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Background: The burden of low coverage of exclusive breastfeeding (EBF) has a significant impact on the health of a newborn and also on the family and social economy in the long term. Even though the prevalence of EBF practices in Ethiopia is low, the practices in the pastoral communities, in particular, are significantly low and affected by individual and community-level factors. Besides, its adverse outcomes are mostly unrecognised. Therefore, this study aimed to assess the individual and community-level factors of low coverage of EBF practices in the emerging regions of Ethiopia. Methods: In this analysis, data from 2016 Ethiopian Demographic and Health Survey (EDHS) were used. A two-stage stratified sampling technique was used to identify 1406 children aged 0 to 23 months in the emerging regions of Ethiopia. A multilevel mixed-effect binary logistic regression analysis was used to determine the individual and community level factors associated with exclusive breastfeeding practices. In the final model, variables with a p-value of < 0.05 and Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) were found to be statistically significant factors that affect exclusive breastfeeding practices. Results: Overall, 17.6% (95% CI: 15.6–19.6) of the children aged 0 to 23 months have received exclusive breastfeeding. Employed mothers (AOR: 0.33, 95% CI: 0.21–0.53), richer household wealth status (AOR: 0.39, 95% CI: 0.16–0.96), mothers undecided to have more children (AOR: 2.29, 95% CI: 1.21–4.29), a child with a history of diarrhoea (AOR: 0.31, 95% CI: 0.16–0.61) were the individual-level factors, whereas Benishangul region (AOR: 2.63, 95% CI: 1.44–4.82) was the community-level factors associated with the exclusive breastfeeding practices. Conclusions: Less than one-fifth of the mothers have practised exclusive breastfeeding in the emerging regions of Ethiopia. The individual-level factors such as mother’s employment status, household wealth status, desire for more children, presence of diarrhoea and community-level factors such as region have contributed to the low coverage of exclusive breastfeeding. Therefore, the federal and regional health bureaus and other implementers should emphasise to those emerging regions by creating awareness and strengthening the existing community-based health extension program to enhance exclusive breastfeeding practices.
The 2016 Ethiopian Demographic and Health Survey data were used for this study. The EDHS is a nationally representative household survey data that has been implemented by the Central Statistical Agency (CSA) of Ethiopia, every 5 years [20]. Ethiopia is divided into two administrative cities and nine regions. These regions are again categorised underdeveloped and emerging regions. The emerging regions are Afar, Somali, Benishangul, and Gambela, where scattered pastoralists predominantly live. Moreover, inadequate infrastructure, inaccessibility of health services, drought, poverty and absence of clear as well as detailed regulations are their common characteristics in emerging regions [44, 45]. Whereas, the developed regions are Amhara, Oromia, Tigray, South Nation Nationalities and Peoples’ Region (SNNPR) and Harari regions and the city administrations characterised by a relatively denser population and better infrastructure, access to health and education. The 2016 EDHS was used the Ethiopian population and housing census, which was conducted in 2007 by the Ethiopian CSA, as a sampling frame. The census used a complete list of 84,915 enumeration areas (EA) created for the 2007 Primary Health Care (PHC) as a frame. The sampling frame contains the EA, location, type of residence, and the estimated number of residential households. The 2016 EDHS was stratified in two stages, and samples of EA were selected independently in each stratum. In this study, the 2016 Ethiopian demographic and health survey childhood datasets of the four emerging regional states, namely Afar, Benishangul, Gambella, and Somali, were used for analysis. All women aged 15–49 years who are the regular members of the selected households were eligible for the female survey. Children aged 0–23 months are the study population. Those non-alive and live with other than their mothers were excluded from the analysis. Finally, a total of 1406 mothers with their children aged 0–23 months were included in the analysis, and data on both were extracted from the 2016 EDHS datasets using STATA version 14 software. Potential individual and community level independent variables were also extracted, and further analysis of the selected variables was done. Exclusive breastfeeding practices was the dependent variable which was measured in two ways for the age groups of less than 6 months and 6–23 months. For mothers who had less than 6 months old children during the data collection period were asked about the feeding of breast milk without anything else in the last 24 h preceding the survey, except for Oral Rehydration Salt (ORS), syrups (vitamins, minerals, medicines), and others for therapeutic purposes. Whereas, mothers who had 6 to 23 months old children were asked about their lifelong (about 6 months) EBF practices using since birth dietary recall method retrospectively [24, 36, 46]. The information on exclusive breastfeeding was collected from mothers’ verbal responses. The mothers were asked about their children current breastfeeding status, the timing of breastfeeding initiation and exclusive breastfeeding practices. Exclusive breastfeeding for infants should be practised for the first 6 months, and then for 18 additional months and more along with complementary foods for better health and development as per the world health organisation recommendation’. On 18 May 2001, the world health assembly urged the member states to promote EBF for 6 months as a global public health recommendation [47, 48]. Two sets of explanatory variables (individual and community–level) were included in this study. Both maternal (socio-demographic and maternal health service-related characteristics) and child-related variables were included in the individual level-variables. Whereas, place of residence, region, distance to a health facility, community-level poverty, and media exposure were the community-level variables. Distance to a health facility was assessed by the question “distance to the nearest health facility is a problem?” and the responses were categorised as “big problem” or “not a problem”. Women empowerment was assessed using decision making power and justification of wife-beating. Women who were empowered were those who participated in decision making either alone or jointly with their husbands in all instances and did not ever justify wife-beating. Community-level poverty was assessed using the asset index based on data from the entire sample on separate scores prepared for rural and urban households, and combined to produce a single asset index for all households as community level and ranked into three (poor, middle, and rich). Community media exposure was assessed as “yes” if they have access to all three media (newsletter, radio, and TV) at least once a week, otherwise “no”. The data were extracted, cleaned, re-coded, and analysed using STATA version 14 (Stata Corp, College Station, TX). Descriptive statistics were presented using tables and narrations. A multilevel mixed-effect logistic regression analysis was conducted after checking the eligibility. The model eligibility was assessed by calculating the Intra-class Correlation Coefficient (ICC) (ICC greater than 5% is eligible for multilevel analysis). In our study, the ICC was 45.0%. Since the DHS data are hierarchical (individual were nested within communities), a two-level mixed-effects logistic regression model was fitted to estimate both the individual and community level variables (fixed and random) effects on exclusive breastfeeding practices [49]; Bi-variable and multivariable analysis were computed. First, in the bi-variable logistic regression analysis, a p-value of less than 0.2 was used to fit the three models (model 1: individual level, model 2: community level, and model 3: both the individual and community level). In the final model (model 3) (mixed-effect), a p-value less than 0.05 and adjusted odds ratio (AOR) with 95% confidence interval (CI) were used to declare statistically significant factors with the exclusive breastfeeding practice among children aged 0 to 23 months of children in the emerging regions of Ethiopia. The measures of variation (random-effects) between clusters were reported using ICC. The ICC refers to the ratio of the between-cluster variance to the total variance, and it tells us the proportion of the total variance in the outcome variable that is accounted at the cluster level. Akaike’s information criterion (AIC) was used to estimate the goodness of fit of the adjusted final model in comparison with the preceding models.
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