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• Published: 16 July 2018

Exclusive breastfeeding practice in Ethiopia and its association with antenatal care and institutional delivery: a systematic review and meta-analysis

• Animut Alebel 1 ,
• Cheru Tesma 2 ,
• Belisty Temesgen 3 ,
• Aster Ferede 2 &
• Getiye Dejenu Kibret 2  

International Breastfeeding Journal volume  13 , Article number:  31 ( 2018 ) Cite this article

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Despite the World Health Organization recommendation of exclusive breastfeeding (EBF) for the first six months of life, the rate remains low both in developed and developing countries. In Ethiopia, findings regarding the prevalence of EBF have been highly variable. Antenatal care and institutional delivery are the most important factors contributing to the practice of EBF however; their effect has not been investigated in Ethiopia.

In this systematic review and meta-analysis, international databases were systematically searched. All observational studies reporting the prevalence of EBF and its association with antenatal care and institutional delivery in Ethiopia were considered. Two authors independently extracted all necessary data using a standardized data extraction format. A random effects meta-analysis model was computed to estimate the pooled prevalence of exclusive breastfeeding. Moreover, the association of antenatal care and institutional delivery with EBF was determined.

After reviewing 619 studies, 32 studies fulfilled the inclusion criteria and were included in the meta-analysis. The pooled prevalence of EBF in Ethiopia was 59.3% (95% Confidence Interval [CI] 53.8, 64.8). The subgroup analysis indicated that the highest prevalence was observed in Afar region (65.6%), followed by SNNP (63.8%), and then by Oromia (61.8%). Additionally, mothers who attended antenatal visits were 2.1 times more likely to practice EBF compared to their counterparts (Odds Ratio [OR] 2.1; 95% CI 1.5, 2.8). Moreover, mothers who gave birth at a health institution were 2.2 times more likely to practice EBF compared to mothers who gave birth at home (OR 2.2; 95% CI 1.3, 3.5).

Conclusions

Exclusive breastfeeding in Ethiopia was significantly lower than the global recommendations. There was evidence that mothers who attended antenatal visits and who gave birth at health institutions had better EBF practices. Based on our findings, we strongly recommended that the utilization of antenatal care and institutional delivery should be improved through health extension workers.

Breast milk is the natural first food for babies, which provides all the energy and nutrients that the infant needs for the first 6 months of life [ 1 ]. The World Health Organization (WHO) recommends that infants should be exclusively breastfed for the first 6 months, and for an additional 18 months or longer, to be breastfed along with complementary foods for the achievement of satisfactory growth and development [ 2 , 3 ]. Exclusive breastfeeding (EBF) is defined as giving breast milk to the infant, without any additional food or drink, not even water in the first 6 months of life, with the exception of vitamins, mineral supplements or medicines [ 4 ].

Although the benefit of exclusive breastfeeding is widely advocated globally, only 35% the of infants worldwide were exclusively breastfed during their first 4 months of life [ 5 , 6 ]. In Africa, Asia, Latin America, and Caribbean countries, evidences suggested that only 47–57% of infants less than 2 months, and 25–31% of infants 2–5 months were exclusively breastfed [ 7 ]. Even though, Sub-Saharan Africa has one of the highest prevalence of breastfeeding at 1 year worldwide; however, only 37% of infants aged less than 6 months are exclusively breastfed [ 8 ]. Non-exclusive breastfeeding has been significantly associated with increased infants and young child mortality. Accordingly, almost 96% of all infant deaths that means 1.24 million deaths occur during the first 6 months of life are attributed to non-exclusive breastfeeding, this figure is substantially higher in Asian and African countries. In addition, non-exclusive breastfeeding also contributes to 55% of diarrheal deaths and 53% of acute respiratory deaths for the first 6 months of life [ 9 ]. Partial or no breastfeeding is associated with a 2.23-fold higher risk of infant deaths resulting from all causes and 2.40 and 3.94 fold higher risk of deaths attributable to pneumonia and diarrhea, respectively as compared with exclusive breastfeeding [ 10 ]. In Ethiopia, suboptimal breastfeeding contributes to an estimated number of 70,000 infant deaths, which accounts 24% total infant death annually. These deaths could be prevented through nutritional interventions like exclusive breastfeeding [ 11 ].

Antenatal Care (ANC) is one of the fundamental strategies recommended to reduce the risk of maternal and neonatal mortality both in developing and developed countries [ 12 , 13 , 14 , 15 ]. It is an ideal entry point for healthcare professionals to provide numerous healthcare interventions to promote maternal and fetal wellbeing including exclusive breastfeeding [ 16 ]. During ANC visits, different nutritional and other health related educations from healthcare professionals are provided, which could have a great contribution to the practice of exclusive breastfeeding. In addition, information provided by healthcare professions concerning infant feeding and the nutritional values of breast milk will increase the knowledge of exclusive breastfeeding [ 16 ]. According to WHO, to provide an effective ANC service of at least four ANC visits are recommended particular to low-income countries [ 17 ]. Moreover, an institutional delivery encourages infants to receive skin to skin contact from their mothers, and this will increase the likelihood of timely initiation of breastfeeding, exclusive breastfeeding and prolonged duration of breastfeeding [ 18 , 19 ]. Furthermore, institutional delivery has a great role to promote breastfeeding through a strategy of the Baby-Friendly Hospital Initiative (BFHI). The BFHI is a key component of the World Health Organization/United Nations Children’s Fund Global Strategy for Infant and Young Child Feeding [ 20 ].

In Ethiopia, different studies have been conducted to determine the prevalence of EBF and associated factors. The findings of these fragmented studies documented that there was a great variability in the prevalence of EBF across the regions of the country. Regarding associated factors, these studies revealed that different maternal and health service related factors influenced EBF; maternal educational level [ 21 , 22 , 23 , 24 , 25 , 26 ], current marital status [ 27 , 28 ], place of residence [ 21 , 29 , 30 ], employment [ 21 , 25 , 28 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 ], economic status of mothers [ 30 , 31 , 37 , 38 ], institutional delivery [ 21 , 23 , 25 , 27 , 37 , 39 , 40 , 41 , 42 ], history of antenatal [ 22 , 29 , 33 , 37 , 38 , 43 , 44 , 45 ] and postnatal care [ 22 , 23 , 25 , 29 , 33 , 34 , 37 , 39 , 43 ], were some of the factors associated with EBF practice. From these factors, we selected the two factors (ANC and institutional delivery) to see their effect on the practice of exclusive breastfeeding. We sorted these factors because of the following reasons: firstly, these factors were the most important factors, which ultimately influencing EBF. Secondly, the effect of ANC and institutional delivery on EBF have reported controversial findings. Regarding these findings, in some studies, ANC was positively associated with EBF [ 22 , 24 , 28 , 29 , 31 , 37 , 39 , 40 , 42 , 45 , 46 , 47 , 48 ]. On the other hand, one Ethiopian study disclosed that ANC was negatively associated with EBF [ 49 ]. Regarding institutional delivery, in some studies it was positively associated with EBF [ 21 , 25 , 28 , 30 , 31 , 36 , 37 , 39 , 40 , 42 , 43 , 45 , 47 , 50 , 51 ]. On the other hand, in two studies it was inversely associated with EBF [ 41 , 44 ]. Therefore, the above-mentioned factors required this meta-analysis.

For better intervention, current and up-to-dated information regarding the prevalence of EBF and its association with ANC and institutional delivery is vital, especially in low and middle-income countries like Ethiopia. However, despite these small and fragmented studies there was no nationwide study, which determines the prevalence of EBF and its association with ANC and institutional delivery in Ethiopia. Hence, the main aim of this systematic review and meta-analysis was to estimate the pooled prevalence of EBF and its association with ANC and institutional delivery in the context of Ethiopia. The findings of this study will be an input to policy makers and program planners working in the area of breastfeeding.

Searching strategies

The current systematic review and meta-analysis was reported by using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) [ 52 ] guideline to determine the pooled prevalence of exclusive breastfeeding practice and its association with ANC and institutional delivery in the context of Ethiopia. The international databases, including PubMed, Google scholar, Science direct and Cochrane library were systematically searched. The search was conducted using the following keywords “prevalence”, “Exclusive breastfeeding”, “Antenatal care”, “Institutional delivery”, “Place of delivery”, “Birth place”, “Skill birth attendance”, and “Ethiopia”. The search terms were used separately and in combination using Boolean operators like “OR” or “AND”. The search was conducted from September 9 to October 10, 2017. All papers published until October 10, 2017 were included in this review.

Eligibility criteria

Inclusion criteria.

Study area: Only studies conducted in Ethiopia.

Publication condition: Articles published in peer reviewed journals.

Study design: All observational study designs (Cross-sectional, case-control and cohort) reporting the prevalence of EBF or studies reporting the associations between ANC and institutional delivery with EBF were considered.

Outcome of interests: Studies reported data on the prevalence of EBF or the association between EBF and ANC or the association between EBF and institutional delivery were considered.

Language: Articles reported in the English language were considered.

Exclusion criteria

Articles, which were not fully accessed, after at least two email contact of the primary author were excluded. Exclusion of these articles is because of inability to assess the quality of articles in the absence of full text.

Outcome measurement

This systematic review has three main outcomes. Exclusive breastfeeding practice, as the primary outcome variable of this study, is defined as giving breast milk to the infant, without any additional food or drink, not even water in the first 6 months of life, with the exception of vitamins, mineral supplements or medicines [ 4 ]. The prevalence was calculated from each primary study by dividing the number of women breastfeeding exclusively to the total number of women who had ever breastfed multiplied by 100. The second outcome was to examine the association between ANC and exclusive breastfeeding. In this study, healthcare professionals considered antenatal care as if a mother received at least four antenatal care visits and more during her pregnancy period. The third outcome of this study was to determine the association between institutional delivery and exclusive breastfeeding. Institutional delivery was defined as giving birth at the health facility. For the second and the third outcomes, we calculated the log odds ratio based on the primary studies that examined the relationship between ANC, institutional delivery with exclusive breastfeeding.

Data extraction

Data were extracted using a standardized data extraction format, which was adopted from the JBI data extraction format. Two authors (AA and CT) independently extracted all necessary data using the format. Any disagreements at the time of data abstraction were resolved through discussion and consensus . The data extraction format included primary author, publication year, study area, study design, response rate, sample size, prevalence with 95% CI and the quality score of each study.

Quality assessment

The Newcastle-Ottawa Scale for cross-sectional studies quality assessment tool was adapted and used to assess the quality of each study [ 53 ]. The tool has three major sections. The first section graded from five stars focuses on the methodological quality of each study. The second section of the tool deals with the comparability of the study. The last section deals with the outcomes and statistical analysis of each original study. Two authors independently assessed the quality of each original study using the tool. Disagreements between the two authors were resolved by taking the mean score of the two authors. Finally, research with a scale of ≥6 out of 10 were considered as high quality.

Statistical analysis

Data were extracted in Microsoft Excel format, then analysis was done using STATA version 13 statistical software. The standard error for each original study was calculated using the binomial distribution formula. Heterogeneity among reported prevalence was assessed by computing p -values for Cochrane Q-statistics and I 2 test [ 54 ]. As the test statistic showed there was a significant heterogeneity among the included studies ( I 2  = 98.7%, p  < 0.001) as a result a random effects meta-analysis model was used to estimate the Der Simonian and Laird’s pooled effect. To minimize the random variations between the point estimates of the primary study subgroup, analysis was done based on study settings (i.e., the area where studies were conducted) and sample size. In addition, to identify the possible sources of heterogeneity univariate meta-regression was conducted by considering the sample size and year of publication as covariates but none of them were found to be statistically significant. Furthermore, Egger’s and Begg’s tests at 5% significant level were not significant for publication bias [ 55 ]. Point prevalence as well as 95% confidence intervals were presented in the forest plot format. In this plot, the size of each box indicated the weight of the study, while each crossed line refers to 95% confidence interval. For the second and third outcomes, log odds ratios were used to examine the association between ANC and institutional delivery with EBF.

As shown in Fig. 1 , in the first step of our search, 619 studies were identified regarding EBF in Ethiopia through PubMed, Google Scholar, Science Direct and others. Of which, 72 studies were excluded due to duplicates. From the remaining 547 studies, 378 articles were excluded after reviewing of their titles based on assessment as non-relevance to this review. The remaining 169 studies were screened by abstracts yielding an additional 109 being excluded. Moreover, 60 full text articles were accessed and assessed for eligibility based on the preset inclusion criteria. Of these, 28 articles were excluded due to the inclusion criteria. Among these, nine of the studies were excluded because they didn’t report our outcome of interests [ 49 , 56 , 57 , 58 , 59 , 60 , 61 , 62 ]. The remaining 19 articles were excluded due to study settings; four of the studies were from Ghana [ 63 , 64 , 65 , 66 ], three of the studies were from Tanzania [ 67 , 68 , 69 ], one from Bangladesh [ 70 ], two from Cameroon [ 71 , 72 ], two from India [ 73 , 74 ], three from Kenya [ 75 , 76 , 77 ] one from Nigeria [ 78 ], two from Malaysia [ 79 , 80 ], two from Congo [ 81 , 82 ], and one from Nepal [ 83 ]. Finally, 32 studies fulfilled the inclusion criteria and included in the systematic review and meta-analysis.

Flow chart to describe the selection of studies for a systematic review and meta-analysis of the effects of ANC and institutional delivery on exclusive breastfeeding in Ethiopia, 2017

Description of the included studies

As shown in Table 1 , these 32 studies were published between 2007 to 2017. In the current meta-analysis, 23,543 breastfeeding women were included to estimate the pooled prevalence of exclusive breastfeeding. Regarding study design, most 29 (71.8%) of the studies are cross-sectional study design. The sample size of the studies ranging from 119 to 5, 227. The lowest prevalence (29.3%) of EBF was observed in a study conducted in Addis Ababa, Ethiopia [ 43 ] whereas the highest prevalence (86.1%) was observed in a study conducted in north Gondar zone, northwest Ethiopia [ 51 ]. In this meta-analysis, from nine regions of the country seven regions were represented. Thirteen of the studies were from Amhara [ 23 , 25 , 29 , 30 , 31 , 33 , 37 , 40 , 42 , 45 , 47 , 48 , 51 ], three from Addis Ababa [ 43 , 59 , 84 ], three from Afar [ 21 , 34 , 50 ], four from Oromia [ 32 , 36 , 38 , 41 ], six from SNNP [ 22 , 24 , 26 , 28 , 44 , 46 ], two from Tigray [ 35 , 39 ]. However, there were no studies reported from Benishangul Gumiz and Gagmbela regions. Concerning the quality score, the score ranged from lowest 3 to highest 8. In related to response rate, almost all studies had a good response rate. The possible reason for this high response rate could be due to most of the studies used interviewers administered questionnaire to collect the data (Table 1 ).

Meta–analysis

The result of 32 included studies indicated that the pooled prevalence of EBF in Ethiopia was 59.3% (95% CI: 53.8, 64.8%) (Fig. 2 ). In this meta-analysis, Genetu et al. (86.1%) reported the highest prevalence of EBF, whereas Shifraw et al. (29.3%) reported the lowest prevalence of exclusive breastfeeding. The result of univariate meta-regression models was presented in the table below (Table 2 ). Publication bias was assessed using Begg’s and Egger’s tests, showing no statistical significant for estimating the prevalence of EBF ( p  = 0.5) and ( p  = 0.2) respectively.

Forest plot of the pooled prevalence of exclusive breastfeeding in Ethiopia

Subgroup analysis

In addition, in this meta-analysis, we performed subgroup analysis based on the regions where the studies were conducted and sample size of the studies. Accordingly, the highest prevalence was reported in Afar region with a prevalence of 65.6% (95% CI: 48.5, 82.7%) followed by SNNP, 63.8% (95% CI: 54.6, 73.0%) and Oromia, 61.8% (95% CI: 46.1, 77.6%). With regard to sample size, the prevalence of EBF was higher in studies having a sample size < 600, 66.2% (95% CI: 61.2, 71.3%) compared to those having a sample size ≥ 600, 49.0% (95% CI: 40.5, 57.6%) (Table 3 ).

The linear trend of exclusive breastfeeding in Ethiopia

In this study, we also describe the linear trend of exclusive breastfeeding in Ethiopia from 2007 to 2017. We found that the general linear trend of exclusive breastfeeding was increased in each successive year (Fig. 3 ).

The linear trend of exclusive breastfeeding in Ethiopia from 2007 to 2017

Association between ANC and exclusive breastfeeding

In this meta-analysis, we examined the association between ANC and EBF practice by using nineteen available studies [ 22 , 24 , 25 , 28 , 29 , 31 , 32 , 36 , 37 , 39 , 40 , 42 , 44 , 45 , 46 , 47 , 48 , 49 , 84 ]. The findings from these nineteen studies revealed that the practice of EBF was significantly associated with antenatal care. Accordingly, the likelihood of EBF practice was 2.1 times higher among mothers’ who had ANC visits as compared to their counterparts (OR: 2.1, 95 %CI: 1.5, 2.8) (Fig. 4 ). High heterogeneity ( I 2  = 88.6% and p - value < 0.001) was observed across the included studies; hence, a random effect meta-analysis model was used to examine the association between ANC and EBF. For this analysis, we also assessed publication bias using Begg’s and Egger’s tests, the result of the test statistics indicated that there was no possible presence of statistically significant publication bias ( p  = 0.4 and ( p  = 0.6) respectively.

The pooled odds ratio of the association between ANC and exclusive breastfeeding in Ethiopia

Association between institutional delivery and exclusive breastfeeding

The third outcome of this research was to determine the association between institutional delivery and exclusive breastfeeding. Twenty studies, which examined the association between institutional delivery and EBF were considered to determine the association between EBF practice and institutional delivery [ 21 , 22 , 25 , 28 , 30 , 31 , 32 , 36 , 37 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 47 , 50 , 51 , 84 ]. In this study, the pooled odds ratio indicated that institutional delivery was positively associated with EBF (OR: 2.2, 95% CI: 1.3, 3.5) (Fig. 5 ). In this meta-analysis, extreme heterogeneity ( I 2  = 95.0% and p - value < 0.001) was observed across the studies hence, a random effect meta-analysis model was employed to estimate the pooled effect. Moreover, to detect the presence of publication bias, we did Begg’s and Egger’s tests. However, none of the tests were revealed significant publication bias with p - value of 0.8 and 0.08 respectively.

The pooled odds ratio of the association between institutional delivery and exclusive breastfeeding in Ethiopia

We conducted this systematic review and meta-analysis to estimate the pooled prevalence of EBF practice in Ethiopia and its association with ANC and institutional delivery. In Ethiopia, conducting this type of study will be paramount as input for program planners and policy makers working in the area of breastfeeding. The result of 32 included studies noted that the pooled prevalence of EBF in Ethiopia was 59.3% (95% CI: 53.8, 64.8%). The overall prevalence indicated in this meta-analysis is higher than a meta-analysis conducted in Iran (49.1%) [ 85 ]. In addition, this finding is higher than the national prevalence reported from other Sub-Saharan African countries included: Cameroon (28.2%), Nigeria (17.4%), Benin (43.1%), Burkina Faso (50.1%), and Ghana (52%), [ 86 ]. On the other hand, our finding is slightly lower than the national prevalence of Malawi (61.2%), Kenya (61.4%), and Peru (68.4%) [ 86 ]. The possible explanations for the above variations could be due to methodological differences (i.e., data analysis and sampling of study participants), variation in infants and maternal sociodemographic characteristics, economical, and health service utilization. Moreover, the higher prevalence of EBF in this meta-analysis could be attributed to the implementation of different strategies by the Ethiopian Government including the Health Extension Program [ 87 ].

In this study, we also performed sub-group analysis based on the study areas (i.e. Regions of the country) where the studies were conducted. The findings of the subgroup analysis indicated that extreme variability was observed in the prevalence of EBF across the regions of the country. The highest (65.6%) prevalence of EBF was reported from the Afar region, whereas the lowest (45.4%) prevalence of EBF was reported from Addis Ababa. The possible explanation for this variation could be due to the cultural variation across the regions of the country. In studies conducted in the Afar region, pastoralist communities were involved [ 88 ]. Therefore, the higher prevalence of EBF in Afar region could be due to the norm and culture to breastfeed the babies in the pastoralist communities [ 21 ]. Another possible explanation might be the difference in the implementation of health extension program [ 50 ]. Moreover, the high prevalence of EBF in Afar region could be also attributed to most of the women spent their time at home. Evidences suggested that mothers working at home is a major enhancing factors of exclusive breastfeeding [ 89 , 90 ].

In this meta-analysis, we tried to describe the linear trend of exclusive breastfeeding in Ethiopia for the past ten years. From the result, we observed that the practice of exclusive breastfeeding practice was slightly increased from 34% in 2007 to 86.1% in 2017. The possible justification for the increased in the practice of EBF could be due to the fact that, the Ethiopian government has developed and implemented different infants and young child feeding guidelines and giving appropriate emphasis to key messages on exclusive breastfeeding practice since 2004 [ 91 ]. Additionally, different interventions are also launched as breastfeeding promotions have been given at health institutions and at the community level by community health extension workers and other healthcare providers [ 50 ]. Health information dissemination using different means, the preparation of training manuals and guidelines are some of the intervention strategies launched to enhance exclusive breastfeeding [ 28 ]. These factors could have a great contribution for the successive increment of exclusive breastfeeding through each year.

The current meta-analysis was also examined the association between ANC and EBF in Ethiopia context. Accordingly, antenatal care was significantly associated with exclusive breastfeeding. Mothers who had ANC visits were almost 2.1 times more likely to practice exclusive breastfeeding as compared to mothers who hadn’t received antenatal care. This finding is consistent with the studies conducted in Rawalpindi [ 92 ] and Singapore [ 93 ]. This could be due to the fact that mothers who had ANC visit may receive different nutritional and other health related educations from health professionals during their follow up time these might have a great impact on exclusive breastfeeding [ 16 ]. Another conceivable explanation could be the increased knowledge and attitudinal changes due to the information provided by the healthcare professional about infants feeding and the nutritional values of breast milk.

Mothers who gave birth at a health institution were almost 2.2 times more likely to practice exclusive breastfeeding as compared to those who gave birth at home. This finding is in agreement with studies conducted in Ghana [ 94 ], India [ 73 ], Tanzania [ 95 ]. This might be because mothers who gave birth at health institution have a good opportunity to receive postnatal counseling regarding the importance of EBF, good position and attachment of breastfeeding from healthcare professionals. Supportive findings indicated that postnatal counseling regarding EBF have a great contribution to practice exclusive breastfeeding [ 23 ]. On the other hand, our finding contradicts with a study reported from Canada [ 96 ]. This study indicated that mothers who gave birth at home were more likely to practice EBF as compared to their counterparts. This controversy finding could be explained by socioeconomic and cultural variation across the study participants.

Limitations of the study

Like other meta-analysis, this meta-analysis has several limitations. The first limitation of this study was only English articles or reports were considered to conduct this nationally based review. In addition, the majority of the studies included in this review were cross-sectional in nature as a result; the outcome variable might be affected by other confounding variables. Moreover, most of the studies included in this review had a small sample size. Therefore, this factor could affect the estimated reports. Furthermore, this meta-analysis represented only studies reported from seven regions of the country. Therefore, the regions may be under-represented due to the limited number of studies included.

The overall prevalence of EBF practice in Ethiopia was significantly low as compared to the global recommendation level of breastfeeding. Mothers who received ANC and an institutional delivery were significantly associated with the better EBF practice. Therefore, based on our findings, we strongly recommended that healthcare workers (midwives and obstetricians) should give a special emphasis to encourage mothers to attend antenatal and postnatal care to improve EBF practice as an opportunity to teach mothers about the importance of exclusive breastfeeding. In addition, improving utilization of antenatal care and institutional delivery through health extension workers are essential interventions to increase exclusive breastfeeding practice. Moreover, besides the institutional level, health extension workers shall give infant and young children feeding advice/counseling at the community.

Abbreviations

Antenatal Care

Demographic and Health Survey

Exclusive Breastfeeding

Ethiopian Demographic and Health Survey

Health Sector Development Plan

World Health Organization

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Animut Alebel

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Alebel, A., Tesma, C., Temesgen, B. et al. Exclusive breastfeeding practice in Ethiopia and its association with antenatal care and institutional delivery: a systematic review and meta-analysis. Int Breastfeed J 13 , 31 (2018). https://doi.org/10.1186/s13006-018-0173-x

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Knowledge and practice of exclusive breastfeeding among mothers in the tamale metropolis of Ghana

• Ruth Nimota Nukpezah   ORCID: orcid.org/0000-0002-4560-3329 1 ,
• Samuel Victor Nuvor 2 &
• Jerry Ninnoni 3  

Reproductive Health volume  15 , Article number:  140 ( 2018 ) Cite this article

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The prevalence of exclusive breastfeeding (EBF) for the first six months of life has remained low worldwide and in Ghana, despite strong evidence in support of its practice. This study was aimed at assessing the knowledge and practice of exclusive breastfeeding among mothers in the Tamale metropolis of Ghana.

In a descriptive cross-sectional study, 393 mother-infant pairs attending child welfare clinics from three health facilities in the Tamale Metropolis were surveyed. A structured item questionnaire was used to collect data on the socio-demographic Characteristics of the participants, their knowledge regarding breastfeeding and level of practice of exclusive breastfeeding (EBF). The results were presented in frequency counts, percentages and inferences were made using a contingency table and chi-square values were computed to check for the relationship between participants demographic characteristics, the Knowledge and the practice of EBF and P value was set at 0.05.

The Analysis of the data was done with SPSS version 20. The study surveyed a total of 393 mothers from Tamale metropolis, of whom 27.7% reported having exclusively breastfed their infant for the first 6 months of life. The socio-demographic of the participants showed that they all had some level of education. The study revealed that 39.4% initiated breastfeeding within one hour after birth. Majority of participants had heard of EBF 277 (70.5%), about 344 (87.5%) of participants believed that EBF should be practised for 5 months in their locality. Pearson Chi-square test of the association between sociodemographic characteristics associated and EBF showed a significant association between EBF and the sex of the child, X 2  = 4.177, P  = .041. Whiles, EBF and the Knowledge on child spacing was X 2  = 17.769, P  < .001 and EBF and knowledge on Breast cancer reduction was also significant X 2  = 4.384, P  = .036.

Conclusions

Although all the participants had some level of education background, a majority did not have adequate knowledge on EBF and EBF practice was low in the study community. Thus, we suggest improved education at the child welfare clinics and the media should be used as a platform to educate women adequately about importance of EBF.

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Plain English

The factors contributing to the reduced rate of EBF practice in developing countries such as those in Africa has been shown to include: lack of knowledge about benefits of breastfeeding, lack of maternal decision-making power, work schedules, recommencing work after maternity leave, lack of support, traditional beliefs and practices. To address the issue, this study explored the knowledge and practice of Exclusive breastfeeding among mothers attending post-natal clinics in the Tamale metropolis. In a descriptive cross-sectional study, 393 mother-infant pairs attending child welfare clinics from three health facilities in the Tamale Metropolis were surveyed.

A structured item questionnaire was used to collect data on the socio-demographic characteristics of the participants, knowledge of mother regarding breastfeeding and level of practice of exclusive breastfeeding. Data analysis was carried out with the aid of IBM Statistical Package for the Social Sciences (SPSS) version 20 for Windows and reported using, tables and prose. The study revealed that though the participants all had some level of education, a majority believed that EBF for a child should be less than 6 months after birth, hence, majority of the participants had inadequate knowledge on EBF. To add to this, the rate of EBF practice was found to be low in the study area.

Breast milk has the essential nutrients that a newborn need to grow healthy and strong. Infants who are exclusively breastfed develop fewer infections; have less severe illnesses and mothers who practice EBF enjoy the benefit of extended lactation amenorrhea [ 1 ]. Adequate knowledge about exclusive breastfeeding is said to be the fundamental tool that can direct the course of EBF practice among mothers [ 2 , 3 ]. Yet [ 4 ], indicated that most mothers have knowledge of EBF 97.6%, but only 64.6% have adequate knowledge and mother’s higher knowledge about breastfeeding correlated with longer duration of practice. Meanwhile [ 5 ], in a study on knowledge of the importance of EBF for the first 6 months, also showed that the knowledge level of participants was (35.7%), this figure was seen to be relatively high. Yet, only about half of the participants (17.9%) practised EBF.

The risk of conditions such as, breast and ovarian cancer is lessened among mothers who adequately practice EBF [ 1 ]. World health organization indicated that EBF protective effect is not limited to the lactation period; it persists for years even after termination of breastfeeding. The benefits of EBF are bigger in settings of poverty, poor nutrition and poor hygiene, where baseline disease rates are higher. This is because giving babies other feds before six months is often associated with errors of contamination during the preparation and administration process. These errors can further lead to diarrheal diseases like cholera and dysentery which can culminate in childhood mortality [ 1 , 5 ].

According to [ 6 ], with EBF coverage of 90%, about 13% of deaths of children less than 5 years could be averted in low and middle-income countries. This assertion is in line with other researchers who opined that initiation of breastfeeding within the first hour of birth may lead to the prevention of about 20% of neonatal deaths [ 7 , 8 ] In low-income/middle-income countries. And optimal breastfeeding has the potential of preventing 12% of all under-5 deaths [ 9 ]. Children who are exclusively breast fed have been shown to be less susceptible to childhood diseases and are 14 times more likely to endure ill-health compared with those who are not breastfed [ 10 ].

Childhood mortality is high in low and middle-income countries where EBF prevalence is low. In Ghana for instance, the recorded rate of infant mortality is 53 per 1, 000 live births while mortality rate of children younger than 5 years is 31 per 1000 live births and these death ratios is partly due to inadequate EBF practice of mothers [ 11 ].

Other studies undertaken in Ghana also concluded that neonatal deaths could be prevented if all infants start breastfeeding within the first hour of birth [ 12 ].

Some of the interventions and policies introduced in Ghana to help encourage EBF practice are infant and young child feeding (IYCF) program, convention on the rights of the child and baby friendly Hospital initiative [ 6 ]. Despite the enactment of these policies, the rate of EBF in Ghana is still lower than the WHO's set goal of 90% for EBF. A report from Ghana multiple indicator cluster surveys showed that EBF in Ghana dropped drastically from 63.7% in 2008 to 46% in 2011 [ 12 ]. More specifically, the rate of EBF in Tamale was 63.3%. In effect, the rate of EBF is low globally (39%), with 36% occurring in low-income countries [ 1 ]. Several factors have been identified as impediments to proper nutrition and infant feeding habits. Substantial among them are, the perceptions surrounding infants feeding practices and inadequate information and support on good feeding practises, especially EBF for the first six months of life [ 13 ]. However, from the literature reviewed at the start of this study, there was no documented literature on the related factors associated with the knowledge and practice of EBF in the Tamale metropolis and no study had coved a vast majority of EBF among lactating mothers in the major Hospitals of the Region. This paper discusses the knowledge and practice of EBF among mothers visiting the child welfare clinics at Tamale West Hospital, Tamale Central Hospital and the Tamale Teaching Hospital in Ghana.

Research methods

Study setting.

Tamale is the capital of Northern Region of Ghana and the metropolitan assembly is one of the 20 administrative districts in the Region. The Metropolitan is divided into three Sub-Metros; Tamale North Sub-Metropolitan, Tamale Central Sub-Metropolitan and Tamale South Sub-Metropolitan. Tamale Teaching Hospital (TTH), Tamale West Hospital (TWH) and Tamale Central Hospital (TCH) are the three main public facilities in the Region. Tamale Teaching Hospital is a tertiary referral Centre for the three northern regions. Tamale West Hospital and TCH are secondary level service point. These health facilities provide maternal and neonatal Care services that enriched the study objectives.

The study populations were resident, lactating mothers of the Tamale Metropolitan area with a child of at least six months and at most two years at the time of the research. The participants attended child welfare clinic (CWC) in Tamale Teaching Hospital, Tamale West Hospital or Tamale Central Hospital. Using mothers who attend CWC at these facilities was useful to the study because these facilities are the main public facility in the region and has lots of client’s patronage at the CWC. The annual estimate of the population of women who attends CWC at the selected Hospitals in 2015 was: TTH = 5986, TWH = 2999 and TCH = 2995. Total = 17,960.

Inclusion criteria

Lactating mothers who had children from ages 6 months - 2 years attending the Child Welfare Clinic (CWC) at Tamale Teaching Hospital, Tamale West Hospital and Tamale Central Hospital.

Exclusion criteria

The study excluded lactating mothers having children with Medical Conditions that prevented the practice of EBF such galactosemia and mothers who were unwilling and mothers with children less than 6 months.

Sampling procedure

Sample size determination.

The desired sample was obtained using the Cochran’s formula for calculating sample size n  =  z 2 pq / d 2 [ 14 ].

Where: n = desired minimal sample population.

z = standard normal deviate which is 1.96 at 95% confidence level.

p  = 63.3% (2011 estimated figure of exclusive breastfeeding rate in Tamale [ 12 ]).

d = degree of accuracy 5%.

Hence substituting the value into the formula: n  =  z 2 pq / d 2 .

To address the possibility of non-response/incomplete questionnaires and attrition, 20% was added to the calculated sample size.

Hence, a total sample size of 428 working mothers with infant pairs was estimated for the study.

Sampling methods

Three types of sampling methods were used at different stages of the study. First and foremost, three Hospitals in Tamale Metropolis were purposively sampled. The Hospitals were: Tamale Teaching Hospital (TTH), Tamale West Hospital (TWH) and Tamale Central Hospital (TCH). These Hospitals were selected as these facilities are the major Hospital in the metropolis, the Hospitals serves as referral centers for clients from the surrounding district and the Hospitals had a child welfare clinic. Secondly, a quota sampling was used to calculate the sample size for each Facility [ 14 ]. Described quota sampling as a type of non-probability sampling where participants were selected non-randomly, based on their known proportion to the population.

The sample size for each facility was estimated proportional to their population size. We recruited an equal proportion of working mothers with infant’s pair from Tamale West Hospital and Tamale Central Hospital, but the proportion was doubled in Tamale Teaching Hospital because of the population size was twice of the Tamale West Hospital and Tamale Central Hospital respectively. Thus, TTH = 5986, TWH = 2999, TCH = 2995, summing up to 17,960 population size. Using, \( Sample\kern0.5em fraction\kern0.5em (f)\kern0.5em =\kern0.5em \frac{sample\kern0.5em size\kern0.5em (n)}{targeted\kern0.5em population\kern0.5em (N)} \) [ 14 ].

This extrapolates to sample size of Tamale Teaching Hospital 214, the sample size of Tamale West Hospital 107, and 107 for Tamale Central Hospital. This gives a total of 428 sample size.

Thirdly, at the facility level, simple random Probability sampling method was used to select the participants. [ 14 ] indicated that probability sampling allowed researchers to make a generalization to the population defined by the sampling frame, whereas nonprobability sampling does not make room for generalization to be made beyond the sample. This assertion informed the researcher’s decision to use a simple random sampling technique to enlist the participants.

The participants were recruited by the researcher within eight (8) consecutive weeks in each of the health facilities. Simple random sampling (balloting) technique was utilized. On each clinic day, a list of mothers- infants pair who were registered for weighting and immunization was used as a sampling frame, they were assigned identification (ID) numbers. The numbers were listed in separate pieces of papers and placed into a bag. The papers were shuffled after which ballots were drawn from the bag without replacement. This exercise was repeated on each clinic day until the required sample of 428 (100%) participants was attained.

The pilot study was conducted among 10 mother-infants pair of similar age (6 to 24 months) in Savelugu Hospital which is a neighbouring community. Based on the responses that were received, appropriate modifications were made to the questionnaires to ensure accuracy, clarity and reproducibility. In addition, Correlation coefficient to check for the instrument’s internal consistencies was also determined using SPSS Cronbach correlation formula . The tools were accepted with the coefficient of 0.877.

Data collection procedure

The research instrument used was a self-administered questionnaire. According to [ 14 ], questionnaire enhances greater privacy and reduces the incidence of bias responses which is often associated with other data of collection instrument such as interviews. The questionnaire consisted of two sections derived from the aim of the study: Knowledge and the practice of Exclusive breastfeeding.

Data were collected at the child welfare clinic of the selected hospitals and the mothers were given an average time of 15-min each to answer the questionnaires. About 428 questionnaires were given out. Only the 393 questionnaires which were completely answered were used for the final analysis. The data collection instrument (questionnaire) was in the English language. For participants who could not read well/understand some of the questions, the question items were read to them and appropriate options chosen by the clients was marked. The questionnaire comprised Yes/No questions on the level of practice of EBF and some categorical itemized questions about the participant's knowledge of EBF. The total number of questions were 25.

Data processing and analysis

Data analysis was carried out in June with the aid of IBM Statistical Package for the Social Sciences (SPSS) version 20 for Windows and reported using, tables and prose. The process for the data analysis included; data coding, sorting, cleaning, editing and checking for errors and biases by doing a thorough counting of the study question items and frequency of occurrences, the grouping of collected data, checking for minimum and maximum counts and analysing and discussing of data. The questionnaire was given to my supervisors to review and the analysis that was done after the study was also given to them to cross-check for approval. A descriptive table was drawn to show the socio-demographic, practice of EBF and Knowledge of participants about EBF. Further inferences were made using a contingency table and chi-square values was computed to check for the relationship between participants demographic characteristics, the Knowledge and the practice of EBF and P value was set at 0.05.

Results and discussion

The data were analysed using frequencies, percentages and prose. The analysis also included cross-tabulation and Pearson chi square test. Some responses were scored dichotomously as Yes = 1 and No = 0 and some questions were multi choice responses. Eight (8) knowledge questions and 8 demographic characteristics questions were presented respectively, whiles the practice Item questions were Nine (9). In carrying out this study, the researcher used a sample of 428 respondents and a total of 428 questionnaires was distributed to the lactating mothers. However, 393 questionnaires were returned fully answered with other questionnaires having 35 missing data. Therefore, the sample size for answering the research questions was 393 indicating 91.8% of total response rate.

Results on socio-demographic characteristics of participants

The distribution of demographic data of respondents involved in the study. From Table  1 , the majority, 204 (51.9%) of the respondents were JHS level and lower, SHS were 100 (25.4%), and lastly, those who had attained tertiary levels were 89 (22.6%). The study, therefore, revealed that majority of the respondents involved in the study were having some form of education. Other sociodemographic characteristics of respondents are summarized in Table 1 .

Results on practice of EBF among participants

From Table  2 , only 109 (27.7%) practiced EBF and 157 (39.9%) still breastfeed baby. In addition, 52 (13.2%) expressed breast milk when away from baby. In conclusion more than half of the participants claimed that their index child has being having episodes of childhood common ailment 260 (66.2%).

Table  3 also showed that the majority, 155 (39.4%) of the respondents-initiated breast feeding within one hour after birth. Again, 195 (49.6%) of the respondents indicated they gave prelateral feeds to their infants during the first six months, 124 (31.6%) indicated not applicable and 74 (18.8%) indicated they give mashed family foods to their infants during the first six months.

The participants gave a lot of reasons for introducing early feeds to their baby as summaries in the table. Regarding the age at which mothers started giving food to their babies, it was realized that majority had introduced feeds to their baby as early as first (1) and second (2) months respectively. At five months, 31 (7.8%) started taking feeds and at six month, 17 (4.3%) babies also started eating.

Results on the knowledge of EBF among participants

The result on knowledge as seen in Table  4 , majority 277 (70.5%) of the participants had heard about EBF, surprisingly most people choose the electronic media 209 (53.2%) as compared to health professionals 135 (34.4%) as their major source of information. Concerning initiation, the majority concorded that EBP should be started immediately after birth 290 (73.8%). It was also noted that majority believed that EBF should be practice for less than 5 months for a child. The table further summarised the rest of the discriptive findings on the knowledge of the participants on EBF.

Results on the factors associated with EBF

Tables 5 and 6 shows the summary of cross tabulation between EBF, demographic characteristics and some knowledge Characteristic respectively.

Discussions of research findings

This research study surveyed a total of 393 mothers from Tamale metropolis, of whom 27.7% reported having exclusively breastfed their infant for the first 6 months of life. The socio-demographic of the participants showed that they all had some level of education. Secondly, most of the lactating women were workers and were middle-income earner who earned between 1000 and 2000 per month. A great majority were matured, they were above 25 years. Literature has shown that there is substantial evidence that breastfeeding women encounter demographic challenges that may affect the initiation and duration of BF. Women who graduated from high school were 70% more likely to breastfeed than those who did not; women who attended college were four times more likely to breastfeed than women who graduated from high school [ 13 ]. In a national study in rural Ghana, education, occupation, economic factors and marital status were the factors affecting EB [ 15 ]. In contrast, to this finding, an inverse relationship was observed in developing countries. This was possibly due to a perception that ‘breastfeeding was old fashioned’ or an indication of ‘lesser social status’. There is an association between higher education and socioeconomic status, this increases the mother’s ability to purchase infant formula. In addition to educational attainment, maternal age has been identified as among the factors most strongly influencing the initiation, duration and level of infant feeding [ 16 ].

It was observed in this study that mothers who were practising EBF were 27.7% which was far below the WHO recommendation of 90% [ 1 ]. Also, in a recent study at Tuna, a rural co-district capital of the Sawla-Tuna-Kabla district in the Northern Region of Ghana, a slightly lower rate of 42.0% EBF was realized [ 17 ]. These demonstrate a wide gap between the desired and the actual practice of EBF in the study area. The low practices of EBF in this area could be due to low knowledge of EBF, since the study revealed that most mothers did not get information regarding EBF from their health providers. Hence, majority of the mothers were not having knowledge on the need to initiate breastfeeding within early. Majority of the lactating mother had some form of academic education, but this did not translate to their practice of EBF. As seen in the demographic characteristics. The low EBF could be due to lack of time to breastfeed the babies, or the social acceptance and recognition’s given to breast baby feeds or the inadequate knowledge on EBF. Furthermore, the study was carried out on mothers at the antenatal clinics of the hospitals in the Tamale metropolis, a regional capital, and one would have expected them to acquire enough knowledge about EBF and practice EBF, but that was not the cause among the people of Tamale metropolis. In addition, it was also realized that inefficient baby-friendly initiative program might have also been practised at the hospital centers where the study was conducted. Mothers who delivered in baby friendly hospital units are more likely to be knowledgeable about EBF than mothers who did not attend these facilities [ 17 ]. A similar observation was also noted in Kware town of Sokoto State of Nigeria where only 31% of the mothers had adequate knowledge of exclusive breastfeeding [ 18 ]. Another related study in a similar socio-cultural background also revealed that only 31% of the mothers had adequate knowledge regarding EBF [ 19 ]. The knowledge about exclusive breast feeding (EBF) and the practice may depend upon the hospital facilities and their policies in caring for pregnant and lactating mothers after delivery. If there has been a policy to educate pregnant mothers on EBF before and after delivery at various hospitals it would have reflected in their care of the newborns. However, high EBF was noted in some other part of Nigeria where the practice of EBF rate was 75.6% among nursing mothers [ 20 ]. It was asserted that the high prevalence of EBF in those studies was because the mothers were mostly workers and took their children with them when they were working, and this makes easier the fostering of EBF practice among mothers. This assertion was also noted by Gladzah, with non-working mothers who were constantly available to breast feed their babies [ 21 ]. The Tamale metropolis is in the temperate zone, and because of the sunny and draughty nature of the weather, this might have compiled the mothers to state complementing breastmilk with other liquid diets for the child for six months of age.

Pearson Chi square test of the sociodemographic characteristics associated with EBF showed a significant association between EBF and the sex of the child, X 2  = 4.177, P  = .041. Whiles, EBF and the Knowledge on child spacing was X 2  = 17.769, P  < .001 and EBF and knowledge on Breast cancer reduction was X 2  = 4.384, P  = .036.

This means that mothers who had adequate knowledge about EBF did practice exclusive breastfeeding. This current finding confirms the observation by Mercer on the maternal role attainment theory [ 22 , 23 ], that stated that in the first stages of “commitment, attachment, and preparation” during pregnancy, the mother acquires the knowledge of breastfeeding and makes a psychological adjustment and prepares for the expectations of her new role. Thus, from the time of birth of infants when motherhood is implicit and understood in the contexts of her social structure, mother’s knowledge of EBF influences the practice [ 21 ]. This clearly shows that mothers in this study had not fully achieved this phase of knowledge involved in maternal role identity and EBF decisions making. Similar to this finding [ 18 ], opined that knowledge on EBF significantly influenced exclusive breastfeeding among working mothers. In fact, the understanding of the importance of breastfeeding helped mothers adhere to EBF practice.

Limitations

This study was mainly a cross-sectional study design. Also, the study participants may present recall bias since infants up to 2 years were included. And lastly, from literature reviewed, perception of mothers was one of the factors that affected EBF, but this was not measured in the current study.

Though majority of the participants had some level of education in the Tamale Metropolis, they had inadequate knowledge about EBF and the rate of EBF was awfully low. Therefore, there was poor knowledge and practice with regards to EBF for the first six months among postpartum mothers in the Tamale Metropolis. These underscore the need to give individual counselling sections to the women at every available opportunity, telling them the importance of EBF to their babies and the women themselves to improve their knowledge about breastfeeding and ultimately their breastfeeding practices.

Abbreviations

Child welfare clinic

• Exclusive breastfeeding

Tamale Central Hospital

Tamale Teaching Hospital

Tamale West Hospital

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Acknowledgements

The authors acknowledge the mothers in the Tamale Metropolis who provided the information used for the study. The University of Cape Coast, Tamale Teaching and the other associated district hospitals also appreciated for the opportunity given to us to carry out this research.

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The datasets upon which analysis and conclusions were made are available and will be offered upon reasonable request.

Ethics approval and consent to participants

Ethical clearance was obtained from the University of Cape Coast Institution Review board on the 9TH March 2016 (Ref: UCC/IRB/3/45) to carry out the research in Tamale. The Tamale regional Health Directorate also gave permission for the study to be carried out at two district Hospitals; West Hospital and Central Hospital. Additionally, permission for the research was also granted by the Tamale Teaching Hospital ethical review board. Participants were assured of privacy and confidentiality and Informed consent was obtained from all participants after the study had been explained to them.

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This article is an extract from the findings of my Master of Nursing thesis. RNN designed the study, developed the questionnaire and wrote the paper. SVN and J N were my first and second supervisors respectively, they both helped in making sure that I chose the right research methods and they gave suggestions to the appropriate tools to use. All authors coordination and helped to draft the manuscript. All authors read and approved the manuscript.

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Nukpezah, R.N., Nuvor, S.V. & Ninnoni, J. Knowledge and practice of exclusive breastfeeding among mothers in the tamale metropolis of Ghana. Reprod Health 15 , 140 (2018). https://doi.org/10.1186/s12978-018-0579-3

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Knowledge and Attitude towards Exclusive Breast Feeding among Mothers Attending Antenatal and Immunization Clinic at Dabat Health Center, Northwest Ethiopia: A Cross-Sectional Institution Based Study

Mulugeta wassie alamirew.

School of Nursing, University of Gondar College of Medicine and Health Sciences, P.O. Box 196, Gondar, Ethiopia

Netsanet Habte Bayu

Nigusie birhan tebeje, selam fiseha kassa, introduction.

To assess knowledge and attitude towards exclusive breast feeding among mothers attending antenatal care and immunization clinic in Dabat Health Center, Northwest Ethiopia, 2016.

Methodology

Institutional based descriptive cross-sectional study was conducted. The data was collected by using pretested, structured interview based questionnaires. The data were entered and analyzed using SPSS version 20.

A total of 384 participants were included in the study with a response rate of 100%. The majority were in the age groups of 20–30 (66.9%) and the mean age was 27.65; 325 (84.6%) were Orthodox Christianity followers. Majority were of Amhara ethnicity 370 (96.4%). Based on knowledge score, 268 (69.8%) were grouped as having good knowledge and regarding attitudinal score, 92 (24%) of the study participants were categorized as having negative attitude towards exclusive breast feeding (EBF) and the remaining 292 (76%) were categorized as having positive attitude.

In this study, the knowledge of study participant mothers towards EBF is low which is less than three-fourths; however positive attitude towards EBF is more than three-fourths in this study. The authors recommend that health care workers who work in the areas of maternal and child health clinic should give appropriate information about EBF.

1. Introduction

Human milk is the ideal nourishment for infants' survival, growth, and development. Particularly in unhygienic conditions, however, breast milk substitutes carry a high risk of infection and can be fatal in infants [ 1 ]. Breast milk contains all the nutrients an infant needs in the first six months of life. Exclusive breast feeding means that the infant receives only breast milk [ 2 ].

Exclusive breast feeding in the first six months of life stimulates babies' immune systems and protects them from diarrhea and acute respiratory infections [ 1 ]. Exclusive breast feeding for the first six months of life is now considered as a global public heath goal that is linked to reduction of infant morbidity and mortality, especially in the developing world [ 3 ].

The world health organization (WHO) recommends exclusive breast feeding (EBF) for the first six months of life while it is advised to provide adequate and safe complementary foods with breast feeding for up to two years and beyond. EBF remains uncommon in most countries (both developed and developing), even in countries with high rates of breast feeding initiation. EBF rates in infants less than six months of age varied from as low as 20% in central and eastern European countries to 44% in south Asia [ 2 , 4 ].

In Africa, more than 95% of infants are currently breastfed, but feeding practices are often inadequate; feeding water and other liquids to breastfed infants is a widespread practice [ 5 ]. The risk of morbidity is reduced by close to 70% when a child is exclusively breastfed. Exclusive breast feeding protected against serious morbidities in the first six months of life [ 6 ]. Research conducted at Ibadan, Nigeria, revealed that prevalence of mothers' knowledge towards EBF is still low, which accounts for about 36.2% and the same thing is true in Ethiopia, where it accounts for about 34.7% [ 7 , 8 ]. Even though many researches are done about mother's knowledge and attitude towards exclusive breast feeding in many areas of Ethiopia, no research is done about it in and around Dabat Health Center. Due to this fact, this research is initiated and conducted, with the objective of assessing the knowledge and attitude towards exclusive breast feeding among mothers attending antenatal care and immunization clinic in Dabat Health Center, North Gondar zone, Northwest Ethiopia.

2.1. Study Design and Period

Institutional based descriptive cross-sectional study was conducted from March 10–30/2016 Gc.

2.2. Study Area

This study was conducted in Dabat Health Center. Dabat is found in northeast of Gondar 814 km far from Addis Ababa, the capital city of Ethiopia, and about 70 km from Gondar, the administrative town of North Gondar zone. It is about 2700 m above sea level. Currently, it has one health center and 3 health posts in the town plus 5 health posts around it. The current population is about 49,000.

2.3. Participants

Participants were all mothers visiting antenatal care and immunization clinic in Dabat Health Center during data collection.

2.4. Sample Size Determination and Sampling Technique

2.4.1. sample size.

We used single population proportion formula by taking proportion of knowledge of mothers towards exclusive breast feeding 65.1% from the previous research [ 9 ] and we used 95% confidence interval. To adjust nonresponse rate of study participants, we added 10% of the sample size.

where a is the level of significance which can be obtained as 1 − confidence interval, P is the prevalence of proportion of mothers' knowledge towards exclusive breast feeding which is equal to 65.1, w is the maximum acceptable difference (margin of error) which is equal to 5%, and Za /2 is the value under standard normal table for the given value of confidence level which is equal to 1.96.

2.5. Instruments

Data collection instruments consist of sociodemographic questionnaire (age, religion, ethnicity, marital status, educational status, occupation, residency, parity, gravidity, and ANC). To assess knowledge about exclusive breast feeding (EBF), nine knowledge questions were used (knowledge about exclusive breast feeding, the right time to give breast milk to a child after birth, what you do with the first milk or colostrum, right time to start complementary foods in addition to breast, foods and/or fluids recommended to give to a child under 6 months, if prelacteal feeding needed for an infant before starting breast milk, breast milk alone without water and other liquids being enough for an infant during the first 6 months of life, and exclusive breast feeding for the first 6 months being used to prevent diarrheal and respiratory diseases for the infant) and for assessment of attitude based on Likert scale (1 = strongly agree, 2 = agree, 3 = disagree, and 4 = strongly disagree) [ 4 ], attitude questionnaire was used. An average of responses on knowledge variables was done by computing variables and mothers who scored less than the average is labelled to have poor knowledge and those scored equal to or above the average score were considered as having good knowledge and all the attitude variables were computed and averaged. Those scored below the average were considered with negative attitude and those scored equal to or above the average were considered with positive attitude.

2.6. Data Collection Methods

A structured and pretested interviewer administrated questionnaire was used to gain data from study participants. First the questionnaire was translated to Amharic language which is a local language in understandable way to exclude misunderstanding to assure data quality. The questionnaire includes sociodemographic characteristics, knowledge, and attitude of study participants towards EBF.

2.7. Data Quality Assurance

Data quality was assured by using different approaches. First adequate orientation was provided for data collectors. After that, 5% of the questionnaires were pretested on volunteer mothers who have similar characteristics with study population in the same area who are not included in the study. After pretest, some questions were modified.

2.8. Data Processing and Analysis

After checking the completeness and appropriateness, the data were entered and coded into SPSS version 20.0 statistical package software for analysis. The result is presented in the form of frequencies and percentages by using tables, charts, and text.

2.9. Ethical Considerations

Ethical clearance was obtained from University of Gondar, College of Medicine and Health Sciences School of Nursing. All process was started after securing written permission from the School of Nursing Office. A permission letter obtained from School of Nursing was submitted to Dabat Health Center Office which is involved in the study. The study subjects were informed clearly and in detail about the importance of the study and a written consent was obtained. They have the right to refuse and withdraw from participating in the research without any explanation and they have the right to ask any question any time. In addition, the name of the study subjects was not included in the questionnaires which would address concern of the study subject.

3.1. Sociodemographic Characteristics and Obstetrical History of Study Participants

A total of 384 mothers were interviewed successfully in this study which makes the response rate 100%. Majority of study participants were in the age groups of 20–30 (66.9%) and the mean age was 27.65, 325 (84.6%) were Orthodox Christianity followers, 56 (14.6%) were Muslims, and 3 (0.8%) were Protestants. Majority were Amhara ethnicity 370 (96.4%), 322 (83.9) were married, 33 (8.6%) were living together, 114 (29.7%) were not able to read and write, and 78 (29.7) completed secondary school. 173 (45.1%) were housewives and 82 (21.4%) were government employee. Majority 199 (51.8%) had four times ANC follow-ups. Eighty point five percent had 1–3 gravidity, and 67.7% had parity of 1–3. Majority (63.5%) of the respondents were urban dwellers while 36.5% lived in the rural areas ( Table 1 ).

Sociodemographic characteristics of the respondents in Dabat Health Center, Northwest Ethiopia, 2016. n = 384.

3.2. Knowledge of Study Participants towards Exclusive Breast Feeding

From the total study participants, based on knowledge score, 268 (69.8%) of the respondents were grouped as having good knowledge and 116 (30.2%) of the study participants were categorized as having poor knowledge. Three hundred fifteen (82%) knew about EBF and 69 (18%) do not know about EBF. Their major source of information was health institutions 255 (66.4%). Two hundred sixty-nine (70%) have good knowledge about right time to give breast milk to a child after birth.

One hundred seventy-four (45.3%) of the respondents have poor knowledge to give the first milk (colostrum) to the newborn, while 210 (54.7%) have good knowledge about it. The majority 250 (65.1%) knew that breast milk alone is enough for infants less than 6 months but 99 (25.8%) answered that breast milk alone is not enough for the infant under 6 months. Two hundred thirty-four (60.9%) of the participants knew that EBF prevents diarrheal and respiratory diseases as it is shown in Table 2 .

Knowledge of study participant mothers towards exclusive breast feeding, Dabat Health Center, Northwest Ethiopia, 2016. n = 384.

3.3. Attitude of Study Participants towards Exclusive Breast Feeding

From this study based on the attitudinal score, 92 (24%) of the study participants were categorized as having negative attitude towards EBF and 292 (76%) were categorized as having positive attitude towards EBF. From study participants, 109 (28.4%) and 130 (33.9%) of them strongly disagree and disagree to the opinion discarding colostrum (first milk), respectively. For the opinion that starting complementary foods before 6 months is important, 12% strongly agree, 15.9% agree, 44% disagree and, 28.1% strongly disagree ( Table 3 ).

Attitude of study participant mothers towards exclusive breast feeding (EBF) in Dabat Health Center, Northwest Ethiopia. n = 384.

4. Discussions

This study shows that mothers who have good knowledge towards EBF are 69.8% which is higher than a study conducted in Abha city, Saudi Arabia, which was 55.3% [ 10 ], and Nigeria that was 31% [ 11 ] and Guba Lafto woreda, Ethiopia (65.1%) [ 9 ]. Contrary to this, the finding is lower than a study conducted in Calabar, Nigeria, which was 80% [ 12 ] and Bedele town in Ethiopia where it is was 87.3% [ 13 ]. These differences may be due to variations in sampling technique, sociocultural status of study participants, health care delivery systems, and economic status of study participants.

In the current study, the knowledge of initiation of breast feeding is 70% which is less than that from a study conducted in Mizan Aman town of Ethiopia that was 73.3% [ 8 ] while it is much higher than that in a study conducted in Odisha which was 52.78% [ 14 ] as well as Tanzania which was 58.8% [ 15 ]. The above dissimilarities may be due to the differences of sample sizes and health care delivery systems.

Knowledge of respondents on colostrum in this study is 54.7% (having good knowledge). This is less than a study conducted in Mangalore which was 86.6% and in a study conducted in Mizan Aman town of Ethiopia that was 60.2%. This difference might be due to the difference of sample size.

In this study based on the attitudinal score, 76% of the respondents have positive attitude towards EBF, while 24% have negative attitude towards EBF. The finding is slightly greater than reports done in Rwanda, Kigali, which was 71.1% [ 16 ] and in Jima town in Ethiopia that was 73.9% [ 17 ]. However, the finding was less than a study result made in Nigeria, which is 84.7%, and Mizan Aman town, which is 89.5% in Ethiopia [ 8 ]. The disagreement among these study results might be attributed to these dissimilarities due to the differences of study settings.

In this study, 66.4% of study participants have information about EBF and their source of information was health institutions. This is more than the study conducted in Mizan Aman town, Southwestern Ethiopia, which was 62.7%, while it is much less than the study conducted in Kigali, Rwanda, that was 74.4 [ 8 , 16 ]. And from this study, 29.4% mothers stated that babies before 6 months should receive BM and sugar. This is much less than the study conducted in Mvomero, Tanzania, which was 37.5% [ 15 ]. The difference may be due to methodological difference.

Limitations of the Study . Since it is difficult to generalize the result to the source population, this study shares the limitations of none probability sampling technique. This study also did not investigate the practice of exclusive breast feeding and it is only quantitative and not qualitative.

5. Conclusion

Knowledge of study participant mothers who attend ANC and immunization clinic towards exclusive breast feeding (EBF) is poor which is less than three-quarters. However, positive attitude towards EBF is more than three-fourths in this study. Based on this conclusion, health care workers who work in the areas of MCH clinic are better to give appropriate information about EBF to mothers who follow ANC and for those who come to immunization. In addition, health care providers who work in the areas of MCH should evaluate mothers' knowledge and attitude for every visit by asking questions related to EBF, health care officials of Dabat Health Center may play their role by actively following activities of health care providers of MCH, and health project implementers shall support and arrange training program for health care providers of MCH to improve mother's knowledge and attitude towards exclusive breast feeding.

Acknowledgments

The authors' great gratitude goes to University of Gondar College of Medicine and Health Science School of Nursing for providing logistic and material support to conduct this research. Finally, the authors' heartfelt thanks go to the supervisors and data collectors for their admirable endeavor during the data collection.

A. Information Sheet

A questionnaire prepared to assess Knowledge and Attitude towards Exclusive Breast Feeding among Mothers Attending Antenatal and Immunization Clinic at Dabat Health Center, North West Ethiopia, 2016.

Introduction . This information sheet and consent form is prepared to explain the study you are being asked to join. Please hear carefully and ask any questions about the study before you agree to join. Are wishing to participate, you need to understand and sign the consent form then you will be requested to give your response.

Purpose . The purpose of this research is to assess knowledge and Attitude towards Exclusive Breast Feeding among Mothers Attending Antenatal and Immunization Clinic at Dabat Health Center, North West Ethiopia. The study will be helpful in determining the current level of knowledge and attitude towards EBF.

Procedure . This study uses institutional based cross-sectional study design, through using interview based Questionnaire, mothers asked to respond to questions in voluntary bases.

Risk and/or Discomfort . There is no any risk or discomfort that the respondents will face by participating in this research except dedication of time for responding the questioner.

Benefits . If you participate in this research project, there may not be direct benefit to you but your participation is likely to help us in assessing the knowledge and your attitude towards EBF. Ultimately, this will help us to work on awareness creation on the benefits of EBF.

Incentives/Payment . There are no payments or incentives for respondents in this research.

Confidentiality . Any personal information registered in the questioner will not be copied and transferred to other bodies. All kinds of information will be kept confidential in a secured place.

Right to Refuse . You have full right to refuse or withdraw from participating in this research at any time you wish without losing any of your right.

B. Consent Form

Hello! Good morning/good afternoon, my name is —————— and I am a data collector from university of Gondar, school of nursing. Thank you for allowing us to share your precious time and for your willingness to participate in this study. The objective of this study is to assess knowledge and attitude of mothers towards exclusive breast feeding, among Mothers Attending Antenatal and Immunization Clinic at Dabat Health Center, Northwest Ethiopia. You are chosen to participate in this study and the study will take about 10 minutes to complete the questionnaire.

We would greatly appreciate your help in responding to this survey.

Are you willing to participate?

•   Yes
•   No

Thank you for voluntarily participate in the study!

C. Questionnaire

See Table 4 .

Questionnaire used to collect the research data.

(a) Sociodemographic characteristics

(b) Questions about knowledge of mothers towards exclusive breast feeding

(c) Questions related to attitude of mothers towards exclusive breast feeding

Conflicts of Interest

The authors declared that there are no conflicts of interest.

Authors' Contributions

Mulugeta Wassie Alamirew carried out the paper's conception, analysis, and interpretation of data and drafted the paper; Netsanet Habte Bayu participated in data collection and analysis; Nigusie Birhan Tebeje participated in data analysis, interpretation, and review of the paper; Selam Fiseha Kassa participated in data collection and analysis. All authors read and approved the final draft of the paper.