Exclusive breastfeeding and mothers’ employment status in Gondar town, Northwest Ethiopia: a comparative cross-sectional study

A community based comparative cross-sectional study was conducted from October 1-30, 2015. The two comparison study groups were employed and unemployed mothers. The study was conducted in Gondar Town, Northwest Ethiopia. Gondar town is located at 737 km from the capital of Ethiopia, Addis Ababa. The town administration is organized into 12 urban kebeles (smallest administrative units). Based on the 2007 national population census projections, the town has a total of urban population of 206,987 and among these 8002 were infants, aged less than one year, from which are 6263 were children aged between 7 and 12 months [11].

All mothers having children of age 7-12 months and living in the town administration during the study period were included in the study. However, employed and unemployed mothers with children of age 7–12 months who were critically ill and unable to be interviewed were excluded.

The sample size was determined using Epi info statistical software version 7 by using ‘two population’ proportion formula. In a similar study conducted by Mequanint [12] prevalence of exclusive breastfeeding differences among employed and unemployed mothers were found to be 44% and 65%, respectively. A confidence level of 95%, a power of 90%, a design effect of 2% and a 5% non-response rate, the final sample size n = 618 + 31 = 649. Finally, 316 employed and 333 unemployed eligible mothers were taken.

A multistage sampling technique was used to reach study participants. The town has 12 urban kebeles from these five kebeles were selected randomly. In the five selected kebeles, the total number of illegible mothers was estimated, household code numbers were given separately for employed and unemployed mothers. Following coding each household, the total sample size of the study was proportionally assigned to the five selected kebeles. Using the code numbers as a sampling frame study participants were selected randomly with computer generated random numbers (Fig. 1). Households were visited during working days to interview unemployed mothers whereas employed mothers were interviewed during the weekends.

The pretested structured interviewer administered questionnaire was used to collect data. The questionnaire consisted of six parts: sociodemographic characteristics, economic indicators, birth related factors, exclusive breastfeeding related factors, knowledge, attitude and practice about exclusive breastfeeding and health service related factors.

The questionnaire was first developed in English and translated to Amharic, the local language. Ten trained data collectors collected the data under the continuous supervision of principal investigators.

Employed mothers: mothers who work outside the home for income in addition to the work they perform at home in raising their children [13].

Knowledge of mother: mothers’ information on the advantages and recommended duration of exclusive breastfeeding. Mothers were asked six knowledge related questions and each correct answer was given a value of 1 and an incorrect answer a value of 0. After computing the sum for each respondent and mean, it was dichotomized into good knowledge ≥ mean, poor knowledge < mean.

Attitude: there were three attitude related questions and mothers who respond the right response to all the three questions the will be categorized as having a good attitude.

Practiced EBF: mothers who fed breast milk only for the first six months.

Predominant breastfeeding: the practice of feeding breast milk along with water [1].

Mixed breastfeeding: the practice of feeding breast milk along with food [1].

Early initiation of breastfeeding: infants who were put to the breast within one hour of birth [1].

Prelacteal feeding: children who have been given something other than breast milk during the first three days of life [1].

A total 649 mothers having children of age 7–12 months were interviewed. The mean age mothers were 28.4 years (± 4.8 years) and the mean age of children was 8.9 months (± 3.604 months). Of the employed mothers 96 (30.4%) were government employed. The majority, 89.5%, of the participants attended secondary education and above (Table 1).

The majority, 80.0%, and 83.1%, of participants, reported they had good knowledge and attitude about exclusive breastfeeding, respectively. The proportion of knowledge on has no significance difference in employment status (Table 1).

The majority, 89.6%, of participants (employed = 282: unemployed = 300) gave birth at health center by a skilled attendant. The majority of participants, 94.5% and 92.2%, practiced breastfeeding their children immediately within one hour of birth, respectively. Furthermore, 92.6% and 98.5%, employed and unemployed mothers were informed about exclusive breastfeeding during any of their antenatal care visits and had support from their partner, respectively (Table 2).

The main reasons reported by employed mothers for not practicing exclusive breastfeeding were that working was a hindrance 84 (26.6%), and concern about the amount of milk 23 (7.3%) immediately after birth.

The overall exclusive breastfeeding practice was 34.8% (95% CI 33.0%, 36.7%). The mean (SD) duration that infants received breast milk only was 4.8 (± 1.4) month. A total of 20.9% (95% CI 16.0%, 25.0%) employed mothers and 48.0% (95% CI 42.0%, 54.0%) unemployed mothers practiced exclusive breastfeeding.

The descriptive statistics comparing sociodemographic, knowledge and attitude characteristics showed a significant difference along the employment status of mothers. Exclusive breastfeeding, marital status, attitude, social support and household socioeconomic positions were significantly different along with the employment status of mothers (Additional file 1).

We fitted three different models to assess exclusive breastfeeding practice. The first model was fitted to assess the overall factors of exclusive breastfeeding practice. Variables such as knowledge, attitude, and employment status were significantly associated with exclusive breastfeeding practice regardless of employment status.

Mothers who had poor attitude (AOR 0.13, 95% CI 0.05, 0.31), and poor knowledge (AOR 0.44, 95% CI 0.24, 0.78) were less likely to practice exclusive breastfeeding than their counterparts. Mothers who were unemployed were 3.4 times more likely to practice exclusive breastfeeding than employed mothers (AOR 3.43, 95% CI 2.38, 4.95) (Table 3).

The second model was fitted only for unemployed mothers. Accordingly, knowledge on exclusive breastfeeding, social support, history of antenatal (ANC) care follow up and mode of delivery showed a significant association (Table 4). Unemployed mothers who had poor knowledge on exclusive breastfeeding were 72.2% less likely to practice exclusive breastfeeding compared to those who had good knowledge (AOR 0.28, 95% CI 0.14, 0.54) and mothers who had no social support were 66.6% less likely to breastfeed exclusively as compared with those who were supported (AOR 0.33, 95% CI 0.16, 0.71). In addition, mothers who had antenatal care follow up as per the recommended frequency were 1.8 times more likely to breastfeed exclusively as compared with to those who had no antenatal care follow up (AOR 0.56, 95% CI 0.32, 0.98) and mothers who birthed by spontaneous vaginal mode were 2.5 times more likely to breastfeed exclusively when compared with those who were delivered by caesarean section (AOR 2.60, 95% CI 1.33, 5.08).

The third model was fitted for employed mothers. As a result, employed mothers who had three and above children were 3.5 times more likely to breastfeed exclusively than those who had below three children (AOR 3.48, 95% CI 1.79, 6.78), employed mothers who had good knowledge of exclusive breastfeeding were more likely exclusively breastfeed (AOR 0.30, 95% CI 0.11, 0.80), and also mothers who had no social support were 3.5 times more likely to breastfeed exclusively than those who have social support (AOR 3.46, 95% CI 1.78, 6.72) (Table 5).

Likewise, women in the wealth index ranking middle were 62% less likely to EBF than lower rank (AOR 0.38, 95% CI 0.17, 0.85).

This study was not supplemented with a qualitative study. We didn’t study the employment characteristics, such as time and sector. There might be misclassification of mothers on their attitude status due to the fewer number of questions. There might be recall bias since mothers were interviewed to recall their experience. Our data collection tool was not validated this might limit the findings generalizability.