of children aged less than 24 months in Ethiopia: A community-based cross-sectional study

  • BMJ Open, Volume 12, No. 10, Year 2022

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Study Justification:
– The study aims to assess the prevalence of early initiation of breastfeeding (EIBF) and associated factors among mothers in Ethiopia.
– Understanding the determinants of EIBF is crucial for improving maternal and child health outcomes.
– The study provides valuable insights into the factors that influence EIBF, which can inform interventions and policies to promote breastfeeding practices in Ethiopia.
Study Highlights:
– The prevalence of EIBF among mothers in Ethiopia was found to be 73.56%.
– Women who delivered at a health facility and had children with a birth order of second to fourth were more likely to initiate early breastfeeding.
– On the other hand, women who gave birth by caesarean section, had multiple births, and had postnatal check-ups were less likely to practice EIBF.
– The region of residence was also significantly associated with EIBF.
Recommendations for Lay Readers:
– The government and stakeholders should prioritize improving access and utilization of basic maternal health services to increase the practice of EIBF.
– Health facilities should promote and support early initiation of breastfeeding, especially for women who give birth by caesarean section or have multiple births.
– Postnatal check-ups should include counseling and support for breastfeeding initiation.
– Efforts should be made to address regional disparities in EIBF rates and ensure equitable access to breastfeeding support services.
Recommendations for Policy Makers:
– Allocate resources to improve access to and utilization of basic maternal health services, particularly in underserved regions.
– Strengthen health facility capacity to provide support for early initiation of breastfeeding, including training healthcare providers and ensuring the availability of necessary equipment and supplies.
– Develop and implement targeted interventions to promote EIBF among women who give birth by caesarean section or have multiple births.
– Incorporate breastfeeding counseling and support into postnatal check-up services.
– Monitor and evaluate the implementation of breastfeeding promotion programs and policies to ensure their effectiveness and address any gaps or challenges.
Key Role Players:
– Ministry of Health: Responsible for developing and implementing policies and programs to promote breastfeeding practices.
– Healthcare Providers: Play a crucial role in providing counseling and support for early initiation of breastfeeding.
– Community Health Workers: Engage with mothers and families at the community level to promote breastfeeding practices and provide education and support.
– Non-Governmental Organizations (NGOs): Contribute to breastfeeding promotion efforts through advocacy, awareness campaigns, and community-based interventions.
– Professional Associations: Provide guidance and training to healthcare providers on breastfeeding practices and support.
Cost Items for Planning Recommendations:
– Training and Capacity Building: Budget for training healthcare providers on breastfeeding counseling and support.
– Equipment and Supplies: Allocate funds for the procurement of breastfeeding support equipment and supplies in health facilities.
– Awareness Campaigns: Set aside a budget for public awareness campaigns on the importance of early initiation of breastfeeding.
– Community Engagement: Allocate resources for community-based interventions and the involvement of community health workers in breastfeeding promotion activities.
– Monitoring and Evaluation: Include funds for monitoring and evaluating the implementation and impact of breastfeeding promotion programs and policies.
Please note that the cost items provided are general categories and not actual cost estimates. The specific budget requirements would depend on the context and scale of implementation.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, as it is based on a community-based cross-sectional study using data from the 2019 Ethiopia Mini Demographic and Health Survey (EMDHS). The study included a large sample size of 2054 mothers and used multilevel mixed-effects logistic regression to identify determinants of early initiation of breastfeeding (EIBF). The prevalence of EIBF was reported with a 95% confidence interval. The study also identified statistically significant factors associated with EIBF, such as place of delivery, mode of delivery, postnatal check-up, type of birth, birth order, and region. The study provides actionable steps to improve EIBF, suggesting that the government and stakeholders should show commitment to improve access and utilization of basic maternal health services. To further improve the evidence, it would be beneficial to include information on the representativeness of the sample and any limitations of the study.

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.

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 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. 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. 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. 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. 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 ANC, antenatal care; DHS, Demographic and Health Survey; HH, household; PCA, principal component analysis; SNNPR, Southern Nations, Nationalities, and People’s Region. 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. Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Mobile Health (mHealth) Applications: Develop and implement mobile applications that provide information and reminders about the importance of early initiation of breastfeeding, as well as tips and guidance for mothers. These apps can be easily accessible and user-friendly, reaching a wide range of mothers in Ethiopia.

2. Telemedicine Services: Establish telemedicine services that allow mothers to consult with healthcare professionals remotely. This can help address barriers to accessing healthcare facilities, especially for mothers in rural areas who may have limited access to transportation.

3. Community Health Workers: Train and deploy community health workers who can provide education and support to mothers in their communities. These workers can conduct home visits, provide counseling on breastfeeding practices, and refer mothers to healthcare facilities when necessary.

4. Maternal Health Clinics: Set up specialized maternal health clinics that focus on providing comprehensive care and support for mothers during pregnancy, childbirth, and the postpartum period. These clinics can offer services such as breastfeeding counseling, postnatal check-ups, and education on maternal and child health.

5. Public Awareness Campaigns: Launch public awareness campaigns to promote the importance of early initiation of breastfeeding and increase knowledge among mothers and their families. These campaigns can utilize various media channels, including radio, television, and social media, to reach a wide audience.

6. Strengthening Health Systems: Invest in strengthening the overall health system in Ethiopia, including improving infrastructure, training healthcare professionals, and ensuring the availability of essential maternal health services and supplies.

It is important to note that these recommendations are based on the information provided and may need to be further tailored and adapted to the specific context and needs of Ethiopia.
AI Innovations Description
The recommendation that can be developed into an innovation to improve access to maternal health based on the study is to focus on the following strategies:

1. Strengthening health facility delivery: The study found that women who delivered at a health facility were more likely to initiate early breastfeeding. Therefore, improving access to and utilization of health facilities for delivery can increase the practice of early initiation of breastfeeding.

2. Promoting vaginal delivery: The study showed that women who gave birth by caesarean section were less likely to practice early initiation of breastfeeding. Encouraging vaginal delivery when medically appropriate can help improve breastfeeding practices.

3. Enhancing postnatal check-ups: Women who had postnatal check-ups were less likely to practice early initiation of breastfeeding. Increasing awareness and access to postnatal care services can help address this issue.

4. Addressing multiple births: The study found that women with multiple births were less likely to practice early initiation of breastfeeding. Implementing targeted interventions and support for mothers of multiple births can help improve breastfeeding practices.

5. Targeting specific regions: The study identified regional variations in early initiation of breastfeeding. Tailoring interventions and programs to address the specific needs and challenges in different regions can be effective in improving breastfeeding practices.

Overall, the recommendation is to focus on improving access and utilization of basic maternal health services, including promoting health facility delivery, encouraging vaginal delivery when appropriate, enhancing postnatal care services, addressing the needs of mothers with multiple births, and implementing region-specific interventions.
AI Innovations Methodology
Based on the provided description, the study aimed to assess the prevalence of early initiation of breastfeeding (EIBF) and associated factors among mothers in Ethiopia. The methodology used a community-based cross-sectional study design and utilized data from the 2019 Ethiopia Mini Demographic and Health Survey (EMDHS). Here are the key steps and findings of the study:

1. Study Design: The study used a community-based cross-sectional design, which involved analyzing data from the 2019 EMDHS.

2. Sampling Strategy: The EMDHS used a two-stage sampling strategy. In the first stage, 305 enumeration areas (EAs) were selected using probability proportional to EA size. In the second stage, a fixed number of households (30) per cluster were selected using equal probability systematic selection.

3. Study Participants: The study included 2054 mothers who had last-born children and were either currently breastfeeding or had breastfed their children during the survey. Mothers who had never breastfed their children were excluded from the study.

4. Outcome Variable: The outcome variable of interest was early initiation of breastfeeding (EIBF), defined as giving breast milk within the first hour of birth to the last child born in the 2 years preceding the survey.

5. Data Analysis: Descriptive statistics were used to present the distribution of background characteristics among the study participants. A two-level multilevel mixed-effects logistic regression analysis was conducted to identify individual and community-level determinants of EIBF.

6. Findings: The prevalence of EIBF among mothers with children aged 0-23 months was 73.56%. Several factors were found to be significantly associated with EIBF:

– Factors positively associated with EIBF: Women who delivered at a health facility and had children with a birth order of second to fourth were more likely to initiate early breastfeeding.

– Factors negatively associated with EIBF: Women who gave birth by caesarean section, had multiple births, and had postnatal check-ups were less likely to practice EIBF.

– Region of residence was also found to be significantly associated with EIBF.

7. Model Selection: Four models 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). The model with the lowest deviance was considered the best-fitted model.

8. Multicollinearity Check: Variance inflation factor (VIF) was used to check for multicollinearity between explanatory variables. A mean VIF value below 10 indicates the absence of multicollinearity.

9. Reporting: Variables with a p-value less than 5% and an adjusted odds ratio (AOR) with a 95% confidence interval (CI) were reported as statistically significant variables associated with EIBF in the final model.

In conclusion, the study found that the prevalence of EIBF in Ethiopia was good, but there were still factors influencing its practice. Factors such as place of delivery, mode of delivery, postnatal check-up, type of birth, birth order, and region were significantly associated with EIBF. The study suggests that improving access and utilization of basic maternal health services can increase the practice of EIBF.


Identifiers:
DOI: 10.1136/bmjopen-2022-062905
Research Areas:
Community Interventions, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care
Study Countries:
Ethiopia
Study Design:
Cross Sectional Study
Study Approach:
Quantitative
Participants Gender:
Female
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