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

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

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

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

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

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

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

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

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

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

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

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

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